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

What affects implementation of the UK major trauma rehabilitation prescription? A survey informed by the behaviour change wheel

OBJECTIVE

Major trauma 'Rehabilitation Prescriptions' aim to facilitate continuity of care and describe patient needs following discharge from UK Major Trauma Centre (MTCs), however research suggests rehabilitation prescriptions are not being implemented as intended. We aimed to identify factors influencing completion and use of rehabilitation prescriptions using the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF).

DESIGN

Online survey informed by the TDF and BCW.

SETTING

UK trauma rehabilitation pathway.

POPULATION

Rehabilitation and trauma service providers involved in completing and/or using rehabilitation prescriptions (n = 78).

ANALYSIS

Mean scores were calculated for TDF behavioural domains, identifying facilitators (score ≥5) and barriers (≤3.5) to rehabilitation prescription implementation. Thematic analysis of free text data informed by the BCW/TDF identified further facilitators and barriers, plus potential behaviour change strategies.

RESULTS

Most respondents worked in UK MTCs (n = 63) and were physiotherapists (n = 34), trauma rehabilitation coordinators (n = 16) or occupational therapists (n = 15). 'Social/professional role and identity', 'knowledge' and 'emotion' (the highest-scoring TDF domains) were facilitators to implementing rehabilitation prescriptions. Qualitative data identified barriers to rehabilitation prescription completion, including 'seen as tick-box exercise','not a priority', lack of resources (IT and workforce), poor inter-service communication, limited knowledge/training. Facilitators included therapist buy-in, standardised training, easy inter-service rehabilitation prescription transfer, usefulness for sharing patient needs.

CONCLUSIONS

Although rehabilitation prescriptions are valued by some service providers, their effectiveness is hindered by negative attitudes, limited knowledge and poor communication. Uncertainties exist about whether rehabilitation prescriptions achieve their goals, particularly in documenting patient needs, engaging patients in rehabilitation, and informing onward referrals following MTC discharge. Improving IT systems, empowering patients, redirecting funding, and providing training might improve their usage. Further research should explore service provider and patient perspectives, and prospective long-term follow-up on outcomes of rehabilitation prescription recommendations.

An Environmental Scan of the Role of Nurses in Preventing Fetal Alcohol Spectrum Disorders

Nurses are in an ideal position to talk to their patients of reproductive age about alcohol use and encourage the prevention of alcohol-exposed pregnancies. Effective conversations can be efficiently included in the clinical encounter to identify alcohol misuse and offer appropriate follow-up. This report presents results of an environmental scan of resources relevant to nursing professionals and nurses' role in addressing alcohol misuse. Gaps in nursing education and practice guidelines with regard to defining the nursing role in preventing alcohol-exposed pregnancies were revealed. Findings identified a need to promote adoption among nurses of evidence-based preventive practices to prevent alcohol misuse.

Experiences of doctors and nurses implementing nurse-delivered cardiovascular prevention in primary care: a qualitative study

AIM

This paper reports on a study of the experiences of general practitioners and practice nurses implementing nurse-delivered cardiovascular prevention to high risk patients in primary care.

BACKGROUND

Difficulties may arise when innovations are introduced into routine daily practice. Whether or not implementation is successful is determined by different factors related to caregivers, patients, type of innovation and context.

METHODS

A qualitative study nested in a randomized trial (2006-2008) to evaluate the effectiveness of nurse-delivered cardiovascular prevention. Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses) participated in the trial. Interviews were held on two occasions: at 3 and at 18 months after commencement of consultation. The first occasion was a group interview with six practice nurses. The second consisted of semi-structured interviews with one general practitioner and one practice nurse from each centre.

FINDINGS

Main barriers to the implementation included: lack of knowledge about the guideline, attitudes towards treatment targets, lack of communication, insufficient coaching by doctors, content of life style advice. At the start of the consultation project, practice nurses expressed concern of losing nursing tasks. Other barriers were related to patients (lack of motivation), the guideline (target population) and organizational issues (insufficient patient recording and computer systems).

CONCLUSIONS

Both general practitioners and practice nurses were positive about nurse-delivered cardiovascular prevention in primary care. Nurses could play an important role in successive removal of barriers to implementation of cardiovascular prevention. Mutual confidence between care providers in the healthcare team is necessary.

Task-shifting Using a Pain Management Protocol in an Emergency Care Service: Nurses' Perception through the Eye of the Rogers's Diffusion of Innovation Theory

It has been shown that over 70% of patients waiting in emergency departments (EDs) do not receive analgesics, despite the fact that more than 78% complain of pain. A clinical innovation in the form of a pain management protocol that includes task-shifting has been implemented in the ED of a university hospital in Switzerland in order to improve pain-related outcomes in patients. This innovation involves a change in clinical practice for physicians and nurses. The aim of this study is to explore nurses' perceptions on how well this innovation is adopted. This descriptive correlational study took place in the ED of a Swiss university hospital; the hospital provides healthcare for the city, the canton, and adjoining cantons. A convenience sample of 37 ED nurses participated. They were asked to complete a questionnaire comprising 56 statements based on Rogers's "Diffusion of Innovation" theory. Nurses' opinions (on a 1-10 Likert scale) indicate that the new protocol benefits the ED (mean [M] = 7.4, standard deviation [SD] = 1.21), is compatible with nursing roles (M = 8.0, SD = 1.9), is not too complicated to apply (M = 2.7, SD = 1.7), provides observable positive effects in patients (M = 7.0, SD = 1.28), and is relatively easy to introduce into daily practice (M = 6.5, SD = 1.0). Further studies are now needed to examine patients' experiences of this innovation.

Leadership in evidence-based practice: a systematic review

Purpose

– This study aims to systematically review published empirical research on leadership as a determinant for the implementation of evidence-based practice (EBP) and to investigate leadership conceptualization and operationalization in this field.

Design/methodology/approach

– A systematic review with narrative synthesis was conducted. Relevant electronic bibliographic databases and reference lists of pertinent review articles were searched. To be included, a study had to involve empirical research and refer to both leadership and EBP in health care. Study quality was assessed with a structured instrument based on study design.

Findings

– A total of 17 studies were included. Leadership was mostly viewed as a modifier for implementation success, acting through leadership support. Yet, there was definitional imprecision as well as conceptual inconsistency, and studies seemed to inadequately address situational and contextual factors. Although referring to an organizational factor, the concept was mostly analysed at the individual or group level.

Research limitations/implications

– The concept of leadership in implementation science seems to be not fully developed. It is unclear whether attempts to tap the concept of leadership in available instruments truly capture and measure the full range of the diverse leadership elements at various levels. Research in implementation science would benefit from a better integration of research findings from other disciplinary fields. Once a more mature concept has been established, researchers in implementation science could proceed to further elaborate operationalization and measurement.

Originality/value

– Although the relevance of leadership in implementation science has been acknowledged, the conceptual base of leadership in this field has received only limited attention.

Engaging pediatric intensive care unit (PICU) clinical staff to lead practice improvement: the PICU participatory action research project (PICU-PAR)

Background

Despite considerable efforts, engaging staff to lead quality improvement activities in practice settings is a persistent challenge. At British Columbia Children’s Hospital (BCCH), the pediatric intensive care unit (PICU) undertook a new phase of quality improvement actions based on the Community of Practice (CoP) model with Participatory Action Research (PAR). This approach aims to mobilize the PICU ‘community’ as a whole with a focus on practice; namely, to create a ‘community of practice’ to support reflection, learning, and innovation in everyday work.

Methodology

An iterative two-stage PAR process using mixed methods has been developed among the PICU CoP to describe the environment (stage 1) and implement specific interventions (stage 2). Stage 1 is ethnographic description of the unit’s care practice. Surveys, interviews, focus groups, and direct observations describe the clinical staff’s experiences and perspectives around bedside care and quality endeavors in the PICU. Contrasts and comparisons across participants, time and activities help understanding the PICU culture and experience. Stage 2 is a succession of PAR spirals, using results from phase 1 to set up specific interventions aimed at building the staff’s capability to conduct QI projects while acquiring appropriate technical skills and leadership capacity (primary outcome). Team communication, information, and interaction will be enhanced through a knowledge exchange (KE) and a wireless network of iPADs.

Relevance

Lack of leadership at the staff level in order to improve daily practice is a recognized challenge that faces many hospitals. We believe that the PAR approach within a highly motivated CoP is a sound method to create the social dynamic and cultural context within which clinical teams can grow, reflect, innovate and feel proud to better serve patients.

Maternal and neonatal nurse perceived value of kangaroo mother care and maternal care partnership in the neonatal intensive care unit

BACKGROUND

Kangaroo Mother Care (KMC) enhances infant and maternal well-being and requires maternal-care partnerships (MCP) for implementation.

OBJECTIVE

To examine maternal and neonatal nurse provider perspectives on the value of KMC and MCP.

STUDY DESIGN

Prospective cohort design of neonatal nurses and mothers of preterm infants self-report anonymous questionnaire. Analyses of categorical independent variables and continuous variables were calculated.

RESULTS

In all, 82.3% of nurses (42) and 100% (143) of mothers participated in the survey. compared with 18% of nurses, 63% of mothers believed "KMC should be provided daily" and 90% of mothers compared with 40% of nurses strongly believed "mothers should be partners in care." In addition, 61% of nonwhite mothers identified that "KMC was not something they were told they could do for their infant" compared with 39% of white mothers. Nonwhite and foreign-born nurses were 2.8 and 3.1 times more likely to encourage MCP and KMC.

CONCLUSION

Mothers held strong positive perceptions of KMC and MCP value compared with nurses. Nonwhite mothers perceived they received less education and access to KMC. Barriers to KMC and MCP exist among nurses, though less in nonwhite, foreign-born, and/or nurses with their own children, identifying important provider educational opportunities to improve maternal KMC access in the NICU.

The Hidden Complexity of Long-Term Care: how context mediates knowledge translation and use of best practices

PURPOSE

Context is increasingly recognized as a key factor to be considered when addressing healthcare practice. This study describes features of context as they pertain to knowledge use in long-term care (LTC).

DESIGN AND METHODS

As one component of the research program Translating Research in Elder Care, an in-depth qualitative case study was conducted to examine the research question "How does organizational context mediate the use of knowledge in practice in long-term care facilities?" A representative facility was chosen from the province of Saskatchewan, Canada. Data included document review, direct observation of daily care practices, and interviews with direct care, allied provider, and administrative staff.

RESULTS

The Hidden Complexity of Long-Term Care model consists of 8 categories that enmesh to create a context within which knowledge exchange and best practice are executed. These categories range from the most easily identifiable to the least observable: physical environment, resources, ambiguity, flux, relationships, and philosophies. Two categories (experience and confidence, leadership and mentoring) mediate the impact of other contextual factors. Inappropriate physical environments, inadequate resources, ambiguous situations, continual change, multiple relationships, and contradictory philosophies make for a complicated context that impacts care provision.

IMPLICATIONS

A hidden complexity underlays healthcare practices in LTC and each care provider must negotiate this complexity when providing care. Attending to this complexity in which care decisions are made will lead to improvements in knowledge exchange mechanisms and best practice uptake in LTC settings.

Nursing intellectual capital theory: testing selected propositions

AIMS

To test the selected propositions of the middle-range theory of nursing intellectual capital.

BACKGROUND

The nursing intellectual capital theory conceptualizes nursing knowledge's influence on patient and organizational outcomes. The theory proposes nursing human capital, nurses' knowledge, skills and experience, is related to the quality of patient care and nurse recruitment and retention of an inpatient care unit. Two factors in the work environment, nurse staffing and employer support for nurse continuing professional development, are proposed to influence nursing human capital's association with patient and organizational outcomes.

DESIGN

A cross-sectional survey design.

METHODS

The study took place in 2008 in six Canadian acute care hospitals. Financial, human resource and risk data were collected from hospital departments and unit managers. Clearly specified empirical indicators quantified the study variables. The propositions of the theory were tested with data from 91 inpatient care units using structural equation modelling.

RESULTS

The propositions associated with the nursing human capital concept were supported. The propositions associated with the employer support for nurse continuing professional development concept were not. The proposition that nurse staffing's influences on patient outcomes was mediated by the nursing human capital of an inpatient unit, was partially supported.

CONCLUSION

Some of the theory's propositions were empirically validated. Additional theoretical work is needed to refine the operationalization and measurement of some of the theory's concepts. Further research with larger samples of data from different geographical settings and types of hospitals is required to determine if the theory can withstand empirical scrutiny.

Nursing intellectual capital theory: operationalization and empirical validation of concepts

AIMS

To present the operationalization of concepts in the nursing intellectual capital theory and the results of a methodological study aimed at empirically validating the concepts.

BACKGROUND

The nursing intellectual capital theory proposes that the stocks of nursing knowledge in an organization are embedded in two concepts, nursing human capital and nursing structural capital. The theory also proposes that two concepts in the work environment, nurse staffing and employer support for nursing continuing professional development, influence nursing human capital.

DESIGN

A cross-sectional design.

METHODS

A systematic three-step process was used to operationalize the concepts of the theory. In 2008, data were collected for 147 inpatient units from administrative departments and unit managers in 6 Canadian hospitals. Exploratory factor analyses were conducted to determine if the indicator variables accurately reflect their respective concepts.

RESULTS

The proposed indicator variables collectively measured the nurse staffing concept. Three indicators were retained to construct nursing human capital: clinical expertise and experience concept. The nursing structural capital and employer support for nursing continuing professional development concepts were not validated empirically.

CONCLUSION

The nurse staffing and the nursing human capital: clinical expertise and experience concepts will be brought forward for further model testing. Refinement for some of the indicator variables of the concepts is indicated. Additional research is required with different sources of data to confirm the findings.

Factors influencing the implementation of the guideline triage in emergency departments: a qualitative study

AIMS AND OBJECTIVES

The objectives are: (1) to identify factors that influence the implementation of the guideline Triage in emergency departments [2004] in emergency departments in the Netherlands, and (2) to develop tailored implementation strategies for implementation of this guideline.

BACKGROUND

Guideline dissemination is no guarantee for guideline implementation. In 2004 the guideline Triage in Emergency Departments was disseminated in Dutch hospitals. Guideline revision was scheduled in 2008. Prior to the revision, factors which influenced the implementation of the guideline [2004] were studied to be addressed at the implementation of the revised guideline.

METHODS

This is an exploratory study using a qualitative design including: a questionnaire sent to all emergency departments in the Netherlands (n = 108): four focus group interviews, including nurses and ward managers and in-depth interviews with ward managers and doctors. Based on the results, tailored implementation strategies and activities were suggested which target the identified influencing factors.

RESULTS

Various factors at individual, social context and organisational level were identified as influencing the implementation of the 2004 version of the guideline, namely: level of knowledge; insight and skills; work preferences; motivation and/or commitment; support; informed doctors; preliminary work and arrangements for implementation; description of tasks and responsibilities; workload and resources. Ward managers, nurses and doctors mentioned similar as well as different factors. Consequently, tailored implementation strategies and activities related to education, maintenance of change, motivation and consensus-building, information, organisation and facilitation were suggested.

CONCLUSION

Nurses, ward managers and doctors broadly indicated similar influencing factors, although the importance of these factors differed for the different groups. For nurses, resistance and lack of resources are most important, ward managers mentioned culture and doctors the availability of doctors at the emergency department.

RELEVANCE TO CLINICAL PRACTICE

Insight into the barriers for implementation and tailoring implementation strategies to these barriers improves the implementation.

A practical communication strategy to improve implementation of evidence-based practice

OBJECTIVE

The purpose of this study was to determine if a consistent communication strategy for implementation of evidence-based practice (EBP), developed with input from staff nurses, improved staff nurse satisfaction with communication of practice changes.

BACKGROUND

Integration of EBP knowledge into clinical practice supports optimal nursing care. Awareness of a practice change and the ability to reference the information may be problematic.

METHODS

A quasi-experimental single group before-after design was used to survey all RNs of a level III neonatal ICU for satisfaction before and after implementation of the EBP communication strategy.

RESULTS

Registered nurse satisfaction improved regarding the amount of communication (P < .001), frequency of communication (P < .014), method of communication (P < .001), and ease of finding information (P < .001).

CONCLUSION

A consistent strategy can improve nurse satisfaction with communication of EBP changes.

Challenge of introducing evidence based medicine into clinical practice

Purpose

This article aims to review the available literature on how clinicians meet the daily challenge of translating medical information into clinical EBM. It also seeks to describe the procedures involved in a local initiative in the UK to develop software applications for implementation of national clinical guidelines to enhance EBM in routine clinical practice.

Design/methodology/approach

It was hypothesised that improved access to these guidelines in routine clinical practice could be achieved through integrated local procedures, thereby enhancing the quality of care provided to children and adolescents with asthma or UTI. A literature search was performed using databases. To explore the preferences of the doctors and other healthcare professionals on how they accessed clinical guidelines, feedback was obtained. Stepwise implementation of the clinical guidelines was instituted over a period of three years in different primary care and hospital settings.

Findings

The professionals actively engaged with all the different stages in the implementation of the clinical guidelines. The majority preferred the interactive computerized system based on its ease of use, better aesthetic features, familiarity with the software and limited dependence on the technical skills of the users.

Research limitations/implications

The limitations of this study include lack of systematic data to assess the clinical effectiveness of the guidelines' implementation. Another apparent limitation of the study is the small size of participants within the paediatric unit of each organisation where the study was conducted.

Practical implications

There is a need for further comparative studies between the local intervention strategies described in this study and other implementation strategies, to identify the most effective implementation methods for electronic guideline‐based systems.

Social implications

Reliable high quality guidelines from reputable professional bodies could be successfully implemented at the primary or hospital‐based levels through a series of coordinated multidisciplinary interactive processes. This study has positive implications for improving the quality of care provided to children and adolescents, enhancing the role of clinical governance, provision of useful information to patients/carers and other healthcare providers.

Originality/value

This study highlights a potentially effective way of implementing and integrating an electronic guideline‐based computer system into local practice.

Institutionalizing evidence-based practice: an organizational case study using a model of strategic change

BACKGROUND

There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice.

METHODS

A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization.

RESULTS

The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP-related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP.

CONCLUSION

Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively.

An exploration of nurses' perceptions regarding the implementation of a best practice guideline on the assessment and management of foot ulcers for people with diabetes

The aim of this qualitative study was to explore nurses' perceptions regarding the implementation of a best practice guideline (BPG) on the assessment and management of foot ulcers for people with diabetes. Fourteen nurses from a community care setting and three hemodialysis units participated in five focus groups and one individual interview. The findings focus on key points regarding the impact of BPG implementation in the areas of patient outcomes, nursing practice, and interdisciplinary teamwork.

Study protocol for the translating research in elder care (TREC): building context through case studies in long-term care project (project two)

Background

The organizational context in which healthcare is delivered is thought to play an important role in mediating the use of knowledge in practice. Additionally, a number of potentially modifiable contextual factors have been shown to make an organizational context more amenable to change. However, understanding of how these factors operate to influence organizational context and knowledge use remains limited. In particular, research to understand knowledge translation in the long-term care setting is scarce. Further research is therefore required to provide robust explanations of the characteristics of organizational context in relation to knowledge use.

Aim

To develop a robust explanation of the way organizational context mediates the use of knowledge in practice in long-term care facilities.

Design

This is longitudinal, in-depth qualitative case study research using exploratory and interpretive methods to explore the role of organizational context in influencing knowledge translation. The study will be conducted in two phases. In phase one, comprehensive case studies will be conducted in three facilities. Following data analysis and proposition development, phase two will continue with focused case studies to elaborate emerging themes and theory. Study sites will be purposively selected. In both phases, data will be collected using a variety of approaches, including non-participant observation, key informant interviews, family perspectives, focus groups, and documentary evidence (including, but not limited to, policies, notices, and photographs of physical resources). Data analysis will comprise an iterative process of identifying convergent evidence within each case study and then examining and comparing the evidence across multiple case studies to draw conclusions from the study as a whole. Additionally, findings that emerge through this project will be compared and considered alongside those that are emerging from project one. In this way, pattern matching based on explanation building will be used to frame the analysis and develop an explanation of organizational context and knowledge use over time.

An improved understanding of the contextual factors that mediate knowledge use will inform future development and testing of interventions to enhance knowledge use, with the ultimate aim of improving the outcomes for residents in long-term care settings.

Implementation of the enteral nutrition practice recommendations

In developing the evidence-based Enteral Nutrition Practice Recommendations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) formed a task force to address the many aspects of safety in the delivery and provision of enteral nutrition support. This recently published document provides healthcare professionals with recommendations that are derived from evidence-based practice. The development and use of clinical practice guidelines (CPGs) is a recent, significant contribution for the dissemination of evidence-based medicine. This involves the review of scientific literature along with clinical skill and knowledge to generate specific recommendations assisting healthcare providers and patients with decisions regarding appropriate healthcare. A primary opportunity to improve patient outcomes will come from the effective delivery of existing therapies rather than from the new development of treatment modalities. Compliance with CPGs is challenging because it depends on a variety of factors. Both general and specific strategies have been devised with the expansion of the new discipline of implementation science. The high degree of evidence now available in medicine gives clinicians more opportunity to improve patient outcomes and quality of care. It remains for clinicians to evaluate their institutional mission and goals, and to investigate those CPGs appropriate to improve patient care in that setting.

Nurses' experiences of guideline implementation: a focus group study

AIMS

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

BACKGROUND

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

DESIGN

Qualitative interview.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Development of a clinical practice guideline for testing nasogastric tube placement

PURPOSE

A Perth metropolitan hospital group standardized changes to nasogastric tube placement, including removal of the "whoosh test" and litmus paper, and introduction of pH testing.

DESIGN AND METHODS

Two audits were conducted: bedside data collection at a pediatric hospital and a point-prevalence audit across seven hospitals.

RESULTS

Aspirate was obtained for 97% of all tests and pH was < or = 5.5 for 84%, validating the practice changes. However, patients on continuous feeds and/or receiving acid-inhibiting medications had multiple pH testing fails.

PRACTICE IMPLICATIONS

Nasogastric tube placement continues to present a challenge for those high-risk patients on continuous feeds and/or receiving acid-inhibiting medications.

Hand hygiene practices: nursing students' perceptions

AIMS AND OBJECTIVES

The present study examines nursing students' perceptions of hand hygiene practices in clinical settings. The objectives were to investigate any factors that affect students' perceptions of their own and healthcare workers' (HCWs) hand hygiene compliance, and to make recommendations for future practice and hand hygiene training in preregistration nursing courses.

BACKGROUND

Effective hand hygiene decontamination can lower the prevalence of healthcare-associated infections (HCAIs); unfortunately, the prevalence of HCAIs continues to rise and so poses challenges to healthcare providers to reduce such infections. Previous studies have shown that hand hygiene compliance in HCWs is generally low and that any increase in compliance is difficult to sustain. Several barriers to hand hygiene compliance have been identified in the literature.

DESIGN

A qualitative interpretive design was used to examine nursing students' perceptions of hand hygiene practices.

METHODS

Ten preregistration students participated in semi-structured qualitative interviews, which were analysed thematically.

RESULTS

Hand hygiene compliance was perceived to be effected by specific barriers which included: time and busyness; clinical procedure; skin condition; lack of knowledge and glove use. Importantly, students perceived other HCWs as being the influencing factor for hand hygiene compliance resulting from the perception that they should 'fit in' with those working in the clinical area.

CONCLUSIONS

The findings support previous literature and found that respondents emphasised the importance of fitting into the clinical area and role models in shaping hand hygiene compliance.

RELEVANCE TO CLINICAL PRACTICE

For nursing students, the influence of other HCWs as role models should not be underestimated.

Patterns of research utilization on patient care units

BACKGROUND

Organizational context plays a central role in shaping the use of research by healthcare professionals. The largest group of professionals employed in healthcare organizations is nurses, putting them in a position to influence patient and system outcomes significantly. However, investigators have often limited their study on the determinants of research use to individual factors over organizational or contextual factors.

METHODS

The purpose of this study was to examine the determinants of research use among nurses working in acute care hospitals, with an emphasis on identifying contextual determinants of research use. A comparative ethnographic case study design was used to examine seven patient care units (two adult and five pediatric units) in four hospitals in two Canadian provinces (Ontario and Alberta). Data were collected over a six-month period by means of quantitative and qualitative approaches using an array of instruments and extensive fieldwork. The patient care unit was the unit of analysis. Drawing on the quantitative data and using correspondence analysis, relationships between various factors were mapped using the coefficient of variation.

RESULTS

Units with the highest mean research utilization scores clustered together on factors such as nurse critical thinking dispositions, unit culture (as measured by work creativity, work efficiency, questioning behavior, co-worker support, and the importance nurses place on access to continuing education), environmental complexity (as measured by changing patient acuity and re-sequencing of work), and nurses' attitudes towards research. Units with moderate research utilization clustered on organizational support, belief suspension, and intent to use research. Higher nursing workloads and lack of people support clustered more closely to units with the lowest research utilization scores.

CONCLUSION

Modifiable characteristics of organizational context at the patient care unit level influences research utilization by nurses. These findings have implications for patient care unit structures and offer beginning direction for the development of interventions to enhance research use by nurses.

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

BACKGROUND

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

AIM

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

METHODS

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

FINDINGS

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

IMPLICATIONS/CONCLUSIONS

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

Barriers to evidence-based nursing: a focus group study

AIM

This paper reports a study to explore the barriers to evidence-based nursing among Flemish (Belgian) nurses.

BACKGROUND

Barriers obstructing the call for an increase in evidence-based nursing have been explored in many countries, mostly through quantitative study designs. Authors report on lack of time, resources, evidence, authority, support, motivation and resistance to change. Relationships between barriers are seldom presented.

METHODS

We used a grounded theory approach, and five focus groups were organized between September 2004 and April 2005 in Belgium. We used purposeful sampling to recruit 53 nurses working in different settings. A problem tree was developed to establish links between codes that emerged from the data.

FINDINGS

The majority of the barriers were consistent with previous findings. Flemish (Belgian) nurses added a potential lack of responsibility in the uptake of evidence-based nursing, their 'guest' position in a patient's environment leading to a culture of adaptation, and a future 'two tier' nursing practice, which refers to the different education levels of nurses. The problem tree developed serves as (1) a basic model for other researchers who want to explore barriers within their own healthcare system and (2) a useful tool for orienting change management processes.

CONCLUSION

Despite the fact that the problem tree presented is context-specific for Flanders (Belgium), it gives an opportunity to develop clear objectives and targeted strategies for tackling obstacles to evidence-based nursing.

Implementation of SIGN 44 guidelines for managing cancer pain in a community setting

This paper discusses the realistic evaluation of an evolving managed clinical network (MCN) in palliative care. The primary focus of this community-based MCN was to improve cancer patients' pain by implementing clinical guidelines. The methods of evaluation included three case studies which featured interviews with patients, relatives and health professionals involved in their care. The results of the case studies were fed back to the network executive group during focus group interviews. The case studies and focus group interviews were carried out at approximately five-monthly intervals. The model of care being implemented by health professionals was refined by the network executive group following each focus group interview. The context, mechanisms and outcomes which evolved from the evaluation contained some elements of a best practice model for controlling pain for patients with advanced cancer.

Nursing students can help support evidence-based practice on clinical nursing units

AIMS

A research study was designed to explore whether research utilization projects underwent by student nurses could have an impact on nursing practice on clinical nursing units.

BACKGROUND

The use of evidence-based practice is becoming essential for nursing managers and nursing staff, but there are many barriers to implementing research findings in practice. Student nurses can be used to assist when staff nurses do not have time during the work day.

METHODS

Baccalaureate nursing students completed a research utilization project during their final comprehensive clinical experience. Telephonic interviews were conducted with the students' preceptors 5 months after the students' clinical experience, to obtain their perceptions of the impact of the student project on the nurses' knowledge and practice.

RESULTS

The staff nurse preceptors reported the projects were well received with the primary impact of the projects being to educate the nursing staff and patients and thus improve the level of nursing practice on the clinical units.

CONCLUSIONS

Student research utilization projects are one way to save time for staff nurses and increase their awareness of current research findings.