IMPROVING NURSING CARE Integrating evidence and innovation into practice Denise Francyna Spoon
Improving Nursing Care Integrating evidence and innovation into practice Denise Francyna Spoon
ISBN: 978-94-6522-458-9 Cover design and lay-out: Joey Roberts | www.ridderprint.nl Print: Ridderprint | www.ridderprint.nl Copyright (C) 2025: Denise Francyna Spoon All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, by photocopying, recording, or otherwise, without the prior written permission of the author.
Verbeteren van verpleegkundige zorg Integreren van wetenschappelijke kennis en innovaties in de praktijk Improving Nursing Care Integrating evidence and innovation into practice Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof.dr.ir. A.J. Schuit en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op 17 september 2025 om 15:30 uur door Denise Francyna Spoon geboren te Westvoorne.
Promotiecommissie: Promotor: Prof.dr. M. van Dijk Overige leden: Prof.dr. F.J. van Lenthe Prof.dr. T. van Achterberg Dr. M. Buljac Copromotor: Dr. W.G. Ista
Contents Chapter 1 General introduction 9 PART 1 IMPLEMENTATION IN NURSING Chapter 2 Implementation strategies used to implement nursing guidelines in daily practice: A systematic review 17 Chapter 3 Implementation strategies of fall prevention interventions in hospitals: A systematic review 55 Chapter 4 Barriers and Facilitators Associated with the Implementation of Technical Improvements in Medical Beds: An Exploratory Case Study 93 Chapter 5 Integrating AI in Nursing: A process evaluation of a pilot implementation study of a Decubitus Risk Prediction Alert based on AI (DRAAI) 121 PART 2 DE-IMPLEMENTATION OF LOW-VALUE CARE IN NURSING Chapter 6 Effects of de-implementation strategies aimed at reducing lowvalue nursing procedures: a systematic review and meta-analysis 159 Chapter 7 Insights in nurses’ self-reported practices and prescribers’ expectations and knowledge and documentation regarding intravenous fluid therapy of hospitalized patients 195 Chapter 8 General discussion 223 Appendix Summary 242 Samenvatting 246 List of publications 250 Abbreviations 252 About the author 254 PhD Portfolio 256 Dankwoord 258
1 Chapter 1 General introduction
10 Chapter 1 Fundamental nursing care Nurses represent nearly half of the global healthcare workforce [1]. As the largest and most trusted members of this workforce, they are uniquely qualified and positioned to enhance the quality of care [2]. Through a team-based approach, nurses collaborate with other healthcare professionals, as well as patients' families and informal caregivers, across a wide range of healthcare settings. They provide holistic care addressing patients’ physical, mental, emotional, social, and spiritual needs [3]. The fundamentals of nursing care are conceptualized within three key dimensions [4, 5]. The first dimension emphasizes integrating patients’ psychosocial needs, encompassing aspects such as communication, privacy, and dignity. The second highlights the importance of nurses’ relational actions, involving behaviors such as active listening and demonstrating empathy. This thesis focusses on the third dimension: patients’ physical needs, centered on ensuring patients’ safety, which is the focus of my thesis. Given that nurses spend the most time in direct patient care, they play a critical role in the early identification and prevention of complications [5]. Nurses’ contributions to patient outcomes are often described as nurse-sensitive outcomes. Identifying these outcomes has proven to be challenging, requiring consensus on definitions, robust evidence of nurse-sensitivity, and appropriate governance to ensure their acceptance among nurses [6, 7]. This thesis addresses two key nursesensitive outcomes: in-hospital falls and pressure ulcers. In-hospital falls are among the most frequently reported adverse events in hospitals [8]. Approximately one in four falls results in injury, with about 10% leading to serious harm [9]. In-hospital fall prevention was identified as one of the eight national improvement goals by the Dutch Health Inspectorate [10]. In 1860, Florence Nightingale stated in her Notes on Nursing: “if [the patient] has a bed-sore, it is generally the fault not of the disease, but of the nursing”[11]. Bed-sores, or pressure ulcers, remain a common issue, despite major advancements in preventive measures. In 2020, Li, Lin [12] reported a pooled prevalence of pressure injuries in hospitalized patients of 12.8% (95% CI 11.8-13.9%). Pressure ulcers contribute to pain, discomfort, prolonged hospital stays, and increased workload for nurses [13, 14].
11 General introduction 1 Nursing guidelines Nursing guidelines are developed and published for various reasons, one of which is to prevent complications. These guidelines are systematically designed to assist nurses in making informed decisions, ensuring the provision of appropriate care and the discontinuation of inappropriate care. Their goal is to reduce unwarranted variations in healthcare delivery and to provide evidence-based recommendations to optimize patient care [15, 16]. Several guidelines exist for preventing in-hospital falls [17, 18]. Most emphasize conducting multifactorial fall risk assessments and implementing targeted interventions based on identified risk factors, such as impaired mobility. Education for nurses, patients, and informal caregivers is also a common recommendation [19]. The European pressure ulcer guideline provides supporting evidence for effective prevention and treatment. A key recommendation is conducting risk assessments using clinical judgment, optionally combined with a validated risk assessment tool that the nurse is familiar with. Additional recommendations focus on selecting tailored preventive measures and educating patients [20]. However, despite the availability of guidelines, their mere existence does not guarantee effective implementation in practice [21]. Implementation science Implementation science is the scientific study of methods and strategies that promote the uptake of evidence-based practice and research into practice [22, 23]. Unlike clinical effectiveness trials, which aim to identify interventions that improve health outcomes, implementation science focuses on the actions, implementation strategies, needed to integrate these interventions into practice [24]. However, implementing guidelines to improve nursing care remains difficult [25]. To support researchers and quality improvement advisors, numerous frameworks, models, and theories (FMT) have been developed [26, 27]. Nilsen [26] provided an overview of how these different FMTs can be categorized and deployed at various stages of the implementation process. Determinant frameworks offer guidance in assessing contextual factors, barriers, and facilitators that may influence implementation success. Process models outline the critical steps involved in entire implementation process. Theories offer insights into the mechanisms of change and provide the theoretical basis for creating change.
12 Chapter 1 De-implementation Generated evidence commonly focuses on new interventions or innovations, and less frequently focusses on reducing unnecessary care, also called low-value care. De-implementation of low-value care concerns minimizing healthcare practices that provide minimal or no health benefit, low-value care is defined as: I. ineffective care which causes more harm than good II. ineffective care, which is not as effective as it could be, is continued for an extensive period, is administered too frequently, or could be replace by a care aid III. unwanted care, which does not improve patients’ condition or align with their preferences [28]. De-implementation of low-value care aligns with the principle of providing appropriate care, which highlights the need to discourage medicalization [29]. Not every carerelated issue requires a medical solution; sometimes, support from the social domain, peer assistance, physical activity, or a combination of these alternatives may be more appropriate than providing medical care [30]. Overuse of care is an important issue, particularly given the rising healthcare costs, the increasing demand for care due to populations with higher life-expectancies, and the shortage of nurses [31]. An example of overuse includes applying physical restraints in cases of delirium or following stroke or brain surgery [32]. Aims and outline thesis The objective of this thesis is to explore the role of implementation science in improving clinical nursing practice, with a particular focus on evaluating strategies for effective implementation or de-implementation. It particularly addresses the implementation of nursing guidelines to prevent complications such as falls and pressure ulcers. Additionally, it explores determinants influencing the reduction of low-value nursing care practices, within the use-case of intravenous fluids administration and prescription in hospitalized patients. The following research questions are addressed: I. Is it possible to identify effective implementation strategies to incorporate fundamental nursing care into practice? II. Is it possible to identify effective de-implementation strategies for reducing lowvalue care in nursing?
13 General introduction 1 The thesis is structured in two parts. The first part focuses on studies related to effective implementation strategies in nursing care. Chapter 2 presents a systematic review examining effective implementation strategies to implement nursing guidelines in daily practice. Nursing guidelines from all healthcare sections were considered for inclusion to get a broader sense of the implementation strategies used in the nursing field. Chapter 3 encompasses a systematic review of implementation strategies aimed to reduce in-hospital falls, one of the most common complications in hospitalized patients. Chapter 4 the identification of determinants that may impact the use of technological innovations in medical beds were explored. These smart beds are equipped with smart functions, such as a fall-detection function [33]. This part concludes with Chapter 5, which includes a process evaluation study of a pilot implementation of an AI-based pressure ulcer risk prediction model. This study investigates the proposed implementation strategies, the adaptations to the AI-based prediction model, as well as the follow-up actions based on its risk predictions. The second part of the thesis focuses on the de-implementation of low-value care in nursing. Chapter 6 presents a systematic review and meta-analysis evaluating the effects of de-implementation strategies in reducing low-value nursing procedures. As in chapter 2, studies from all healthcare sectors in which nurses are employed were considered for inclusion. Chapter 7 addresses low-value nursing care related to intravenous fluid therapy in hospitalized patients. The study presented here includes a survey study among nurses and prescribers from three hospitals to assess their knowledge and self-reported practices. Additionally, a retrospective chart review examined documentation practices to provide further insights. Chapter 8 concludes this thesis with a general discussion on the findings and methods, followed by a scenario envisioning healthcare in 2040.
14 Chapter 1 References 1. Boniol, M., et al., The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage? BMJ Glob Health, 2022. 7(6). 2. Flaubert, J., S. Le Menestrel, and D. Williams, The Role of Nurses in Improving Health Care Access and Quality., in The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity., E. National Academies of Sciences, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., Editor. 2021, National Academies Press (US): Washington (DC). 3. Jasemi, M., et al., A Concept Analysis of Holistic Care by Hybrid Model. Indian J Palliat Care, 2017. 23(1): p. 71-80. 4. Feo, R., et al., Developing effective and caring nurse-patient relationships. Nurs Stand, 2017. 31[28]: p. 54-63. 5. Kitson, A.L., et al. Reclaiming and redefining the Fundamentals of Care: Nursing's response to meeting patients' basic human needs. 2013. 6. Burston, S., W. Chaboyer, and B. Gillespie, Nurse-sensitive indicators suitable to reflect nursing care quality: a review and discussion of issues. J Clin Nurs, 2014. 23(13-14): p. 1785-95. 7. Speroni, K.G., et al., Effect of Shared Governance on Nurse-Sensitive Indicator and Satisfaction Outcomes: An International Comparison. J Nurs Adm, 2021. 51(5): p. 287-296. 8. Hempel, S., et al., Review of the Evidence on Falls Prevention in Hospitals: Task 4 Final Report. 2012, Santa Monica, CA: RAND Corporation. 9. Rubenstein, L.Z. and K.R. Josephson, The epidemiology of falls and syncope. Clin Geriatr Med, 2002. 18(2): p. 141-58. 10. Inspectie Gezondheidszorg en Jeugd, Verbeterdoelen in beeld 2022 - ziekenhuizen. 2023. 11. Nightingale, F., Notes on nursing: What it is, and what it is not. 1860, New York D Appleton and Company. 12. Li, Z., et al., Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. Int J Nurs Stud, 2020. 105: p. 103546. 13. Padula, W.V. and B.A. Delarmente, The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 2019. 16(3): p. 634-640. 14. Hauck, K.D., et al., Healthy Life-Years Lost and Excess Bed-Days Due to 6 Patient Safety Incidents: Empirical Evidence From English Hospitals. Med Care, 2017. 55(2): p. 125-130. 15. Ollenschläger, G., et al., Improving the quality of health care: using international collaboration to inform guideline programmes by founding the Guidelines International Network (G-I-N). Qual Saf Health Care, 2004. 13(6): p. 455-60. 16. Coopey, M., M.P. Nix, and C.M. Clancy, Translating Research Into Evidence-based Nursing Practice and Evaluating Effectiveness. Journal of Nursing Care Quality, 2006. 21(3): p. 195-202. 17. Registered Nurses’ Association of Ontario, Preventing Falls and Reducing Injury from Falls 2017, Registered Nurses’ Association of Ontario: Toronto, ON. 18. LeLaurin, J.H. and R.I. Shorr, Preventing Falls in Hospitalized Patients: State of the Science. Clin Geriatr Med, 2019. 35(2): p. 273-283. 19. Montero-Odasso, M., et al., World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing, 2022. 51[9]. 20. European Pressure Ulcer Advisory Panel, N.P.I.A.P., Pan Pacific Pressure Injury Alliance, , Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline., E. Haesler, Editor. 2019. 21. Burgers, J., T. van der Weijden, and R. Grol, Clinical Practice Guidelines as a Tool for Improving Patient Care, in Improving Patient Care. 2020. p. 103-129.
15 General introduction 1 22. Wensing, M., et al., Evidence for objects of implementation in healthcare: considerations for Implementation Science and Implementation Science Communications. Implementation Science, 2022. 17(1): p. 83. 23. Eccles, M., et al., Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol, 2005. 58(2): p. 107-12. 24. Powell, B.J., et al., A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 2015. 10(1): p. 21. 25. Gagliardi, A.R., S. Alhabib, and G. members of Guidelines International Network Implementation Working, Trends in guideline implementation: a scoping systematic review. Implement Sci, 2015. 10: p. 54. 26. Nilsen, P., Making sense of implementation theories, models and frameworks. Implement Sci, 2015. 10: p. 53. 27. Freitas de Mello, N., et al., Models and frameworks for assessing the implementation of clinical practice guidelines: a systematic review. Implementation Science, 2024. 19(1): p. 59. 28. Verkerk, E.W., et al., Low-value care in nursing: A systematic assessment of clinical practice guidelines. Int J Nurs Stud, 2018. 87: p. 34-39. 29. Robertson-Preidler, J., N. Biller-Andorno, and T.J. Johnson, What is appropriate care? An integrative review of emerging themes in the literature. BMC Health Serv Res, 2017. 17(1): p. 452. 30. Integraal Zorgakkoord (IZA). 2024 [cited 2024 28-10-2024]; Available from: https://www. dejuistezorgopdejuisteplek.nl/programmas/integraal-zorgakkoord/. 31. van Merode, F., et al., The Hidden Reserve of Nurses in The Netherlands: A Spatial Analysis. Nurs Rep, 2024. 14(2): p. 1353-1369. 32. Amato, S., J.P. Salter, and L.C. Mion, Physical restraint reduction in the acute rehabilitation setting: a quality improvement study. Rehabil Nurs, 2006. 31(6): p. 235-41. 33. Ghersi, I., M. Mariño, and M.T. Miralles, Smart medical beds in patient-care environments of the twenty-first century: a state-of-art survey. BMC Medical Informatics and Decision Making, 2018. 18(1): p. 63.
2 Chapter 2 Implementation strategies used to implement nursing guidelines in daily practice: A systematic review Denise Spoon Tessa Rietbergen Anita Huis Maud Heinen Monique van Dijk Leti van Bodegom-Vos Erwin Ista International Journal of Nursing Studies (November 2020)
18 Chapter 2 Abstract Objectives Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice. Design Systematic review. PROSPERO registration number: CRD42018104615. Data sources We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles. Review methods Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patientrelated nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the ‘Cochrane risk of bias tool’ for controlled studies, and the ‘Newcastle-Ottawa Quality Assessment form’ for cohort studies. Results A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled beforeafter studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n=9) and infection prevention (n=7). Studies were predominantly performed in hospitals (n=34) and nursing homes (n=11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n=36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n=52), followed by deployment of local opinion leaders (54.7%, n=29) and audit and feedback (41.5%, n=22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.
2 19 Implementation strategies used to implement nursing guidelines in daily practice Conclusions A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes. Keywords Systematic review, Nursing, Guideline adherence, Implementation science, Nursing guidelines, Implementation strategies What is already known about the topic? • Effective implementation strategies are required to successfully introduce the increasing number of available (inter)national nursing guidelines. • Publishing or disseminating a nursing guideline does not ensure its effective use in practice. What this paper adds • Besides education, a wide range of implementation strategies are used to implement nursing guidelines into daily practice. • The level of evidence for strategies directed at implementing nursing guidelines is limited due to a lack of well-conducted studies. • Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes. Funding The Netherlands Organization for Health Research and Development (ZonMw) funded this study; with the Grant No. 516004017. The sponsor had no role in collection, analysis and interpretation of data, and had no role in writing the report, and in the decision to submit this article for publication.
20 Chapter 2 Introduction Nurses are increasingly expected to provide evidence-based care intended to enhance quality of care [1]. Therefore, an increasing number of nursing guidelines are being published. A guideline in general contains evidence-based recommendations for healthcare providers, policy makers, and patients about health interventions intended to optimize patient care. Guidelines are published with the aim of reducing unwarranted variation in healthcare delivery [2-4]. Still, healthcare providers’ adherence to guideline recommendations has proven suboptimal [5-8]. Publishing or disseminating a guideline alone will not ensure adequate use of a guideline in practice. An essential second step is to apply strategies to effectively implement the guideline [9). Using a theory, model or framework, is expected to increase the probability of success of the implementation [10]. This also holds for performing a barrier assessment and tailoring strategies [11], which are often elements in theories, models or frameworks. As nursing and medical care, as well as the associated guidelines, differ in nature, other strategies may be needed to anchor nursing guidelines in practice. Previous reviews about nursing guideline implementation considered studies addressing a single implementation strategy, such as education [12] or facilitation [13], or a specific setting, such as nursing homes [14]. More and more implementation studies in the field of nursing are being conducted [15]. However, to the best of our knowledge, the implementation strategies of nursing guidelines, independent of type or setting, have not been systematically reviewed to this date. A systematic review could provide insights useful in all areas of nursing. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations in implementing nursing guidelines in practice. Methods Design This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [16]; the research protocol was registered on PROSPERO (registration number: CRD42018104615).
2 21 Implementation strategies used to implement nursing guidelines in daily practice Search Relevant studies were searched in the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019. Various search terms were purposefully selected to cover all nursing fields and implementation synonyms. A biomedical information specialist of the medical library of the Erasmus MC – University Medical Centre Rotterdam guided the search. The full search strategy is presented in Overview of the supplemental files: Supplement 1. Search strategy. The titles and abstracts of all search results were screened on relevance by DS and EI independently, according to specified eligibility criteria, using Endnote® [17]. Next, the full texts of possibly relevant articles were checked for inclusion by DS. Consensus on final inclusion was achieved by discussion (DS, EI). After the initial search, a reference and citation check was performed for all relevant studies (by DS, EI). To ensure having a complete overview of all published studies, several previously published systematic reviews were screened for relevant included studies [12-14, 18]. Eligibility criteria The scope of the review was limited to studies that considered the implementation of a nursing guideline, defined as recommendations about health interventions mainly provided by nurses (>50%), intended to optimize patient care and based on either national or international guidelines. The following inclusion criteria were applied: 1) studies had to describe the implementation strategies and outcomes of the implementation of the nursing guideline; 2) studies had to measure either the effects of the implemented nursing guideline on patient-related nursing outcomes (e.g. pain, falls, pressure ulcers), or adherence to the guideline by the healthcare professionals measured by observation or documentation; 3) studies had to include a reference group (e.g., with and without guideline). Case studies of individual patients, letters and editorials were not eligible. To optimize the objectivity of the included study results, we excluded studies with only survey outcomes. We excluded bundle implementation studies because of their protocollike characteristics. No search limitations were imposed on language. Outcome measures The primary outcomes were; 1) impact on patient-related nursing outcomes, and 2) adherence to the guideline. Studies were classified with a positive effect when a statistically significant improvement in patient-related nursing outcomes and/or adherence was reported.
22 Chapter 2 The secondary outcomes were the number and types of implementation strategies per study. The different strategies used were categorized according to the Cochrane Effective Practice and Organisation of Care taxonomy [19]. The Effective Practice and Organisation of Care taxonomy includes four domains of interventions: Implementation strategies, Delivery arrangements, Financial arrangements and Governance arrangements. Data extraction Relevant information from the included articles was extracted in a data abstraction form. This form was piloted for the first five studies and finalized after discussion (DS, TR, EI). Data included country of origin, setting, type of guideline, participants, implementation strategies, barrier assessment, use of implementation theory or framework, and outcomes. Depending on the measurements performed in the included studies, both or either of the primary outcomes (i.e. patient-related nursing outcomes or adherence to the guideline) were collected. All data abstraction forms were initially completed by DS and checked by either TR or EI. Differences were discussed when necessary. Risk of bias assessment The risk of bias of the included studies was assessed with two tools. The Cochrane risk of bias tool was used for the controlled studies [20]. This tool consists of nine items, of which each is scored high, low or unclear risk of bias. The ‘Newcastle-Ottawa Quality Assessment form for Cohort studies’ was used for cohort before-after studies [21]. The Newcastle-Ottawa Quality Assessment consists of three parts; selection, comparison and outcome. For each part a number of stars can be assigned, resulting in an overall score (good, fair or poor). Both risk of bias tools were included in the data abstraction form, initially completed by DS and checked by either TR or EI. Discrepancies were resolved by discussion. The Newcastle-Ottawa Quality Assessment form for Cohort Studies contains a question on whether the follow-up was long enough for the outcome to appear [21]. In line with recommendations of the World Health Organisation (WHO) on implementation research, we took it that a period of at least of 3 months, for baseline and after measurement each, was sufficient [22]. After discussion DS, TR, and EI jointly decided that a three-month period was sufficient. Regarding the before-after studies, a follow-up period less than three months therefore resulted in poor scores on the outcome part of the Newcastle-Ottawa Quality Assessment form for Cohort Studies. The Cochrane tool does not contain such a parameter.
2 23 Implementation strategies used to implement nursing guidelines in daily practice Analysis and synthesis Meta-analysis was precluded due to heterogeneity across studies. This heterogeneity concerned differences in guidelines, implementation strategies, outcome measures, timing of follow-up measurements, and the level of detail of the used strategies. Instead we provided a descriptive and narrative synthesis of the primary outcomes guideline adherence and patient-related nursing outcomes of the individual implementation studies. We provided a summary table with all crucial elements of the implementation processes (duration, used implementation strategies, barrier assessment, use of implementation framework, used implementation outcomes Supplement 2). The number of implementation strategies were categorized into the four EPOC categories (Delivery, Financial, Government and Implementation strategies). The total number of implementation strategies that were used in the implementation studies were summarized as median with IQR. The median number of used implementation strategies was provided for all studies, per EPOC category (Delivery, Financial, Government and Implementation strategies), for the studies that presented a positive significant change on one or more of their primary outcomes, and for the studies who reported no significant change. Further, the relative change percentage was calculated for the studies providing patientrelated nursing outcomes. Calculating a relative change of guideline adherence before the (re)implementation of a guideline is expected to be of low-value, because the adherence rate to a not yet implemented guideline will always be low at baseline. Moreover, not all studies measured adherence at baseline. Therefore, we chose not to calculate the relative change of our other primary outcome ‘adherence’. For the before-after studies, the relative change was computed by dividing the absolute outcome by the baseline level, preferably for the primary outcome of that individual study. However, in some studies the patient-related nursing outcome was a secondary outcome. For controlled studies, we first computed the relative change separately for the intervention group and the control group. Subsequently, the calculated relative change percentage in the intervention group was divided by the calculated relative change in the control group [23]. Supplement 3 Calculations of relative change percentage for the patient-related nursing outcomes provide an example of how the relative changes were calculated for both study groups. Of note is that the relative change for the before-after studies could have been overestimated due to the lack of a control group. The association between the relative change and the total number of EPOC strategies used in the included studies was visualized in a scatterplot, for the controlled studies and the before-after studies separately. The difference between the median relative change for studies using only strategies from the EPOC category Implementation
24 Chapter 2 strategies or using a combination of strategies from different EPOC categories was assessed using the Mann-Whitney U test. For comparable groups of similar guidelines with similar outcomes (at least 3 studies), the median relative change was assessed and related to the use of EPOC category implementation strategies alone or to the use of a combination of strategies from different EPOC categories. Results Study selection The initial search strategy and the cross-reference check yielded a total of 17058 records. After 8539 duplicates were removed, 8519 abstracts were assessed for eligibility. Twohundred-and-five full-text records remained and were assessed for eligibility, after which eventually 54 records, regarding 53 unique studies, were included for the synthesis' (Figure 1 Flow diagram for identification, screening and eligibility according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol). Study characteristics Study design, setting and guideline topic The 54 papers described 53 unique implementation studies on 21 guideline topics. Fifteen had a controlled before-after, randomized controlled trial or cluster randomized controlled trial design; 38 studies (71.7%) had a before-after design. Most studies were conducted in western countries (USA n=10, Netherlands n=9, Australia n=8). Half of the studies were performed in a single centre (n=27, 50.9%). Most of the guidelines regarded skin care (n=9) and infection prevention (n=7). Two studies addressed the implementation of a combination of several guidelines, respectively six [24] and three [25, 26]. The most studied setting was a hospital (n=34, 64.2%), followed by a nursing home (n=11), general practice (n=5), home care (n=2), and inpatient rehabilitation centre (n=1). Table 1 Study characteristics broken down by guideline topic shows the study characteristics of the included studies, Supplement 2 provides a more detailed description of the included studies.
2 25 Implementation strategies used to implement nursing guidelines in daily practice Figure 1 Flow diagram for identification, screening and eligibility according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol [16].
26 Chapter 2 Table 1 Study characteristics broken down by guideline topic Author, Year Country Design Setting, Single/Multi centre Guideline topic Van den Boogaard, 2009 [27] Netherlands Before-After Hospital - Intensive Care Unit (PICU and Intensive Care Unit) in a tertiary hospital, Single centre Agitation - Delirium Trogrlic, 2019 [28] Netherlands Before-After Hospital - Intensive Care Units in 1University Medical Centre and five community hospitals, Multi centre Agitation - Delirium Pun, 2005 [29] USA Before-After Hospital - Intensive Care Unit wards of the Van der Bilt University Medical Centre in Nashville and the Veterans Administration Tennessee Valley Healthcare System-York Campus, Multi centre Agitation - Delirium and sedation Edwards, 2007 [24] Canada Before-After Hospital and nursing homes - 7 hospitals + 2 home visiting nursing service organisations and one public health unit, Multi centre Combination of multiple guidelines - Asthma, breastfeeding, deliriumdementia-depression, smoking cessation, venous leg ulcers, diabetes Van Gaal (a,b), 2011 [25, 26] Netherlands Cluster Randomized Controlled Trial Hospital and nursing homes - 1 university hospital. 2 large teaching hospitals, one small hospital and 6 nursing homes. 10 hospital wards + 10 Nursing home wards, Multi centre Combination of multiple guidelines - Pressure ulcer, urinary tract infection and falls Seto, 1991 [30] China Before-After Hospital - 6 wards, 3 male, 3 female, Single centre Infection prevention - Catheter associated urinary tract infections Huis, 2013 [31] Netherlands Cluster Randomized Controlled Trial Hospital - 3 hospitals in the Netherlands, Multi centre Infection prevention - hand hygiene Rao, 2009 [32] United Kingdom Cluster Randomized Controlled Trial Nursing home - 12 nursing homes in and surrounding south London, Multi centre Infection prevention - Hand hygiene, environmental and disposal hygiene. Zhu, 2018 [33] China Before-After Hospital - Shanghai Public Health Clinical Centre, Single centre Infection prevention - Nonpharmacological fever management in HIV patients Cabilan, 2014 [34] Australia Before-After Hospital, Single centre Infection prevention - Peripheral cannula infections Frigerio, 2012 [35] Italy Before-After Hospital - 6 Orthopaedic Surgery, 2 Traumatology, 1 Neurosurgery, 1 Neurology, 1 General Surgery, 2 General Medicine, Single centre Infection prevention - Peripheral venous catheter management
2 27 Implementation strategies used to implement nursing guidelines in daily practice Author, Year Country Design Setting, Single/Multi centre Guideline topic Gomarverdi, 2019 [36] Iran Cluster Randomized Controlled Trial Hospital -Intensive Care Unit wards in two different hospitals, Multi centre Infection prevention - Standard precautions in Intensive Care Units Abraham , 2019 [37] Germany Cluster Randomized Controlled Trial Nursing home - 120 nursing homes, Multi centre Mobility - physical restraint use Ward, 2010 [38] Australia Cluster Randomized Controlled Trial Nursing home - residential aged care facilities with at least 20 beds, 88 facilities included, Multi centre Mobility - Preventing falls Köpke, 2012 [39] Germany Cluster Randomized Controlled Trial Nursing homes, 36 in total, Multi centre Mobility - Use of physical restraints Lockwood, 2018 [40] Australia Before-After Hospital - Two private hospitals in a regional area, Multi centre Mobility - Venous - thromboembolism prevention programme Törmä, 2014 [41] Sweden Controlled BeforeAfter Nursing homes - 4, Multi centre Nutritional Cahill, 2014 [42] Canada / USA Before-After Hospital - 5 participating Intensive Care Unit's (one divided in 3 units) in Canada and the USA. In non- and teaching hospitals, Multi centre Nutritional - Enteral nutrition in the Intensive Care Unit Johnson, 2017 [43] United Kingdom Before-After Hospital - tertiary neonatal intensive care unit, Single centre Nutritional - improve nutrition and growth of preterm infants in neonatal intensive care. Giugliani, 2010 [44] Angola Before-After Hospital - Therapeutic feeding centre, consists of a separate ward for severely malnourished children only, Single centre Nutritional - Malnutrition care in rural Africa Lopez, 2004 [45] China Before-After Hospital - Tertiary care teaching hospital, Single centre Nutritional - nutrition support in mechanically ventilated, critically ill adult patients. Ames, 2011 [46] USA Before-After Hospital - 4 different critical care units, Multi centre Oral Care - Prevention of VAP De Visschere, 2012 [47] Belgium Cluster Randomized Controlled Trial Nursing homes - In Flanders Belgium, Multi centre Oral care
28 Chapter 2 Author, Year Country Design Setting, Single/Multi centre Guideline topic Van der Putten, 2013 [48] Netherlands Cluster Randomized Controlled Trial Nursing homes - Within 100km radius of the centre of the Netherlands, Multi centre Oral care Lozano, 2004 [49] USA Cluster Randomized Controlled Trial Primary care paediatric practices, Multi centre Other - Asthma treatment Clark, 2001 [50] United Kingdom Before-After Hospital - a large teaching hospital, Single centre Other - Blood transfusion Tian, 2017 [51] Belgium Before-After Hospital, Single centre Other - Cancer related fatigue Van Lieshout, 2016 [52] Netherlands Cluster Randomized Controlled Trial General Practices, Multi centre Other - Cardiovascular risk management in general practices Downey, 2015 [53] Australia Before-After Hospital - A 18 bed Head, neck and lung medical oncology ward, Single centre Other - Crushing medication in case of Tube feeding only Sipila, 2008 [54] Finland Before-After General practices - 31 in total, Multi centre Other - Early detection, prevention and treatment of CVD (Cardiovascular disease) Snelgrove-Clarke, 2015 [55] Canada RCT Hospital - University affiliated teaching hospital in Atlantic, Single centre Other - Foetal Health Surveillance Featherston, 2018 [56] USA Before-After Community mental health centre, Single centre Other - Paediatric mental healthcare Jagt-van Kampen, 2015 [57] Netherlands Before-After Hospital - Academic children’s hospital, Single centre Other - Paediatric palliative care Duff, 2013 [58] Australia Before-After Hospital - a 250-bed magnet designated private hospital, Single centre Other - Prevention of venous thromboembolism Vander Weg, 2017 [59] USA Before-After Hospital - General medical units of four US Department of Veterans Affairs hospitals, Multi centre Other - Smoking cessation Reynolds, 2016 [60] USA Before-After Hospital - Neuro critical care unit, Single centre Other - Stroke care Cheater, 2006 [61] United Kingdom Cluster Randomized Controlled Trial Family practice, Multi centre Other - Urinary incontinence Savvas, 2014 [62] Australia Before-After Nursing home - Residential aged care facilities across three Australian states, Multi centre Pain - Australian Pain Society
2 29 Implementation strategies used to implement nursing guidelines in daily practice Author, Year Country Design Setting, Single/Multi centre Guideline topic Dulko, 2010 [63] USA Before-After Hospital, Single centre Pain - Cancer related Choi, 2014 [64] South-Korea Before-After Hospital - A university affiliated tertiary hospital, Single centre Pain - Cancer related Kingsnorth, 2015 [65] Canada Before-After Hospital - a large academic paediatric rehabilitation hospital, Single centre Pain - Paediatric pain Habich, 2012 [66] USA Before-After Hospital - Paediatric Intensive Care Unit at a community hospital located in a suburb of Chicago, IL, Single centre Pain - Paediatric pain assessment and management guidelines Bale, 2004 [67] USA Before-After Nursing homes - 6, Multi centre Skin care Harrison, 2005 [68] Canada Before-After Home care - The Ottawa Community Care Access Centre, an eastern Ontario home care-authority, Multi centre Skin care - Leg ulcers De Laat, 2006 [69] Netherlands Before-After University hospital, Single centre Skin care - pressure ulcer Paquay, 2010 [70] Belgium Before-After Home care - 5 participating home nursing agencies, Multi centre Skin care - pressure ulcer De Laat, 2007 [71] Netherlands Before-After Hospital - Critical care unit in an academic hospital, Single centre Skin care - pressure ulcer Beeckman, 2013 [72] Belgium Cluster Randomized Controlled Trial Nursing home - 11 wards, Multi centre Skin care - pressure ulcer care Koh, 2018 [73] Singapore Before-After Hospital - Two orthopaedic wards, Single centre Skin care - pressure ulcer prevention Rosen, 2006 [74] USA Before-After Nursing home, Single centre Skin care - pressure ulcer prevention Lopez, 2011 [75] Australia Before-After Hospital - Australian Capital Territory hospitals, Single centre Skin care - Skin tears Jolliffe, 2019 [76] Australia Before-After Other - Inpatient Rehabilitation setting, Single centre Stroke care Bjartmarz, 2017 [77] Iceland Before-After Hospital - Neurology and rehabilitation ward in university hospital, Single centre Stroke care Abbreviations: VAP - Ventilator Associated Pneumonia; CVD - Cardiovascular disease
30 Chapter 2 Participants Twenty-seven studies provided no description of the targeted professionals other than ‘nurses’. In some studies, nurse aids, student nurses or nurse practitioners were (part of) the target group, few studies targeted multiple professionals (physicians, physical therapists, etc.). The median number of involved caregivers per study (n=27) was 118 (IQR 34 – 238); twenty-six studies did not provide the number of involved caregivers. Sixteen studies did not describe any details of the targeted patients; the other studies described basic characteristics regarding age and gender. Several studies described baseline characteristics related to the guideline of interest. Regarding 35 of all included studies, the median sample size of included patients was 373 (IQR 140 – 1577); seventeen studies did not report the sample size. Also shown in Supplement 2. Description of included studies. Risk of bias assessment Nine controlled studies scored low risk of bias on most items (seven or more out of the nine items), as shown in Supplement 4 Cochrane risk of bias for controlled studies. The remaining six studies scored unclear or high risk of bias on three or more out of nine items. Thirty-two of the 38 before-after studies scored poor, assessed with the Newcastle-Ottawa Quality Assessment form for Cohort Studies (Supplement 5). Thirty of these 32 studies scored poor on the comparability part. These studies did not control for age, sex, or other factors, or did not correct for confounding when comparing the before and after groups. Four before-after studies were assessed as good; two as fair. Implementation outcomes All studies used a variety of implementation strategies, which were rarely comparable and with variable outcomes. The duration of the measurements, the intensity and the degree of details of the used strategies varied across studies. Twenty-one studies measured both patient-related nursing outcomes and guideline adherence. Eleven of these studies found a significant improvement on both outcomes. Overall, thirty-six studies (68%) measured a significant positive change on either patient-related nursing outcome measure(s) or guideline adherence. Patient-related nursing outcomes Patient-related nursing outcomes were measured in 30 studies. Twenty-one (70%) measured a significant positive change, seven measured no change, and two studies did not perform statistical tests. All studies reported findings indicating a positive change or no change. However, one study [41] reported a significant negative effect on one of the patient-related nursing outcome measures that were addressed. Törmä et al. [41]
2 31 Implementation strategies used to implement nursing guidelines in daily practice compared two implementation strategies (external facilitation and education outreach visits) in order to introduce nutritional guidelines. Besides no differences in nutritional parameters after 18 months, they found significant deteriorations for functional and cognitive status, as well as for the EQ-5D index (quality of life questionnaire), (p<0.05) in the intervention group that received educational outreach visits. Ten of the controlled studies (n=15) measured patient-related nursing outcomes. Six found a significant positive effect; four found no effect. Twenty-two of the beforeafter studies (n=37) measured patient-related nursing outcomes. Thirteen found a significant positive effect, seven found no significant effect (n=7), and two performed no statistical tests (n=2). When comparing the controlled and before-after studies, we found no significant difference between these groups on reported significant change in patient-related nursing outcomes (p≥0.05). Relative change percentage on the patient-related nursing outcomes All relative change are shown in Supplement 6 Relative change percentage in the controlled studies on the patient-related nursing outcomes and Supplement 7 Relative change percentage in the before-after studies on the patient-related nursing outcomes. The median relative change measuring patient-related nursing outcomes was 2.7% (IQR 1.0– 40.6) for the controlled studies (n=10), and 22.1% (IQR 8.7 – 81.4) for the beforeafter studies (n=19). This differed significantly between the controlled and before-after groups (p=0.009). The scatterplots for the controlled (figure 2) and before-after (figure 3) studies show that there was no association between the total number of used strategies and the relative change on the patient-related nursing outcomes. For the controlled studies the slope suggests that using more strategies, will result in a lower relative change. However, the sample is too small to conclude this (n=10). The median relative change for studies that used strategies from the EPOC category implementation strategies alone was 13.8% (IQR 3.6-81.9). For the studies that used a combination of strategies from the EPOC categories the median was 20.1% (IQR 3.267.3), however this was not statistically different (p=0.95).
32 Chapter 2 Figure 2 Scatterplot relating the total number of EPOC implementation strategies used to the relative change percentage in patient-related nursing outcomes for the controlled studies Figure 3 Scatterplot relating the total number of EPOC implementation strategies used to the relative change percentage in patient-related nursing outcomes for the before-after studies We created three groups of studies with comparable patient-related nursing outcomes regarding comparable nursing guidelines. One group consisted of five studies [69, 71-74] regarding pressure ulcers. The median relative change percentage for these studies was 27.8 (IQR 11.1 – 58.3). The outcomes were comparable between these studies,
2 33 Implementation strategies used to implement nursing guidelines in daily practice but not exactly derived in the same way. For example, Koh et al. [73] reported that they measured the incidence of pressure ulcers on the heel only. The other four studies provided no details about the location of pressure ulcers. The second group consisted of four studies [41-44] regarding nutritional intake. The median relative change percentage for these studies was 3.3 (IQR 0.9 – 11.0). The third group consisted of three studies [46-48] regarding oral care, with a median relative change percentage of 3.3. Guideline adherence Guideline adherence was measured in 44 studies, of which 26 (59,1%) showed a significant improvement, fourteen measured no change, and four did not perform statistical tests. Due to the heterogeneity in measuring adherence across all studies, we cannot draw an overall conclusion on the change in adherence rates. For example, several studies measured adherence rates regarding pain management (assessment and/or treatment). Kingsnorth et al. [65] found a significant and clinically relevant improvement in the documentation of pain scores, from 9% adherence rate at baseline to 100% adherence rate two years later. Dulko et al. [63] showed an increase in adherence rate for initial comprehensive pain assessment from 1% to 43% (p = 0.008). Twelve of the controlled studies (n=15) measured adherence. In six studies a significant positive effect on adherence was found (n=6); six found no effect (n=6). Thirty-two of the before-after studies (n=32) measured adherence. Twenty studies found a significant positive effect on adherence (n=20), eight found no effect (n=8), and four performed no statistical tests (n=4). When comparing the controlled and before-after studies, we found no significant difference between these groups on effect on adherence (Pearson Chi-Square 0.564, p>.05). Implementation strategies Description of the details of the implementation strategies varied widely between studies. Some provided a detailed process description, others just mentioned the type of strategy (e.g., audit and feedback). Table 2 provides an overview of applied strategies categorized according to the Cochrane Effective Practice and Organisation of Care taxonomy and Supplement 2 provides a detailed description of the implementation strategies. Each study used more than one strategy, with a median of 6 (IQR 4-8). Apart from one study [63], studies applied at least one educational strategy; e.g., educational material (n=38, 71.7%), meeting (n=43, 81.1%), outreach (n=10, 18.9%) or inter-professional education (n=14,26.4%). Next to educational strategies, the use of local opinion leaders (n=29, 54.7%), and audit and feedback (n=22, 41.5%) were regularly applied. Only one study, Rosen et al. [74]
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