Developing guideline-based quality indicators: assessing gaps in pain management practice.

AIM: In this article, the authors discuss a multiphase approach for developing quality indicators based on pain practice guidelines, and the challenges associated with the process. The presentation is based on previously published reporting standards for guideline-based quality indicators. METHODS: The following steps of the indicator development process were undertaken: topic selection; guideline selection; extraction of recommendations; quality indicator selection and practice test. RESULTS: Eleven practice guidelines were reviewed for quality, and three high-quality guidelines were compared for pertinent recommendations. From these three guidelines, 12 recommendations were extracted and judged appropriate to examine the practice gap for nursing students and clinicians on an oncology and palliative care unit. Quality indicators were then identified by a consensus process, resulting in 24 discrete indicators that were included in the practice test. CONCLUSION: Quality indicators can be used to examine gaps in pain management practice, and to evaluate change after guideline implementation. However, their development can be challenging, and guideline developers could facilitate uptake of guidelines by including clear, relevant quality indicators as part of guideline creation and presentation.

Evidence-Based Practice in Clinical Nursing Education: A Scoping Review.

BACKGROUND: Nursing students require education that integrates evidence-based practice (EBP) knowledge across classroom and clinical settings. This study was conducted to identify and examine the literature related to nursing students' use of evidence in clinical education and to identify associated research gaps. METHOD: A scoping review describing the extent, range, and nature of the research activity focused on students' use of evidence in clinical education. RESULTS: Included studies (N = 37) describe the barriers and facilitators to nursing students' EBP and describe the evaluation of strategies that support nursing students' engagement in EBP. Most commonly identified barriers include a lack of knowledge and skills for EBP; negative attitudes toward EBP in students, faculty, and nurses; and lack of support in the clinical setting. Evaluated strategies included educational sessions and EBP projects, either alone or in combination, as well as other stand-alone interventions. All but two of the intervention studies reported positive subjective or objective outcomes. CONCLUSION: On the basis of these results, educators can engage in combined educational strategies that focus on addressing described barriers. [J Nurs Educ. 2017;56(9):534-541.].

Ottawa Model of Implementation Leadership and Implementation Leadership Scale: mapping concepts for developing and evaluating theory-based leadership interventions.

PURPOSE: Leadership in health care is instrumental to creating a supportive organizational environment and positive staff attitudes for implementing evidence-based practices to improve patient care and outcomes. The purpose of this study is to demonstrate the alignment of the Ottawa Model of Implementation Leadership (O-MILe), a theoretical model for developing implementation leadership, with the Implementation Leadership Scale (ILS), an empirically validated tool for measuring implementation leadership. A secondary objective is to describe the methodological process for aligning concepts of a theoretical model with an independently established measurement tool for evaluating theory-based interventions. METHODS: Modified template analysis was conducted to deductively map items of the ILS onto concepts of the O-MILe. An iterative process was used in which the model and scale developers (n=5) appraised the relevance, conceptual clarity, and fit of each ILS items with the O-MILe concepts through individual feedback and group discussions until consensus was reached. RESULTS: All 12 items of the ILS correspond to at least one O-MILe concept, demonstrating compatibility of the ILS as a measurement tool for the O-MILe theoretical constructs. CONCLUSION: The O-MILe provides a theoretical basis for developing implementation leadership, and the ILS is a compatible tool for measuring leadership based on the O-MILe. Used together, the O-MILe and ILS provide an evidence- and theory-based approach for developing and measuring leadership for implementing evidence-based practices in health care. Template analysis offers a convenient approach for determining the compatibility of independently developed evaluation tools to test theoretical models.

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.

Moving knowledge to action: a qualitative study of the Registered Nurses' Association of Ontario Advanced Clinical Practice Fellowship program.

UNLABELLED: With funding from the Ontario Ministry of Health and Long-Term Care, the Registered Nurses' Association of Ontario (RNAO) established the Advanced Clinical Practice Fellowship (ACPF) program in 2000 to improve patient care and outcomes through advanced nursing knowledge and skills. This paper describes the perceptions of ACPF fellows regarding their influence on quality of care and patient outcomes, specifically, the types of practice change activities initiated, successful implementation and influence on outcomes, barriers encountered and strategies used to address them and influence change. METHODS: Thirty telephone interviews were conducted with ACPF fellows after completing their fellowship. Interviews were analyzed using descriptive content analysis. RESULTS: Fifty-one practice change activities were identified. Ratings for successful implementation (1 = not successful, 10 = extremely successful) were 7.2/10; ratings for successful influence on outcomes were 7.4/10. Barriers identified were (a) resistant attitudes, (b) time and workload, (c) lack of administrative support and (d) lack of mentor's involvement. Strategies proposed were (a) building a knowledge base, (b) negotiation and dialogue and (c) self-reliance and persistence. IMPLICATIONS: The ACPF program is an innovative and highly utilized initiative. While this program supports strategic directions of government and nursing professional groups, further research will validate and expand on the specific ways in which the initiative influences professional development, healthcare delivery 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.

Impacting Canadian public health nurses' job satisfaction.

OBJECTIVE: Workforce recruitment and retention challenges are being experienced in public health as in other Canadian health sectors. While there are many nurses working in public health, little research has been done about their job satisfaction. Job satisfaction is linked to recruitment, retention and positive client outcomes. The purpose of this research was to examine the relationships between three modifiable work environment factors (autonomy, control-over-practice, and workload) and Canadian public health nurses' (PHNs) job satisfaction. METHODS: Data were from the 2005 National Survey of the Work and Health of Nurses (response rate, 79.7%; 18,676 nurses). Bivariate and multivariate logistic regression analyses were used for this secondary analysis. Findings were discussed with practicing PHNs, policy-makers and researchers from across Canada at a knowledge translation (KT) 'Think-Tank'. RESULTS: Among the 271 PHNs, 53.5% reported being 'very satisfied' with their jobs. The interaction between autonomy and workload was a significant predictor of PHNs' job satisfaction, (OR 0.97, 95% CI 0.96-0.99, p < 0.01) as was the interaction between age and workload (OR 1.01, 95% CI 1.00-1.01, p < 0.01). Think-Tank participants selected priority areas for application to public health practice, management and research. CONCLUSION: Despite being an important practice factor, this is the first study to reveal the negative influence of PHNs' autonomy when in interaction with an excessive workload. Significant workload findings and the presence of generational differences suggest the need for development of workload measurement tools and public health human resource strategies tailored to a multi-generational workforce.

Implementation of clinical guidelines for adults with asthma and diabetes: a three-year follow-up evaluation of nursing care.

AIMS AND OBJECTIVES: To report on a three-year follow-up evaluation in Canada of nursing care indicators following the implementation of the Adult Asthma Care Best Practice Guideline and the Reducing Foot Complications for People with Diabetes Best Practice Guideline and to describe the contextual changes in the clinical settings. BACKGROUND: The Registered Nurses' Association of Ontario in Canada has developed and published more than 42 guidelines related to clinical nursing practice and healthy work environments. To date, evaluation has involved one-year studies of the impact of guideline implementation on the delivery of care in hospital and community settings, but little is known about whether changes in practice that were made during the initial implementation period have been sustained. DESIGN: Longitudinal follow-up study. METHODS: Site observations and interviews were conducted with key informants at two hospitals. Indicators of nursing care changes identified six months post-implementation were compared with indicators found during a retrospective chart audit at the same sites three years later. Fisher exact tests were used to compare outcomes for the two time periods. RESULTS: Three out of 12 indicators related to asthma care remained consistently high (≥ 84% of audited charts) and four indicators declined significantly (p < 0.01). There were significant (p ≤ 0.05) improvements in nine out of 12 indicators related to diabetes foot care. Important contextual changes were made to better address the guideline recommendations for foot care in the out-patient program and the electronic documentation system. CONCLUSIONS: Sustainability of guideline implementation recommendations was enhanced with the use of an electronic documentation system. RELEVANCE TO CLINICAL PRACTICE: Long-term follow-up of both clinical indicators and contextual factors are important to monitor to promote sustained implementation of guidelines.

Knowledge to action: implementing a guideline for second stage labor.

PURPOSE: To quantify practice changes associated with implementing a clinical practice guideline for the second stage of labor in term nulliparous women with epidural anesthesia and to describe the lessons learned about knowledge translation. The main clinical practice guideline recommendation was waiting up to 2 hours before pushing after full dilatation. DESIGN AND METHODS: Pre- and post-evaluation of clinical outcomes and knowledge translation strategies associated with implementing the second stage of labor clinical practice guideline at two birthing units within a large teaching hospital. RESULTS: The implementation of the clinical practice guideline resulted in a significant increase in median waiting time before pushing of 33 minutes at Site 1. This change was also reflected in the twofold increase in the proportion of women waiting longer than 120 minutes before pushing at this site. There was no change in waiting time at Site 2. The duration of the second stage did not change significantly at either site. The median pushing time decreased at both sites but was only statistically significant at Site 1. CLINICAL IMPLICATIONS: Bringing about practice change in obstetrics is complex. The measured change in this study was less than we expected. Greater success might have been achieved by enhancing feedback to care providers and more frequent audits of practice. We need to better understand the subtle influences in attitude and culture that prevented successful implementation in one site. For units considering a similar process, we recommend a commensurately greater level of presence in the units to encourage compliance with the clinical practice guideline in order to achieve the desired level of practice change.

Multidisciplinary collaborative maternity care in Canada: easier said than done.

OBJECTIVE: To describe care provider attitudes towards multidisciplinary collaborative maternity care in Canada and the factors influencing such care from the perspective of members of national professional associations of care providers. METHODS: A qualitative descriptive approach was used. Leaders of national associations nominated key members, who were invited to participate in semi-structured telephone interviews. RESULTS: Twenty-five participants from six national care provider associations (family physicians, obstetricians, registered midwives, registered nurses, nurse practitioners, and rural physicians) were interviewed. Participants described at least one of two main benefits of collaborative maternity care: a partial solution to the human resources shortage in maternity care, and improved maternity care for women. Despite their belief that collaboration is needed, participants expressed concern about the effects of collaboration on their practice. In particular, some participants were concerned about how collaborative models could support woman-centred care or respond to local community needs and promote continuity of care. Significant barriers to collaboration include structural factors (fee structure, liability issues) and interdisciplinary rivalry between groups of providers (turf protection, lack of mutual respect). Strategies to promote collaboration that were supported by the participants include strong national leadership and interdisciplinary education. CONCLUSION: Representatives of professional associations of care providers believe that multidisciplinary collaborative maternity care is needed to sustain the availability of care providers and to improve access and women's choices for maternity care in Canada. However, they perceive that strong leadership and education are needed to address significant structural and relational barriers to collaborative practice.

Evaluation of a multiple component intervention to support the implementation of a 'Therapeutic Relationships' best practice guideline on nurses' communication skills.

OBJECTIVE: To determine if there was an improvement in nurses' communication skills 5 months after a multiple component intervention to implement the Registered Nurses' Association of Ontario best practice guideline 'Establishing Therapeutic Relationships'. METHODS: A matched pair, before and after design was used. Eight client scenarios with corresponding client comments were read aloud to nurses who were asked to respond verbally, as though they were interacting with the client. Responses were audio-taped and transcribed. The frequency and quality of nurses' active listening, initiating and assertiveness skills were measured pre- and post-implementation of the guideline. RESULTS: Twenty-two nurses responded at both time points. Active listening skills were most frequently used. There was a statistically significant decrease in the number of active listening skills used, but a statistically significant improvement in the quality of active listening and initiating statements and frequency of initiating skills. CONCLUSION: Nurses demonstrated improvements in selected communication skills following the implementation of a multiple component intervention that included a best practice guideline. PRACTICE IMPLICATIONS: A combination of strategies that support the implementation of a best practice guideline is described. Results indicate some improvement in communication skills that are essential to the establishment of therapeutic nurse-client relationships.

Sources and models for moving research evidence into clinical practice.

High quality research evidence for nursing practice is available from the Cochrane Library and in clinical practice guidelines produced by professional associations. The transfer of research evidence into practice is a complex process, and changing provider behavior is a challenge, even when the relative advantages are strong. An active approach with multifaceted interventions based on the assessment of barriers has been found most effective. An array of interventions for implementing research findings in practice is included, and promising organizational and theoretical perspectives on increasing the use of research evidence for nursing practice are described.

Facilitating the use of evidence in practice: evaluating and adapting clinical practice guidelines for local use by health care organizations.

This article describes a framework for evaluating and adapting existing practice guidelines for local use by health care organizations and groups. The framework presents the major issues related to guideline adaptation and breaks them down into manageable steps. Many steps of the framework are illustrated using the process used by the Registered Nurses Association of Ontario to develop best practice guidelines for breastfeeding.

Labor support: nurses' self-efficacy and views about factors influencing implementation.

OBJECTIVE: To develop and evaluate a questionnaire assessing nurses' self-efficacy for labor support and to describe nurses' perceptions of factors assisting and preventing the provision of labor support. DESIGN: Two surveys completed by participants. SETTING: Five Canadian hospitals. PARTICIPANTS: For Phase 1, 81% (55/68) of maternity nurses at one hospital participated; for Phase 2, 88% (152/173) of labor and delivery (L&D) nurses at four hospitals participated. MAIN OUTCOMES: Phase 1, psychometric properties of a new scale; Phase 2, nurses' self-efficacy for labor support and content analysis of nurses' comments. RESULTS: Phase 1: The Cronbach's alpha coefficient of the self-efficacy scale was .98, with a test-retest correlation of r(s) = .93. Higher (more positive) self-efficacy scores were found for L&D nurses compared with postpartum nurses, p < .0001. Phase 2: Mean self-efficacy scores for L&D nurses were high (range 86.9 to 92.1 out of 98). Written comments (n = 304) about the influencing factors in each work setting were coded into the following categories: staffing, physical environment, teamwork, management support, and negative staff attitudes. CONCLUSIONS: Phase 1 provided beginning evidence of the reliability and validity of the Self-Efficacy Labor Support Scale. Phase 2 found that L&D nurses' self-efficacy or confidence to provide labor support was high. Therefore, it is recommended that future attention needs to be focused on factors related to the provision of labor support (staffing, physical environment, teamwork, management support, and negative staff attitudes). Attention to organizational factors is vital if nurses are the professional group to provide the evidence-based practice of continuous support for women in labor.