Exploring the complexity of student nurse relationships with adolescent patients when placing nasogastric tubes.

This article aims to explore the complexity of student nurse relationships with adolescent patients when placing nasogastric tubes. The potential inter-connectiveness of this relationship is debated within this article and an evaluation of current practice identifies potential implications for both patients and nursing care.

A brief guide to immunisation and the immunocompromised child or young person.

Immunisation in children with a compromised immune system is not straightforward. Children with autoimmune disorders are especially at risk of vaccine-preventable diseases due to their underlying disease and the immunosuppressive treatment that is often required for a long period. This article explores some of the complexities that need to be considered when planning individual vaccination programmes.

Nutritional support for children and young people: nasogastric tubes.

The need to offer nutritional support to children and young people is commonplace for health professionals. This article explores the use and indication of nasogastric tubes (NGT) in children and young people, before explaining the process of inserting NGTs and the ongoing management of this method of nutritional support.

Understanding evidence-informed decision-making: a rural interorganizational breastfeeding network.

BACKGROUND: Networks are a vehicle for mobilizing knowledge, but there is little research about evidence-informed decision-making in community settings. Breastfeeding is a powerful intervention for population health; combined system and community interventions can increase exclusive breastfeeding rates by 2.5 times. This study examined evidence-informed decision-making within an interorganizational network, including the facilitators and barriers to achieving network goals. METHODS: A mixed method case study design was used. The primary sources of data were focus group discussion and questionnaire administration. Data were analyzed concurrently using framework analysis and social network analysis. RESULTS: Key findings were at the interorganizational and external levels: 1) Relationships and trust are connected to knowledge exchange 2) Need for multiple levels of leadership. CONCLUSIONS: The findings of this study have potential implications for enhancing the use of evidence-informed decision-making as other networks work toward Baby Friendly Initiative (BFI) designation and also highlights the potential for network maps to be used as a knowledge mobilization tool.

When east meets west: a qualitative study of barriers and facilitators to evidence-based practice in Hunan China.

BACKGROUND: Research into evidence-based practice has been extensively explored in nursing and there is strong recognition that the organizational context influences implementation. A range of barriers has been identified; however, the research has predominantly taken place in Western cultures, and there is little information about factors that influence evidence-based practice in China. The purpose of this study was to explore barriers and facilitators to evidence-based practice in Hunan province, a less developed region in China. METHODS: A descriptive qualitative methodology was employed. Semi-structured interviews were conducted with staff nurses, head nurses and directors (n = 13). Interviews were translated into English and verified for accuracy by two bilingual researchers. Both Chinese and English data were simultaneously analyzed for themes related to factors related to the evidence to be implemented (Innovation), nurses' attitudes and beliefs (Potential Adopters), and the organizational setting (Practice Environment). RESULTS: Barriers included lack of available evidence in Chinese, nurses' lack of understanding of what evidence-based practice means, and fear that patients will be angry about receiving care that is perceived as non-traditional. Nurses believed evidence-based practice was to be used when clinical problems arose, and not as a routine way to practice. Facilitators included leadership support and the pervasiveness of web based social network services such as Baidu () for easy access to information. CONCLUSION: While several parallels to previous research were found, our study adds to the knowledge base about factors related to evidence-based practice in different contextual settings. Findings are important for international comparisons to develop strategies for nurses to provide evidence-based care.

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.

A Dozen Strategies Along the Ten Steps Baby-Friendly Initiative Journey.

To improve the quality of care and maternal-newborn outcomes, Hôpital Montfort implemented the Registered Nurses' Association of Ontario Best Practice Guideline on Breastfeeding, which supports the Baby-Friendly Initiative (BFI). This journey was challenging yet rewarding. Overall, we report success with increased mother-infant skin-to-skin contact at birth and breastfeeding immediately postpartum. However, challenges with formula supplementation rates continue. This paper discusses 12 strategies that emerged from lessons learned and provides links to our policies and patient education materials. The information may be helpful to others, as implementation of parts of the BFI are inserted in criteria for the Canadian accreditation.

Optimal Pain Assessment in Pediatric Rehabilitation: Implementation of a Nursing Guideline.

In Ontario, Canada, the Registered Nurses' Association promotes a Best Practice Spotlight Organization initiative to enhance evidence-based practice. Qualifying organizations are required to implement strategies, evaluate outcomes, and sustain practices aligned with nursing clinical practice guidelines. This study reports on the development and evaluation of a multifaceted implementation strategy to support adoption of a nursing clinical practice guideline on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital. Multiple approaches were employed to influence behavior, attitudes, and awareness around optimal pain practice (e.g., instructional resources, electronic reminders, audits, and feedback). Four measures were introduced to assess pain in communicating and noncommunicating children as part of a campaign to treat pain as the fifth vital sign. A prospective repeated measures design examined survey and audit data to assess practice aligned with the guideline. The Knowledge and Attitudes Survey (KNAS) was adapted to ensure relevance to the local practice setting and was assessed before and after nurses' participation in three education modules. Audit data included client demographics and pain scores assessed annually over a 3-year window. A final sample of 69 nurses (78% response rate) provided pre-/post-survey data. A total of 108 pediatric surgical clients (younger than 19 years) contributed audit data across the three collection cycles. Significant improvements in nurses' knowledge, attitudes, and behaviors related to optimal pain care for children with disabilities were noted following adoption of the pain clinical practice guideline. Targeted guideline implementation strategies are central to supporting optimal pain practice.

Implementing a Fetal Health Surveillance Guideline in Clinical Practice: A Pragmatic Randomized Controlled Trial of Action Learning.

AIMS: The aim of this study was to determine the effects of an Action Learning intervention on nurses' use of a fetal health surveillance (FHS) guideline during labor of women who were low risk on admission for delivery. METHODS: Using a pragmatic randomized controlled trial, nurses were randomized to Action Learning (n = 44) or Usual Care (n = 45). Low-risk women were assigned to either an Action Learning nurse (n = 122) or a Usual Care nurse (n = 148). Data on practices during an episode of care (nurses' FHS practices from admission through to delivery in low-risk women) were collected at three trial time points: 1 month prior, during 6 months, and 1 month following. Guideline adherence, women's perception of birth experience, and enablers and inhibitors to intermittent auscultation (IA) were collected. Multivariate logistic regression determined the variables (chosen by the nurses) that predicted Action Learning nurses' adherence to FHS practices. FINDINGS: Statistically significant change was not evident between nurses' rate of FHS practices in the Action Learning group compared with Usual Care (Δ6.8%, odds ratio [OR] 0.16, 95% confidence interval [CI] 0.84-2.83). Postpartum, women reported high satisfaction with no significant difference by study group. Two labor events, epidural and narcotic analgesia, most influenced guideline appropriate care (p = .000, OR -4.04; p = .000, OR = 2.89) within the experimental group. LINKING EVIDENCE TO ACTION: Despite lack of between-group significant changes in FHS practices, Action Learning nurses, who chose areas of practice that presented obstacles to their guideline adherence ability (epidurals and narcotics), significantly changed their FHS practices. Researchers need to consider whether practice is long-standing acceptance of the evidence by healthcare providers, and the provider's intentions for implementation effectiveness when choosing an implementation strategy. Supportive nurses, Doppler availability, and clear policies support adherence to an IA guideline. Deimplementation of ineffective practice is warranted.

Achieving a climate for patient safety by focusing on relationships.

OBJECTIVE: Despite many initiatives, advances in patient safety remain uneven in part because poor relationships among health professionals have not been addressed. The purpose of this study was to determine whether relationships between health professionals contributed to a patient safety climate, after implementation of an intervention to improve inter-professional collaboration. DESIGN/SETTING: This was a secondary analysis of data collected to evaluate the Interprofessional Model of Patient Care (IPMPC) at The Ottawa Hospital in Ontario, Canada, which consists of five sites. A series of generalized estimating equation models were generated, accounting for the clustering of responses by site. PARTICIPANTS: Thirteen health professionals including physicians, nurses, physiotherapists and others (n = 1896) completed anonymous surveys about 1 year after the IPMPC was introduced. INTERVENTION: The IPMPC was implemented to improve interdisciplinary collaboration. MAIN OUTCOME MEASURES: Reliable instruments were used to measure collaboration, respect, inter-professional conflict and patient safety climate. RESULTS: Collaboration (ß = 0.13; P = 0.002) and respect (ß = 1.07; P = 0.03) were significant independent predictors of patient safety climate. Conflict was an independent and significant inverse predictor of patient safety climate (ß = -0.29; P = 0.03), but did not moderate linkages between collaboration and patient safety climate or between respect and patient safety climate. CONCLUSIONS: Through the IPMPC, all health professionals learned how to collaborate and build a patient safety climate, even in the presence of inter-professional conflict. Efforts by others to foster better work relationships may yield similar improvements in patient safety climate.

An organizational intervention to influence evidence-informed decision making in home health nursing.

OBJECTIVE: The aims of this study were to field test and evaluate a series of organizational strategies to promote evidence-informed decision making (EIDM) by nurse managers and clinical leaders in home healthcare. BACKGROUND: EIDM is central to delivering high-quality and effective healthcare. Barriers exist and organizational strategies are needed to support EIDM. METHODS: Management and clinical leaders from 4 units participated in a 20-week organization-focused intervention. Preintervention (n = 32) and postintervention (n = 17) surveys and semistructured interviews (n = 15) were completed. RESULTS: Statistically significant increases were found on 4 of 31 survey items reflecting an increased organizational capacity for participants to acquire and apply research evidence in decision making. Support from designated facilitators with advanced skills in finding, appraising, and applying research was the highest rated intervention strategy. CONCLUSIONS: Results are useful to inform the development of organizational infrastructures to increase EIDM capacity in community-based healthcare organizations.

Measuring the effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: a systematic review.

BACKGROUND: Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice. AIM: To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals' use of evidence in clinical practice. METHODS: A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentee's needs; and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively. RESULTS: Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners' knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals' behaviors and impact on practitioners' and patients' outcomes: some outcomes improved, while others showed no difference. LINKING EVIDENCE TO ACTION: Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.

Using the NHS sustainability framework to understand the activities and resource implications of Canadian nursing guideline early adopters.

AIMS AND OBJECTIVES: To examine the activities and resource implications for the initial cohort of healthcare organisations involved in the introduction of multiple nursing guidelines. BACKGROUND: The Best Practice Spotlight Organization initiative was launched in 2003 as part of the Registered Nurses' Association of Ontario's Best Practice Guidelines programme. While previous research has evaluated improvements in patient care and outcomes, there has been limited research from an organisational perspective on the activities conducted to introduce nursing guidelines. DESIGN: Secondary analysis of retrospective narrative data. METHODS: We conducted a content analysis of the 2004-2006 annual reports from the seven participating sites. We used both deductive and inductive approaches to categorise the guideline implementation activities and their resource implications. RESULTS: All sites reported implementing multiple guidelines (four to nine guidelines per site) and used a wide range of implementation activities that clearly addressed nine of the 10 NHS Sustainability dimensions. The dimension not reported was benefits beyond helping patients. All sites established steering committees that involved staff and senior leaders, reviewed selected guidelines and recommendations, reviewed existing policies and procedures and developed new policies and procedures, recruited champions or peer mentors, applied for additional external funding to support activities, developed relationships with external clinical partners, included guideline implementation in orientation, developed intra-agency web-based and print communications for the project, and evaluated practice changes. For each of these activities, the sites reported expenditures and resource usage. CONCLUSIONS: The organisational processes used for the introduction of new nursing guidelines in Canada are remarkably consistent with factors identified by leaders and change agents in the UK who developed the NHS Sustainability Model. RELEVANCE TO CLINICAL PRACTICE: A multidimensional framework for sustainability is useful for planning successful guideline implementation across an organisation. Examples of specific activities and resource implications for organisational change are provided.

Multi-level barriers analysis to promote guideline based nursing care: a leadership strategy from home health care.

BACKGROUND: Understanding the types of barriers that exist when implementing change can assist healthcare managers to tailor implementation strategies for optimal patient outcomes. AIM: The aim of this paper is to present an organising framework, the Barriers Assessment Taxonomy, for understanding barriers to nurses' use of clinical practice guideline recommendations. Barriers to recommendations are illustrated using the Barriers Assessment Taxonomy and insights discussed. METHOD: As part of a pilot implementation study, semi-structured interviews (n = 26) were conducted to understand barriers to nurses' use of nine guideline recommendations for diabetic foot ulcers. Content analysis of verbatim transcripts included thematic coding and categorising barriers using the Barriers Assessment Taxonomy. RESULTS: Nineteen barriers were associated with nine recommendations, crossing five levels of the health care delivery system. The Barriers Assessment Taxonomy revealed that all recommendations had individual and organisational level barriers, with one recommendation having barriers at all levels. Individual level barriers were most frequent and lack of knowledge and skills was the only barrier that crossed all recommendations. IMPLICATIONS FOR NURSING MANAGEMENT: The Barriers Assessment Taxonomy provides a framework for nursing managers to understand the complexity of barriers that exist, and can assist in choosing intervention strategies to support improved quality care and patient outcomes.

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

SIGNIFICANCE: The importance of leadership to influence nurses' use of clinical guidelines has been well documented. However, little is known about how to develop and evaluate leadership interventions for guideline use. PURPOSE: The purpose of this study was to pilot a leadership intervention designed to influence nurses' use of guideline recommendations when caring for patients with diabetic foot ulcers in home care nursing. This paper reports on the feasibility of implementing the study protocol, the trial findings related to nursing process outcomes, and leadership behaviors. METHODS: A mixed methods pilot study was conducted with a post-only cluster randomized controlled trial and descriptive qualitative interviews. Four units were randomized to control or experimental groups. Clinical and management leadership teams participated in a 12-week leadership intervention (workshop, teleconferences). Participants received summarized chart audit data, identified goals for change, and created a team leadership action. Criteria to assess feasibility of the protocol included: design, intervention, measures, and data collection procedures. For the trial, chart audits compared differences in nursing process outcomes. PRIMARY OUTCOME: 8-item nursing assessments score. Secondary outcome: 5-item score of nursing care based on goals for change identified by intervention participants. Qualitative interviews described leadership behaviors that influenced guideline use. RESULTS: Conducting this pilot showed some aspects of the study protocol were feasible, while others require further development. Trial findings observed no significant difference in the primary outcome. A significant increase was observed in the 5-item score chosen by intervention participants (p = 0.02). In the experimental group more relations-oriented leadership behaviors, audit and feedback and reminders were described as leadership strategies. CONCLUSIONS: Findings suggest that a leadership intervention has the potential to influence nurses' use of guideline recommendations, but further work is required to refine the intervention and outcome measures. A taxonomy of leadership behaviors is proposed to inform future research.

The SITS framework: sustaining innovations in tertiary settings.

Background: To date, little attention has focused on what the determinants are and how evidence-based practices (EBPs) are sustained in tertiary settings (i.e., acute care hospitals). Current literature reveals several frameworks designed for implementation of EBPs (0-2 years), yet fewer exist for the sustainment of EBPs (>2 years) in clinical practice. Frameworks containing both phases generally list few determinants for the sustained use phase, but rather state ongoing monitoring or evaluation is necessary. Notably, a recent review identified six constructs and related strategies that facilitate sustainment, however, the pairing of determinants and how best to sustain EBPs in tertiary settings over time remains unclear. The aim of this paper is to present an evidence-informed framework, which incorporates constructs, determinants, and knowledge translation interventions (KTIs) to guide implementation practitioners and researchers in the ongoing use of EBPs over time. Methods: We combined the results of a systematic review and theory analysis of known sustainability frameworks/models/theories (F/M/Ts) with those from a case study using mixed methods that examined the ongoing use of an organization-wide pain EBP in a tertiary care center (hospital) in Canada. Data sources included peer-reviewed sustainability frameworks (n = 8) related to acute care, semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level, chart audits (n = 200), and document review (n = 29). We then compared unique framework components to the evolving literature and present main observations. Results: We present the Sustaining Innovations in Tertiary Settings (SITS) framework which consists of 7 unique constructs, 49 determinants, and 29 related KTIs that influence the sustainability of EBPs in tertiary settings. Three determinants and 8 KTIs had a continuous influence during implementation and sustained use phases. Attention to the level of application and changing conditions over time affecting determinants is required for sustainment. Use of a participatory approach to engage users in designing remedial plans and linking KTIs to target behaviors that incrementally address low adherence rates promotes sustainability. Conclusions: The SITS framework provides a novel resource to support future practice and research aimed at sustaining EBPs in tertiary settings and improving patient outcomes. Findings confirm the concept of sustainability is a "dynamic ongoing phase".

Caesareans by request.

PURPOSE: To describe the attitudes of nulliparas (women who have never given birth) about caesarean delivery on maternal request, and to examine their characteristics, perceptions and fears related to vaginal birth and caesarean delivery. DESIGN: Cross-sectional survey. PARTICIPANTS: Canadian nulliparas, 18 to 24 years of age, attending an educational institution. METHODS: A previously developed questionnaire was adapted, evaluated for validity and pretested. The questionnaire was presented in class by a research assistant. Participants placed questionnaires in a box to maintain confidentiality. The main outcome measure was participants' attitudes toward caesarean delivery on request. Descriptive, bivariate and multivariate regression statistical analyses were done. RESULTS: Of 260 women invited, 140 (53.8%) participated. Participants' mean age was 20.4 years, and 95 per cent were born in Quebec. The majority (63.3%) had heard about caesarean delivery on maternal request, but only 28.6 per cent had a favourable attitude toward it. Having fears about vaginal birth (p < 0.001), thinking that caesarean delivery was less stressful than vaginal birth (p = 0.042) and that vaginal birth had more negative consequences for the mother (p = 0.014) and a positive attitude of peers (p = 0.013) were four factors associated with a favourable attitude. For this group of respondents, these four factors would successfully predict attitudes to caesarean section upon maternal request 66.5 per cent of the time.

A Mixed Method Study: Defining the Core Learning Needs of Nurses Delivering Care to Children and Young People with Rheumatic Disease to Inform Paediatric Musculoskeletal Matters, a Free Online Educational Resource.

Children and young people with rheumatic diseases and their families are often supported by nurses who may not have had specialist training in paediatric rheumatology. The purpose of our study was to establish the core learning needs of all nurses who may encounter these children and young people in their clinical practice and use this information to inform the content and format of Paediatric Musculoskeletal Matters Nursing (PMM-Nursing) Engagement with nurses working in different roles and with various levels of experience in musculoskeletal medicine informed these learning needs and PMM-Nursing content. Mixed methods ascertained learning needs under the following themes: (1) Need for increased awareness about rheumatic disease; (2) Impact of experience and nursing role; (3) Need for increased knowledge about rheumatic disease and management. In addition, our methods informed design components for an impactful learning and information resource. Representatives from stakeholder nursing groups, social sciences, and web development used this information to create a suitable framework for PMM-Nursing. The content of PMM-Nursing is now live and freely available.

Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study.

Background: To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting. Methods: We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review (n = 29), chart audits (n = 200), and semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level. Results: We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0-2 yrs), sustained phase (>2-10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment. Conclusion: This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic "ongoing process."