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Organizational factors that support the implementation of a nursing Best Practice Guideline

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Abstract

The context of the healthcare setting may play a crucial role in influencing the implementation of best practice guidelines in nursing. Further study is required to understand these organizational factors. Two variables, organizational culture and leadership, are thought to influence the adoption of best practice guidelines. A discussion of organizational factors that influence best practice guideline adoption is presented. A small pilot study is provided as an example of methods for further research. A quantitative survey of nursing staff was conducted. Results from the pilot study reveal variability in best practice guideline implementation despite the presence of a culture of organizational learning and transformational leadership. There is beginning evidence in the literature that culture and leadership are key elements influencing guideline implementation. In this pilot work on two inpatient units where a nursing best practice guideline was implemented, a supportive organizational culture and key people leading change were present. Implications for further studies are offered. Nursing leaders interested in promoting the use of best practice guidelines must pay attention to the organizational context in which nursing care occurs. A supportive culture where learning is valued coupled with transformational leadership may be key factors in the implementation and the sustainability of best practice guidelines.

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... The capacities identified were consolidated into five thematic areas: 1) transparency of network policies, procedures, and organizational intent (Schnackenberg & Tomlinson, 2014), 2) knowledge sharing and collaboration (Nahapiet & Goshal, 1998), 3) creation of management policies and guidelines, 4) development and maintenance of intentional, long-term relationships with external stakeholders (Christoplos, 2010), and 5) clear expectations and guidelines for network officers and members (e.g. Marchionni & Ritchie, 2008). ...
... Underlying each of the above themes is the importance of organizational leadership, which has been found to be strongly related with organizational performance (Lamm et al., 2019). Effective organizational leaders have numerous responsibilities, including acquiring information necessary for the organization's purpose as well as clarifying and evaluating the information before disseminating it to organizational employees, members, and stakeholders (Lamm et al., 2019;Marchionni & Ritchie, 2008). Additionally, effective leaders must identify appropriate needs and requirements for their organization, plan activities and programming, and take the necessary risks to challenge existing processes and move from planning to action (Lamm et al., 2019). ...
... Effective leaders also gather and maintain resources and establish external monitoring and feedback mechanisms (Lamm et al., 2019). Each of the responsibilities aids a leader in controlling the procedures and outputs of an organization, and when used in conjunction, may contribute to increased organizational functioning and performance (Lamm et al., 2019;Marchionni & Ritchie, 2008). ...
... Of the nine studies included in the review, one was qualitative (Christenbery et al., 2016), one used mixed methodology (Wilson et al., 2015) and seven were quantitative studies Davies et al., 2011;Engström et al., 2015;Estabrooks et al., 2007Estabrooks et al., , 2008Hauck et al., 2013;Marchionni & Ritchie, 2008) ( Table 5). ...
... Emotional exhaustion (inversely proportional relationship with increased relational capital) leads to less evidence use (Estabrooks et al., 2008;Marchionni & Ritchie, 2008 certification positively influences behaviours, desire and ability to use EBP, but conversely, greater barriers to participating in EBP research or implementing evidence are reported . ...
... Evidence use is related to critical thinking and questioning (Davies et al., 2011). Questioning clinical practice leads to an increase in the time spent on the Internet, which influences the use of evidence (Marchionni & Ritchie, 2008 To identify and examine individual and contextual factors at the unit level that influence research utilisation among nurses working in acute care hospitals, and to identify any differences between adult and paediatric units. The specific purpose of the analyses reported in this paper was to conceptually model an ideal patient care unit, i.e., a patient care unit displaying features optimal for research use ...
Article
Aims and objectives: To review, synthesise and integrate primary research on the relationship between professional empowerment and evidence-based practice (EBP) in nursing. Background: Professional empowerment research exposes an association between empowerment and positive work behaviours and attitudes. Empowerment is associated with nurses' productivity, autonomy and resources. However, implementing evidence into practice is not easy due to barriers to EBP, namely organisational and cultural. Research demonstrating the relationship between professional empowerment and EBP will provide direction for future interventions aimed at the development of an effective healthcare sector. Design: A mixed-methods systematic review, according to the Joanna Briggs Institute approach, with results reported according to PRISMA. The associated checklist for systematic reviews was also used. Method: The electronic databases searched for relevant studies included: Medline, Cumulative Nursing and Allied Health Literature (CINAHL), JBI Database of Systematic Reviews and Implementation Reports, and The Cochrane Library; thesis and dissertation databases; and Web pages of reference organisations and Scientific Events programs. Quality assessments, data extraction and analysis were completed on all included studies, according JBI. Thematic analysis was used to synthesise the data. Results: We identified 477 studies. After removing duplicates and reviewing title and abstract following the inclusion and exclusion criteria, 26 papers were evaluated for eligibility. The review included 9 articles. The literature was categorised into three themes: (a) organisational and leadership characteristics, (b) individual characteristics, and (c) outcomes/consequences. Conclusion: This review highlights the importance of empowering environments in EBP. A relationship was evident between leadership, organisation, empowerment, individual characteristics and the use and implementation of evidence, resulting in tangible and measurable gains. However, more robust studies are needed. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018086414).
... I implementeringslitteraturen ses forskellige definitioner på, hvad organisationskultur anses at vaere. I flere studier karakteriseres kultur som: "how things are around here" (Dodek et al., 2010;Marchionni and Ritchie, 2008;Urquhart et al., 2012), og flere studier naevner kultur som betydningsfuld, men definerer ikke eksplicit begrebet (Borgert et al., 2015;Chaudoir et al., 2013;Dopson et al., 2003). Saerligt to perspektiver på organisationskultur går igen, og de defineres som: 1) et moderne perspektiv og 2) et symbolistisk perspektiv. ...
... Yderligere fremhaeves kultur som af central betydning for implementering af evidensbaseret viden og herunder for brugen af kliniske retningslinjer (Dodek et al., 2010;Marchionni and Ritchie, 2008). Rycroft-Malone (2008) rejser i sit studie en drøftelse af den herskende diskurs omhandlende brugen af evidensbaseret viden som et individuelt anliggende. ...
... 3.8.5.5. KULTUR SOM ANALYTISK GREB I implementeringslitteraturen fremtraeder organisationskultur ofte med afsaet i den amerikanske professor i organisationsudvikling Edgars Scheins teori (1983,1969), hvor kultur ses som et system af faelles meninger blandt sundhedsprofessionelle, som er baseret på faelles karakteristika og kollektive vaerdier (Marchionni and Ritchie, 2008;Scott-Findlay and Estabrooks, 2006;Scott et al., 2003). Hos Schein (1983) er antagelser, normer og vaerdier knyttet til artefakter, som er manifestationer af vaerdier, der er manifestationer af antagelser, som fungerer i et dialektisk forhold. ...
... Compared to the other wards, the somatic ward had the most stable group of professionals and a supportive team leader. This accords with previous research, which has shown that a supportive culture, a shared focus to change, and a motivational leader are key factors in the implementation and sustainability of guidelines [25][26][27]. A recent study found that use of pain management champions can increase self-efficacy and induce behavior change [28]. ...
... However, it is important to keep in mind that each nursing home has an individual culture, working methods, hierarchies, etc., therefore each nursing home will need to tailor implementation strategies to the culture and context of that particular nursing home. An essential prerequisite for successful implementation is a nursing home culture that stimulates working according to guidelines [25,30]. ...
Article
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The recognition and treatment of pain in nursing home residents presents challenges best addressed by a multidisciplinary approach. This approach is also recommended in the applicable Dutch guideline; however, translating guidelines into practical strategies is often difficult in nursing homes. Nevertheless, a better understanding of guideline implementation is key to improving the quality of care. Here we describe and qualitatively evaluate the implementation process of the multidisciplinary guideline ‘Recognition and treatment of chronic pain in vulnerable elderly’ in a Dutch nursing home. The researchers used interviews and document analyses to study the nursing home’s implementation of the guideline. The project team of the nursing home first filled out an implementation matrix to formulate goals based on preferred knowledge, attitudes, and behaviors for the defined target groups. Together with experts and organizations, pharmacotherapy audit meetings were organized, an expert pain team was appointed, a policy document and policy flowchart were prepared, and ‘anchor personnel’ were assigned to disseminate knowledge amongst professionals. Implementation was partially successful and resulted in a functioning pain team, a pain policy, the selection of preferred measurement instruments, and pain becoming a fixed topic during multidisciplinary meetings. Nevertheless, relatively few professionals were aware of the implementation process.
... The work environment and cultural factors drive clinician receptivity to and for translation of evidence, but are often ignored during the implementation of EBP interventions, resulting in avoidable lapses in safety and care (Keyworth, Epton, Goldthorpe, Calam, & Armitage, 2020;Kotzer & Arellana, 2008;Marchionni & Ritchie, 2008). Across healthcare, there is often a disregard for implementation science and instead is reliant on practical lessons learned, scattered communication, technologically diverse systems, low fidelity documentation platforms, leadership and culture, and system processes (Dror, 2011;Krzyzanowska, Kaplan, & Sullivan, 2011;Thier et al., 2020). ...
... Importantly, employee attitudes, values and beliefs are not held in a vacuum and contribute to the organisational climate and workplace culture (Atkins & Michie, 2015;Wallin, Ewald, Wikblad, Scott-Findlay, & Arnetz, 2006). Therefore, to support knowledge translation and implement EBP interventions, work environments must be strategically managed so as to maximise clinician engagement, minimise unwarranted practice variation and sustain change, and thus positively impact on patient safety, quality care and employee satisfaction (Braithwaite et al., 2017;Grant & Coyer, 2020;Kaplan et al., 2010;Kourouche et al., 2019;Marchionni & Ritchie, 2008;Thier et al., 2020). A systematic approach is needed to strengthen or mitigate environmental factors to better sustain policy initiatives, knowledge transfer and clinician behaviour change. ...
Article
Purpose Survey tools, such as the Alberta Context Tool, reliably measure context but researchers have no process to map context to clinician behaviour and develop strategies to support practice change. Therefore, we aimed to map the Alberta Context Tool to the Theoretical Domains Framework and the Behaviour Change Wheel. Method The multi-centre study used the Alberta Context Tool to collect data from a convenience sample of nurses working in two emergency departments. These findings were categorised as barriers and enablers, and then mapped to the Theoretical Domains Framework to examine for behavioural domains. Using the Behaviour Change Wheel functions, strategies were developed to target clinician behaviour change. Results Survey response rate was 42% (n = 68). Nurses perceived a positive work environment in the dimensions of Social Capital (median 4.00, IQR 0.33), Culture (median 3.83, IQR 1.16) and Leadership (median 3.60, IQR 1.1). Low scoring dimensions included Formal Interactions (median 2.75, IQR 1.00); Time (median 2.60, IQR 1.00) Staffing (median 3.0, IQR 2.00) and Space (median 3.0, IQR 2.00). Enablers (n = 77) and barriers (n = 25) were identified in both sites. The Theoretical Domains Framework was mapped to Alberta Context Tool barriers and enablers. The behaviour change strengths included: social and professional role; beliefs about capability; goals; and emotions. Using the Behaviour Change Wheel functions, 67 strategies were developed to address barriers and enablers. Conclusions The Alberta Context Tool successfully measured two emergency environments identifying barriers and enablers. This approach enabled environment dimensions to be targeted with practical solutions to support evidence-based practice implementation.
... Organizational culture was included as an organizational contextual feature in 22 of 36 (61%) studies. Organizational openness to trialing new innovations and a learning culture were highly associated with implementation success [30][31][32][33][34][35]. Conversely, an absence of a learning culture can act as a major hindrance to Note: MMAT scores vary from 25% (one criterion met) to 100% (all criteria met). ...
... On the contrary, lack of support from colleagues was a barrier to constructing a change culture [53]. Strong leadership, coupled with a culture of learning or openness to innovation, was important to successful implementation [31,32,34,35,37,40,41,43,52]. ...
Article
Full-text available
Background: Organizational contextual features have been recognized as important determinants for implementing evidence-based practices across healthcare settings for over a decade. However, implementation scientists have not reached consensus on which features are most important for implementing evidence-based practices. The aims of this review were to identify the most commonly reported organizational contextual features that influence the implementation of evidence-based practices across healthcare settings, and to describe how these features affect implementation. Methods: An integrative review was undertaken following literature searches in CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane databases from January 2005 to June 2017. English language, peer-reviewed empirical studies exploring organizational context in at least one implementation initiative within a healthcare setting were included. Quality appraisal of the included studies was performed using the Mixed Methods Appraisal Tool. Inductive content analysis informed data extraction and reduction. Results: The search generated 5152 citations. After removing duplicates and applying eligibility criteria, 36 journal articles were included. The majority (n = 20) of the study designs were qualitative, 11 were quantitative, and 5 used a mixed methods approach. Six main organizational contextual features (organizational culture; leadership; networks and communication; resources; evaluation, monitoring and feedback; and champions) were most commonly reported to influence implementation outcomes in the selected studies across a wide range of healthcare settings. Conclusions: We identified six organizational contextual features that appear to be interrelated and work synergistically to influence the implementation of evidence-based practices within an organization. Organizational contextual features did not influence implementation efforts independently from other features. Rather, features were interrelated and often influenced each other in complex, dynamic ways to effect change. These features corresponded to the constructs in the Consolidated Framework for Implementation Research (CFIR), which supports the use of CFIR as a guiding framework for studies that explore the relationship between organizational context and implementation. Organizational culture was most commonly reported to affect implementation. Leadership exerted influence on the five other features, indicating it may be a moderator or mediator that enhances or impedes the implementation of evidence-based practices. Future research should focus on how organizational features interact to influence implementation effectiveness.
... Management has a significant influence on the success of implementation, due to the managers' accountability, commitment and involvement (Birken et al., 2013, Bishop et al., 2013, Bostrom et al., 2013, Lukas et al., 2007, Marchionni and Ritchie, 2008, Shimada et al., 2013. A recent review concluded that managers' time spent, activities and engagement can influence the quality of clinical outcomes, processes and performance (Parand et al., 2014). ...
... This is consistent with other studies that found that management was not always necessary, if the planning and conducting of the implementation were taken care of by other means (Damschroder et al., , Øvretveit et al., 2012. However, management engagement is pointed out as important for successful implementation in several other studies (Birken et al., 2013, Bostrom et al., 2013, Kirchner et al., 2012, Marchionni and Ritchie, 2008, Ploeg et al., 2007, Sandstrom et al., 2011, Øvretveit, 2005, and must not be underestimated on the basis of this dissertation. ...
... This was informed by the fact that they strengthen the SMEs' agility to build competitive advantage amidst the contemporary digital world. Based on huge scholarship (Ling & Yttri, 2002;Marchionni & Ritchie, 2007;Rogers, 2003;Samson & Hornby, 1988) on what members want from a group, we conceptualize subjective norms in terms of the functional and/or psychological influences of other peoples' opinions, including those of superior and peer groups (Taylor & Todd, 1995;Venkatesh & Davis, 2000). ...
... Awa et al. (2011) observe that a cohort made up of executives with integrated cost-cutting behavior, optimization backgrounds, database management and related areas influences adoption of new technologies. Social participation, group cohesiveness, and social mobility presuppose moving from functional to psychological motives and of course the adoption of untried technologies (Choudrie & Dwivedi, 2005;Marchionni & Ritchie, 2007;Rogers, 2003). Lu et al. (2003) found subjective norm to be an important determinant of intention and practically epitomizes the perception of others about adoption behavior(s). ...
Article
Full-text available
This paper provides further insight into IS adoption by investigating how 12 factors within the technology-organization-environment (T-O-E) framework explain SMEs’ adoption of enterprise resource planning (ERP) software. Survey data were collected from executives of SMEs drawn from six fast service enterprises with strong operations in Port Harcourt, Nigeria. Purposive and snow ball sampling was adopted and the proposed framework was tested using the logistic regression; specifically, the likelihood ratios, Hosmer and Lemeshow’s goodness of fit, and Nagelkerke R2 were used. The hypothesized relationships were supported at either p < 0.01 or 0.05 with each factor differing in its statistical coefficient and some bearing negative values; suggesting that some factors do not pose much threat to adopters but to non-adopters. Thus, adoption of ERP by SMEs is well-explained by T-O-E framework though it is more driven by technological factors than by organizational and environmental factors. Implicit is t...
... 14,15 Lack of support from leaders is described as a major barrier to research utilization, 16,17 and implementation effectiveness is significantly related to management support. 18 A recent review has provided moderate-level evidence that clinical leaders have a positive impact on successful information technology adoption in healthcare organizations. 19 However, the perspective of managers, who are most often in charge of the practical implementation, has not been studied adequately. ...
... 16 In addition, staff turnover was perceived as a barrier, while the large size of the units was seen as a barrier to information flow and the flat management structure among physicians as a barrier to managing them. Important management tasks are to create supportive organizational culture 18 where implementation can take place and provide necessary resources, such as time, training, equipment, and guidance. Nurse management behavior has been found to influence front-line nurses' motivation. ...
Article
The role of nurse and physician managers is considered crucial for implementing eHealth interventions in clinical practice, but few studies have explored this. The aim of the current study was to examine the perceptions of nurse and physician managers regarding facilitators, barriers, management role, responsibility, and action taken in the implementation of an eHealth intervention called Choice into clinical practice. Individual qualitative interviews were conducted with six nurses and three physicians in management positions at five hospital units. The findings revealed that nurse managers reported conscientiously supporting the implementation, but workloads prevented them from participating in the process as closely as they wanted. Physician managers reported less contribution. The implementation process was influenced by facilitating factors such as perceptions of benefits from Choice and use of implementation strategies, along with barriers such as physician resistance, contextual factors and difficulties for front-line providers in learning a new way of communicating with the patients. The findings suggest that role descriptions for both nurse and physician managers should include implementation knowledge and implementation skills. Managers could benefit from an implementation toolkit. Implementation management should be included in management education for healthcare managers to prepare them for the constant need for implementation and improvement in clinical practice.
... People may to the group norms, even in opposition to their feelings. Innovative individuals have a high level of social participation and social mobility to obtain positive attitudes toward adopting technology [41]. The tenth and final hypothesis is as follows. ...
Article
Full-text available
Background: With the massive e-commerce transactions and document transfers, reliable system protection is needed. A digital signature is a tool that consists of encryption and decryption algorithms in a secret key to prevent data theft and online fraud. Objective: This research proposes an integrated technology-organization-environment (TOE) and the unified theory of acceptance and use of technology (UTAUT) to determine the factors affecting consumer intention to adopt the digital signature system. This research uses finance and information system departments’ perspectives in various industries. Methods: The analytical method is the Structural Equation Modeling (SEM) approach using the Smart Partial Least Square statistical version 3.0 software to examine the hypothesized connections between latent variables. Results: The results show that support from top management, size of the enterprise, and social influence have significant and positive effects on digital signature adoption. Meanwhile, user involvement and perceived simplicity have a negative effect on the adoption of a digital signature system in finance and information system departments. Conclusion: The current research suggests that executive levels in the finance and information system departments encourage the adoption of digital signature tools in doing daily tasks to increase efficiency. Keywords: Digital signature, consumer intention, finance and information system, structural equation modeling, TOE and UTAUT
... Pettigrew et al., presents multiple contextual factors contribute to a strategic change [58]. Typically, a supportive organizational culture and individuals leading the change are locally instrumental for the integration process [59]. In line with this, our study showed that over the certification implementation process at the local level, the 'referent of action' played an essential role and it appeared they adopted the champion role. ...
Article
Full-text available
Background The implementation of certification procedures across healthcare systems is an essential component of the management process. Several promising approaches were developed toward a successful implementation of such policies; however, a precise adaptation and implementation to each local context was essential. Local activities must be considered in order to generate more pragmatic recommendations for managers. In this study, we built a framework for the implementation of certification procedures at nurse activity level. This was developed using two objectives: the identification of key implementation process components, and the integration of these components into a framework which considered the local socio-material context of nurses’ work. Methods We used a two-step mixed approach. The first was inductive and consisted of a qualitative case study conducted between April and December 2019. Here, we analyzed the implementation of certification procedures in a French teaching hospital. Data were collected using semi-structured interviews and observations. In the second approach, emerging data were deductively analyzed using the Quality Implementation Tool (QIT) and Translational Mobilization Theory (TMT). Analyses were combined to construct an implementation framework. Results Sixteen interviews were conducted with participants from different organizational levels, managers, mid-managers, and nurses. Additionally, 83 observational hours were carried out in two different wards. Our results showed that, (1) All retrieved elements during the process were successfully captured by the QIT components, only one component was not applicable. (2) We identified elements related to the local activity context, with the different interrelationships between actors, actions, and contexts using the TMT. (3) Our analyses were integrated and translated into a framework that presents the implementation of certification procedures in healthcare facilities, with a specific interest to the nurse/mid-manager level. By initially using QIT, the framework components took on a transversal aspect which were then adapted by TMT to the local work context. Conclusions We successfully generated a framework that supports the implementation of certification procedures at the activity level. Our approach identified a broader vision of the interactions between proximity managers, teams, and contexts during change mobilization, which were not encompassed by transversal framework only, such as QIT. In the future, more empirical studies are needed to test this framework.
... [39][40][41] Application of best evidence is linked to hospital infrastructure and resources, physician education and training, and research affiliation, but these relations have not been well studied for these fractures. 32,[39][40][41][42][43][44][45][46][47][48][49][50][51][52][53] The aim of this study was to examine how low-risk pediatric distal radius fractures are being managed in Ontario, and to determine whether different hospital and physician types are making different choices regarding care. ...
Article
Full-text available
Background: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently. Methods: We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management. Results: We analyzed 70 801 fractures. A total of 20.8% (n = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up. Interpretation: While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.
... As identi ed in the content, context and process model of Pettigrew et al. (1992), multiple contextual factors contribute to a strategic change (48). Typically, a supportive organisational culture and key people leading the change, are instrumental at the local level of integration processes (49). In terms of change leaders, the action referent or champion of action are key actors in implementing certi cation programs. ...
Preprint
Full-text available
Background The implementation of certification procedures across healthcare systems is an essential component of the management process. In the past, several promising approaches have been developed towards the successful implementation of such policies, however, precise adaptation and implementation at the local context is essential. Thus, local activities must be considered to generate more pragmatic recommendations for managers. In this pilot study, we built an implementation framework for the inception of certification in healthcare facilities, particularly at nurse level activities. Our hypothesis comprised two objectives: the identification of key implementation process components, and the precise definition of these elements within local social activities. Methods This study used a two-step abductive approach. The first was inductive, and consisted of a qualitative case study, where we analysed the implementation of certification procedures in a French teaching hospital. The study was conducted between April and December 2019. Data were collected using semi-structured interviews, and observations by shadowing. In the second step, the emerging data were analysed using two approaches: The Quality Implementation Tool (QIT) and Translational Mobilisation Theory (TMT). Results Sixteen interviews were conducted with managers and nurses. We also accumulated 83 observational hours from two different wards. Our results showed that, first, all the retrieved elements over the implementation of certification procedures were captured by the QIT components and only one component was no applicable for the studied case. Second, we identified the elements in the local context of activity, with the different interrelationships between actors, actions and contexts, through the TMT. Third, our analyses were integrated and translated into a framework that described the implementation of certification procedures in healthcare facilities and with interest to the implementation at nurse/mid-managers level. In adopting QIT, the framework components took a transversal aspect then adapted to the local context of work through the TMT. Conclusions In this study, we generated an implementation framework that underpinned a certification procedures implementation. Our approach revealed broad interactions between proximity managers, teams and contexts during change mobilisation, not captured by transversal framework only as QIT. Going forward, this framework must be tested in future empirical studies.
... As identi ed in the content, context and process model of Pettigrew et al. (1992), multiple contextual factors contribute to a strategic change (48). Typically, a supportive organisational culture and key people leading the change, are instrumental at the local level of integration processes (49). In terms of change leaders, the action referent or champion of action are key actors in implementing certi cation programs. ...
Preprint
Full-text available
Background: The implementation of certification procedures across healthcare systems is an essential component of the management process. In the past, several promising approaches have been developed towards the successful implementation of such policies, however, precise adaptation and implementation at the local context is essential. Thus, local activities must be considered to generate more pragmatic recommendations for managers. In this pilot study, we built an implementation framework for the inception of certification in healthcare facilities, particularly at nurse level activities. Our hypothesis comprised two objectives: the identification of key implementation process components, and the precise definition of these elements within local social activities. Methods: This study used a two-step abductive approach. The first was inductive, and consisted of a qualitative case study, where we analysed the implementation of certification procedures in a French teaching hospital. The study was conducted between April and December 2019. Data were collected using semi-structured interviews, and observations by shadowing. In the second step, the emerging data were analysed using two approaches: The Quality Implementation Tool (QIT) and Translational Mobilisation Theory (TMT). Results: Sixteen interviews were conducted with managers and nurses. We also accumulated 83 observational hours from two different wards. Our results showed that, first, all the retrieved elements over the implementation of certification procedures were captured by the QIT components and only one component was no applicable for the studied case. Second, we identified the elements in the local context of activity, with the different interrelationships between actors, actions and contexts, through the TMT. Third, our analyses were integrated and translated into a framework that described the implementation of certification procedures in healthcare facilities and with interest to the implementation at nurse/mid-managers level. In adopting QIT, the framework components took a transversal aspect then adapted to the local context of work through the TMT. Conclusions: In this study, we generated an implementation framework that underpinned a certification procedures implementation. Our approach revealed broad interactions between proximity managers, teams and contexts during change mobilisation, not captured by transversal framework only as QIT. Going forward, this framework must be tested in future empirical studies.
... Quality healthcare is dependent on effective organizational factors, including interdisciplinary teamwork, a supportive culture, and good leadership (Barr & Dowding, 2019;Marchionni & Ritchie, 2008;McAlearney, 2008). As the healthcare system has evolved to align business and medical imperatives (Murdock & Brammer, 2011), the tendency to separate leadership and administration from clinical care has given way to leadership development becoming a core approach in physician, nurse, and allied health training (Ackerman et al., 2019). ...
Article
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Background: Healthcare requires effective leadership to improve patient outcomes, manage change, and achieve organizational goals. Purpose: The purpose of this study was to evaluate interventions aimed at improving leadership behavior in health professionals. Methods: A systematic literature review of key databases (PubMed, CINAHL, Embase, and Scopus) was performed in September 2018. Data were extracted and synthesized. Results: Thirty-three articles from 31 studies met the inclusion criteria. Self-reported leadership behavior showed a significant postprogram improvement. Objective observations were more likely to show improved leadership behavior than subjective observations. Face-to-face delivery of leadership development was more effective than online delivery. Interventions incorporating the elements of personal development planning, self-directed learning, workplace-based learning, and reflection were more likely to develop leadership behavior. Conclusions/implications for practice: Leadership interventions had a beneficial effect on the leadership behaviors of participants based on both subjective and objective changes in behavior. In addition to focusing on individual skill development, interventions that aim to develop leadership should consider the organizational, social, cultural, and political contexts in which behavioral change is expected. Workplace-based learning should be included in program development.
... We already know that measures of nurses' knowledge (e.g. pen and paper or computer tests) do not correlate perfectly with nurses' performance, as contextual factors play a major role in translating knowledge into action (Marchionni, & Ritchie, 2008). But if nurses' lack the knowledge of best practices, they are less likely to perform them even if the context is receptive (Funk, Champagne, Wiese, & Tornquist, 1991). ...
Article
Background Vascular access devices(VAD), centrally CVAD) or peripherally(PIV) located, are common in the nursing profession. A high proportion of admitted patients require a VAD to enable administration of intravenous treatments or diagnostic modalities. As the primary caregivers for these patients, nurses are responsible for ongoing care and maintenance of these devices. Objective This scoping review examines the current state of practicing nurses knowledge around routine care and maintenance of adult VADs. Methods In the fall of 2018, the following databases were searched: Medline‐Ovid 1946 to current, Embase‐Ovid 1947 to current, Ebsco CINAHL Plus with full text, and ProQuest Nursing & Allied Health database and articles were selected according to the PRISMA‐ScR checklist. Inclusion criteria: original research published in peer‐reviewed journals; in English or French; focused on practising nurses’ knowledge about the routine care and maintenance of adult VADs. Results Of the 4099 abstracts identified, 36 full‐text articles were included. Study characteristics are reported in addition to themes found in the literature: the relationship between demographic data and CVAD/PIV knowledge, the state of nurses’ CVAD/PIV knowledge, and nurses’ CVAD/PIV knowledge scores. Overall, significant gaps in nurses’ knowledge on the care and maintenance of VADs are noted. Conclusion The variability in nurses’ knowledge around both CVAD and PIV led the authors to conclude that there is room for improvement in the educational preparation of nurses and a need for workplace training. Relevance to Clinical Practice This scoping review intends to highlight the knowledge gap of nurses with regards to best practices for VAD routine care and maintenance and demonstrate the need for education, both in educational and healthcare institutions, to ensure high quality care and improved patient outcomes related to VADs.
... Evidence shows that managerial support is important to improve use of clinical practice guidelines. (225,243,244) This alerts to the need for a focus on support and supervision visits by healthcare services managers at the regional level and at the facility level. Lack of sufficient health workforce was identified as a main barrier for guidelines use. ...
... Building the innovation into the existing workflow improves the effectiveness of the intervention. Providing ongoing feedback to the team can also improve the effectiveness (Marchionni, & Ritchie, 2008). A registered nurse champion provided ongoing feedback to nursing peers while an advance practice registered nurse provided feedback to the provider team on a weekly basis. ...
Article
Introduction: Depression is a common comorbidity of epilepsy that is under-recognized and under-diagnosed. To improve recognition, a brief screening tool, the Neurological Disorders Depression Inventory-Epilepsy-Youth (NDDI-E-Y) was implemented in a level-IV pediatric epilepsy clinic. Method: This quality improvement is a pre-post design measuring the impact of standardized depression screening, via the NDDI-E-Y tool, in youth 12-17 years with epilepsy. Those with positive screens, scores > 32, received social work evaluation and mental health resources. Education was provided to all patients in standard discharge paperwork. Results: Of N = 176 patients evaluated, n = 112 met criteria to complete the NDDI-E-Y. Fifteen percent (n = 17) of patients had positive screens, suggesting that they are at risk for depression. Discussion: Depression is a challenge when managing patients with epilepsy and may impact their quality of life and seizure control. Routine depression screening is recommended and feasible in the outpatient setting with a standardized work process.
... Specifically, what leaders do to facilitate and support EBP has not been considered in Chinese nursing research (Cheng, Broome, Feng, & Hu, 2017a, 2017bCheng et al., 2017) (Aarons & Aarons, 2006;Aarons, Ehrhart, Moullin, Torres, & Green, 2017;Brimhall et al., 2015;Marchionni & Ritchie, 2008;Masood & Afsar, 2017;Paparone, 2015;Powell et al., 2017). Leadership in general refers to a process of influencing others to accomplish shared objectives (Yukl, 2006); however, instruments measuring leadership in general do not capture the particular leadership strategies and behaviours that are critical to implementing EBP (Aarons, Ehrhart, & Farahnak, 2014). ...
Article
Aim To translate the Implementation Leadership Scale (ILS) into Chinese and evaluate how Chinese nursing staff and leaders understood and responded to the Chinese ILS. Background Leadership is a critical factor for implementing evidence‐based practice. The ILS is a valid and reliable instrument to understand leadership for evidence‐based practice; however, this scale or the other similar instrument does not exist in Chinese. Methods We followed the translation and cross‐cultural validation guideline developed by Sousa and Rojjanasrirat. Translation included two forward and blind backward translations, and their comparisons. Two rounds of cognitive interview were used to evaluate the linguistic validity. Results The translation process took 12 months. In the forward and backward translations, 24 translation issues were identified, of which semantic equivalence issues were most frequent. Ten nurses participated in each round of cognitive interviews and 33 linguistic issues were found. The final Chinese ILS had seven significant adaptations to the original instrument. Conclusion This study provided a deep understanding of using the ILS in the local context and laid the foundation for future psychometric statistical testing. Implications for nursing management ILS could support organizational leadership development programs and strategies to facilitate and support EBP implementation and sustainment. This article is protected by copyright. All rights reserved.
... Evidence shows that managerial support is important to improve use of clinical practice guidelines. [38][39][40] This alerts to the need for a focus on support and supervision visits by healthcare services managers at the regional level and at the facility level. Lack of sufficient health workforce was identified as a main barrier for guidelines use. ...
Article
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Objective To explore healthcare providers’ views on barriers to and facilitators of use of the national family planning (FP) guideline for FP services in Amhara Region, Ethiopia. Design Qualitative study. Setting Nine health facilities including two hospitals, five health centres and two health posts in Amhara Region, Northwest Ethiopia. Participants Twenty-one healthcare providers working in the provision of FP services in Amhara Region. Primary and secondary outcome measures Semistructured interviews were conducted to understand healthcare providers’ views on barriers to and facilitators of the FP guideline use in the selected FP services. Results While the healthcare providers’ views point to a few facilitators that promote use of the guideline, more barriers were identified. The barriers included: lack of knowledge about the guideline’s existence, purpose and quality, healthcare providers’ personal religious beliefs, reliance on prior knowledge and tradition rather than protocols and guidelines, lack of availability or insufficient access to the guideline and inadequate training on how to use the guideline. Facilitators for the guideline use were ready access to the guideline, convenience and ease of implementation and incentives. Conclusions While development of the guideline is an important initiative by the Ethiopian government for improving quality of care in FP services, continued use of this resource by all healthcare providers requires planning to promote facilitating factors and address barriers to use of the FP guideline. Training that includes a discussion about healthcare providers’ beliefs and traditional practices as well as other factors that reduce guideline use and increasing the sufficient number of guideline copies available at the local level, as well as translation of the guideline into local language are important to support provision of quality care in FP services.
... Rogers (2003) holds the view that adopters of new technological innovations tend to be consumers of a younger age bracket, good educational level and healthy income. is view is supported by other authors such as Choudrie and Dqivedi (2005), Madden and Savage (2000), Mason and Hacker (2003), as well as Marchionni and Ritchie (2007). ...
Conference Paper
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Technological advancements are of such a nature that it cannot be guaranteed that adoption will occur on the part of the consumer. Acceptance and adoption of new technologies on the part of the consumer is a product of successful diffusion and consumer sentiment. Students incur the same banking charges as any other consumer when using mobile banking, irrespective of income and other variables. As a result, it is purported that mobile banking adoption is low amongst a student population. is paper therefore aims to determine the prevalence of mobile banking amongst university students in the Gauteng region of South Africa. e study is quantitative in nature and was administered to university students in the Gauteng area. Data was analysed by means of descriptive statistics, using SPSS. Findings revealed that only 65% of graduate students do make use of mobile banking, opposed to 35% that do not make use of the service. Reasons for the slow adoption of mobile banking included concerns around security and privacy when using mobile banking together with cost and reliability of the service. Findings are of value to the banking sector which can develop and adapt future strategies to successfully penetrate the student market, thereby unlocking cost savings and increased market penetration.
... [1] Simply relying on nurses' knowledge and skills may not be deliver EBP, except if there is effective organisational drive for implementation processes. [12][13][14] While several authors report impact of healthcare organisation on EBP in nursing practice, [9,[15][16][17] there exist confusion about the role of nurse managers, particularly in the Nigerian context. ...
Article
Background and objective: Evidence-based practice (EBP) is widely acknowledged as an essential aspect of healthcare delivery. Nurse managers are expected to contribute to the development of organisational cultures promoting EBP. However, there are indications that nurse managers are not necessarily empowered to drive implementation due to hierarchical constraints. This study explores how nurse manager’s position in the hospital hierarchy influences EBP implementation in nursing, in the Nigerian acute care settings.Methods: A qualitative case study methodology is utilised to gather data from two large acute care settings in Nigeria. Drawing on semi-structured interview, twenty-one ward managers and two nurse managers were interviewed. Data were transcribed and inductively analysed to generate four overarching themes.Results: Nurse managers were hugely constrained by lack of autonomy to mobilise resources for EBP related activities. The hierarchical structure of the settings promoted top-down decision-making processes which in turn, limited nurse manager’s visibility in the boardroom. Consequently, nurse managers were excluded from key strategic planning within the organisation and could not drive EBP implementation.Conclusions: Findings highlight need for nurse managers to have greater visibility and managerial influence to enable them create opportunities for implementation of EBP in nursing. Implications for nursing management: Administratively, there is need for nurses to have greater involvement in management. Adequate authority and leadership visibility as well as managerial influence would enable nurse managers create opportunities for successful implementation.
... 9 , 10 However, as literary and documentary evidence has shown, it is difficult to evaluate the effectiveness of lifelong learning on improvements in best practices, because lifelong learning includes knowledge and skills acquired from lectures, as well as from other organizational variables, such as length of time at the hospital, group discussions, being well equipped, and having adequate staff. [11][12][13][14] Furthermore, knowledge and skills can become obsolete if they are not updated. [15][16][17] Many studies have shown that knowledge decreases considerably 3 months after a formative experience and declines drastically after 6 months or 1 year. ...
Article
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Since 2009, the Department of Continuing Education at the Orthopedic and Trauma Center Hospital in Turin, Italy, has provided a training course for nurses in the management of central vascular access devices (CVADs). The course focuses on dressing and flushing procedures, as well as compliance with other CVAD guidelines. An observational study was conducted among nurses to determine the level of best practices in areas with a high prevalence of nurses trained in the management of CVADs. A correlation was observed between best practices and having attended the course, but other variables also influenced best practices.
... Mentoring, a knowledge translation intervention, has the potential to influence sustained guideline implementation (Abdullah et al., 2014;Maher, Gustafson, & Evans, 2007;Marchionni & Ritchie, 2007). Mentoring is defined by three critical characteristics: (a) mentors are more experienced than mentees in guideline implementation; (b) mentors provide individualized support based on mentees' learning needs related to the implementation; and (c) mentoring occurs in the context of a beneficial and committed interpersonal relationship (Abdullah et al., 2014). ...
Article
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The purpose of this study was to assess the impact of a mentored guideline implementation (Registered Nurses’ Association of Ontario Prevention of Falls and Falls Injuries in the Older Adult Best Practice Guideline) focused on enhancing sustainability in reducing fall rates and number of serious falls and the experience of staff in three acute care hospitals. The National Health Service (NHS) Sustainability Model was used to guide the study. Interviews and focus groups were held with 82 point-of-care professional staff, support staff, volunteers, project leaders, clinical leaders, and senior leaders. Study results supported the importance of the factors in the NHS model for sustainability of the guideline in these practice settings. There were no statistically significant decreases in the overall fall rate and number of serious falls. The results supported strategies of participating hospitals to become senior friendly organizations and provided opportunities to enhance staff collaboration with patients and families.
... This model was selected as it has been developed through previous research in the NHS and has been used to analyse and learn retrospectively from change programmes in organisations (Pettigrew et al., 1992;Pettigrew et al., 1989). The model has subsequently been used, in the UK and internationally, to guide investigation of the implementation of a range of change initiatives in both private and public health care (Marchionni and Ritchie, 2008;Stetler et al., 2007;Ross et al., 2004;Newton et al., 2003;Peppard and Preece, 1995). Pettigrew et al., 1992, p276 ...
... Further, sociologists believe that often members of a group exhibit cohesiveness even against their own feelings in order to show commitment to the group norms. Innovative individuals have positive attitudes, ability to communicate with others and a high level of social participation and social mobility (Rogers, 2003;Marchionni and Ritchie, 2007;Choudrie and Dwivedi, 2005). Lu et al. (2003) found subjective norm to be an important determinant of intention and practically epitomizes the perception of others about adoption behavior(s). ...
Article
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Purpose The purpose of this paper is to attempts to provide further insight into IS adoption by investigating how 12 factors within the technology-organization-environment framework explain small- and medium-sized enterprises’ (SMEs) adoption of enterprise resource planning (ERP) software. Design/methodology/approach The approach for data collection was questionnaire survey involving executives of SMEs drawn from six fast service enterprises with strong operations in Port Harcourt. The mode of sampling was purposive and snow ball and analysis involves logistic regression test; the likelihood ratios, Hosmer and Lemeshow’s goodness of fit, and Nagelkerke’s R² provided the necessary lenses. Findings The 12 hypothesized relationships were supported with each factor differing in its statistical coefficient and some bearing negative values. ICT infrastructures, technical know-how, perceived compatibility, perceived values, security, and firm’s size were found statistically significant adoption determinants. Although, scope of business operations, trading partners’ readiness, demographic composition, subjective norms, external supports, and competitive pressures were equally critical but their negative coefficients suggest they pose less of an obstacle to adopters than to non-adopters. Thus, adoption of ERP by SMEs is more driven by technological factors than by organizational and environmental factors. Research limitations/implications The study is limited by its scope of data collection and phases, therefore extended data are needed to apply the findings to other sectors/industries and to factor in the implementation and post-adoption phases in order to forge a more integrated and holistic adoption framework. Practical implications The model may be used by IS vendors to make investment decisions, to meet customers’ needs, and to craft informed marketing programs that would appeal to actual and potential adopters and cause them to progress in the customer loyalty ladder. Originality/value The paper contributes to the growing research on IS innovations’ adoption by using factors within the T-O-E framework to explains SMEs’ adoption of ERP.
... A great deal of research has highlighted the importance of transformational leadership for organizational performance (Howell and Avolio, 1993;Yammarino et al., 1993;Yukl, 2006). For example, research has found a relationship between transformational leadership and organizational commitment (Avolio et al., 2004;Searle-Leach, 2005;Bycio et al., 1995); job satisfaction (Podsakoff et al., 1996;Walumbwa et al., 2005) and communicating planned organizational change (Battilana et al., 2010) influence attitudes towards EBP (Moser et al., 2004;Aarons, 2006;Sandström et al., 2011) and commitment to change (Hill et al., 2012;Damanpour and Schneider, 2006;Jung et al., 2003;Gumusluoglu and Ilsev, 2009), research utilization (Kajermo et al., 2008) and implementation of guidelines (Marchionni and Ritchie, 2008). Research has also found that culture and climate for improvement are better with leadership support (Ginsburg et al., 2005;Hallencruetz, 2012). ...
Thesis
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Research developments have led to increased opportunities for the use of improved diagnostic and treatment methods in physiotherapy and other areas of health care. The emergence of the evidence-based practice (EBP) movement has led to higher expectations for a more research-informed health care practice that integrates the best available research evidence with clinical experience and patient priorities and values. Physiotherapy research has grown exponentially, contributing to an increased interest in achieving a more evidence-based physiotherapy practice. However, implementation research has identified many individual and contextual barriers to research use. Strategies to achieve a more EBP tend to narrowly target individual practitioners to influence their knowledge, skills and attitudes concerning research use. However, there is an emerging recognition that contextual conditions such as leadership and culture are critical to successfully implementing EBP. Against this background, the overall aim of this thesis was to explore conditions at different levels, from the individual level to the organizational level and beyond, for the use of research and implementation of an evidence-based physiotherapy practice. The thesis consists of four interrelated papers that address various aspects of the aim. Individual and focus group interviews were conducted with physiotherapists and managers within physiotherapy in various county councils in Sweden between 2011 and 2014. Data were analysed using qualitative content analysis, direct content analysis and hermeneutics. It was found that many different types of motivation underlie physiotherapists’ use of research in their clinical practice, from amotivation (i.e. a lack of intention to engage in research use) to intrinsic motivation (research use is perceived as interesting and satisfying in itself). Most physiotherapists tend to view research use in favourable terms. Physiotherapists’ participation in a research project can yield many individual learning experiences that might contribute to a more research-informed physiotherapy practice. However, organizational learning was more limited. Numerous conditions at different levels (individual, workplace and extra-organizational levels) provide support for physiotherapists’ use of research in their clinical practice. However, physiotherapy leaders appear to contribute to a modest degree to establishing a culture that is conducive to implementing EBP in physiotherapy practice. Instead, EBP issues largely seem to depend on committed individual physiotherapists who keep to up to date with research in physiotherapy and inform colleagues about the latest research findings.
... As the age of the farmer increases the physical strength declines thereby reducing the farmer's ability to use new technology also older farmers may be more conservative, less flexible and more skeptical about the benefits of Maendeleo stove. Akudugu, Guo and Dadzie, (2012) and Marchionni and Ritchie (2007) concluded that the adopter of a new technology is typically younger as younger people are more likely to adopt improved technological practices as they are risk takers and that since they are still accumulating economic resources they would opt to adopt more technologies. ...
Article
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Fuel wood provides the main source of energy for cooking and space heating for over 80 percent of households living in Kenya. The heavy reliance on the biomass energy has exerted an imbalance in demand and supply consequently resulting in adverse environmental effects in Kenya. As part of innovation efforts, several energy-conserving technologies have been developed. A unique cook stove named Maendeleo was developed and promoted in Kenya and more so, West Pokot County, northern of Kenya, with the goal of reducing the quantity of wood households use for energy, and ultimately reduce pressure on local forests. However, despite the demonstrated technological multiple benefits and the institutional promotional efforts of the Maendeleo stove technology; the adoption level of this innovation has remained low. An important question investigated in this study was what makes potential users not utilize such valuable innovations? Socio-cultural, economic, political and institutional barriers are considered to contribute to low uptake of such innovations. This study therefore, sought to assess socio- economic factors influencing the adoption of the Maendeleo stove in the rural setting of Kapenguria Division. A survey research methodology with ex-post facto design was employed. The results showed that the age of the respondents had the highest influence on the non-adoption of the Maendeleo stove. Given the relatively low adoption level of Maendeleo stove in the county, and the projected increase in the number of people relying on biomass, this study recommends that the government and development partners put in place a programme for the promotion and dissemination of Maendeleo stove. There should be further investigation into the adoption behaviour of the respondents on the reasons for non-adoption and discontinuance of use of the Maendeleo stove.
... Healthcare organisations need to provide an environment conducive to implementing EBM in order for their staff members to effectively provide the highest level of patient care. [19][20][21] Organisations should also be wary of creating a 'blame culture' whereby healthcare personnel who attempt to work flexibly within protocols are reprimanded; this response may prevent the development of new approaches, such as the implementation of EBM, in existing practices. 22 23 Patients are becoming more knowledgeable as health information is now easily accessible through the internet. ...
Article
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Objective To explore the factors, including barriers and facilitators, influencing the practice of evidence-based medicine (EBM) across various primary care settings in Malaysia based on the doctors’ views and experiences. Research design The qualitative study was used to answer the research question. 37 primary care physicians participated in six focus group discussions and six individual in-depth interviews. A semistructured topic guide was used to facilitate both the interviews and focus groups, which were audio recorded, transcribed verbatim, checked and analysed using a thematic approach. Participants 37 primary care doctors including medical officers, family medicine specialists, primary care lecturers and general practitioners with different working experiences and in different settings. Setting The study was conducted across three primary care settings—an academic primary care practice, private and public health clinics in Klang Valley, Malaysia. Results The doctors in this study were aware of the importance of EBM but seldom practised it. Three main factors influenced the implementation of EBM in the doctors’ daily practice. First, there was a lack of knowledge and skills in searching for and applying evidence. Second, workplace culture influenced doctors’ practice of EBM. Third, some doctors considered EBM as a threat to good clinical practice. They were concerned that rigid application of evidence compromised personalised patient care and felt that EBM did not consider the importance of clinical experience. Conclusions Despite being aware of and having a positive attitude towards EBM, doctors in this study seldom practised EBM in their routine clinical practice. Besides commonly cited barriers such as having a heavy workload and lack of training, workplace ‘EBM culture’ had an important influence on the doctors’ behaviour. Strategies targeting barriers at the practice level should be considered when implementing EBM in primary care.
... Adherence to clinical practice guidelines is impacted by multiple factors. The successful implementation and use of clinical practice guidelines is dependent upon the culture and leadership style of the unit 22 , the mental and emotional state of nursing staff, and the quality of the relationship between nursing and medical staff 23 . The clinical practice guideline produces recommendations for required interventions dependent upon the pain assessment score. ...
Article
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Aim: To describe a process for mapping current practice within the neonatal intensive care unit (NICU) to inform practice change. There are evidence based recommendations for practices concerning neonatal pain. Despite these guidelines, there continues to be poor utilisation of evidence to guide pain assessment and management in the NICU. Methods: This study mapped current practices for postoperative pain assessment and management in one surgical NICU. Patient records of postoperative neonates were examined using a retrospective chart review to determine if knowledge was transferred into practice through compliance with clinical practice guidelines. Results: Compliance with the clinical guideline was poor. Pain assessments were under-recorded for the five days following surgery. There were no differences for preterm, wound location or type of surgery (p>0.05). The mean duration in hours of opioid infusions varied, fentanyl (63 - range 11-117) and morphine (37 - range 5-106). In 50% the opioid was ceased with extubation. Weaning practices were inconsistent, an opioid weaning score was attended in less than 30% of neonates. Conclusions: Despite the availability of clinical practice guideline, pain practices remain inconsistent; however, improved compared to previous studies. Recommendations following this study include raising awareness about postoperative pain, revising the guideline and providing education for pain management techniques.
... Therefore, context is essential to consider when researching the effects of facilitation strategies on guideline implementation . Emerging evidence especially focuses on the importance of the role of leadership in successfully translating research evidence into practice (Gifford, Davies, Edwards, Griffin, & Lybanon, 2007;Hauck, Winsett, & Kuric, 2013;Marchionni & Ritchie, 2008;Sandström, Borglin, Nilsson, & Willman, 2011). Davies et al. (2006) found leadership to be the main predictor of nurses' continued use of guideline recommendations in a variety of clinical topics. ...
Article
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Background: Emerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process. Aims: To describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people. Methods: Semistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs. Results: This study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: "realising commitment"; "negotiating conditions"; and "encouragement to keep momentum going." The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the "building of a bridge" emerged as one way of understanding the findings. Linking evidence to action: Our findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved.
... Research on knowledge translation has helped to identify some of the barriers that may hinder this process. Among nurses, these include political issues (both local and broad) (Currie et al., 2007), limited time, limited knowledge, limited support (Timmins et al., 2012), limited skill-base, poor leadership (Marchionni and Ritchie, 2008), limited access to timely information, professional identities (McKenna et al., 2004), and organizational characteristics (Dobbins et al., 1998;Chummun and Tiran, 2008). Similarly, following a more recent integrative review of extant research, Solomons and Spross (2011) concluded, "barriers to EBP [evidence-based practice] can occur at both individual and institutional levels and within the four dimensions of an organization" (p. ...
Purpose: Evidence-based practice is pivotal to effective patient care. However, its translation into practice remains limited. Given the central role of primary care in many healthcare systems, it is important to identify strategies that bolster clinician-capacity to promote evidence-based care. The purpose of this paper is to identify strategies to increase Practice Nurse capacity to promote evidence-based sexual healthcare within general practice. Design/methodology/approach: A survey of 217 Practice Nurses in an Australian state and ten respondent-interviews regarding two resources to promote evidence-based sexual healthcare - namely, a clinical aide and online training. Findings: The perceived impact of both resources was determined by views on relevance and design - particularly for the clinical aide. Resource-use was influenced by role and responsibilities within the workplace, accessibility, and support from patients and colleagues. Research limitations/implications: This is the first Australian study to reveal strategies to promote evidence-based sexual healthcare among Practice Nurses. The findings provide a platform for future research on knowledge translation processes, particularly among clinicians who might be disengaged from sexual healthcare. Practical implications: Given the benefits of evidence-based practices, it is important that managers recognize their role, and the role of their services, in promoting these. Without explicit support for evidence-based care and recognition of the Practice Nurse role in such care, knowledge translation is likely to be limited. Originality/value: Knowledge translation among Practice Nurses can be facilitated by: resources-deemed informative, relevant, and user-friendly, as well as support from patients, colleagues, and their workplace.
... 44 Lastly, previous studies have reported the effect of organizational factors on implementation of QI interventions and provider compliance with EB care. 42,[45][46][47] Specifically, success of an implementation strategy is a function of the relationship between the nature of the evidence, the context in which the proposed change is implemented, and the methods through which change is facilitated. [48][49][50][51] Our future plan includes assessing organizational factors associated with successful implementation and dissemination of EB-CPMs. ...
Article
Background and objectives: Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children's Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals. Methods: Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses. Results: At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions (P = .026) and length of stay (P < .001), a trend toward reduced costs (P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction (P = .119), a significant reduction in length of stay (P < .001) and cost (P = .053), a slight increase in hospital resource use (P = .032), and no change in ICU transfers or deaths. Conclusions: Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.
... Studies have shown that the typical adopter of a new technology is younger, has a high income, has a high level of education, and is a male (Rogers, 2003;Laukkanen & Pasanen, 2008;Chinn & Fairlie, 2004;Marchionni & Ritchie, 2007). As for gender and how it might differ with regard to the adoption of technology, studies about the relationship between gender and internet use show that males use the internet more than females (Chen & Wellman, 2004). ...
... Leadership to support evidence-based practice in speech pathology. The role of strong leadership in creating a context which supports research implementation in healthcare has been described in the literature (e.g., Crow, 2006;Halm, 2010;Kitson et al., 1998;Marchionni & Ritchie, 2008;McCormack et al., 2002;Newhouse, 2007). In speech pathology, the role of leadership in creating evidence-based services is beginning to gain recognition and support. ...
Article
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Background: The role of speech pathologists working in the acute hospital setting has evolved away from service provision to people with aphasia and their families towards a stronger focus on dysphagia. Evidence-based practice (EBP) can be conceptualised as the integration of four streams of evidence: research-based clinical evidence, clinical expertise, patient preferences and values, and the practice context. EBP is an important tenet in current healthcare. However, it is not clear whether speech pathologists in the acute setting are using EBP to support their aphasia management. Not adopting evidence-based approaches to care has the potential to result in a negative impact on people with aphasia and their families, healthcare services, and speech pathologists, who experience a sense of dissonance related to their current service provision This paper explores acute aphasia management through an EBP lens in an attempt to better understand this dilemma. Aims: This paper applies the conceptual framework of EBP to acute aphasia management. An extensive, systematically conducted review of the international literature relating to health professionals was undertaken. The findings are presented as a narrative literature review. Main Contribution: This paper describes and evaluates how the different streams of research evidence, clinical expertise, patient preferences and values, and the practice context contribute to speech pathologists’ management of acute aphasia. Further, the paper identifies current gaps in the literature and suggests a research agenda for the field. Conclusions: Little is known about how speech pathologists integrate and implement the different streams of evidence in EBP, and how these contribute to acute aphasia practice. Speech pathologists report that clinical guidelines containing low-level evidence are the main source of research information. Other sources of knowledge include colleagues, professional development events, and websites. Additional challenges to the management of people with aphasia in the acute hospital setting may be posed by the physical environment, the culture of the acute hospital setting, and the provision of leadership to support evidence-based approaches to care. The challenge of using a person-centred approach to care for people with aphasia is acknowledged. Further research exploring speech pathologists’ perceptions of their role in acute aphasia management, the clinical decision-making process of speech pathologists in relation to acute aphasia management, and the experiences of people with aphasia and their families in the acute setting is required. This will allow for the design of patient-centred approaches to care, and enable the implementation of evidence-based acute aphasia management.
Article
Background: Organisational and unit-level context can have a significant impact on implementation of evidence in practice, the latter being particularly important in the complex intensive care context. Evaluating the context may allow modifiable characteristics to be identified and addressed. Objectives: The objective was to examine the relationship between dimensions of the context and research utilisation in one intensive care unit. Methods: This study used a quantitative cross-sectional survey. All registered nurses working in one Australian quaternary referral hospital intensive care unit were surveyed using the Alberta Context Tool and research utilisation instrument. Descriptive statistics were used, and bivariate analysis was undertaken to determine associations among demographic data, dimensions of context, and research utilisation. Results: The survey response rate was 33% (67/205). Most respondents were women with a mean of 8 years of intensive care nursing experience. The dimensions of culture, evaluation, informal interactions, structural/electronic resources, and organisational slack (time and space) were positively correlated with research utilisation. Conclusions: Research utilisation was associated with numerous context dimensions, emphasising their effect on knowledge translation in this setting. Intensive care nurses are in a unique position to impact care delivery and provide evidence-based care to ensure optimal outcomes to patients at high risk of morbidity and mortality. Identified dimensions may be targeted and developed in future strategies to optimise the context for translating evidence into this complex practice environment.
Conference Paper
El objetivo del trabajo es analizar la relación entre competencias profesionales y uso de evidencias científicas en la toma de decisiones entre Licenciados en Nutrición (LN) de hospitales públicos de Toluca, Estado de México. Diez competencias medidas se relacionaron positiva y significativamente con la práctica basada en evidencias (PBE) entre LN. Las capacidades para aplicar evidencias en casos concretos, para convertir necesidades de información en preguntas de investigación y las habilidades generales para la investigación fueron las competencias más fuertemente relacionadas. El uso de evidencias en la toma de decisiones es un área de oportunidad para mejorar la calidad de la atención sanitaria. Fortalecer, desde la formación profesional de los LN, competencias como las habilidades para la investigación y la capacidad de aplicar información encontrada en casos concretos, tiene el potencial para estimular la PBE.
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Aim To establish a middle‐range theory of organizational learning in hospitals. Design A realist review of the literature, conducted according to established standards for realist and meta‐narrative evidence syntheses. Middle‐range theory development, performed according to Smith & Liehr's recommendations. Data sources Two comprehensive scientific databases and six discipline‐focused databases spanning healthcare, life sciences, business, sociology and psychology were searched from inception to 12 May 2016. Review Methods Citations meeting the inclusion criteria were appraised using the Mixed Methods Appraisal Tool. Data extraction was guided by a focus on the contextual factors, mechanisms and outcomes associated with organizational learning. Results The initial search yielded 2,332 citations, 147 of which were ultimately included in the review. The included citations were generally of high quality. Reviewed evidence indicates certain aspects of organizational context can be conducive to mechanisms of organizational learning, leading to a range of positive organizational outcomes. Conclusion This review updates and expands on a previous review of the literature on organizational learning in hospitals, refines the concept of organizational learning in hospitals and provides a middle‐range theory of organizational learning in hospitals. Impact This updated review provides a strong evidence base for future work on the topic of organizational learning in hospitals. The refined concept of organizational learning makes it possible to develop reliable, valid research instruments that better reflect of the full scope of organizational learning. Finally, the middle‐range theory guides researchers and clinical leaders as they advance the science and practice of organizational learning. This article is protected by copyright. All rights reserved.
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Aim To provide a clear definition and description of organizational learning in hospitals. Background Organizational learning is a promising strategy nurse managers and leaders can use to improve organizational performance. A clear definition and description of organizational learning is necessary to advance theory, research, and practice in this field. Methods Walker & Avant's method was used to conduct a concept analysis of organizational learning in hospitals. Data sources included 147 empirical studies, 16 review articles, 3 dictionary entries, and 3 book chapters. Results Organizational learning occurs when experiences are translated into positive changes in the organization's collective knowledge, cognition, and actions. Organizational context plays a key role in the learning process. Other manifestations of the concept are identified. Conclusions This concept analysis provides a clear definition of organizational learning and a description of its defining attributes, antecedents, empirical referents, and consequences. Implications for Nursing Management Nurse managers and leaders can improve patient and organizational outcomes by creating an environment conducive to translating experiences into organizational learning. Further research is needed to continue advancing the science of organizational learning in hospitals. This article is protected by copyright. All rights reserved.
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RESUMEN En el sector salud, las brechas entre la generación del conocimiento científico y su uso para la toma de decisiones comprometen la calidad de la atención brindada. Estas brechas se han relacionado con diferentes factores, entre ellos el capital social. Este trabajo explora el papel del capital social en el uso del conocimiento en el sector salud. Para hacerlo se recurrió a una revisión de la literatura de los últimos veinte años. Los hallazgos reportaron que las tres dimensiones del capital social, es decir, el capital estructural, el capital relacional y el capital cognitivo, se han relacionado teóricamente con la gestión y el uso del conocimiento y que el capital social se considera un predictor significativo de la práctica basada en evidencias. Se concluye que fomentar la confianza y los lazos de comunicación entre los empleados, así como buscar relaciones con investigadores, potencian el uso de las evidencias científicas en la toma de decisiones. Estas acciones se traducen en beneficios para los usuarios finales del sistema de salud. Palabras clave: capital social; práctica basada en la evidencia; gestión del conocimiento; uso del conocimiento; toma de decisiones. ABSTRACT In the health sector, gaps persist between scientific knowledge´s production and its use for decision-making; and these gaps compromise the quality of provided care. These gaps have been related to different factors, including social capital. This
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Purpose Despite the importance of evidence-based practice, the translation of knowledge into quality healthcare continues to be stymied by an array of micro, meso and macro factors. The purpose of this paper is to suggest a need to consider different – if not unconventional approaches – like the role of positive emotion, and how it might be used to promote and sustain knowledge translation (KT). Design/methodology/approach By reviewing and coalescing two distinct theories – the broaden-and-build theory of positive emotions and the organisational knowledge creation theory – this paper presents a case for the role of positive emotion in KT. Findings Theories pertaining to positive emotion and organisational knowledge creation have much to offer KT in healthcare. Three conceptual “entry points” might be particularly helpful to integrate the two domains – namely, understanding the relationship between knowledge and positive emotions; positive emotions related to Nonaka’s concept of knowledge creation; and the mutual enrichment contained in the parallel “upward spiralling” of both theories. Research limitations/implications This is a conceptual paper and as such is limited in its applicability and scope. Future work should empirically explore these conceptual findings, delving into positive emotion and KT. Originality/value This is the first paper to bring together two seemingly disparate theories to address an intractable issue – the translation of knowledge into quality healthcare. This represents an important point of departure from current KT discourse, much of which continues to superimpose artefacts like clinical practice guidelines onto complex healthcare context.
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Background: A healthy workplace culture enables nurses to experience valuable learning in the workplace. Learning in the workplace enables the provision of evidence-based and continuously improving safe patient care, which is central to achieving good patient outcomes. Therefore, nurses need to learn within a workplace that supports the implementation of evidence-based, professional practice and enables the best patient outcomes; the influence of workplace culture may play a role in this. Objectives: The purpose of this review was to critically appraise and synthesize the best available qualitative evidence to understand both the nurses' learning experiences within the workplace and the factors within the workplace culture that influence those learning experiences. Inclusion criteria types of participants: Registered and enrolled nurses regulated by a nursing and midwifery board and/or recognized health practitioner regulation agency (or their international equivalent). Phenomena of interest: This review considered studies that described two phenomena of interest: the nurses' learning experience, either within an acute healthcare workplace or a workplace-related learning environment and the influence of workplace culture on the nurses' learning experience (within the workplace or workplace-related learning environment). Context: This review considered studies that included nurses working in an acute healthcare organization within a Western culture. Types of studies: This review considered studies that focused on qualitative evidence and included the following research designs: phenomenological, grounded theory and critical theory. Search strategy: Published and unpublished studies in English from 1980 to 2013 were identified using a three-step search strategy, searching various databases, and included hand searching of the reference lists within articles selected for appraisal. Methodological quality: For studies meeting the inclusion criteria, methodological quality was assessed using a standardized checklist from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Data extraction: Qualitative data were extracted from articles included in the review using the standardized data extraction tool from the JBI-QARI. Data synthesis: Qualitative research findings were pooled using the Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI-QARI). This involved the aggregation and synthesis of findings to generate a set of categories, which were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that could be used as a basis for evidence-based practice. Results: Fourteen articles were identified following appraisal and a total of 105 findings (85 unequivocal and 20 credible) were extracted from included studies and grouped into eight categories based on similarity of meaning. Subsequently, categories were grouped into two synthesized findings. The two synthesized findings were as follows: ORGANIZATIONAL INFLUENCES: Enabling nurses to demonstrate accountability for their own learning, along with clear organizational systems that provide resources, time, adequate staffing and support, demonstrates encouragement for and the value of nurses' learning and education. Relational dynamics: Nurses value their peers, expert nurses, preceptors, mentors and educators facilitating and encouraging their learning and professional development. Conclusion: An optimal workplace culture is central for nurses to experience valuable and relevant learning in the workplace. To emphasize the importance of nurses' learning in the workplace, working and learning is understood as an integrated experience. Consequently, a dual system that enables nurses to demonstrate accountability for their own learning, along with clear organizational and educational systems, is required to demonstrate the value in nurses' learning and education.
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Aim and objectives: The aim of present study was to explore successful factors to prevent pressure ulcers (PU) in hospital settings. Background: PU prevalence has been recognized as a quality indicator for both patient safety and quality of care in hospital and community settings. Most PU can be prevented if effective measures are implemented and evaluated. The Swedish Association of Local Authorities and Regions (SALAR) initiated nationwide PU prevalence studies in 2011. In 2014, after four years of measurement, the prevalence was still unacceptably high on a national level. The mean prevalence of PU in the spring of 2014 was 14% in hospital settings with a range from 2.7% to 36.4%. Design: Qualitative semi-structured interviews were conducted. Methods: A qualitative content analysis, in addition to PARIHS frameworks was used in the analysis of the data text. Individual interviews and focus groups were used to create opportunities for both individual responses and group interactions. The study was conducted at six hospitals during the fall of 2014. Results: Three main categories were identified as successful factors to prevent PU in hospitals: creating a good organization, maintaining persistent awareness, and realising the benefits for patients. Conclusion: The goal for all healthcare personnel must be delivering high-quality, sustainable care to patients. Prevention of PU is crucial in this work. It seems to be easier for small hospitals (with a low number of units/beds) to develop and sustain an effective organization in prevention work. Relevance to clinical practice: The nurse managers' attitude and crucial to enable the personnel to work actively with PU prevention. Strategies are proposed to advance clinical leadership, knowledge, skills, and abilities for the crucial implementation of PU prevention. This article is protected by copyright. All rights reserved.
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Purpose/Objectives: To measure the effect of clinical decision support (CDS) on oncology nurse evidence-based practice (EBP). Design: Longitudinal cluster-randomized design. Setting: Four distinctly separate oncology clinics associated with an academic medical center. Sample: The study sample was comprised of randomly selected data elements from the nursing documentation software. The data elements were patient-reported symptoms and the associated nurse interventions. The total sample observations were 600, derived from a baseline, posteducation, and postintervention sample of 200 each (100 in the intervention group and 100 in the control group for each sample). Methods: The cluster design was used to support randomization of the study intervention at the clinic level rather than the individual participant level to reduce possible diffusion of the study intervention. An elongated data collection cycle (11 weeks) controlled for temporary increases in nurse EBP related to the education or CDS intervention. Main Research Variables: The dependent variable was the nurse evidence-based documentation rate, calculated from the nurse-documented interventions. The independent variable was the CDS added to the nursing documentation software. Findings: The average EBP rate at baseline for the control and intervention groups was 27%. After education, the average EBP rate increased to 37%, and then decreased to 26% in the postintervention sample. Mixed-model linear statistical analysis revealed no significant interaction of group by sample. The CDS intervention did not result in an increase in nurse EBP. Conclusions: EBP education increased nurse EBP documentation rates significantly but only temporarily. Nurses may have used evidence in practice but may not have documented their interventions. Implications for Nursing: More research is needed to understand the complex relationship between CDS, nursing practice, and nursing EBP intervention documentation. CDS may have a different effect on nurse EBP, physician EBP, and other medical professional EBP.
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Vaak wordt in implementatiemodellen uitgegaan van een stapsgewijze lineaire aanpak, waarin fasen elkaar netjes opvolgen. Een implementatieproces verloopt echter zelden lineair en gaat dikwijls gepaard met tegenslagen en onverwachte wendingen. Ditzelfde geldt voor het implementatieproces van het evidence-based gedachtegoed in een instelling of een afdeling. Om hierop voorbereid te zijn moet een plan van aanpak niet alleen flexibel zijn, maar ook geschikt om de tegenslagen en problemen te signaleren, zodat daar snel op ingespeeld kan worden en een valse start wordt voorkomen.
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Binnen het plan van aanpak worden keuzes gemaakt voor methoden en principes die gehanteerd worden bij de implementatie. In dit hoofdstuk wordt ingegaan op vier methodische werkwijzen die vaak gebruik worden in zorg- en onderwijssettings bij het implementeren van veranderingen: de PDCA-cyclus van Deming, het Participatief Actieonderzoek (PAO), het implementatiemodel van Grol en Wensing en Responsieve Evaluatie (RE).
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Tables reporting the content of instruments (Tables S3-S6) and overview of development and assessment of measurement properties (Table S10).
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Résumé Les taux de plaies de pression (escarres) nosocomiales sont un indicateur de la qualité des soins. Les infirmières ont la responsabilité professionnelle d’éviter ou de limiter le développement de ce type de plaies. Dans une perspective clinicoadministrative, l’élaboration d’un programme pour guider le développement des compétences infirmières en cours d’emploi s’appuyant sur une démarche structurée et des fondements théoriques pertinents offre l’opportunité d’affirmer un leadership infirmier pour les milieux qui préconisent une pratique axée sur la qualité et la sécurité des soins.
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Context: Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. Objective: To review barriers to physician adherence to clinical practice guidelines. Data sources: We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. Study selection: Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. Data extraction: Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators. Data synthesis: The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. Conclusions: Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.
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This article explores the question of why the management of change has become an issue in the National Health Service (NHS). It reports the results of a study which explored reasons for variability in the observed rate and pace of strategic service change in the NHS. The metaphor of ‘receptive’ and ‘non‐receptive’ contexts for change is introduced and eight ‘signs and symptoms’ of receptivity outlined. Some examples are presented. These results give us a logic and language which may enable us to understand processes of change in the NHS.
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Implementation of organizational learning is complicated by the lack of a systematic approach that includes the measurement of learning capability. We propose that by identifying and measuring the essential organizational characteristics and management practices that promote organizational learning, one could develop a benchmark of learning capability that would enable managers to design interventions to overcome specific barriers in building a learning organization. Based upon a review of the literature, we developed an Organizational Learning Survey (OLS) to measure learning capability. Our research with five different organizations indicates that the OLS does discriminate between organizations on those characteristics important to learning. We also discuss the implications of using such an approach for intervention and change in building more effective learning organizations. The paper also discusses other perspectives of organizational learning, some of the limitations of the OLS measurement scale and future research directions.
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A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care.
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To recommend effective strategies for implementing clinical practice guidelines (CPGs). The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE from January 1990 to June 1996, inclusive, with the use of the MeSH heading "practice guidelines" and relevant text words. Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians' performance or health care outcomes were emphasized. Articles were reviewed to determine the effect of various factors on the adoption of guidelines. The articles showed that CPG dissemination or implementation processes have mixed results. Variables that affect the adoption of guidelines include qualities of the guidelines, characteristics of the health care professional, characteristics of the practice setting, incentives, regulation and patient factors. Specific strategies fell into 2 categories: primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines. The interventions were shown to be weak (didactic, traditional continuing medical education and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers and delivered by peers or opinion leaders) and relatively strong (reminder systems, academic detailing and multiple interventions). The evidence shows serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic.
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Evidence-based practice, or evidence-based decision-making, is rapidly developing as a growth industry in nursing and the health professions more widely. It has its origins in the work of the British epidemiologist Archie Cochrane and has recently been re-energized in Canada by the National Forum on Health and its call for a culture of evidence-based decision-making. Before we adopt evidence-based nursing (EBN) as a mantra for the 21st century, we should examine its origins and its consequences, and we should probe related concepts, 2 of which are the nature and structure of practice-based knowledge and the nature and structure of evidence generally. Findings of a recent survey of nurses in western Canada are used to illustrate that nurses use a broad range of practice knowledge, much of which is experientially based rather than research-based.
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Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. To review barriers to physician adherence to clinical practice guidelines. We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators. The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.
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Studies of clinical guideline implementation have focused almost entirely on changing individual clinician behavior with single intervention strategies and without much attention to the situational context. The goal of this project was to learn from clinic leaders, seasoned in the guideline implementation process, what contextual variables they viewed as important and whether implementation success could be expected if only a single implementation strategy was used. In 1998, 12 people with extensive experience in leading clinical guideline implementation were identified who were thought to have particularly keen insight into the process. They were interviewed to generate variables they considered important, as well as strategies they considered effective when used appropriately. A modified nominal group/Delphi process was then used for rating these variables and strategies, and the reactions of international experts were obtained to add perspective to this information. Eighty-seven variables and 25 strategies were identified, clustering in 6 categories (ranked in order of importance by the panel): organizational capabilities for change, infrastructure for implementation, implementation strategies, medical group characteristics, guideline characteristics, and external environment. All six categories were considered to be important, key, or essential by the experienced implementers, although variables within a medical group that directly affect its ability to undertake planned change were rated as much more important than either guideline characteristics or the external environment. Although the opinions of those experienced in the process of guideline implementation are primarily of value for generating hypotheses, panel members believe that implementation efforts focusing on the individual physician with a single strategy are unlikely to be successful. Rather, implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and external environment.
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This paper proposes a framework for understanding the concept of a learning organization from a normative perspective. A questionnaire was developed to operationally measure the described management practice attributes of a learning organization. Using a sample of four organizations and 612 subjects, support was found for three a priori predictive hypotheses derived from a conceptual framework. Implications of the results and further empirical research are discussed, especially for linking learning organization attributes to performance using larger samples and multiple measures.
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The authors present a case study of organizational learning in an internal medicine ward and a cardiac surgery ward of a university-affiliated hospital. The study is based on a structural and cultural approach to organizational learning. The structural facet of this approach consists of organizational learning mechanisms (OLMs), which are institutionalized structural and procedural arrangements that allow organizations to systematically collect, analyze, store, disseminate, and use information relevant to the performance of the organization. The cultural facet consists of shared values without which OLMs are likely to be enacted as rituals rather than as mechanisms to detect and correct error. Based on semistructured interviews and unstructured observations, the authors identify the OLMs that operate in the two hospital units and the cultures in which they are embedded.
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Nine types of organizational cultures are defined in terms of the extent transformational and transactional leadership and their effects form accepted ways of behaving. The Organizational Description Questionnaire (ODQ) is used by members of the organizations to describe their cultures.The nine types of organizations include the high-contrast culture with both strong transformational and transactional qualities to the "garbage can" which lacks either kind of leadership of consequence. A majority of organizations are somewhere inbetween either loosely guided, coasting, or contractual.
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Maximizing the clinical effectiveness of health care delivery is currently a priority in the UK. Clinical guidelines are being used as a means of informing and encouraging practitioners to provide evidence-based care. Although considerable effort has gone into developing guidelines for nursing, little is known about the relative effectiveness of different ways of communicating them to potential users, and ensuring that they are incorporated into practice. This review, therefore, was undertaken in order to ascertain the current level of knowledge concerning methods of dissemination and implemention of clinical guidelines for nursing practice. A selective review of the literature using three major databases elicited a large amount of anecdotal and descriptive material, but very little research evidence. More research was available concerning the effectiveness of guidelines on medical practice, although this is not necessarily directly transferable to nursing. Current developments concerning the dissemination and implementation of nursing guidelines are discussed. There is an urgent need for evaluative research into the various methods of dissemination and implementation of clinical guidelines if the demand for clinical effectiveness is to be met.
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BACKGROUND. Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals. OBJECTIVES. To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. RESEARCH DESIGN. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. RESULTS. Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing), and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. CONCLUSIONS. Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.
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Discusses the feasibility of disseminating and implementing guidelines in routine practice, informed by discussions with senior actors in the field of guidelines implementation. Comments about the lack of protected budgets to support guideline dissemination and implementation strategies and common strategies of using “soft money” or resources for specific initiatives to support such activities. The “opportunity costs” of strategies need to be considered. In addition there are implications for the implementation of the NHS information strategy. For clinical governance as a whole, not only is it likely that widespread cultural change is required, but also the capacity of the system still needs considerable expansion if sufficient educational activities are to become routine.
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Purpose – The correlation between organizational unit managers’ leadership styles and the level of organizational learning in their units was tested. Design/methodology/approach – A positive correlation was hypothesized between transformational leadership and organizational learning as manifested by organizational learning mechanisms – OLMs (the structural component) and by organizational learning values (the cultural component). The research was conducted at 44 community clinics of a health‐care organization in Israel. Findings – The findings attested to the central role of organizational leaders in determining the effectiveness of organizational learning. The theoretical, methodological, and practical implications of the findings are discussed. Originality/value – Suggests that, in addition to separating the sources of reporting, and increasing the number of measures, future studies should also extend the research to different kinds of organizations, addressing different purposes, environments, work forces, and so forth.
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Aims first, to develop an instrument for a holistic analysis of learning organizations; and second, to test the validity and reliability of this instrument. The framework developed was mainly influenced by the work of Mike Pedler, Tom Boydell and John Burgoyne, Peter M. Senge as well as Chris Argyris and Donald A. Schön. Analyses eight existing diagnosis tools. The Learning Organization Diamond Tool was based on a concept of a learning organization regarded as a structure of related elements. Data consisting of 691 answers were gathered from 25 Finnish organizations in 1998. After analysis the reliability of the instrument was measured with Cronbach’s alpha. Cronbach’s alphas for the elements of the tool varied between 0.5141 and 0.8617. Validity of the tool was established by presenting the process as a chain of phases from theory to statements. Comparison between the tool developed and other tools presented in this article yields somewhat contradictory findings, because the purposes of the instruments differ. The tool developed here aims to create a holistic picture for further analysis and discussions and to serve as an internal tool for development. More tailored instruments should be developed for more specific purposes. The article is aimed at an audience involved in learning organizations and their development.
On the basis of interviews, the authors report on a number of practical issues in a critical area of clinical quality—the implementation of clinical guidelines.
This paper proposes a framework for understanding the concept of a learning organization from a normative perspective. A questionnaire was developed to operationally measure the described management practice attributes of a learning organization. Using a sample of four organizations and 612 subjects, support was found for three a priori predictive hypotheses derived from a conceptual framework. Implications of the results and further empirical research are discussed, especially for linking learning organization attributes to performance using larger samples and multiple measures.
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This is the seventh in a series of eight articles analysing the gap between research and practiceSeries editors: Andrew Haines and Anna DonaldDespite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.1 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change.2 Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. 3 4 In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews. Summary points Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings Passive dissemination of information is generally ineffective It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice Further research on the relative effectiveness and efficiency of different strategies is required Identification and inclusion of systematicreviews We searched Medline records dating from 1966 to June 1995 using a strategy developed in collaboration with the NHS Centre for Reviews and Dissemination. The search identified 1139 references. No reviews from the Cochrane Effective Practice and Organisation of Care Review Group4 had been published during this time. In addition, we searched the Database of Abstracts of Research Effectiveness (DARE) (http://www.york.ac.uk/inst/crd) but did not identify any other review meeting the inclusion criteria. We searched for any review …
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The concept of organizational learning has continued to capture the interests of scholars and practitioners. At the core of this notion is the belief that organizational learning provides a number of advantages. Some of these advantages include improved team performance, enhanced service quality, better quality-of-work life and, ultimately, competitive advantage. Hence, not surprisingly, there is a sustained upsurge in the interest of organizational learning. Moreover, there is widespread acceptance that learning could occur at the individual, team and organizational levels. Understanding of learning orientations at these three levels has the capacity to advance the current knowledge and practice of organizational learning. In spite of an outpouring of literature on learning, empirical research on organizational learning is still scarce. Thus, the three linkages addressed in this current study include: individual learning and organizational learning; team learning and organizational learning; and individual learning and team learning. These linkages were examined in a field study of an Australian hospital, where 189 respondents participated in an organization-wide survey. Interestingly, individual learning was not significantly related to organizational learning. However, individual learning was a significant predictor of team learning. Team learning was significantly related to organizational learning. The implications of the research findings are discussed.
Article
Getting evidence into practice: the meaning of `context'Aim of paper. This paper presents the findings of a concept analysis of `context' in relation to the successful implementation of evidence into practice.Background. In 1998, a conceptual framework was developed that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice [Kitson A., Harvey G. & McCormack B. (1998) Quality in Health Care7, 149]. One of the key elements of the framework was `context', that is, the setting in which evidence is implemented. It was proposed that key factors in the context of health care practice had a significant impact on the implementation and uptake of evidence. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide some theoretical and conceptual rigour to its content.Methods. Morse's [Morse J.M. (1995) Advances in Nursing Science17, 31; Morse J.M., Hupcey J.E. & Mitcham C. (1996) Scholarly Inquiry for Nursing Practice. An International Journal10, 253] approach to concept analysis was used as a framework to review semi-nal texts critically and the supporting research literature in order to establish the conceptual clarity and maturity of `context' in relation to its importance in the implementation of evidence-based practice.Findings: Characteristics of the concept of context in terms of organizational culture, leadership and measurement are outlined. A main finding is that context specifically means `the setting in which practice takes place', but that the term itself does little to reflect the complexity of the concept. Whilst the themes of culture and leadership are central characteristics of the concept, the theme of `measurement' is better articulated through the broader term of `evaluation'.Conclusions. There is inconsistency in the use of the term and this has an impact on claims of its importance. The concept of context lacks clarity because of the many issues that impact on the way it is characterized. Additionally, there is limited understanding of the consequences of working with different contexts. Thus, the implications of using context as a variable in research studies exploring research implementation are as yet largely unknown. The concept of context is partially developed but in need of further delineation and comparison.
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Fueled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be given to issues of leadership, culture, team development, and information technology at all levels. A number of contingent factors influence these efforts in both countries, which must each balance a number of tradeoffs between centralization and decentralization in efforts to sustain the impetus for quality improvement over time. The multilevel change framework and associated properties provide a framework for assessing progress along the journey.
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When existing evaluations find little or no evidence of consensus recommendations leading to action, one can justifiably ask why so much of this review was dedicated to analyzing alternative ways of producing such "words without action." There are, however, at least two reasons why consensus recommendations should be produced with care and attention to validity. First, recommendations do sometimes have an impact on behavior as a consequence of mere dissemination activity--the Dutch program, for instance, was more successful than most. This success may occur when the target audience is already particularly receptive to change and the message is timely and delivered by a credible source in a clinically relevant way. Thus, although "such a conjunction of favorable conditions is probably the exception rather than the rule for consensus topics" (46, 240) it does happen. Second, the output from consensus processes is increasingly a potential input to other processes. Consensus recommendations can be used as the criteria for evaluation and appraisal aimed at changing practice behavior, making administrative decisions on resource allocation, or defining research protocols. For instance, quality assurance activities, such as peer assessment, practitioner certification, or utilization review, are actively seeking criteria with which to make judgments and elicit changes in practice to improve the quality of care. Funding agencies are looking for information to help make reimbursement, capital expenditure, or fee-for-service decisions on cessation of insurance for particular procedures or approaches. These uses of the consensus criteria are potentially major and controversial. Therefore, even if dissemination rarely leads to action, consensus processes should still be done carefully and with valid techniques. The use of their recommendations embedded within other activities may well lead to (forced) changes in behavior. On ethical grounds alone, we should be as sure as possible that the behavior changes being implied and encouraged are indeed advisable. For these reasons, the review describes the decision points in the production process for consensus recommendations as a start on the development of a set of recognized standards. The review offers a critical appraisal of the various methodological choices available at each decision point. The seven decision points are selecting a topic, picking the consensus group, providing background preparation, identifying information inputs, choosing a group judgment process, defining the criteria for recommendations, and choosing a report preparation procedure and format. At least two important points emerged from this review. First, the research is often not well enough developed to give clear indications for many of the choices on what is the "best" alternative.(ABSTRACT TRUNCATED AT 400 WORDS)