Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP

Barriers and facilitators of evidence-based practice in the Portuguese context: perceptions of formal nursing leaders

INTRODUCTION

Formal nursing leaders play an important role in promoting and sustaining evidence-based practice (EBP) in the clinical context, particularly by creating a conducive environment for change and increasing clinicians' awareness of the positive results of EBP. However, nursing leaders encounter both barriers and facilitators in their work; therefore, it is important to understand their perceptions on this topic.

OBJECTIVE

The objective of this study was to understand the perceptions of formal nursing leaders about barriers and facilitators for EBP.

METHODS

A descriptive exploratory study with a qualitative approach was conducted. A convenience sample was obtained, consisting of formal nursing leaders from three Portuguese health care institutions. Data were collected through semi-structured interviews. Content analysis was conducted using MAXQDA Analytic Pro 2022 software.

RESULTS

Seventeen formal nursing leaders were interviewed. Five categories of EBP barriers were identified: (1) scarce resources and inefficient resource management; (2) non-conducive organizational culture; (3) distance between academia and the clinical context; (4) demotivation; and (5) resistance to change. Seven categories of EBP facilitators were identified: (1) availability of resources and efficient resource management; (2) conducive organizational culture; (3) partnerships between academia and the clinical context; (4) motivation and commitment; (5) leadership; (6) organization that regulates professional practice; and (7) multidisciplinary meetings.

CONCLUSIONS

This study identified barriers and facilitators for EBP through the perceptions of formal nursing leaders. Collaborative multidisciplinary efforts by leaders, direct care professionals, academics, and researchers should be conducted to overcome barriers and strengthen facilitators for EBP.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A242.

Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial

BACKGROUND

Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI's hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI's effect on implementation climate, which in turn will (3) mediate LOCI's effect on MBC fidelity.

METHODS

Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses.

RESULTS

LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI's effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI's improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate LOCI's effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI's effect on MBC fidelity during the same period (pm = 0.71, p = .045).

CONCLUSIONS

LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.

Improving integrated depression and non-communicable disease care in Malawi through engaged leadership and supportive implementation climate

BACKGROUND

Low- and middle-income countries often lack access to mental health services, leading to calls for integration within other primary care systems. In sub-Saharan Africa, integration of depression treatment in non-communicable disease (NCD) settings is feasible, acceptable, and effective. However, leadership and implementation climate challenges often hinder effective integration and quality of services. The aim of this study was to identify discrete leadership strategies that facilitate overcoming barriers to the integration of depression care in NCD clinics in Malawi and to understand how clinic leadership shapes the implementation climate.

METHODS

We conducted 39 in-depth interviews with the District Medical Officer, the NCD coordinator, one NCD provider, and the research assistant from each of the ten Malawian NCD clinics (note one District Medical Officer served two clinics). Based on semi-structured interview guides, participants were asked their perspectives on the impact of leadership and implementation climate on overcoming barriers to integrating depression care into existing NCD services. Thematic analysis used both inductive and deductive approaches to identify emerging themes and compare among participant type.

RESULTS

The results revealed how engaged leadership can fuel a positive implementation climate where clinics had heightened capacity to overcome implementation barriers. Effective leaders were approachable and engaged in daily operations of the clinic and problem-solving. They held direct involvement with and mentorship during the intervention, providing assistance in patient screening and consultation with treatment plans. Different levels of leadership utilized their respective standings and power dynamics to influence provider attitudes and perceptions surrounding the intervention. Leaders acted by informing providers about the intervention source and educating them on the importance of mental healthcare, as it was often undervalued. Lastly, they prioritized teamwork and collective ownership for the intervention, increasing provider responsibility.

CONCLUSION

Training that prioritizes leadership visibility and open communication will facilitate ongoing Malawi Ministry of Health efforts to scale up evidence-based depression treatment within NCD clinics. This proves useful where extensive and external monitoring may be limited. Ultimately, these results can inform successful strategies to close implementation gaps to achieve integration of mental health services in low-resource settings through improved leadership and implementation climate.

TRIAL REGISTRATION

These findings are reported from ClinicalTrials.gov, NCT03711786. Registered on 18/10/2018. https://clinicaltrials.gov/ct2/show/NCT03711786 .

The use of constant observation with people with dementia in hospitals: a mixed-methods systematic review

OBJECTIVES

Constant observation is used in hospitals with people with dementia to manage their safety. However, opportunities for proactive care are not consistently recognised or utilised. A systematic review of constant observation was conducted to understand measures of effectiveness and facilitators for person-centred approaches.

METHOD

Electronic databases were searched between 2010 and 2022. Four reviewers completed screening, quality assessments and data extraction with 20% checked for consistency. Findings were presented through narrative synthesis (PROSPERO registration CRD42020221078).

FINDINGS

Twenty-four studies were included. Non-registered staff without specific training were the main providers of constant observation. Assessments and processes clarifying the level of observation encouraged reviews that linked initiation and discontinuation to a patient's changing needs. Examples of person-centred care, derived from studies of volunteers or staff employed to provide activities, demonstrated meaningful engagement could reassure a person and improve their mood. Proactive approaches that anticipated distress were thought to reduce behaviours that carried a risk of harm but supporting evidence was lacking.

CONCLUSION

Non-registered staff are limited by organisational efforts to reduce risk, leading to a focus on containment. Trained staff who are supported during constant observation can connect with patients, provide comfort and potentially reduce behaviours that carry a risk of harm.

The Price of Practice Change: Assessing the Cost of Integrating Research Findings Into Clinical Practice

BACKGROUND

Clinicians, health care administrators, and implementation scientists know that it takes intentional effort, resources, and implementation strategies to integrate research findings into routine clinical practice. An oft-cited concern for those considering whether and how to implement an evidence-based program is how much it will cost to implement the change. Yet information about the cost of implementation is not often available to health care decision-makers. Teams that received Implementation Award funding from PCORI are conducting implementation projects to promote the uptake of evidence-based practices in health care settings. As part of their implementation efforts, a number of teams have examined the costs of implementation. In this Topical Collection, 5 teams will report their findings on implementation costs and discuss their methods for data collection and analysis.

DISCUSSION

The teams' costing efforts provide specific information about the costs sites can expect to incur in promoting the uptake of specific evidence-based programs. In addition, the papers illuminate 3 key features of the teams' approaches to measuring the cost of implementation: (1) the use of specific micro-costing methods with time-driven activity-based costing serving as the most popular method; (2) different ways to categorize and organize costs, including a site-based and non-site-based framework; and (3) cost collection challenges experienced by the teams.

CONCLUSION

The cost of implementation is a critical consideration for organizations seeking to improve practice in accordance with research findings. This Topical Collection describes detailed approaches to providing this type of cost information and highlights insights to be gained from a rigorous focus on implementation cost.

The role of nursing leadership in promoting evidence-based nursing practice

Although the undermining of the nursing profession, time constraints, and the lack of inclusive teaching of evidence-based nursing (EBN) in the nursing school's curriculum have long been identified as being some of the main barriers to the adoption of evidence-based practice (EBP) by nurses, the specific role of nurse leaders in directly influencing and supporting evidence-based nursing is not well demonstrated. This opinion piece discusses potential factors that influence the implementation of EBP into clinical routine practice, as well as how nursing leadership styles can contribute to its promotion in contemporary healthcare settings.

Individual-level associations between implementation leadership, climate, and anticipated outcomes: a time-lagged mediation analysis

BACKGROUND

Leaders can improve implementation outcomes by developing an organizational climate conducive to the implementation of evidence-based practices (EBP). This study tested the lagged associations between individual-level perceptions of implementation leadership, implementation climate, and three anticipated implementation outcomes, that is EBP acceptability, appropriateness, and feasibility.

METHODS

Screening tools and treatment methods for posttraumatic stress disorder were implemented in 43 Norwegian mental health services. A sample of 494 child and adult mental health care professionals (M = 43 years, 78% female) completed surveys addressing perceptions of first-level leaders' (n = 47) implementation leadership and their clinics' implementation climate. Single-level structural equation models estimating both direct, indirect, and total effects were used to investigate whether perceived implementation climate mediated the association between perceived implementation leadership and perceived acceptability, appropriateness, and feasibility of screening tools and treatment methods.

RESULTS

Regarding the treatment methods, implementation leadership was associated with therapists' perceptions of acceptability, appropriateness, and feasibility. Implementation climate also mediated between implementation leadership and the outcomes. Regarding the screening tools, implementation leadership was not associated with the outcomes. However, implementation climate mediated between implementation leadership and therapists' perceptions of acceptability and feasibility, but not appropriateness. Analyses with the implementation climate subscales showed stronger associations for therapists' perceptions of the treatment methods than of screening tools.

CONCLUSIONS

Leaders may promote positive implementation outcomes, both directly and through implementation climate. With regard to the effect sizes and explained variance, results indicated that both implementation leadership and implementation climate were more strongly associated with the therapists' perceptions of the treatment methods, implemented by one group of therapists, than the screening tools, implemented by all therapists. This may imply that implementation leadership and climate may have stronger effects for smaller implementation teams within a larger system than for system-wide implementations or when the clinical interventions being implemented are more complex rather than simple ones.

TRIAL REGISTRATION

ClinicalTrials NCT03719651, 25 October 2018.

Achieving transformation to lean management systems in health care

OBJECTIVE

To understand what factors and organizational dynamics enable Lean transformation of health care organizations.

DATA SOURCES

Primary data were collected through two waves of interviews in 2016-2017 with leaders and staff at seven veterans affairs medical centers participating in Lean enterprise transformation.

STUDY DESIGN

Using an observational study design, for each site we coded and rated seven potential enablers of transformation. The outcome measure was the extent of Lean transformation, constructed by coding and rating 11 markers of depth and spread of transformation. Using multivalue coincidence analysis (CNA), we identified enablers that distinguished among sites having different levels of transformation. We identified representative quotes for the enablers.

DATA COLLECTION METHODS

We interviewed 121 executive leaders, middle managers, expert consultants, systems redesign staff, frontline supervisors, and staff.

PRINCIPAL FINDINGS

Two sites achieved high Lean transformation, three medium, and two low. Together leadership support and capability development were sufficient for the three-level Lean transformation outcomes with 100% consistency and 100% coverage. High scores on both corresponded to high Lean transformation; medium on either one corresponded to medium transformation; and low on both corresponded to low transformation. Additionally, low scores in communication and availability of data and very low scores in alignment characterized low-transformation sites. Sites with high leadership support also had a high veteran engagement.

CONCLUSIONS

This multisite study develops a novel measure of the extent of organization-wide Lean transformation and uses CNA to identify enablers linked to transformation. It provides insights into why and how some organizations are more successful at transformation than others. Findings support the applicability of the organization transformation model that guided the study and highlight the roles of executive leadership and capability development in the dynamics of transformation.

Exploring the relationship between midwives' work environment, women's safety culture, and intent to stay

BACKGROUND

The shortage of midwives is a concern for healthcare systems as it compromises the quality maternity care. Various studies argue that a favorable work environment increases nurses' job satisfaction and intention to continue working at their current workplace.

AIM

To analyze the work environment and its relationship with women's clinical safety culture and midwives' intention to stay in their current job and the midwifery profession.

METHODS

A cross-sectional, correlational study was performed on N = 218 midwives working in Spain. Standardized instruments were used, including The Practice Environment Scale of the Nursing Work Index (PES-NWI) and the Hospital Survey on Patient Safety Culture (HSOPSC). Descriptive and bivariable statistics were used. The study followed the STROBE guidelines.

RESULTS

The work environment in the labor wards was mixed, according to the PES-NWI classification. The mean total score of the PES-NWI significantly and positively correlated with the mean total score of the HSOPSC (rs = 0.498, p < 0.001), indicating that as the quality of midwives' work environment increased, women's clinical safety increased. Significant correlations were observed between the midwives' intent to stay in the hospital where they work and features of women's safety culture.

CONCLUSION

The results of this study showed significant relationships between the work environment, women's safety culture, and midwives' intentions to leave their job/profession. Creating a favorable working environment could be a potentially effective strategy that encourages improvement in the women's safety culture in healthcare organizations and greater intention of midwives to stay at their current job.

Development of a tool to identify barriers and enablers to practice innovation in midwifery: A participatory action research study

INTRODUCTION

Transferring research evidence into midwifery practice is fraught with challenges and obstacles. Implementation tools can streamline the process and are most effective when they are discipline-specific; however, there are currently no midwifery specific implementation tools. The aim of this study was to develop a midwifery specific tool to identify barriers and enablers to evidence-informed practice change within the clinical setting.

METHODS

Participatory action research methodology was employed to ensure potential end-users contributed to content and format of the tool. Purposeful sampling ensured participants were selected from a range of midwifery practice settings in Western Australia and the United Kingdom. Data were collected through stakeholder advisory groups (SAGs) and online surveys.

RESULTS

Ten midwives participated in this project. Consultation occurred through face-to-face SAG meetings and online surveys until consensus was reached among participants about the content, format, and functionality of the end product which we called the 'Midwifery Tool for Change' (MT4C).

CONCLUSIONS

To our knowledge, the MT4C is the first readiness for change context assessment tool specific to midwifery practice settings. Evaluation of the MT4C in real-world practice change implementation initiatives will enable further refinement of the tool.

Perceptual differences in nursing implementation leadership and climate: a cross-sectional study

BACKGROUND

The literature on perceptual differences between managers and staff regarding social dynamic factors (e.g., leadership, climate) in nursing settings is sparse. Addressing this gap in knowledge is critical for informing implementation efforts and improving patient and organizational outcomes. The purpose of this study was to test the perceptual differences regarding implementation leadership and implementation climate between nursing staff and their managers.

METHODS

This study was a secondary analysis of cross-sectional survey data collected in 2016-2017. The setting included 22 adult medical-surgical units nested in 7 acute care hospitals in the Eastern and Midwestern United States. Participants were registered nurses (N = 261) and nurse managers (N = 22) who completed an electronic survey consisting of the Implementation Leadership Scale (ILS), the Implementation Climate Scale (ICS), and demographic items. Differences in perception were analyzed at the unit level using structural equation modeling to develop latent difference score models (LDS). We assessed associations of the LDSs with manager ILS and ICS scores, years of nursing experience, and years of experience working on the current unit. The association of ILS LDS with the observed nursing staff ICS scores was also analyzed.

RESULTS

Higher manager scores on the ILS and ICS were associated with greater perceptual differences in implementation leadership and implementation climate. Greater years of experience as a nurse were associated with greater perceptual differences in ILS and ICS scores. Greater tenure on the unit was associated with smaller differences on the ILS knowledge domain. Greater perceptual differences regarding implementation leadership were associated with worse staff ratings of implementation climate.

CONCLUSIONS

Although this study observed significant relationships among manager ILS and ICS scores, staff-manager perceptual differences, and staff ratings of implementation climate in nursing settings, it is still unclear why perceptual differences in implementation leadership and climate exist and how to address them. Future studies are warranted to test the effect of perceptual differences on implementation and patient outcomes.

Organization-level variation in therapists' attitudes toward and use of measurement-based care

PURPOSE

Despite significant interest in improving behavioral health therapists' implementation of measurement-based care (MBC)-and widespread acknowledgment of the potential importance of organization-level determinants-little is known about the extent to which therapists' use of, and attitudes toward, MBC vary across and within provider organizations or the multilevel factors that predict this variation.

METHODS

Data were collected from 177 therapists delivering psychotherapy to youth in 21 specialty outpatient clinics in the USA. Primary outcomes were use of MBC for progress monitoring and treatment modification, measured by the nationally-normed Current Assessment of Practice Evaluation-Revised. Secondary outcomes were therapist attitudes towards MBC. Linear multilevel regression models tested the association of theory-informed clinic and therapist characteristics with these outcomes.

RESULTS

Use of MBC varied significantly across clinics, with means on progress monitoring ranging from values at the 25th to 93rd percentiles and means on treatment modification ranging from the 18th to 71st percentiles. At the clinic level, the most robust predictor of both outcomes was clinic climate for evidence-based practice implementation; at the therapist level, the most robust predictors were: attitudes regarding practicality, exposure to MBC in graduate training, and prior experience with MBC. Attitudes were most consistently related to clinic climate for evidence-based practice implementation, exposure to MBC in graduate training, and prior experience with MBC.

CONCLUSIONS

There is important variation in therapists' attitudes toward and use of MBC across clinics. Implementation strategies that target clinic climate for evidence-based practice implementation, graduate training, and practicality may enhance MBC implementation in behavioral health.

Organizational culture and readiness for evidence-based practice in the Kingdom of Saudi Arabia: A pre-experimental study

AIM

This study aims to establish postgraduate students' perceptions of the organizational culture and readiness for evidence-based practice of their workplaces in the Kingdom of Saudi Arabia.

BACKGROUND

Nurse shortages and a reliance on a transient nurse workforce have long been a challenge in the Kingdom of Saudi Arabia. Developing a home-grown nurse workforce, a key objective of the Government of Saudi Arabia, can help to address this. Evidence-based practice offers a mechanism to address this. Evidence-based practice implementation is heavily reliant on the prevailing organizational culture. Establishing the organizational culture and readiness for evidence-based practice is crucial for sustainable evidence-based practice implementation.

METHODS

A pre-experimental pilot study collected data from the same participants at three different points. As part of this, a questionnaire measuring organizational culture and readiness for evidence-based practice was administered twice. Descriptive, inferential and correlational statistics were employed to analyse the data.

RESULTS

Results demonstrated improved participant perceptions of the organizational culture and readiness for evidence-based practice of their workplaces between the first (M = 76.58, SD = 19.2) and second (M = 92.10, SD = 23.68) data collection points, indicating moderate movement towards a culture of evidence-based practice. Strengths, challenges and opportunities for improvement were identified.

CONCLUSION

This study established participants' perceptions of the organizational culture and readiness for evidence-based practice of their workplaces, affording insight into context-specific strategies to embed evidence-based practice in health care organizations.

IMPLICATIONS FOR NURSING MANAGEMENT

Assessing an organization's culture and readiness for evidence-based practice (EBP) can afford insight on the strengths, challenges and opportunities that exist to equip nurse managers to advance evidence-based practice at individual, professional and organizational levels. This study demonstrated the importance of promoting an environment conducive to EBP and putting in place the necessary resources to support evidence-based practice implementation. Nurse managers can play a central role in this.

How is leadership behavior associated with organization-related variables? Translation and psychometric evaluation of the implementation leadership scale in German primary healthcare

Background

The Implementation Leadership Scale (ILS) was developed to assess leadership behavior with regard to being proactive, knowledgeable, supportive, or perseverant in implementing evidence-based practices (EBPs). As part of a study on the implementation of a digitally supported polypharmacy management application in primary care, the original ILS was translated and validated for use in the German language.

Rationale

This study aimed to translate the original ILS into German and evaluate its psychometric properties.

Methods

The validation sample consisted of 198 primary care physicians in a cluster-randomized controlled trial in which the intervention group implemented a digitally supported clinical decision support system for polypharmacy management. The ILS was assessed using a 12-item scale. The study included a process evaluation with two evaluation waves between 2019 and 2021. The ILS was used within this process evaluation study to assess the leadership support with regard to the implementation of the polypharmacy management. The ILS was translated in a multi-step process, including pre-testing of the instrument and triple, back-and-forth translation of the instrument. We tested the reliability (Cronbach’s alpha) and validity (construct and criterion-related validity) of the scale.

Results

The four-dimensional structure of the instrument was confirmed (comparative fit index = .97; root mean square error of approximation = .06). Convergent validity was demonstrated by correlations with organizational innovation climate, social capital, and workload, which was consistent with the proposed hypothesis. Criterion-related validity of the ILS was demonstrated by predicting the organizational readiness for change scores using structural equation modeling. The reliability of the scale was good (α = .875).

Conclusion

The German version of the ILS created in this study is a reliable and valid measure. The original four-dimensional structure of the ILS was confirmed in a primary care setting. Further psychometric testing is needed to establish the validity and reliability of the ILS and to transfer it to other health care settings. It is a useful tool for identifying the areas for implementation leadership development. Further research is needed on how, why, and when distinct types of leadership behaviors have different effects on healthcare organizations in implementation processes.

Generation and Use of Evidence by Local Health Departments: The Role of Leader Attributes

OBJECTIVE

The purpose of this study was to examine whether certain types of leaders were associated with the degree to which local health departments (LHDs) generate and use evidence to inform their service offering.

DESIGN

Pooled, cross-sectional analysis using 4 waves (2010, 2013, 2016, and 2019) of the National Profiles of Local Health Departments sponsored by the National Association of County and City Health Officials (NACCHO). Univariate analysis was used to assess the extent to which LHDs were generating and using evidence to improve the health of their local communities and whether this changed over time. Multinomial logistic regression models were used to examine the relationships between LHD leader attributes and the extent to which LHDs were generating and using evidence.

PARTICIPANTS

Between 1496 and 2087 (varied by survey round) LHDs from throughout the United States.

MAIN OUTCOME MEASURES

Two outcome variables pertaining to the generation of evidence: (1) how recently an LHD completed a community health assessment and (2) how recently an LHD completed a community health improvement plan. A third outcome variable reflected how extensively an LHD used the Community Guide, a compendium of evidence-based findings.

RESULTS

In 2010, 25.1% and 41.4% of all LHDs had not completed a community health assessment or a community health improvement plan, respectively; by 2019, those figures declined significantly to 14.6% and 24.7%. Similarly, in 2010, 61.7% of all LHDs were not using the Community Guide; by 2019, that percentage declined significantly to 42.5%. Multivariable analysis revealed that leader experience was a more robust correlate of evidence generation and use by LHDs than leader education.

CONCLUSIONS

While LHDs' generation and use of evidence have grown over the past decade, there is room for improvement. Local health department leader attributes-education and experience-highlight targeted opportunities to fill gaps in the use of evidence-based public health practices.

A qualitative descriptive study of the role of nurse, allied health and physician middle managers who function as knowledge brokers in hospitals

BACKGROUND

Knowledge brokers (KB) are increasingly being employed in health care to implement evidence-based practice and improve quality of care. Middle managers (MMs) may play a KB role in the implementation of an innovative or evidence-based practice in hospitals. However, how MMs' broker knowledge in hospitals and their impact on practice has not been adequately studied.

AIM

To describe the role that MMs play in brokering knowledge in hospitals and their impact.

METHOD

A qualitative descriptive study was conducted to generate a detailed description of MM experiences as KBs in hospitals. Data were collected using semi-structured telephone interviews with MMs in Ontario, Canada. Participants were purposively sampled to ensure variation in MM characteristics and a diverse representation of perspectives. Data were collected and analyzed concurrently using an inductive constant comparative approach.

RESULTS

Twenty-one MMs from teaching and non-teaching hospitals participated. MMs described 10 roles and activities they enacted in hospitals that aligned with published KB roles. We found differences across professional groups and hospital type. Teaching status emerged as a potential factor relating to how MM KBs were able to function within hospitals. MMs reported enhanced patient, provider, and organizational outcomes.

LINKING EVIDENCE TO ACTION

Middle managers may play an important KB role in the implementation of evidence-based practice in hospitals. An improved understanding of the KB roles that MMs play may be important in boosting evidence base practice in health care to ultimately improve quality of care. Administrators need a better understanding of the current KB roles and activities MMs enact as this may lead to more organizational structures to support MM KBs in health care.

Exploring nurse beliefs and perceived readiness for system wide integration of evidence based practice in a large pediatric health care system

PURPOSE

Evidence-based practice (EBP) within healthcare leads to improved patient outcomes, high-quality care, job satisfaction, reduced turnover, professional autonomy, and validates nursing practice. Although a plethora of research focuses on implementing EBP, there has been little attention on assessing organizational readiness for integration. The primary aims of this study were to explore nursing beliefs and attitudes about EBP and explore the culture and readiness among pediatric nurses for system-wide integration of EBP.

DESIGN AND METHODS

This study was a quantitative, cross-sectional survey-based study conducted at a large pediatric health system.

RESULTS

Overall pediatric nurses had a mean score of 61.78 ± 9.32 on the EBPB (n = 396). Results of the EBPB Scale and OCRSIEP showed no statistical difference between nursing roles EBPB scores; however, nursing leaders had higher scores than any other nursing role. The OCRSIEP had a mean score of 84.98 ± 19.53 (n = 388).

CONCLUSIONS

Findings suggest that pediatric nurses believe that EBP results in the best clinical care for patients and can improve clinical care, but they lack the skills and time necessary to engage in the process. This study found that increasing awareness of EBP resources and developing EBP competencies may assist pediatric nurse leaders with EBP integration into daily practice.

PRACTICE IMPLICATIONS

Increasing visibility and competencies of EBP may positively impact organizational readiness by increasing confidence needed to remove identified barriers and engrain EBP in the organization's culture.

Taking advanced clinical practice to the streets: an evaluation of the benefits and challenges in homeless health care

Homelessness in the UK continues to rise. People who are homeless are more likely to have poor health and die early, and face multiple barriers to accessing health care. Ten years have passed since the Marmot review recommended action on these disparities. In the context of significant health inequalities, advanced clinical practitioners (ACPs) offer a different approach to homeless health care, providing complete episodes of care in complex situations and leading in integrating multiple agencies, service development and strategic advocacy. ACPs can use their expertise in this specialty to deliver education that raises awareness and reduces prejudice. Their research skills can identify gaps and expand the evidence base to improve practice at local and national levels. However, ACPs must promote their own roles, work closely with people with lived experience and be supported by their employers to embrace all four pillars of advanced clinical practice for the full benefits to be realised.

Challenges of de-implementing feeding tube auscultation: A qualitative study

AIM

This qualitative study explored de-implementation of feeding tube auscultation practice in adult patients by critical care nurses.

BACKGROUND

Despite years of evidence suggesting inaccuracy and harm, auscultation (air bolus method) continues to be used by the majority of critical care nurses to verify small-bore feeding tube placement in adults.

DESIGN

This descriptive qualitative study used thematic analysis with telephone interview data.

METHODS

Fourteen critical care nurses from four stratified groups within the United States (by hospital type and auscultation practice) participated in telephone interviews.

RESULTS

Two major themes of individual influence and organizational leadership emerged from the data. Categories identified key components required for auscultation de-implementation.

CONCLUSIONS

Nurses feel obligated to follow hospital policies and expressed less accountability for their own practice. Organizational leadership involvement is recommended to facilitate de-implementation of this tradition-based, low-value practice and mitigate harm events.

Organizational readiness to change as a leverage point for improving safety: a national nursing home survey

Background

A stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate.

Methods

Seven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains.

Results

One thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3–9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P < 0.05), especially for interpersonal domains.

Conclusions

Organizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.

Evidence-based practice and patient-centered care: Doing both well

BACKGROUND

Health care organizations increasingly strive to deliver care that is both evidence based and patient centered. Although often complementary, fundamental contradictions may exist between these goals, and the organizational culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other.

PURPOSE

We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical centers that are able to provide inpatient care that is both evidence based and patient centered from those where performance is either mixed or low in both domains.

METHODOLOGY/APPROACH

We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational literature, as well as emergent themes.

RESULTS

We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that facilitated delivery of both EBP and PCC.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Organizations that excel in providing both EBP and PCC exhibit unique characteristics and processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.

A systematic review exploring the impact of focal leader behaviours on health care team performance

AIM

The aim of this study is to understand how the behaviour of focal leaders impacts health care team performance and effectiveness.

BACKGROUND

Despite recent shifts towards more collectivistic leadership approaches, hierarchical structures that emphasize the role of an individual focal leader (i.e., the formal appointed leader) are still the norm in health care. Our understanding of the effect of focal leader behaviours on health care team performance remains unclear.

EVALUATION

A systematic review was conducted. Five electronic databases were searched using key terms. One thousand forty-seven records were retrieved. Data extraction, quality appraisal and narrative synthesis were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

KEY ISSUES

Fifty papers met the criteria for inclusion, were reviewed and synthesized under the following categories: task-focused leadership, directive leadership, empowering leadership and relational focused leadership.

CONCLUSIONS

Categories are discussed in relation to team performance outcomes, safety specific outcomes, individual-level outcomes and outcomes related to interpersonal dynamics. Emerging themes are explored to examine and reflect on how leadership is enacted in health care, to catalogue best practices and to cascade these leadership practices broadly.

IMPLICATIONS FOR NURSING MANAGEMENT

Empowering and relational leadership styles were associated with positive outcomes for nursing team performance. This underscores the importance of training and encouraging nursing leaders to engage in more collaborative leadership behaviours.

Conceptualizing the clinical decision-making process in managing temporomandibular disorders: A qualitative study

Management of patients with temporomandibular disorders (TMD) appears to be more challenging than for other dental conditions. This study aimed to explore the decision-making process in TMD management, and thereby to conceptualize the decision-making process in dentistry. Individual semi-structured interviews were conducted during 2018 and 2019 with a purposive sample of 22 general dental practitioners from the Public Dental Healthcare Services and private practices in the Region of Västerbotten, Northern Sweden. The interviews were analysed using the Grounded Theory approach of Charmaz. Data analysis resulted in the core category 'Combining own competence and others' expectations in the desire to do the right thing'. The dentists showed interest in and a desire to apply professional knowledge, but also reflected on challenges and complexity in the decision-making process for TMD. The challenges were primarily related to organisational factors and lack of self-confidence. This identifies a need for re-organisation of daily clinical management in dentistry, and a need for more postgraduate training to improve self-confidence. The complexity of the decision-making process for TMD makes the study findings applicable in other dental situations.

Evidence-Based Practice in Oncology Nursing: Oncology Nursing Society Survey Results

BACKGROUND

Evidence-based practice (EBP) is a clinical decision-making approach that improves quality and outcomes in health care but is not yet standard in clinical settings.

OBJECTIVES

The purpose of this study was to determine EBP beliefs, knowledge, implementation strategy self-efficacy, and competencies among a national sample of oncology nurses.

METHODS

Oncology nurses completed an online survey of EBP attributes and open-ended questions. Analyses were conducted on data collected from 893 participants from a range of healthcare organizations across a diverse geographic sample of the United States.

FINDINGS

Respondents rated themselves competent to question clinical practice to improve quality care. Oncology nurses reported competency to question clinical practice but deficits in EBP knowledge and skills.

Enhancing the verbal handover process for nurses in inpatient orthopedic wards: a best practice implementation project

OBJECTIVES

This evidence-based quality improvement project aimed to evaluate the effectiveness of a handover guide in improving handovers from registered nurses to enrolled nurses.

INTRODUCTION

Nursing handover involves the transfer of the responsibility of care for a patient from one nurse to another. Handover techniques vary in different healthcare organizations. Non-standardized, incomplete handovers can lead to delays or errors in treatment, increased lengths of stay, and poor health outcomes.

METHODS

This project was conducted in two orthopedic wards of a tertiary hospital, and occurred in four phases over 12 months. The project utilized the JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) tools.

RESULTS

The baseline audit in March 2017 revealed a poor compliance in handover of essential patient information. The post-intervention audit showed a significant increase (P < 0.001) in the compliance of handover of essential patient information. Registered nurses' handovers of patient information to enrolled nurses improved from 11% to 27% (P < 0.000). Verbal face-to-face handovers occurred throughout the implementation. Eighty-two per cent of the nurses felt that the handover guide had reduced the number of monitoring errors and delays in treatment.

CONCLUSION

The project has successfully improved nurses' clinical handovers and contributed to safe patient care. Further audits are required to sustain the evidence-based practice change. Nursing leaders play a significant role in supporting the project and building a positive evidence-based practice environment.

Best leadership practices of nurses in hospital risk management: case study

OBJECTIVE

To highlight the best leadership practices of nurses who contribute to hospital risk management.

METHOD

Single case study with two integrated units of analysis, with a qualitative approach. Data collected from April to November 2018, through focused interviews with nurse managers, non-participant observation and documentary research. Analysis using the analytical technique to the explanation construction.

RESULTS

Three thematic categories were evidenced, demonstrating that the best leadership practices involve technical and non-technical competencies anchored in behavioral development, scientific knowledge, guidelines for quality and patient safety and participatory management of the health team.

CONCLUSION

The best leadership practices of nurses who contribute to hospital risk management pervade technical skills and/or formal positions, valuing each team professional in a unique way and emphasizing the importance of scientific knowledge and the professional reference model that the nurse exercises in hospitals.

Validation of the Implementation Climate Scale in Nursing

BACKGROUND

One critical factor in effective implementation of evidence-based practices (EBPs) in nursing is an organizational context that facilitates and supports implementation efforts. Measuring implementation climate can add useful insights on the extent to which the organizational context supports EBP implementation.

AIMS

This study cross-validates and examines the psychometric properties of the Implementation Climate Scale (ICS), which measures nurses' perceptions of their unit's climate for EBP implementation.

METHODS

This study analyzed ICS data from two cross-sectional studies, including 203 nurses from California and 301 nurses from Florida. Analyses included evaluation of internal consistency, multilevel aggregation statistics, and confirmatory factor analyses.

RESULTS

The 18-item ICS demonstrated comparable psychometric properties to the original measure development paper in both samples. Confirmatory factor analyses provided support for the scale's factor structure in both samples.

LINKING EVIDENCE TO PRACTICE

The ICS is a pragmatic measure that can be used to assess unit implementation climate in nursing contexts. Results from the ICS from nurses and nurse leaders can provide insights into implementation-specific barriers and facilitators within the organizational context.

Differences in beliefs on and implementation of evidence-based practice according to type of health care institution-A national cross-sectional study among Slovenian nurses

AIM

To explore the differences in beliefs on and implementation of evidence-based practice in nurses working in different types of health care institutions.

BACKGROUND

Optimal organizational context and knowledge are essential to support evidence-based practice and sustain the use of evidence in professional nursing practice.

METHOD

A cross-sectional study was conducted. A total of 1,014 nurses from 20 Slovenian hospitals and 29 primary health care centres participated. Variables included the following: Evidence-Based Practice Beliefs and Implementation Scale, educational and training activities, job satisfaction, job training, perceived research and evidence-based practice knowledge, and access to databases.

RESULTS

Beliefs on evidence-based practice were explained by evidence-based practice (β = 0.249) and research (β = 0.162) knowledge, length of employment (β = 0.124), job satisfaction (β = 0.117), training in evidence-based practice (β = -0.092) and holding a master's degree (β = 0.077). Implementation of evidence-based practice depended on beliefs (β = 0.306) and the type of health care institution (β = 0.132). The highest implementation result was seen in primary health care centres (<0.001).

CONCLUSION

Training in evidence-based practice and perceived knowledge of evidence-based practice significantly influence the beliefs on and implementation of evidence-based practice. Nurses employed at primary health care centres who had completed a task-shifting training programme achieved significantly better results for implementation of evidence-based practice.

IMPLICATIONS FOR NURSING MANAGEMENT

The indirect effects of development training programmes for the implementation of EBP have not yet been studied. Development activities and change implementation processes in nursing foster education and training opportunities, which have significantly influenced the implementation of EBP.

The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams

Background

Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams.

Methods

The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation).

Results

The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process.

Conclusion

To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05905-z.

Otago exercise programme-from evidence to practice: a qualitative study of physiotherapists' perceptions of the importance of organisational factors of leadership, context and culture for knowledge translation in Norway

Background

Falls and fall-related injuries are a major public health problem and an international priority for health services. Despite research showing that evidence-based fall prevention is effective, its translation into practice has been delayed and limited. Although organisational factors such as leadership, culture and context are key factors for implementing evidence-based practice, there is still limited information on whether these factors represent barriers in the Norwegian and international healthcare context. Thus, this study aimed to explore the views of physiotherapists in clinical practice and their leaders’ views on the importance of organisational factors, such as leadership, culture and contextual and human resources, regarding successful knowledge translation of the Otago evidence-based fall programme in a Norwegian community.

Methods

Four in-depth interviews with physiotherapists and a focus group interview with nine physiotherapists and leaders representing local hospitals and municipalities were conducted to collect data. The data were analysed using a thematic analysis.

Results

The analysis yielded an overarching theme: an empowering leader as an anchor is needed for successful knowledge translation of physiotherapists’ and leaders’ views about the role of organisational structure, leadership, culture, financial resources and competence in research-based knowledge, as well as how to enhance the clinical staff’s expertise. Four main themes further elaborated on the overarching theme: (1) multifactor leadership—the importance of reinforcement, knowledge, goals and attention; (2) potential for change in professional roles as shaped by culture, context and type of practice; (3) knowledge translation—the tension between real-life capabilities, optimism and learning; and (4) different types of support—environmental resources and social influences.

Conclusions

This study highlighted the importance of organisational factors in knowledge translation in fall prevention. The findings emphasise the importance of leaders’ role and style in providing a supportive culture and contextual factors during the knowledge translation process. This study provides an understanding of the knowledge translation and sustainability of evidence-based practice and the Otago exercise programme for fall prevention programmes for community-dwelling older adults in Norway.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12913-020-05853-8.

Organizational Facilitators and Barriers to Medication for Opioid Use Disorder Capacity Expansion and Use

Medication for opioid use disorder (MOUD) is a key strategy for addressing the opioid use disorder crisis, yet gaps in MOUD provision impede this strategy's benefits. The research reported here sought to understand what distinguishes low- and high-performing organizations in building and using capacity to provide MOUD. As part of a mixed methods MOUD implementation trial, semi-structured telephone interviews were conducted with personnel from low- and high-performing MOUD-providing organizations. Seventeen individuals from 17 organizations were interviewed. Findings demonstrate the importance of individual, organization, and community-level factors in supporting the building and use of MOUD capacity. Low- and high-performing organizations showed different patterns of facilitators and barriers during the implementation process. The key difference between low- and high-performing organizations was the level of organizational functioning. A better understanding of an organization's assets and deficits at the individual, organizational, and community levels would allow decision-makers to tailor their approaches to MOUD implementation.

A Quasi-Experimental Study of a Basics of Evidence-Based Practice Educational Intervention for Health and Social Care Professionals

Education is one of the central interventions to promote evidence-based practice (EBP) in service organizations. An educational intervention to promote EBP among health and social care professionals was implemented in a Finnish hospital. The aim of this study was to explore the outcomes of an educational intervention, focusing on the basics of EBP for health and social care professionals, using a quasi-experimental study design. The data were collected with a questionnaire before, immediately after, and 6 months after the education (n = 48). The data were analyzed with descriptive statistics and nonparametric tests. Immediately after the education, an increase was found in the EBP knowledge of participants, in participants’ confidence in their own ability to conduct database searches and read scientific articles, and in the number of participants using databases at work. Six months after the education, improvements were still found between the first and the third measurement in the participants’ knowledge and confidence in their own ability to conduct database searches and read scientific articles. The number of those who had made an initiative about a research topic regarding the development of their own work had increased from the first to the third measurement. The educational intervention produced a statistically significant improvement on most of the areas evaluated. Significant improvements were often found even 6 months after the education was finished. However, the low completion rate and a quasi-experimental before and after design limit the conclusions that can be derived from this study.

Components of impactful dementia training for general hospital staff: a collective case study

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation.Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping.Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators.Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered.

Testing a theory of strategic implementation leadership, implementation climate, and clinicians' use of evidence-based practice: a 5-year panel analysis

BACKGROUND

Implementation theory suggests that first-level leaders, sometimes referred to as middle managers, can increase clinicians' use of evidence-based practice (EBP) in healthcare settings by enacting specific leadership behaviors (i.e., proactive, knowledgeable, supportive, perseverant with regard to implementation) that develop an EBP implementation climate within the organization; however, longitudinal and quasi-experimental studies are needed to test this hypothesis.

METHODS

Using data collected at three waves over a 5-year period from a panel of 30 outpatient children's mental health clinics employing 496 clinicians, we conducted a quasi-experimental difference-in-differences study to test whether within-organization change in implementation leadership predicted within-organization change in EBP implementation climate, and whether change in EBP implementation climate predicted within-organization change in clinicians' use of EBP. At each wave, clinicians reported on their first-level leaders' implementation leadership, their organization's EBP implementation climate, and their use of both EBP and non-EBP psychotherapy techniques for childhood psychiatric disorders. Hypotheses were tested using econometric two-way fixed effects regression models at the organization level which controlled for all stable organizational characteristics, population trends in the outcomes over time, and time-varying covariates.

RESULTS

Organizations that improved from low to high levels of implementation leadership experienced significantly greater increases in their level of EBP implementation climate (d = .92, p = .017) and within-organization increases in implementation leadership accounted for 11% of the variance in improvement in EBP implementation climate beyond all other covariates. In turn, organizations that improved from low to high levels of EBP implementation climate experienced significantly greater increases in their clinicians' average EBP use (d = .55, p = .007) and within-organization improvement in EBP implementation climate accounted for 14% of the variance in increased clinician EBP use. Mediation analyses indicated that improvement in implementation leadership had a significant indirect effect on clinicians' EBP use via improvement in EBP implementation climate (d = .26, 95% CI [.02 to .59]).

CONCLUSIONS

When first-level leaders increase their frequency of implementation leadership behaviors, organizational EBP implementation climate improves, which in turn contributes to increased EBP use by clinicians. Trials are needed to test strategies that target this implementation leadership-EBP implementation climate mechanism.

The tensions between micro-, meso- and macro-levels: physiotherapists' views of their role towards fall prevention in the community - a qualitative study

BACKGROUND

Falls are a global public health concern. Physiotherapists are a key resource in this context, but there is sparse knowledge about how they perceive their role in the primary care setting. Therefore, the purpose of the present study is to explore physical therapists' (PTs) view of how they experience and perceive their role working with fall prevention in a community care setting.

METHODS

Semi-structured interviews were conducted with 17 physiotherapists. Data were analysed using a qualitative thematic analysis.

RESULTS

The analysis resulted in a core theme and three subthemes. The core theme was 'capability to cope with the tensions between the micro-, meso- and macro-levels in fall, prevention', which indicated the importance of an evolving multifaceted, evidence based and innovative physiotherapy role. A key factor for this role is to take an integrative biopsychosocial approach based on how biological and psychosocial factors are uniquely related in fall prevention. The three themes were as follows: 1) always moving and changing: the competent explorative knowledge-hungry clinician's multifaceted role; 2) multiprofessional - but in the end alone; 3) reaching out - from the bottom to the top. Success in the role of physiotherapists in fall prevention depends on the empowering leadership and working culture, as well as on the time and multifaceted professional competence of the clinicians.

CONCLUSION

Our findings indicate that the PTs' role reflects their abilities to change and improve their professional work in accordance with evidence based knowledge. To ensure good quality the PTs focused on the special needs of the patients, evidence-based fall prevention, interdisciplinary team work, good clinical competences, good skills in communication, and interpersonal relations. Attention should be placed on the importance of biopsychosocial perspective framing in the actual clinical and political context. The PTs saw the need for working at the micro-, meso- and macro-levels to succeed in the work of fall prevention.

Evaluating an Evidence-Based Practice Curriculum for Nurses Entering Clinical Practice in the Veterans Health Administration

Introduction

The Veterans Health Administration (VHA) registered nurse (RN) Transition to Practice (TTP) program is a 1-year comprehensive, standardized curriculum taught for entry-level nurses to assist them in transitioning to VA-trained, competent, professional RNs. The TTP program includes revised modules on Evidence-Based Practice (EBP) clinical decision making. The revised curriculum emphasizes EBP as a problem-solving approach to clinical decision making rather than a project-based approach to implement practice changes. The goal of this quality improvement project was to evaluate the content, delivery, and outcomes of a revised Evidence-Based Practice Curriculum (EBPC) for use in the VHA RN TTP program.

Methods

Focus groups were conducted with TTP coordinators, who teach the program and facility EBP content experts from 32 VHA Medical Centers. All attended a three-day face-to-face training at a central location. Qualitative data were managed and analyzed with a rapid assessment process.

Discussion

Leaders within and outside of organizations are commonly believed to affect the success of implementing and sustaining any program or initiative through their influence on organizational climate, leadership processes, and leadership alignment across multiple levels of leadership. Our findings were in line with other research showing that leaders should prioritize EBP and fuel it with resources to create sustainable change.

Conclusions

In conclusion, the EBPC was reviewed very favorably by all who planned to use it in their facilities in teaching the content to practicing registered nurses. Future evaluation will focus on the degree to which faculty use the program, how they use the modules, and what feedback nurses provide after exposure to EBPC.

A Mixed Methods Study of Organizational Readiness for Change and Leadership During a Training Initiative Within Community Mental Health Clinics

This longitudinal mixed-methods study explored variation in organizational readiness for change and leadership behavior across seven organizations during a 12-month training initiative in person-centered care planning. Quantitative data was used to examine trajectories of organizational readiness for change and leadership behavior over time and qualitative data explored provider perspectives on the trajectory of these organizational factors during the 12-month training initiative. Findings indicated that levels of organizational readiness for change and leadership behavior varied across clinics, but most experienced a significant positive change at the mid-point of the training. Organizational readiness for change was positively correlated with leaderships behaviors across time. Provider focus group findings gave insight into their initial resistance to adopting the new practice and their increasing receptivity in the second 6 months due to increased understanding of the practice and leadership endorsement. Increasing provider openness to a new practice prior to training and having a consistently engaged leadership have the potential to improve the efficiency of a training initiative.

Feasibility and usefulness of a leadership intervention to implement evidence-based falls prevention practices in residential care in Canada

Background

Leadership is critical to supporting and facilitating the implementation of evidence-based practices in health care. Yet, little is known about how to develop leadership capacity for this purpose. The aims of this study were to explore the (1) feasibility of delivering a leadership intervention to promote implementation, (2) usefulness of the leadership intervention, and (3) participants’ engagement in leadership to implement evidence-based fall prevention practices in Canadian residential care.

Methods

We conducted a mixed-method before-and-after feasibility study on two units in a Canadian residential care facility. The leadership intervention was based on the Ottawa model of implementation leadership (O-MILe) and consisted of two workshops and two individualized coaching sessions over 3 months to develop leadership capacity for implementing evidence-based fall prevention practices. Participants (n = 10) included both formal (e.g., managers) and informal (e.g., nurses and care aids leaders). Outcome measures were parameters of feasibility (e.g., number of eligible candidates who attended the workshops and coaching sessions) and usefulness of the leadership intervention (e.g., ratings, suggested modifications). We conducted semi-structured interviews guided by the Implementation Leadership Scale (ILS), a validated measure of 12-item in four subcategories (proactive, supportive, knowledgeable, and perseverant), to explore the leadership behaviors that participants used to implement fall prevention practices. We repeated the ILS in a focus group meeting to understand the collective leadership behaviors used by the intervention team. Barriers and facilitators to leading implementation were also explored.

Results

Delivery of the leadership intervention was feasible. All participants (n = 10) attended the workshops and eight participated in at least one coaching session. Workshops and coaching were rated useful (≥ 3 on a 0–4 Likert scale where 4 = highly useful) by 71% and 86% of participants, respectively. Participants rated the O-MILe subcategories of supportive and perseverant leadership highest for individual leadership, whereas supportive and knowledgeable leadership were rated highest for team leadership.

Conclusions

The leadership intervention was feasible to deliver, deemed useful by participants, and fostered engagement in implementation leadership activities. Study findings highlight the complexity of developing implementation leadership and modifications required to optimize impact. Future trials are now required to test the effectiveness of the leadership intervention on developing leadership for implementing evidence-based practices.

Professional Identity of Nurse Manager in the Light of the Structural Dialectic Care Model

Objectives: To identify in the scientific literature the identity-related configurations inherent to the nurse’s managerial practices of a professional that works in a hospital setting, and to analyze them in the light of the Structural Dialectic Care Model (SDCM). Materials and method: The article concerns about a qualitative research where an integrative review was made enabling the selection of 15 articles, analyzed in light of the SDCM. Results: From the 15 selected articles, three thematic axes were established: Leadership, care and conflicts. Conclusions: It was concluded that the SDCM has made it possible to discover the nurse’s identity models as a managerial agent in the diverse pluralities articulated to the identity-related processes of such professional.

An integrative review of leadership competencies and attributes in advanced nursing practice

Aim

To establish what leadership competencies are expected of master level‐educated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature.

Background

Developments in health care ask for well‐trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed.

Design

Integrative review.

Methods

Embase, Medline and CINAHL databases were searched (January 2005–December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers.

Results

Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies.

Conclusions

This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence‐based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes.

Impact

These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.

The Influence of Transformational Leadership and Leader Attitudes on Subordinate Attitudes and Implementation Success

Recent literature has focused on identifying factors that facilitate or impede the implementation of innovation in organizations. Attitudes toward change and transformational leadership are regarded as important determinants of implementation success. This study tested a multilevel model of transformational leadership and leaders’ attitudes toward the innovation being implemented as predictors of staff attitudes and implementation success. Participants were 565 service providers ( n = 478) and their supervisors ( n = 87) working in mental health organizations currently implementing an evidence-based practice (EBP). Results provided support for positive relationships between transformational leadership and staff attitudes toward EBP, as well as staff attitudes toward EBP and implementation success. Moreover, results supported an indirect relationship between transformational leadership and implementation success through employees’ attitudes toward EBP. The results suggest that the leader’s behaviors are likely more critical to innovation implementation than the leader’s attitudes.

De-implementation of tradition-based practices in critical care: A qualitative study

AIM

To explore the process of tradition-based practice (TBP) de-implementation by critical care nurses.

BACKGROUND

Ritualistic and routine practices have been described as sacred cows or TBPs. Many clinical practices have insufficient or no evidence and may lead to poor patient outcomes. De-implementation (termination) of potentially harmful, ineffective, or non cost-effective TBP is necessary to facilitate evidence-based practice (EBP) in the clinical setting.

DESIGN

Descriptive qualitative inquiry guided this study.

METHODS

Twenty-two critical care nurses from an acute care hospital in central Florida participated. Individual and focus group interviews were performed March to July 2016 and analysed using thematic analysis.

RESULTS

Three themes were identified: (a) uncertainty, (b) desire to know, and (c) preparing for practice change. Nurses were uncertain about the scientific underpinnings of everyday clinical practices and had difficulty differentiating TBP from EBP. De-implementation processes and strategies appeared to replicate implementation processes.

CONCLUSION

More research is needed to evaluate de-implementation processes and strategies used for de-implementation. An emphasis should be placed on ensuring that nurses are knowledgeable about fundamental EBP skills to encourage assessment of clinical practices for supporting research evidence. Awareness and understanding of TBPs will facilitate a more comprehensive approach towards achieving the gold standard of EBP.

Using Gemba Boards to Facilitate Evidence-Based Practice in Critical Care

BACKGROUND

Tradition-based practices lack supporting research evidence and may be harmful or ineffective. Engagement of key stakeholders is a critical step toward facilitating evidence-based practice change. Gemba, derived from Japanese, refers to the real place where work is done. Gemba boards (visual management tools) appear to be an innovative method to engage stakeholders and facilitate evidence-based practice.

OBJECTIVES

To explore the use of gemba boards and gemba huddles to facilitate practice change.

METHODS

Twenty-two critical care nurses participated in interviews in this qualitative, descriptive study. Thematic analysis was used to code and categorize interview data. Two researchers reached consensus on coding and derived themes. Data were managed with qualitative analysis software.

RESULTS

The code gemba occurred most frequently; a secondary analysis was performed to explore its impact on practice change. Four themes were derived from the gemba code: (1) facilitation of staff, leadership, and interdisciplinary communication, (2) transparency of outcome data, (3) solicitation of staff ideas and feedback, and (4) dissemination of practice changes. Gemba boards and gemba huddles became part of the organizational culture for promoting and disseminating evidence-based practices.

CONCLUSIONS

Unit-based, publicly located gemba boards and huddles have become key components of evidence-based practice culture. Gemba is both a tool and a process to engage team members and the public to generate clinical questions and to plan, implement, and evaluate practice changes. Future research on the effectiveness of gemba boards to facilitate evidence-based practice is warranted.

Promoting Evidence-Based Practice at a Primary Stroke Center: A Nurse Education Strategy

BACKGROUND

Promoting a culture of evidence-based practice within a health care facility is a priority for health care leaders and nursing professionals; however, tangible methods to promote translation of evidence to bedside practice are lacking.

OBJECTIVES

The purpose of this quality improvement project was to design and implement a nursing education intervention demonstrating to the bedside nurse how current evidence-based guidelines are used when creating standardized stroke order sets at a primary stroke center, thereby increasing confidence in the use of standardized order sets at the point of care and supporting evidence-based culture within the health care facility.

METHODS

This educational intervention took place at a 286-bed community hospital certified by the Joint Commission as a primary stroke center. Bedside registered nurse (RN) staff from 4 units received a poster presentation linking the American Heart Association's and American Stroke Association's current evidence-based clinical practice guidelines to standardized stroke order sets and bedside nursing care. The 90-second oral poster presentation was delivered by a graduate nursing student during preshift huddle. The poster and supplemental materials remained in the unit break room for 1 week for RN viewing. After the pilot unit, a pdf of the poster was also delivered via an e-mail attachment to all RNs on the participating unit. A preintervention online survey measured nurses' self-perceived likelihood of performing an ordered intervention based on whether they were confident the order was evidence based. The preintervention survey also measured nurses' self-reported confidence in their ability to explain how the standardized order sets are derived from current evidence. The postintervention online survey again measured nurses' self-reported confidence level. However, the postintervention survey was modified midway through data collection, allowing for the final 20 survey respondents to retrospectively rate their confidence before and after the educational intervention. This modification ensured that the responses for each individual participant in this group were matched.

RESULTS

Registered nurses reported a significant increase in perceived confidence in ability to explain how standardized stroke order sets reflect current evidence after the intervention (n = 20, P < .001). This sample was matched for each individual respondent. No significant change was shown in unmatched group mean self-reported confidence ratings overall after the intervention or separately by unit for the progressive care unit, critical care unit, or intensive care unit (n = 89 preintervention, n = 43 postintervention). However, the emergency department demonstrated a significant increase in group mean perceived confidence scores (n = 20 preintervention, n = 11 postintervention, P = .020). Registered nurses reported a significantly higher self-perceived likelihood of performing an ordered nursing intervention when they were confident that the order was evidence based compared with if they were unsure the order was evidence based (n = 88, P < .001).

DISCUSSION

This nurse education strategy increased RNs' confidence in ability to explain the path from evidence to bedside nursing care by demonstrating how evidence-based clinical practice guidelines provide current evidence used to create standardized order sets. Although further evaluation of the intervention's effectiveness is needed, this educational intervention has the potential for generalization to different types of standardized order sets to increase nurse confidence in utilization of evidence-based practice.