Clinical nursing leaders’, team members’ and service managers’ experiences of implementing evidence at a local level

The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis

Background

Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influence their KB efforts.

Methods

We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

Results

We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Conclusion

Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organizations. Future studies are required to refine and strengthen this framework.

Trial registration

A protocol for this review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07387-z.

Nursing turnover intentions: The role of leader emotional intelligence and team culture

AIM

To explore the influence of leader emotional intelligence on the working culture prevailing in teams that ultimately impacts nurses' intent to leave the job.

BACKGROUND

Global shortages of nursing professionals have been concerning issues of extreme vitality in the delivery of superior services. Though the state-of-the-art system provides relief, the hospital management continued worrying about losing highly skilled nursing professionals due to a higher level of emotional exhaustion exhibiting progressive turnover.

METHODS

A survey technique was employed for data collection from nurses. Further data were analysed by structural equation modelling in the light of 313 substantial responses by using SmartPLS.

RESULTS

The findings revealed that leader emotional intelligence impulses critical constructive effects by fulfilling the needs of nurses and has an impact on their turnover intentions simultaneously.

CONCLUSION

The research provides an empirical lens of leadership and culture, which noticeably explain turnover intention. This study affirmed solid connections amongst the leader emotional intelligence, team culture and turnover intentions.

IMPLICATIONS FOR NURSING MANAGEMENT

The study provides valuable insight for health management organisations to focus on factors that decrease the turnover intention of nurses. Considering a global shortage of nurses, nursing management must consider crucial aspects of the work environment and plan interventions to restrain nursing turnover intentions.

Redeveloping the JBI Model of Evidence Based Healthcare

BACKGROUND

In 2005, Pearson et al. presented a developmental framework of evidence-based practice that sought to situate healthcare evidence and its role and use within the complexity of practice settings globally. A decade later, it was deemed timely to re-examine the Model and its component parts to determine whether they remain relevant and a true and accurate reflection of where the evidence-based movement is today.

METHODS

A two-phase process was employed for this project. Phase 1 involved a citation analysis, conducted using the index citation of the original source article on the Joanna Briggs Institute (JBI) Model by Pearson et al. The databases searched were Web of Science and Google Scholar from year of publication (2005) to July 2015. Duplicates and articles in languages other than English were removed, and all results were imported and combined in an Excel spreadsheet for review, coding and interpretation. Phase 2 (model revision) occurred in two parts. Part 1 involved revision of the Model by an internal working group. This revised version of the Model was then subjected to a process of focus group discussion (Part 2) that engaged staff of the Joanna Briggs Collaboration during the 2015 annual general meeting. These data were recorded then transcribed for review and consideration.

RESULTS

The citation analysis revealed that the Model was primarily utilized to conceptualize evidence and evidence-based healthcare, but that language used in relation to concepts within the Model was variable. Equally, the working group and focus group feedback confirmed that there was a need to ensure the language utilized in the Model was internationally appropriate and in line with current international trends. This feedback and analysis informed the revised version of the JBI Model.

CONCLUSION

Based on the citation analysis, working group and focus group feedback the new JBI Model for Evidence Based Healthcare attempts to utilize more internationally appropriate language to detail the intricacies of the relationships between systems and individuals across different settings and the need for contextual localization to enable policy makers and practitioners to make evidence-based decisions at the point of care.

Middle managers' role in implementing evidence-based practices in healthcare: a systematic review

BACKGROUND

Middle managers are in a unique position to promote the implementation of evidence-based practices (EBPs) in healthcare organizations, yet knowledge of middle managers' role in implementation and determinants (e.g., individual-, organizational-, and system-level factors) which influence their role remains fractured, spanning decades and disciplines. To synthesize understanding, we undertook a systematic review of studies of middle managers' role in healthcare EBP implementation and determinants of that role.

METHODS

We searched MEDLINE/PubMed and Business Source Complete (Ebsco) for literature on middle managers' role in healthcare EBP implementation and its determinants. We abstracted data from records that met inclusion criteria (i.e., written in English, peer-reviewed, and reporting either a protocol or results of an empirical study) into a matrix for analysis. We summarized categorical variables using descriptive statistics. To analyze qualitative data, we used a priori codes and then allowed additional themes to emerge.

RESULTS

One hundred five records, spanning across several countries and healthcare settings and relating to a range of EBPs, met our inclusion criteria. Studies of middle managers' role in healthcare EBP implementation and its determinants substantially increased from 1996 to 2015. Results from included studies suggest that middle managers shape implementation climate in addition to fulfilling the four roles hypothesized in extant theory of middle managers' role in implementation. However, extant studies offered little understanding of determinants of middle managers' role.

CONCLUSIONS

Our findings suggest that middle managers may play an important role in facilitating EBP implementation. Included studies offered little understanding regarding the relative importance of various roles, potential moderators of the relationship between middle managers' roles and EBP implementation, or determinants of middle managers' role in EBP implementation. Future studies should seek to understand determinants and moderators of middle managers' role. Clearer understanding may facilitate the translation of evidence into practice.

Altruistic leadership and affiliative humor's role on service innovation: Lessons from Spanish public hospitals

Despite literature identifies aspects that might promote innovation, the relationship between the leadership style and nurses' innovative behavior still remains unclear, and little research has provided evidence of this. To help advance in knowledge of effects of leadership on nurses' innovative behavior, we researched the effect of altruistic leadership on nurses' innovative behavior. In addition, the mediating role of affiliative humor in the relationship between altruistic leadership and nurses' innovative behavior was examined. Questionnaire survey method was followed with a sample of 324 nurses working in public hospitals in Spain. We used structural equation models, to check the research hypotheses. This research reveals that affiliative humor partially mediates the relationship between altruistic leadership and nurses' innovative behavior. Thus, unselfish leaders are crucial to promoting innovative behaviors among nurses, and affiliative humor plays a fundamental role to explain how altruistic leaders enhance nurses' innovative behavior.

The effectiveness of research implementation strategies for promoting evidence-informed policy and management decisions in healthcare: a systematic review

BACKGROUND

It is widely acknowledged that health policy and management decisions rarely reflect research evidence. Therefore, it is important to determine how to improve evidence-informed decision-making. The primary aim of this systematic review was to evaluate the effectiveness of research implementation strategies for promoting evidence-informed policy and management decisions in healthcare. The secondary aim of the review was to describe factors perceived to be associated with effective strategies and the inter-relationship between these factors.

METHODS

An electronic search was developed to identify studies published between January 01, 2000, and February 02, 2016. This was supplemented by checking the reference list of included articles, systematic reviews, and hand-searching publication lists from prominent authors. Two reviewers independently screened studies for inclusion, assessed methodological quality, and extracted data.

RESULTS

After duplicate removal, the search strategy identified 3830 titles. Following title and abstract screening, 96 full-text articles were reviewed, of which 19 studies (21 articles) met all inclusion criteria. Three studies were included in the narrative synthesis, finding policy briefs including expert opinion might affect intended actions, and intentions persisting to actions for public health policy in developing nations. Workshops, ongoing technical assistance, and distribution of instructional digital materials may improve knowledge and skills around evidence-informed decision-making in US public health departments. Tailored, targeted messages were more effective in increasing public health policies and programs in Canadian public health departments compared to messages and a knowledge broker. Sixteen studies (18 articles) were included in the thematic synthesis, leading to a conceptualisation of inter-relating factors perceived to be associated with effective research implementation strategies. A unidirectional, hierarchal flow was described from (1) establishing an imperative for practice change, (2) building trust between implementation stakeholders and (3) developing a shared vision, to (4) actioning change mechanisms. This was underpinned by the (5) employment of effective communication strategies and (6) provision of resources to support change.

CONCLUSIONS

Evidence is developing to support the use of research implementation strategies for promoting evidence-informed policy and management decisions in healthcare. The design of future implementation strategies should be based on the inter-relating factors perceived to be associated with effective strategies.

TRIAL REGISTRATION

This systematic review was registered with Prospero (record number: 42016032947).

Supporting first-line managers in implementing oral care guidelines in nursing homes

This study investigated first-line managers’ experience of and responses to a concise leadership intervention to facilitate the implementation of oral care clinical practice guidelines (CPGs) in nursing homes. Leadership is known to be an important element in knowledge implementation but little is known as to what supports managers to facilitate the process. By means of a process evaluation with mixed methods, the context and a three-month leadership program was explored, including activities during and in relation to the program, and the effects in terms of oral care CPG implementation plans. While the managers appreciated the intervention and considered improved oral care to be a priority, their implementation plans mainly focused the dissemination of an oral care checklist. The findings suggest that extended implementation interventions engaging both managers and clinical staff are needed, and that a concise intervention does not facilitate first-line managers to adopt behaviors known to facilitate knowledge implementation.

A systematic review of factors influencing knowledge management and the nurse leaders' role

AIM

To describe factors facilitating or inhibiting the development of registered nurses' competency and nurse leader's role in knowledge management.

BACKGROUND

Nurses' competency directly influences patient safety and the quality and effectiveness of patient care. Challenges of nurse leaders in knowledge management include acquiring, assessing and utilising current knowledge and assessing and enhancing competency.

EVALUATION

A systematic search was conducted in PubMed, CINAHL, SCOPUS and ERIC databases in April 2015. The search identified 18 relevant research articles published between 2009 and 2015. The quality of the studies was appraised in accordance with study designs.

KEY ISSUE

Knowledge management is facilitated by an organisation culture that supports learning, sharing of information and learning together. Leader commitment and competency were factors related to leadership facilitating knowledge management.

CONCLUSION

Nurse leaders need evidence-based interventions to support shared learning and to create infrastructures that facilitate competence development. Future research is especially needed to evaluate connections between knowledge management and patient outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT AND LEADERSHIP

The results of this review can be utilised in enhancing factors to facilitate knowledge management in clinical practice and identifying nurse leaders' role in strengthening nurses' competency.

A Critical Qualitative Study of the Position of Middle Managers in Health Care Quality Improvement

To date, health care quality improvement (QI) has focused on the engagement of executive leadership and frontline staff as key factors for success. Little work has been done on understanding how mid-level unit/program managers perceive their role in QI and how capacity could be built at this level to increase success. We present ethnographic data on the experience of hospital middle managers to consider how the expectations and capacity of their current position might influence QI progress organizationally.

Clinical nursing leaders' perceptions of nutrition quality indicators in Swedish stroke wards: a national survey

AIM

To describe nursing leaders' perceptions of nutrition quality in Swedish stroke wards.

BACKGROUND

A high risk of undernutrition places great demand on nutritional care in stroke wards. Evidence-based guidelines exist, but healthcare professionals have reported low interest in nutritional care. The Donabedian framework of structure, process and outcome is recommended to monitor and improve nutrition quality.

METHOD

Using a descriptive cross-sectional design, a web-based questionnaire regarding nutritional care quality was delivered to eligible participants.

RESULT

Most clinical nursing leaders reported structure indicators, e.g. access to dieticians. Among process indicators, regular assessment of patients' swallowing was most frequently reported in comprehensive stroke wards compared with other stroke wards. Use of outcomes to monitor nutrition quality was not routine. Wards using standard care plans showed significantly better results.

CONCLUSION

Using the structure, process and outcome framework to examine nutrition quality, quality-improvement needs became visible. To provide high-quality nutrition, all three structure, process and outcome components must be addressed.

IMPLICATIONS FOR NURSING MANAGEMENT

The use of care pathways, standard care plans, the Senior Alert registry, as well as systematic use of outcome measures could improve nutrition quality. To assist clinical nursing leaders in managing all aspects of quality, structure, process and outcome can be a valuable framework.

Knowledge translation strategies for enhancing nurses' evidence-informed decision making: a scoping review

BACKGROUND

Nurses are increasingly expected to engage in evidence-informed decision making (EIDM); the use of research evidence with information about patient preferences, clinical context and resources, and their clinical expertise in decision making. Strategies for enhancing EIDM have been synthesized in high-quality systematic reviews, yet most relate to physicians or mixed disciplines. Existing reviews, specific to nursing, have not captured a broad range of strategies for promoting the knowledge and skills for EIDM, patient outcomes as a result of EIDM, or contextual information for why these strategies "work."

AIM

To conduct a scoping review to identify and map the literature related to strategies implemented among nurses in tertiary care for promoting EIDM knowledge, skills, and behaviours, as well as patient outcomes and contextual implementation details.

METHODS

A search strategy was developed and executed to identify relevant research evidence. Participants included registered nurses, clinical nurse specialists, nurse practitioners, and advanced practice nurses. Strategies were those enhancing nurses' EIDM knowledge, skills, or behaviours, as well as patient outcomes. Relevant studies included systematic reviews, randomized controlled trials, cluster randomized controlled trials, non-randomized trials (including controlled before and after studies), cluster non-randomized trials, interrupted time series designs, prospective cohort studies, mixed-method studies, and qualitative studies. Two reviewers performed study selection and data extraction using standardized forms. Disagreements were resolved through discussion or third party adjudication.

RESULTS

Using a narrative synthesis, the body of research was mapped by design, clinical areas, strategies, and provider and patient outcomes to determine areas appropriate for a systematic review.

CONCLUSIONS

There are a sufficiently high number of studies to conduct a more focused systematic review by care settings, study design, implementation strategies, or outcomes. A focused review could assist in determining which strategies can be recommended for enhancing EIDM knowledge, skills, and behaviours among nurses in tertiary care.

A model (CMBP) for collaboration between university college and nursing practice to promote research utilization in students' clinical placements: a pilot study

BACKGROUND

A collaborative project was initiated in Norway between a university college and a hospital in order to improve RNs' and nursing students' research utilization in clinical placements. This paper describes the model (CMBP) that was developed, its first application, and evaluation.

AIM

The evaluation aimed at describing nurses' and students' experiences of the CMBP related to collaboration, facilitation, learning, and impact on nursing care.

METHODS

Thirty-eight students from the second and third year of nursing education, and four nurses answered questionnaires with closed and open ended questions. In addition two of the nurses wrote diaries. Data were subjected to qualitative and quantitative analysis.

FINDINGS

Almost all participants reported that collaboration between nursing college and nursing practice had been beneficial. Most students and all nurses reported about valuable learning, increased understanding of research utilization, and improved quality of nursing care. Both students and RNs recommended the CMBP to be used in all clinical placements to support academic learning and increase research utilization in clinical practice.

CONCLUSION

Despite study limitations the findings indicate that the CMBP has a potential to be a useful model for teaching RNs' and students EBP. However, further refinement of the model is needed, followed by a more comprehensive implementation and evaluation.

Educating DNP students about critical appraisal and knowledge translation

Consumers expect that health care providers will use the best evidence when assisting them in making decisions about treatment options. Nurses at all educational levels report that they lack knowledge to critically appraise research studies and the skills to effectively implement evidence-based practice (EBP) in their clinical settings. Organizational culture and management support of innovation are critical factors in the adoption of EBP. Doctor of Nursing Practice (DNP) graduates can have a pivotal role in the transfer of knowledge to practice, yet critical appraisal and EBP competencies for DNP and Master of Science in Nursing (MSN) students have not been well differentiated in nursing curricula. Also students' attitudes toward EBP, self-efficacy beliefs, utilization, and knowledge gaps are rarely evaluated before courses are designed. This article reports on the development of a DNP-level EBP course to help students evaluate and apply research findings to clinical practice.

The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project)

Background

Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.

Methods/Design

A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.

Discussion

Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.

Trial registration

ACTRN12611000020987

Impact of engaging middle management in practice interventions on staff support and learning culture: a quasi-experimental design

AIM

This study evaluated the impact of different levels of engaging middle management in ward based strategies implemented by a project educator.

BACKGROUND

The challenge for learning in practice is to develop effective teams where experienced staff engage and foster learning with students and other novice staff.

DESIGN

A quasi-experimental pre- and post- intervention four group design was conducted from November 2009 to May 2010 across four general surgical and four general medical inpatient matched units in two settings in South East Queensland, Australia.

METHOD

Staff survey data was used to compare control and intervention groups (one actively engaging nurse managers) before and after 'practice learning' interventions. The survey comprised demographic data and data from two validated scales (support instrument for nurses facilitating learning and clinical learning organisational culture).

RESULTS

Number of surveys returned pre- and post-intervention was 336 from 713 (47%). There were significant differences across many subscales pertaining to staff perception of support in the intervention groups, with only one change in the control group. The number of significant different subscales in the learning culture was also greater when middle management supported the intervention.

IMPLICATIONS FOR NURSING MANAGEMENT

Middle management should work closely with facilitators to assist embedding practice interventions.

Using a knowledge utilization framework to explore how findings from one study can be applied to other nursing contexts

AIM

To discuss the complexities of moving research into practice and through a case example, explore how empirical findings from one specific study could be applied to nursing in other contexts.

BACKGROUND

The processes of moving research findings into practice are complex and multidimensional. In this paper, an innovative approach to social support, network-focused nursing (NFN), is used as a case example to illustrate these complexities. Social support is associated with better recovery and survival after illness and based on this, a NFN programme was developed in a Danish oncology youth unit. Subsequently, a research study was undertaken to investigate the programme and based on the findings, the concept NFN was developed.

METHODS

A knowledge utilization framework is used to explore how empirical findings from the NFN study could be applied to nursing more generally. Aligned with this, the specific considerations for implementing NFN are explicated.

DISCUSSION

Strong leadership, education, management support and effective communication are critical factors for research utilization. Moving research into practice requires openness to new ideas. Nursing and healthcare policies therefore need to support environments in which creativity and innovation can flourish. NFN was developed in teenager and young adult cancer care, but its principles may be transferable to other clinical environments.

CONCLUSIONS

It is important that nurse managers and policy makers ensure that support and education are available to nurses to facilitate moving research into practice. Moreover, resources need to be considered, particularly in countries where financial and organizational infrastructures may be weak.

Developing leadership capacity for guideline use: a pilot cluster randomized control trial

SIGNIFICANCE

The importance of leadership to influence nurses' use of clinical guidelines has been well documented. However, little is known about how to develop and evaluate leadership interventions for guideline use.

PURPOSE

The purpose of this study was to pilot a leadership intervention designed to influence nurses' use of guideline recommendations when caring for patients with diabetic foot ulcers in home care nursing. This paper reports on the feasibility of implementing the study protocol, the trial findings related to nursing process outcomes, and leadership behaviors.

METHODS

A mixed methods pilot study was conducted with a post-only cluster randomized controlled trial and descriptive qualitative interviews. Four units were randomized to control or experimental groups. Clinical and management leadership teams participated in a 12-week leadership intervention (workshop, teleconferences). Participants received summarized chart audit data, identified goals for change, and created a team leadership action. Criteria to assess feasibility of the protocol included: design, intervention, measures, and data collection procedures. For the trial, chart audits compared differences in nursing process outcomes.

PRIMARY OUTCOME

8-item nursing assessments score. Secondary outcome: 5-item score of nursing care based on goals for change identified by intervention participants. Qualitative interviews described leadership behaviors that influenced guideline use.

RESULTS

Conducting this pilot showed some aspects of the study protocol were feasible, while others require further development. Trial findings observed no significant difference in the primary outcome. A significant increase was observed in the 5-item score chosen by intervention participants (p = 0.02). In the experimental group more relations-oriented leadership behaviors, audit and feedback and reminders were described as leadership strategies.

CONCLUSIONS

Findings suggest that a leadership intervention has the potential to influence nurses' use of guideline recommendations, but further work is required to refine the intervention and outcome measures. A taxonomy of leadership behaviors is proposed to inform future research.