Optimal Pain Assessment in Pediatric Rehabilitation: Implementation of a Nursing Guideline.

In Ontario, Canada, the Registered Nurses' Association promotes a Best Practice Spotlight Organization initiative to enhance evidence-based practice. Qualifying organizations are required to implement strategies, evaluate outcomes, and sustain practices aligned with nursing clinical practice guidelines. This study reports on the development and evaluation of a multifaceted implementation strategy to support adoption of a nursing clinical practice guideline on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital. Multiple approaches were employed to influence behavior, attitudes, and awareness around optimal pain practice (e.g., instructional resources, electronic reminders, audits, and feedback). Four measures were introduced to assess pain in communicating and noncommunicating children as part of a campaign to treat pain as the fifth vital sign. A prospective repeated measures design examined survey and audit data to assess practice aligned with the guideline. The Knowledge and Attitudes Survey (KNAS) was adapted to ensure relevance to the local practice setting and was assessed before and after nurses' participation in three education modules. Audit data included client demographics and pain scores assessed annually over a 3-year window. A final sample of 69 nurses (78% response rate) provided pre-/post-survey data. A total of 108 pediatric surgical clients (younger than 19 years) contributed audit data across the three collection cycles. Significant improvements in nurses' knowledge, attitudes, and behaviors related to optimal pain care for children with disabilities were noted following adoption of the pain clinical practice guideline. Targeted guideline implementation strategies are central to supporting optimal pain practice.

Using the NHS sustainability framework to understand the activities and resource implications of Canadian nursing guideline early adopters.

AIMS AND OBJECTIVES: To examine the activities and resource implications for the initial cohort of healthcare organisations involved in the introduction of multiple nursing guidelines. BACKGROUND: The Best Practice Spotlight Organization initiative was launched in 2003 as part of the Registered Nurses' Association of Ontario's Best Practice Guidelines programme. While previous research has evaluated improvements in patient care and outcomes, there has been limited research from an organisational perspective on the activities conducted to introduce nursing guidelines. DESIGN: Secondary analysis of retrospective narrative data. METHODS: We conducted a content analysis of the 2004-2006 annual reports from the seven participating sites. We used both deductive and inductive approaches to categorise the guideline implementation activities and their resource implications. RESULTS: All sites reported implementing multiple guidelines (four to nine guidelines per site) and used a wide range of implementation activities that clearly addressed nine of the 10 NHS Sustainability dimensions. The dimension not reported was benefits beyond helping patients. All sites established steering committees that involved staff and senior leaders, reviewed selected guidelines and recommendations, reviewed existing policies and procedures and developed new policies and procedures, recruited champions or peer mentors, applied for additional external funding to support activities, developed relationships with external clinical partners, included guideline implementation in orientation, developed intra-agency web-based and print communications for the project, and evaluated practice changes. For each of these activities, the sites reported expenditures and resource usage. CONCLUSIONS: The organisational processes used for the introduction of new nursing guidelines in Canada are remarkably consistent with factors identified by leaders and change agents in the UK who developed the NHS Sustainability Model. RELEVANCE TO CLINICAL PRACTICE: A multidimensional framework for sustainability is useful for planning successful guideline implementation across an organisation. Examples of specific activities and resource implications for organisational change are provided.

Perspectives of significant others in dialysis modality decision-making: a qualitative study.

OBJECTIVE: To explore the experience of the dialysis modality decision-making process from the perspective of the significant other. METHODS: A qualitative interpretive description study was conducted using the Interprofessional Shared Decision Making Model (Légaré et al., 2011). Data collection included one-on-one, semi-structured interviews, the Decisional Regret Scale, and the SURE tool. RESULTS: Ten significant others were interviewed. They included wives, husbands, and daughters of dialysis patients. Their roles involved providing a positive outlook, "being with", advocating, caregiving, learning together, sharing opinions, and communicating values, preferences and treatment feasibility. Broader factors influencing significant others included choosing life, unanticipated life change, and personal health problems. Implementation of the chosen modality resulted in unanticipated events, relationship changes and challenges to travelling. CONCLUSION: Significant others play supportive roles for dialysis patients and are involved in the decision-making process associated with treatment decisions. Significant others may have concurrent emotional, informational, and physical needs that affect their role in making and/or implementing the decision.

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.

Activities and Attributes of Nurse Practitioner Leaders: Lessons from a Primary Care System Change.

Nurse practitioners (NPs) are being encouraged to practice to the full extent of their skills, and they have a critical role to play in leading health system reform. The evidence in support of NP-led initiatives is growing; however, in spite of the positive outcomes associated with these initiatives, considerable opposition to and debate about the potential for NPs to lead health system change and interprofessional teams continues. To date, we know very little about NP leadership activities, particularly those activities that contribute to primary care system change, and there are very few examples of this type of leadership. The qualitative descriptive study here was part of a larger case study that examined stakeholder participation in a system change led by NPs. The change involved the introduction of a new NP-led model of team-based primary care delivery in Ontario, Canada. Data from participant interviews and public documents were analyzed to describe the activities and attributes (perseverance, risk-taking and effective communication) of two NP leaders who were the drivers of this change. Knowledge of these activities and attributes has the potential to inform NP leadership roles in health system policy planning and implementation. However, to be able to provide effective leadership in system change, NPs need access to educational content about public policy and opportunities to develop and practice the skills required to work with multiple stakeholders, including those who oppose change.

Development and evaluation of a workshop to support evidence-based practice change in long-term care.

To support evidence-based practice changes in long-term care, we used a practice development approach with interactive workshops to engage teams from 10 organizations in participatory change. Data from postworkshop surveys and subsequent semistructured interviews indicated that participants felt empowered to identify a priority challenge and initiate change. Notably, the workshop intervention enhanced collaboration between professional and unregulated staff, fostered the development of shared vision, and provided the impetus to tackle workplace barriers to change.