Indicators to measure implementation and sustainability of nursing best practice guidelines: A mixed methods analysis.

Background: The use of best practice guidelines (BPGs) has the potential to decrease the gap between best evidence and nursing and healthcare practices. We conducted an exploratory mixed method study to identify strategies, processes, and indicators relevant to the implementation and sustainability of two Registered Nurses' Association of Ontario (RNAO) BPGs at Best Practice Spotlight Organizations® (BPSOs). Methods: Our study had four phases. In Phase 1, we triangulated two qualitative studies: a) secondary analysis of 126 narrative reports detailing implementation progress from 21 BPSOs spanning four sectors to identify strategies and processes used to support the implementation and sustainability of BPGs and b) interviews with 25 guideline implementers to identify additional strategies and processes. In Phase 2, we evaluated correlations between strategies and processes identified from the narrative reports and one process and one outcome indicator for each of the guideline. In Phase 3, the results from Phases 1 and 2 informed indicator development, led by an expert panel. In Phase 4, the indicators were assessed internally by RNAO staff and externally by Ontario Health Teams. A survey was used to validate proposed indicators to determine relevance, feasibility, readability, and usability with knowledge users and BPSO leaders. Results: Triangulation of the two qualitative studies revealed 46 codes of implementation and sustainability of BPGs, classified into eight overarching themes: Stakeholder Engagement, Practice Interventions, Capacity Building, Evidence-Based Culture, Leadership, Evaluation & Monitoring, Communication, and Governance. A total of 28 structure, process, or outcome indicators were developed. End users and BPSO leaders were agreeable with the indicators according to the validation survey. Conclusions: Many processes and strategies can influence the implementation and sustainability of BPGs at BPSOs. We have developed indicators that can help BPSOs promote evidence-informed practice implementation of BPGs.

The Implementation in Context (ICON) Framework: A meta-framework of context domains, attributes and features in healthcare.

BACKGROUND: There is growing evidence that context mediates the effects of implementation interventions intended to increase healthcare professionals' use of research evidence in clinical practice. However, conceptual clarity about what comprises context is elusive. The purpose of this study was to advance conceptual clarity on context by developing the Implementation in Context Framework, a meta-framework of the context domains, attributes and features that can facilitate or hinder healthcare professionals' use of research evidence and the effectiveness of implementation interventions in clinical practice. METHODS: We conducted a meta-synthesis of data from three interrelated studies: (1) a concept analysis of published literature on context (n = 70 studies), (2) a secondary analysis of healthcare professional interviews (n = 145) examining context across 11 unique studies and (3) a descriptive qualitative study comprised of interviews with heath system stakeholders (n = 39) in four countries to elicit their tacit knowledge on the attributes and features of context. A rigorous protocol was followed for the meta-synthesis, resulting in development of the Implementation in Context Framework. Following this meta-synthesis, the framework was further refined through feedback from experts in context and implementation science. RESULTS: In the Implementation in Context Framework, context is conceptualized in three levels: micro (individual), meso (organizational), and macro (external). The three levels are composed of six contextual domains: (1) actors (micro), (2) organizational climate and structures (meso), (3) organizational social behaviour (meso), (4) organizational response to change (meso), (5) organizational processes (meso) and (6) external influences (macro). These six domains contain 22 core attributes of context and 108 features that illustrate these attributes. CONCLUSIONS: The Implementation in Context Framework is the only meta-framework of context available to guide implementation efforts of healthcare professionals. It provides a comprehensive and critically needed understanding of the context domains, attributes and features relevant to healthcare professionals' use of research evidence in clinical practice. The Implementation in Context Framework can inform implementation intervention design and delivery to better interpret the effects of implementation interventions, and pragmatically guide implementation efforts that enhance evidence uptake and sustainability by healthcare professionals.

Insights from using an outcomes measurement properties search filter and conducting citation searches to locate psychometric articles of tools used to measure context attributes.

OBJECTIVES: To describe our experience with using a methodological outcomes measurement search filter (precise and sensitive versions of a filter designed to locate articles that report on psychometric properties of measurement tools) and citation searches to locate psychometric articles for tools that can be used to measure context attributes. To compare the precise filter when used alone and with reference list checking to citation searching according to number of records found, precision, and sensitivity. RESULTS: Using the precise filter, we located 130 of 150 (86.6%) psychometric articles related to 22 of 31 (71.0%) tools that potentially measured an attribute of context. In a subset of six tools, the precise filter alone was more precise than searching with the precise filter combined with reference list searching, or citation searching alone. The precise filter combined with reference list checking was the most sensitive search method examined. Overall, we found the precise filter helpful for our project as it decreased record screening time. For non-patient reported outcomes tools, we had less success with locating psychometric articles using the precise filter because some psychometric articles were not indexed in PubMed. More research that systematically evaluates database searching methods is needed to validate our findings.

The effectiveness of champions in implementing innovations in health care: a systematic review.

BACKGROUND: Champions have been documented in the literature as an important strategy for implementation, yet their effectiveness has not been well synthesized in the health care literature. The aim of this systematic review was to determine whether champions, tested in isolation from other implementation strategies, are effective at improving innovation use or outcomes in health care. METHODS: The JBI systematic review method guided this study. A peer-reviewed search strategy was applied to eight electronic databases to identify relevant articles. We included all published articles and unpublished theses and dissertations that used a quantitative study design to evaluate the effectiveness of champions in implementing innovations within health care settings. Two researchers independently completed study selection, data extraction, and quality appraisal. We used content analysis and vote counting to synthesize our data. RESULTS: After screening 7566 records titles and abstracts and 2090 full text articles, we included 35 studies in our review. Most of the studies (71.4%) operationalized the champion strategy by the presence or absence of a champion. In a subset of seven studies, five studies found associations between exposure to champions and increased use of best practices, programs, or technological innovations at an organizational level. In other subsets, the evidence pertaining to use of champions and innovation use by patients or providers, or at improving outcomes was either mixed or scarce. CONCLUSIONS: We identified a small body of literature reporting an association between use of champions and increased instrumental use of innovations by organizations. However, more research is needed to determine causal relationship between champions and innovation use and outcomes. Even though there are no reported adverse effects in using champions, opportunity costs may be associated with their use. Until more evidence becomes available about the effectiveness of champions at increasing innovation use and outcomes, the decision to deploy champions should consider the needs and resources of the organization and include an evaluation plan. To further our understanding of champions' effectiveness, future studies should (1) use experimental study designs in conjunction with process evaluations, (2) describe champions and their activities and (3) rigorously evaluate the effectiveness of champions' activities. REGISTRATION: Open Science Framework ( https://osf.io/ba3d2 ). Registered on November 15, 2020.

Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.