An exploration of the factors that influence the implementation of evidence into practice

Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study

OBJECTIVES

Organizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation-individually, and their interactions-were associated with delirium in LTC.

DESIGN

Retrospective cross-sectional analysis of secondary data.

SETTING AND PARTICIPANTS

We included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces.

METHODS

Delirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates.

RESULTS

Delirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms [odds ratio (OR) = 0.63]. Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially.

CONCLUSIONS AND IMPLICATIONS

Unit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study

BACKGROUND

The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP.

OBJECTIVE

The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic.

METHODS

We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name "X-Clinic." We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods.

RESULTS

Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%).

CONCLUSIONS

We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Factors Shaping the Implementation of Strategies to Prevent Acute Kidney Injury: A Qualitative Study

Reducing the prevalence of acute kidney injury (AKI) is an important patient safety objective set forth by the National Quality Forum. Despite international guidelines to prevent AKI, there continues to be an inconsistent uptake of these interventions by cardiac teams across practice settings. The IMPROVE-AKI study was designed to test the effectiveness and implementation of AKI preventive strategies delivered through team-based coaching activities. Qualitative methods were used to identify factors that shaped sites' implementation of AKI prevention strategies. Semi-structured interviews were conducted with staff in a range of roles within the cardiac catheterization laboratories, including nurses, laboratory managers, and interventional cardiologists (N = 50) at multiple time points over the course of the study. Interview transcripts were qualitatively coded, and aggregated code reports were reviewed to construct main themes through memoing. In this paper, we report insights from semi-structured interviews regarding workflow, organizational culture, and leadership factors that impacted implementation of AKI prevention strategies.

Telemedicine: Niche or mainstream? A bibliometric analysis and review of the output of highly ranked clinical journals

Historically, telemedicine research is predominantly published in discipline-specific telemedicine journals. However, in recent times the number of publications on telemedicine in clinical journals has increased. Acceptance of telemedicine research by clinical journals indicates a maturing of the telemedicine field. This bibliometric study reviewed telemedicine-related literature published in clinical journals from 2008 to 2018. A search was conducted in PubMed using two types of clinical outlets. (1) Top 20 journals with highest Impact Factor in the field of Medicine. (2) Top five journals with highest Impact Factor in most common Medical Specialty Areas. Analysis showed that there is a steady growth of literature relating to research and non-research publications appearing in clinical journals. Top five journals in the field of Medicine - BMJ, JAMA, Cochrane database, Medical Journal of Australia and Lancet have published 64% (n = 270) of telemedicine-related articles for the study period. Disease areas associated with telemedicine publications are consistent with global disease priorities. The review demonstrated that the most significant increase in telemedicine research published in clinical journals was focused on patient care.

Navigating the facilitation journey: a qualitative, longitudinal evaluation of 'Eat Walk Engage' novice and experienced facilitators

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) and integrated-PARIHS (i-PARIHS) frameworks position facilitation as an overarching strategy to enable implementation. In the revised i-PARIHS framework, facilitation is operationalised through a multi-level model with novice, experienced and expert facilitators working together in a network structure to build facilitation knowledge and skills along a continuum. To date, there has been limited evaluation of this facilitation model in practice, which is the aim of the study reported here.

METHODS

A descriptive, qualitative longitudinal study was undertaken to track a team of four novice and two experienced facilitators involved in facilitating the implementation of an intervention known as 'Eat Walk Engage' to improve multidisciplinary team delivery of age-friendly care principles in hospital. Over an 18-month period, repeat interviews were conducted to explore the learning, development, and evolving roles of novice facilitators and the roles of the experienced facilitators in providing support and mentoring. Interview data were analysed using a descriptive qualitative approach and findings were interpreted in collaboration with the participating facilitators.

RESULTS

The findings demonstrated experiential learning in both the novice and experienced facilitator groups as they enacted their roles in practice. The novice facilitators progressively transitioned to becoming more experienced facilitators and the experienced facilitators became increasingly expert, in line with the i-PARIHS concept of a facilitation journey from novice to expert. Strategies to support this development included a staggered approach to learning, regular meetings between the experienced and novice facilitators, reflective writing and informal peer support and networking. However, the roles were not without challenge and these challenges changed over time, from a more specific focus on the demands of the facilitator role to concerns about embedding and sustaining improvements in practice.

CONCLUSIONS

Within a network of peers and a mentored relationship with more experienced facilitators, individuals who are new to an implementation facilitator role can transition along a continuum to become experienced facilitators. Building implementation facilitation capability in this way takes time and requires tailored support and mentorship using a mix of structured and flexible approaches incorporating opportunities for reflection to support individual and group learning.

Getting to implementation: Adaptation of an implementation playbook

Introduction

Implementation strategies supporting the translation of evidence into practice need to be tailored and adapted for maximum effectiveness, yet the field of adapting implementation strategies remains nascent. We aimed to adapt "Getting To Outcomes"® (GTO), a 10-step implementation playbook designed to help community-based organizations plan and evaluate behavioral health programs, into "Getting To Implementation" (GTI) to support the selection, tailoring, and use of implementation strategies in health care settings.

Methods

Our embedded evaluation team partnered with operations, external facilitators, and site implementers to employ participatory methods to co-design and adapt GTO for Veterans Health Administration (VA) outpatient cirrhosis care improvement. The Framework for Reporting Adaptations and Modifications to Evidenced-based Implementation Strategies (FRAME-IS) guided documentation and analysis of changes made pre- and post-implementation of GTI at 12 VA medical centers. Data from multiple sources (interviews, observation, content analysis, and fidelity tracking) were triangulated and analyzed using rapid techniques over a 3-year period.

Results

Adaptations during pre-implementation were planned, proactive, and focused on context and content to improve acceptability, appropriateness, and feasibility of the GTI playbook. Modifications during and after implementation were unplanned and reactive, concentrating on adoption, fidelity, and sustainability. All changes were collaboratively developed, fidelity consistent at the level of the facilitator and/or implementer.

Conclusion

GTO was initially adapted to GTI to support health care teams' selection and use of implementation strategies for improving guideline-concordant medical care. GTI required ongoing modification, particularly in steps regarding team building, context assessment, strategy selection, and sustainability due to difficulties with step clarity and progression. This work also highlights the challenges in pragmatic approaches to collecting and synthesizing implementation, fidelity, and adaptation data.

Trial registration

This study was registered on ClinicalTrials.gov (Identifier: NCT04178096).

Musculoskeletal disorder (MSD) prevention practices by nurses working in health care settings: Facilitators and barriers to implementation

The incidence of musculoskeletal disorders (MSD) in the healthcare professional population is concerning. In particular, the high incidence of back injuries is an issue for nurses. Although many MSD prevention initiatives are being implemented, these practices are not succeeding in reducing MSDs. Why are these efforts struggling to close the gap between knowledge and practice? This article aims to report on individual and organizational factors that may influence nurses' implementation of MSD prevention practices. A survey was sent to nurses in the Quebec health and social services network. A total of 399 questionnaires were completed and analyzed. The results revealed that nurses have the required knowledge on MSD prevention practices, but have difficulty applying them in their professional context. It would appear that successful implementation of MSD prevention practices relies mainly on organizational factors, including management support, organizational culture, feedback mechanisms, and training that is adapted to the work environment.

Reporting unit context data to stakeholders in long-term care: a practical approach

Background

The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context.

Methods

We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis.

Results

Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method.

Conclusions

We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration

BACKGROUND

Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients.

METHODS

In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat.

RESULTS

From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)).

CONCLUSION

Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616000544471p.

Improving the Physical Health of Psychiatric Hospital Residents: An Evaluation of an Obesity Education Program for Mental Health Professionals

Background: People living with mental health disorders are at increased risk for developing obesity due to poor diet, physical inactivity, and antipsychotic medications. In the United States, the obesity rate is 36% in the general population and more than 50% for people living with mental health disorders. Although mental health clinicians concentrate on managing psychiatric disorders, they seldom recognize the gradual increase in body mass index of their patients. The result is a disconnection between the clinical management of psychiatric disorders and the medical management of obesity. Purpose: This study assessed the effectiveness of an evidence-based education program for improving the obesity management practices of mental health clinicians caring for residents at a state psychiatric hospital. Methods: This was a quasi-experimental study design with a pretest and posttest evaluation. Convenience sampling was used to recruit mental health professionals, or clinicians, at a large psychiatric hospital in the Southern region of the United States. Data was collected with the Advising and Treating Overweight and Obese Patient questionnaire (17 items). Data analysis included descriptive and inferential statistics. The findings were reported in accordance with the TREND and GREET guidelines. Results: The education program was completed by 50 MHCs. The pretest indicated that 76% of MHCs were not involved in helping obese residents manage their weight, but the posttest indicated 90% were involved. There was a significant increase in MHC knowledge about obesity management and reported actions 90-days after the program. MHCs were unable to arrange follow-up visits for residents, a task not directly within their control. Conclusions: Mental health clinicians reported increased knowledge and improved clinical practice after an education program. Because the outcomes were reported at 90-days after the program, further research needs to evaluate the longitudinal impact of this type of program, where the reported behaviors are correlated to process and clinical outcome measures for obesity.

Development of a qualitative data analysis codebook informed by the i-PARIHS framework

BACKGROUND

The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and its predecessor, PARIHS, have been widely utilized in implementation studies. Although i-PARIHS developers have focused on creating tools to guide facilitators in its application in practice, tools are also needed for evaluation and research. Codebooks with clear and meaningful code labels and definitions are an important component of qualitative data analysis and have been developed for other widely used frameworks. There is no such codebook for i-PARIHS. Additionally, sub-constructs for the Innovation, Recipients, and Context constructs lack definitions, and there is no sub-classification of facilitation activities for the Facilitation construct. The lack of a standardized codebook hinders our ability to synthesize research findings across studies, explore and test the range of activities that are utilized in facilitation efforts, and potentially validate and further refine i-PARIHS. This paper describes a rigorous process of developing a detailed qualitative codebook informed by the i-PARIHS framework.

METHODS

A workgroup of qualitative researchers conducted a rigorous four-phase process to develop a codebook informed by i-PARIHS. In phase 1, workgroup members reviewed and discussed literature, consulted an organizational scientist, and drafted and refined subcodes and definitions for i-PARIHS constructs. In phase 2, they obtained feedback from an expert panel and further refined subcodes and definitions. In phase 3, they obtained feedback from i-PARIHS developers/experts and incorporated it into the codebook. Finally, two studies piloted the application of the codebook which informed the final version.

RESULTS

The resulting i-PARIHS-informed codebook includes definitions for the four main constructs of the framework: Innovation, Recipients, Context, and Facilitation; subcodes and definitions for characteristics of each of these constructs; and instructions for the suggested application of individual codes and use of the codebook generally.

CONCLUSIONS

The standardized codes and definitions in the codebook can facilitate data exploration, pattern identification, and insight development informed by the i-PARIHS framework. Qualitative analysts can also use them to explore interactions between i-PARIHS constructs, maximize the potential for comparing findings across studies, and support the refinement of the i-PARIHS framework using empirical findings from multiple studies.

Context Matters in Evidence Implementation Globally Comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis"

Context influences the effectiveness of healthcare interventions and should be considered to inform their implementation. However, context remains poorly defined in the knowledge translation (KT) literature. The paper by Squires and colleagues constitutes a valuable contribution to the field of KT as it provides the basis for a comprehensive framework to assess the influence of context on implementation success. In their study, Squires et al identified 66 context features, grouped into 16 attributes. Their findings highlight a great convergence in the context features mentioned by stakeholders across countries, experience levels and roles in KT. Thus, the proposed framework could eventually transfer to several implementation settings. However, all study participants were from high-income countries. It would therefore be important to replicate this research in low- and middle-income countries (LMICs). A common understanding of what context means is essential to assessing its influence on the implementation of healthcare interventions globally.

Clinician perspectives on implementing a team-based metacognitive strategy training approach to stroke rehabilitation

INTRODUCTION

The objective of this research study was to explore site and clinician specific experiences, successes and challenges in implementing a complex intervention (cognitive orientation to daily occupational performance approach) to enhance stroke team's ability to address cognitive impairments as part of comprehensive stroke rehabilitation.

METHODS

A focus group was held with clinicians from five study sites, all rehabilitation stroke hospitals in a large urban setting, to discuss implementation experiences. Participants were clinicians (site champions) from each of the five participating stroke program study sites and included four occupational therapists, three physiotherapists and one speech-language pathologist. Thematic analysis was used to identify themes that represented clinicians' perspectives.

RESULTS

Implementing this complex team-based intervention was influenced by three themes-organizational support, experiential evidence, and clinicians' perspectives. Continued implementation of the intervention following the withdrawal of study support was represented on a continuum that ranged from not using the approach at all to implementing it with all patients. Sites where managers encouraged and supported use of the intervention within teams (organization support), continued to use it after the study support period as did clinicians who were willing to try new interventions (clinicians' perspectives). Development of iterative conclusions through implementation or attempts to implement the intervention had both positive and negative effects on continued implementation (experiential evidence).

CONCLUSIONS

Strategies that reinforce development of positive experiential evidence and building organizational support for innovative practice were found to be useful adjuncts in facilitating implementation of complex interprofessional interventions.

Translating Clinical Research to Clinical Care in Nephrology: A Qualitative Study of Nephrology Clinicians

Rationale & Objective

Study Design

Setting & Participants

Analytical Approach

Results

Limitations

Conclusions

Age- and Sex-Specific Needs for Children Undergoing Inflammatory Bowel Disease Surgery: A Qualitative Study

INTRODUCTION

The use of enhanced recovery protocols (ERP) is extending to pediatric surgical populations, such as patients with inflammatory bowel diseases (IBDs). Given the variation in age- and sex-specific characteristics of pediatric IBD patients, it is important to understand the unique needs of subgroups, such as male versus female or preadolescent versus older patients, when implementing ERPs. We gathered clinician, patient, and caregiver perspectives on age- and sex-specific needs for children undergoing IBD surgery.

METHODS

We used semistructured interviews and focus groups to assess ERP needs and perceived differences in needs between preadolescent (10-13 y), older (14-19 y), male, and female IBD patients. Participants included clinicians, patients who had recent IBD surgery, and patients' caregivers.

RESULTS

Forty-eight clinicians, six patients, and eight caregivers participated. Three broad categories of themes emerged: concerns, needs, and experiences related to the (1) surgical care process; (2) continuum of IBD care; and (3) suggestions to make surgical care more patient centered. With regard to surgical care processes, stakeholders reported different communication needs for preadolescent and older children. Key themes about the continuum of IBD care were the need (1) for support from child life specialists and (b) to address young women's health issues. Suggestions to make surgical care more patient centered included providing older children with patient experiences that reflect their perspective as young adults.

CONCLUSIONS

The findings highlight the need to adopt a patient-centered approach for ERP use that actively addresses age- and sex-specific factors while engaging patients and caregivers as partners with clinicians to improve surgical care for children with IBD.

Distress management in cancer patients: Guideline adaption based on CAN-IMPLEMENT

Objective

This study aimed to adapt relevant clinical practice guidelines for distress management in cancer patients based on A Guideline Adaptation and Implementation Planning Resource (CAN-IMPLEMENT), and develop Cancer-related Distress Management Guidelines in the context of the research site.

Methods

According to CAN-IMPLEMENT, the symptoms of cancer patients in Shanghai were investigated, and a work plan was formulated to adapt cancer-related distress management guidelines. The relevant clinical practice guidelines for distress management in cancer patients were searched, screened and assessed, the contents of the included clinical practice guidelines were screened, extracted and integrated, and the Cancer-related Distress Management Guidelines was developed. After peer review, the Cancer-related Distress Management Guidelines was finally formed.

Results

The physical symptom distress score was higher than the psychological symptom distress score among cancer patients in Shanghai. Two clinical practice guidelines related to distress management in cancer patients were included after searching, screening, assessment and selection systematically. The domain scores of the draft Cancer-related Distress Management Guidelines on Appraisal of Guidelines for Research and Evaluation II (AGREE II) were 73.75%–87.50%, respectively. The scores of most recommendations on feasibility, appropriateness, meaningfulness and effectiveness were at least 90%. The final guidelines included 13 recommendations.

Conclusions

The quality of the draft Cancer-related Distress Management Guidelines based on two included guidelines was well-accepted. The final Cancer-related Distress Management Guidelines needs to be further verified in clinical practice for feasibility, suitability and effectiveness.

Primary palliative care integrated model in paediatric ICU: an international cross-sectional study

OBJECTIVES

Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC.

METHODS

International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models.

RESULTS

High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores.

CONCLUSIONS

All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN12556149.

Sustained effects of the INFORM cluster randomized trial: an observational post-intervention study

BACKGROUND

Numerous studies have examined the efficacy and effectiveness of health services interventions. However, much less research is available on the sustainability of study outcomes. The purpose of this study was to assess the lasting benefits of INFORM (Improving Nursing Home Care Through Feedback On perfoRMance data) and associated factors 2.5 years after removal of study supports. INFORM was a complex, theory-based, three-arm, parallel cluster-randomized trial. In 2015-2016, we successfully implemented two theory-based feedback strategies (compared to a simple feedback approach) to increase nursing home (NH) care aides' involvement in formal communications about resident care.

METHODS

Sustainability analyses included 51 Western Canadian NHs that had been randomly allocated to a simple and two assisted feedback interventions in INFORM. We measured care aide involvement in formal interactions (e.g., resident rounds, family conferences) and other study outcomes at baseline (T1, 09/2014-05/2015), post-intervention (T2, 01/2017-12/2017), and long-term follow-up (T3, 06/2019-03/2020). Using repeated measures, hierarchical mixed models, adjusted for care aide, care unit, and facility variables, we assess sustainability and associated factors: organizational context (leadership, culture, evaluation) and fidelity of the original INFORM intervention.

RESULTS

We analyzed data from 18 NHs (46 units, 529 care aides) in simple feedback, 19 NHs (60 units, 731 care aides) in basic assisted feedback, and 14 homes (41 units, 537 care aides) in enhanced assisted feedback. T2 (post-intervention) scores remained stable at T3 in the two enhanced feedback arms, indicating sustainability. In the simple feedback group, where scores were had remained lower than in the enhanced groups during the intervention, T3 scores rose to the level of the two enhanced feedback groups. Better culture (β = 0.099, 95% confidence interval [CI] 0.005; 0.192), evaluation (β = 0.273, 95% CI 0.196; 0.351), and fidelity enactment (β = 0.290, 95% CI 0.196; 0.384) increased care aide involvement in formal interactions at T3.

CONCLUSIONS

Theory-informed feedback provides long-lasting improvement in care aides' involvement in formal communications about resident care. Greater intervention intensity neither implies greater effectiveness nor sustainability. Modifiable context elements and fidelity enactment during the intervention period may facilitate sustained improvement, warranting further study-as does possible post-intervention spread of our intervention to simple feedback homes.

Critical perspectives on implementation of evidence-based practice in occupational therapy – Exemplified by Lifestyle Redesign® in a Danish context

Introduction

Evidence-based practice is an increasing demand in occupational therapy (OT), although multiple barriers can hinder the translation of research knowledge into practice. The article illuminates the transformation of results from a randomised controlled trial into a practice development project with future practice implementation in mind.

Method

A case study was carried out, consisting of a comparison of the US randomised controlled trials (RCTs) Lifestyle Redesign® and the derived Danish practice development project.

Results

The study showed how results from RCTs of Lifestyle Redesign® were transformed into a practice development project with intentions to implement the programme in a Danish context. The modifications of the US RCT into a practice development project in Denmark compromised the study’s scientific execution. The practice development project was used to legitimise the intervention within OT locally by testing an evidence-based intervention, without using associated scientific tools and without considering barriers and facilitators for implementing the project in clinical practice.

Conclusion

Research design compromises in practice development projects may have implications for the internal and external dynamics of professionalisation processes regarding OT and the recognition of OT as a scientific discipline and an autonomous profession, nationally and internationally.

Leadership as a Facilitator of Evidence Implementation by Nurse Managers: A Metasynthesis

Evidence-based practice is often not implemented in nursing for reasons relating to leadership. This article aims to cast light on the factors that facilitate nursing evidence implementation perceived by nurse managers in their practical experiences of this implementation. It is a qualitative, narrative metasynthesis of primary studies on nurse managers' leadership-related facilitation experiences, following the Joanna Briggs Institute meta-aggregative approach and the Promoting Action on Research Implementation in Health Services (PARiHS) model. Eleven primary studies were included and three general categories were identified as leadership-related factors facilitating evidence implementation: teamwork (communication between managers and staff nurses), organizational structures (strategic governance), and transformational leadership (influence on evidence application and readiness for change among leaders). Nurse managers act as facilitators of evidence-based practices by transforming contexts to motivate their staff and move toward a shared vision of change. Always providing support as managers and colleagues, sharing their experience in the clinic environment.

Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period

Background

An ever-increasing technological development in the field of radiology urges a need for guidelines to provide predictable and just health services. A musculoskeletal guideline was developed in Norway in 2014, without active implementation.

Purpose

To investigate the impact of active guideline implementation on the use of musculoskeletal diagnostic imaging most frequently encountered in general practice (pain in the neck, shoulders, lower back, and knees).

Material and Methods

The total number of outpatient radiological examinations across modalities registered at the Norwegian Health Economics Administration between January 2013 and February 2019 was assessed using an interrupted time series design.

Results

A 12% reduction in the total examination of Magnetic Resonance Imaging shoulder and knee, and x-ray lower back and shoulder was found at a significant level (p = 0.05). Stratified analysis (Magnetic Resonance Imaging examination as one group and x-ray examinations as the other) showed that this reduction mainly was due to the reduction in the use of Magnetic Resonance Imaging examinations (shoulder and knee) which was reduced by 24% at a significant level (p = 0.002), while x-ray examinations had no significant level change (p = 0.71). No other statistically significant changes were found.

Conclusion

The impact of the implementation on the use of imaging of the neck, shoulder, lower back, and knee is uncertain. Significant reductions were demonstrated in the use of some examinations in the intervention county, but similar effects were not seen when including a control group in the analysis. This indicates a diffusion of the implementation, or other interventions or events that affected both counties and occurred in the intervention period.

Involvement of Civil Society Organization in Facilitating the Implementation of Ten Steps for Successful Breastfeeding: Analysis of Health Care Workers' Perspectives?

Despite the present of national policy support, the prevalence of early breastfeeding initiation in Indonesia are still low. Research has shown that health care workers are the most reliable source for breastfeeding advice, but sadly they were often lacking in capacity. The aim of the study to assess the involvement of civil society organization (CSO) and its associated factors in facilitating the implementation of Ten Steps for Successful Breastfeeding (TSSB) based on health care workers' perspectives in Malang and Sidoarjo districts, East Java Province, Indonesia. We used qualitative approach to in-depth interview 117 participants and conducted 14 FGDs in Sidoarjo and Malang East Java. the PARiHS framework was used to identify the role of CSO in facilitating the BFHI implementation from the health workers perspective to offer insight on the facilitation process and development of future recommendations. The study found that the health care workers' have good knowledge on the benefits of breastfeeding with significant portion of the knowledge that they hold are coming from trainings provided by the CSO. There was cultural context barriers within the community, where grandmothers are considered as an important influence factor esspecially for working mothers. The implementation of training by the CSO was considered appropriate due to its ability to address some pressing structural obstacles and provide not only training to improve evidence but also help in addressing other contextual barriers. The CSO has offered opportunities not only for dissemination of evidence-based intervention but also to close gaps on resources provision to attend courses.

Palliative and end-of-life care in care homes: protocol for codesigning and implementing an appropriate scalable model of Needs Rounds in the UK

INTRODUCTION

Palliative and end-of-life care in care homes is often inadequate, despite high morbidity and mortality. Residents can experience uncontrolled symptoms, poor quality deaths and avoidable hospitalisations. Care home staff can feel unsupported to look after residents at the end of life. Approaches for improving end-of-life care are often education-focused, do not triage residents and rarely integrate clinical care. This study will adapt an evidence-based approach from Australia for the UK context called 'Palliative Care Needs Rounds' (Needs Rounds). Needs Rounds combine triaging, anticipatory person-centred planning, case-based education and case-conferencing; the Australian studies found that Needs Rounds reduce length of stay in hospital, and improve dying in preferred place of care, and symptoms at the end of life.

METHODS AND ANALYSIS

This implementation science study will codesign and implement a scalable UK model of Needs Rounds. The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to identify contextual barriers and use facilitation to enable successful implementation. Six palliative care teams, working with 4-6 care homes each, will engage in two phases. In phase 1 (February 2021), stakeholder interviews (n=40) will be used to develop a programme theory to meet the primary outcome of identifying what works, for whom in what circumstances for UK Needs Rounds. Subsequently a workshop to codesign UK Needs Rounds will be run. Phase 2 (July 2021) will implement the UK model for a year. Prospective data collection will focus on secondary outcomes regarding hospitalisations, residents' quality of death and care home staff capability of adopting a palliative approach.

ETHICS AND DISSEMINATION

Frenchay Research Ethics Committee (287447) approved the study. Findings will be disseminated to policy-makers, care home/palliative care practitioners, residents/relatives and academic audiences. An implementation package will be developed for practitioners to provide the tools and resources required to adopt UK Needs Rounds.

REGISTRATION DETAILS

Registration details: ISRCTN15863801.

Implementation and Evaluation of a Standardized Nurse-Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care

BACKGROUND

Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse-administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care.

AIM

This study aimed to implement and evaluate the interRAI AC assessment system using a multi-strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

METHODS

This nurse-led quality improvement study was piloted in a 200-bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance).

RESULTS

In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre-implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed.

LINKING EVIDENCE TO ACTION

Despite challenges to implementing a system-wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis

Background

Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.

Objectives

Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.

Design

A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.

Participants

In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.

Data sources

Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.

Results

The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.

Limitations

Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.

Conclusions

This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.

Study registration

This study is registered as PROSPERO CRD42017081030.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

How Barunga Aboriginal community implemented and sustained an anaemia program - A case study evaluation

ISSUE ADDRESSED

Anaemia persists as a public health issue in many Aboriginal communities despite having standard practice guidelines. This case study reveals how Barunga Aboriginal Community in the Northern Territory (NT), Australia, implemented an Anaemia Program (1998-2016) which contributed to low anaemia prevalence in children aged under 5 years.

METHODS

This retrospective qualitative case study used purposive sampling to describe the Anaemia Program and factors influencing its implementation. Themes were developed from convergence of three data sources: interviews, program observation and document review. Data were inductively analysed by an Aboriginal and non-Aboriginal researcher and themes were validated by Barunga community health practitioners and compared to practice guidelines and implementation literature.

RESULTS

Health practitioners reported that the Anaemia Program contributed to a marked reduction in childhood anaemia prevalence over time. This was supported by available prevalence data. The locally adapted Anaemia Program was unique in the NT with a novel approach to community supplementation for anaemia prevention in addition to anaemia treatment. Supportive implementation influences included: Aboriginal leadership and the use of culturally supportive processes which reinforced the development of trust and strong relationships facilitating community acceptance of the Program. Routine, opportunistic and flexible health care practice, a holistic approach and a stable, skilled and experienced team sustained program implementation.

CONCLUSIONS

The holistic and successful Barunga Anaemia Program is supported by evidence and guidelines for treating and preventing childhood anaemia. The contextualisation of these guidelines aligned with the literature on effective Aboriginal primary health care implementation. SO WHAT?: This Anaemia Program provides a model for implementation of evidence-informed guidelines in an Aboriginal primary health care setting.

Use of an electronic medical record dashboard to identify gaps in osteoporosis care

Using an electronic medical record (EMR)-based dashboard, this study explored osteoporosis care gaps in primary care. Eighty-four physicians shared their practice activities related to bone mineral density testing, 10-year fracture risk calculation and treatment for those at high risk. Significant gaps in fracture risk calculation and osteoporosis management were identified.

PURPOSE

To identify care gaps in osteoporosis management focusing on Canadian clinical practice guidelines (CPG) related to bone mineral density (BMD) testing, 10-year fracture risk calculation and treatment for those at high risk.

METHODS

The ADVANTAGE OP EMR tool consists of an interactive algorithm to facilitate assessment and management of fracture risk using CPG. The FRAX® and Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tools were embedded to facilitate 10-year fracture risk calculation. Physicians managed patients as clinically indicated but with EMR reminders of guideline recommendations; participants shared practice level data on management activities after 18-month use of the tool.

RESULTS

Eighty-four physicians (54%) of 154 who agreed to participate in this study shared their aggregate practice activities. Across all practices, there were 171,310 adult patients, 40 years of age and older, of whom 17,214 (10%) were at elevated risk for fracture. Sixty-two percent of patients potentially at elevated risk for fractures did not have BMD testing completed; most common reasons for this were intention to order BMD later (48%), physician belief that BMD was not required (15%) and patient refusal (20%). For patients with BMD completed, fracture risk was calculated in 29%; 19% were at high risk, of whom 37% were not treated with osteoporosis medications as recommended by CPG.

CONCLUSION

Despite access to CPG and fracture risk calculators through the ADVANTAGE OP EMR tool, significant gaps remain in fracture risk calculation and osteoporosis management. Additional strategies are needed to address this clinical inertia among family physicians.

Pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing-BHiRCH-NH Study)

OBJECTIVES

To pilot a complex intervention to support healthcare and improve early detection and treatment for common health conditions experienced by nursing home (NH) residents.

DESIGN

Pilot cluster randomised controlled trial.

SETTING

14 NHs (7 intervention, 7 control) in London and West Yorkshire.

PARTICIPANTS

NH residents, their family carers and staff.

INTERVENTION

Complex intervention to support healthcare and improve early detection and treatment of urinary tract and respiratory infections, chronic heart failure and dehydration, comprising: (1) 'Stop and Watch (S&W)' early warning tool for changes in physical health, (2) condition-specific care pathway and (3) Situation, Background, Assessment and Recommendation tool to enhance communication with primary care. Implementation was supported by Practice Development Champions, a Practice Development Support Group and regular telephone coaching with external facilitators.

OUTCOME MEASURES

Data on NH (quality ratings, size, ownership), residents, family carers and staff demographics during the month prior to intervention and subsequently, numbers of admissions, accident and emergency visits, and unscheduled general practitioner visits monthly for 6 months during intervention. We collected data on how the intervention was used, healthcare resource use and quality of life data for economic evaluation. We assessed recruitment and retention, and whether a full trial was warranted.

RESULTS

We recruited 14 NHs, 148 staff, 95 family carers and 245 residents. We retained the majority of participants recruited (95%). 15% of residents had an unplanned hospital admission for one of the four study conditions. We were able to collect sufficient questionnaire data (all over 96% complete). No NH implemented intervention tools as planned. Only 16 S&W forms and 8 care pathways were completed. There was no evidence of harm.

CONCLUSIONS

Recruitment, retention and data collection processes were effective but the intervention not implemented. A full trial is not warranted.

TRIAL REGISTRATION NUMBER

ISRCTN74109734 (https://doi.org/10.1186/ISRCTN74109734). ORIGINAL PROTOCOL: BMJ Open. 2019;9(5):e026510. doi:10.1136/bmjopen-2018-026510.

The needs of key-stakeholders for evaluating client's experienced quality of home care: a qualitative approach

BACKGROUND

To optimize home care, it is essential to determine how care recipients experience quality of care. Traditionally, quality of care is measured with normative quality indicators such as safety, efficiency, or prevalence rates such as falls. The growing interest for qualitative patient-reported experience measures in home care requires insight into the needs of care receivers, providers, and organizations as key-stakeholders. Each stakeholder has their own needs that are important to communicate and use to conduct thorough comparisons before implementing new experience measures. This study aims to understand the needs of clients, formal/informal caregivers, and managers/policy officers in measuring client's experienced quality of care in home care.

METHODS

Four focus group interviews and 25 semi-structured interviews with key-stakeholders were conducted and analyzed by means of content analysis. The value-proposition canvas was used as a thematic framework to explore the purpose of experience quality of care measures and related pains and gains.

RESULTS

There were two main purposes for measuring experienced quality of care: first improving the primary care process of individual clients and second for learning and improving in home care team. Using experienced quality of care measures for external accountability and transparency on an organizational or national level were considered less relevant. Among others, participants described not having time and no clear procedure for conducting an evaluation as a pain of the current methods used to evaluate perceived quality of home care. As gains they put forward the ability to informally evaluate experiences during care delivery and to openly discuss complaints with a familiar caregiver.

CONCLUSIONS

This study advocates that home care organizations should be aware of the goal of quality of care measures. They should consider selecting experienced quality of care measures mainly for improving primary care processes of individual clients. The results also underline the relevance of adopting next to quantitative evaluations, more narrative evaluation methods which support communicating openly on care experiences, leading to concrete point-of-improvement. The findings of this study can serve as a guide for both the development or selection of adequate methods, from the perspectives of key-stakeholders, in assessing experienced quality in home care.

Aligning three substance use disorder interventions among a tribe in the Southwest United States: Pilot feasibility for cultural re-centering, dissemination, and implementation

In this article we describe cultural re-centering, dissemination, and implementation activities in partnership between an American Indian reservation community and a university in the Southwest United States. We offer examples of cultural adaptation and implementation of evidence-based treatments (e.g., Motivational Interviewing, Community Reinforcement Approach and the Community Reinforcement and Family Training) using the Interactive Systems Framework. Facilitators and barriers are described within each study including recruitment strategies, training, and sustainability of counselors in the community. Through this Tribal-university partnership, we offer insight on the cultural adaptation and implementation process that will be translatable and clinically meaningful to other rural and reservation communities.

Determining Attitudes of Nurses Toward Evidence-Based Nursing in a University Hospital Sample

AIM

This study aimed to determine the attitudes of nurses working in a university hospital toward evidence-based nursing.

METHOD

This descriptive and cross-sectional research included 529 nurses working in a university hospital during November 1 to November 30, 2018. Data were collected using the information form and Attitude Toward Evidence-Based Nursing Questionnaire (AEBNQ). Descriptive statistical methods, the Shapiro–Wilk test, the Mann–Whitney U test, and the Kruskal–Wallis test were used for statistical analyses.

RESULTS

The average age of the nurses was 36.55±9.29 years, 91.1% were female, and the average work experience was 12.61±9.56 years. Moreover, 53.4% of the nurses were working in surgical departments, and 50.3% were working as clinical nurses. The total mean score of AEBNQ of the nurses was 58.23±9.34, and it was determined that their attitudes toward evidence-based nursing was positive. It was confirmed that for some subscales, the mean scores of AEBNQ of the female nurses and nurses working in internal disease departments were significantly high.

CONCLUSION

Attitudes of the nurses toward evidence-based nursing were found to be positive. It was concluded that the department in which the nurses worked and being female affected their attitudes toward evidence-based nursing.

The use of BEME reviews in the medical education literature

INTRODUCTION

Knowledge syntheses in medical education are intended to promote the translation to, and mobilization of, research knowledge into practice. Despite the effort invested in conducting them, how these knowledge syntheses are used is unclear. This study aimed to explore how knowledge syntheses published by the Best Evidence Medical Education Collaboration (BEME) have been used in a cross-section of published literature.

METHODS

Citation patterns for BEME reviews were explored using data drawn from Web of Science and Scopus, and a sub-sample of citing papers.

RESULTS

Bibliometric data on 3419 papers citing 29 BEME reviews were analysed. More detailed data were extracted from a random sample of 629 full-text papers.

DISCUSSION

BEME reviews were most often positioned to consolidate and summarize the current state of knowledge on a particular topic and to identify gaps in the literature; they were also used to justify current research, and less frequently to contextualize and explain results, or direct future areas of research. Their use to identify instruments or methodological approaches was relatively absent.

CONCLUSION

While BEME reviews are primarily used to justify and support other studies, the current literature does not demonstrate their translation to educational practice.

Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery models

BACKGROUND

Pelvic Floor Muscle Training (PFMT) has been shown to be effective for pelvic organ prolapse in women, but its implementation in routine practice is challenging due to lack of adequate specialist staff. It is important to know if PFMT can be delivered by different staff skill mixes, what barriers and facilitators operate in different contexts, what strategies enable successful implementation and what are the underlying mechanisms of their action. PROPEL intervention was designed to maximise the delivery of effective PFMT in the UK NHS using different staff skill mixes. We conducted a realist evaluation (RE) of this implementation to understand what works, for whom, in what circumstances and why.

METHODS

Informed by the Realist and RE-AIM frameworks, the study used a longitudinal, qualitative, multiple case study design. The study took place in five, purposively selected, diverse NHS sites across the UK and proceeded in three phases to identify, test and refine a theory of change. Data collection took place at 4 time points over an 18 month implementation period using focus groups and semi-structured interviews with a range of stakeholders including service leads/managers, senior practitioners, newly trained staff and women receiving care in the new service models. Data were analysed using thematic framework approach adapted to identify Context, Mechanism and Outcome (CMO) configurations of the RE.

RESULTS

A heightened awareness of the service need among staff and management was a mechanism for change, particularly in areas where there was a shortage of skilled staff. In contrast, the most established specialist physiotherapist-delivered PFMT service activated feelings of role protection and compromised quality, which restricted the reach of PFMT through alternative models. Staff with some level of prior knowledge in women's health and adequate organisational support were more comfortable and confident in new role. Implementation was seamless when PFMT delivery was incorporated in newly trained staff's role and core work.

CONCLUSION

Roll-out of PFMT delivery through different staff skill mixes is possible when it is undertaken by clinicians with an interest in women's health, and carefully implemented ensuring adequate levels of training and ongoing support from specialists, multi-disciplinary teams and management.

Emerging roles for research intensive PhD prepared nurses: Beyond faculty positions

Research-intensive PhD programs need to prepare nurse scientists to bridge the chasms between research, and practice and policy in an increasingly complex healthcare system. In practice, nurse scientists are critical to building capacity for research, promoting excellence in patient-centered care, and achieving or exceeding national quality benchmarks. Moreover, they provide methodological expertise and insight to address pressing clinical questions. PhD-prepared nurses also leverage their research expertise and practice knowledge to transform health policy in roles as organizational executives and leaders, advocates, and communicators. Re-envisioning nursing PhD curricula is required to ensure that PhD students are capable of not only conducting rigorous and impactful science, but launching careers across sectors of healthcare. Here, we summarize viewpoints of a special session from the October 2019 PhD Summit "Re-Envisioning PhD Programs of the Future" sponsored by the University of Pennsylvania School of Nursing and literature to invigorate thinking about ways to promote career transitions into nontraditional vital positions for nurse scientists. Advancing the health of patients and communities depends on preparing the next generation of nurse scientist to pursue career trajectories outside of traditional academic institutions.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Reducing the knowledge to action gap in hospital nutrition care - Developing and implementing nutritionDay 2.0

BACKGROUND & AIMS

In hospital nutrition care the difficulty of translating knowledge to action often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awareness of malnutrition, specific local remedial actions rarely followed. Thus, reducing the Knowledge-to-action (KTA) gap in nutrition care requires more robust and focused strategies. This study describes the strategy, methods, instruments and experience of developing and implementing nutritionDay 2.0, an audit and feedback intervention that uses quality and economic indicators, feedback, benchmarking and self-defined action strategies to reduce the KTA gap in hospital nutrition care.

METHODS

We used an evidence based multi-professional mixed-methods approach to develop and implement nutritionDay 2.0 This audit and feedback intervention is driven by a Knowledge-to-Action framework complemented with robust stakeholder analysis. Further evidence was synthesized from the literature, online surveys, a pilot study, World Cafés and individual expert feedback involving international health care professionals, nutrition care scientists and patients.

RESULTS

The process of developing and implementing nutritionDay 2.0 over three years resulted in a new audit questionnaire based on 36 nutrition care quality and economic indicators at hospital, unit and patient levels, a new action-oriented feedback and benchmarking report and a unit-level personalizable action plan template. The evaluation of nutritionDay 2.0 is ongoing and will include satisfaction and utility of nutritionDay 2.0 tools and short-, mid- and long-term effects on the KTA gap.

CONCLUSION

In clinical practice, nutritionDay 2.0 has the potential to promote behavioural and practice changes and improve hospital nutrition care outcomes. In research, the data generated advances knowledge about institutional malnutrition and quality of hospital nutrition care. The ongoing evaluation of the initiative will reveal how far the KTA gap in hospital nutrition care was addressed and facilitate the understanding of the mechanisms needed for successful audit and feedback.

TRIAL REGISTRATION

Registration in clinicaltrials.gov: Identifier: NCT02820246.

Sustaining an Evidence-Based Program Over Time: Moderators of Sustainability and the Role of the Getting to Outcomes® Implementation Support Intervention

Problematic rates of alcohol, e-cigarette, and other drug use among US adolescents highlight the need for effective implementation of evidence-based programs (EBPs), yet schools and community organizations have great difficulty implementing and sustaining EBPs. Although a growing number of studies show that implementation support interventions can improve EBP implementation, the literature on how to improve sustainability through implementation support is limited. This randomized controlled trial advances the literature by testing the effects of one such implementation intervention-Getting To Outcomes (GTO)-on sustainability of CHOICE, an after-school EBP for preventing substance use among middle-school students. CHOICE implementation was tracked for 2 years after GTO support ended across 29 Boys and Girls Club sites in the greater Los Angeles area. Predictors of sustainability were identified for a set of key tasks targeted by the GTO approach (e.g., goal setting, evaluation, collectively called "GTO performance") and for CHOICE fidelity using a series of path models. One year after GTO support ended, we found no differences between GTO and control sites on CHOICE fidelity. GTO performance was also similar between groups; however, GTO sites were superior in conducting evaluation. Better GTO performance predicted better CHOICE fidelity. Two years after GTO support ended, GTO sites were significantly more likely to sustain CHOICE implementation when compared with control sites. This study suggests that using an implementation support intervention like GTO can help low-resource settings continue to sustain their EBP implementation to help them get the most out of their investment. ClinicalTrials.gov Identifier: NCT02135991.

Stakeholder Assessment of Evidence-Based Guideline Dissemination and Implementation in a Dental Group Practice

OBJECTIVE

This evaluation captures the perspectives of multiple stakeholders within a salaried dental care delivery organization (dentists, dental assistants, dental hygienists, and dental management) on the implementation of a pit-and-fissure sealant guideline in the Kaiser Permanente Dental Program. Also assessed is the role of formal processes and structures in providing a framework for guideline implementation.

METHODS

We collected qualitative data through field observations, stakeholder interviews (n = 6), and focus groups (30 participants in 5 focus groups). Field observation notes captured summaries of conversations and other activities. Interviews and focus groups were recorded and transcribed. We analyzed transcripts and field notes using a template analysis with NVivo 12 software to identify themes related to the existing implementation process of clinical guidelines and stakeholder perspectives on the strengths and weaknesses of this process.

RESULTS

Stakeholders perceived 2 main barriers for achieving implementation of the pit-and-fissure sealant guideline: 1) shortcomings in the implementation infrastructure resulting in lack of clarity about the roles and responsibilities in the guideline implementation process and lack of effective mechanisms to disseminate guideline content and 2) resource constraints, such as limited human, space, and material resources. Perceived opportunities for the dissemination and implementation of guidelines included recognition of the importance of guidelines in dental practice and well-functioning workflows within dental specialties.

CONCLUSION

Our research points to the importance of developing and maintaining an infrastructure to ensure standardized, predictable mechanisms for implementation of guidelines and thereby promoting practice change. While addressing resource constraints may not be possible in all circumstances, an important step for improving guideline implementation-wherever feasible-would be the development of a robust implementation infrastructure that captures and delineates roles and responsibilities of different clinical actors in the guideline implementation process.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by health care leadership and administrators to understand possible reasons for a lack of guideline implementation and provide suggestions for establishing sustainable infrastructure to promote the adoption of clinical guidelines in salaried dental clinics.

Adapting Digital Social Prescribing for Suicide Bereavement Support: The Findings of a Consultation Exercise to Explore the Acceptability of Implementing Digital Social Prescribing within an Existing Postvention Service

This paper describes a consultation exercise to explore the acceptability of adapting digital social prescribing (DSP) for suicide bereavement support. Bereavement by suicide increases the risk of suicide and mental health issues. Social prescribing improves connectedness and empowerment and can provide digital outcomes-based reporting to improve the capacity for measuring the effectiveness of interventions. Our aim was to consult on the acceptability and potential value of DSP for addressing the complexities of suicide bereavement support. Our approach was underpinned by implementation science and a co-design ethos. We reviewed the literature and delivered DSP demonstrations as part of our engagement process with commissioners and service providers (marrying evidence and context) and identified key roles for stakeholders (facilitation). Stakeholders contributed to a co-designed workshop to establish consensus on the challenges of providing postvention support. We present findings on eight priority challenges, as well as roles and outcomes for testing the feasibility of DSP for support after suicide. There was a consensus that DSP could potentially improve access, reach, and monitoring of care and support. Stakeholders also recognised the potential for DSP to contribute substantially to the evidence base for postvention support. In conclusion, the consultation exercise identified challenges to facilitating DSP for support after suicide and parameters for feasibility testing to progress to the evaluation of this innovative approach to postvention.

A typology of barriers and enablers of scientific evidence use in conservation practice

Over the last decade, there has been an increased focus (and pressure) in conservation practice globally towards evidence-based or evidence-informed decision making. Despite calls for increased use of scientific evidence, it often remains aspirational for many conservation organizations. Contributing to this is the lack of guidance on how to identify and classify the array of complex reasons limiting research use. In this study, we collated a comprehensive inventory of 230 factors that facilitate or limit the use of scientific evidence in conservation management decisions, through interviews with conservation practitioners in South Africa and UK and a review of the healthcare literature. We used the inventory, combined with concepts from knowledge exchange and research use theories, to construct a taxonomy that categorizes the barriers and enablers. We compared the similarities and differences between the taxonomies from the conservation and the healthcare fields, and highlighted the common barriers and enablers found within conservation organizations in the United Kingdom and South Africa. The most commonly mentioned barriers limiting the use of scientific evidence in our case studies were associated with the day-to-day decision-making processes of practitioners, and the organizational structures, management processes and resource constraints of conservation organizations. The key characteristics that facilitated the use of science in conservation decisions were associated with an organization's structure, decision-making processes and culture, along with practitioners' attitudes and the relationships between scientists and practitioners. This taxonomy and inventory of barriers and enablers can help researchers, practitioners and other conservation actors to identify aspects within their organizations and cross-institutional networks that limit research use - acting as a guide on how to strengthen the science-practice interface.

Research Competencies Assessment Instrument for Nurses: Preliminary Psychometric Properties

BACKGROUND AND PURPOSE

Clinician research competencies influence research use for evidence-based practice (EBP). We aimed to develop, refine, and psychometrically assess the Research Competencies Assessment Instrument for Nurses (RCAIN) to measure registered nurse research competencies (i.e., knowledge, skills, attitudes) focused on EBP-related domains: research process, knowledge synthesis, and knowledge translation activities.

METHODS

The preliminary psychometrics (face, content, construct/criterion validity) were evaluated based on 63 completed surveys.

RESULTS

The Cronbach's α coefficients were .871, .813, and .946 for each domain, respectively; interitem correlations ranged from .472 to .833 (explained variance: 68.5%). Three components/factors revealed: comprehension of and skills required in research process and application of knowledge and skills. The revised RCAIN consists of 19 five-point Likert-type questions.

CONCLUSIONS

The RCAIN assesses modifiable characteristics and explains variance in practice, health system, and patient outcomes. Further assessments are underway.

Systematic review of determinants influencing knowledge implementation in occupational therapy

INTRODUCTION

In knowledge translation, implementation strategies are more effective in fostering practice change. When using these strategies, however, many determinants, such as individual or organisational factors, influence implementation. Currently, there is a lack of synthesis concerning how these determinants influence knowledge implementation (KI). The aim of this systematic review was to document how determinants influence KI outcomes with occupational therapists.

METHOD

Following the PRISMA statement, we systematically reviewed the literature on KI in occupational therapy across 12 databases: MEDLINE, Embase, CINAHL, AMED, PsychINFO, Cochrane Library, FirstSearch, Web of Science, ProQuest Dissertations & Theses, ERIC, Education Source and Sociological Abstracts. Eligible studies reported KI strategies specifically with occupational therapists. Selected studies were appraised for quality with the Mixed Methods Appraisal Tool. Using the Consolidated Framework for Implementation Research (CFIR), we categorised reported mentions of CFIR (sub-)constructs to identify the determinants studied most often, how they were documented and what influence they had on outcomes.

RESULTS

Twenty-two studies were analysed for this review. CFIR (sub-)constructs were mentioned 81 times, and seven (sub-)constructs received at least 5% of these mentions (4/81). These were as follows: (i) Adaptability of the practice; (ii) Learning climate; (iii) Leadership engagement; (iv) Available resources; (v) Knowledge and Beliefs about the Intervention; (vi) Individual Stage of Change; and vii) Executing the KI strategy. The Inner setting domain was the most documented and the domain with the most (sub-)constructs with at least four mentions (3/7). Most studies used questionnaires as assessment tools, but these were mainly non-standardised scales. The data were too heterogenous to perform a meta-analysis.

CONCLUSION

Seven (sub-)constructs mentioned most often would benefit from being assessed for salience by researchers intending to develop a KI strategy for occupational therapists. Future research aimed at improving our understanding of KI should also consider using standardised tools to measure the influence of determinants.

The effectiveness of alcohol-based gel for hand sanitising in infection control

This article aims to evaluate the evidence relating to the effectiveness of alcohol-based gel for hand sanitising, or 'handrub', in infection control in healthcare settings with particular reference to renal nursing, as this has become pertinent due to the increasing reliance on evidence-based practice. There is a need to implement better infection control strategies and education, to reinforce knowledge among the public, health professionals and those at high risk of infection not only in renal nursing, but also in other areas of practice. Healthcare-associated infections (HCAIs) put patients' safety at risk, increase morbidity and mortality, extend the length of hospital admission and increase the cost to the NHS. There is evidence that the prevalence of HCAIs in England can be minimised through the use of different infection control measures. For example, alcohol-based handrub has been found to be associated with minimising the spread of gastrointestinal infections not only in hospital settings, but also in childcare centres. In addition, the UK national guidelines recommend regular handwashing (implementing the right technique) when hands are visibly dirty and hand disinfection with alcohol-based handrub when they are not visibly dirty. This should be before, in between and after different healthcare activities are performed.

Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators

BACKGROUND

Suicide prevention is a global priority. Psychiatric hospitalization presents an opportunity to intervene positively with, for example, psychological therapies. However, evidenced-based suicide-prevention psychological treatments are rarely available on in-patient wards. Understanding staff engagement with research investigating suicide-prevention psychological treatments is crucial for their effective, efficacious, and pragmatic implementation. A pilot randomised control trial and feasibility study of Cognitive Behavioural Suicide Prevention therapy provided the opportunity for a qualitative investigation of staff experiences and views of a psychological intervention for people with suicidal experiences on psychiatric in-patient wards.

AIMS

To investigate staff acceptability of Cognitive Behavioural Suicide Prevention therapy for psychiatric inpatients based on their perceptions of their experiences during the conduct of a clinical trial.

METHOD

Transcribed audio-recordings of qualitative interviews and a focus group (n = 19) of purposively sampled staff from eight psychiatric wards were analysed using inductive Thematic Analysis.

RESULTS

Facilitators and barriers were identified for: i) the conduct of the research, and, ii) the suicide-prevention intervention (Cognitive Behavioural Suicide Prevention therapy). Research-related barriers comprised communication difficulties between staff and researchers, and increased staff workload. Research-related facilitators included effective staff/researcher relationships, and alignment of the intervention with organisational goals. Suicide-prevention intervention-related barriers comprised staffs' negative beliefs about suicide which impacted on their referral of inpatients to the clinical trial, and staff perceptions of insufficient information and unfulfilled expectations for involvement in the therapy. Facilitators included staff beliefs that the therapy was beneficial for inpatients, the service and their own clinical practice.

CONCLUSIONS

Staff beliefs that 'suicide-talk' could precipitate suicidal behaviour resulted in covert gatekeeping and restricted referral of only inpatients judged as stable or likely to engage in therapy, which may not be those who could most benefit. Such threats to sample representativeness have implications for future therapy research design. The findings provide novel information for researchers and practitioners regarding the conduct of psychological treatment and research in psychiatric units.

Why is reporting quality improvement so hard? A qualitative study in perioperative care

OBJECTIVES

Quality improvement (QI) may help to avert or mitigate the risks of suboptimal care, but it is often poorly reported in the healthcare literature. We aimed to identify the influences on reporting QI in the area of perioperative care, with a view to informing improvements in reporting QI across healthcare.

DESIGN

Qualitative interview study.

SETTING

Healthcare and academic organisations in Australia, Europe and North America.

PARTICIPANTS

Stakeholders involved in or influencing the publication, writing or consumption of reports of QI studies in perioperative care.

RESULTS

Forty-two participants from six countries took part in the study. Participants included 15 authors (those who write QI reports), 12 consumers of QI reports (practitioners who apply QI research in practice), 11 journal editors and 4 authors of reporting guidelines. Participants identified three principal challenges in achieving high-quality QI reporting. First, the broad scope of QI reporting-ranging from small local projects to multisite research across different disciplines-causes uncertainty about where QI work should be published. Second, context is fundamental to the success of a QI intervention but is difficult to report in ways that support replication and development. Third, reporting is adversely affected by both proximal influences (such as lack of time to write up QI) and more distal, structural influences (such as norms about the format and content of biomedical research reporting), leading to incomplete reporting of QI findings.

CONCLUSIONS

Divergent terminology and understandings of QI, along with existing reporting norms and the challenges of capturing context adequately yet succinctly, make for challenges in reporting QI. We offer suggestions for improvement.