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.

Impact of Donation Physicians on Deceased Organ Donation: A Systematic Review.

Background: An emerging strategy to increase deceased organ donation is to use dedicated donation physicians to champion organ donation. We sought to conduct a systematic review of the effectiveness of donation physicians in improving organ donation outcomes. Objective: A systematic review was conducted following Cochrane principles. MEDLINE, Embase, and CINHAL databases were searched from inception to March 26, 2020. Methods: Quantitative studies examining the effects of donation physicians on all deceased organ donation outcomes were considered for inclusion. Review articles, editorials and opinion articles, and case studies were excluded. Study selection was completed independently by 2 team members; all discrepancies were resolved by consensus. Two team members independently extracted data from studies. Results: A total of 1017 studies were screened, and 12 met inclusion criteria. Included studies were published between 1994 and 2019. Half used an interrupted time series design (n = 6; 50%), 3 (25%) were cohort studies, and 3 (25%) used a before-and-after study design. Outcomes (reported in greater than 50% of included articles) included consent/refusal rate (n = 8; 67%), number of potential donors (n = 7; 58%), and number of actual donors (n = 7; 58%). Across studies and design types, there was an increase in potential organ donors ranging from 8% to 143% (Mdn = 33%), an increase in actual organ donors from 15% to 113% (Mdn = 27%), an increase in donor consent rate from -3% to 258% (Mdn = 12%), and an increase in deceased donor transplants from 13% to 24% (Mdn = 19%) following the introduction of donation physicians. Conclusions: Donation physicians have the potential to significantly improve deceased organ donation. Further implementation and evaluation of donation physician programs is warranted. However, implementation should be undertaken with a clear plan for a methodologically rigorous evaluation of outcomes.

Contexte: Le recours à des médecins responsables du don d'organes est une stratégie émergente qui vise à favoriser les dons d'organes après le décès. Nous avons voulu vérifier son efficacité par le biais d'une revue systématique. Sources: La revue systématique a été réalisée conformément aux principes de Cochrane. Les bases de données MEDLINE, Embase et CINHAL ont fait l'objet d'une recherche depuis leur création jusqu'au 26 mars 2020. Méthodologie: Ont été sélectionnées les études quantitatives mesurant l'effet des médecins responsables du don d'organes sur tous les résultats de dons d'organes provenant de personnes décédées. Les articles de revue, éditoriaux, articles d'opinion et études de cas ont été exclus. Deux membres de l'équipe ont procédé de façon indépendante à la sélection des études et à l'extraction des données; les divergences ont été résolues par consensus. Résultats: Des 1 017 études sélectionnées, 12 satisfaisaient aux critères d'inclusion. Les études incluses avaient été publiées entre 1994 et 2019. La moitié des études incluses avait utilisé un modèle de série chronologique interrompu (n = 6; 50 %), trois (25 %) étaient des études de cohorte et trois (25 %) avaient une conception d'étude « avant-après ¼. Les résultats (rapportés dans plus de 50 % des articles inclus) comprenaient le taux de consentement/refus (n = 8; 67 %), le nombre de donneurs potentiels (n = 7; 58 %) et le nombre de donneurs réels (n = 7; 58 %). Après l'introduction de médecins responsables du don d'organes, selon l'étude et le type de conception, on a observé une augmentation allant de 8 à 143 % (augmentation médiane [AM]: 33 %) du nombre de donneurs potentiels, de 15 à 113 % (AM: 27 %) du nombre réel de donneurs, de -3 à 258 % (AM: 12 %) du taux de consentement et de 13 à 24 % (AM: 19 %) du nombre de transplantations d'organes provenant de donneurs décédés. Conclusion: L'introduction de médecins responsables du don d'organes est susceptible d'améliorer significativement le don d'organes après le décès. Il est justifié de poursuivre la mise en œuvre et l'évaluation des programmes intégrant des médecins responsables du don d'organes. La mise en œuvre doit cependant être entreprise avec un plan clair visant une évaluation méthodique et rigoureuse des résultats.

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.

Individual and organizational factors of nurses' job satisfaction in long-term care: A systematic review.

BACKGROUND: In long-term care facilities, nurses' job satisfaction predicts staff turnover, which adversely affects resident outcomes. Thus, it is important to develop a comprehensive understanding of factors affecting nurses' job satisfaction in long-term care facilities. OBJECTIVES: To analyze factors associated with job satisfaction among nurses in nursing homes from individual and organizational perspectives utilizing a deductive approach. DESIGN: Systematic literature review SETTING: Nursing homes. PARTICIPANTS: Registered nurses and licensed practical nurses in nursing homes. METHODS: A systematic literature review of seven online databases (EMBASE, CINAHL, PsychINFO, MEDLINE, PubMed, Scopus, and Web of Science) to July 23, 2020 was conducted. Studies were included if they examined factors associated job satisfaction in the target population and setting. Decision rules on how to determine factors important to nurse job satisfaction were developed a priori. Two team members independently screened the publications for inclusion, extracted data, and assessed included publications for methodological quality; conflicts were resolved through a consensus process and consultation of the third senior team member when needed. RESULTS: Twenty-eight studies were included. Of these, 20 studies were quantitative, 6 were qualitative, and 2 were mixed methods. Factors associated with job satisfaction were grouped into two categories: individual and organizational. Individual factors significantly associated with job satisfaction were age, health status, self-determination/autonomy, psychological empowerment, job involvement, work exhaustion, and work stress. Individual factors identified as not important or equivocal were gender and experience as a nurse/in aged care. No organizational factors were identified as important for nurses' job satisfaction. Facility ownership, supervisor/manager support, resources, staffing level, and social relationships were identified as equivocal or not important. Findings from qualitative studies identified relationship with residents as an important factor for job satisfaction. CONCLUSIONS/IMPLICATIONS: Factors identified as important to nurses' job satisfaction differ from those reported among care aides in nursing homes and nurses employed in acute care settings, suggesting that there is a need for unique approaches to enhance nurses' job satisfaction in nursing homes.

To whom health care aides report: Effect on nursing home resident outcomes.

INTRODUCTION: Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes. DESIGN AND METHODS: We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care. RESULTS: Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, ß = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices. DISCUSSION AND IMPLICATIONS: Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs' increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.

Factors affecting job satisfaction in long-term care unit managers, directors of care and facility administrators: A secondary analysis.

AIM: To identify demographic-, individual- and organisational-level predictors of job satisfaction among managers in residential long-term care (LTC) facilities. BACKGROUND: Job satisfaction predicts turnover among managers in LTC settings. However, factors affecting job satisfaction among LTC facility managers remain poorly understood. METHODS: A secondary analysis of data from Phase 2 of the Translating Research in Elder Care programme including 168 managers (unit managers, directors of care and facility administrators) from 76 residential LTC homes in three Canadian provinces. Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale was used to measure job satisfaction. Predictors of job satisfaction determined using general estimating equations. RESULTS: The efficacy subscale of burnout was positively predicted job satisfaction at the individual level (B = .104, p = .046). At the organisational level, social capital (B = .224, p = .018), adequate orientation (B = .166, p = .015) and leadership (B = .155, p = .018) were associated with higher job satisfaction. CONCLUSIONS: These data suggest that improving LTC managers' self-perceived efficacy, leadership, social capital and adequate orientation may enhance their job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: Predictors of managers' job satisfaction are modifiable and therefore may be amenable to intervention.

Factors Associated With Nurses' Job Satisfaction In Residential Long-term Care: The Importance of Organizational Context.

OBJECTIVES: We examined demographic, individual, and organizational context factors associated with nurses' job satisfaction in residential long-term care (LTC) settings. Job satisfaction has implications for staff turnover, staff health, and quality of care. DESIGN: A cross-sectional analysis of survey data collected in the Translating Research in Elder Care program. SETTING AND PARTICIPANTS: N = 756 nurses (registered nurses: n = 308; licensed practical nurses: n = 448) from 89 residential LTC settings in 3 Western Canadian provinces. METHODS: We used a generalized estimating equation model to assess demographic, individual, and organizational context factors associated with job satisfaction. Job satisfaction was measured using the Michigan Organizational Assessment Questionnaire Job Satisfaction Scale. RESULTS: Demographic, individual, and organizational context factors were associated with job satisfaction among nurses in residential LTC settings. At the demographic level, hours worked in 2 weeks (B = 0.002, P = .043) was associated with job satisfaction. At the individual level, emotional exhaustion-burnout (B = -0.063, P = .02) was associated with lower job satisfaction, while higher scores on empowerment (meaning) (B = 0.140, P = .015), work engagement (vigor) (B = 0.096, P = .01), and work engagement (dedication) (B = 0.129, P = .001) were associated with higher job satisfaction. With respect to organizational context, culture (B = 0.175, P < .001), organizational slack-space (eg, perceived availability and use of adequate space; B = 0.043, P = .040), and adequate orientation (B = 0.092, P < .001) were associated with higher job satisfaction. CONCLUSIONS AND IMPLICATIONS: We identified previously unexamined modifiable organizational features (organizational slack-space and adequate orientation) as factors associated with LTC nurses' job satisfaction in the Canadian context. Our findings support future efforts to improve job satisfaction through improvements in organizational space and provision of adequate workplace orientation.

Understanding context: A concept analysis.

AIMS: To conduct a concept analysis of clinical practice contexts (work environments) in health care. BACKGROUND: Context is increasingly recognized as important to the development, delivery, and understanding of implementation strategies; however, conceptual clarity about what comprises context is lacking. DESIGN: Modified Walker and Avant concept analysis comprised of five steps: (1) concept selection; (2) determination of aims; (3) identification of uses of context; (4) determination of its defining attributes; and (5) definition of its empirical referents. METHODS: A wide range of databases were systematically searched from inception to August 2014. Empirical articles were included if a definition and/or attributes of context were reported. Theoretical articles were included if they reported a model, theory, or framework of context or where context was a component. Double independent screening and data extraction were conducted. Analysis was iterative, involving organizing and reorganizing until a framework of domains, attributes. and features of context emerged. RESULT: We identified 15,972 references, of which 70 satisfied our inclusion criteria. In total, 201 unique features of context were identified, of these 89 were shared (reported in two or more studies). The 89 shared features were grouped into 21 attributes of context which were further categorized into six domains of context. CONCLUSION: This study resulted in a framework of domains, attributes and features of context. These attributes and features, if assessed and used to tailor implementation activities, hold promise for improved research implementation in clinical practice.

Attributes of context relevant to healthcare professionals' use of research evidence in clinical practice: a multi-study analysis.

BACKGROUND: To increase the likelihood of successful implementation of evidence-based practices, researchers, knowledge users, and healthcare professionals must consider aspects of context that promote and hinder implementation in their setting. The purpose of the current study was to identify contextual attributes and their features relevant to implementation by healthcare professionals and compare and contrast these attributes and features across different clinical settings and healthcare professional roles. METHODS: We conducted a secondary analysis of 145 semi-structured interviews comprising 11 studies (10 from Canada and one from Australia) investigating healthcare professionals' perceived barriers and enablers to their use of research evidence in clinical practice. The data was collected using semi-structured interview guides informed by the Theoretical Domains Framework across different healthcare professional roles, settings, and practices. We analyzed these data inductively, using constant comparative analysis, to identify attributes of context and their features reported in the interviews. We compared these data by (1) setting (primary care, hospital-medical/surgical, hospital-emergency room, hospital-critical care) and (2) professional role (physicians and residents, nurses and organ donor coordinators). RESULTS: We identified 62 unique features of context, which we categorized under 14 broader attributes of context. The 14 attributes were resource access, work structure, patient characteristics, professional role, culture, facility characteristics, system features, healthcare professional characteristics, financial, collaboration, leadership, evaluation, regulatory or legislative standards, and societal influences. We found instances of the majority (n = 12, 86%) of attributes of context across multiple (n = 6 or more) clinical behaviors. We also found little variation in the 14 attributes of context by setting (primary care and hospitals) and professional role (physicians and residents, and nurses and organ donor coordinators). CONCLUSIONS: There was considerable consistency in the 14 attributes identified irrespective of the clinical behavior, setting, or professional role, supporting broad utility of the attributes of context identified in this study. There was more variation in the finer-grained features of these attributes with the most substantial variation being by setting.

Individual and organizational predictors of allied healthcare providers' job satisfaction in residential long-term care.

BACKGROUND: Job satisfaction is a predictor of intention to stay and turnover among allied healthcare providers. However, there is limited research examining job satisfaction among allied health professionals, specifically in residential long-term care (LTC) settings. The purpose of this study was to identify factors (demographic, individual, and organizational) that predict job satisfaction among allied healthcare providers in residential LTC. METHODS: We conducted a secondary analysis of data from Phase 2 of the Translating Research in Elder Care program. A total of 334 allied healthcare providers from 77 residential LTC in three Western Canadian provinces were included in the analysis. Generalized estimating equation modeling was used to assess demographics, individual, and organizational context predictors of allied healthcare providers' job satisfaction. We measured job satisfaction using the Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale. RESULTS: Both individual and organizational context variables predicted job satisfaction among allied healthcare providers employed in LTC. Demographic variables did not predict job satisfaction. At the individual level, burnout (cynicism) (ß = -.113, p = .001) and the competence subscale of psychological empowerment (ß = -.224, p = < .001), were predictive of lower job satisfaction levels while higher scores on the meaning (ß = .232, p = .001), self-determination (ß = .128, p = .005), and impact (ß = .10, p = .014) subscales of psychological empowerment predicted higher job satisfaction. Organizational context variables that predicted job satisfaction included: social capital (ß = .158, p = .012), organizational slack-time (ß = .096, p = .029), and adequate orientation (ß = .088, p = .005). CONCLUSIONS: This study suggests that individual allied healthcare provider and organizational context features are both predictive of allied healthcare provider job satisfaction in residential LTC settings. Unlike demographics and structural characteristics of LTC facilities, all variables identified as important to allied healthcare providers' job satisfaction in this study are potentially modifiable, and therefore amenable to intervention.