Kathryn Smith Higuchi

Measuring the Effectiveness of Mentoring as a Knowledge Translation Intervention for Implementing Empirical Evidence: A Systematic Review

Background Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice. Aim To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals’ use of evidence in clinical practice. Methods A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentees needs; and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively. Results Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners’ knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals’ behaviors and impact on practitioners’ and patients’ outcomes: some outcomes improved, while others showed no difference. Linking Evidence to Action Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.

Spreading and sustaining best practices for home care of older adults: a grounded theory study

BackgroundImproving health care quality requires effective and timely spread of innovations that support evidence-based practices. However, there is limited rigorous research on the process of spread, factors influencing spread, and models of spread. It is particularly important to study spread within the home care sector given the aging of the population, expansion of home care services internationally, the high proportion of older adult users of home care services, and the vulnerability of this group who are frail and live with multiple chronic conditions. The purpose of this study was to understand how best practices related to older adults are spread within home care organizations.MethodsFour home care organizations in Ontario, Canada that had implemented best practices related to older adults (falls prevention, pain management, management of venous leg ulcers) participated. Using a qualitative grounded theory design, interviews were conducted with frontline providers, managers, and directors at baseline (n =44) and 1 yearar later (n =40). Open, axial, and selective coding and constant comparison analysis were used.ResultsA model of the process of spread of best practices within home care organizations was developed. The phases of spread included (1) committing to change, (2) implementing on a small scale, (3) adapting locally, (4) spreading internally to multiple users and sites, and (5) disseminating externally. Factors that facilitated progression through these phases were (1) leading with passion and commitment, (2) sustaining strategies, and (3) seeing the benefits. Project leads, champions, managers, and steering committees played vital roles in leading the spread process. Strategies such as educating/coaching and evaluating and feedback were key to sustaining the change. Spread occurred within the home care context of high staff and manager turnover and time and resource constraints.ConclusionsSpread of best practices is optimized through the application of the phases of spread, allocation of resources to support spread, and implementing strategies for ongoing sustainability that address potential barriers. Further research will help to understand how best practices are spread externally to other organizations.

An interprofessional educational intervention on delirium for health care teams: Providing opportunities to enhance collaboration

Interprofessional collaborative practice is acknowledged as enhancing patient-centred care (Health Canada, 2004). Successful collaborative practice requires educational experiences that enhance team building (Hall & Weaver, 2001). Learning activities must provide the opportunity for health care providers to learn to work together and share in problem solving and decision making (Health Canada, 2004). This approach is particularly applicable in the management of terminally ill patients experiencing delirium. Delirium is a common major complication of advanced illness, particularly in the older adult and during the last weeks of life (Breitbart & Strout, 2000). Health care professionals experience feelings of incompetence, lack of confidence, and stress surrounding the care they provide these patients and report insufficient knowledge and skills in this area (Brajtman, 2005). As no one health care professional can meet all of these patients’ multiple, complex needs, interprofessional health care teams are particularly important in delivering delirium care. We developed an interprofessional educational intervention on delirium for a palliative care team to enhance team cohesiveness and effectiveness in dealing with delirious patients. Specifically, we wished to develop and assess content, instructional strategies and evaluation instruments; provide educational resources; enhance participants’ awareness of the roles and contributions of the different team members; and increase their knowledge of delirium. This pilot study received ethical approval from the university and clinical agency Research Ethics Boards.

Development of an evaluation tool for a clinical practice guideline on nursing assessment and device selection for vascular access.

This study developed and tested a chart audit tool to assess the implementation of evidence-based recommendations for vascular access nursing assessment and device selection. Chart audits of 71 patients were conducted in a home healthcare agency and a community hospital prior to guideline implementation. Observations of initial infusion therapy and chart audit documentation of 31 patients were also compared. Results from observations indicated that nurses provided care consistent with the recommendations, but findings from chart audits indicated that assessment and decisionmaking were poorly documented. Studies that use only precomparison and postcomparison by chart audit may miss changes in nursing practice.

Integrating clinical guidelines into nursing education.

A project planning group consisting of college and university representatives from a collaborative undergraduate nursing program developed an inclusive, process-oriented faculty development initiative to enhance the integration of clinical guidelines in clinical courses. In the first phase, results of a needs assessment were used to inform the development of a six-hour workshop for the third year clinical faculty in acute care, mental health, and community health. Pre-post surveys were conducted with students and clinical faculty during the first phase. Results from the workshop and surveys were used to develop a four-hour workshop for clinical faculty in all years of the program. The relatively short workshop process shows promise for initiating integration of clinical guidelines in undergraduate nursing education.

Practice Change in Long-Term Care Facilities in Ontario: Views of Managers and Staff

Little is known about how the use of data and feedback influences change in long-term care, and that was the focus of this study. Semistructured interviews were conducted with 126 frontline staff and managers from 19 randomly selected Ontario long-term care facilities. Content analysis revealed that staff members use data for problem identification and solution finding, justifying change, and monitoring change. Frontline providers primarily provided resident-based examples of data and feedback processes, whereas managers mainly described organization-based examples. Few participants discussed how information from mandated databases and related feedback processes could be used to inform change. Knowledge gained from this study will help organizations better understand the perspectives of different team members about data and feedback, thereby informing interventions that will enhance resident outcomes and quality service delivery in long-term care.

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

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

Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence‐Based Care in Long‐Term Care Settings

BACKGROUND Evidence-based improvements in long-term care (LTC) are challenging due to human resource constraints. AIMS To evaluate implementation of a multimodal, participatory intervention aimed at improving evidence-based care. METHODS Using a qualitative descriptive design, we conducted and inductively analyzed individual interviews with staff at midpoint and end-point to identify action plan implementation processes and challenges. The 9-month intervention engaged professional and unregulated staff in an on-site workshop and provided support for their development and implementation of site-specific action plans. RESULTS Ten of 12 enrolled sites participated for the full study period. Interviews were conducted with 44 and 69 participants at midpoint and end-point, respectively. Seven of 10 sites focused their action plan on team functioning and communication. Main achievements described at end-point were improved team communication, better staff engagement, and improved teamwork. Internal and external supports for action plan implementation were described as critical for success. DISCUSSION Three factors influenced change: vertically and horizontally linked teams, external facilitator support for action plan implementation, and coaching by Best Practice Coordinators that emphasized organizational change and normalization of evidence-based practice. IMPLICATIONS Team functioning and communication are forerunners of clinical practice changes in LTC. An off-site model of facilitation is promising and may provide a more efficient means to reach a wider array of LTC settings. LINKING EVIDENCE TO ACTION Practice changes need engagement of all staff.

A Sustainability Oriented and Mentored Approach to Implementing a Fall Prevention Guideline in Acute Care Over 2 Years

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.

Stakeholder Participation in System Change: A New Conceptual Model

BACKGROUND A recent change in Canadas primary care system led to the introduction of Nurse Practitioner-Led clinics. The literature suggests that stakeholders can influence system change initiatives. However, very little is known about healthcare stakeholder motivations, particularly stakeholders who are seen as resistors to change. AIM To examine stakeholder participation in the system change process that led to the introduction of the first Nurse Practitioner-Led clinic in Ontario. METHODS This single case study included two site visits, semistructured individual tape-recorded interviews, and the examination of relevant public documents. Qualitative content analysis was used to analyze the data. RESULTS Sixteen individuals from different healthcare sectors and professions participated in the interviews and 20 documents were reviewed. Six key themes emerged from the data. Linking Evidence to Action The findings from the study present a new perspective on stakeholder participation that includes both those who supported the proposed change and those who advocated for a different change. The findings identify stakeholder activities used to shape, share, and protect their visions for system change. The conceptual model presented in this study adds to the understanding of challenges and complexities involved in healthcare system change. Understanding why and how stakeholders participate in change can help healthcare leaders in planning activities to enhance stakeholder involvement in healthcare system change.