Implementation strategies to facilitate the uptake of practice guidelines in nursing: A systematic review

Dr. Christine Cassidy PhD RNAssistant Professor | School of Nursing, Dalhousie University

Affiliate Scientist | IWK Health

ccassidy@dal.ca | @cecassidyRN

Margaret B. Harrison, Christina Godfrey, Ian D. Graham, on behalf of the Implementation Strategies in Nursing Systematic Review Working Group

The KT Gap

Practice & PolicyEvidence

Nursing Practice Guidelines

Nurses are the largest group of practitioners in the health system

Potential to translate evidence into practice

Practice guidelines can reduce variations in nursing practice and improve patient care

(Mackey & Bassendowski, 2017; IoM, 2011)

Guideline Implementation

Implementation of practice guidelines is complex and inconsistent in practice

Previous research has evaluated effectiveness of implementation strategies in different contexts

Unclear which strategies are effective at implementing guidelines in nursing practice

(Grol, 2001; Fischer et al., 2016; Jones et al., 2015; Watkins et al., 2015)

Study Aim

Determine the effectiveness of implementation strategies to facilitate the uptake of guidelines focused on nursing care

Methods

Systematic review following Cochrane systematic review and meta-analysis guidance

Due to significant differences between studies, including intervention dose, mode of delivery, and outcomes measured, we were not able to conduct a meta-analysis

We conducted a narrative synthesis of implementation strategies used and their effectiveness

Eligibility Criteria

Nurses (Registered Nurses, Nurse Practitioners, Licensed Practical Nurses)

Intervention used to implement a guideline in nursing (i.e., implementation strategy)

Usual practice, usual care, or traditional dissemination

Professional knowledge, practice, patient health status, resource use, expenditures

P

I

C

O

Search Strategy & Study SelectionSystematic review of 5 electronic databases + Cochrane Effective Practice and Organization of Care (EPOC) specialized registry

Nursing library scientists at Queen’s University adapted EPOC search strategy for nursing literature

Searched up to September 30th, 2020

Two reviewers independently screened titles and abstracts, full-text papers, and assessed study quality using the EPOC Risk of Bias 2.0 Checklist

Data Abstraction & Analysis Two reviewers used standardized form

Categorized implementation strategies using EPOC taxonomy

Inductive thematic analysis approach for strategies not included in EPOC taxonomy

Narrative synthesis & descriptive statistics

Results

38,172 records identified

924 full-text review

41 studies in 46 papers included

Implementation Strategies Used36 studies reported multi-component strategies5 studies reported single component strategies40/41 Studies used educational strategies

Educational Meetings(n=33)Educational Materials(n=27)Educational Outreach Visits(n=12)Audit & Feedback (n=11)

33

27

12

11

Educational Strategies UsedVariety of educational strategies usedDifferences in mode of delivery and frequency

33

27

12

11

Lectures Small Group Work Pamphlets Videos

Implementation Strategies Used - Not in EPOC Taxonomy

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Facilitation

Adaptation to Local Context

Changes to Org Policy

Participatory Approach

Number of Studies

28/41 studies included a combination of educational strategies and other implementation strategies not in the EPOC taxonomy

Implementation Strategy Effectiveness

63%

80%

54%

59%

64%

0% 20% 40% 60% 80% 100%

Expenditures

Resource Use

Patient Health Status

Professional Practice

Professional Knowledge

Percentage of Outcomes Reported as Positive

Positive Outcomes

(n=9/14)

(n=29/49)

(n=14/26)

(n=4/5)

(n=5/8)

Effectiveness of Strategies Not in EPOC Taxonomy

60%

Percentage of Outcomes Reported as Positiven=26/43 outcomes

Discussion Majority of studies evaluated educational strategies and showed positive and significant effects on outcomes

Nursing appears to be advancing the evidence-base on implementation strategies

Additional implementation strategies may be more useful for nursing contexts

EPOC search strategy requires enhancement to access relevant nursing literature

Discussion Majority of studies evaluated educational strategies and showed positive and significant effects on outcomes

Nursing appears to be advancing the evidence-base on implementation strategies

Additional implementation strategies may be more useful for nursing contexts

EPOC search strategy requires enhancement to access relevant nursing literature

Discussion Majority of studies evaluated educational strategies and showed positive and significant effects on outcomes

Nursing appears to be advancing the evidence-base on implementation strategies

Additional implementation strategies may be more useful for nursing contexts

EPOC search strategy requires enhancement to access relevant nursing literature

Conclusion

Practice Guidelines

Educational Strategies

Practice & Policy

Conclusion

Practice Guidelines

Educational Strategies

Practice & Policy

Conclusion

Practice Guidelines

Educational Strategies

Participatory Strategies

Practice & Policy

Thank you!

33

27

12

11

Dr. Christine Cassidy PhD RNAssistant Professor | School of Nursing, Dalhousie UniversityAffiliate Scientist | IWK Healthccassidy@dal.ca | @cecassidyRN

On behalf of the Implementation Strategies in Nursing Systematic Review Working Group