The nursing work of hospital-based clinical practice guideline implementation: an explanatory systematic review using Normalisation Process Theory

The potential of narrative-based medicine interventions targeting hospital practitioner burnout: findings from a scoping review

PURPOSE

To map the empirical literature with regards to narrative-based medicine interventions targeting burnout in hospital-based practitioners.

METHODS

A systematic search of electronic databases (n = 6) and manual searches was conducted informed by the Joanna Briggs Institute scoping review guidelines. Papers were independently screened for quality. Semi-structured interviews were held with practitioners to further explore the acceptability and feasibility of the interventions from the review.

RESULTS

The searches yielded 4,439 articles. Following screening by title and abstract, 73 papers remained for full-text review. Six papers were included in the final analysis. Gaps were noted in relation to reporting of intervention details, and of implementation considerations across the dataset. Narrative interventions were considered acceptable by stakeholders but significant issues of compatibility and feasibility were identified.

CONCLUSIONS

Narrative-based interventions are complex and warrant a systematic research approach. Addressing factors related to implementation in addition to mechanisms of action is essential to progress this promising interdisciplinary knowledge base.

A seesaw of equilibrium, midwives' experiences of infection prevention and control guideline adherence: A qualitative descriptive study

Background

Infection prevention and control guidelines play a key role in preventing infections which can impact mothers and their newborn's quality of life. Despite the presence of evidenced-based infection prevention and control guidelines, midwives' adherence can be suboptimal internationally. The identification of facilitators and barriers to infection prevention and control guidelines can support practice and facilitate midwifery care.

Aim

To understand midwives' experiences of the barriers and facilitators when adhering to infection prevention and control guidelines.

Methods

A qualitative descriptive study using semi-structured interviews with 10 midwives from February to March 2022. The interviews were audio recorded, transcribed verbatim, and analysed utilising Braun and Clarke's thematic analysis framework involving the six steps of becoming familiar with the data, generating initial codes, generating themes, reviewing themes, defining and naming the themes, and presenting themes.

Findings

Two themes developed; seesaw for equilibrium and back to basics: learning on your feet. Midwives experienced conflicting emotional motivators in the need for professional integrity towards infection prevention and control guideline adherence. The work environment impacts on midwives' ability to adhere to guidelines and communication and education have a vital role to play in infection prevention and control guideline adherence.

Conclusions

While midwives have a strong sense of protection of professional integrity, work conditions such as environment, organisational structures, and management systems affect midwives' adherence to infection prevention and control guidelines. Effective education, training, and communication are required to promote infection prevention and control guideline adherence.

Using PURPOSE-T in clinical practice: A realist evaluation

AIM

To explain how the clinical and organisational context influenced the way the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE-T) is used by nursing staff to support their clinical judgement and decision making about care planning and delivery.

METHODS

A realist process evaluation was undertaken in a large acute hospital trust using mixed methods incorporating organisational policy review, staff semi-structured, ethnographic observation of clinical care and patient record review. Approximately 75 h of ethnographic field work involving 72 patients, 15 patient record reviews and 16 staff interviews were undertaken on 4 wards.

FINDINGS

Findings suggest PURPOSE-T assisted nurses differently depending on their level of experience. Those with less experience use it as an educational guide, while those with more experience made an initial clinical judgement and used PURPOSE-T as a safety net to ensure they hadn't missed anything. Nurses were concerned about demonstrating good documentation of assessment, care planning and delivery in order to underpin consistent communication about care and because they had an underlying fear of being blamed if things went wrong. There is an array of other contextual features that impact the planning and delivery of pressure area care that go beyond the use of PURPOSE-T alone, including systematic equipment provision, competing patient safety initiatives and rehabilitation requirements.

CONCLUSION

The findings reinforce the assertion that PU-RAIs are complex interventions and could inform the development of a more integrated system of care which takes into account the contextual features associated with PU prevention in modern hospitals.

The effect of pressure injury prevention care bundles on pressure injuries in hospital patients: A complex intervention systematic review and meta-analysis

BACKGROUND

Numerous interventions for pressure injury prevention have been developed, including care bundles.

OBJECTIVE

To systematically review the effectiveness of pressure injury prevention care bundles on pressure injury prevalence, incidence, and hospital-acquired pressure injury rate in hospitalised patients.

DATA SOURCES

The Medical Literature Analysis and Retrieval System Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus, the Cochrane Library and two registries were searched (from 2009 to September 2023).

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials and non-randomised studies with a comparison group published in English after 2008 were included. Studies reporting on the frequency of pressure injuries where the number of patients was not the numerator or denominator, or where the denominator was not reported, and single subgroups of hospitalised patients were excluded. Educational programmes targeting healthcare professionals and bundles targeting specific types of pressure injuries were excluded.

PARTICIPANTS AND INTERVENTIONS

Bundles with ≥3 components directed towards patients and implemented in ≥2 hospital services were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Screening, data extraction and risk of bias assessments were undertaken independently by two researchers. Random effects meta-analyses were conducted. The certainty of the body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Nine studies (seven non-randomised with historical controls; two randomised) conducted in eight countries were included. There were four to eight bundle components; most were core, and only a few were discretionary. Various strategies were used prior to (six studies), during (five studies) and after (two studies) implementation to embed the bundles. The pooled risk ratio for pressure injury prevalence (five non-randomised studies) was 0.55 (95 % confidence intervals 0.29-1.03), and for hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31 (95 % confidence intervals 0.12-0.83). All non-randomised studies were at high risk of bias, with very low certainty of evidence. In the two randomised studies, the care bundles had non-significant effects on hospital-acquired pressure injury incidence density, but data could not be pooled.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Whilst some studies showed decreases in pressure injuries, this evidence was very low certainty. The potential benefits of adding emerging evidence-based components to bundles should be considered. Future effectiveness studies should include contemporaneous controls and the development of a comprehensive, theory and evidence-informed implementation plan.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42023423058.

TWEETABLE ABSTRACT

Pressure injury prevention care bundles decrease hospital-acquired pressure injuries, but the certainty of this evidence is very low.

Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals

Purpose

Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients.

Participants and Methods

This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients.

Results

The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes.

Conclusion

The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.

Enhancing skin health and safety in aged care (SKINCARE trial): A cluster-randomised pragmatic trial

BACKGROUND

Older nursing home residents are prone to develop different skin conditions at the same time, including xerosis cutis, skin tears, pressure ulcers, incontinence-associated dermatitis or intertrigo. Guidelines and recommendations mainly address these skin conditions separately. The overall aim of this study was to measure the effects of the implementation of a skincare and prevention package.

TRIAL DESIGN

A two-arm cluster-randomised controlled trial was conducted.

METHODS

In nursing homes being assigned to the intervention group, an evidence-based and structured skincare and prevention programme was implemented for six months. Nursing home residents in the control group received standard care as usual. Blinded dermatologists conducted head-to-toe skin assessments, and the researchers assessed skin barrier parameters including stratum corneum hydration and transepidermal water loss at the upper and lower extremities after three and six months. Outcomes included the cumulative incidence of incontinence-associated dermatitis, skin tears, pressure ulcers and intertrigo, and were presented as intention-to-treat and per protocol analysis. Skin dryness and resident-reported outcomes (pain, itch, quality of life) were assessed.

RESULTS

A random sample of 17 nursing homes in the federal state of Berlin, Germany, was drawn and randomised in intervention (n = 9) and control groups (n = 8). In total, 165 participants were allocated to the intervention, and 149 participants were allocated to the control group. The cumulative incidence of skin tears (19.2 %, 95 % CI 12.8-27.8), pressure ulcers (13.6 %, 95 % CI 8.1-21.9) and intertrigo (27.0 %, 95 % CI 18.4-37.7) was lower in the intervention compared to the control group, with cumulative incidences of 27.2 % (95 % CI 19.3-36.9) for skin tears, 16.9 % (95 % CI 10.6-25.9) for pressure ulcer, and 37.8 % (95 % CI 27.5-49.4) for intertrigo. The incidence of incontinence-associated dermatitis was higher in the intervention group (26.3 %, 95 % CI 17.9-36.8) compared to the control group (23.1 %; 95 % CI 14.6-34.5). Mean skin dryness was lower in the intervention group but showed variation. The impact on pain, itch, and quality of life was trivial.

CONCLUSIONS

The present study results indicate that the implementation of tailored and evidence-based nursing routines improves skin health and safety in residential long-term care. Evidence suggests that multiple adverse skin conditions can be prevented by regular skin assessments and individually tailored skincare routines. Positive effects on skin dryness were observed, but skin physiology parameters did not indicate changes of the skin barrier function.

TRIAL REGISTRATION

This study is registered at the German Clinical Trials Register (registration number: DRKS00015680; date of registration: January 29th, 2019) and ClinicalTrials.gov (NCT03824886; date of registration: January 31st, 2019).

Predicting Postoperative Hospital Stays Using Nursing Narratives and the Reverse Time Attention (RETAIN) Model: Retrospective Cohort Study

Background

Nursing narratives are an intriguing feature in the prediction of short-term clinical outcomes. However, it is unclear which nursing narratives significantly impact the prediction of postoperative length of stay (LOS) in deep learning models.

Objective

Therefore, we applied the Reverse Time Attention (RETAIN) model to predict LOS, entering nursing narratives as the main input.

Methods

A total of 354 patients who underwent ovarian cancer surgery at the Seoul National University Bundang Hospital from 2014 to 2020 were retrospectively enrolled. Nursing narratives collected within 3 postoperative days were used to predict prolonged LOS (≥10 days). The physician's assessment was conducted based on a retrospective review of the physician's note within the same period of the data model used.

Results

The model performed better than the physician's assessment (area under the receiver operating curve of 0.81 vs 0.58; P=.02). Nursing narratives entered on the first day were the most influential predictors in prolonged LOS. The likelihood of prolonged LOS increased if the physician had to check the patient often and if the patient received intravenous fluids or intravenous patient-controlled analgesia late.

Conclusions

The use of the RETAIN model on nursing narratives predicted postoperative LOS effectively for patients who underwent ovarian cancer surgery. These findings suggest that accurate and interpretable deep learning information obtained shortly after surgery may accurately predict prolonged LOS.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

Indicators to measure implementation and sustainability of nursing best practice guidelines: A mixed methods analysis

Background

The use of best practice guidelines (BPGs) has the potential to decrease the gap between best evidence and nursing and healthcare practices. We conducted an exploratory mixed method study to identify strategies, processes, and indicators relevant to the implementation and sustainability of two Registered Nurses' Association of Ontario (RNAO) BPGs at Best Practice Spotlight Organizations® (BPSOs).

Methods

Our study had four phases. In Phase 1, we triangulated two qualitative studies: a) secondary analysis of 126 narrative reports detailing implementation progress from 21 BPSOs spanning four sectors to identify strategies and processes used to support the implementation and sustainability of BPGs and b) interviews with 25 guideline implementers to identify additional strategies and processes. In Phase 2, we evaluated correlations between strategies and processes identified from the narrative reports and one process and one outcome indicator for each of the guideline. In Phase 3, the results from Phases 1 and 2 informed indicator development, led by an expert panel. In Phase 4, the indicators were assessed internally by RNAO staff and externally by Ontario Health Teams. A survey was used to validate proposed indicators to determine relevance, feasibility, readability, and usability with knowledge users and BPSO leaders.

Results

Triangulation of the two qualitative studies revealed 46 codes of implementation and sustainability of BPGs, classified into eight overarching themes: Stakeholder Engagement, Practice Interventions, Capacity Building, Evidence-Based Culture, Leadership, Evaluation & Monitoring, Communication, and Governance. A total of 28 structure, process, or outcome indicators were developed. End users and BPSO leaders were agreeable with the indicators according to the validation survey.

Conclusions

Many processes and strategies can influence the implementation and sustainability of BPGs at BPSOs. We have developed indicators that can help BPSOs promote evidence-informed practice implementation of BPGs.

The integration of technology into a home-based visuo-cognitive training intervention for people with Parkinson's: Is the future digital?

BACKGROUND

Mobile applications and technology (e.g., stroboscopic glasses) are increasingly being used to deliver combined visual and cognitive (termed visuo-cognitive) training that replaces standard pen and paper-based interventions. These 'technological visuo-cognitive training' (TVT) interventions could help address the complex problems associated with visuo-cognitive dysfunction in people with long term neurological conditions such as Parkinson's disease. As data emerges to support the effectiveness of these technologies, patient perspectives offer an insight into how novel TVT is received by people living with long term neurological conditions.

OBJECTIVE

To explore experiences of people with Parkinson's in using technology as part of a home-based visuo-cognitive training programme compared to traditional approaches to rehabilitation.

METHODS

Eight people with Parkinson's who took part in a pilot randomised cross-over trial, investigating the efficacy and feasibility of TVT compared to standard care, were interviewed to explore their experiences of each arm of the training they received. Integration of Normalisation Process Theory (NPT) into the analysis enabled examination of the potential to embed novel TVT into a home-based rehabilitation intervention for people with Parkinson's disease.

RESULTS

Three key themes emerged from the thematic analysis as factors influencing the implementation potential of TVT for people with Parkinson's disease: perceived value of technology, perceived ease of use and support mechanisms. Further examination of the data through the lens of NPT revealed that the implantation and embedding of novel technology was dependent on positive user experience, individual disease manifestation and engagement with a professional.

CONCLUSIONS

Our findings provide insights into the challenges of engaging with technology-based interventions while living with a progressive and fluctuating disease. When implementing technology-based interventions for people with Parkinson's, we recommend that patients and clinicians collaborate to determine whether the technology fits the capacity, preference, and treatment needs of the individual patient.

The SITS framework: sustaining innovations in tertiary settings

Background

To date, little attention has focused on what the determinants are and how evidence-based practices (EBPs) are sustained in tertiary settings (i.e., acute care hospitals). Current literature reveals several frameworks designed for implementation of EBPs (0-2 years), yet fewer exist for the sustainment of EBPs (>2 years) in clinical practice. Frameworks containing both phases generally list few determinants for the sustained use phase, but rather state ongoing monitoring or evaluation is necessary. Notably, a recent review identified six constructs and related strategies that facilitate sustainment, however, the pairing of determinants and how best to sustain EBPs in tertiary settings over time remains unclear. The aim of this paper is to present an evidence-informed framework, which incorporates constructs, determinants, and knowledge translation interventions (KTIs) to guide implementation practitioners and researchers in the ongoing use of EBPs over time.

Methods

We combined the results of a systematic review and theory analysis of known sustainability frameworks/models/theories (F/M/Ts) with those from a case study using mixed methods that examined the ongoing use of an organization-wide pain EBP in a tertiary care center (hospital) in Canada. Data sources included peer-reviewed sustainability frameworks (n = 8) related to acute care, semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level, chart audits (n = 200), and document review (n = 29). We then compared unique framework components to the evolving literature and present main observations.

Results

We present the Sustaining Innovations in Tertiary Settings (SITS) framework which consists of 7 unique constructs, 49 determinants, and 29 related KTIs that influence the sustainability of EBPs in tertiary settings. Three determinants and 8 KTIs had a continuous influence during implementation and sustained use phases. Attention to the level of application and changing conditions over time affecting determinants is required for sustainment. Use of a participatory approach to engage users in designing remedial plans and linking KTIs to target behaviors that incrementally address low adherence rates promotes sustainability.

Conclusions

The SITS framework provides a novel resource to support future practice and research aimed at sustaining EBPs in tertiary settings and improving patient outcomes. Findings confirm the concept of sustainability is a "dynamic ongoing phase".

Mapping research findings on change implementation in nursing practice: A scoping literature review

AIMS

The aim of this study was to map the diverse factors impacting change implementation in nursing practices and investigate different implementation strategies.

DESIGN

Scoping literature review following PRISMA-ScR extension.

METHODS

Data were collected from PubMed, Ebsco, Scopus and ScienceDirect databases from 1990 onwards. Only English peer-reviewed studies reporting an implementation of change in nursing practice were included. Of 9,954 studies, 425 abstracts were scanned and 98 full-text articles were screened. Finally, 28 studies were selected.

RESULTS

A multifaceted approach, with a tailored intervention, was the most effective implementation strategy. Most identified factors were considered systematic, for example resource availability, leadership and knowledge. However, others related to local social and material context were identified in fewer number of studies. These seem to be operational elements for implementation processes. Both types of factors are essential and must be considered for successful implementation.

CONCLUSION

We advocate the development of framework including systematic factors and which capture the local context flexibility.

What fuels suboptimal care of peripheral intravenous catheter-related infections in hospitals? A qualitative study of decision-making among Spanish nurses

Background

Peripheral intravenous catheters (PIVC) are commonly used in hospital worldwide. However, PIVC are not exempt from complications. Catheter-related bloodstream infections (CRBSI) increase morbidity and mortality rates, and costs for the healthcare organization. PIVC care is shaped by the complex mix of professional and organizational culture, such as knowledge gaps, low perception of impact of PIVCs on patient safety, or lack of hospital guidelines.

Aim

To explore determinants of decision-making about the prevention of PIVC-BSI among nurses in Spanish hospitals.

Methods

We conducted a descriptive qualitative study with semi-structured interviews in three public hospitals, the Balearic Islands Health Care Service in Spain. We considered hospital ward nurses working routinely with inpatients at any of the three hospitals for enrolment in the study. We approached relevant informants to identify suitable participants who recruited other participants through a ‘snowball’ technique. Fourteen inpatient nurses from the hospital took part in this study between September and November 2018. We employed several triangulation strategies to underpin the methodological rigour of our analysis and conducted the member checking, showing the information and codes applied in the recording of the interviews to identify the coherence and any discrepancies of the discourse by participants. We used the COREQ checklist for this study.

Findings

We identified four major themes in the analysis related to determinants of care: The fog of decision-making in PIVC; The taskification of PIVC care; PIVC care is accepted to be suboptimal, yet irrelevant; and chasms between perceived determinants of poor PIVC care and its solutions.

Conclusion

The clinical management of PIVCs appear ambiguous, unclear, and fragmented, with no clear professional responsibility and no nurse leadership, causing a gap in preventing infections. Furthermore, the perception of low risk on PIVC care impact can cause a relevant lack of adherence to the best evidence and patient safety. Implementing facilitation strategies could improve the fidelity of the best available evidence regarding PIVC care and raise awareness among nurses of impact that excellence of care.

Rationale and design of a randomized controlled clinical trial; Titration of Oxygen Levels (TOOL) during mechanical ventilation

BACKGROUND

Both hyperoxemia and hypoxemia are deleterious in critically ill patients. Targeted oxygenation is recommended to prevent both of these extremes, however this has not translated to the bedside. Hyperoxemia likely persists more than hypoxemia due to absence of immediate discernible adverse effects, cognitive biases and delay in prioritization of titration.

METHODS

We present the methodology for the Titration Of Oxygen Levels (TOOL) trial, an open label, randomized controlled trial of an algorithm-based FiO2 titration with electronic medical record-based automated alerts. We hypothesize that the study intervention will achieve targeted oxygenation by curbing episodes of hyperoxemia while preventing hypoxemia. In the intervention arm, electronic alerts will be used to titrate FiO2 if SpO2 is ≥94% with FiO2 levels ≥0.4 over 45 min. FiO2 will be titrated per standard practice in the control arm. This study is being carried out with deferred consent. The sample size to determine efficacy is 316 subjects, randomized in a 1:1 ratio to the intervention vs. control arm. The primary outcome is proportion of time during mechanical ventilation spent with FiO2 ≥ 0.4 and SpO2 ≥ 94%. We will also assess proportion of time during mechanical ventilation spent with SpO2 < 88%, duration of mechanical ventilation, length of ICU and hospital stay, hospital mortality, and adherence to electronic alerts as secondary outcomes.

CONCLUSION

This study is designed to evaluate the efficacy of a high fidelity, bioinformatics-based, electronic medical record derived electronic alert system to improve targeted oxygenation in mechanically ventilated patients by reducing excessive FiO2 exposure.

Early Titration of Oxygen During Mechanical Ventilation Reduces Hyperoxemia in a Pilot, Feasibility, Randomized Control Trial for Automated Titration of Oxygen Levels

Timely regulation of oxygen (Fio₂) is essential to prevent hyperoxemia or episodic hypoxemia. Exposure to excessive Fio₂ is often noted early after onset of mechanical ventilation. In this pilot study, we examined the feasibility, safety, and efficacy of a clinical trial to prioritize Fio₂ titration with electronic alerts to respiratory therapists.

Assessing the Integrative Framework for the Implementation of Change in Nursing Practice: Comparative Case Studies in French Hospitals

The implementation of healthcare policies in healthcare organizations is a pivotal issue for managers. They generally require a change in professional practices. In previous work, we developed the Integrative Framework for Implementation of change in Nursing Practices (IFINP) to support implementation initiatives for such change in nursing practices. We aimed to assess the generalizability of IFINP in other organizational settings and explore links between strategic and socio-material factors during implementation. We used a comparative qualitative case study at three French hospitals to assess the implementation of certification procedures. Data were collected from 33 semi-structured interviews with managers and nurses. Narratives reflecting actions and interactions were extracted and deductively analyzed using IFINP components. The results showed that the framework was flexible and captured the different aspects of implementation actions and interactions at the three hospitals. Strong interferences were identified between mobilization mechanisms and strategic elements. Interferences were observed mostly between ‘reflexive monitoring and work articulation’, and ‘reflexive monitoring and sense-making’ mechanisms. Leadership was integrated into the different mechanisms, especially the ‘translation’ mechanism. The IFINP facilitated a greater understanding of strategic elements and associated relationships with social and material factors during implementation. It helps to provide a clear definition of the managers’ role when implementing new nurse practices.

Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development

Background

Normalisation Process Theory (NPT) is frequently used to inform qualitative research that aims to explain and evaluate processes that shape late-stage translation of innovations in the organisation and delivery of healthcare. A coding manual for qualitative researchers using NPT will facilitate transparent data analysis processes and will also reduce the cognitive and practical burden on researchers.

Objectives

(a) To simplify the theory for the user. (b) To describe the purposes, methods of development, and potential application of a coding manual that translates normalisation process theory (NPT) into an easily usable framework for qualitative analysis. (c) To present an NPT coding manual that is ready for use.

Method

Qualitative content analysis of papers and chapters that developed normalisation process theory, selection and structuring of theory constructs, and testing constructs against interview data and published empirical studies using NPT.

Results

A coding manual for NPT was developed. It consists of 12 primary NPT constructs and conforms to the Context-Mechanism-Outcome configuration of realist evaluation studies. Contexts are defined as settings in which implementation work is done, in which strategic intentions, adaptive execution, negotiating capability, and reframing organisational logics are enacted. Mechanisms are defined as the work that people do when they participate in implementation processes and include coherence-building, cognitive participation, collective action, and reflexive monitoring. Outcomes are defined as effects that make visible how things change as implementation processes proceed and include intervention mobilisation, normative restructuring, relational restructuring, and sustainment.

Conclusion

The coding manual is ready to use and performs three important tasks. It consolidates several iterations of theory development, makes the application of NPT simpler for the user, and links NPT constructs to realist evaluation methods. The coding manual forms the core of a translational framework for implementation research and evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01191-x.

Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study

Background

To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting.

Methods

We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review (n = 29), chart audits (n = 200), and semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level.

Results

We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0-2 yrs), sustained phase (>2-10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment.

Conclusion

This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic "ongoing process."

Implementing the Routine Use of Electronic Mental Health Screening for Youth in Primary Care: Systematic Review

BACKGROUND

Adolescents often present at primary care clinics with nonspecific physical symptoms when, in fact, they have at least 1 mental health or risk behavior (psychosocial) issue with which they would like help but do not disclose to their care provider. Despite global recommendations, over 50% of youths are not screened for mental health and risk behavior issues in primary care.

OBJECTIVE

This review aimed to examine the implementation, acceptability, feasibility, benefits, and barriers of e-screening tools for mental health and risk behaviors among youth in primary care settings.

METHODS

Electronic databases-MEDLINE, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews-were searched for studies on the routine screening of youth in primary care settings. Screening tools needed to be electronic and screen for at least 1 mental health or risk behavior issue. A total of 11 studies that were reported in 12 articles, of which all were from high-income countries, were reviewed.

RESULTS

e-Screening was largely proven to be feasible and acceptable to youth and their primary care providers. Preconsultation e-screening facilitated discussions about sensitive issues and increased disclosure by youth. However, barriers such as the lack of time, training, and discomfort in raising sensitive issues with youth continued to be reported.

CONCLUSIONS

To implement e-screening, clinicians need to change their behaviors, and e-screening processes must become normalized into their workflows. Co-designing and tailoring screening implementation frameworks to meet the needs of specific contexts may be required to ensure that clinicians overcome initial resistances and perceived barriers and adopt the required processes in their work.

A framework for the implementation of certification procedures in nurse level: a mixed approach study

Background

The implementation of certification procedures across healthcare systems is an essential component of the management process. Several promising approaches were developed toward a successful implementation of such policies; however, a precise adaptation and implementation to each local context was essential. Local activities must be considered in order to generate more pragmatic recommendations for managers. In this study, we built a framework for the implementation of certification procedures at nurse activity level. This was developed using two objectives: the identification of key implementation process components, and the integration of these components into a framework which considered the local socio-material context of nurses’ work.

Methods

We used a two-step mixed approach. The first was inductive and consisted of a qualitative case study conducted between April and December 2019. Here, we analyzed the implementation of certification procedures in a French teaching hospital. Data were collected using semi-structured interviews and observations. In the second approach, emerging data were deductively analyzed using the Quality Implementation Tool (QIT) and Translational Mobilization Theory (TMT). Analyses were combined to construct an implementation framework.

Results

Sixteen interviews were conducted with participants from different organizational levels, managers, mid-managers, and nurses. Additionally, 83 observational hours were carried out in two different wards. Our results showed that, (1) All retrieved elements during the process were successfully captured by the QIT components, only one component was not applicable. (2) We identified elements related to the local activity context, with the different interrelationships between actors, actions, and contexts using the TMT. (3) Our analyses were integrated and translated into a framework that presents the implementation of certification procedures in healthcare facilities, with a specific interest to the nurse/mid-manager level. By initially using QIT, the framework components took on a transversal aspect which were then adapted by TMT to the local work context.

Conclusions

We successfully generated a framework that supports the implementation of certification procedures at the activity level. Our approach identified a broader vision of the interactions between proximity managers, teams, and contexts during change mobilization, which were not encompassed by transversal framework only, such as QIT. In the future, more empirical studies are needed to test this framework.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06940-0.

Organizing work in local service implementation: an ethnographic study of nurses' contributions and competencies in implementing a municipal acute ward

BACKGROUND

The increased prevalence of chronic diseases and an ageing population challenge healthcare delivery, particularly hospital-based care. To address this issue, health policy aims to decentralize healthcare by transferring responsibility and introducing new services in primary healthcare. In-depth knowledge of associated implementation processes is crucial for health care managers, policymakers, and the health care personnel involved. In this article, we apply an ethnographic approach in a study of nurses' contributions to the implementation of a new inpatient service in an outpatient primary care emergency clinic and explore the competencies involved. The approach allowed us to explore the unexpressed yet significant effort, knowledge and competence of nurses that shaped the new service.

METHODS

The study combines observations (250 h) and several in situ interviews with healthcare personnel and individual in-depth interviews with nurses (n = 8) at the emergency clinic. In our analysis, we draw on a sociological perspective on healthcare work and organization that considers nursing a practice within the boundaries of clinical patient work, organizational structures, and managerial and professional requirements.

RESULTS

We describe the following three aspects of nurses' contributions to the implementation of the new service: (1) anticipating worst-case scenarios and taking responsibility for preventing them, (2) contributing coherence in patient care by ensuring that new and established procedures are interconnected, and (3) engaging in "invisible work". The nurses draw on their own experiences from their work as emergency nurses and knowledge of the local and regional contexts. They utilize their knowledge, competence, and organizing skills to influence the implementation process and ensure high-quality healthcare delivery in the extended service.

CONCLUSIONS

Our study illustrates that nurses' contributions are vital to coordinating and adjusting extended services. Organizing work, in addition to clinical work, is a crucial aspect of nursing work. It 'glues' the complex and varied components of the individual patient's services into coherent and holistic care trajectories. It is this organizing competence that nurses utilize when coordinating and adjusting extended services. We believe that nurses' organizing work is generally invaluable in implementing new services, although it has not been well emphasized in practice and research.

Sense of courage: The mediating role of courage between emotional reflexivity and work-life integration among nurses in Indian hospitals

Objectives

This study aimed to determine the relationship between emotional reflexivity and work-life integration through the mechanism of moral courage and enhance our understanding of the importance of these nursing concepts to enable the nurses to develop better coping strategies for work-life integration.

Methods

A cross-sectional survey was performed with 249 nurses, including staff nurses, ICU and critical care nurses, operation theatre nurses, pediatric nurses from 17 hospitals. Emotional Reflexivity, work-life integration, and courage were measured using a demographic information questionnaire, Life Project Reflexivity Scale (LPRS), Nurse’s Moral Courage Scale (NMCS), and Work-Life Boundary Enactment (WLBE) scale. A series of multiple regressions analyzed the mediating effect.

Results

Emotional Reflexivity was positively correlated with work-life integration (β = 0.66, P < 0.01). There was a positive correlation between emotional reflexivity and moral courage. But the path did not get the necessary support in the structural equation modeling (SEM) (β = −0.13, P = 0.40). When controlling for courage (β = 0.42, P < 0.01), the association was significant between emotional reflexivity and work-life integration with partial mediation.

Conclusion

The study reported a positive correlation between reflexivity and work-life integration. Thus, nurses’ work-life integration becomes better by reinforcing their emotional reflexivity and moral courage.

Patient knowledge and experience of hyperbaric oxygen treatment

INTRODUCTION

This paper presents a quantitative and qualitative study exploring patients' knowledge and experience of hyperbaric oxygen treatment (HBOT).

METHODS

Participants included 29 patients with appropriate indications who were undertaking HBOT at facilities in two different locations: Hobart, Australia, and Plymouth, United Kingdom. Participants completed surveys prior to commencing HBOT, after five sessions, and on completion of HBOT. Semi-structured one-to-one interviews were conducted with each individual on conclusion of their course. Data were analysed using descriptive statistics and interpretive description.

RESULTS

Prior to referral, 15/29 (52%) of participants knew HBOT was used to treat divers, and of these, 9/15 (60%) were familiar with its use for non-divers. Only one third sought additional information about the process between referral for HBOT and attending their medical assessment. Anxiety was a pre-treatment concern amongst participants. However, when re-measured after five sessions and upon completion of the HBOT course, anxiety was reduced. The interview data revealed themes based around the physical, emotional and social aspects of HBOT: (1) anxiety within self; (2) naivety to normalisation; (3) enjoyment being a 'diver'; and (4) burdens of HBOT.

CONCLUSIONS

Many patients experienced anxiety prior to commencing HBOT but, with support, quickly adjusted to treatment, transitioning from a state of naivety to normalisation in their experience of the hyperbaric chamber. They enjoyed feeling like a 'diver' and considered aspects of the burdens of treatment, such as finances or logistics, a minor inconvenience. These results highlight the need for psychosocial support during treatment by identifying gaps in patient preparation for HBOT.

Implementation of national childbirth guidelines in Brazil: barriers and strategies

The present report describes the process and results obtained with a knowledge translation project developed in three stages to identify barriers to the Implementation of the National Guidelines for Normal Childbirth in Brazil, as well strategies for effective implementation. The Improving Programme Implementation through Embedded Research (iPIER) model and the Supporting Policy Relevant Reviews and Trials (SUPPORT) tools provided the methodological framework for the project. In the first stage, the quality of the Guidelines was evaluated and the barriers preventing implementation of the recommendations were identified through review of the global evidence and analysis of contributions obtained in a public consultation process. In the second stage, an evidence synthesis was used as the basis for a deliberative dialogue aimed at prioritizing the barriers identified. Finally, a second evidence synthesis was presented in a new deliberative dialogue to discuss six options to address the prioritized barriers: 1) promote the use of multifaceted interventions; 2) promote educational interventions for the adoption of guidelines; 3) perform audits and provide feedback to adjust professional practice; 4) use reminders to mediate the interaction between workers and service users; 5) enable patient-mediated interventions; and 6) engage opinion leaders to promote use of the Guidelines. The processes and results associated with each stage were documented and formulated to inform a review and update of the Guidelines and the development of an implementation plan for the recommendations. Effective implementation of the Guidelines is important for improving the care provided during labor and childbirth in Brazil.

[Implementation of the National Childbirth Guidelines in Brazil: barriers and trategiesObstáculos y estrategias para la aplicación de las Directrices Nacionales para el Parto Normal en el Brasil]

The present report describes the process and results obtained with a knowledge translation project developed in three stages to identify barriers to the National Childbirth Guidelines in Brazil as well strategies for effective implementation. The Improving Programme Implementation through Embedded Research (iPIER) model and the Supporting Policy Relevant Reviews and Trials (SUPPORT) tools provided the methodological framework for the project. In the first stage, the quality of the Guidelines was evaluated and the barriers preventing implementation of the recommendations were identified through review of the global evidence and analysis of contributions obtained in a public consultation process. In the second stage, an evidence synthesis was used as basis for a deliberative dialogue aimed at prioritizing the barriers identified. Finally, a second evidence synthesis was presented in a new deliberative dialogue to discuss six options to address the prioritized barriers: 1) promote the use of multifaceted interventions; 2) promote educational interventions for the adoption of guidelines; 3) perform audits and provide feedback to adjust professional practice; 4) use reminders to mediate the interaction between workers and service users; 5) enable patient-mediated interventions; and 6) engage opinion leaders to promote the use of guidelines. The processes and results associated with each stage were documented and formulated to inform a review and update of the Guidelines and the development of an implementation plan for the recommendations. An effective implementation of the Guidelines is relevant to improve the care provided during labor and childbirth in Brazil.

Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home

BACKGROUND

Despite widespread adoption of patient-centered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation.

OBJECTIVE

Examine reasons practices obtained and maintained PCMH recognition and what resources were needed.

DESIGN

Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey.

PARTICIPANTS

105 practice leaders from 294 sampled practices (36% response rate).

APPROACH

Content analysis of interviews with practice leaders to identify themes.

RESULTS

Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs.

CONCLUSION

PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.

Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning

PURPOSE

Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA.

MATERIALS AND METHODS

Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed.

RESULTS

Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice.

CONCLUSION

This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised.IMPLICATIONS FOR REHABILITATIONRedesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making.Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty.Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice.Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre.

Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in hospital settings: A multi-method study using normalisation process theory

Purpose

To examine the use of Normalisation Process Theory (NPT) to establish if, and in what ways, the AMBER care bundle can be successfully normalised into acute hospital practice, and to identify necessary modifications to optimise its implementation.

Method

Multi-method process evaluation embedded within a mixed-method feasibility cluster randomised controlled trial in two district general hospitals in England. Data were collected using (i) focus groups with health professionals (HPs), (ii) semi-structured interviews with patients and/or carers, (iii) non-participant observations of multi-disciplinary team meetings and (iv) patient clinical note review. Thematic analysis and descriptive statistics, with interpretation guided by NPT components (coherence; cognitive participation; collective action; reflexive monitoring). Data triangulated across sources.

Results

Two focus groups (26 HPs), nine non-participant observations, 12 interviews (two patients, 10 relatives), 29 clinical note reviews were conducted. While coherence was evident, with HPs recognising the value of the AMBER care bundle, cognitive participation and collective action presented challenges. Specifically: (1) HPs were unable and unwilling to operationalise the concept of ‘risk of dying’ intervention eligibility criteria (2) integration relied on a ‘champion’ to drive participation and ensure sustainability; and (3) differing skills and confidence led to variable engagement with difficult conversations with patients and families about, for example, nearness to end of life. Opportunities for reflexive monitoring were not routinely embedded within the intervention. Reflections on the use of the AMBER care bundle from HPs and patients and families, including recommended modifications became evident through this NPT-driven analysis.

Conclusion

To be successfully normalised, new clinical practices, such as the AMBER care bundle, must be studied within the wider context in which they operate. NPT can be used to the aid identification of practical strategies to assist in normalisation of complex interventions where the focus of care is on clinical uncertainty in acute hospital settings.

Using the Knowledge-to-Action Framework to understand experiences of breastfeeding guideline implementation: A qualitative study

AIM

To examine the perceptions and experiences of health care professionals and mothers in relation to the implementation of a breastfeeding clinical practice guideline (CPG).

BACKGROUND

Breastfeeding CPG applications remain limited, and qualitative studies have indicated the need to overcome the perception by professionals of difficulties in applying recommendations.

METHODS

A qualitative study was conducted in a Spanish public hospital that implemented the Registered Nurses´ Association of Ontario breastfeeding CPG from 2012 through 2015. Between May and August 2017, 27 semi-structured interviews were conducted with managers, with professionals in maternity and paediatric departments and with mothers. Deductive content analysis was performed following the stages in the Knowledge-To-Action (KTA) Framework.

RESULTS

We obtained five main categories: (a) problem as opportunity; (b) adequate context and adapted recommendations; (c) extent of implementation; (d) impact of results; and (e) knowledge use normalization.

CONCLUSIONS

The KTA Framework assists understanding of the participation of the main actors in breastfeeding CPG implementation.

IMPLICATIONS FOR NURSING MANAGEMENT

The nature of the interventions and the participation of managers, different professionals and mothers in a multi-unit setting generate a complex implementation process that reveals key factors to be taken into account in future CPG implementations.

Exploring the scope for Normalisation Process Theory to help evaluate and understand the processes involved when scaling up integrated models of care: a case study of the scaling up of the Gnosall memory service

Purpose

The scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT).

Design/methodology/approach

The article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project.

Findings

NPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future.

Research limitations/implications

The research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies.

Practical implications

NPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up.

Social implications

NPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up.

Originality/value

This paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models.

Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory

BACKGROUND

Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives.

METHODS

This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'.

RESULTS

Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners.

CONCLUSIONS

This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.

The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review

BACKGROUND

Identifying factors that influence sustained implementation of hospital-based interventions is key to ensuring evidence-based best practice is maintained across the NHS. This study aimed to identify, appraise and synthesise the barriers and facilitators that influenced the delivery of sustained healthcare interventions in a hospital-based setting.

METHODS

A systematic review reported in accordance with PRISMA. Eight electronic databases were reviewed in addition to a hand search of Implementation Science journal and reference lists of included articles. Two reviewers were used to screen potential abstracts and full text papers against a selection criteria. Study quality was also independently assessed by two reviewers. Barriers and facilitators were extracted and mapped to a consolidated sustainability framework.

RESULTS

Our searching identified 154,757 records. We screened 14,626 abstracts and retrieved 431 full text papers, of which 32 studies met the selection criteria. The majority of studies employed a qualitative design (23/32) and were conducted in the UK (8/32) and the USA (8/32). Interventions or programmes were all multicomponent, with the majority aimed at improving the quality of patient care and/ or safety (22/32). Sustainability was inconsistently reported across 30 studies. Barriers and facilitators were reported in all studies. The key facilitators included a clear accountability of roles and responsibilities (23/32); ensuring the availability of strong leadership and champions advocating the use of the intervention (22/32), and provision of adequate support available at an organisational level (21/32). The most frequently reported barrier to sustainability was inadequate staff resourcing (15/32). Our review also identified the importance of inwards spread and development of the initiative over time, as well as the unpredictability of sustainability and the need for multifaceted approaches.

CONCLUSIONS

This review has important implications for practice and research as it increases understanding of the factors that faciliate and hinder intervention sustainability. It also highlights the need for more consistent and complete reporting of sustainability to ensure that lessons learned can be of direct benefit to future implementation of interventions.

TRIAL REGISTRATION

The review is registered on PROSPERO ( CRD42017081992 ).

Health staff experiences with the implementation of early essential newborn care guidelines in Da Nang municipality and Quang Nam province in Viet Nam

Background

The World Health Organization (WHO) recommends early essential newborn care (EENC) – The First Embrace – as a simple lifesaving procedure for newborns. The successful implementation of EENC at scale requires an understanding of health staff experiences, including facilitators, barriers, and local adaptations of EENC. This study aims to gain insight into health staff experiences with implementation of EENC guidelines after participation in training and coaching initiatives in Da Nang municipality and Quang Nam province in Viet Nam.

Methods

In each province/municipality, we randomly selected one hospital from the following categories: public provincial/municipal hospital, public district hospital, and private hospital. We conducted in-depth interviews with 19 hospital staff (11 midwives, 5 doctors and 3 health managers) and two trainers during 7 days between September and October 2017. We used deductive/inductive thematic analysis to generate themes.

Results

The health staff reported improved staff and mother satisfaction, and health benefits for both mothers and newborns after implementing EENC. Facilitators to successful implementation were management support for resource allocation and collaboration across departments, and creative demand generation. Barriers included staff shortage, skepticism about the new protocols and practices and challenges translating knowledge and skills from trainings and coaching into practice.

Conclusions

After implementing EENC, through training and coaching using the WHO approach, health staff reported improved staff and mother satisfaction as well as health benefits for both mothers and newborns. An approach to develop competencies, with a focus on practical training and coaching, should be promoted to form, reinforce and sustain recommended EENC practices among health staff.

Applying normalization process theory and process mapping to understand implementation of a co-management program for older hip fracture patients in China: a qualitative study

This qualitative study identified the barriers to the implementation of a multidisciplinary co-management program for older hip fracture patients and provided evidence for future intervention improvement and scale-up.

INTRODUCTION

Multidisciplinary co-management has been recommended as an effective intervention for hip fracture management in older people. This study is a process evaluation of a multidisciplinary co-management program in an orthopaedic hospital in Beijing, China, to better understand the barriers to implementation.

METHODS

Data collection involved semi-structured interviews with key implementers of the co-management intervention (surgeon, geriatrician, physician, nurse, physiotherapist and anaesthetist) and observations of patients' journey to map the care processes were conducted in Beijing Jishuitan Hospital. Data were transcribed, qualitatively coded and analysed using normalization process theory to understand the intervention process from four constructs: coherence, cognitive participation, collective action and reflexive monitoring.

RESULTS

Ten stakeholder interviews were conducted. Despite multidisciplinary co-management intervention was meaningful and valued by participants, barriers to its implementation were identified. These included unmatched investment and benefit (cognitive participation), challenges of facing increased workload (collective action), deficient training and supervision system (collective action), limited accommodating capacity of hospital (collective action) and difficulties in accessing information about the effect of the intervention (reflexive monitoring).

CONCLUSIONS

Multiple barriers to the effective implementation of the multidisciplinary co-management program in China were identified. The process evaluation highlights key aspects in less willingness to fully invest in the program, inappropriate workload allocation and lack of training and supervision which need to be addressed before scaling up.

Developing and sustaining digital professionalism: a model for assessing readiness of healthcare environments and capability of nurses

Introduction

Technological change in healthcare demands new ways of working. Access to, and use of, digital technology by nurses in Australia lags behind other professions. Governance frameworks and professional standards guide scopes of practice; however, there is an urgent need for current registered nurses to master using digital technology and model digital professionalism to the next generation. Sustaining digital professionalism requires organisational readiness to accommodate changing technological environments.

Methods

Previous original research findings investigating the nature and scope of digital technology use by nurses were systematically analysed. With reference to current understandings of capability, a matrix for assessing organisational readiness of capability of digital technology use by nurses was developed.

Results

The 4E3P digital professionalism model articulates the elements necessary for establishing organisational readiness and assessing the capability development of individuals and groups. When the physical and social environment is conducive and the 4E elements of equipment, electronic access, engagement and education are present, preparedness, proficiency and professional behaviours can be nurtured and supported.

Discussion

The model describes the physical and social attributes that enable capability development for sustaining digital professionalism to advance nursing practice. When elements of the matrix are lacking, both individuals and groups miss opportunities to develop and sustain digitally professional behaviour.

Conclusion

It is imperative that healthcare environments in Australia support the development of digital professionalism. Deployment of the 4E3P digital professionalism model will enable identification and remediation of challenges, barriers or risks to promote sustainability found within physical and social healthcare environments.

Evidence-based practice integration in hospital wards-The complexities and challenges in achieving evidence-based practice in clinical nursing

AIM

Exploring the processes involved in two different strategies to integrate evidence-based practice into nursing practice.

DESIGN

Classical grounded theory methodology was used.

METHODS

Data were collected through 90 hr of observation and 4 focus groups among clinical nurses in two different hospital wards.

RESULTS

We identified a multidimensional evidence-based practice integration framework that illuminates the complexities involved in the integration process. The dimensions were approaches to evidence-based practice, positions of evidence-based practice and levels of evidence-based practice. The interactions between the dimensions gave five combinations; an explicit evidence-based practice performed as a parallel to daily work at the systems level, an implicit evidence-based practice integrated into daily work at the systems level, an explicit evidence-based practice integrated into daily work at the individual level, an explicit evidence-based practice integrated into daily work at the systems level and an implicit evidence-based practice integrated into daily work at the individual level.

Enhancing SKIN health and safety in aged CARE (SKINCARE Trial): a study protocol for an exploratory cluster-randomized pragmatic trial

BACKGROUND

Aged long-term care receivers are affected by various adverse skin conditions like pressure ulcers, incontinence-associated dermatitis, dryness, intertrigo, and many more. Prevention of these skin problems and the provision of general hygiene and skin care activities are key areas of nursing practice. Numerous condition-specific guidelines are available and are implemented separately. On the other hand, there is huge overlap in terms of etiology, pathogenesis, and prevention of the skin conditions mentioned above. This leads to fragmented practice neglecting shared etiologies and prevention and treatment principles.

METHODS

The overall aims of this trial are to test the feasibility and to estimate possible effects of the implementation of a comprehensive skin care and prevention strategy targeting main nursing-relevant skin problems at the same time. A two-arm cluster-randomized controlled trial will be performed in 20 nursing homes randomly selected from the population of nursing homes of the state of Berlin, comparing skin care according to the skin care and prevention strategy with standard skin care.

DISCUSSION

It is expected that the implementation of this evidence-based skin care and prevention strategy will reduce the incidence of pressure ulcers, incontinence dermatitis, and other skin problems frequently related to care dependency. This trial will benefit individual patients and aged nursing home residents in general given the high prevalence and incidence of the addressed skin conditions. Findings of this exploratory trial may lay the foundation for a change in the development and evaluation of clinical standards and practices in general as it moves the perspective from individual conditions to a more comprehensive view on overlapping or coexisting health problems, in this case common skin conditions, in old-age long-term care receivers.

TRIAL REGISTRATION

The study is registered at the German Clinical Trials Register https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015680 (Deutsches Register Klinischer Studien, or DRKS; registration number: DRKS00015680 , date of registration: January 29, 2019) and ClincialTrials.gov (registration number: NCT03824886 , date of registration: January 31, 2019).

Advancing mobile learning in Australian healthcare environments: nursing profession organisation perspectives and leadership challenges

Background

Access to, and use of, mobile or portable devices for learning at point of care within Australian healthcare environments is poorly governed. An absence of clear direction at systems, organisation and individual levels has created a mobile learning paradox, whereby although nurses understand the benefits of seeking and retrieving discipline or patient-related knowledge and information in real-time, mobile learning is not an explicitly sanctioned nursing activity. The purpose of this study was to understand the factors influencing mobile learning policy development from the perspective of professional nursing organisations.

Methods

Individual semi-structured interviews were undertaken with representatives from professional nursing organisations in December 2016 and January 2017. Recruitment was by email and telephone. Qualitative analysis was conducted to identify the key themes latent in the transcribed data.

Results

Risk management, perceived use of mobile technology, connectivity to information and real-time access were key themes that emerged from the analysis, collectively identifying the complexity of innovating within an established paradigm. Despite understanding the benefits and risks associated with using mobile technology at point of care, nursing representatives were reluctant to exert agency and challenge traditional work patterns to alter the status quo.

Conclusions

The themes highlighted the complexity of accessing and using mobile technology for informal learning and continuing professional development. Mobile learning cannot occur at point of care until the factors identified are addressed. Additionally, a reluctance by nurses within professional organisations to advance protocols to govern digital professionalism needs to be overcome. For mobile learning to be perceived as a legitimate nursing function requires a more wholistic approach to risk management that includes all stakeholders, at all levels. The goal should be to develop revised protocols that establish a better balance between the costs and benefits of access to information technology in real-time by nurses.

The Development of a Pediatric Medication Administration Guideline for Preprocedure Nurse Callers

PURPOSE

This article describes the authors' development of a pediatric medication administration guideline for use by preprocedure nurse callers. Preprocedure refers to procedures done with general anesthesia such as surgery, endoscopy, or magnetic resonance imaging.

DESIGN

This article describes a process improvement project.

METHODS

The literature was searched using Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Google Scholar, and Google. No existing peer-reviewed pediatric preprocedure medication administration guidelines were found. A guideline with instructions for commonly prescribed pediatric medications was developed.

FINDINGS

Use of the guideline improves patient safety by providing clear medication administration instructions, while increasing the efficiency and autonomy of our nurse callers. Surveys of the nurse callers demonstrated that the guideline was clear, caregivers were receptive to receiving instructions from nurse callers, and use of the guideline decreased the number of calls made to other providers.

CONCLUSIONS

The use of a medication administration guideline improves patient safety, nurse efficiency, and nurse autonomy.

Appraising the quality standard underpinning international clinical practice guidelines for the selection and care of vascular access devices: a systematic review of reviews

OBJECTIVE

Catheter-related bloodstream infections are one of the most important adverse events for patients. Evidence-based practice embraces interventions to prevent and reduce catheter-related bloodstream infections in patients. At present, a growing number of guidelines exist worldwide. The purpose of the study was to assess clinical practice guidelines for peripheral and central venous access device care and prevention of related complications.

DESIGN

Systematic review of clinical practice guidelines: We conducted a search of the literature published from 2005 to 2018 using Medline/PubMed, Embase, CINAHL, Ovid, ScienceDirect, Scopus and Web of Science. We also evaluated grey literature sources and websites of organisations that compiled or produced guidelines. Guideline quality was assessed with the Appraisal of Guidelines for Research and Evaluation, Second Edition tool by three independent reviewers. Cohen's kappa coefficient was used to evaluate the concordance between reviewers.

RESULTS

We included seven guidelines in the evaluation. The concordance between observers was substantial, K=0.6364 (95% CI 0.0247 to 1.2259). We identified seven international guidelines, which scored poorly on crucial domains such as applicability (medium 39%), stakeholder involvement (medium 65%) and methodological rigour (medium 67%). Guidelines by Spanish Health Ministry and UK National Institute for Health and Care Excellence presented the highest quality.

CONCLUSIONS

It is crucial to critically evaluate the validity and reliability of clinical practice guidelines so the best, most context-specific document is selected. Such choice is a necessary prior step to encourage and support health organisations to transfer research results to clinical practice. The gaps identified in our study may explain the suboptimal clinical impact of guidelines. Such low adoption may be mitigated with the use of implementation guides accompanying clinical documents.

Implementation of a knowledge mobilization model to prevent peripheral venous catheter-related adverse events: PREBACP study-a multicenter cluster-randomized trial protocol

Background

Peripheral venous catheters are the most commonly used invasive devices in hospitals worldwide. Patients can experience multiple adverse events during the insertion, maintenance, and management of these devices. Health professionals aim to resolve the challenges of care variability in the use of peripheral venous catheter through adherence to clinical practice guidelines. The aim of this cluster-randomized controlled trial is to determine the efficacy of a multimodal intervention on incidence of adverse events associated with the use of peripheral venous catheters in adult hospital patients. Additional aims are to analyze the fidelity of nurses and the relationship between contextual factors on the use of best available and the outcomes of the intervention.

Methods

Five public hospitals in the Spanish National Health System, with diverse profiles, including one university hospital and four second-level hospitals, will be included. In total, 20 hospitalization wards will be randomized for this study by ward to one of two groups. Those in the first group receive an intervention that lasts 12 months implementing evidence-based practice in healthcare related to peripheral catheters through a multimodal strategy, which will contain updated and poster protocols insertion, maintenance and removal of peripheral venous catheters, technologies applied to e-learning, feedback on the results, user and family information related to peripheral catheter, and facilitation of the best evidence by face-to-face training session. Primary outcome measures: Incidence of adverse events associated with the use of peripheral venous catheters is measured by assessing hospital records. Secondary outcome measures: Nurses’ adherence to clinical practice guidelines, clinical outcomes, and the cost of implementing the multimodal intervention.

Discussion

Clinical implementation is a complex, multifaceted phenomenon which requires a deep understanding of decision-making, knowledge mobilization, and sense making in routine clinical practice. Likewise, the inclusion of strategies that promote fidelity to recommendations through multicomponent and multimodal intervention must be encouraged. The use of a transfer model could counterbalance one of the greatest challenges for organizations, the evaluation of the impact of the implementation of evidence in the professional context through quality indicators associated with prevention and control of infections.

Trial registration

Current Controlled Trials ISRCTN10438530. Registered 20 March 2018.

A Technology Intervention for Nurses Engaged in Preventing Catheter-Associated Urinary Tract Infections

Catheter-associated urinary tract infections account for 40% of healthcare-acquired infections. This study explored the addition of cloud-based software technology to an established nursing quality improvement program to reduce catheter-associated urinary tract infections. Unit-based nurse champions evaluated peers' evidence-based catheter-associated urinary tract infection prevention practices using manual, paper-based feedback. That process achieved reduced rates of catheter-associated urinary tract infection over 18 months. However, it was resource intensive. Cloud-based software technology was introduced to replace the paper. Nurse champions' satisfaction, catheter-associated urinary tract infection and indwelling urinary catheter utilization, and prevention practices were compared before and after the technology intervention. Compliance with the provision of a chlorhexidine bath demonstrated improvement (P = .003), while other practice measures did not significantly change. The indwelling urinary catheter utilization ratio was lower (P = .01), yet the intervention yielded no change in catheter-associated urinary tract infection rates. The short time interval of the intervention was potentially a contributing factor in no significant rate change. Nurse champions (N = 14) were more satisfied with the cloud-based technology (P = .004), the clarity of improvement targets (P = .004), and the speed of sharing data (P = .001). Their time to share data decreased from 4 days or more to 1 hour or less. Nurse champions readily adopted the cloud-based technology. These findings suggest additional research on technology innovations for nursing quality improvement is needed.

Assessing the implementation processes of a large-scale, multi-year quality improvement initiative: survey of health care providers

Background

Beginning in 2012, Lean was introduced to improve health care quality and promote patient-centredness throughout the province of Saskatchewan, Canada with the aim of producing coordinated, system-wide change. Significant investments have been made in training and implementation, although limited evaluation of the outcomes have been reported. In order to better understand the complex influences that make innovations such as Lean “workable” in practice, Normalization Process Theory guided this study. The objectives of the study were to: a) evaluate the implementation processes associated with Lean implementation in the Saskatchewan health care system from the perspectives of health care professionals; and b) identify demographic, training and role variables associated with normalization of Lean.

Methods

Licensed health care professionals were invited through their professional associations to complete a cross-sectional, modified, online version of the NoMAD questionnaire in March, 2016. Analysis was based on 1032 completed surveys. Descriptive and univariate analyses were conducted. Multivariate multinomial regressions were used to quantify the associations between five NoMAD items representing the four Normalization Process Theory constructs (coherence, cognitive participation, collective action and reflexive monitoring).

Results

More than 75% of respondents indicated that neither sufficient training nor resources (collective action) had been made available to them for the implementation of Lean. Compared to other providers, nurses were more likely to report that Lean increased their workload. Significant differences in responses were evident between: leaders vs. direct care providers; nurses vs. other health professionals; and providers who reported increased workload as a result of Lean vs. those who did not. There were no associations between responses to normalization construct proxy items and: completion of introductory Lean training; participation in Lean activities; age group; years of professional experience; or employment status (full-time or part-time). Lean leader training was positively associated with proxy items reflecting coherence, cognitive participation and reflexive monitoring.

Conclusions

From the perspectives of the cross-section of health care professionals responding to this survey, major gaps remain in embedding Lean into healthcare. Strategies that address the challenges faced by nurses and direct care providers, in particular, are needed if intended goals are to be achieved.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3045-6) contains supplementary material, which is available to authorized users.

The work and challenges of care managers in the implementation of collaborative care: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice.

ABSTRACT

Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role.

Smartphone App Using Mindfulness Meditation for Women With Chronic Pelvic Pain (MEMPHIS): Protocol for a Randomized Feasibility Trial

Background

Female chronic pelvic pain (CPP) is defined as intermittent or constant pelvic or lower abdominal pain occurring in a woman for at least 6 months. Up to a quarter of women are estimated to be affected by CPP worldwide and it is responsible for one fifth of specialist gynecological referrals in the United Kingdom. Psychological interventions are commonly utilized. As waiting times and funding capacity impede access to face-to-face consultations, supported self-management (SSM) has emerged as a viable alternative. Mindfulness meditation is a potentially valuable SSM tool, and in the era of mobile technology, this can be delivered to the individual user via a smartphone app.

Objective

To assess the feasibility of conducting a trial of a mindfulness meditation intervention delivered by a mobile phone app for patients with CPP. The main feasibility objectives were to assess patient recruitment and app adherence, to obtain information to be used in the sample size estimate of a future trial, and to receive feedback on usability of the app.

Methods

Mindfulness Meditation for Women With Chronic Pelvic Pain (MEMPHIS) is a three-arm feasibility trial, that took place in two hospitals in the United Kingdom. Eligible participants were randomized in a 1:1:1 ratio to one of three treatment arms: (1) the intervention arm, consisting of a guided, spoken mindfulness meditation app; (2) an active control arm, consisting of a progressive muscle relaxation app; and (3) usual care (no app). Participants were followed-up for 6 months. Key feasibility outcomes included the time taken to recruit all patients for the study, adherence, and estimates to be used in the sample size calculation for a subsequent full-scale trial. Upon completion of the feasibility trial we will conduct focus groups to explore app usability and reasons for noncompliance.

Results

Recruitment for MEMPHIS took place between May 2016 and September 2016. The study was closed March 2017 and the report was submitted to the NIHR on October 26, 2017.

Conclusions

This feasibility trial will inform the design of a large multicentered trial to assess the clinical effectiveness of mindfulness meditation delivered via a smartphone app for the treatment of CPP.

Trial Registration

ClinicalTrials.gov: NCT02721108; https://clinicaltrials.gov/ct2/show/NCT02721108 (Archived by WebCite at http://www.webcitation.org/6wLMAkuaU); BioMed Central: ISRCTN10925965; https://www.isrctn.com/ISRCTN10925965 (Archived by WebCite at http://www.webcitation.org/6wLMVLuys)

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

OBJECTIVES

To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration.

DESIGN AND METHODS

A scoping review was undertaken based on the methodological framework of Arksey and O'Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes.

RESULTS

Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal.

CONCLUSIONS

A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.

Effectiveness of Internet-based interventions in managing chemotherapy-related symptoms in patients with cancer: a systematic literature review

PURPOSE

The aims of this review were to (1) examine the effectiveness of Internet-based interventions on cancer chemotherapy-related physical symptoms (severity and/or distress) and health-related quality of life (HRQOL) outcomes and (2) identify the design elements and processes for implementing these interventions in oncology practices.

METHODS

A systematic review was performed. The Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and PsycINFO were searched for studies dating from January 2000 through to October 2016. Based on pre-determined selection criteria, data was extracted from eligible studies. Methodological quality of studies was assessed using an adapted version of the Cochrane Collaboration Back Review Group checklist.

RESULTS

The literature search yielded 1766 studies of which only six RCTs fulfilled the eligibility criteria. Although the content, duration, and frequency of interventions varied considerably across studies, commonly used elements included tailored information, education, self-management support, and communication with clinicians. Five studies measured symptom distress and four of them reported statistically significant differences between study groups. Of the three studies that measured HRQOL, two reported improvement (or no deterioration over time) for the intervention group. However, several methodological issues including high attrition rates, poor adherence to interventions, and use of non-validated measures affect confidence in the strength of evidence.

CONCLUSION

Despite the evidence in support of using the Internet as a worthwhile tool for effective patient engagement and self-management of chemotherapy-related symptoms outside clinic visits, methodological limitations in the evidence base require further well-planned and quality research.

Supporting the use of theory in cross-country health services research: a participatory qualitative approach using Normalisation Process Theory as an example

OBJECTIVES

To describe and reflect on the process of designing and delivering a training programme supporting the use of theory, in this case Normalisation Process Theory (NPT), in a multisite cross-country health services research study.

DESIGN

Participatory research approach using qualitative methods.

SETTING

Six European primary care settings involving research teams from Austria, England, Greece, Ireland, The Netherlands and Scotland.

PARTICIPANTS

RESTORE research team consisting of 8 project applicants, all senior primary care academics, and 10 researchers. Professional backgrounds included general practitioners/family doctors, social/cultural anthropologists, sociologists and health services/primary care researchers.

PRIMARY OUTCOME MEASURES

Views of all research team members (n=18) were assessed using qualitative evaluation methods, analysed qualitatively by the trainers after each session.

RESULTS

Most of the team had no experience of using NPT and many had not applied theory to prospective, qualitative research projects. Early training proved didactic and overloaded participants with information. Drawing on RESTORE's methodological approach of Participatory Learning and Action, workshops using role play, experiential interactive exercises and light-hearted examples not directly related to the study subject matter were developed. Evaluation showed the study team quickly grew in knowledge and confidence in applying theory to fieldwork.Recommendations applicable to other studies include: accepting that theory application is not a linear process, that time is needed to address researcher concerns with the process, and that experiential, interactive learning is a key device in building conceptual and practical knowledge. An unanticipated benefit was the smooth transition to cross-country qualitative coding of study data.

CONCLUSION

A structured programme of training enhanced and supported the prospective application of a theory, NPT, to our work but raised challenges. These were not unique to NPT but could arise with the application of any theory, especially in large multisite, international projects. The lessons learnt are applicable to other theoretically informed studies.