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.

The relationship among evidence-based practice and client dyspnea, pain, falls, and pressure ulcer outcomes in the community setting.

BACKGROUND: There are gaps in knowledge about the extent to which home care nurses' practice is based on best evidence and whether evidence-based practice impacts patient outcomes. AIM: The purpose of this study was to investigate the relationship between evidence-based practice and client pain, dyspnea, falls, and pressure ulcer outcomes in the home care setting. Evidence-based practice was defined as nursing interventions based on best practice guidelines. METHODS: The Nursing Role Effectiveness model was used to guide the selection of variables for investigation. Data were collected from administrative records on percent of visits made by Registered Nurses (RN), total number of nursing visits, and consistency of visits by principal nurse. Charts audits were used to collect data on nursing interventions and client outcomes. The sample consisted of 338 nurses from 13 home care offices and 939 de-identified client charts. Hierarchical generalized linear regression approaches were constructed to explore which variables explain variation in client outcomes. RESULTS: The study found documentation of nursing interventions based on best practice guidelines was positively associated with improvement in dyspnea, pain, falls, and pressure ulcer outcomes. Percent of visits made by an RN and consistency of visits by a principal nurse were not found to be associated with improved client outcomes, but the total number of nursing visits was. LINKING EVIDENCE TO ACTION: Implementation of best practice is associated with improved client outcomes in the home care setting. Future research needs to explore ways to more effectively foster the documentation of evidence-based practice interventions.

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.

Developing team leadership to facilitate guideline utilization: planning and evaluating a 3-month intervention strategy.

BACKGROUND: Research describes leadership as important to guideline use. Yet interventions to develop current and future leaders for this purpose are not well understood. AIM: To describe the planning and evaluation of a leadership intervention to facilitate nurses' use of guideline recommendations for diabetic foot ulcers in home health care. METHOD: Planning the intervention involved a synthesis of theory and research (qualitative interviews and chart audits). One workshop and three follow-up teleconferences were delivered at two sites to nurse managers and clinical leaders (n=15) responsible for 180 staff nurses. Evaluation involved workshop surveys and interviews. RESULTS: Highest rated intervention components (four-point scale) were: identification of target indicators (mean 3.7), and development of a team leadership action plan (mean 3.5). Pre-workshop barriers assessment rated lowest (mean 2.9). Three months later participants indicated their leadership performance had changed as a result of the intervention, being more engaged with staff and clear about implementation goals. CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT: Creating a team leadership action plan to operationalize leadership behaviours can help in delivery of evidence-informed care. Access to clinical data and understanding team leadership knowledge and skills prior to formal training will assist nursing management in tailoring intervention strategies to identify needs and gaps.

The Top 30 Rising Stars Program: an inter-organizational approach to leadership succession planning.

An effective leadership development program is an organizational investment that advances individual performance while strengthening organizational capabilities. The Top 30 Rising Stars Program is a leadership succession program designed to enable leadership capacity building within and across organizations. Key components of the program include formal learning, stretch opportunities, and mentorship. Evaluation results reveal high participant satisfaction and an increase in reported self-confidence in their ability to assume a formal leadership position.

Help Me Cope and Make It Easier: A Perspective from Community Nursing.

SE Health is one of Canada's largest social enterprises, providing home and community care to Canadians since 1908. The organization's 8,000 staff make 18,000 contacts with people in their homes, per day, to deliver healthcare services. Registered nurses and registered practical nurses provide assessments and treatments and support patients and their families to remain healthy, stay safe at home, self-manage and be independent.

Knowledge to action: integrating the use of evidence in management decision making.

This article describes an intervention project focused on laying the foundation for the integration of evidence in management decision making in a home healthcare organization. The current state and readiness for change were assessed, revealing barriers and enablers to using evidence in decision making. Strategies were developed and implemented to address the barriers. Practical steps are outlined to assist other healthcare organizations wishing to embark on the journey of integrating evidence in management decision making.

Lessons on COVID-19 from Home and Community: Perspectives of Nursing Leaders at All Levels.

The initial focus of the COVID-19 pandemic was on the surge capacity of hospitals. Moving forward, however, the attention needs to shift toward keeping people healthy at home. In this paper, we discuss critical insights from the home and community care sector, which shed light on pre-pandemic fault lines that have widened. The paper, however, takes a positive look at how a better future can be built, particularly for those most vulnerable in society. We offer three key insights and analyses as well as examples of how one national homecare organization in Canada, SE Health, is facing the pandemic. We discuss the following key insights: (1) pre-pandemic systemic biases and barriers were exasperated during the pandemic, which impacted the most vulnerable; (2) nurse leaders were faced with unprecedented fear and anxiety from both patients and their staff colleagues; and (3) the pandemic provided an opportunity for significant learning, innovation and capacity development. The pandemic is far from over - we are in a marathon, not a sprint. The paper concludes with how nurse leaders can lead the way in navigating through the pandemic and build a better "new normal."

Leadership Perspective: Bringing Nursing Back to the Future Through People-Powered Care.

At a time when there is a growing interest in person- and family-centred care and integrated community-based models, the unique strengths and expertise of home care nursing is a strategic lever for change across all healthcare settings. In this paper, we explore the theme of people-powered care as a universal starting point - a new approach to health and wellness that is anchored in the strengths of people, their networks and the patterns of everyday life. Leveraging key insights from home and community care, along with broader societal shifts towards personalization and empowerment, we discuss how nurses in all areas of the system can lead the way by empowering staff, patients and their families. Finally, we look at the implications for nursing leadership including how our knowledge, skills and abilities must continue to evolve to effectively impact change and enable this vital transformation to occur.

Developing and sustaining nursing leadership for healthy work environments.

The current nursing shortage and increasing demand for healthcare service in the home and community compound the urgent need for service providers to better attract and retain nurses. Nursing leaders can enhance recruitment and retention by promoting healthy work environments, and developing leadership can help service providers become a better place to work. This case study illustrates how one community healthcare organization successfully implemented healthy workplace strategies using the Registered Nurses' Association of Ontario (RNAO) Healthy Work Environments Best Practice Guideline, Developing and Sustaining Nursing Leadership. A detailed description of the process undertaken for project implementation and evaluation is provided, along with lessons learned and recommendations.

More time where it matters: improving work environments in home healthcare nursing.

The nursing profession is currently experiencing a shift to community care, more complex clients and a shortage of human resources. Home healthcare organizations can increase job satisfaction and retention by better managing nurses' workloads and ensuring more time for direct client care. This project used innovative technology and dynamic methods to document nurses' work lives, identify areas for process improvements and increase time available for direct client care. This case study provides insight into ways in which organizations can streamline non-care activities and discusses implications for nursing leaders at the local and regional levels.

The ALIVE program: developing a web-based professional development program for nursing leaders in the home healthcare sector.

Home healthcare nurses often work in isolation and rarely have the opportunity to meet or congregate in one location. As a result, nurse leaders must possess unique leadership skills to supervise and manage a dispersed employee base from a distance. The nature of this dispersed workforce creates an additional challenge in the ability to identify future leaders, facilitate leadership capacity, and enhance skill development to prepare them for future leadership positions. The ALIVE (Actively Leading In Virtual Environments) web-based program was developed to meet the needs of leaders working in virtual environments such as the home healthcare sector. The program, developed through a partnership of three home healthcare agencies, used nursing leaders as content experts to guide program development and as participants in the pilot. Evaluation findings include the identification of key competencies for nursing leaders in the home healthcare sector, development of program learning objectives and participant feedback regarding program content and delivery.

A mixed methods pilot study with a cluster randomized control trial to evaluate the impact of a leadership intervention on guideline implementation in home care nursing.

BACKGROUND: Foot ulcers are a significant problem for people with diabetes. Comprehensive assessments of risk factors associated with diabetic foot ulcer are recommended in clinical guidelines to decrease complications such as prolonged healing, gangrene and amputations, and to promote effective management. However, the translation of clinical guidelines into nursing practice remains fragmented and inconsistent, and a recent homecare chart audit showed less than half the recommended risk factors for diabetic foot ulcers were assessed, and peripheral neuropathy (the most significant predictor of complications) was not assessed at all. Strong leadership is consistently described as significant to successfully transfer guidelines into practice. Limited research exists however regarding which leadership behaviours facilitate and support implementation in nursing. The purpose of this pilot study is to evaluate the impact of a leadership intervention in community nursing on implementing recommendations from a clinical guideline on the nursing assessment and management of diabetic foot ulcers. METHODS: Two phase mixed methods design is proposed (ISRCTN 12345678). Phase I: Descriptive qualitative to understand barriers to implementing the guideline recommendations, and to inform the intervention. Phase II: Matched pair cluster randomized controlled trial (n = 4 centers) will evaluate differences in outcomes between two implementation strategies. PRIMARY OUTCOME: Nursing assessments of client risk factors, a composite score of 8 items based on Diabetes/Foot Ulcer guideline recommendations. INTERVENTION: In addition to the organization's 'usual' implementation strategy, a 12 week leadership strategy will be offered to managerial and clinical leaders consisting of: a) printed materials, b) one day interactive workshop to develop a leadership action plan tailored to barriers to support implementation; c) three post-workshop teleconferences. DISCUSSION: This study will provide vital information on which leadership strategies are well received to facilitate and support guideline implementation. The anticipated outcomes will provide information to assist with effective management of foot ulcers for people with diabetes. By tracking clinical outcomes associated with guideline implementation, health care administrators will be better informed to influence organizational and policy decision-making to support evidence-based quality care. Findings will be useful to inform the design of future multi-centered trials on various clinical topics to enhance knowledge translation for positive outcomes.

What nurses want: diffusion of an innovation.

We investigated the usability of personal digital assistants (PDAs) to improve research utilization and timely access to electronic practice information to assist in clinical decisions. Nurses used a decision support tool on a PDA to collect point-of-care outcomes data. Follow-up interviews documented usability. Nurses liked the portability and size of the PDA, as well as ease of use of the PDA software. Electronic decision support tools at point of care have the potential to improve nurses' research utilization and quality of care.

Evidence in the palm of your hand: development of an outcomes-focused knowledge translation intervention.

AIM: The aim of the project was to develop an electronic information gathering and dissemination system to support both nursing-sensitive outcomes data collection and evidence-based decision-making at the point-of-patient care. BACKGROUND: With the current explosion of health-related knowledge, it is a challenge for nurses to regularly access information that is most current. The Internet provides timely access to health information, however, nurses do not readily use the Internet to access practice information because of being task-driven and coping with heavy workloads. Mobile computing technology addresses this reality by providing the opportunity for nurses to access relevant information at the time of nurse-patient contact. METHOD: A cross-sectional, mixed-method design was used to describe nurses' requirements for point-of-care information collection and utilization. The sample consisted of 51 nurses from hospital and home care settings. Data collection involved work sampling and focus group interviews. FINDINGS: In the hospital sector, 40% of written information was recorded onto "personal papers" at point-of-care and later transcribed into the clinical record. Nurses often sought information away from the point-of-care; for example, centrally located health records, or policy and procedure manuals. In home care, documentation took place in clients' homes. The most frequent source of information was "nurse colleagues." Nurses' top priorities for information were vital signs data, information on intravenous (IV) drug compatibility, drug references, and manuals of policies and procedures. IMPLICATIONS: A prototype software system was designed that enables nurses to use handheld computers to simultaneously document patients' responses to treatment, obtain real-time feedback about patient outcomes, and access electronic resources to support clinical decision-making. CONCLUSION: The prototype software system has the potential to increase nurses' access to patient outcomes information and evidence for point-of-care decision-making.