Planned change or emergent change implementation approach and nurses' professional clinical autonomy.

BACKGROUND: Nurses' clinical autonomy is considered important for patients' outcome and influenced by the implementation approach of innovations. Emergent change approach with participation in the implementation process is thought to increase clinical autonomy. Planned change approach without this participation is thought not to increase clinical autonomy. Evidence of these effects on clinical autonomy is however limited. AIMS AND OBJECTIVES: To examine the changes in clinical autonomy and in personal norms and values for a planned change and emergent change implementation of an innovation, e.g. intensive insulin therapy. DESIGN: Prospective comparative study with two geographically separated nurses' teams on one intensive care unit (ICU), randomly assigned to the experimental conditions. METHODS: Data were collected from March 2008 to January 2009. Pre-existing differences in perception of team and innovation characteristics were excluded using instruments based on the innovation contingency model. The Nursing Activity Scale was used to measure clinical autonomy. The Personal Values and Norms instrument was used to assess orientation towards nursing activities and the Team Learning Processes instrument to assess learning as a team. RESULTS: Pre-implementation the measurements did not differ. Post-implementation, clinical autonomy was increased in the emergent change team and decreased in the planned change team. The Personal Values and Norms instrument showed in the emergent change team a decreased hierarchic score and increased developmental and rational scores. In the planned change team the hierarchical and group scores were increased. Learning as a team did not differ between the teams. CONCLUSIONS: In both teams there was a change in clinical autonomy and orientation towards nursing activities, in line with the experimental conditions. Emergent change implementation resulted in more clinical autonomy than planned change implementation. RELEVANCE TO CLINICAL PRACTICE: If an innovation requires the nurses to make their own clinical decisions, an emergent change implementation should help to establish this clinical autonomy.

Intensive insulin therapy implementation by means of planned versus emergent change approach.

BACKGROUND: Nurses' participation in decisions about new care procedures and protocols is potentially of benefit for patient outcomes. Whether nurses' participation in decisions is allowed in the implementation of innovations depends on the implementation approach used for the introduction. A planned change implementation approach does not allow it, an emergent change implementation approach does. AIM: To compare a planned change and an emergent change implementation approach to introduce an intensive insulin therapy to an intensive care unit (ICU). DESIGN: A prospective comparative study in an ICU in the Netherlands of two teams of nurses using either implementation approach. METHODS: Pre-introduction of the comparability of the two teams was assessed. The nurse compliance to the protocol was assessed as being nurses' behaviour according to the protocol and leading to acceptable glucose values. The effectiveness of the implementation was assessed by measuring the percentage of patients' glucose values within the target range, the occurrence of hypoglycaemic events and the time to glucose value normalization. Data were collected from December 2007 till January 2009. RESULTS: In the emergent change approach team there was better nurse compliance measurements than in the planned change approach team (83.5% vs 66,8% conform protocol), a better percentage of glucose values in the target range (53,5% vs 52.8%) and a shorter time to glucose value normalization. CONCLUSION: The implementation approach allowing nurse participation was associated with better nurse compliance and patient outcome measurements. The implementation approach did not conflict with introducing an evidence-based innovation. It was also associated with more effective adaptation of the protocol to changing circumstances. RELEVANCE FOR CLINICAL PRACTICE: When a new treatment requires adaptability to changing circumstances to be most effective, nurses' participation in decisions about the implementation of the treatment should be considered.

A contingency perspective on team learning and innovation in nursing.

AIMS: To report a correlational study of the relation between team learning activities and implementation-effectiveness of innovations in nursing teams. BACKGROUND: Non-compliance to implementation of innovations is a problem in nursing teams. In the literature, team learning is proposed as a facilitator for change. Still, studies reporting the effects of team learning activities on the implementation of innovations in nursing teams are scarce. To address this gap in the literature, this study explored the influence of team learning on the implementation of two innovations. DESIGN: A cross-sectional survey. METHODS: The survey was conducted in 2008-2009 with a sample of 469 nurses, representing 30 nursing teams from The Netherlands and Belgium. The relationship between variables representing team learning and the use and the knowledge of an incremental (n = 14) or a radical innovation (n = 16) was examined by correlation and multiple regression analyses. RESULTS: Correlation analyses revealed positive relationships between the team learning activities handling production-oriented information and implementation-effectiveness of an incremental innovation. In addition, team learning activities about development-oriented information positively affected the implementation of a radical innovation. Multiple regression yielded models that explain 83% of the variance on the use of an incremental variable, 73% on knowledge of a radical innovation, and 80% on use of a radical innovation. CONCLUSION: In nursing teams, team learning activities that relate to the production of nursing care affect the implementation of an incremental innovation. The implementation of a radical innovation is effected by team learning activities that relate to the development of the provided nursing care.

Feasibility of a nursing rehabilitation guideline for patients with stroke: evaluating the use by nurses.

PURPOSE: To determine the feasibility of the Clinical Nursing Rehabilitation Stroke-guideline (CNRS-guideline) in the care of stroke patients in terms of the experiences, views and attitudes of nurses towards the guideline and their adoption of the guideline and how often the recommendations were used. METHOD: A four phase cross sectional design was used. Demographic data were collected from nurses (n=30) and patients (n=105). After each test phase the nurses received questionnaires about their experiences of the guideline including questions about their attitude towards the guideline and adoption of the guideline. Also, how often the recommendations were used was registered. RESULTS: The nurses' general impression of the recommendations scored a median of 6.0. A majority of the nurses indicated that the aims of the guideline were clear, that it provided new insights into stroke care. Among the challenges experienced were lack of knowledge and skills and organizational difficulties. Half of the nurses adopted the guideline and the nurses' attitude towards the guideline scored a median of 6.0. CONCLUSION: The guideline provides nurses with an important means for evidence based care for patients with stroke. The guideline was feasible for nurses to use but various challenges need ongoing attention when planning implementation. IMPLICATIONS FOR REHABILITATION: • The CNRGS-guideline was found to be feasible for nurses to use in the daily care of patients with stroke, but various challenges, need an ongoing attention. • The CNRGS-guideline is an important step in the stimulation of quality improvement and efficiency and may result in better outcome and satisfaction of patients with stroke. • The CNRGS-guideline provides nurses with an important means to provide evidence based care for patients with stroke.

Psychometric properties of the Dutch version of the American Nursing Activity Scale in an intensive care unit.

AIM: To report the development and psychometric testing of the Dutch version of the Nursing Activity Scale in a Dutch intensive care unit nursing population. BACKGROUND: The Nursing Activity Scale developed by Schutzenhofer measures professional clinical autonomy, by inquiring about the nurses' intention to exercise their own clinical decisions. This autonomy is increasingly relevant due to the ongoing professionalization, nurses increasingly have to make their own clinical decisions. DESIGN: Instrument development. METHOD: The study was conducted from November 2007-February 2008 and consisted of the following steps: translation, expert panel content validation, reliability testing and further content validation, test-retest stability examination, additional internal consistency, and validity assessment. RESULTS: After the first reliability testing two items seen to describe a situation not applicable to intensive care unit nursing in the Netherlands were deleted from the questionnaire. In the test-retest stability assessment the intra class correlation coefficient was 0·76. The Cronbach's alpha of the final questionnaire was 0·82. The alphas of the subsamples with higher scores were significantly different from those with lower scores, supporting the validity of the weighing of the items. CONCLUSION.: The Dutch version of the nursing activity scale consists of 28 items and provides the opportunity to measure professional clinical autonomy for Dutch intensive care nurses using a well-established method.

Team learning and innovation in nursing, a review of the literature.

The capability to learn and innovate has been recognized as a key-factor for nursing teams to deliver high quality performance. Researchers suggest there is a relation between team-learning activities and changes in nursing teams throughout the implementation of novelties. A review of the literature was conducted in regard to the relation between team learning and implementation of innovations in nursing teams and to explore factors that contribute or hinder team learning. The search was limited to studies that were published in English or Dutch between 1998 and 2010. Eight studies were included in the review. The results of this review revealed that research on team learning and innovation in nursing is limited. The included studies showed moderate methodological quality and low levels of evidence. Team learning included processes to gather, process, and store information from different innovations within the nursing team and the prevalence of team-learning activities was contributed or hindered by individual and contextual factors. Further research is needed on the relation between team learning and implementation of innovations in nursing.

Innovative behaviour: the effect of structural and psychological empowerment on nurses.

AIM: This paper is a report of a study to investigate the relationship between structural empowerment/psychological empowerment and innovative behaviour. BACKGROUND: Innovative behaviour is essential for nurses in today's dynamic healthcare systems. Empowerment has become an increasingly important factor in predicting innovative behaviour. Structural empowerment refers to power based on the employee's position in the organization, while psychological empowerment consists of the fundamental personal convictions that employees have about their role in the organization. METHODS: A cross-sectional correlational survey was conducted in The Netherlands in 2007 with 519 Registered Nurses. The instruments used were the Conditions of Work Effectiveness Questionnaire II, the Psychological Empowerment Instrument and the Questionnaire Innovative Behaviour. Four hypotheses were tested using descriptive statistics, bivariate and multiple regression and one-way analysis of variance. RESULTS: Structural and psychological empowerment were statistically significant predictors of innovative behaviour. Informal power and impact were the most relevant determinants of innovative behaviour, the latter the strongest. Psychological empowerment functioned as a mediator between structural empowerment and innovative behaviour. The expected moderating effect of structural empowerment was not proven. CONCLUSION: Organizations need to create the right conditions to be able to strengthen nurses' empowerment. Networking is an important skill which should be incorporated in the nursing education. Future research should take into consideration nursing culture and personality traits as determining factors. Replication of this study in another setting and a study examining causality are recommended so that additional empirical evidence may be obtained.

The tailored implementation of the nursing programme 'Coping with Itch'.

AIM: The aim of the study was to implement the nursing programme 'Coping with itch'. BACKGROUND: The nursing programme 'Coping with itch' is intended to reduce itch and to help patients to cope with itch. The programme is carried out at a nurse clinic at the dermatology outpatient department. Implementation of this programme was undertaken in five hospitals in the Netherlands using the tailored implementation approach based on the contingency model of van Linge. METHOD: The implementation procedure started with a diagnostic interview to gather data on the characteristics of the dermatology outpatient departments subsumed in four dimensions: structure, human resource practices, culture and politics. These characteristics were then compared with the demands of the programme. Discrepancies between the demands of the new programme and the characteristics of each organization guided the choice of the implementation strategies. Implementation strategies were mostly directed at the structure or human resource dimensions. Then, the results of the implementation were examined according to three criteria: professional adherence, continuation and barriers, using nurses' self-report forms on the consultations and the Barriers and Facilitators questionnaire. RESULTS: Seventy-seven self-report forms were completed by the nurses for first consultations at the itch clinic and 81 for follow-up consultations. Results concerning professional adherence show that nurses are able to carry out the programme 'Coping with itch'. All five hospitals continued the itch clinic after completion of the implementation study. Two barriers to the implementation were frequently mentioned by the nurses: the necessary time investment and the lack of extra financial compensation. CONCLUSION: The use of a tailored implementation approach has led to the reasonably successful implementation of the nursing programme 'Coping with itch'. Relevance to clinical practice. The contingency model is a useful model for the tailored implementation of a nursing programme in daily practice.