A Canadian Survey of Self-Management Strategies and Satisfaction with Ability to Control Pain: Comparison of Community Dwelling Adults with Neuropathic Pain versus Adults with Non-neuropathic Chronic Pain.

BACKGROUND: Individuals with chronic pain with neuropathic characteristics (CPNC) describe a different pain experience compared with those with chronic pain without neuropathic characteristics (CP). AIMS: The aim of this study was to describe and compare pain, self-management strategies, and satisfaction with ability to control pain between adults with CPNC versus CP. PARTICIPANTS: Seven hundred and ten community-dwelling adults with chronic pain participated in a cross-sectional survey. METHODS: CPNC was defined as a score ≥12 on the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Self-management and pain control was compared between participants with CPNC and CP using frequency, percent, relative risk (RR), odds ratios (ORs), and 95% confidence intervals (CIs). RESULTS: Participants with CPNC (188/710) reported lower socioeconomic status, poorer general health, and more intense, frequent, and widespread pain. They were more likely to use prescription medications to manage pain (adjusted OR = 2.25, CI = 1.47-3.42). They were more likely to use potentially negative strategies to ease the emotional burden of living with chronic pain, including substance use (adjusted OR = 1.58, CI = 1.06-2.35), denial (adjusted OR = 2.21, CI = 1.49-3.28), and behavioral disengagement (adjusted OR = 1.68, CI = 1.16-2.45), and they were more likely to be completely dissatisfied with their ability to control pain (RR = 1.77, CI = 1.21-2.58). CONCLUSIONS: Individuals with CPNC have distinct pain and self-management experiences compared with those with CP that may lead to negative coping strategies and dissatisfaction with ability to control pain. Therefore, self-management assessment and support should be tailored by pain condition.

What Are the Barriers and Facilitators for the Self-Management of Chronic Pain with and without Neuropathic Characteristics?

Chronic pain requires affected individuals to self-manage their health. This study compared barriers and facilitators of self-management in two groups of people with chronic pain: those with and without neuropathic characteristics. A cross-sectional survey study of community-dwelling Canadians was conducted. The sample (n = 710) included randomly selected participants who reported chronic pain. The Self-Report Leeds Assessment of Neuropathic Symptoms and Signs was used to screen for neuropathic characteristics. Barriers and facilitators of self-management included self-efficacy (Pain Self-Efficacy Questionnaire), depression (Patient Health Questionnaire 9), social support and relationship with health care provider (Chronic Illness Resources Survey), and pain intensity (numeric rating scale). Participants were asked which factors they felt made pain management easier or harder. Statistical analyses included frequency, percent, relative risk (RR), and 95% confidence intervals (CI). Self-confidence to manage pain was the most commonly perceived self-management barrier/facilitator by both groups; however, participants with neuropathic characteristics (n = 188) were more likely to report low self-efficacy than those without neuropathic characteristics (n = 522) (RR = 2.1, CI = 1.62-2.72, ref = high self-efficacy). Participants with neuropathic characteristics were also more likely to screen positive for depression (RR = 2.30, CI = 1.73-3.06, ref = no/mild depression). There were no group differences in social support and relationship with health professional, but 40.8% felt they were not involved as equal partners in decision making and goal setting related to their care. Health professionals should consider collaborative decision making when seeking to support self-management abilities. Addressing low self-efficacy and depression may be especially important for supporting self-management by individuals with neuropathic characteristics.

Health-related quality of life at healing in individuals with chronic venous or mixed-venous leg ulceration: a longitudinal assessment.

AIMS: To identify factors associated with longitudinal changes in health-related quality of life in community-dwelling individuals with venous or mixed-venous leg ulcers. BACKGROUND: Most care focuses primarily on healing; this research may additionally lead to strategies to improve quality of life. DESIGN: Data from four studies (2000-2009) were combined (2012) to examine quality of life in community-dwelling individuals referred for care of chronic leg wounds. METHODS: Data collection occurred at baseline, 3, 6, 9 and 12 months or at healing and included a comprehensive clinical assessment and measures of pain (McGill), functional autonomy (EQ-5D™ ) and quality of life (SF-12TM ). Physical Component Summary and Mental Component Summary scores (SF-12TM ) were categorized by whether or not there was an improvement (≥3 points) over time. Multivariable logistic regression modelling was used to identify factors associated with improvement. RESULTS/FINDINGS: Mean age of this sample (n = 519) was 67·5 years, 55·9% were women. Median time to healing was 70 days. Mean Physical Component Summary score increased from 37·0-41·5; factors associated with improvement included independent mobility, family history, problems with usual activities, fewer comorbidities and higher baseline pain. Mean Mental Component Summary score improved from 50·5-53·7; factors associated with improvement included anxiety or depression at baseline and living with others. CONCLUSION: Chronic leg ulceration has a substantial, negative impact on health-related quality of life. Ascertaining characteristics associated with changes in quality of life will contribute to the development of comprehensive strategies for prevention, care and improved quality of life.

Factors associated with health-related quality of life in chronic leg ulceration.

BACKGROUND: Individuals with chronic leg ulceration may have significantly impaired health-related quality of life (HRQOL) due to pain, impaired mobility, poor sleep, depression, restricted work capacity, and social isolation. The study purpose was to examine the associations among sociodemographic and clinical factors and HRQOL in a large sample of community-dwelling adults being treated for leg ulcers. METHODS: Data are from the cross-sectional baseline assessment of the Canadian Bandaging Trial, a multi-center, randomized controlled trial conducted to assess time to healing with two forms of high-compression bandaging. All participants received a comprehensive, standardized clinical assessment, and completed the 12-item Short Form (SF-12) and McGill Pain Questionnaire. SF-12 data were compared to age- and sex-adjusted norms, and multivariable logistic regression was used to identify factors associated with whether individuals were below, or at/above their normative values on the physical and mental component summary (PCS, MCS). RESULTS: Of 424 individuals enrolled over a 50-month period, 407 (96 %) completed the SF-12. Mean age was 65 ± 17 years, and 55 % were women. Mean PCS was 39.1 ± 9.9 with 91 (22.4 %) scoring at/above the mean value for their age and sex; equivalent values for the MCS were 51.4 ± 9.9 and 209 (51.4 %). Higher levels of pain, younger age, larger size and longer duration of ulcer, and limited mobility were associated with poorer HRQOL. CONCLUSIONS: Findings confirm the considerable burden of illness associated with leg ulcers. Given the chronic and recurring nature of the condition, strategies focused on improving HRQOL and healing are needed for this vulnerable population.

Different context, different results: venous ulcer healing and the use of two high-compression technologies.

AIMS AND OBJECTIVES: To update the evidence for the relative effectiveness of the four-layer and short-stretch compression technologies used for the treatment of venous ulcers. BACKGROUND: Compression bandages are the most effective method for venous ulcer healing. Both four-layer and short-stretch compression are effective but the relative benefit of one over the other is not fully understood. DESIGN: Meta-analysis of data from randomised trials of short-stretch and four-layer compression bandages. METHODS: We conducted a hazards ratio meta-analysis that combined the results from the existing review evidence with the latest randomised trial. RESULTS: Prior to inclusion of the Canadian Bandaging Trial, the meta-analysis of the available evidence from four trials indicated that short-stretch bandaging was associated with a lower chance of healing than four-layer bandaging. Adding this trial to the meta-analysis however, the relative benefit for the four-layer bandaging did not persist. CONCLUSIONS: Addition of the largest trial of compression technologies attenuated the apparent relative benefit for four-layer bandaging over short-stretch seen in the previous systematic reviews. This may be because the latest trial was large and found no difference in healing rates, attributed to the fact that both technologies were in common use in the trial centres, rather than being a trial of a new bandaging technology over an existing technology. RELEVANCE TO CLINICAL PRACTICE: This analysis indicates that the choice of a compression system can be safely made with equal regard to clinician choice, patient preference and economic considerations as these technologies appear comparable in terms of healing rates.

Profiling frequent presenters to the emergency department for mental health complaints: socio-demographic, clinical, and service use characteristics.

BACKGROUND: A small subset of individuals makes a disproportionate number of ED visits for mental health complaints. STUDY OBJECTIVES: To explore the population profile and associated socio-demographic, clinical, and service use factors of individuals who make frequent visits (5+ annually) to hospital EDs for mental health complaints. METHODS: Case-control study using electronic health record data. RESULTS: Frequent presenters represented 3% of mental health ED patients and accounted for 18% of visits. Several factors were significantly associated with frequent ED use, including limited social support, documented personality disorder/traits, regular antipsychotic use, self-reported alcohol use, and having multiple referral sources.

The safety at home study: an evidence base for policy and practice change.

This paper explores the policies and practices that are needed to improve the safety of home care in light of the most recent evidence about home care safety in Canada. Four areas for policy and practice change are addressed: 1) the promotion of effective communication processes in home care through cross-sector collaboration, case management and technology innovations; 2) screening for safety risk factors; 3) standardizing care processes, packaging and equipment; and 4) supporting family/caregivers and strengthening clients' ability to engage in therapeutic self-care. Evidence-based strategies for change are presented within the context of the evidence about home care safety issues.

Leg ulcer nursing care in the community: a prospective cohort study of the symptom of pain.

BACKGROUND: Chronic wounds are managed almost entirely by community nurses. Almost all individuals with leg ulcers report acute pain usually related to dressing change. Little is known about pain after healing. The purpose of this study was to explore the course of pain from baseline to time of healing of leg ulcers (venous or mixed etiology). In order to understand this phenomenon and develop implications for nursing practice, objectives included: 1) Measure incidence and prevalence of pain at baseline and healing; 2) Describe characteristics associated with leg ulcer pain at baseline; 3) Identify predictors of leg ulcer pain at healing. METHODS: Data were from one randomized controlled trial (2004-2008) of 424 individuals with leg ulcers in the community receiving evidence-informed nursing management. The primary outcome was pain at the time of healing. Predictive factors included demographic, circumstance of living, clinical and ulcer characteristics. Multivariable logistic regression identified the subset of predictors of pain at healing. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Eighty-two percent of participants reported pain at baseline and 32% at healing. Five percent with no pain at baseline reported pain at healing. Thirty-seven percent reported moderate to severe pain at baseline and 11% at healing. Twenty percent of all those who healed reported pain interfered with work moderately to extremely at time of healing. Being female (OR=1.64, 95% CI 1.00, 2.68, p=0.05), use of short-stretch vs. four-layer bandages (OR=1.73, 95% CI 1.06, 2.82, p=0.03), lower SF-12 PCS (OR=0.97, 95% CI 0.94, 0.99, p=0.02) and MCS (OR=0.98, 95% CI 0.95-1.00, p=0.04) scores, use of non-steroidal anti-inflammatory drugs (OR=2.28, 95% CI 1.06, 4.88, p=0.03), and tender pain (OR=2.17, 95% CI 1.29, 3.66, p=<0.01) were associated with pain at time of healing. CONCLUSIONS: Pain is an issue on admission for chronic wounds and at healing, yet 58% with moderate to severe pain on admission were not taking pain medication(s). Future studies should examine the role of pain at healing and at subsequent ulcer recurrence. Mobility and other factors that may contribute to pain at time of healing should also be assessed. Community nurses are encouraged to consider pain when planning care on admission and also after wound healing, when most patients are discharged from care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00202267.

Frequent emergency department use by individuals seeking mental healthcare: a systematic search and review.

OBJECTIVE: The aim of this study was to compare research on individuals who frequently use the ED for mental health complaints including parameters used to identify the population, as well as socio-demographic, clinical, and service use factors. METHODS: Systematic search and review of Medline, Cinahl, PsycInfo, and HealthStar (1980 to 2011). Double-data extraction ensured accuracy. Descriptive statistics were reported. RESULTS: Thirteen studies were included. Median sample size was 100. Parameters varied across studies. Profile: young, unemployed males living in transient accommodations, diagnosis of a psychotic disorder, self-referral to the ED for symptoms/unmet needs, and discharge to community resources. CONCLUSIONS: Consistently used, meaningful definitions/parameters are needed.

Turning knowledge into action at the point-of-care: the collective experience of nurses facilitating the implementation of evidence-based practice.

BACKGROUND: Facilitation is considered a way of enabling clinicians to implement evidence into practice by problem solving and providing support. Practice development is a well-established movement in the United Kingdom that incorporates the use of facilitators, but in Canada, the role is more obtuse. Few investigations have observed the process of facilitation as described by individuals experienced in guideline implementation in North America. AIM: To describe the tacit knowledge regarding facilitation embedded in the experiences of nurses implementing evidence into practice. METHODS: Twenty nurses from across Canada were purposively selected to attend an interactive knowledge translation symposium to examine what has worked and what has not in implementing evidence in practice. This study is an additional in-depth analysis of data collected at the symposium that focuses on facilitation as an intervention to enhance evidence uptake. Critical incident technique was used to elicit examples to examine the nurses' facilitation experiences. Participants shared their experiences with one another and completed initial data analysis and coding collaboratively. The data were further thematically analyzed using the qualitative inductive approach of constant comparison. RESULTS: A number of factors emerged at various levels associated with the successes and failures of participants' efforts to facilitate evidence-based practice. Successful implementation related to: (a) focus on a priority issue, (b) relevant evidence, (c) development of strategic partnerships, (d) the use of multiple strategies to effect change, and (e) facilitator characteristics and approach. Negative factors influencing the process were: (a) poor engagement or ownership, (b) resource deficits, (c) conflict, (d) contextual issues, and (e) lack of evaluation and sustainability. CONCLUSIONS: Factors at the individual, environmental, organizational, and cultural level influence facilitation of evidence-based practice in real situations at the point-of-care. With a greater understanding of factors contributing to successful or unsuccessful facilitation, future research should focus on analyzing facilitation interventions tailored to address barriers and enhance facilitators of evidence uptake.

Emergency department visits for symptoms experienced by oncology patients: a systematic review.

PURPOSE: The aim of this review was to explore the range and prevalence of cancer treatment or disease-related symptoms in the emergency department and their associated outcomes. METHODS: A systematic review examined studies cited in Medline, Embase, PsycINFO, and CINAHL published from 1980 to July 2011. Eligible studies measured emergency department visits for symptom assessment in adult oncology patients. Two reviewers independently screened citations and double data extraction was used. Descriptive analysis was conducted. RESULTS: Of 1,298 citations, six prospective and 12 retrospective descriptive studies were included. Of these, eight focused on multiple symptoms and 10 targeted specific symptoms. The studies were published between 1995 and 2011, conducted in seven countries, and had a median sample size of 143 (range 9-27,644). Of the 28 symptoms reported, the most common were febrile neutropenia, infection, pain, fever, and dyspnea. Definitions provided for individual symptoms were inconsistent. Of 16 studies reporting admission rates, emergency visits resulted in hospital admissions 58 % (median) of the time in multi-symptom studies (range 31 % to 100 %) and 100 % (median) of the time in targeted symptoms studies (range 39 % to 100 %). Of 11 studies reporting mortality rates, 13 % (median) of emergency visits captured in multi-symptom studies (range 1 % to 56 %) and 20 % (median) of visits in targeted symptoms studies (range 4 % to 67 %) resulted in death. CONCLUSIONS: Individuals with cancer present to emergency departments with a myriad of symptoms. Over half of emergency department visits resulted in hospital admissions. Few symptoms were defined adequately to compare data across studies, thereby revealing an important gap in cancer symptom reporting.

Cost-effectiveness of compression technologies for evidence-informed leg ulcer care: results from the Canadian Bandaging Trial.

BACKGROUND: Venous leg ulcers, affecting approximately 1% of the population, are costly to manage due to poor healing and high recurrence rates. We evaluated an evidence-informed leg ulcer care protocol with two frequently used high compression systems: 'four-layer bandage' (4LB) and 'short-stretch bandage' (SSB). METHODS: We conducted a cost-effectiveness analysis using individual patient data from the Canadian Bandaging Trial, a publicly funded, pragmatic, randomized trial evaluating high compression therapy with 4LB (n = 215) and SSB (n = 209) for community care of venous leg ulcers. We estimated costs (in 2009-2010 Canadian dollars) from the societal perspective and used a time horizon corresponding to each trial participant's first year. RESULTS: Relative to SSB, 4LB was associated with an average 15 ulcer-free days gained, although the 95% confidence interval [-32, 21 days] crossed zero, indicating no treatment difference; an average health benefit of 0.009 QALYs gained [-0.019, 0.037] and overall, an average cost increase of $420 [$235, $739] (due to twice as many 4LB bandages used); or equivalently, a cost of $46,667 per QALY gained. If decision makers are willing to pay from $50,000 to $100,000 per QALY, the probability of 4LB being more cost effective increased from 51% to 63%. CONCLUSIONS: Our findings differ from the emerging clinical and economic evidence that supports high compression therapy with 4LB, and therefore suggest another perspective on high compression practice, namely when delivered by trained registered nurses using an evidence-informed protocol, both 4LB and SSB systems offer comparable effectiveness and value for money.

Pain and psychological characteristics in women waiting for gynaecological surgery.

OBJECTIVE: Pain is frequently a complaint prior to gynaecological surgery. Psychological factors are also known to influence the experience of pain. The primary objective of this study was to assess the prevalence of pain and the relationship between psychological factors and pain in women awaiting gynaecological surgery. METHODS: Four hundred twenty-nine women in a tertiary care centre in southeastern Ontario were included in this cross-sectional analysis, which was embedded in a larger prospective study. Pain was assessed using the Brief Pain Inventory, anxiety using the State Trait Anxiety Inventory, depressive symptoms using the Center for Epidemiologic Studies Depression Scale, somatization using the Seven Symptom Screening Test, and catastrophizing with an abbreviated coping strategies questionnaire. RESULTS: Eighteen percent of women reported high anxiety, 37% reported depressive symptoms, 47% had two or more symptoms of somatization, and 40% reported elevated pain catastrophizing. Approximately one third reported moderate to severe pain intensity and interference. Of those reporting pain, 81% believed their pain was due to their primary condition. Depressive symptoms, somatization, and catastrophizing were associated with elevated pain intensity and interference. CONCLUSION: The responses suggest a substantial burden of pain, anxiety, and depressive symptoms in women awaiting gynaecological surgery. Further research is needed to assess the management of these symptoms and their impact on health care resources and the well-being of women in this setting.

Priorities, barriers and facilitators for remote support of cancer symptoms: a survey of Canadian oncology nurses.

A survey of 368 Canadian oncology nurses revealed that 54% provided remote support to oncology patients. The most common symptoms identified were fatigue, pain, nausea, constipation, and anxiety. Frequent symptoms which nurses felt low confidence in managing were anxiety, neuropathy, depression, anorexia and skin alterations. Most nurses agreed that guidelines were needed that were accessible, and improved continuity of care. Forty-three per cent of respondents felt that existing guidelines were inadequate for complex symptoms. Only 54% of respondents agreed they had received enough symptom management training. Common barriers included time constraints, obtaining accurate patient information via telephone, high workloads and knowledge or training deficits. Facilitating factors for provision of remote support included access to an electronic health record, accessible team members, available technology and ease of documentation.

Roadmap for a participatory research-practice partnership to implement evidence.

BACKGROUND: Our research team has undertaken implementation of evidence in the form of practice guideline recommendations for populations in hospital, community, and long-term care settings with diverse provider and patient populations (people with chronic wounds, e.g., pressure and leg ulcers, heart failure, stroke, diabetes, palliative care, cancer, and maternity care). Translating evidence into clinical practice at the point of care is a complex and often overwhelming challenge for the health system as well as for individual practitioners. PURPOSE: To ensure that best available evidence is integrated into practice, "local evidence" needs to be generated and this process accomplishes a number of things: it focuses all involved on the "same page," identifies important facilitating factors as well as barriers, provides empirical support for planning, and in itself is a key aspect of implementation. In doing this work, we developed a roadmap, the Queen's University Research Roadmap for Knowledge Implementation (QuRKI) that outlines three major phases of linked research and implementation activity: (1) issue identification/clarification; (2) solution building; and (3) implementation, evaluation, and nurturing the change. In this paper, we describe our practical experience as researchers working at point-of-care and how research can be used to facilitate the implementation of evidence. An exemplar is used to illustrate the fluid interplay of research and implementation activities and present the range of supporting research. IMPLICATIONS: QuRKI serves as a guide for researchers in the formation of a strategic alliance with the practice community for undertaking evidence-informed reorganization of care. Using this collaborative approach, researchers play an integral role in focusing on, and using evidence during all discussions. We welcome further evaluation of its usefulness in the field.

Activating knowledge for patient safety practices: a Canadian academic-policy partnership.

BACKGROUND: Over the past decade, the need for healthcare delivery systems to identify and address patient safety issues has been propelled to the forefront. A Canadian survey, for example, demonstrated patient safety to be a major concern of frontline nurses (Nicklin & McVeety 2002). Three crucial patient safety elements, current knowledge, resources, and context of care have been identified by the World Health Organization (WHO 2009). To develop strategies to respond to the scope and mandate of the WHO report within the Canadian context, a pan-Canadian academic-policy partnership has been established. APPROACH: This newly formed Pan-Canadian Partnership, the Queen's Joanna Briggs Collaboration for Patient Safety (referred throughout as "QJBC" or "the Partnership"), includes the Queen's University School of Nursing, Accreditation Canada, the Canadian Patient Safety Institute (CPSI), the Canadian Institutes of Health Research, and is supported by an active and committed advisory council representing over 10 national organizations representing all sectors of the health continuum, including patients/families advocacy groups, professional associations, and other bodies. This unique partnership is designed to provide timely, focused support from academia to the front line of patient safety. QJBC has adopted an "integrated knowledge translation" approach to identify and respond to patient safety priorities and to ensure active engagement with stakeholders in producing and using available knowledge. Synthesis of evidence and guideline adaptation methodologies are employed to access quantitative and qualitative evidence relevant to pertinent patient safety questions and subsequently, to respond to issues of feasibility, meaningfulness, appropriateness/acceptability, and effectiveness. SUMMARY: This paper describes the conceptual grounding of the Partnership, its proposed methods, and its plan for action. It is hoped that our journey may provide some guidance to others as they develop patient safety models within their own arenas.

The Canadian Bandaging Trial: Evidence-informed leg ulcer care and the effectiveness of two compression technologies.

OBJECTIVE: To determine the relative effectiveness of evidence-informed practice using two high compression systems: four-layer (4LB) and short-stretch bandaging (SSB) in community care of venous leg ulcers. DESIGN AND SETTING: Pragmatic, multi-centre, parallel-group, open-label, randomized controlled trial conducted in 10 centres. Cognitively intact adults (≥18 years) referred for community care (home or clinic) with a venous ulceration measuring ≥0.7cm and present for ≥1 week, with an ankle brachial pressure index (ABPI) ≥0.8, without medication-controlled Diabetes Mellitus or a previous failure to improve with either system, were eligible to participate. METHODS: Consenting individuals were randomly allocated (computer-generated blocked randomization schedule) to receive either 4LB or SSB following an evidence-informed protocol. Primary endpoint: time-to- healing of the reference ulcer. SECONDARY OUTCOMES: recurrence rates, health-related quality of life (HRQL), pain, and expenditures. RESULTS: 424 individuals were randomized (4LB n = 215; SSB n = 209) and followed until their reference ulcer was healed (or maximum 30 months). An intent-to-treat analysis was conducted on all participants. Median time to ulcer healing in the 4LB group was 62 days [95% confidence interval (CI) 51 to 73], compared with 77 days (95% CI 63 to 91) in the SSB group. The unadjusted Kaplan-Meier curves revealed the difference in the distribution of cumulative healing times was not significantly different between group (log rank χ2 = 0.001, P = 0.98) nor ulcers recurrence (4LB, 10.1%; SSB, 13.3%; p = 0.345). Multivariable Cox Proportional Hazard Modeling also showed no significant between-bandage differences in healing time after controlling for significant covariates (p = 0.77). At 3-months post-baseline there were no differences in pain (no pain: 4LB, 22.7%; SSB, 26.7%; p = 0.335), or HRQL (SF-12 Mental Component Score: 4LB, 55.1; SSB, 55.8; p = 0.615; SF-12 Physical Component Score: 4LB, 39.0; SSB, 39.6; p = 0.675). The most common adverse events experienced by both groups included infection, skin breakdown and ulcer deterioration. CONCLUSIONS: The Canadian Bandaging Trial revealed that in the practice context of trained RNs using an evidence-informed protocol, the choice of bandage system (4LB and SSB) does not materially affect healing times, recurrence rates, HRQL, or pain. From a community practice perspective, this is positive news for patient-centred care allowing individual/family and practitioner choice in selecting compression technologies based on circumstances and context. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00202267.

Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model.

Most shared decision-making (SDM) models within healthcare have been limited to the patient-physician dyad. As a first step towards promoting an interprofessional approach to SDM in primary care, this article reports how an interprofessional and interdisciplinary group developed and achieved consensus on a new interprofessional SDM model. The key concepts within published reviews of SDM models and interprofessionalism were identified, analysed, and discussed by the group in order to reach consensus on the new interprofessional SDM (IP-SDM) model. The IP-SDM model comprises three levels: the individual (micro) level and two healthcare system (meso and macro) levels. At the individual level, the patient presents with a health condition that requires decision-making and follows a structured process to make an informed, value-based decision in concert with a team of healthcare professionals. The model acknowledges (at the meso level) the influence of individual team members' professional roles including the decision coach and organizational routines. At the macro level it acknowledges the influence of system level factors (i.e. health policies, professional organisations, and social context) on the meso and individual levels. Subsequently, the IP-SDM model will be validated with other stakeholders.

Use and effects of implementation strategies for practice guidelines in nursing: a systematic review.

BACKGROUND: Practice guidelines can reduce variations in nursing practice and improve patient care. However, implementation of guidelines is complex and inconsistent in practice. It is unclear which strategies are effective at implementing guidelines in nursing. This review aimed to describe the use and effects of implementation strategies to facilitate the uptake of guidelines focused on nursing care. METHODS: We conducted a systematic review of five electronic databases in addition to the Cochrane Effective Practice and Organization of Care (EPOC) Group specialized registry. Studies were included if implementation of a practice guideline in nursing and process or outcome of care provided by nurses were reported. Two reviewers independently screened studies, assessed study quality, extracted data, and coded data using the EPOC taxonomy of implementation strategies. For those strategies not included in the EPOC taxonomy, we inductively categorized these strategies and generated additional categories. We conducted a narrative synthesis to analyze results. RESULTS: The search identified 46 papers reporting on 41 studies. Thirty-six studies used a combination of educational materials and educational meetings. Review findings show that multicomponent implementation strategies that include educational meetings, in combination with other educational strategies, report positive effects on professional practice outcomes, professional knowledge outcomes, patient health status outcomes, and resource use/expenditures. Twenty-three of the 41 studies employed implementation strategies not listed within the EPOC taxonomy, including adaptation of practice guidelines to local context (n = 9), external facilitation (n = 14), and changes to organizational policy (n = 3). These implementation strategies also corresponded with positive trends in patient, provider, and health system outcomes. CONCLUSIONS: Nursing guideline implementation may benefit from using the identified implementation strategies described in this review, including participatory approaches such as facilitation, adaptation of guidelines, and organizational policy changes. Further research is needed to understand how different implementation strategy components work in a nursing context and to what effect. As the field is still emerging, future reviews should also explore guideline implementation strategies in nursing in quasi or non-experimental research designs and qualitative research studies.

Facilitation as a role and process in achieving evidence-based practice in nursing: a focused review of concept and meaning.

BACKGROUND: Facilitation is proposed as an important strategy to assist practitioners to implement evidence into practice. However, from a front-line nursing perspective, what is actually involved in facilitation, particularly in regards to research utilization, is poorly understood. AIM: To examine the current state of knowledge surrounding the concept of facilitation as a role and process in the implementation of research findings within the nursing context. Building on a previous concept analysis, we examined how facilitation has evolved over the last decade, particularly focusing on the practical elements (e.g., what it entails to operationalize and implement facilitation in nursing). METHODS: A systematic search of electronic databases identified theory and research-based nursing papers explicitly focused on facilitation in research utilization. Through a content analysis, we examined how the concept is being used, described, and applied within nursing. RESULTS: Facilitation continues to be described as supporting and enabling practitioners to improve practice through evidence implementation. Certain aspects of the role and the strategies being employed to promote change are more evident. It was possible to formulate these into a taxonomy. Key findings include: * facilitation is now being viewed as an individual role as well as a process involving individuals and groups; * project management/leadership are important components; * no matter which approach is selected, tailoring facilitation to the local context is critical; * there is a growing emphasis on evaluation, particularly linking outcomes to nursing actions. CONCLUSIONS: Further understanding of what facilitators are actually doing to enable changes in nursing practice based on research findings will provide the groundwork for the design and evaluation of practical strategies for evidence-based practice in nursing. Research is needed to clarify how facilitation may be used to implement change in nursing practice along with evaluation of the effectiveness of various approaches.