Experiences of the implementation of clinical practice guidelines--interviews with nurse managers and nurses in hospital care

Developing evidence-based medication therapy management tools for psychiatric nurses: An evaluative qualitative case study

RATIONALE, AIMS AND OBJECTIVES

Clinical use of psychotropic medications involves diverse risks, addressable by nursing interventions. The research had a dual purpose: developing an "Evidence-Based Medication Therapy Management Guideline" and a "Medication Administration-Tracking Chart" and evaluating their use through an evaluative case study.

METHODS

Evidence-based guideline and chart development and evaluative case study. Initially, Evidence-Based Medication Therapy Management Guideline and Medication Administration Tracking Chart for managing medication in a psychiatric unit were developed. Subsequently, their efficacy was evaluated in a case study involving 10 participating nurses used in the psychiatric unit with 123-bed of a training and research hospital in Turkey. Data was collected through personal forms, interviews, medication charts, and researcher observations, and the analysis employed Merriam's case study method.

RESULTS

Three themes (inception, implementation, termination, and sustainers) and 12 sub-themes emerged. Nurses stated that the research tools filled their information gaps, enhancing the medication therapy management process's effectiveness and safety, improving nursing care quality and continuity, and benefiting patient outcomes. Nurses expressed a desire to consistently use the tools in the unit and provided suggestions.

CONCLUSION

Nurses highlighted the tools' potential to enhance medication safety, psychiatric care, and patient outcomes. However, their stance on using evidence-based tools revealed an approach/avoidance conflict, balancing benefits and barriers. Experience emerged as a hindrance in embracing evidence-based clinical tools. This study is among the first to comprehensively develop evidence-based medication management guideline and administration-tracking chart for psychiatric nurses globally and in our country. Routine use of the tools is expected to enhance nurses' expertise in psychotropic medication management, leading to improved patient outcomes in medication-related aspects.

Sepsis screening protocol implementation: a clinician-validated rapid realist review

INTRODUCTION

The failed or partial implementation of clinical practices negatively impacts patient safety and increases systemic inefficiencies. Implementation of sepsis screening guidelines has been undertaken in many settings with mixed results. Without a theoretical understanding of what leads to successful implementation, improving implementation will continue to be ad hoc or intuitive. This study proposes a programme theory for how and why the successful implementation of sepsis screening guidelines can occur.

METHODS

A rapid realist review was conducted to develop a focused programme theory for the implementation of sepsis screening guidelines. An independent two-reviewer approach was used to iteratively extract and synthesise context and mechanism data. Theoretical context-mechanism-outcome propositions were refined and validated by clinicians using a focus group and individual realist interviews. Implementation resources and clinical reasoning were differentiated in articulating mechanisms.

RESULTS

Eighteen articles were included in the rapid review. The theoretical domains framework was identified as the salient substantive theory informing the programme theory. The theory consisted of five main middle-range propositions. Three promoting mechanisms included positive belief about the benefits of the protocol, belief in the legitimacy of using the protocol and trust within the clinical team. Two inhibiting mechanisms included pessimism about the protocol being beneficial and pessimism about the team. Successful implementation was defined as achieving fidelity and sustained use of the intervention. Two intermediate outcomes, acceptability and feasibility of the intervention, and adoption, were necessary to achieve before successful implementation.

CONCLUSION

This rapid realist review synthesised key information from the literature and clinician feedback to develop a theory-based approach to clinical implementation of sepsis screening. The programme theory presents knowledge users with an outline of how and why clinical interventions lead to successful implementation and could be applied in other clinical areas to improve quality and safety.

Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study

OBJECTIVES

Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements.

METHODS

A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted.

RESULTS

Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs.

CONCLUSIONS

Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.

Perceived enabling factors and barriers for the implementation of improvements in health care in order to achieve patient-centred care: A case report from Sweden

RATIONALE, AIM, AND OBJECTIVES

More knowledge is needed regarding the complex factors and perceptions that enable the implementation of change in health care. The study aimed to examine the enabling factors and barriers encountered in the implementation of improvements in health care in order to achieve patient-centred care (PCC) and to study if there was a correlation in the extent the improvements were perceived to be implemented and the preconditions that were considered to affect them.

METHODS

Using a mixed method design, data were gathered via a questionnaire and individual interviews with health care personnel, clinic managers, and first-line managers. The data collection and analyses were based on the framework for Promoting Action on Research Implementation in Health Services (PARiHS). Correlations between PCC improvements and preconditions for improvements were performed.

RESULTS

A high level of involvement, knowledge, and adequate resources were considered important to achieve an implementation of PCC with joint responsibility. Leadership and management need to be explicit and promote continuous follow-up and feedback. Preconditions for improvement had a linear correlation with the perceived level of implementation. Knowledge-related preconditions had greatest impact on implementation.

CONCLUSIONS

The PARiHS framework was appropriate to use since the three components of evidence, context, and facilitation present different important preconditions in the implementation process. Evidence was the highest rated contributor since evidence-based practices in health care are necessary. It is vital that the important role of the context and facilitators is acknowledged in the implementation process to enable a successful implementation of change. There is a need to incorporate a clear strategy involving all levels in the organization. Furthermore, leaders play an important role in the implementation by facilitating communication and support and by having trust in facilitators and health care personnel. The results are applicable to other interventions implementing change in health care.

Context as a Facilitator of the Implementation of Evidence-based Nursing: A Meta-synthesis

Nurses have numerous difficulties in implementing science due to obstacles related to the work context. The aim is to explore the work-context-related facilitators of the application of evidence in clinical practice by nursing professionals. Qualitative meta-synthesis of primary studies on nurses' experiences of work-context-related facilitators, as defined by the Promoting Action on Research Implementation in Health Services model. Using the Qualitative Appraisal and Review Instrument of the Joanna Briggs Institute. Of the total 57 primary research articles included, an explanatory model of the facilitating factors related to the work context was generated on the basis of four general categories: institutional support (leadership), multidisciplinary support (teamwork and communication), culture of improving quality of care (nursing professionals' attitudes towards change) and use of research (valuing research). Action can be taken on the facilitating factors of the evidence-based practice application in nursing clinical environments, providing resources and motivation from the organization.

The experiences of the agency registered nurse: An integrative literature review

AIM

To examine experienced registered nurses' motivations for choosing agency work, their experiences and perceptions of agency nursing and how they meet their regulatory professional development obligations.

BACKGROUND

Agency registered nurses are employed by healthcare organizations to meet staffing shortfalls and contain costs.

METHODS

Using an integrative review framework, four databases (CINAHL, Medline, Embase and Scopus) were systematically searched between 2000 and 2017: study selection followed the Preferred Reporting Items for Systematic reviews and Meta-analyses.

RESULTS

Our search identified 491 sources. From these, two primary qualitative sources were included in this review. Four themes were identified: orientation, allocation of the agency nurse, isolation in clinical practice and lack of education opportunities.

CONCLUSION

Given the limited literature on agency nurses and how to support them, further research is required on this subject.

IMPLICATIONS FOR NURSING MANAGEMENT

Support for agency nurses is necessary, so they can seamlessly integrate with the healthcare team to provide safe patient care. This review may assist managers to identify strategies to effectively engage and support agency registered nurses in the acute care nursing team. The gaps identified highlight the need for further research to explore agency nurses' motivations, and support needs to inform future strategic workforce planning.

The Chinese version of attitudes towards guidelines scale: validity and reliability assessment

Background

The use of guidelines has shown to improve clinical practice process and structure of health care, but health care providers don’t always use and keep up-to-date with the new clinical practice guidelines. Nurses’ attitudes towards guidelines have shown to be the most frequently identified factor affecting their actual use of clinical practice guidelines, but no instruments for measuring it are available in China. There are scales validated in the western countries, but there is no information about their validity in Chinese health care. The purpose of this study is to test the validity and reliability of Chinese Attitudes towards guidelines - scale for nurses.

Methods

The study was conducted from April to July 2017. The Attitudes towards guidelines scale was translated into Chinese with forward-backward translation method and a questionnaire survey was conducted. Eight hundred randomly selected nurses (final N = 768) from Geriatrics, Internal medical and Rehabilitation departments of 16 hospitals were drawn in Sichuan province, China. Construct validity was evaluated by exploratory and confirmatory factor analysis, and reliability was assessed by test-retest reliability (represented by intra class correlation) and internal consistency (expressed by Cronbach’s coefficients). The test-retest reliability was examined with a sample of 32 clinical nurses who filled out the questionnaire 14 days after the first survey.

Results

Exploratory factor analysis supported a four-factor model for the Chinese version of the scale. Confirmatory factor analysis indicated that the hypothetical four-factor model fitted the data relatively well. The intra class correlation coefficient was 0.85 (95%CI, 0.68–0.93) and the Cronbach’s alpha values for the four subscales ranged from 0.645 to 0.912.

Conclusions

The results support the acceptable level of validity and reliability of the Chinese version of Attitudes towards guidelines scale, which can be used to assess nurses’ attitudes towards guidelines in China. Future testing for the Chinese version of Attitudes towards guidelines scale needs to be carried out to see whether these results are generalizable to other professionals and occupational groups and to be used to revise attitudes towards specific guidelines in China.

National survey in elderly care on the process of adopting a new regulation aiming to prevent and treat malnutrition in Sweden

Guided by the i-PARIHS framework, this study investigates perceived facilitators in the process of adopting a new regulation launched in 2015 which aims to prevent and treat malnutrition. In May 2016, a national web-based questionnaire was emailed to chief medical nurses in elderly care in all Swedish municipalities (n = 290). The response rate in this cross-sectional study was 75% (n = 217). Fifty per cent of the municipalities had adopted new routines, 42% had started and 8% had not. One third of the respondents considered malnutrition to be a major problem in elderly care and about half considered the new national regulation to have strengthened local work. A logistic regression showed that the odds for having adopted new routines were higher for CMNs with long experience in elderly care and who had previously worked to prevent malnutrition, and for those who considered the new national regulation helpful. To extract underlying factors in the adoption process, two principal component analyses were performed for key actors and support. For key actors, the analysis yielded four factors, explaining 67% of the total variance; (a) first line team, (b) expert team, (c) management team and (d) surrounding resources. For support, the analysis yielded three factors, which explained 65% of the total variance; (a) agile teamwork, (b) management and leadership and (c) acceptance. The slow adoption rate of the regulation raises questions about its impact; this might be an effect of the general trend of decentralisation in the Swedish welfare sector, and in elderly care in particular, making it hard to attain change that is steered centrally. However, malnutrition is a pronounced problem in elderly care and the mandatory nature of the new regulation therefore warrants further investigation of whether its launch has contributed to a reduction of malnutrition by investigating outcomes and preventive actions carried out in practice.

Management Practices Promoting Sustained Implementation of the Quality Register Senior Alert for Older Adults in Municipal Care in Sweden

Background:

Senior Alert is a national quality register aimed at supporting a standardized, structured, and systematic preventive care process for adults aged 65 and over in the areas malnutrition, pressure ulcers, falls, problems with oral health and bladder dysfunction. Therefore, the quality register is particularly suitable for older adults with multimorbidity.

Aim:

The aim was to describe management practices that contributed to the sustained implementation of the quality register Senior Alert in municipal elderly care in Sweden.

Methods:

The design of this pilot study was descriptive and inductive. The sample of n = 12 included managers (n = 7) and care staff (n = 5) at seven municipal care homes for older adults in Sweden. The study was performed between April 2014 and June 2014 using two methods: Individual interviews and nonparticipant unstructured observations. Data were analyzed using qualitative content analysis.

Results:

The analysis led to the following generic categories: leading teamwork, leading a preventive care process and leading a supportive organizational structure, and to one main category: management promoting learning and quality improvement.

Conclusion:

To be sustainable, Senior Alert implementations in municipal elderly care need management. Management, by leading teamwork, a preventive care process and a supportive organizational structure, is essential for achieving learning and quality improvement.

Adherence to Swedish guidelines for pain treatment in relation to pediatric tonsil surgery: A survey of the multidisciplinary team

BACKGROUND

Pain management in children after tonsil surgery is essential, and optimal pain treatment has been discussed for many years. Data from the National Tonsil Register in Sweden (NTRS) and a national mapping have demonstrated the need for national pain treatment guidelines for pediatric tonsil surgery. As a result, Swedish national guidelines, together with updated patient information on the website tonsilloperation.se, were developed and implemented in 2013.

OBJECTIVES

The objective of this study was to evaluate the professionals' opinions of and adherence to pain treatment guidelines for pediatric tonsil surgery patients in a two-year follow-up.

METHOD

This descriptive cross-sectional study was based on data from an inter-professional questionnaire, which was validated by an expert group using a content validity index (S-CVI 0.93). The questionnaire was sent to all Swedish ear, nose and throat (ENT) departments (n = 49) that the NTRS identified as performing tonsil surgery on children younger than 18 years of age. In each clinic, we asked for responses from staff in each of the following professions: ENT physicians, anesthesia physicians, registered nurse anesthetists, and registered nurses in the ENT departments.

RESULTS

Respondents from 48 ENT departments participated, and 139/163 (85%) completed questionnaires were returned. The guidelines were reported as being clear, ensuring patient safety and providing optimal pharmacological treatment. Treatment was given according to the guidelines: Half of the departments gave pre- or intraoperative treatment with clonidine, betamethasone and high-dose paracetamol (acetaminophen). A multimodal pain approach (paracetamol and COX-inhibitors) after hospital discharge was prescribed by all departments after tonsillectomy and, extensively, after tonsillotomy. One-third of the departments prescribed paracetamol with a higher normal dose for the first three postoperative days. Half of the departments prescribed rescue analgesics, clonidine or opioids after tonsillectomy. None of the departments prescribed codeine or tramadol, drugs that are discouraged in the guidelines. The majority of the departments used the website tonsilloperation.se to provide information to the patients and their caregivers.

CONCLUSION

The respondents' opinions of and the ENT departments adherence to the Swedish national guidelines were considered to be good. The national implementation process in Sweden has impacted the manner in which ENT departments treat pain after tonsil surgery.

Changing nutrition care practices in hospital: a thematic analysis of hospital staff perspectives

Background

Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital.

Methods

A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions.

Results

Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team.

Conclusions

Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.

Trial registration

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

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.

Management of Children with Autism Spectrum Disorder in the Anesthesia and Radiographic Context

OBJECTIVE

As a primary objective, this study purports to develop guidelines to better care for children with autism spectrum disorder (ASD), particularly regarding these children's preparation for anesthesia and radiologic procedures.

METHODS

Using a Delphi method with an online distribution of questionnaire, guidelines for caring for children with ASD were created. Twenty-one participants were included in the expert panel. These participants were working with children with ASD in several anesthesia and radiology departments in Sweden. A list of items was created from a previous survey and the literature. In the first round, the items with <60% agreement were discarded. Items were merged, and a new list was created. Two more similar rounds were performed. In the last 2 rounds, 21 participants responded, and 80% agreement was considered to be consensus.

RESULTS

The final guidelines consisted of 14 items and a checklist of 16 factors. The 5 areas covered by the items and the checklist were as follows: planning involving parents/guardians, features in the environment, and use of time, communication, and the health care professionals. The organization was important in making it possible for the health care professional to care for the individual child according to the child's needs. It was important to involve the parents/guardians to obtain knowledge about the functioning of the child.

CONCLUSION

A caring encounter involving a child with ASD in the anesthesia and radiology contexts requires advance planning, catered specifically to the individual needs of each child. To accomplish this, general knowledge regarding ASD and ASD's particular manifestation in the child entrusted to their care is required from the health care workers. The organization needs to have structures in place to facilitate this process.

To Assess Prerequisites Before an Implementation Strategy in an Orthopaedic Department in Sweden

Promoting Action on Research Implementation in Health Services (PARiHS) asserts that the success of knowledge implementation relates to multiple factors in a complex and dynamic way, and therefore the effects of implementation strategies vary by method and context. An instrument based on the PARiHS framework was developed to help assess critical factors influencing implementation strategies so that strategies can be tailored to promote implementation.The purpose of this study was to use the Evaluation Before Implementation Questionnaire (EBIQ), to describe staff perceptions in one orthopaedic department, and to investigate differences between wards.Staff members in four different wards at one orthopaedic department at a university hospital in Sweden were invited to complete a questionnaire related to planning for the implementation of a clinical practice guideline. The 23 items in the EBIQ were expected to capture staff perceptions about the evidence, context, and facilitation factors that influence the implementation process. Descriptive statistics and differences between wards were analyzed. Although the overall response rate was low (n = 49), two of the four wards accounted for most of the completed questionnaires (n = 25 and n = 12, respectively), enabling a comparison of these wards. We found significant differences between respondents' perceptions at the two wards in six items regarding context and facilitation in terms of receptiveness to change, forms of leadership, and evaluation and presence of feedback and facilitators.The EBIQ instrument requires further testing, but there appears to be initial support for pre-implementation use of the EBIQ as a means to enhance planning for implementation.

Lack of existing guidelines for a large group of patients in Sweden: a national survey across the acute surgical care delivery chain

RATIONALE, AIMS AND OBJECTIVES

Evidence-informed healthcare is the fundament for practice, whereby guidelines based on the best available evidence should assist health professionals in managing patients. Patients seeking care for acute abdominal pain form a common group in acute care settings worldwide, for whom decision-making and timely treatment are of paramount importance. There is ambiguity about the existence, use and content of guidelines for patients with acute abdomen. The objective was to describe and compare guidelines and management of patients with acute abdomen in different settings across the acute care delivery chain in Sweden.

METHOD

A national cross-sectional design was used. Twenty-nine ambulance stations, 17 emergency departments and 33 surgical wards covering all six Swedish health regions were included, and 23 guidelines were quality appraised using the validated Appraisal of Guidelines for Research & Evaluation II tool.

RESULTS

There is a lack of guidelines in use for the management of this large group of patients between and within different healthcare areas across the acute care delivery chain. The quality appraisal identified that several guidelines were of poor quality, especially the in-hospital ones. Further, range orders for analgesics are common in the ambulance services and the surgical wards, but are seldom present in the emergency departments. Also, education in pain management is more common in the ambulance services. These findings are noteworthy as, hypothetically, the same patient could be treated in three different ways during the same care episode.

CONCLUSIONS

There is an urgent need to develop high-quality evidence-based clinical guidelines for this patient group, with the entire care process in focus.

Implementation of national guidelines for the prevention and treatment of overweight and obesity in children and adolescents: a phenomenographic analysis of public health nurses' perceptions

Objective

To explore and describe how public health nurses (PHNs) perceive the implementation of national guidelines for the prevention and treatment of overweight and obesity among children and adolescents in well-baby clinics and school health services.

Design, sample, and measurements

An explorative descriptive design was carried out through individual interviews with 18 PHNs and analysed according to the phenomenographic tradition.

Results

Four implementation strategies were described and assigned a metaphor: the structured PHN, pragmatic PHN, critical PHN, and the resigned PHN. Competence, patient receptiveness, internal consensus, interdisciplinary collaboration, resources, and organizational embedding were the determinants identified that most frequently affect implementation, and these determinants were distributed at different levels of the organization. The extent of facilitation seemed to determine which implementation strategy would be used.

Conclusions

How PHNs implemented the guidelines for overweight and obesity were affected by determinants at different organizational levels. Contextual facilitation of implementation seemed better in larger organizations, but factors such as leadership, drive, and experience compensated in smaller municipalities. The implementation of guidelines was hindered when the barriers exceeded the benefits.

Barriers and facilitators of nurses' use of clinical practice guidelines: An integrative review

BACKGROUND

Preventable harm continues to be one of the leading causes of patient death. Each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism. However, as shown in the recent reduction in hospital acquired infections, the number of deaths could be reduced if healthcare providers used evidence-based therapies, which are often included in clinical practice guidelines (CPGs).

PURPOSE

The purpose of this integrative review is to appraise and synthesize the current literature on barriers to and facilitators in the use of clinical practice guidelines (CPGs) by registered nurses.

DESIGN

Whittemore and Knafl integrative review methodology was used. Primary quantitative and qualitative studies about the nurses' use of CPGs and published in peer-reviewed journals between January 2000 and August 2015 were included.

METHODS

The Critical Skills Appraisal Program (CASP) was used to critically appraise the quality of sixteen selected quantitative and qualitative studies.

RESULTS

Internal factors were attitudes, perceptions, and knowledge whereas format and usability of CPGs, resources, leadership, and organizational culture were external factors influencing CPG use.

CONCLUSION

Given each barrier and facilitator, interventions and policies can be designed to increase nurses' use of CPGs to deliver more evidence based therapy. In order to improve the use of CPGs and to ensure high quality care for all patients, nurses must actively participate in development, implementation, and maintenance of CPGs.

Implementing research results in clinical practice- the experiences of healthcare professionals

Background

In healthcare research, results diffuse only slowly into clinical practice, and there is a need to bridge the gap between research and practice. This study elucidates how healthcare professionals in a hospital setting experience working with the implementation of research results.

Method

A descriptive design was chosen. During 2014, 12 interviews were carried out with healthcare professionals representing different roles in the implementation process, based on semi-structured interview guidelines. The analysis was guided by a directed content analysis approach.

Results

The initial implementation was non-formalized. In the decision-making and management process, the pattern among nurses and doctors, respectively, was found to be different. While nurses’ decisions tended to be problem-oriented and managed on a person-driven basis, doctors’ decisions were consensus-oriented and managed by autonomy. All, however, experienced a knowledge-based execution of the research results, as the implementation process ended.

Conclusion

The results illuminate the challenges involved in closing the evidence-practice gap, and may add to the growing body of knowledge on which basis actions can be taken to ensure the best care and treatment available actually reaches the patient.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1292-y) contains supplementary material, which is available to authorized users.

Appraisal of guidelines for pre-operative body wash

The pre-operative body wash is a strategy for reducing post-operative infection. However, there is a lack of knowledge about its importance. The purpose of the present study was to evaluate the quality of guidelines for the pre-operative body wash using the AGREE instrument--35 guidelines containing instructions for the pre-operative body wash or preparation were included. The AGREE instrument was employed to establish a quality assessment framework that facilitated a comparison of the guidelines. The results were based on the six domains of the AGREE instrument, all of which were found to have low adherence. Descriptive statistics were used to present the assessment score. The AGREE instrument is useful for evaluating the quality of clinical guidelines. The development of evidence-based guidelines must include clinical activities. Further research is required to clarify the pre-operative body wash process and how it should be performed to reduce post-operative infection.

Speech pathologists' experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study

Background

Communication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists’ implementation of stroke CPGs. This study aimed to describe speech pathologists’ experiences and current use of guidelines, and to identify what factors influence speech pathologists’ implementation of stroke CPGs.

Methods

Speech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data.

Results

320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline “somewhat useful” or “very useful”. Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided.

Conclusions

There are many different factors that can influence speech pathologists’ implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.

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

OBJECTIVE

To investigate the dynamics of nurses' work in implementing Clinical Practice Guidelines.

DESIGN

Hybrid: systematic review techniques used to identify qualitative studies of clinical guideline implementation; theory-led and structured analysis of textual data.

DATA SOURCES

CINAHL, CSA Illumina, EMBASE, MEDLINE, PsycINFO, and Sociological Abstracts.

METHODS

Systematic review of qualitative studies of the implementation of Clinical Practice Guidelines, analysed using Directed Content Analysis, and interpreted in the light of Normalisation Process Theory.

RESULTS

Seven studies met the inclusion criteria of the review. These revealed that clinical practice guidelines are disposed to normalisation when: (a) They are associated with activities that practitioners can make workable in practice, and practitioners are able to integrate it into their collective workflow. (b) When they are differentiated from existing clinical practice by its proponents, and when claims of differentiation are regarded as legitimate by their potential users. (c) When they are associated with an emergent community of practice, and when members of that community of practice enrol each other into group processes that specify their engagement with it. (d) When they are associated with improvements in the collective knowledge of its users, and when users are able to integrate the application of that knowledge into their individual workflow. And, (e) when nurses can minimise disruption to behaviour norms and agreed professional roles, and mobilise structural and cognitive resources in ways that build shared commitments across professional boundaries.

CONCLUSIONS

This review demonstrates the feasibility and benefits of theory-led review of studies of nursing practice, and proposes a dynamic model of implementation. Normalisation Process Theory supports the analysis of nursing work. It characterises mechanisms by which work is made coherent and meaningful, is formed around sets of relational commitments, is enacted and contextualised, and is appraised and reconfigured. It facilitates such analysis from within the frame of nursing knowledge and practice itself.

Care providers' experiences of guidelines in daily work at a municipal residential care facility for older people

AIM

To describe care providers' narrated experiences of guidelines in daily work at a municipal residential care facility for older people.

BACKGROUND

Guidelines are used as a way of promoting high-quality health care. Most research concerning guidelines has focused on physician behaviour and to improve one specific aspect of care. Care providers working within municipal residential care of older people have described that working with multiple guidelines sometimes exposed them to contradictory demands and trouble their conscience.

DESIGN

A qualitative descriptive design was adopted.

METHODS

Interviews with eight care providers were carried out between February and March 2012 and analysed by qualitative content analysis.

RESULTS

Care providers described experiences that guidelines are coming from above and are controlling and not sufficiently anchored at their workplace. Furthermore, they described guidelines as stealing time from residents, colliding with each other, lacking practical use and complicating care, and challenging care providers' judgment. The overall understanding is that care providers describe experiences of struggling to do their best, prioritising between arcane guidelines while keeping the residents' needs in the foreground.

CONCLUSION

In order to prevent fragmented use, guidelines have to be coordinated and adapted to the reality of daily practice before implementation. It seems essential to provide opportunities for discussions between care providers, registered nurses and management about how to make guidelines work within their daily practice. Sufficient support, knowledge and involvement are likely key issues that can help care providers to constructively work according to guidelines and thus, by extension, improve the quality of care.

Documentation of Nursing Care in Advanced Home Care

Nursing documentation in advanced home care (AHC) is essential in communication between nurses and interprofessionally for evaluation of patient care. Poor documentation could be a threat to high quality care and patient safety. The aim of this study was to describe documentation of nursing care within AHC. Sixty nursing records from two AHC-units in Sweden were collected and a content analysis was performed. The results revealed documentation from a broad spectrum of advanced nursing care, consisting of both planned and acute care. However, the documentation was often fragmented and information sometimes hard to find. Nursing documentation often described caring needs, but lacked interventions and evaluations. Further development and research on nursing documentation and its connection to evidence-based practice within AHC is needed.

Psychometric evaluation of a questionnaire and primary healthcare nurses' attitudes towards research and use of research findings

AIM

This article investigates attitudes towards and awareness of research and use of research findings among primary healthcare nurses, determinants of attitudes and evaluation of psychometric properties of an instrument measuring nurses' attitudes.

BACKGROUND

The production of new knowledge is ongoing and the amount of research of relevance for health care has increased, but there remains a gap between what is known and what is done in practice. To enhance evidence-based practice and patient safety, the use of research findings needs to be encouraged and promoted.

METHOD

An explanatory study using a cross-sectional survey was conducted in 2005-2006. The survey included items about background data and the instrument attitudes towards and awareness of research and development in nursing. 1054 nurses participated in the study. Factor analyses and Cronbach's alpha were used to evaluate internal structure and internal consistency of the instrument.

RESULT

The nurses generally held positive attitudes towards research. Although most of the nurses reported using research in practice, 37% claimed that they never or rarely used research findings. Half of the respondents perceived they had the ability to analyse scientific reports/articles. This ability and research use were significant determinants of attitudes. Factor analysis of the scale resulted in a three-factor solution, which differs from the seven-factor structure previously identified by the originators of the instrument.

CONCLUSION

Our results support the view that implementation of research is a complex process involving several factors. The different factor structure identified suggests that further work is needed on this instrument.

Towards a general theory of implementation

Understanding and evaluating the implementation of complex interventions in practice is an important problem for healthcare managers and policy makers, and for patients and others who must operationalize them beyond formal clinical settings. It has been argued that this work should be founded on theory that provides a foundation for understanding, designing, predicting, and evaluating dynamic implementation processes. This paper sets out core constituents of a general theory of implementation, building on Normalization Process Theory and linking it to key constructs from recent work in sociology and psychology. These are informed by ideas about agency and its expression within social systems and fields, social and cognitive mechanisms, and collective action. This approach unites a number of contending perspectives in a way that makes possible a more comprehensive explanation of the implementation and embedding of new ways of thinking, enacting and organizing practice.

Skin-to-skin care in neonatal intensive care units in the Nordic countries: a survey of attitudes and practices

AIM

To investigate the application of skin-to-skin care (SSC) in the Nordic countries, the existence of guidelines for SSC and the attitudes of neonatal staff towards SSC.

METHODS

One questionnaire was distributed at unit level and one at staff level in all Nordic neonatal intensive care units (n = 109).

RESULTS

The unit questionnaire was answered by 95 (87%) units and the staff questionnaire by 1446 staff members (72%). All units offered SSC to various degrees, but guidelines only existed at 47% of them. Units in Denmark, Norway and Sweden seemed to use SSC earlier, longer and in more medically complicated situations than units in Finland and Iceland. Seventy-seven per cent of the units had private rooms where parents and infants could stay together, still the physical environment of the units limited the use of SSC. Medical risks were considered the main barrier for further implementation of SSC, while general development and early interaction were the most frequently mentioned benefits.

CONCLUSION

Skin-to-skin care is implemented in all Nordic neonatal units, but offered to various degrees, to various populations and to varying extents. Danish, Norwegian and Swedish units are offering SSC more extensively than units in Finland and Iceland.

Use of and attitudes toward current care guidelines among primary and secondary care nurses in Finland

Attitudes toward, familiarity with, and use of clinical guidelines in general and the national Hypertension Guideline were studied. A questionnaire study was conducted before and after an educational program (VALTIT) among primary and secondary care nurses in Päijät-Häme, Finland. The program included centralized training sessions and interactive local workshops. Prior to the program, a majority of nurses had a positive attitude toward guidelines but used guidelines seldom. Primary care nurses were better aware of the Hypertension Guideline than secondary care nurses, but the guideline was poorly used by both groups. At the follow-up, familiarity with the Hypertension Guideline and use of guidelines increased among primary care nurses. In future, primary care nurses will have a more autonomous role in patient care and should participate in clinical guideline development and related research. Our study has shown they are a potential target of such interventions.