Sustainability

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Sustainability Scaling up of Nursing Best
Practice Guideline Implementation

• Barbara Davies RN PhD
• Associate Professor
• Co-Director Nursing Best Practice Research Unit
• bdavies_at_uottawa.ca

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Objectives

• Present results of one study examining
  determinants of sustainability related to nursing
  best practice guideline implementation
• Present highlights of two studies (leadership,
  expanded diffusion)
• Discuss related terms, concepts and models about
  expansion, spread and scaling up
• Generate discussion and debateyour thoughts?
• Discuss ideas for future research healthy
  workplace environments for nurses

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Nursing Best Practice Clinical Guidelines
1999-2002

• Cycle 1
• Falls
• Continence
• Constipation
• Pressure ulcers (Assessment)
• Cycle 2
• Healthy adolescents
• Client centered care
• Crisis intervention
• Pain
• Therapeutic relationships
• Pressure ulcers (management)
• Supporting families
• Cycle 3
• Adult asthma control
• Breastfeeding
• Screening for delirium, dementia and depression
• Smoking cessation
• Reducing foot complications for people with
  diabetes

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Development of guidelinesRegistered Nurses
Association of Ontario

• Topic selection Suggestions from focus groups,
  MOHLTC
• Expert panel Researchers, administrators,
  experienced nurses from different contexts, other
  disciplines
• Delineation of scope
• Literature review, critical appraisal, evidence
  tables
• Development of consensus recommendations
• Stakeholder review Professional associations,
  experts
• First 3 Cycles had pilot implementation/evaluatio
  n with minimal revision to the guidelines
• Published on the web for free download and in
  hard copy at cost http//www.rnao.org/Page.asp?Pag
  eID861SiteNodeID133

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Selection of Pilot Sites

• RFP process, peer reviewed (RNAO,
  Decision-makers, researchers)
• All selected sites had a lead organization
• (acute care, long-term care, public health,
  visiting nursing)
• Cycle 1 Cluster of several organizations in a
  region
• Cycle 2 Smaller clusters
• Cycle 3 No requirement for clusters, Requirement
  for small amount of management time

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Implementation process

• Cycle 1 Common elements across cycles
• Launch Teams from all sites, presentations by
  guideline leaders, 2 days
• Selection of site specific clinical resource
  nurse(s)
• Developed education materials, documentation
  resources, policy review, general coordination
• Site specific nursing and multi-disciplinary
  task forces
• Monthly problem solving teleconferences cross
  guidelines
• Cycle 2 Workshop on Implementation strategies
• Cycle 3 Implementation Toolkit 85 (pages)

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Guideline Implementation Strategies

• Systematic review of 235 studies
• Majority (86) multi-faceted with modest -
  moderate improvements, but considerable variation
• Limited information about which implementation
  strategies are likely to be efficient
• Grimshaw et al. (2004) Effectiveness and
  efficiency of guideline dissemination and
  implementation strategies Health Technology
  Assessment 8 ( 6) http//www.hta.nhsweb.nhs.uk/
• http//www.cadth.ca/index.php/en/compus/optimal-t
  her-resources/interventions

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Cochrane Reviews

• Guidelines in professions allied to medicine
  Thomas et al.1999
• 18 studies
• 13 studies included physicians and nurses
• Only 4 studies targeted nurses
• 1 study dieticians
• Improvements
• Processes of care 3/5 studies
• Outcomes 6/8 studies
• Some evidence guideline driven care is effective

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The Issue

• Once the initial pilot implementation funding is
  over, do nurses, managers and senior executives
  continue to implement guideline recommendations?

Nancy Edwards RN PhD Jenny Ploeg RN
PhD Evangeline Danseco PhD Tazim Virani RN RN
PhD (c) Maureen Dobbins RN PhD Project
Coordinator SURE study Cindy Versteeg RN MScN
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Research Questions

• What are the patterns of use of evidence-based
  recommendations by nurses and administrators who
  participated in a Nursing guideline
  implementation project 2 and 3 years after a
  pilot implementation?
• What organizational factors predict sustained use
  of evidence-based recommendations?

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Sustainability Background

• Little research on long-term impact of clinical
  guidelines or innovations in practice
• The word sustainability found in 2 of 1000
  sources screened for a systematic review of the
  diffusion of innovations in health care
  organizations (Greenhalgh, 2004)
• A kind of bottom line- many innovations are
  important, only if they continue to be used
  (Rogers, 2003)

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Models

• The Ottawa Model of Research Use
• Graham I Logan J (2004) CJNR
• Diffusion of Innovations
• Rogers, E M (1995, 2005) Free Press
• Framework for the Dissemination and Utilization
  of Research for Health-Care Policy and Practice
• Dobbins M et al. (2002) The Online Journal of
  Knowledge Synthesis for Nursing

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Methods
Ontario 1 million square kms 12 million people

• Prospective panel study with repeated measures
  annually for two years
• 45 health care organizations to be invited
• Predictor variables
• Nurses and administrators scores of perceived
  utility
• Organizational culture
• Perceived characteristics of innovation
• Demographic variables

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Measures International Expert Panel

• Five Experts from Australia, Canada, England,
  Scotland, USA
• NICEBIRG
• Reviewed Proposed Definitions
• Assessed content validity of semi-structured
  questionnaires
• Validity rated on a four-point scale
• Asked for areas of omissions and suggestions
• 80 of items rated as relevant

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Definitions

• Sustained Use
• Continued implementation of evidence-based best
  practice guideline recommendations
• Expanded Use
• New and/or different implementation of
  recommendations Gone beyond the original
  six-month pilot implementation

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Procedures (Multi-method Study)

• Interviews
• Clinical resource nurses, administrators, staff
• Site Visits
• I day, lead organization
• Agenda planned in collaboration with each site
• Observations of practice settings, meetings
  nurses, quality assurance groups, unit teams,
  patient volunteers
• Document Reviews
• Policies, clinical protocols, pathways, patient
  education materials

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Integrative Process

• Synthesis by a research analyst in consultation
  with site visit team (PI, Research Coordinator,
  Clinical Expert)
• Preparation of a 5-8 page executive summary
  report
• Report reviewed and validated by key informants
  from the organization and revisions were made

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Three year follow-up

• Teleconference (audio-recorded)
• Site visitor team and 2 to 4 key informants from
  the organization
• Structured agenda

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Results

• Participation rate
• 90 Organizations (37/41)
• 92 Decision-makers (112/122)
• 80 Nurses (77/96)
• 16 site visits made
• Average of 5 interviews per organization

21 Hospitals 10 Long-term care 6 Community care
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Results

• Sustainability status based on meeting four of
  six criteria
• Current practice
• Continuing education
• Policies/procedures
• Leadership
• Workplace culture
• Self-assessment on success of project and
  sustainability

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Sustainability Status at Year 2
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Sustainability Status at Year 2

• 43 Sustained (16/37)
• with 69 of these as expanded (11/16)
• 57 Not sustained (21/37)
• Most not sustained in the first and second
  cohorts (17/21, 81)
• Year 3
• 59 sustained

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Quantitative organizational variables

• Leadership
• Defined as recognizable role models, leaders,
  champions or administrative support for
  continuing the implementation
• the only predictor explaining 47 of the variance
  in how strongly the guideline permeated the
  organization
• Not perceived utility, organizational culture for
  change, organizational stability, perception of
  educational support, organizational support for
  guideline implementation or perceived
  characteristics of the innovation

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Facilitators for Sustained or Expanded Long-Term
Use of Guidelines

• Leadership by champions
• Management support at all levels
• Ongoing staff education
• Guideline integrated into policies and procedures
• Staff buy-in and ownership
• Synergy with partners and external influences
• Guideline characteristics
• Multidisciplinary involvement

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Facilitators

• 1. Leadership by Champions
• Strong leadership support
• Designated champion
• Numerous champions or specialist support
• So its been tough, theres been a lot of
  stress, the nursing population is aging, workload
  is increasing, complexity is increasing, a lot of
  role identification is happening concurrently so
  if it wasnt for the champions to carry the
  torch, its a body and name to keep banging the
  drum, the troops will soon forget about what they
  learned.

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Facilitators

• 2. Management Support
• Support at all levels
• Support and buy-in from administration/
  management
• I think really it was a management decision to
  try to base all service and to have staff be
  aware of best practice and to be using that as a
  guideline to be thinking about their practice
  individually and organizationally. my
  management team has continued to put it on the
  table, so thats what I think theres been huge
  administrative buy-in to the whole best practice
  idea.

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Facilitators

• 3. Ongoing Staff Education
• Guideline added to orientation
• Financial support for education
• Increased awareness
• Visible results/ exemplars
• So I think the increased education really
  contributed to them wanting to continue using it
  because they could see that it was successful.
  And it gave them a good teaching tool for their
  patients. They could explain a lot more to the
  patients because they knew a lot more.

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Facilitators

• 4. Guideline Integrated in Policies and
  Procedures
• Standardized documentation or tools
• Computer systems, e-records
• Policy and procedure changes
• Infused in practice incorporated into hiring and
  competency
• The implementation of a revised daily care
  record that facilitated them documenting what
  they did do to prevent ulcers

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Barriers for Sustained or Expanded Long-Term Use
of Guidelines

• Changes in staffing and structure
• Lack of sustained leadership by champions
• Heavy workload and limited time
• Limited ongoing staff education
• Lack of follow-up and feedback
• Staff resistance
• Limited management commitment or support
• Guideline not embedded or integrated into
  policies, procedures or documentation

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Barriers

• 1. Changes in staffing and structure
• Change in managers, leadership, educators, CRN
  and champions
• High staff turnover
• Restructuring, closing or adding units
• I guess there were so many changes going on at
  the same timethere were changes, uncertainty
  regarding divestment, the staff were concerned
  about their future, whether they have a job when
  we are divested and all that. So there were so
  many things going on. And then the program
  manager on the district was also off. There was
  lots of unrest in the environment which impacts
  on the staffing.

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Barriers

• 2. Lack of sustained leadership by champions
• Original CRN no longer there
• No designated lead or champion
• There was no visible support after the resource
  nurse left There is no visible support from
  administration

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Barriers

• 3. Heavy workload and limited time
• I think the time is always an issue for nurses.
  You need to build in time for people to talk
  about their practice and their work with clients
  and they need time to reflect on their own
  practice. So you have to somehow build that in to
  the time that nurses have, and unfortunately as
  we know there is a nursing shortage so time is of
  the essence. When you get caught up in doing the
  actual physical work, there isnt always that
  other reflection discussion time available, so I
  think thats problematic.

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Different patterns A lull

• We sort of slid back but we certainly are moving
  forward again weve been really aggressively
  working with the staff to get back on track again
  
• Key turning point (Vivid story)
• Own patient having a serious problem
• Photos taken to document incident
• Champion hired

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Limitations and future plans

• What about actual patient/client outcomes?
• While some organizations are tracking selected
  clinical and patient indicators, many are not
• COLTURE study led by Dr. Kathy Higuchi in
  progress (funded by CNF)
• Frustration expressed about need for system
  change. Program of Research 5 studies
• Evidence-Informed Nursing Service Delivery Models
  
• Dr. Nancy Edwards Doris Grinspun 22 Co-Inv
  (CHSRF Research, Exchange and Impact for System
  Support)

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Strengths

• Use of mixed methods
• Large number of agencies from various sectors
  involved
• Collaborative model engaging front-line nurses,
  managers, researchers
• Field research

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Conclusions

• Implementing changes in nursing practice to be
  more evidence-based takes time, is dynamic,
  long-term and iterative process
• Some organizations may take 2-3 years to show
  that guideline recommendations are routine part
  of nursing practice
• Full Report CHSRF
• http//chsrf.ca/final_research/ogc/pdf/davies_fina
  l_e.pdf

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Leadership strategies to influence the use of
guidelines

• Support from managers and a key project lead are
  consistently identified as important
• Yet, little is known about their key behaviors
  and activities
• Secondary analysis of qualitative data from Cycle
  1 sites with 4 as sustained and 5 as
  non-sustained
• Data from 32 interviews
• Grounded theory approach for analysis

Gifford, W., Davies, B., Edwards, N., Graham, I.
( 2006) Nursing Leadership Vol. 19
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Gifford, Davies, Edwards Graham (2006).
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REISS 3 Expanded Health Systems Diffusion

• Research Questions
• What factors contribute to internal and external
  expanded use of nursing guidelines?
• What are the costs and benefits associated with
  expanded systems diffusion in two exemplary
  organizations

Barbara Davies Judith Ritchie Angela Downey,
Nancy Edwards, Wendy Gifford, Heather McConnell,
Cécile Michaud, Jenny Ploeg, Margo Rowan
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Mapping and measuring spread

• Use of complexity science
• Needed a holistic sense to capture the inner
  workings layers of interlacing networks,
  meanings across different organizational
  levels 5
• Created a story of spread for each organization
• (special thanks Margo Rowan)
• Developed diagrams depicting spread within and
  outside each org.includes zig zags
• Developed Criteria
• Converted info from diagrams to begin to develop
  a quantitative scoring system for internal and
  external spread

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Knowledge to Action from Graham et al Lost in
Knowledge Translation Time for a Map?
Monitor knowledge use
Select, tailor implement interventions
Evaluate outcomes
Assess barriers to knowledge use
Sustain knowledge use
Adapt knowledge to local context
Identify Problem Identify, Review Select
knowledge
http//www.jcehp.com/vol26/2601graham2006.pdf
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Sustainability model and leaders guide (UK)

• Process Benefits beyond helping patients,
  credibility of evidence, adaptability ,
  monitoring patients
• Staff Training and involvement, behaviors,
  senior leaders, clinical leaders
• Organization Fit with goals and the culture,
  infrastructure
• Maher L, Gustafson D, Evans A. Sustainability
  Model and Guide. NHS Institute for Innovation
  and Improvement 2007 www.institute.nhs.uk/sustain
  ability

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What next?A pilot or scaled up?

• Professionalism in nursing
• Developing sustaining effective staffing
  workload practices
• Workplace health, safety well being of the
  nurse
• Preventing and managing violence in the workplace

• Developing and sustaining nursing leadership
• Collaborative practice
• Embracing cultural diversity in health care
  Developing cultural competence

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Nursing Best Practice Research Unit Bringing the
best knowledge to nursing and healthcare
Enhancing practice and improving health and
system outcomes.