Sustaining guideline implementation: A multisite perspective on activities, challenges and supports.

AIMS AND OBJECTIVES: To examine activities conducted, challenges encountered and supports used when sustaining nursing practice guideline implementation in multiple healthcare organisations over 3 years. BACKGROUND: Numerous models and frameworks exist to guide the implementation of guidelines, yet very few focus on sustaining improved practice changes. It is not known if one intervention or multiple interventions are required, nor the long-term activities, challenges and supports for sustaining improved practices. DESIGN: Qualitative descriptive study. METHODS: We conducted focus group interviews with steering committee members and individual interviews with leaders and direct care providers at the end of a 3-year guideline implementation study. The National Health Service Sustainability Model was used to guide data collection and analysis. RESULTS: The eight sites included three teaching hospitals, a community hospital, a long-term care facility, two community health agencies and a community health centre. Individual interviews were conducted with 36 leaders and 26 direct care providers. Focus group interviews were conducted with steering committee members (n = 70) at each site. Guideline implementation activities (n = 45) included developing new outcome monitoring systems, conducting chart audits, communicating progress to internal stakeholders, appointing interprofessional staff to steering committees, developing educational sessions and resources for staff and patients, revising policies and procedures, and developing partnerships with external organisations. Supports included lessons learned from previous and concurrent change initiatives, and commitment, involvement and positive attitudes of staff and leaders. CONCLUSION: Activities identified by the participants addressed all 10 factors in the Sustainability Model in the three areas of process, staff and organisation. The challenges and supports encountered provide insights into the process of guideline implementation and sustainability. RELEVANCE TO CLINICAL PRACTICE: A multilevel action plan for staff, leaders and the organisation is recommended when introducing and sustaining practice changes.

Stakeholder Participation in System Change: A New Conceptual Model.

BACKGROUND: A recent change in Canada's primary care system led to the introduction of Nurse Practitioner-Led clinics. The literature suggests that stakeholders can influence system change initiatives. However, very little is known about healthcare stakeholder motivations, particularly stakeholders who are seen as resistors to change. AIM: To examine stakeholder participation in the system change process that led to the introduction of the first Nurse Practitioner-Led clinic in Ontario. METHODS: This single case study included two site visits, semistructured individual tape-recorded interviews, and the examination of relevant public documents. Qualitative content analysis was used to analyze the data. RESULTS: Sixteen individuals from different healthcare sectors and professions participated in the interviews and 20 documents were reviewed. Six key themes emerged from the data. Linking Evidence to Action The findings from the study present a new perspective on stakeholder participation that includes both those who supported the proposed change and those who advocated for a different change. The findings identify stakeholder activities used to shape, share, and protect their visions for system change. The conceptual model presented in this study adds to the understanding of challenges and complexities involved in healthcare system change. Understanding why and how stakeholders participate in change can help healthcare leaders in planning activities to enhance stakeholder involvement in healthcare system change.