Studies on guideline implementation, change processes and contextual factors in Swedish neonatal nursing Lars Wallin, RN, PhD Postdoctoral Fellow Faculty of Nursing, University of Alberta KU03, Quebec City, September 25-26, 2003

Lars Wallin KU03 Issues 10 years ago (and still) the knowledge base for neonatal nursing increases rapidly how to make use of this knowledge, make changes and improve patient care quality?

Lars Wallin KU03 Neonatal nursing guideline project local and national level of work mixture of evidence and clinical experience 13 guidelines (different areas) dissemination by conference, mailing and journal

Lars Wallin KU03 Overview thesis content Guideline project Data collection Followup1998 Wallin L, Boström AM, Harvey G, Wikblad K, Ewald U. National guidelines for Swedish neonatal care. Evaluation of the clinical application. International Journal for Quality in Health Care 2000;12(6): papers Wallin L, Boström AM, Harvey G, Wikblad K, Ewald U. Progress of unit based QI: An evaluation of a support strategy. Quality and Safety in Health Care 2002;11(4): Wallin L, Boström AM, Wikblad K, Ewald U. Sustainability in changing clinical practice promotes evidence based nursing care. Journal of Advanced Nursing 2003; 41(5): RCT Guideline Implementation paper (so far) Wallin L, Ewald U, Wikblad K, Arnetz B. Predictors of organisational improvement in neonatal care - staff perceptions as compared with objective measures. (Manuscript 2003)

Lars Wallin KU03 Study 1 One year after guideline dissemination Survey to all neonatal nurse managers in Sweden the guidelines were known appropriate and useful approx 50 implementation projects reported some guidelines more frequently used

Lars Wallin KU03 Guideline utilization n=30 Units totally applying the guidelines n=10 Units using the guidelines as educational material n=20 Units using the guidelines in changing clinical practice n=2 LEARN n=12 PLAN n=2 STUDY n=4 DO Extent in guideline application

Lars Wallin KU03 Utilization - five factors consistency in QI method (method for change) experience of nursing research  4 years experience as a nurse manager sufficient staff resources (rated by nurse manager) units with an assistant nurse manager Open question: restructuring and cutbacks the major obstacles

Lars Wallin KU03 Study 2 - improving clinical practice Natural experimental design 240 nurses in 4-day basic training QI-courses Control Group 156 nurses from various health care institutions. No national context for improvement projects. Intervention Group 84 nurses from neonatal units took part in a national project Postal questionnaire 4 years after the basic training courses

Lars Wallin KU03 Plan IG 100 % CG 100 % Do IG 89 % CG 62 % Study IG 63 % CG 27 % Learn IG 45 % CG 17 % Results - progress improvement work

Lars Wallin KU03 Involvement in changing clinical practice in the long run Four years after the training courses 39 % of all nurses still active - no difference between the groups Continued involvement consistency in approach to change education level (BN) enhancement of knowledge influence on clinical practice development as a nurse Interrupted involvement change of workplace organisational restructuring a lack of facilitation and knowledge

Lars Wallin KU03 Study 3 Recycling the sample from study 2 4 years after the QI courses 39% still involved in QI-related activities 61% had discontinued the QI-work Compared on research related factors by a questionnaire

Lars Wallin KU03 Results - research related activities The nurses who had continued the QI-work reported more activity in searching for research literature implementation of specific research findings in practice discussion of research findings with colleagues They were more likely to have leadership support consultation from a skilled researcher statistical support No differences regarding library and the Internet time restraints, workload and staff resources

Lars Wallin KU03 New research project - studying the change process reflecting on earlier studies and a proposed framework: evidence, context and facilitation an implementation strategy for Kangaroo Mother Care urgent to explore randomised controlled study - testing the impact of an external facilitator

Lars Wallin KU03 Study 4 Assessment of contextual factors 4 units, 200 staff personnel Repeated measurement QWC questionnaire

Lars Wallin KU03 Results – aggregated level Target levels %

Lars Wallin KU03 Predictors

Lars Wallin KU03 Commitment to improving care and work environment an additional index in 2002 data collection changes in work tempo and work-related exhaustion accounted for 24% of explained variance, indicating the higher the work tempo and work-related exhaustion, the lower the commitment for change and improvement

Lars Wallin KU03 Overall summary several factors on societal, organisational and individual level related to knowledge utilisation health care finances reorganisations approach to improvement leadership facilitation education level sustainability networking guideline implementation utilisation of research findings involvement in guideline development? time? professional development power staff turnover work tempo and exhaustion commitment to improvement improvement work

Lars Wallin KU03 Overall conclusions Leadership role essential and possible to develop Nursing research in basic nursing training enhances individual nurse capacity A learning and professional supportive organisation probably the key to a more evidence-based nursing Change does not come easy, facilitation and sustainability vital components