Objectives

1
(No Transcript)
2
Objectives

• At the end of this session, participants will
  have
• An introduction to the Registered Nurses
  Association of Ontario (RNAO) Best Practice
  Guidelines Program
• from concept to reality, and
• lessons learned along the way.
• A greater understanding of RNAO best practice
  guidelines
• how they are developed, and
• how they can be used.

3
RNAO Best Practice Guidelines Program

• Multi-year funding support from the Government of
  Ontario

4
Program Mandate
To develop, pilot implement, evaluate and
disseminate nursing best practice guidelines.
5
Goals for Best Practices

• Improve patient care
• Reduce variation in care
• Transfer research evidence into practice
• Promote nursing knowledge base
• Assist with clinical decision making
• Identify gaps in research
• Stop interventions that have little effect or
  cause harm
• Reduce cost

6
Five Broad Areas of Focus
1. Gerontology 2. Primary Health Care 3. Home
Health Care 4. Mental Health Care 5. Emergency
Care
7
What are Best Practice Guidelines (BPG)?

• Systematically developed statements (based on
  best available evidence) to assist practitioner
  and patient decisions about appropriate health
  care for specific clinical (practice)
  circumstances
• (Field Lohr, 1990)

8
Comparing Standards of Practice to BPG

• BPG
• Based on evidence from a critical review of the
  literature
• Suggested guidelines for individuals and
  organizations
• Emphasis on synthesis of the literature

• Standard
• Based on values, morals, legislation
• Minimum requirements for individual practitioner
• Basis for determining professional competence,
  misconduct malpractice
• Emphasis on legal ethical requirements

9
Comparing Standards of Practice to BPG (2)

• Standard
• Defines acceptable and unacceptable behaviour
• Defines process for making decisions

• BPG
• Provides extensive background information to make
  informed decisions

10
Planning
Program Phases
Development
Pilot Implementation
Evaluation
Revision
Dissemination
11
Planning/ Development
12
Guideline Development Methodology

• Getting started
• Guideline topic selection
• Panel recruitment and establishment
• Search, retrieval and critical appraisal of
  evidence sources
• Identification of existing clinical practice
  guidelines

13
Guideline Development Methodology (2)

• Defining the scope
• Guideline appraisal
• Screen for inclusion criteria
• Use of AGREE Instrument

14
AGREE Instrument 6 Domains

• Scope Purpose
• Stakeholder Involvement
• Rigor of Development
• Clarity Presentation
• Applicability
• Editorial Independence

www.agreecollaboration.org
15
Guideline Development Methodology (3)

• Development of recommendations
• Evaluation indicators
• External stakeholder review
• Publication
• Revision

16
BPG Table of Contents

• Summary of Recommendations
• Interpretation of Evidence
• Responsibility for Development
• Purpose Scope
• Development Process
• Definition of Terms
• Background Context
• Practice Recommendations
• Education Recommendations
• Organization Policy Recommendations

• Research Gaps Future Implications
• Evaluation/Monitoring of Guideline
• Implementation Strategies
• Process for Update/Review of Guideline
• References
• Bibliography
• Appendices

17
Types of Evidence?
18
Levels of Evidence

• Ia Meta-analysis or systematic review of
  randomized control trials
• Ib At least one randomized controlled trial
• IIa At least one well-designed controlled study
  without randomization.
• IIb At least one other type of well-designed
  quasi-exp. study without randomization
• III Well-designed non-exp. descriptive studies
• IV Expert committee reports or opinions and/or
  clinical experiences of respected authorities

19
Additional Sources of Evidence

• Qualitative Research
• Clinical Experience
• Patient Preferences
• Contextual Influence

20
Pilot Implementation
21
Toolkit Implementation of Clinical Practice
Guidelines

• Selecting a guideline
• Assessing the organization for environmental
  readiness
• Identifying, assessing and engaging stakeholders
• Implementing strategies
• Securing resources
• Evaluating outcomes

22
No Magic Bullets
RNAO (2002). Toolkit Implementation of Clinical
Practice Guidelines
23
Evaluation
24
BPG Evaluation

• 50 organizations across Ontario to pilot
  implement/evaluate BPGs
• Canadian Health Services Research Foundation
  (CHSRF) funded study Sustained Use of Research
  Evidence (SURE)
• Development and testing of measures
• Monographs published containing developed and
  tested evaluation tools

25
Challenges/Barriers to Successful Implementation

• Attitudes we do it already
• Workload Interferes with education sessions
• Lack of continuity Limited time with patients
• Limited resources staff education, purchase of
  equipment
• Organizational constraints use of agency nurses,
  staff changes
• Lack of prompts Documentation not changed to
  prompt recording of intervention

26
Facilitators of Successful Implementation

• Support Financial, ideas, information
• Collaboration Education sessions with allied
  staff
• BPG Champions Positive early experiences
• Administration involvement buy-in from
  management, steering committees
• Clinical Resource Nurse Dedicated role,
  availability
• Education Tools, sessions, paid time
• Congruence with current practice, beliefs and
  values

27
Best Practice Research Evaluation Unit

• On March 11, 2005, the RNAO and the University
  of Ottawa, School of Nursing partnered and
  launched a research unit. A major role of the
  unit will be to
• Evaluate the knowledge dissemination, transfer,
  translation and uptake of clinical practice
  guidelines and their impact on medium and
  long-term nursing practice and
• Promote greater collaboration and research
  exchange between and among researchers,
  decision-makers, doctoral students and health
  care organizations.

28
Dissemination
29
Website to rememberwww.rnao.org/bestpractices

• Materials available for free download
• All published BPG (English and some in French)
• Teaching materials, Evaluation tools
• ToolkitImplementation of Clinical Practice
  Guidelines
• Educators Resource Kit
• Inventory of Research Gaps
• BPG newsletter

30
Ways of Introducing BPG to Others

• Website
• BPG on the website, CD, hard copy
• Best Practice Guidelines Newsletter
• Making it Happen video
• Best Practice Champions Network
• Biennial BPG International Conference
• Annual Best Practice Summer Institute (1 week
  residential)

31
Ways of Introducing BPG to Others (2)

• Advanced Clinical/Practice Fellowships (only in
  Ontario)
• RNAO Doctoral Fellowships (25,000)
• Workshops
• Best Practice Spotlight Organizations

32
Using BPG in Practice

• Relevance to practice setting
• Relevance to client population
• Commitment of care providers to implementation
• Environmental support
• Expert and educational
• Administrative support including budget and
  materials

33
Using BPG

• Identify the priority recommendations for
  implementation
• Determine which recommendations students/staff
  can use to make decisions
• Prepare examples to explain how the
  recommendations could be used

34

• Remember
• Each BPG needs to be reviewed and applied, based
  on specific needs of the organization or practice
  setting, as well as the needs and wishes of the
  client
• Not a cookbook but a tool for decision-making

35
Where can you go from here?

• What would you like to see happen now that you
  know more about BPG?
• How can educators and practitioners work together
  to reduce the knowledge-practice gap?
• What next steps can be implemented to achieve
  desired outcomes?

36
Closing Thoughts

• If you have a dream that doesnt scare you
• You dont have a big enough dream!

37
References

• 1. DiCenso, A., Virani, T., Bajnok, I., Borycki,
  E., Davies, B., Ian, G. et al. (2002). A toolkit
  to facilitate the implementation of clinical
  practice guidelines in healthcare settings.
  Hospital Quarterly, 5, 55-60.
• 2. Edwards, N., Davies, B., Ploeg, J., Dobbins,
  M., Skelly, J., Ralphs-Thibodeau, S. (2005).
  Evaluating best practice guidelines. Canadian
  Nurse, 101(2), 19-23.
• 3. Field, M.J. Lohr, K.N. (eds). (1990).
  Guidelines for clinical practice Directions for
  a new program. Institute of Medicine, National
  Academy Press, Washington, DC.
• 4. Grinspun, D., Virani, T., Bajnok, I. (2001).
  Nursing best practice guidelines The RNAO
  project. Hospital Quarterly, 4,(2) 54-57.
• 5. Registered Nurses Association of Ontario.
  (2002). Toolkit Implementation of clinical
  practice guidelines. Toronto Author.

38

• Never doubt that a small group of
  thoughtful,committed citizens can change the
  world.Indeed, it's the only thing that ever
  has.
• - Margaret Mead (anthropologist)