Attitudes toward practice guidelines among intensive care unit personnel: a cross-sectional anonymous survey

Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study

OBJECTIVES

Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements.

METHODS

A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted.

RESULTS

Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs.

CONCLUSIONS

Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.

Clinician attitudes towards cancer treatment guidelines in Australia

OBJECTIVES

Clinical Practice Guidelines (CPGs) are designed to guide treatment decisions, yet adherence rates vary widely. To characterise perceived barriers and facilitators to cancer treatment CPG adherence in Australia, and estimate the frequency of previous qualitative research findings, a survey was distributed to Australian oncologists.

RESULTS

The sample is described and validated guideline attitude scores reported for different groups. Differences in mean CPG attitude scores across clinician subgroups and associations between frequency of CPG use and clinician characteristics were calculated; with 48 respondents there was limited statistical power to find differences. Younger oncologists (< 50 years) and clinicians participating in three or more Multidisciplinary Team Meetings were more likely to routinely or occasionally use CPGs. Perceived barriers and facilitators were identified. Thematic analysis was conducted on open-text responses. Results were integrated with previous interview findings and presented in a thematic, conceptual matrix. Most barriers and facilitators identified earlier were corroborated by survey results, with minor discordance. Identified barriers and facilitators require further exploration within a larger sample to assess their perceived impact on cancer treatment CPG adherence in Australia, as well as to inform future CPG implementation strategies. This research was Human Research Ethics Committee approved (2019/ETH11722 and 52019568810127, ID:5688).

Designing an optimal infection prevention service: Part 2

Background

The importance of infection prevention and control (IPC) services to prevent threats from healthcare-associated infections and improve the quality of healthcare delivery is undeniable. However, IPC services across the UK and Ireland have substantial variability in terms of team structures and delivery models.

Aim

The aim of this study was to define an optimal IPC service in different contexts and settings within the United Kingdom and Ireland.

Methods

This mixed methods study adopted discussion huddles with IPC teams to explore various components of IPC programmes and services. A Nominal Group technique was then undertaken to achieve a group consensus of what an optimal infection prevention service should look like.

Results

Five discussion huddles were conducted which included 53 participants in total. Key themes arising were IPC Service Priorities, IPC Service Enablers for Success, and Necessary Skills and Expertise Required for Delivering an Effective IPC Service. For the nominal technique, 45 responses were identified which were determining the key priorities for an effective IPC service and 69 responses for establishing key enablers for success.

Discussion

These findings supported the development of a conceptual model for designing an optimal infection prevention service, which can be used to develop IPC services at an international, national, regional and local level. A focus is required around implementation of these highlighted enablers, so are effectively embedded into infection prevention and control services, and wider healthcare settings.

Quantification of diurnal variation in “glove hygiene” compliance in COVID ICUs: an exploratory study

Background

Hand hygiene compliance (HHC) monitoring is almost always done in daytime. Documentation of HHC in health care workers (HCWs) is limited during odd hours and nighttime. The objective of the study was to determine diurnal variation in HHC in different categories of health care workers in tertiary care hospital in North India.

Methods

A prospective, observational study was conducted in 3 COVID-19 intensive care units (ICUs) with closed-circuit television (CCTV) cameras. Dedicated infection control nurses monitored HHC among various HCWs (doctors, nursing staff, technicians, hospital and sanitary attendants) during day and nighttime, in 20-minute durations. The difference in HHC by-professional category and for each WHO moment was assessed using χ² test and P value.

Results

A total of 705 opportunities were observed over a period of 7 days, with overall compliance of 53%. Day and nighttime compliance was recorded to be 60.7% and 42.1%, respectively (P < .001). HCC was highest amongst resident doctors with little diurnal variation. However, nurses and housekeeping staff exhibited significant diurnal variation. The compliance at “after” moments was much higher than “before” moments in all professional categories.

Conclusion

There was a significant decrease in compliance during nighttime, amongst all HCWs, with maximum variation exhibited by nursing staff. The present study underlines the importance of monitoring HHC at odd hours, to elicit a more accurate picture round the clock. Health care facilities monitoring compliance only during the daytime may substantially overestimate HHC.

Operating room technician trainees teach medical students - an inter-professional peer teaching approach for infection prevention strategies in the operation room

Background

Education is a cornerstone strategy to prevent health-associated infections. Trainings benefit from being interactive, simulation-based, team-orientated, and early in professional socialization. We conceived an innovative inter-professional peer-teaching module with operating room technician trainees (ORTT) teaching infection prevention behavior in the operating room (OR) to medical students (MDS).

Methods

ORTT delivered a 2-h teaching module to small groups of MDS in a simulated OR setting with 4 posts: ‘entering OR’; ‘surgical hand disinfection’; ‘dressing up for surgery and preparing a surgical field’, ‘debriefing’. MDS and ORTT evaluated module features and teaching quality through 2 specific questionnaires. Structured field notes by education specialist observers were analyzed thematically.

Results

On Likert scales from − 2 to + 2, mean overall satisfaction was + 1.91 (±0.3) for MDS and + 1.66 (±0.6 SD) for ORTT while teaching quality was rated + 1.89 (±0.3) by MDS and self-rated with + 1.34 (±0.5) by ORTT. Students and observers highlighted that the training fostered mutual understanding and provided insight into the corresponding profession.

Conclusions

Undergraduate inter-professional teaching among ORTT and MDS in infection prevention and control proved feasible with high educational quality. Inducing early mutual understanding between professional groups might improve professional collaboration and patient safety.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0526-2) contains supplementary material, which is available to authorized users.

The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians' perceptions of professional and cultural factors that influence doctors' attitudes and practices in a large Australian hospital

BACKGROUND

Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers' adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors' behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors' IPC practices will contribute to development of new strategies to improve IPC, overall.

METHODS

This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors' IPC practices, using thematic analysis of data.

RESULTS

Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors' responsibilities for preventing them; and lack of clarity about senior consultants' obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors' own assessment of patients' infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised.

CONCLUSIONS

Failure of healthcare and professional organisations to address doctors' poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.

The Chinese version of attitudes towards guidelines scale: validity and reliability assessment

Background

The use of guidelines has shown to improve clinical practice process and structure of health care, but health care providers don’t always use and keep up-to-date with the new clinical practice guidelines. Nurses’ attitudes towards guidelines have shown to be the most frequently identified factor affecting their actual use of clinical practice guidelines, but no instruments for measuring it are available in China. There are scales validated in the western countries, but there is no information about their validity in Chinese health care. The purpose of this study is to test the validity and reliability of Chinese Attitudes towards guidelines - scale for nurses.

Methods

The study was conducted from April to July 2017. The Attitudes towards guidelines scale was translated into Chinese with forward-backward translation method and a questionnaire survey was conducted. Eight hundred randomly selected nurses (final N = 768) from Geriatrics, Internal medical and Rehabilitation departments of 16 hospitals were drawn in Sichuan province, China. Construct validity was evaluated by exploratory and confirmatory factor analysis, and reliability was assessed by test-retest reliability (represented by intra class correlation) and internal consistency (expressed by Cronbach’s coefficients). The test-retest reliability was examined with a sample of 32 clinical nurses who filled out the questionnaire 14 days after the first survey.

Results

Exploratory factor analysis supported a four-factor model for the Chinese version of the scale. Confirmatory factor analysis indicated that the hypothetical four-factor model fitted the data relatively well. The intra class correlation coefficient was 0.85 (95%CI, 0.68–0.93) and the Cronbach’s alpha values for the four subscales ranged from 0.645 to 0.912.

Conclusions

The results support the acceptable level of validity and reliability of the Chinese version of Attitudes towards guidelines scale, which can be used to assess nurses’ attitudes towards guidelines in China. Future testing for the Chinese version of Attitudes towards guidelines scale needs to be carried out to see whether these results are generalizable to other professionals and occupational groups and to be used to revise attitudes towards specific guidelines in China.

Encouraging interprofessional collaboration: The effects of clinical protocols

AIMS AND OBJECTIVES

To consider the characteristics of protocol documents themselves as a factor influencing the nature of care delivery and their potential to facilitate greater interprofessional collaboration.

BACKGROUND

Healthcare guidelines and clinical protocols provide important guidance and direction to health professionals in their delivery of care. By detailing requirements and actions to be taken in specified circumstances or contexts, these documents may facilitate a broadening of the pool of people able to deliver care.

DESIGN

Critical reading of four clinical protocols representing the range of protocol types in use was carried out to consider the extent to which the documentation of guidelines and protocols and the documents themselves might be considered as vehicles for increased collaboration in health care.

METHODS

A "close reading" rubric was developed directing the researcher to look for evidence in each protocol of the following: authorship, person or group responsible for the protocol's development; stated document purpose; target readers, either stated or implied; the particular subjects, the document names and the objects created by them such as care pathways; the use of specific terminology and imagery, the documents' form and structure; and evidence of intertextuality referring to other documents, for example legislation or policy statements. Tabulation of the coding analysis is presented.

RESULTS

Nurses were the only professional group named in the documents as assignees or subjects. "Patients" and "care" are the objects created, and the scientific-biomedical discourse with its associated procedural language was dominant.

CONCLUSIONS

Many protocols have been developed to standardise practice and increase the effectiveness of teamwork. They may, however, constrain collaboration in healthcare settings because they diminish a nursing "voice" and create the expectation that nurses alone work across the spectrum of protocols.

RELEVANCE TO CLINICAL PRACTICE

An unintended consequence of the global use of clinical protocols and guidelines to support safe and efficient healthcare delivery may be to reduce interprofessional collaboration.

Australian general practitioner attitudes to clinical practice guidelines and some implications for translating osteoarthritis care into practice

Clinical practice guidelines (CPGs) have been shown to improve processes of care and health outcomes, but there is often a discrepancy between recommendations for care and clinical practice. This study sought to explore general practitioner (GP) attitudes towards CPGs, in general and specifically for osteoarthritis (OA), with the implications for translating OA care into practice. A self-administered questionnaire was conducted in January 2013 with a sample of 228 GPs in New South Wales and South Australia. Seventy-nine GPs returned questionnaires (response rate 35%). Nearly all GPs considered that CPGs support decision-making in practice (94%) and medical education (92%). Very few respondents regarded CPGs as a threat to clinical autonomy, and most recognised that individual patient circumstances must be taken into account. Shorter CPG formats were preferred over longer and more comprehensive formats, with preferences being evenly divided among respondents for short, 2-3-page summaries, flowcharts or algorithms and single page checklists. GPs considered accessibility to CPGs to be important, and electronic formats were popular. Familiarity and use of The Royal Australian College of General Practitioners OA Guideline was poor, with most respondents either not aware of it (30%; 95% confidence interval (CI) 27 - 41%), had never used it (19%; 95% CI 12 - 29%) or rarely used it (34%; 95% CI 25-45%). If CPGs are to assist with the translation of evidence into practice, they must be easily accessible and in a format that encourages use.

Barriers for the implementation of guidelines in palliative care-results from a national survey of professionals

BACKGROUND

In 2015, an evidence- and consensus-based palliative care guideline in adults with incurable cancer was published by the German Guideline Program. Barriers and enablers for the guideline implementation of members of the German Association for Palliative Medicine (DGP) were unknown. Therefore, the aims of this study were (1) to evaluate professionals' knowledge, motivation, and outcome expectancy towards already existing recommendations for palliative care and (2) to evaluate the self-experienced competence in five medical key topics presented in the new guideline.

METHODS

A web-based online survey with all DGP members in 2014 using a specifically designed questionnaire including 62 questions was used. Independent predictors for identified barriers were analysed using multivariable logistic regression analyses.

RESULTS

All 4786 members with known email address were invited, 1181 followed the link, 1138 began to answer, and 1031 completed the questionnaire. Fifty-four percent know already existing recommendations concerning palliative care, 8.4% know and use these recommendations; of the latter group, 44.2% do not notice any improvement of their treatment when applying them. Of key symptoms addressed in the guideline, depression was the symptom with lowest perceived competence (63.7 vs. > 90% for other symptoms). Non-physicians and those working in settings with little contact to seriously ill or dying patients feel less competent in almost all symptoms.

CONCLUSION

Emphasis on the high-quality and evidence- and consensus-based character of the guideline should be underlined in future implementation processes. Implementation strategies should focus on depression and non-physicians and those professionals working in settings with little contact to seriously ill patients.

Barriers and facilitators to the implementation of an evidence-based electronic minimum dataset for nursing team leader handover: A descriptive survey

INTRODUCTION

There is widespread use of clinical information systems in intensive care units however, the evidence to support electronic handover is limited.

OBJECTIVES

The study aim was to assess the barriers and facilitators to use of an electronic minimum dataset for nursing team leader shift-to-shift handover in the intensive care unit prior to its implementation.

METHODS

The study was conducted in a 21-bed medical/surgical intensive care unit, specialising in cardiothoracic surgery at a tertiary referral hospital, in Queensland, Australia. An established tool was modified to the intensive care nursing handover context and a survey of all 63 nursing team leaders was undertaken. Survey statements were rated using a 6-point Likert scale with selections from 'strongly disagree' to 'strongly agree', and open-ended questions. Descriptive statistics were used to summarise results.

RESULTS AND DISCUSSION

A total of 39 team leaders responded to the survey (62%). Team leaders used general intensive care work unit guidelines to inform practice however they were less familiar with the intensive care handover work unit guideline. Barriers to minimum dataset uptake included: a tool that was not user friendly, time consuming and contained too much information. Facilitators to minimum dataset adoption included: a tool that was user friendly, saved time and contained relevant information. Identifying the complexities of a healthcare setting prior to the implementation of an intervention assists researchers and clinicians to integrate new knowledge into healthcare settings.

CONCLUSION

Barriers and facilitators to knowledge use focused on usability, content and efficiency of the electronic minimum dataset and can be used to inform tailored strategies to optimise team leaders' adoption of a minimum dataset for handover.

Explaining transgression in respiratory rate observation methods in the emergency department: A classic grounded theory analysis

BACKGROUND

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often inaccurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs.

OBJECTIVE

To develop a substantive theory explaining ED registered nurses' reasoning when they miss or misreport respiratory rate observations.

DESIGN

This research project employed a classic grounded theory analysis of qualitative data.

PARTICIPANTS

Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed responses from individual interviews and open-ended responses from an online questionnaire.

METHODS

Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were employed to code data. This approach facilitated the identification of the main concern of the participants and aided in the generation of theory explaining how the participants processed this issue.

RESULTS

The main concern identified is that ED registered nurses do not believe that collecting an accurate respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational requirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The theory 'Rationalising Transgression', explains how participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing strategies that adjust the significance of the organisational requirement. These strategies include; Compensating, when nurses believe they are compensating for errant behaviour by enhancing the patient's outcome; Minimalizing, when nurses believe that the patient's outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy that sanctions negligent behaviour and occurs when nurses 'cut corners' to get the job done. Nurses' use these strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising transgression CONCLUSION: This research reveals that despite continuing education regarding gold standard guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses' understanding of acceptable practice methods. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes.

Critical attitudes and beliefs towards guidelines amongst palliative care professionals - results from a national survey

BACKGROUND

Little is known about palliative care professionals' attitudes towards guidelines. In 2015, the German Association for Palliative Medicine (DGP) published an evidence based guideline for palliative care in adults with incurable cancer. Before publication we conducted a national survey among members of the DGP to detect possible barriers and facilitators for its implementation. The aim of the present publication was to evaluate critical attitudes and beliefs which could hinder the effective implementation of the new guideline and to evaluate differences within professional groups and medical specialisations.

METHODS

This web-based online survey was addressed to all members of the DGP in summer 2014. Twenty-one questions concerning attitudes and beliefs towards guidelines were a priori developed to represent the following topics: scepticism regarding the quality of guidelines, doubts about the implementation of guidelines, restrictions in treatment options through guidelines, discrepancy between palliative care values and guidelines. Differences within professions and specialisations were tested using Kruskal-Wallis tests.

RESULTS

All 4.786 members with known email address were invited, 1.181 followed the link, 1.138 began to answer the questionnaire and 1.031 completed the questionnaire. More than half of participating members were physicians and one third nurses. Scepticism regarding the quality of existing guidelines was high (range 12.8-73.2%). Doubts regarding practical aspects of guidelines were less prevalent but still high (range 21.8-57.6%). About one third (range 5.4-31.4%) think that guidelines restrict their treatment options. In addition, 38.8% believed that guidelines are a kind of cookbook and restrict the flexibility of individual patient care. The majority saw no or little discrepancy between palliative care values and guidelines (range 68.4-82.6%). There were relatively small but significant differences between professions and specialisations.

CONCLUSION

The person-centred and individual approach of palliative care does not seem to contradict the acceptance of guidelines. Main barriers were related to scepticism regarding the quality of guidelines and the implementation of guidelines in general.

Development of evidence-based practice in occupational health services in Sweden: a 3-year follow-up of attitudes, barriers and facilitators

PURPOSE

The Swedish government initiated an investigation of how to secure and develop the competence of the occupational health services. The primary aim of the present study was to investigate whether the development of evidence-based practice (EBP) in the Swedish occupational health services in relation to attitudes, knowledge and use improved during the first 3 years of the government's initiative.

METHODS

The study has a mixed methods design combining questionnaires and interviews with data collection at baseline and at 3-year follow-up.

RESULTS

The response rate was 66% at baseline and 63% at follow-up. The results show that practitioners' knowledge of EBP was moderate at baseline and improved at follow-up (p = 0.002; 95% CI 0.01; 0.21). Practitioners experienced lower levels of organizational and managerial support for EBP at follow-up (p < 0.001; 95% CI 0.18; 0.38). The results revealed that managers viewed responsibility for implementing EBP as a matter for individual practitioners rather than as an organizational issue.

CONCLUSIONS

Occupational health service managers and practitioners are generally positive to EBP. However, the findings emphasize the need to educate managers in how to support EBP at the organizational level by creating an infrastructure for EBP in the OHS.

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

Adherence to the Women's Preventive Services Guidelines in the Affordable Care Act

OBJECTIVE

To assess the adherence of women's health providers in New Mexico to the Women's Preventive Services Guidelines and to examine how providers' knowledge, attitudes, and external barriers are associated with adherence.

DESIGN

Cross-sectional, descriptive survey.

SETTING

New Mexico.

PARTICIPANTS

Women's health providers in New Mexico, including nurse practitioners, certified nurse-midwives, and family practice and obstetrician-gynecologist physicians.

METHODS

Participants completed a self-administered survey to measure knowledge, attitudes, external barriers, and adherence to each of the eight guidelines. Adherence was defined as following a guideline more than 90% of the time.

RESULTS

The response rate was 22% (399/1,798). Among the eight guidelines, participant adherence ranged from 17.2% to 88.4%. Only 39.7% of participants indicated adherence to most of the guidelines (four or more). Overall, provider adherence was directly associated with familiarity with the guidelines (odds ratio = 3.69; 95% confidence interval [1.96, 6.96]), self-efficacy to implement them (odds ratio = 4.25; 95% confidence interval [2.21, 8.20]), and younger age (odds ratio = 0.97; 95% confidence interval [0.94, 1.00]).

CONCLUSION

Adherence to the Women's Preventive Services Guidelines by providers in New Mexico is variable and, for many recommended practices, less than optimal. New targeted implementation strategies are needed to address barriers to adherence.

Can theoretical intervention improve hand hygiene behavior among nurses?

Background

Hand washing is the best strategy to prevent known nosocomial infections but the nurses’ hand hygiene is estimated to be poor in Iran.

Objective

This study aimed to determine the effectiveness of BASNEF (Behavior, Attitude, Subjective Norms, and Enabling Factors) model on hand hygiene adherence education.

Methods

This controlled quasi-experimental study was conducted on 70 hemodialysis unit nurses (35 case and 35 control) in the health and educational centers of the University of Medical Sciences of Urmia, Iran. To collect the data, a six-part validated and reliable questionnaire was used. The data were analyzed using SPSS version18, using Wilcoxon, Mann–Whitney, chi-square, and Fisher’s exact tests. The significance level was considered P<0.05.

Results

The mean age was 38.4±8.1 years for the intervention group and 40.2±8.0 years for the control group. There was no significant difference between the two groups for any demographic variables. Also, before the intervention, there was no significant difference between the two groups for any components of the BASNEF model. Post-intervention, the attitude, subjective norms, enabling factors, and intention improved significantly in the intervention group (P<0.001), but hand hygiene behavior did not show any significant change in the intervention group (P=0.16).

Conclusion

Despite the improving attitudes and intention, the intervention had no significant effect on hand hygiene behavior among the studied nurses.

A Survey of Adherence to Guidelines to Prevent Healthcare-Associated Infections in Iranian Intensive Care Units

BACKGROUND

Healthcare-associated infections (HAIs) are acquired by patients while receiving care. The highest incidence of HAIs has been documented in admissions to intensive care units. Adherence to evidence-based practices is the most important step for preventing HAIs.

OBJECTIVES

To determine the rate of adherence to evidence-based post-insertion recommended care practices after admission into the intensive care unit for the following devices: central line catheter, indwelling urinary catheter, and mechanical ventilator.

PATIENTS AND METHODS

A structured observational cross-sectional research design was used. Data were collected using a checklist and a self-report questionnaire. The minimum sample size required for this study was 276 post-insertion care episodes, and 332 episodes were observed. The ANOVA test was used to identify any significant differences among the mean scores of the three devices.

RESULTS

Overall observed adherence rates were 18.3%, 59.1%, and 43.1% for central line catheters, indwelling urinary catheter, and mechanical ventilator, respectively. Of the observed episodes of device care, only in 9.4% of the episodes was regular oral care performed for patients on mechanical ventilators and only in 19.3% of the episodes were indwelling urinary catheters properly secure after insertion. More so, in none (0.0%) of the episodes was the central line catheter hub disinfected before being accessed.

CONCLUSIONS

Evidence-based post-insertion recommended care practices were not consistently and uniformly implemented in the intensive care units. Establishment of a program for the surveillance of adherence to recommended guidelines is required for improving compliance by health professionals and the quality of preventive care.

Barriers and facilitators of nurses' use of clinical practice guidelines: An integrative review

BACKGROUND

Preventable harm continues to be one of the leading causes of patient death. Each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism. However, as shown in the recent reduction in hospital acquired infections, the number of deaths could be reduced if healthcare providers used evidence-based therapies, which are often included in clinical practice guidelines (CPGs).

PURPOSE

The purpose of this integrative review is to appraise and synthesize the current literature on barriers to and facilitators in the use of clinical practice guidelines (CPGs) by registered nurses.

DESIGN

Whittemore and Knafl integrative review methodology was used. Primary quantitative and qualitative studies about the nurses' use of CPGs and published in peer-reviewed journals between January 2000 and August 2015 were included.

METHODS

The Critical Skills Appraisal Program (CASP) was used to critically appraise the quality of sixteen selected quantitative and qualitative studies.

RESULTS

Internal factors were attitudes, perceptions, and knowledge whereas format and usability of CPGs, resources, leadership, and organizational culture were external factors influencing CPG use.

CONCLUSION

Given each barrier and facilitator, interventions and policies can be designed to increase nurses' use of CPGs to deliver more evidence based therapy. In order to improve the use of CPGs and to ensure high quality care for all patients, nurses must actively participate in development, implementation, and maintenance of CPGs.

The Many Organisational Factors Relevant to Planning Change in Emergency Care Departments: A Qualitative Study to Inform a Cluster Randomised Controlled Trial Aiming to Improve the Management of Patients with Mild Traumatic Brain Injuries

BACKGROUND

The Neurotrauma Evidence Translation (NET) Trial aims to design and evaluate the effectiveness of a targeted theory-and evidence-informed intervention to increase the uptake of evidence-based recommended practices for the management of patients who present to an emergency department (ED) with mild head injuries. When designing interventions to bring about change in organisational settings such as the ED, it is important to understand the impact of the context to ensure successful implementation of practice change. Few studies explicitly use organisational theory to study which factors are likely to be most important to address when planning change processes in the ED. Yet, this setting may have a unique set of organisational pressures that need to be taken into account when implementing new clinical practices. This paper aims to provide an in depth analysis of the organisational context in which ED management of mild head injuries and implementation of new practices occurs, drawing upon organisational level theory.

METHODS

Semi-structured interviews were conducted with ED staff in Australia. The interviews explored the organisational context in relation to change and organisational factors influencing the management of patients presenting with mild head injuries. Two researchers coded the interview transcripts using thematic content analysis. The "model of diffusion in service organisations" was used to guide analyses and organisation of the results.

RESULTS

Nine directors, 20 doctors and 13 nurses of 13 hospitals were interviewed. With regard to characteristics of the innovation (i.e. the recommended practices) the most important factor was whether they were perceived as being in line with values and needs. Tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) was relatively low for managing acute mild head injury symptoms, and mixed for managing longer-term symptoms (higher change commitment, but relatively low change efficacy). Regarding implementation processes, the importance of (visible) senior leadership for all professions involved was identified as a critical factor. An unpredictable and hectic environment brings challenges in creating an environment in which team-based and organisational learning can thrive (system antecedents for innovation). In addition, the position of the ED as the entry-point of the hospital points to the relevance of securing buy-in from other units.

CONCLUSIONS

We identified several organisational factors relevant to realising change in ED management of patients who present with mild head injuries. These factors will inform the intervention design and process evaluation in a trial evaluating the effectiveness of our implementation intervention.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering

BACKGROUND

Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging.

METHODS

An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention.

RESULTS

There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05).

CONCLUSIONS

Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.

Influence of Institutional Guidelines on Oral Hygiene Practices in Intensive Care Units

BACKGROUND

Maintaining oral hygiene is a key component of preventing ventilator-associated pneumonia; however, practices are inconsistent.

OBJECTIVES

To explore how characteristics of institutional guidelines for oral hygiene influence nurses' oral hygiene practices and perceptions of that practice.

METHODS

Oral hygiene section of a larger survey study on prevention of ventilator-associated pneumonia. Critical care nurses at 8 hospitals in Northern California that had more than 1000 ventilator days in 2009 were recruited to participate in the survey. Twenty-one questions addressed oral hygiene practices and practice perceptions. Descriptive statistics, analysis of variance, and Spearman correlations were used for analyses.

RESULTS

A total of 576 critical care nurses (45% response rate) responded to the survey. Three types of institutional oral hygiene guidelines existed: nursing policy, order set, and information bulletin. Nursing policy provided the most detail about the oral hygiene care; however, adherence, awareness, and priority level were higher with order sets (P < .05). The content and method of disseminating these guidelines varied, and nursing practices were affected by these differences. Nurses assessed the oral cavity and used oral swabs more often when those practices were included in institutional guidelines.

CONCLUSIONS

The content and dissemination method of institutional guidelines on oral hygiene do influence the oral hygiene practices of critical care nurses. Future studies examining how institutional guidelines could best be incorporated into routine workflow are needed.

Knowledge, attitudes, beliefs and behaviour intentions for three bowel management practices in intensive care: effects of a targeted protocol implementation for nursing and medical staff

BACKGROUND

Bowel management protocols have the potential to minimize complications for critically ill patients. Targeted implementation can increase the uptake of protocols by clinicians into practice. The theory of planned behaviour offers a framework in which to investigate clinicians' intention to perform the behaviour of interest. This study aimed to evaluate the effect of implementing a bowel management protocol on intensive care nursing and medical staffs' knowledge, attitude, subjective norms, perceived behavioural control, behaviour intentions, role perceptions and past behaviours in relation to three bowel management practices.

METHODS

A descriptive before and after survey using a self-administered questionnaire sent to nursing and medical staff working within three intensive care units before and after implementation of our bowel management protocol (pre: May - June 2008; post: Feb - May 2009).

RESULTS

Participants had significantly higher knowledge scores post-implementation of our protocol (pre mean score 17.6; post mean score 19.3; p = 0.004). Post-implementation there was a significant increase in: self-reported past behaviour (pre mean score 5.38; post mean score 7.11; p = 0.002) and subjective norms scores (pre mean score 3.62; post mean score 4.18; p = 0.016) for bowel assessment; and behaviour intention (pre mean score 5.22; post mean score 5.65; p = 0.048) for administration of enema.

CONCLUSION

This evaluation, informed by the theory of planned behaviour, has provided useful insights into factors that influence clinician intentions to perform evidence-based bowel management practices in intensive care. Addressing factors such as knowledge, attitudes and beliefs can assist in targeting implementation strategies to positively affect clinician behaviour change. Despite an increase in clinicians' knowledge scores, our implementation strategy did not, however, significantly change clinician behaviour intentions for all three bowel management practices. Further research is required to explore the influence of opinion leaders and organizational culture on clinicians' behaviour intentions related to bowel management for intensive care patients.

'How do we know if this is the best?' Mental health-care professionals' views on national guidelines for psychosocial interventions

National guidelines are released regularly, and professionals are expected to adopt and implement them. However, studies dealing with mental health-care professionals' views about guidelines are sparse. The aim of the present study was to highlight mental health-care staff's views on the Swedish national guidelines for 'psychosocial interventions for schizophrenia or schizophrenia-type symptoms' and their implementation. The study took place in the southeast parts of Sweden, and data were collected through five group interviews consisting of 16 professionals working either in the county council or in the municipalities. The transcribed text was analysed by content analysis, revealing two categories. The first category 'a challenge to the practice of care as known' reflected that the release of guidelines could be perceived as a challenge to prevailing care and culture. The second category 'anticipating change to come from above' mirrored views on how staff expected the implementation process to flow from top to bottom. To facilitate working in accordance with guidelines, we suggest that future guidelines should be accompanied by an implementation plan, where the educational needs of frontline staff are taken into account. There is also a need for policy makers and managers to assume responsibility in supporting the implementation of evidence-based practice.

Physicians' attitudes toward guidelines for stroke: a survey of korean neurologists

Background and Purpose

Clinical practice guidelines (CPGs) are regarded as an essential guidance tool for practicing physicians. We surveyed physicians in Korea in order to evaluate their attitudes toward the Korean CPGs for stroke.

Methods

We obtained participation agreement for our survey from 27 centers of the 33 most actively contributing to the Korean Stroke Registry. A total of 174 neurologists participated in a questionnaire interview regarding their attitudes toward CPGs for stroke.

Results

Of 174 participating neurologists, 65 (37.4%) were stroke neurologists. The average age was 33.6±7.1 and 49 (28.2%) were female. Most of the respondents held positive attitudes and opinions regarding the use of the guidelines, whereas only a small percentage (14.9%) responded negatively. More than 60% of the physicians in the survey reported adherence to the Korean CPGs in dyslipidemia management for the secondary prevention of stroke.

Conclusions

The positive attitudes and opinions toward the guidelines imply that physicians' attitudes should not be regarded as a potential barrier to the implementation of Korean CPGs for stroke practiced by general physicians.

Evaluation of the implementation of a bowel management protocol in intensive care: effect on clinician practices and patient outcomes

AIMS AND OBJECTIVES

To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices.

BACKGROUND

Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour.

DESIGN

Before and after study.

METHODS

Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101; postimplementation, n = 107).

RESULTS

No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48; post, 60%, n = 64).

CONCLUSION

Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour.

RELEVANCE TO CLINICAL PRACTICE

This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.

How occupational health care professionals experience evidence-based guidelines in Finland: a qualitative study

AIMS AND OBJECTIVES

Evidence-based guidelines are currently the most relevant source of information in practice. The adherence to and use of guidelines is often influenced by attitudes towards the guidelines themselves, which have not been sufficiently explored in occupational health. This study examines the attitude of Finnish occupational nurses' and doctors' attitudes towards evidence-based guidelines.

METHODS

Ten occupational doctors and eight occupational nurses were interviewed in Southern Finland on their attitudes towards evidence-based guidelines in 2009.

RESULTS

The nurses were not very familiar with the concept of evidence-based medicine. Rather, they used recommendations developed in their workplace or by their employer. The evidence base of these recommendations was not clear. The doctors considered the evidence-based guidelines reliable and practical, but did not always act according to them. Participants felt that they did not have time to check guidelines during their working hours. Participants wished for clearer, shorter guidelines on occupational health care topics, which would help in their practical daily work and clarify roles in teamwork.

CONCLUSIONS

Based on these positive attitudes, the use of guidelines may be more common than it seems. The viewpoints of all occupational health professional groups should be taken into account in guideline development, particularly on the availability and usability of the guidelines.

Mapping attitudes and awareness with regard to national guidelines: an e-mail survey among decision makers

INTRODUCTION

The adoption of evidence-based guidelines within the mental health field has been slow. Changing inadequate practice is therefore a formidable challenge for mental health-care managers.

AIM

To explore decision-makers' attitudes and awareness regarding the national guidelines for psychosocial interventions targeting people with schizophrenia.

METHOD

A questionnaire distributed by e-mail to 592 Swedish decision-makers was analysed using descriptive and comparative techniques.

RESULTS

Significantly more of the top-level mental health-care managers than politicians stated that they knew about the national guidelines (i.e. their release and content) and they considered the guidelines to be a good source of support for planning and allocating resources.

CONCLUSION

If those responsible for allocating resources (i.e. politicians) are unaware of the dissemination of national guidelines or their content, and they do not perceive the national guidelines to be a good source of support for planning and allocating resources, this is likely to have a negative influence on the remit of nurse managers as well as nursing practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Top-level mental health-care managers have a vital role to play in the implementation of national guidelines. However, our findings indicate that implementing national guidelines in practice could be virtually impossible without strategic government support.

Care providers' experiences of guidelines in daily work at a municipal residential care facility for older people

AIM

To describe care providers' narrated experiences of guidelines in daily work at a municipal residential care facility for older people.

BACKGROUND

Guidelines are used as a way of promoting high-quality health care. Most research concerning guidelines has focused on physician behaviour and to improve one specific aspect of care. Care providers working within municipal residential care of older people have described that working with multiple guidelines sometimes exposed them to contradictory demands and trouble their conscience.

DESIGN

A qualitative descriptive design was adopted.

METHODS

Interviews with eight care providers were carried out between February and March 2012 and analysed by qualitative content analysis.

RESULTS

Care providers described experiences that guidelines are coming from above and are controlling and not sufficiently anchored at their workplace. Furthermore, they described guidelines as stealing time from residents, colliding with each other, lacking practical use and complicating care, and challenging care providers' judgment. The overall understanding is that care providers describe experiences of struggling to do their best, prioritising between arcane guidelines while keeping the residents' needs in the foreground.

CONCLUSION

In order to prevent fragmented use, guidelines have to be coordinated and adapted to the reality of daily practice before implementation. It seems essential to provide opportunities for discussions between care providers, registered nurses and management about how to make guidelines work within their daily practice. Sufficient support, knowledge and involvement are likely key issues that can help care providers to constructively work according to guidelines and thus, by extension, improve the quality of care.

Monitoring hand hygiene: meaningless, harmful, or helpful?

Whereas monitoring adherence to hand hygiene (HH) guidelines is standard practice in most acute care facilities, practice improvement has been slow. In hospitals primarily concerned with reputation, incentives to report high HH rates may create negative consequences. Practice change will require increased staff engagement and more sustainable methods to monitor HH and provide feedback.

Attitude and practice of the health care professionals towards the clinical practice guidelines in King Khalid University Hospital in Saudi Arabia

RATIONALE, AIMS AND OBJECTIVES

To explore the opinion and practice of the health care providers in King Khalid University Hospital (KKUH) towards clinical practice guidelines (CPGs).

METHODS

A cross-sectional self-reported anonymous survey was distributed to 2225 health care professionals working in KKUH clinical departments.

RESULTS

The response rate was 56.5%. The respondents had a positive attitude towards CPGs; 90% thought that CPG unify patients' care and 96% agreed that CPGs improve the quality of services provided. The respondents' practice in using CPGs concurred with their attitude and opinion. A total of 86.3% agreed that CPGs changed the way they manage their patients and 71.8% agreed with the statement that they have already used CPGs in the management of the patients. Compared to nurses, physicians were significantly less likely to use CPGs in practice (P < 0.05); moreover, the practice of using guidelines differs significantly according to the years of experience, with 71% of respondents with experience of 15 years or more using CPGs in the management of their patients, compared to 60% among respondents with less years of experience (P < 0.05).

CONCLUSION

The health care providers at KKUH have positive practice and attitude towards CPGs in general, which could positively influence the future introduction and implementation of evidence-based CPGs.

An investigation of nurses' knowledge, attitudes, and practices regarding disinfection procedures in Italy

BACKGROUND

This study assessed the level of knowledge, attitudes, and practice regarding disinfection procedures among nurses in Italian hospitals.

METHODS

A face-to-face interview gathered the following information: demographic and practice characteristics; knowledge about the healthcare-associated infections (HAIs) and the disinfection practices; attitudes towards the utility of guidelines/protocols and perception of the risks of acquiring/transmitting HAIs; compliance with antisepsis/disinfection procedures; and sources of information.

RESULTS

Only 29% acknowledged that urinary and respiratory tract infections were the two most common HAIs and this knowledge was significantly higher in those with a higher level of education. Attitudes towards the utility of guidelines/protocols for disinfection procedures showed a mean score of 9.1. The results of the linear regression model indicated a more positive attitude in female nurses, in those with a lower number of years of activity, and in those needing additional information about disinfection procedures. Nurses with higher educational level and with a higher perception of risk of transmitting an infectious disease while working were more likely to perform appropriate antisepsis of the surgical wound and handwashing before and after medication.

CONCLUSIONS

Plan of successful prevention activities about HAIs and provide pointers to help optimize disinfection procedures and infection prophylaxis and management are needed.

An integrated knowledge translation experience: use of the Network of Pediatric Audiologists of Canada to facilitate the development of the University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP v1.0)

Pediatric audiologists lack evidence-based, age-appropriate outcome evaluation tools with well-developed normative data that could be used to evaluate the auditory development and performance of children aged birth to 6 years with permanent childhood hearing impairment. Bagatto and colleagues recommend a battery of outcome tools that may be used with this population. This article provides results of an evaluation of the individual components of the University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP) version 1.0 by the audiologists associated with the Network of Pediatric Audiologists of Canada. It also provides information regarding barriers and facilitators to implementing outcome measures in clinical practice. Results indicate that when compared to the Parents' Evaluation of Aural/Oral Performance of Children (PEACH) Diary, audiologists found the PEACH Rating Scale to be a more clinically feasible evaluation tool to implement in practice from a time, task, and consistency of use perspective. Results also indicate that the LittlEARS(®) Auditory Questionnaire could be used to evaluate the auditory development and performance of children aged birth to 6 years with permanent childhood hearing impairment (PCHI). The most cited barrier to implementation is time. The result of this social collaboration was the creation of a knowledge product, the UWO PedAMP v1.0, which has the potential to be useful to audiologists and the children and families they serve.

Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey

BACKGROUND

Clinical practice guidelines (CPGs) have become a very popular tool for decision making in healthcare. While there is some evidence that CPGs improve outcomes, there are numerous factors that influence their acceptability and use by healthcare providers. While evidence of clinicians' knowledge, perceptions and attitudes toward CPGs is extensive, results are still disperse and not conclusive. Our study will evaluate these issues in a large and representative sample of clinicians in Spain.

METHODS/DESIGN

A mixed-method design combining qualitative and quantitative research techniques will evaluate general practitioners (GPs) and hospital-based specialists in Spain with the objective of exploring attitudes and perceptions about CPGs and evidence grading systems. The project will consist of two phases: during the first phase, group discussions will be carried out to gain insight into perceptions and attitudes of the participants, and during the second phase, this information will be completed by means of a survey, reaching a greater number of clinicians. We will explore these issues in GPs and hospital-based practitioners, with or without previous experience in guideline development.

DISCUSSION

Our study will identify and gain insight into the perceived problems and barriers of Spanish practitioners in relation to guideline knowledge and use. The study will also explore beliefs and attitudes of clinicians towards CPGs and evidence grading systems used to rate the quality of the evidence and the strength of recommendations. Our results will provide guidance to healthcare researchers and healthcare decision makers to improve the use of guidelines in Spain and elsewhere.

Diurnal variation in hand hygiene compliance in a tertiary level multidisciplinary intensive care unit

BACKGROUND

Hand hygiene compliance among health care providers is considered to be the single most effective factor to reduce hospital acquired infections. Despite continuous education and awareness, compliance with hand hygiene guidelines has remained low, particularly during evening shifts.

OBJECTIVE

Our objective was to determine the compliance with hand hygiene guidelines among doctors, nurses, and paramedical staff during day and night duties in a multidisciplinary intensive care unit (ICU).

METHODS

We used a prospective, observational, 6-month study conducted in a 34-bed ICU within a tertiary care teaching hospital. All doctors, nurses, and paramedical staff in the ICU were included. An investigator, placed within the ICU setting, observed the hand hygiene practices during day and night. Day and night shift change times were 08:00 and 20:00 hours, respectively.

RESULTS

Of the 5639 opportunities for hand hygiene, 3383 (59.9%) were properly performed. Overall rates of compliance were 66.1% for doctors, 60.7% for nurses, and 38.6% for paramedical staff. Hand hygiene compliance dropped during the night for doctors (81% vs 46%, respectively, P < .001), for nurses (64% vs 55%, respectively, P = .02), and for paramedical staff (44% vs 31%, respectively, P = .01). Characterization of noncompliance is as follows: "No handwashing after procedure" in 41%, "improper duration of handwashing" in 32%, and "no handwashing done at all" in 27% of the events. "No handwashing done at all" occurred in 55% of the time at night with doctors having the highest rate of noncompliance, making 163 (34%) contacts without handwashing.

CONCLUSION

Whereas compliance with hand hygiene guidelines was lower at night compared with day, irrespective of discipline in all 3 groups of health care providers, both periods of compliance would benefit from additional training focusing on the importance of hand hygiene around the clock.

Nurses' experiences of guideline implementation: a focus group study

AIMS

The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines?

BACKGROUND

The implementation of clinical guidelines seems to be dependent on multiple context-specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation.

DESIGN

Qualitative interview.

METHODS

Data were generated by four focus group interviews involving nurses working in out-patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data.

RESULTS

Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses' awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation.

CONCLUSIONS

Clinical guidelines can be promising tools in enhancing evidence-based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices.

RELEVANCE TO CLINICAL PRACTICE

Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.

Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey

BACKGROUND

Although use of sedation protocols and daily sedation interruption (DSI) improve outcome, their current use and barriers affecting their use are unclear.

METHODS

We designed a multidisciplinary, Web-based survey to determine current use of sedation protocols and DSI and the perceived barriers to each, and administered it to members of the Society of Critical Care Medicine.

RESULTS

The 904 responders were physicians (60%), nurses (14%), or pharmacists (12%); 45% worked in a university hospital. Of 64% having a sedation protocol, 78% used it for >or=50% of ventilated patients. Reasons for lack of protocol use included no physician order (35%), lack of nursing support (11%), and a fear of oversedation (7%). Daily sedation interruption was used by only 40%. Barriers to DSI included lack of nursing acceptance (22%), concern about risk of patient-initiated device removal (19%), and inducement of either respiratory compromise (26%) or patient discomfort (13%). Clinicians who prefer propofol were more likely to use DSI than those who prefer benzodiazepines (55% vs 40, P < .0001).

CONCLUSIONS

Current intensive care unit sedation practices are heterogeneous, and the barriers preventing the use of both sedation protocols and DSI are numerous. These barriers should be addressed on an institutional basis to boost the use of these evidence-based practices.

Assessment of attitudes of intensive care unit staff toward clinical practice guidelines

Although studies on the implementation and adherence to specific practice guidelines have been proliferating, research examining the attitude of healthcare workers toward practice guidelines in general has been lacking. This study is a secondary analysis of data collected from 39 volunteer hospitals participating in the National Nosocomial Infection Surveillance System on attitudes of intensive care unit staff regarding practice guidelines in general. Age, profession, type of intensive care unit, and race were identified as significant predictors of attitude scores in this study. Understanding the differences in perceived barriers is important for the adherence to practice guidelines.