Determinants of the Sustained Use of Research Evidence in Nursing

by Barbara Davies | Dec 01, 2006

Key Implications for Decision Makers

  • Nursing best practice guidelines provide a summary of quality research evidence with recommendations targeted to the scope of practice for nurses working in hospitals, home visiting services, public health departments, and long-term care.
    • Implementing clinical practice guidelines is an effective way to improve quality of care and services.
  • Sustaining implementation of clinical practice guidelines:
    • Implementing recommendations is a long-term process. This study shows promising results, with 16 of 37 (43 percent) participating organizations continuing to implement nursing best practice guidelines two years after the pilot implementation.
    • After three years, at least 22 of 37 organizations (59 percent) were continuing the implementation of these guidelines.
    • Most of the organizations that sustained the implementation of the guidelines also expanded use of the guidelines by implementing in more units or agencies, engaging more partners, encouraging multidisciplinary involvement, and/or integrating the guidelines with other quality improvement initiatives.
  • Facilitators for sustained or expanded long-term use of guidelines:
    • Nursing leadership is critical to sustaining and expanding the use of clinical practice guidelines.
    • Leadership at all levels of an organization is needed to support nurse-led guideline innovations. Critical and prominent nurse leaders were staff champions, advanced practice nurses, managers, and senior executives. Sustained practice change involves people both at the front lines and at executive levels.
    • Sustainability is likely when organizations have an organizational culture for evidence-informed practice, provide ongoing education about the topic, integrate the guideline recommendations into policies and procedures, and collaborate with partners in their community.
  • A longer-term perspectiveis needed for implementing and evaluating the outcomes of clinical practice guidelines. Changing nursing practice to be more evidence-informed is a dynamic and iterative process.
    • Healthcare organizations, professional associations, and guideline developers need to engage in long-term evaluation to acknowledge the time, resources, and complexity of implementing clinical practice guidelines.
    • A mixed-methods approach using interviews, document reviews, and site visits can provide a comprehensive picture of the process of sustaining and expanding clinical practice guidelines.

Executive Summary

A. Context: Nursing Best Practice Guidelines

  • Nursing best practice guidelines provide a summary of quality research evidence with recommendations targeted to the scope of practice for nurses working in hospitals, home visiting services, public health departments, and long-term care. Implementing clinical practice guidelines is an effective way to improve quality of care and services.
  • The Registered Nurses' Association of Ontario is a leader in producing nursing guidelines. Since 1999, with funding from the government of Ontario and the assistance of hundreds of nurses on expert panels with multi-disciplinary stakeholder review, the association has produced 29 guidelines, updated every three years, accessible for free at www.rnao.org.
  • This study evaluated whether the first 17 guidelines, implemented from 2000-04, are being "sustained" in practice following an initial six-month pilot. In other words, once the initial pilot implementation funding is over, do nurses, managers, and senior executives continue to implement the clinical guideline recommendations? What factors affect the likelihood that guideline implementation will be sustained after two years?

B. Implications

  • Nursing leadership is critical to sustaining and expanding the use of clinical practice guidelines. Leadership at all levels of an organization is needed for nurse-led guideline innovations. Critical and prominent nurse leaders were staff champions, advanced practice nurses, managers, and senior executives.
  • Important elements that need to be in place to ensure sustainability of the guideline implementation include ongoing and supportive leadership, management support, continuing education, an organizational culture supportive of evidence-informed practice, and integration of guideline recommendations into organizational policies and procedures.
  • Changing nursing practice to be more evidence-informed is a dynamic, long-term, and iterative process. Guidelines can be expanded by implementing in more units or agencies, engaging more partners, encouraging multidisciplinary involvement, and integrating the guidelines with other quality improvement initiatives.

C. Approach: Sustainability of Practice Change

  • Forty-five organizations piloted 17 clinical practice guidelines for six months in three cohorts, with funding administered by the Registered Nurses' Association of Ontario from the government of Ontario from 2001-04.
  • Two years after the pilot implementation, sources of data included interviews with key informants (senior nurse administrators, unit managers, clinical resource nurses or advanced practice nurses, and staff nurses), site visits, and document reviews. Three years after the pilot implementation, a teleconference was conducted with the site visitor team and key informants from the organization.
  • Definitions and questionnaires were developed by the study team and reviewed for validity by an international expert panel because no existing tools on sustainability were found in the literature.
  • Qualitative methods were used to finalize the criteria for sustainability and to identify key facilitators and barriers. This approach involved coding the transcripts and documents and was refined through constant comparison, independent ratings, and iterative discussions.
  • An executive summary report of the results from the interviews, site visits, and document reviews, with comments on the sustainability status of the guidelines and main facilitators and barriers, was prepared by the study team and validated by key informants from each organization.
  • Quantitative analyses included the following: 1) a multiple regression predicting how strongly the guidelines have permeated the organization, with the following as predictors: leadership, ongoing education, policies and procedures, and workplace culture; 2) a logistic regression predicting sustainability status (yes/no) two years after the pilot implementation, with organizational characteristics at pilot implementation as predictors; and 3) a multiple regression predicting the likelihood of implementation, based on the type of guideline, type of facility, and perceptions of cost savings.

D. Results: Determinants of Sustainability

  • After two years, reorganization of healthcare in the province of Ontario led to 41 out of the original 45 organizations remaining. Thirty-seven of 41 organizations participated in this study, representing an excellent response rate of 90 percent. One hundred eighty-nine of 218 key informants (87 percent) were interviewed, with an average of five informants per organization.
  • After two years, 16 of 37 (43 percent) participating healthcare organizations continue to implement nursing best practice guidelines. After three years, at least 22 of 37 participating organizations (59 percent) were sustaining implementation of clinical practice guidelines.
  • Most of the organizations that were sustaining implementation of the guidelines also expanded use of the guidelines by implementing in more units or agencies, engaging more partners, encouraging multidisciplinary involvement, and integrating the guidelines with other quality improvement initiatives.
  • Leadership, defined as recognizable role models, leaders, champions, or administrative support for the continued implementation of the guidelines, was the main predictor, explaining 47 percent of variance in how strongly the guidelines have permeated the organization.
  • Top facilitators for sustaining and expanding the use of guidelines were leadership by champions, management support, ongoing staff education, integration of the guidelines into policies and procedures, staff buy-in and ownership, synergy with partners, and multidisciplinary involvement.
  • Top barriers were changes in staffing and organizational structure, lack of sustained leadership by champions, heavy workload and limited time, limited ongoing staff education, lack of follow-up and feedback, staff resistance, limited management commitment or support, and the guideline not being integrated in policies and procedures.