The effectiveness of methods of dissemination and implementation of clinical guidelines for nursing practice: a selective review

Facilitating successful implementation of a person-centred intervention to support family carers within palliative care: a qualitative study of the Carer Support Needs Assessment Tool (CSNAT) intervention

BACKGROUND

An understanding of how to implement person-centred interventions in palliative and end of life care is lacking, particularly for supporting family carers. To address this gap, we investigated components related to successful implementation of the Carer Support Needs Assessment Tool (CSNAT) intervention, a person-centred process of carer assessment and support, using Promoting Action on Research Implementation in Health Services (PARIHS) as a theoretical framework. This study identifies how the PARIHS component of 'facilitation' and its interplay with the components of 'context' and 'evidence' affect implementation success.

METHODS

MRC Framework Phase IV study to evaluate implementation of the CSNAT intervention at scale, over six months, in 36 UK palliative care services. 38 practitioners acting as internal facilitators in 35/36 services were interviewed. Field notes were collected during teleconference support sessions between the external and internal facilitators.

RESULTS

Successful implementation was associated with internal facilitators' 'leverage' including their positioning within services, authority to change practice, and having a team of supportive co-facilitators. Effective facilitation processes included a collaborative approach, ongoing communication, and proactive problem solving to address implementation barriers. Facilitators needed to communicate the evidence and provide legitimacy for changing practice. Contextual constraints on facilitation included having to adjust recording systems to support implementation, organisational changes, a patient-focused culture and lack of managerial support.

CONCLUSIONS

The CSNAT intervention requires attention to both facilitation processes and conducive organisational structures for successful implementation. These findings are likely to be applicable to any person-centred process of assessment and support within palliative care.

Increasing Adherence to Brain Trauma Foundation Guidelines for Hospital Care of Patients With Traumatic Brain Injury

BACKGROUND

The Brain Trauma Foundation has developed treatment guidelines for the care of patients with acute traumatic brain injury. The Adam Williams Initiative is a program established to provide education and resources to encourage hospitals across the United States to incorporate the guidelines into practice.

OBJECTIVE

To explore the relationship in hospitals between participation in the Adam Williams Initiative and adherence to the Brain Trauma Foundation guidelines for patients with acute traumatic brain injury.

METHOD

Hospitals that participated in the Adam Williams Initiative entered data into an online tracking system of patients with traumatic brain injury for at least 2 years after the initial site training. Data included baseline hospital records and daily records on hospital care of patients with traumatic brain injury, including blood pressure, intracranial pressure, cerebral perfusion pressure, oxygenation, and other data relevant to the 15 key metrics in the Brain Trauma Foundation guidelines.

RESULTS

The 16 hospitals funded by the Adam Williams Initiative had good overall adherence to the 15 key metrics of the recommendations detailed in the Brain Trauma Foundation guidelines. Variability in results was primarily due to data collection methods and analysis.

CONCLUSIONS

The Adam Williams Initiative helps promote adherence to the Brain Trauma Foundation guidelines for hospital care of patients with traumatic brain injury by providing a platform for developing and standardizing best practices. Participation in the initiative is associated with high adherence to clinical guidelines, a situation that may subsequently improve care and outcomes for patients with traumatic brain injury.

Improving the Knowledge, Attitudes, and Practices of Mental Health Professionals Regarding Dual Diagnosis Treatment - a Mixed Methods Study of an Intervention

This study examined an intervention, which aimed at improving the dual diagnosis treatment at eight Danish mental health centres. The intervention included training in dual diagnosis treatment to program champions who were intended to implement at their workplace the knowledge gained from training. The study used mixed methods (questionnaires, interviews, and field observations) to examine whether there was a change in the knowledge, attitudes, and practices of the colleagues of the program champions following the intervention. Results showed that the intervention overall yielded improvement in knowledge and attitudes, while the impact on assessment and treatment practices was limited. Possible factors that might have affected the implementation of the intervention as well as the weaknesses of the intervention and the study are discussed.

Practice development: a concept analysis

Exploration of the term `practice development' is required for the discipline of infection control nursing. Improved understanding of the term would allow practitioners to approach practice development in a more constructive and measurable fashion. A concept analysis based on the model of Walker and Avant is therefore presented. The analysis includes the definition of the term `practice development' and discussion of how it is presented in the literature. Illustrative cases are used to achieve clarification of the concept, culminating in identification of the empirical referents, these being: (1) identified patient need and (2) a change in nursing practice and demonstrably improved care.

Examining the use of facilitation within guideline dissemination and implementation studies in nursing

BACKGROUND

Facilitation is a mechanism for implementing practice guidelines in nursing. Facilitation aims to prepare clinicians and organisations for implementation and to provide support and help in problem-solving as implementation progresses. However, any evidence supporting its effectiveness is limited due to a lack of empirical testing.

AIM

: To examine the presence and role of facilitation in studies included in an existing systematic review of guideline dissemination and implementation in nursing.

METHODS

Using a descriptive, exploratory approach, we examined 28 studies for elements of facilitation that were included in a review of the effectiveness of interventions to increase the use of practice guidelines in nursing. We conducted a content analysis of a subset of studies that included facilitation activity to gather descriptions of study interventions, characteristics and skills required, use of theory, and effectiveness. Extracted data were analysed using a previously developed taxonomy containing 53 activities related to facilitation.

RESULTS

Ten of the 28 studies exhibited evidence of facilitation process and activity. Only two of the 10 studies explicitly referred to 'facilitators,' with just one indicating that facilitators were a part of the implementation intervention being tested. We identified facilitation processes in the eight remaining studies even though the authors did not report it as such. All studies used facilitation activities in combination with other interventions, the most common being educational meetings or distribution of educational materials. We found evidence related to facilitation for 37 of the 53 facilitation activities (70%) in the taxonomy in at least one study or across studies. An additional three novel facilitation-related activities were identified. Most studies exhibited evidence of external facilitation activity whereby researchers outside of the setting assisted nurses to implement guidelines. Theory informed the development or selection of implementation interventions in 60% (n = 6) of the studies. Drawing conclusions regarding effectiveness of interventions involving facilitation was difficult due to the small number of studies that were included. Furthermore, the included studies varied in the detail provided about the intervention or combination of interventions tested and how interventions were delivered.

CONCLUSIONS

Using an existing systematic review for the purpose of gaining insight into additional research questions was valuable. Although facilitation process and activities are used in interventions to enhance guideline uptake in nursing, these were not conceptualized or referred to by researchers as 'facilitation.' As such, facilitation may be a broader intervention that includes organizing and delivering other interventions. Further research is required to evaluate the relationship between facilitation and other guideline implementation interventions in nursing. The facilitation uncovered within included studies was located primarily in the context of research as it was the researchers who performed most of the facilitation activities. Future inquiries must explore non-researcher-initiated and delivered facilitation intervention activities by following local groups naturally within clinical contexts.

Developing program theory for purveyor programs

Background

Frequently, social interventions produce less for the intended beneficiaries than was initially planned. One possible reason is that ideas embodied in interventions are not self-executing and require careful and systematic translation to put into practice. The capacity of implementers to deliver interventions is thus paramount. Purveyor organizations provide external support to implementers to develop that capacity and to encourage high-fidelity implementation behavior. Literature on the theory underlying this type of program is not plentiful. Research shows that detailed, explicit, and agreed-upon program theory contributes to and encourages high-fidelity implementation behavior. The process of developing and depicting program theory is flexible and leaves the researcher with what might be seen as an overwhelming number of options.

Methods

This study was designed to develop and depict the program theory underlying the support services delivered by a South African purveyor. The purveyor supports seventeen local organizations in delivering a peer education program to young people as an HIV/AIDS prevention intervention. Purposive sampling was employed to identify and select study participants. An iterative process that involved site visits, a desktop review of program documentation, one-on-one unstructured interviews, and a subsequent verification process, was used to develop a comprehensive program logic model.

Results

The study resulted in a formalized logic model of how the specific purveyor is supposed to function; that model was accepted by all study participants.

Conclusion

The study serves as an example of how program theory of a ‘real life’ program can be developed and depicted. It highlights the strengths and weakness of this evaluation approach, and provides direction and recommendations for future research on programs that employ the purveyor method to disseminate interventions.

An evaluation of the implementation of a best practice guideline on tracheal suctioning in intensive care units

Aim  To minimise suctioning-induced complications in intensive care patients, it is crucial that nurses are able to perform the procedure safely and act in accord with research-based recommendations. This paper reports the process of developing, disseminating and implementing the best practice guideline and an evaluation of the process and outcomes of care during and following its implementation in intensive care units. Methods  The study was divided into four phases: (i) to develop the best practice guideline and plan strategies for its dissemination and implementation; (ii) to audit the current practice of nurses in the tracheal suctioning of patients in intensive care units with an artificial airway; (iii) to disseminate and implement the best practice guideline; and (iv) to evaluate the process as well as outcome of care following its implementation in intensive care units. Results  The pretest results indicate that gaps exist between actual nursing practice and recommendations based on research evidence. Most nurses performed the skills in accord with the best practice guideline, with 65% nurses scoring above the 70% level. The post-test audit results show that, overall, nurses demonstrated a good endotracheal suctioning technique, with 96% scoring above 75%, indicating an overall improvement in compliance with the guideline. A statistically significant difference was found between the pretest (73%) and post-test (89%) compliance scores (t = -7.67, P < 0.005). Conclusions  This implementation project highlights the importance of using a rigorous and systematic process to ensure the formal testing of an intervention. Some essential principles in implementing evidence are necessary, such as involving relevant staff and having a range of strategies and clear processes for implementation.

Community re-engagement and interprofessional education: the impact on health care providers and persons living with stroke

PURPOSE

This study evaluated the impact of an educational intervention that integrates concepts of a community re-engagement framework (CR) and interprofessional collaboration (IPC) on health care providers' (HCP) practice with persons living with stroke (PLS).

METHOD

A mixed-methods design was used in which HCPs (n = 67) and PLS (n = 29) participated from 9 organizations across the care continuum. Pre- and postintervention surveys and interviews were conducted with the HCPs. One-on-one interviews with stroke clients were also conducted pre and post intervention. Quantitative responses were analyzed in SPSS (Chicago, Illinois, USA) for descriptive frequencies and differences between pre- and postintervention groups. Qualitative open-ended responses were thematically coded using NVivo7.

RESULTS

Significant increases occurred in HCPs' knowledge of CR, confidence levels in working with PLS, enhanced understanding of the complex needs of PLS, and positive self-reported impacts on practice. PLS reported positive perceptions of care pre and post intervention.

CONCLUSIONS

The intervention provided HCPs with a common language and framework to work collaboratively and holistically in delivering care consistent with stroke best practices.

Evaluation of the dissemination and implementation of pressure ulcer guidelines in Dutch nursing homes

RATIONALE, AIMS AND OBJECTIVES

Annual national prevalence surveys have been conducted in the Netherlands over the past 10 years and have revealed high prevalence rates in Dutch nursing homes. Pressure ulcer guideline implementation is one of the factors that can influence prevalence rates. Previous research has shown that these guidelines are often only partly implemented in Dutch nursing homes. Reasons for this lack of pressure ulcer guideline implementation are not known. Therefore, the aim of this study is to investigate the current situation regarding pressure ulcer guideline dissemination and implementation in Dutch nursing homes.

METHODS

Semi-structured interviews were conducted in eight nursing homes in the Netherlands from January till December 2008. In each nursing home, interviews were held with eight persons.

RESULTS

The implementation of pressure ulcer guidelines was lacking in some of the nursing homes. Risk assessment scales were often not used in practice, repositioning schemes were not always available and, when they were, they were often not used in practice. Knowledge about guideline recommendations was also lacking and pressure ulcer education was inadequate. Barriers to applying guideline recommendations in practice were mostly related to personnel and communication.

CONCLUSIONS

The implementation of pressure ulcer guidelines does not seem to be successful in all nursing homes and needs more attention. Barriers mentioned by the interviewees in applying guideline recommendations need to be addressed. Providing adequate education for nursing home staff and increasing attention for pressure ulcer care can be the first steps in improving the implementation of pressure ulcer guidelines.

Awareness of hypertension guidelines in Taiwanese nurses: a questionnaire survey

BACKGROUND AND RESEARCH OBJECTIVE

Nurses play an important role in hypertension prevention and management because of their unique positions in patient education. However, the effectiveness of patient education relies largely on the nurse's level of awareness of the current hypertension guidelines. The purpose of this study was to examine the level of awareness of hypertension guidelines and associated factors among nurses in Taiwan.

SUBJECTS AND METHODS

A cross-sectional survey was conducted in 10 hospitals in northern Taiwan. The Hypertension Management Questionnaire was developed based on the Taiwan Hypertension Guidelines and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

RESULTS

The survey return rate was 95.9%. A total of 1418 nurses were included in the analysis. Adequate guideline awareness was found in 49.5% of the total sample. Among the 7 dimensions of the Hypertension Management Questionnaire, the definition of hypertension, methods for blood pressure measurements, and impact of high blood pressure on cardiovascular disease had the lowest rates of correct answers. Multiple regression analysis revealed that the nurses' clinical experience, educational level, work setting, in-service education training on hypertension, and level of the hospital (R2 = 35.4%, F = 52.89, P < .001) independently predicted the nurse's level of awareness.

CONCLUSIONS

A large proportion of the nurses in northern Taiwan had insufficient knowledge of the hypertension guidelines.

Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards

AIMS

By developing, implementing and delivering a noise reduction intervention programme, we aimed to attempt to reduce the high noise levels on inpatient wards.

BACKGROUND

Sleep is essential for human survival and sleep deprivation is detrimental to health and well being. Exposure to noise has been found to disrupt sleep in hospitalised patients which is to be expected as noise levels have been measured and reported as high.

DESIGN

A primarily nursing focused, multi-method approach, involving development of clinical guidelines, ward environment review and a staff noise awareness and education programme, was used to target mainly nursing staff plus other healthcare staff on three wards within one hospital.

METHODS

This practice development initiative was carried out in three key phases (1) Preaudit of ward noise levels, (2) The development, implementation and delivery of a noise reduction intervention programme, (3) Postaudit of ward noise levels.

RESULTS

Preintervention average peak decibel levels over 24 hours were found to be 96.48 dB(A) and postintervention average peak decibel levels were measured at 77.52 dB(A), representing an overall significant reduction in noise levels (p < 0.001).

CONCLUSIONS

This study describes one way to reduce peak noise levels on inpatient hospital wards.

RELEVANCE TO CLINICAL PRACTICE

Sleep deprivation is detrimental to patients with acute illness, so any developments to improve patients' sleep are important. Nurses have a key role in leading, developing and implementing changes to reduce peak noise levels on inpatient wards in hospitals. This nurse-led practice development programme has demonstrated how improvements can be achieved by significantly reducing peak noise levels using simple multi-method change strategies.

Protocol-based care: the standardisation of decision-making?

AIM

To explore how protocol-based care affects clinical decision-making.

BACKGROUND

In the context of evidence-based practice, protocol-based care is a mechanism for facilitating the standardisation of care and streamlining decision-making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol-based care does, in the reality of practice, standardise decision-making is unknown. This paper reports on a study that explored the impact of protocol-based care on nurses' decision-making.

DESIGN

Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit.

METHODS

Within each site, data collection included observation, postobservation semi-structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed.

RESULTS

Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision-making. The primary approach to knowledge exchange and acquisition was person-to-person; decision-making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised.

CONCLUSIONS

While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses' decision-making process. This has significant implications for the political goal of standardisation.

RELEVANCE TO CLINICAL PRACTICE

The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses' decision-making processes in parallel to paying attention to the influence of context.

Nurses' experiences of guideline implementation: a focus group study

AIMS

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

BACKGROUND

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

DESIGN

Qualitative interview.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review

BACKGROUND

Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field.

METHODS

A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1) screening on the basis of references and abstracts and (2) screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews.

RESULTS

Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws. A substantial proportion (although not all) of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective. Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation. In addition, characteristics of professionals - e.g., awareness of the existence of the guideline and familiarity with its content - likewise affect implementation. Furthermore, patient characteristics appear to exert influence: for instance, co-morbidity reduces the chance that guidelines are followed. Finally, environmental characteristics may influence guideline implementation. For example, a lack of support from peers or superiors, as well as insufficient staff and time, appear to be the main impediments.

CONCLUSION

Existing reviews describe various factors that influence whether guidelines are actually used. However, the evidence base is still thin, and future sound research - for instance comparing combinations of implementation strategies versus single strategies - is needed.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

BACKGROUND

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.

METHODS

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.

RESULTS

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.

CONCLUSION

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

Factors influencing best-practice guideline implementation: lessons learned from administrators, nursing staff, and project leaders

BACKGROUND

Clinical practice guidelines are promising tools for closing the research evidence-practice gap, yet effective and timely implementation of guidelines into practice remains fragmented and inconsistent. Factors influencing effective guideline implementation remain poorly understood, particularly in nursing. A sound understanding of barriers and facilitators is critical for development of effective and targeted guideline implementation strategies.

AIM

This paper reports the perceptions of administrators, staff, and project leaders about factors influencing implementation of nursing best practice guidelines.

METHODS

Twenty-two organizations, in clusters of two to five, implemented one of seven guidelines in acute, community and long-term care settings. The topics were client centered care, crisis intervention, healthy adolescent development, pain assessment, pressure ulcers, supporting and strengthening families and therapeutic relationships. Fifty-nine administrators, 58 staff and 8 project leaders participated in post implementation semi-structured telephone interviews. Qualitative thematic analysis was conducted.

FINDINGS

Factors at individual, organizational and environmental levels were identified as influencing guideline implementation. Facilitators included learning about the guideline through group interaction, positive staff attitudes and beliefs, leadership support, champions, teamwork and collaboration, professional association support, and inter-organizational collaboration and networks. Barriers included negative staff attitudes and beliefs, limited integration of guideline recommendations into organizational structures and processes, time and resource constraints, and organizational and system level change. Similarities and differences in perceptions of these factors were found among staff, project leaders and administrators.

IMPLICATIONS/CONCLUSIONS

Best practice guideline implementation strategies should address barriers related to the individual practitioner, social context, and organizational and environmental context, and should be tailored to different groups of stakeholders (i.e., nursing staff, project leaders and administrators). Health care administrators need to recognize the "real" costs and complexity associated with successful implementation of guidelines and the need to ensure corporate commitment at the onset.

Tracing and identifying the impact of evidence-use of a modified pipeline model

AIM

This paper opens up a discussion about effective ways of tracing and identifying impact of evidence implementation in the field of nursing, through the use of Nutley et al.'s concept of an impact continuum, and Glasziou's Pipeline Model.

APPROACH

Work to date on improving and evaluating the use of evidence in health care settings has tended to focus on evidence implementation as an endpoint or entity, often seen and measured in terms of change in practice. However, the direct application of evidence to practice is not straightforward. Glasziou's Pipeline Model of the different stages through which evidence flows, in the process of implementation, is critically reviewed in relation to five key issues: the type of evidence entering the pipeline; the linearity of the model; leakages and blockages in the pipeline; levels of impact; and impact measurement. The Pipeline Model is then combined with Nutley et al.'s continuum of impacts in order to present a Modified Pipeline Model.

DISCUSSION AND CONCLUSIONS

The Modified Pipeline Model enables evidence implementation to be viewed as a process rather than an entity in itself, which in turn enables longitudinal assessment of barriers and facilitators to evidence "flow." By flow we mean the way in which evidence is transferred from reporting or publication stages to patient outcomes. It also allows identification of the multiple impacts that can occur through the process of evidence implementation, which may be impact on the way the nurse thinks about practice to the healing rate of a leg ulcer. Finally, the Modified Model raises the issue of impacts beyond the pipeline, that is, those outcomes for patients that result from adherence to evidence-based care. This Modified Pipeline Model thus has the potential to support individuals and organizations in enhanced implementation planning, evaluation and management.

Evaluation of current care effectiveness: a survey of hypertension guideline implementation in Finnish health centres

OBJECTIVE

To assess the extent and style of implementation of the Hypertension Guideline (HT Guideline) in Finnish primary health centres, and to identify a scale of contrasting implementation styles in the health centres (with the two ends of the scale being referred to as information implementers or disseminators respectively).

DESIGN

A cross-sectional study. Development of a questionnaire and criteria for assessing the extent and style of implementation of the HT Guideline.

SETTING

Primary healthcare.

SUBJECTS

All head physicians and senior nursing officers in Finnish health centres (n =290).

MAIN OUTCOME MEASURES

The extent of adoption of the HT Guideline in health centres and the characteristics associated with the implementation style.

RESULTS

Responses were received from 410 senior medical staff (246 senior nursing officers and 164 head physicians) representing altogether 264 health centres (91%) in Finland. The HT Guideline had been introduced into clinical practice in most health centres (89%). The style of implementation varied widely between health centres: at opposite ends of the implementation scale were 21 implementer health centres, which used multiple implementation channels, and 23 disseminator health centres, which used few or no implementation channels. The implementers had typically larger population bases and had organized services around the family doctor system, while the disseminators were smaller and had organized services according to a traditional model (appointments could be with any doctor in the surgery).

CONCLUSION

The Finnish HT Guideline has become well known in most health centres since being introduced into clinical practice. However, the style of implementation varies markedly between health centres.

Implementing nursing practice guidelines: a complex undertaking

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.

Using action research to construct national evidence-based nursing care guidance for gerontological nursing

AIM

This paper explores the development of a low-cost, involving methodology for constructing nursing-focused evidence-based national care guidance, known as Best Practice Statements, the intended users of which are gerontological nurses practising throughout Scotland.

DESIGN

The Best Practice Statement construction methodology forms one cycle in a five-year longitudinal action research study that aims to achieve evidence-based nursing, facilitate professional networking to support practice development and promote the principles and practice of gerontological nursing. Achieving these aims involved designing a virtual Practice Development College.

METHODS

A Community of Practice comprising practising gerontological nurses, expert advisors, academic teaching and research nurses collaborated in face-to-face meetings and in the virtual Practice Development College to delineate and refine the procedural model for Best Practice Statement construction. Focus groups, telephone interviews, analysis of on-line archives and documentary outputs formed the analytic dataset.

RESULTS

Qualitative analysis indicated that, from the perspective of the community of practice, the emerging methodology facilitated the melding of knowledge sources reflecting the dominant evidence hierarchy with other forms of evidence valued by gerontological nurses, in the Best Practice Statement.

RELEVANCE TO CLINICAL PRACTICE

Current methods of care guidance construction rarely address the concerns of nurses and the evidence from which guidelines are developed is narrowly defined with regard to inclusion and acceptability. In contrast this model focuses on nursing issues, embraces a wider definition of evidence and ensures that the published Best Practice Statements are credible and achievable in gerontological practice, where they are tested and refined as an inherent aspect of the development process.

Nursing best practice statements: an exploration of their implementation in clinical practice

AIMS AND OBJECTIVES

To explore implementation of the first five Best Practice Statements from the perspective of nurses involved in their development.

BACKGROUND

Best Practice Statements were introduced in Scotland to encourage consistent evidence-based nursing practice. As a new initiative, research was required to investigate their clinical implementation.

DESIGN AND METHODS

In this descriptive study, semi-structured interviews of a purposive sample of nurses (n = 15) were undertaken. Content analysis was used to identify themes emerging from the interview data.

FINDINGS

Four main themes emerged from analysis of transcripts: variations in use of the Best Practice Statements; benefits to patients; benefits to practitioners; and, barriers and drivers to use. Amongst participants, personal users adopted the statements in their own practice but enablers also actively encouraged others to use the statements. Whether participants acted as enablers depended on individual, team and organizational factors. The ability of participants to act as leaders was influential in determining their ability both to facilitate local implementation and to encourage others to regard the Best Practice Statements as a priority for implementation.

CONCLUSIONS

This exploratory study highlighted examples of patients and practitioners benefiting from the Best Practice Statements. Such findings suggest these statements could become a useful tool in promoting evidence-based nursing practice. However, implementation of the Best Practice Statements varied between participants and their organizations. Nurses who were most effective in promoting local implementation of the Best Practice Statements adopted facilitator and leadership roles within their organizations.

RELEVANCE TO PRACTICE

By relating research findings to the literature on guideline and research utilization, this study gives further insight into the implementation of evidence-based practice by nurses. In particular, it supports the conclusion that to be truly effective, initiatives to promote evidence-based practice require nurses to act as local facilitators and leaders.

Guidelines for clinical practice: development, dissemination and implementation

Clinical guidelines are one of the most promising and effective advances for defining and improving the quality of care. However, their development, dissemination and implementation in practice are rarely straightforward. Within nursing practice, guidelines have the potential to ensure the clinical application of research findings, thus ensuring that the profession rejects ineffective practices while employing those shown to work. Nevertheless, the benefits and limitations of clinical guidelines should be carefully considered by practitioners, managers and consumers of health care alike.

Spirituality and child development: a concept analysis

BACKGROUND

If children are to be given the opportunity to develop to their full potential, fostering spiritual growth must be part of the process of caring for them. However, the meaningful application of spiritual care in everyday practice is fraught with difficulties. In addition to a lack of understanding of the term itself and of the expression of spirituality, in child health these difficulties are further compounded by the stage of a child's development.

AIM

The aims of this paper are to explore spiritual awareness in children by providing examples of the expression of spiritual beliefs in relation to the developmental stage of the child, and to identify the implications of the findings for clinical practice.

METHOD

A model of concept development, using the cyclical process of 'significance', 'use' and 'application' was applied, and formed the philosophical underpinnings for the paper. This framework is particularly relevant to child health, as there is little evidence to draw on, particularly in relation to a child's spiritual needs.

FINDINGS

Five primary research papers which met the inclusion criteria were reviewed, and provided examples of spiritual beliefs and their manifestations in children. The examples highlighted the diversity and complexity of children's thinking.

CONCLUSIONS AND RECOMMENDATIONS

Health care professionals working with children should receive education about the spiritual needs of children. Assessment tools should be developed to facilitate detailed assessment of children's spiritual needs. Professionals need to listen to and communicate with children at different stages of development if spiritual distress is to be identified. Families' health care beliefs should be respected and considered when planning care.

Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district

The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.

A pilot project to evaluate implementation of clinical guidelines

With the global emphasis on quality care based on evidence, this pilot project aimed to examine changes in nursing practice following dissemination and implementation of clinical guidelines. The project implemented a fall prevention guideline in an acute care hospital. Fall preventive nursing practice of the hospital was compared before and after implementation of the guidelines. Results about the changes in nursing practice are discussed in terms of the methods and processes of dissemination and implementation, as well as the features of the guidelines.

Development of clinical guidelines for the sedation of children

Young children may be unwilling or unable to cooperate if they are required to remain motionless for a prolonged period of time. In the hospitalized child, investigative procedures perceived as painful or threatening may need the administration of a sedative. Clinical guidelines, within a large teaching hospital NHS trust in the North of England, were implemented in an attempt to reduce the diversity of the practices of healthcare professionals caring for the child requiring sedation. The guidelines were formulated by a multidisciplinary team and, in conjunction with active dissemination strategies, resulted in a change in practice that included: (1) improved communication and cooperation between departments, (2) implementation of starvation times before the administration of a sedative, and (3) the appropriate referrals to a senior paediatrician to seek advice if contraindications to sedation were identified. Audit was integral to the process, facilitating the comparison of actual practice with the standards developed from the guidelines and ensuring a continuous monitoring programme.

Public awareness and health education: findings from an evaluation of health services for incontinence in England

Improving the health and well being of local populations is a feature of international and national health policy and initiatives. Promotion of health has been attempted traditionally via health education and public awareness campaigns. More recently, attention has been drawn to inter-agency collaboration and alliances in formalised health improvement programmes. This study has evaluated health services for incontinence in two health authorities in England in relation to health education and public awareness. One health authority had an established continence service and the other did not. A convenience sample of self selecting respondents from an earlier postal survey were interviewed via the telephone (n=376). Significantly, more people in the health authority with a continence service than the one without received information on incontinence from within formal health services (p<0.001) and read about services in health centres and clinics (p<0.001), whereas people in the health authority without a continence service were more likely to obtain information on incontinence from local newspapers (p<0.01) and local chemist shops (p<0.01). People in the health authority without a continence service were significantly more likely to feel that services could be improved than those where there was a service (p<0.0001). Only a minority of people with incontinence had received information about their condition or related health care and services. The availability of a continence service significantly influenced the information received. More information on incontinence had been obtained from informal sources than formal health sources. Local initiatives on the availability of services and how to access them, as well as health education information on incontinence may be more effective in raising public awareness and should supplement national campaigns.

Implementing evidence-based health care: the nurse teachers' role in supporting the dissemination and implementation of SIGN clinical guidelines

The effectiveness of clinical care and treatment is central to the quality of health care. Clinical guidelines, audit and research are interrelated activities central to the delivery of high quality services and care. A culture is required that supports the implementation of clinical guidelines and encourages clinicians to critically appraise and evaluate their practice and to become more involved in clinical audit and research. An essential element in the effective implementation of clinical guidelines is educational support. This paper will describe the results of a study which explored the nature of the Scottish Intercollegiate Guidelines Network (SIGN) and the nurse teachers' role in supporting the dissemination and implementation of clinical guidelines within acute care nursing and subsequent curriculum design.

Clinical guidelines in nursing, midwifery and the therapies: a systematic review

BACKGROUND

While nursing, midwifery and professions allied to medicine (PAMs) are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness in relation to these professions. We identified 18 evaluations of guidelines which met established quality for evaluations of interventions aimed at changing professional practice. This paper describes characteristics of guidelines evaluated and the effectiveness of different dissemination and implementation strategies used.

METHODS

Guideline evaluations conducted since 1975 which used a randomized controlled trial, controlled before-and-after, or interrupted time-series design, were identified using a combination of database and hand searching.

FINDINGS

It is mostly impossible to tell whether the guidelines evaluated were based on evidence. The most common method of guideline dissemination was the distribution of printed educational materials. Three studies compared different dissemination and/or implementation strategies: findings suggest educational interventions may be of value in the dissemination of guidelines and confer a benefit over passive dissemination.

Implementation of research findings to reduce postoperative pain at night

This study was designed to introduce and evaluate a research-based intervention to improve night-time pain management. It involved the provision of patient information and the introduction of structured night-time pain assessment. The implementation of the intervention was undertaken by local opinion leader. The study involved 417 patients from two matched orthopaedic wards in a before and after trial with comparison group. Outcomes of night-time pain control were elicited from ward documentation and patients by structured interviews on the second postoperative morning. These incorporated retrospective pain assessments, analgesic provision and nursing comfort measures provided the previous night. The intervention was associated with statistically significant reductions in both average and worst overnight pain scores. The frequency of night-time pain assessment by nursing staff increased significantly, although patients did not volunteer reports of pain more frequently and analgesics and other comfort measures were no more frequent. The intervention required an investment in educational support but no additional resources were needed for the successful reduction in pain scores.

Effect of clinical guidelines in nursing, midwifery, and the therapies: a systematic review of evaluations

BACKGROUND

Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness, 18 evaluations of guidelines were identified that meet Cochrane criteria for scientific rigor.

METHODS

Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series design were identified through a combination of database and hand searching.

RESULTS

18 studies met the inclusion criteria. Three studies evaluated guideline dissemination or implementation strategies, nine compared use of a guideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared with standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring process and in which guidelines were expected to have a positive impact on performance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings.

CONCLUSIONS

Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care. However, many studies fell short of the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC) for methodological quality.

Establishing evidence-based practice: issues and implications in critical care nursing

Evidence-based practice is the application of the best available empirical evidence, including recent research findings to clinical practice in order to aid clinical decision-making. The implementation of these findings is vital for optimizing patient outcomes, improving clinical practice, providing cost-effective high quality care and enhancing the credibility of nurses. The use of research findings to improve practice has been discussed and promoted for the last 20 years. The author argues that Rogers' theoretical model of the Diffusion of Innovations may prove useful in understanding the problem of the slow diffusion of the application of research evidence in clinical nursing practice. Many authors have discussed potential barriers to using research in clinical practice in order to facilitate utilization of findings. However, recent studies all document that a gap between research findings and their implementation in clinical practice still exists. This appears to hold true across a variety of practice settings, including nurses working in critical care. The diffusion of innovations in current critical care nursing practice at each stage of Rogers' theory will be examined, with recommendations given to facilitate the establishment of evidence-based practice (EBP).