A realist synthesis of evidence relating to practice development: findings from the literature analysis

Participatory Methods to Improve and Develop Pediatric Nursing Practice: A Scoping Review

Children's nurses in African pediatric settings are often responsible for leading practice improvements. There is a shortage of contextually relevant guidance to inform the design of practice improvement projects in African care settings. Distinctive features of children's nursing practice in Africa include high levels of family caregiver involvement, and organizational and professional cultures which value participation. While established practice improvement methods offer many strengths, methods developed in other geographies should not be adopted uncritically. Our purpose in undertaking this review was to inform selection of methods for a multi-center practice improvement project in Africa. Our aim was to identify types of participatory methods used to improve and develop pediatric nursing practice. We used the PRISMA-ScR method to conduct a scoping review to identify published reports of participatory methods used to improve and develop pediatric nursing practice. We undertook structured searches of five bibliographic databases to identify articles. Only articles written in the English language were included and no limitation was applied to publication date. We identified 7,406 titles and abstracts. After screening, 76 articles met the inclusion criteria. A wide range of participatory methodologies were identified; just under half (n = 34) reported on methods that were not recognized or named methodologies but can be described as collaborative in nature. Plan-do-study-act cycles were reported in 22 articles. There was considerable heterogeneity in frameworks, practical tools and/or nursing models on which the participatory methods were based and there was no apparent relationship between these and the choice of participatory methods. The outcomes identified were also heterogenous in nature and were grouped according to whether they improved structure and/or processes and patient outcomes. Most of the included articles stem from high-income countries with little evidence from low-middle-income countries and none in African settings. Less than half of the included articles involved family caregivers in their practice improvement methodologies. This review highlights the need for greater application of formalized methods for practice improvement and improved rigor and consistency in reporting outcomes. There is also a need to formalize participatory practice improvement methodologies specifically suited to Africa's context of children's nursing.

'Guiding Lights for effective workplace cultures': enhancing the care environment for staff and patients in older people's care settings

While much attention has been given to organisational culture, there has been less focus on workplace culture. Yet workplace culture strongly influences the way care is delivered, received and experienced. An effective workplace culture is crucial for the well-being of individual staff members and teams as well as for patients' experiences and outcomes of care. This article describes the 'Guiding Lights for effective workplace cultures' which were developed by the authors and provide a framework to assist in understanding and promoting effective workplace cultures and creating environments where staff and patients feel safe and valued. There are four Guiding Lights: 'collective leadership', 'living shared values', 'safe, critical, creative learning environments' and 'change for good that makes a difference'. Each one articulates what good workplace cultures are through descriptors and intermediate outcomes and together produce a set of ultimate outcomes. The Guiding Lights provide nurses working in older people's care settings with an opportunity to learn from, and celebrate, what is going well in their workplaces and to consider areas that require further development.

Determinants that influence knowledge brokers' and opinion leaders' role to close knowledge practice gaps in rehabilitation: A realist review

RATIONALE

Despite the available evidence to support optimal practices in rehabilitation, significant knowledge practice gaps persist. Opinion leaders (OLs) and knowledge brokers (KBs) can enhance the success of knowledge translation (KT) interventions and improve uptake of best practices among clinicians. However, the literature on the mechanisms underpinning OLs'/KBs' activities, and guidance on the type of support needed for successful implementation of these roles in rehabilitation contexts is scarce. This research aimed to highlight the differences and similarities between OLs and KBs with respect to context, mechanism, and outcomes as well as describe the common patterns of OLs and KBs by creating a context-mechanism-outcomes configuration.

METHODS

We conducted a realist review to synthesize the available evidence on OLs/KBs as active KT strategies. A search was conducted across five databases up to November 2019. Two independent reviewers extracted the data using a structured form. A context-mechanism-outcome configuration was used to conceptualize a cumulative portrait of the features of OLs/KBs roles.

RESULTS

The search identified 3282 titles after removing duplicates. Seventeen studies (reported in 20 articles) were included in the review. Findings suggest a number of desirable features of OLs/KBs roles that may maximize the achievement of targeted outcomes namely being (a) embedded within their organization as "insiders"; (b) adequately skilled to perform their role; (c) identified as able to fulfil the role; (d) appropriately trained; and (e) able to use different KT interventions.

CONCLUSION

Findings of this realist review converge to create a context-mechanism-outcomes configuration with suggestions to optimally utilize OLs/KBs in rehabilitation. The configurations suggest desirable features that can lead to a greater potential to achieve targeted goals. It is preferable that OLs/KBs be embedded in the organization and that they are adequately skilful and well-trained. Also, OLs/KBs should perform the required roles using KT interventions adapted to the local context.

Designing and implementing two facilitation interventions within the 'Facilitating Implementation of Research Evidence (FIRE)' study: a qualitative analysis from an external facilitators' perspective

BACKGROUND

The 'Facilitating Implementation of Research Evidence' study found no significant differences between sites that received two types of facilitation support and those that did not on the primary outcome of documented compliance with guideline recommendations. Process evaluation highlighted factors that influenced local, internal facilitators' ability to enact the roles as envisaged. In this paper, the external facilitators responsible for designing and delivering the two types of facilitation intervention analyse why the interventions proved difficult to implement as expected, including the challenge of balancing fidelity and adaptation.

METHODS

Qualitative data sources included notes from monthly internal-external facilitator teleconference meetings, from closing events for the two facilitation interventions and summary data analyses from repeated interviews with 16 internal facilitators. Deductive and inductive data analysis was led by an independent researcher to evaluate how facilitation in practice compared to the logic pathways designed to guide fidelity in the delivery of the interventions.

RESULTS

The planned facilitation interventions did not work as predicted. Difficulties were encountered in each of the five elements of the logic pathway: recruitment and selection of appropriate internal facilitators, preparation for the role, ability to apply facilitation knowledge and skills at a local level, support and mentorship from external facilitators via monthly teleconferences, working collaboratively and enabling colleagues to implement guideline recommendations. Moreover, problems were cumulative and created tensions for the external facilitators in terms of balancing the logic pathway with a more real-world, flexible and iterative approach to facilitation.

CONCLUSION

Evaluating an intervention that is fluid and dynamic within the methodology of a randomised controlled trial is complex and challenging. At a practical level, relational aspects of facilitation are critically important. It is essential to recruit and retain individuals with the appropriate set of skills and characteristics, explicit support from managerial leaders and accessible mentorship from more experienced facilitators. At a methodological level, there is a need for attention to the balance between fidelity and adaptation of interventions. For future studies, we suggest a theoretical approach to fidelity, with a focus on mechanisms, informed by prospective use of process evaluation data and more detailed investigation of the context-facilitation dynamic.

Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence-Based Care in Long-Term Care Settings

BACKGROUND

Evidence-based improvements in long-term care (LTC) are challenging due to human resource constraints.

AIMS

To evaluate implementation of a multimodal, participatory intervention aimed at improving evidence-based care.

METHODS

Using a qualitative descriptive design, we conducted and inductively analyzed individual interviews with staff at midpoint and end-point to identify action plan implementation processes and challenges. The 9-month intervention engaged professional and unregulated staff in an on-site workshop and provided support for their development and implementation of site-specific action plans.

RESULTS

Ten of 12 enrolled sites participated for the full study period. Interviews were conducted with 44 and 69 participants at midpoint and end-point, respectively. Seven of 10 sites focused their action plan on team functioning and communication. Main achievements described at end-point were improved team communication, better staff engagement, and improved teamwork. Internal and external supports for action plan implementation were described as critical for success.

DISCUSSION

Three factors influenced change: vertically and horizontally linked teams, external facilitator support for action plan implementation, and coaching by Best Practice Coordinators that emphasized organizational change and normalization of evidence-based practice.

IMPLICATIONS

Team functioning and communication are forerunners of clinical practice changes in LTC. An off-site model of facilitation is promising and may provide a more efficient means to reach a wider array of LTC settings.

LINKING EVIDENCE TO ACTION

Practice changes need engagement of all staff.

A Framework for Latino Nursing Leadership

There is an urgent need for Latino leaders in nursing, yet little has been written about Latino leaders and leadership. Leadership comes with challenges and opportunities in particular for Latino nurses who contend with specific cultural imperatives and obstacles. In this article, I review the current healthcare environment and propose a framework for Latino nursing leadership within the context of current challenges and opportunities and my personal experience in nursing. This framework is meant to serve as a guide for the development of Latino nurses who will improve the health and well-being of those in the most vulnerable communities by utilizing their cultural strengths and professional skills to deliver quality and compassionate care.

Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions

Background

Support workers make up the majority of the workforce in health and social care services for older people. There is evidence to suggest that support workers are not deployed as effectively as possible, are often undervalued, and that there are gaps in understanding support worker roles across different care settings. In the context of a population that is growing older, having a skilled and knowledgeable workforce is an imperative. Workforce development includes the support required to equip those providing care to older people with the right skills, knowledge and behaviours to deliver safe and high-quality services.

Objective

The review answered the question ‘how can workforce development interventions improve the skills and the care standards of support workers within older people’s health and social care services?’.

Design

A realist synthesis was conducted. In realist synthesis, contingent relationships are expressed as context–mechanism–outcomes (CMOs), to show how particular contexts or conditions trigger mechanisms to generate outcomes. The review was conducted in four iterative stages over 18 months: (1) development of a theoretical framework and initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce, guided by the programme theories; (3) ‘testing out’ the synthesis findings to refine the programme theories and establish their practical relevance/potential for implementation; and (4) forming recommendations about how to improve current workforce development interventions to ensure high standards in the care of older people.

Participants

Twelve stakeholders were involved in workshops to inform programme theory development, and 10 managers, directors for training/development and experienced support workers were interviewed in phase 4 of the study to evaluate the findings and inform knowledge mobilisation.

Results

Eight CMO configurations emerged from the review process, which provide a programme theory about ‘what works’ in developing the older person’s support workforce. The findings indicate that the design and delivery of workforce development should consider and include a number of starting points. These include personal factors about the support worker, the specific requirements of workforce development and the fit with broader organisational strategy and goals.

Conclusions and recommendations

The review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers in older people’s health and social care services. Implications for the practice of designing and delivering older person’s support workforce development interventions are directly related to the eight CMO configuration of the programme theory. Our recommendations for future research relate both to aspects of research methods and to a number of research questions to further evaluate and explicate our programme theory.

Limitations

We found that reports of studies evaluating workforce development interventions tended to lack detail about the interventions that were being evaluated. We found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented and/or evaluated.

Study registration

This study is registered as PROSPRERO CRD42013006283.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Thinking big, supporting families and enabling coping: the value of social work in patient and family centered health care

Patient and family-centered care has become a focus in health services. Social work has a rich history of providing responsive patient care. This study identified the contribution and value of social work to PFCC from the key stakeholder perspectives of health social workers (n = 65). Utilizing interpretive description, four themes emerged: (1) Thinking big and holistically, (2) Intervening with families, (3) Enabling patient and family coping, and (4) Maximizing hospital and community resources. Barriers included a lack of power, professional isolation and role creep. Implications for research and practice are provided.

Assessment and treatment of physical health problems among people with schizophrenia: national cross-sectional study

BACKGROUND

In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population.

AIMS

To examine the quality of assessment and treatment of physical health problems in people with schizophrenia. Method Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey.

RESULTS

Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received.

CONCLUSIONS

Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.

What does practice development (PD) offer mental health-care contexts? A comparative case study of PD methods and outcomes

Practice development (PD) in mental health nursing has been progressing over the last decade; however, the level and impact of PD activity in the field of mental health remains poorly understood outside localized project impact. More specific reporting and comparative analysis of PD outcomes will improve this situation. In response, this paper presents three case scenarios from work taking place in Australia and New Zealand, as working examples of how PD methodologies have been applied within mental health practice settings. Using a comparative framework that captures the contributing assumptions, practices, processes and conditions imperative to effective PD work within a mental health-care context, three case vignettes are reviewed. The critical question driving this paper is 'what mental health-care services does PD offer in terms of transformational change approaches and the promotion of effective workplace cultures?' Conditions considered necessary for successful PD initiatives within mental health contexts are explored such as how PD converges and diverges with mental health-related theories, plus where and how PD activity best integrates with the specific elements associated with mental health-care provision. The findings are further reviewed in line with reports of PD outcomes from other fields of health care.

The Power of Synergy: An Academic/Clinical Partnership for Transformational Change

Background. A programme of postgraduate study was developed in partnership between a health board and a university in New Zealand, having identified critical thinking and practice change as key determinants of good care delivery. Aim. To explore the impact after 12 months of a postgraduate programme for registered nurses on patient assessment and clinical reasoning, and the status of implementation plans for improved patient care. Design. Outcome evaluation using a survey and focus groups. Setting. On location at a hospital in a small city in New Zealand that provides healthcare services for 102,000 people across rural and urban areas. Participants. Registered nurses who had completed the programme (N=28) and seven clinical mentors. Methods. A survey, focus groups, and follow-up data about quality improvement projects were used to explore how the programme was experienced and its impact. Results. The survey revealed perceptions of improved knowledge and skills but a lack of confidence in communicating with medical staff. Of 28 quality improvement projects planned, all but three had been implemented and were still in use. Two themes were generated from focus group data: “new ways of thinking” and “doing things differently.” Conclusions. This academic/clinical partnership positively influenced nurses’ knowledge and skills, encouraged critical thinking and self-efficacy, and resulted in the sustained implementation of nurse-initiated projects intended to improve patient care.

Improving skills and care standards in the support workforce for older people: a realist review

INTRODUCTION

In the context of a population that is growing older, and a number of high-profile scandals about care standards in hospital and community settings, having a skilled and knowledgeable workforce caring for older people is an ethical and policy imperative. Support workers make up the majority of the workforce in health and social care services for older people (aged 65 years and over), and yet little is known about the best way to facilitate their development. Given this gap, this review will draw on evidence to address the question: how can workforce development interventions improve the skills and the care standards of support workers within older people's health and social care services?

METHODS AND ANALYSIS

As we are interested in how and why workforce development interventions might work, in what circumstances and with whom, we will conduct a realist review, sourcing evidence from health, social care, policing and education. The review will be conducted in four steps over 18 months to (1) construct a theoretical framework, that is, the review's programme theories; (2) retrieve, review and synthesise evidence relating to interventions designed to develop the support workforce guided by the programme theories; (3) 'test out' our synthesis findings and refine the programme theories, establish their practical relevance/potential for implementation and (4) formulate recommendations about improvements to current workforce development interventions to contribute to the improvement of care standards in older people's health and social care services, potentially transferrable to other services.

ETHICS AND DISSEMINATION

Ethical approval is not required to undertake this review. Knowledge exchange activities through stakeholder engagement and online postings are embedded throughout the lifetime of the project. The main output from this review will be a new theory driven framework for skill development for the support workforce in health and social care for older people.

TRIAL REGISTRATION NUMBER

CRD42013006283.

Evaluation of leadership practices: how to develop a vision

Leadership competencies and more specifically a strategic vision are essential to managing increasingly complex healthcare organisations and change. However, Switzerland, like many other countries, has identified a lack of leadership skills among nurse leaders. Therefore the Royal College of Nursing’s (RCN) Clinical Leadership Programme has been adapted, implemented and evaluated in the Swiss nursing context. The aim of this qualitative study was to evaluate the Leadership Programme’s support for vision development. In-depth interviews with six nurse leaders, who were purposefully selected according to the quantitative results of the overall mixed-methods evaluation project were included. Interviews were audio-recorded and transcribed prior to qualitative content analysis. Findings showed the different approaches used in the process of vision formation. Some used cognitive-analytical techniques and proceeded very methodically and systematically, whereas others described a more intuitive approach. Some also used a combination of both approaches. Participants experienced fostering and hindering factors on different levels – personal as well as organisational. The identified factors in vision development may be helpful in the planning of educational programmes to facilitate visionary skills among nurse leaders. Vision formation requires time for reflection and the ability of creative thinking, which is distinct from day-to-day management tasks.

Turning knowledge into action at the point-of-care: the collective experience of nurses facilitating the implementation of evidence-based practice

BACKGROUND

Facilitation is considered a way of enabling clinicians to implement evidence into practice by problem solving and providing support. Practice development is a well-established movement in the United Kingdom that incorporates the use of facilitators, but in Canada, the role is more obtuse. Few investigations have observed the process of facilitation as described by individuals experienced in guideline implementation in North America.

AIM

To describe the tacit knowledge regarding facilitation embedded in the experiences of nurses implementing evidence into practice.

METHODS

Twenty nurses from across Canada were purposively selected to attend an interactive knowledge translation symposium to examine what has worked and what has not in implementing evidence in practice. This study is an additional in-depth analysis of data collected at the symposium that focuses on facilitation as an intervention to enhance evidence uptake. Critical incident technique was used to elicit examples to examine the nurses' facilitation experiences. Participants shared their experiences with one another and completed initial data analysis and coding collaboratively. The data were further thematically analyzed using the qualitative inductive approach of constant comparison.

RESULTS

A number of factors emerged at various levels associated with the successes and failures of participants' efforts to facilitate evidence-based practice. Successful implementation related to: (a) focus on a priority issue, (b) relevant evidence, (c) development of strategic partnerships, (d) the use of multiple strategies to effect change, and (e) facilitator characteristics and approach. Negative factors influencing the process were: (a) poor engagement or ownership, (b) resource deficits, (c) conflict, (d) contextual issues, and (e) lack of evaluation and sustainability.

CONCLUSIONS

Factors at the individual, environmental, organizational, and cultural level influence facilitation of evidence-based practice in real situations at the point-of-care. With a greater understanding of factors contributing to successful or unsuccessful facilitation, future research should focus on analyzing facilitation interventions tailored to address barriers and enhance facilitators of evidence uptake.

Barriers and enablers to implementation of a New Zealand-wide guideline for assessment and management of cardiovascular risk in primary health care: a template analysis

AIM

The aim of this study was to identify the enablers and barriers to guideline implementation in a primary healthcare setting by employing the Promoting Action on Research Implementation in Health Services (PARIHS) framework as a template for data analysis and interpretation.

BACKGROUND

The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable, and, in spite of much investigation, remains resistant to explanation of what works and why. Optimising the enablers and minimising the barriers to implementation of a guideline for reducing cardiovascular disease risk has the potential to significantly reduce the burden of disease. The PARIHS framework has been successfully applied in a number of clinical contexts and has been found useful in illuminating the barriers and enablers to evidence implementation.

APPROACH

This qualitative study involved focus groups with 20 primary healthcare nurses, 4 general practitioners, 5 managers, and individual interviews with 3 funder/planners who discussed their contribution to the use of a guideline for the assessment and management of cardiovascular risk. Template analysis based on the PARIHS framework was applied to semi-structured narrative data to provide an in-depth analysis of the barriers and enablers to implementation of the guideline.

CONCLUSIONS

The lack of facilitation of the guideline into practice was a major barrier to implementation. Implementation plans that address the concerns and complexities of everyday practice are an essential aspect of guideline development. The PARIHS framework was found to be comprehensive and accommodating of the complexity of everyday practice associated with guideline implementation in primary health care. The pertinence of the framework confirms its usefulness as a tool to guide implementation.

Engaged scholarship and research impact: integrating the doing and using of research in practice

Demonstrating impact from research has always been a key consideration in the knowledge production business. However, it can be argued that the models and frameworks available for enabling such impact to be demonstrated are poorly developed. Those that do exist are predominantly derived from a linear uni-dimensional perspective of the knowledge flow from the academy to practice. Little sustained attention has been given to the development of models and ways of working that go beyond traditional approaches to impact monitoring through impact factors and citation indices. Engaged scholarship offers a framework that has as an explicit intention, the creation of connections between researchers/universities and practitioners/health care providers.

In this paper a model is offered derived from the theory of ‘engaged scholarship’. The principles of engaged scholarship will be outlined, as well as an articulation of engaged scholarship as an approach to the co-production of knowledge. An example of a practice development and evaluation study will be offered that is consistent with the principles of engaged scholarship. The need for a strategic approach to the development of engaged scholarship will be highlighted, as well as the need for sustained partnerships between the academy and practice.

Facilitation as a role and process in achieving evidence-based practice in nursing: a focused review of concept and meaning

BACKGROUND

Facilitation is proposed as an important strategy to assist practitioners to implement evidence into practice. However, from a front-line nursing perspective, what is actually involved in facilitation, particularly in regards to research utilization, is poorly understood.

AIM

To examine the current state of knowledge surrounding the concept of facilitation as a role and process in the implementation of research findings within the nursing context. Building on a previous concept analysis, we examined how facilitation has evolved over the last decade, particularly focusing on the practical elements (e.g., what it entails to operationalize and implement facilitation in nursing).

METHODS

A systematic search of electronic databases identified theory and research-based nursing papers explicitly focused on facilitation in research utilization. Through a content analysis, we examined how the concept is being used, described, and applied within nursing.

RESULTS

Facilitation continues to be described as supporting and enabling practitioners to improve practice through evidence implementation. Certain aspects of the role and the strategies being employed to promote change are more evident. It was possible to formulate these into a taxonomy. Key findings include: * facilitation is now being viewed as an individual role as well as a process involving individuals and groups; * project management/leadership are important components; * no matter which approach is selected, tailoring facilitation to the local context is critical; * there is a growing emphasis on evaluation, particularly linking outcomes to nursing actions.

CONCLUSIONS

Further understanding of what facilitators are actually doing to enable changes in nursing practice based on research findings will provide the groundwork for the design and evaluation of practical strategies for evidence-based practice in nursing. Research is needed to clarify how facilitation may be used to implement change in nursing practice along with evaluation of the effectiveness of various approaches.

Using consensus methods to develop clinical practice guidelines for intensive care: the intensive care collaborative project

BACKGROUND

Clinical practices or procedures based on the best available evidence are an essential resource within an intensive care unit (ICU). Maintaining the currency of a local clinical practice manual is challenging however, particularly in relation to the time required, other workload pressures and the availability of staff with relevant skills to interrogate the literature. The aim of the Intensive Care Collaborative (ICC) project was to use the synergism of group processes to develop state-based clinical guidelines for six common intensive care practices - eye care, oral care, endotracheal tube management, suctioning, arterial line management, and central venous catheter (CVC) management.

METHODS

Participants were 55 senior nurse clinicians from all nine area health services in NSW, seven academic facilitators, and staff from the Intensive Care Coordination and Monitoring Unit (ICCMU). A range of approaches were used to develop the six clinical practice guidelines (CPG) and related systematic literature reviews, including a preparatory educational seminar for participants, formation of working groups of clinicians, with subsequent teleconferences, e-mail and online forums to identify the scope of each guideline and review the literature. A consensus development conference (CDC) was conducted to finalise the reviews with a nominal group technique (NGT) used to develop recommendations for practice. External Validation Panels (EVP) verified the recommendations in each clinical practice guideline. Group voting was undertaken using a Likert scale (1-3 disagree, 4-6 neutral, 7-9 agree) with consensus agreement set as a median of at least seven.

RESULTS

Eighty-three recommendations for practice were developed for the six Clinical Practice Guidelines; 50% were based on research literature evidence (23% with high levels of evidence). The balance were based on consensus opinion of the panel members. Only five recommendations were not validated by external validation.

CONCLUSION

This project has demonstrated a method for guideline development that is robust, incorporating evidence from research and clinical expertise utilising an objective egalitarian framework.