IMPLEMENTING EVIDENCE

Clinical guideline development and implementation

The previous section considered the nature of evidence and the role of research as a type of evidence. National clinical guidelines are a major and significant source and

resource of evidence and while they are not the main focus of this research they are readily available to all health care practitioners.

Clinical guidelines can be viewed as a type of evidence (research based) presented in a format that is easy for practitioners to use (SIGN, 2002). However, they can also be seen as a method of the application of evidence and it is for this reason that they are included here as a bridge between evidence and implementation. The literature on guideline development and use is considerable and as they are not the main focus of this thesis, they will only be considered here in brief. However, they do have a role in EBP and to date a considerable amount of time and financial resources have been committed to their development. Much of the work relating to the development of guidelines and their use in practice has focussed on the medical profession. Indeed, many nurses view guidelines as a medical imposition to dictate nursing care (Davenport, 2000). Guidelines differ from standards, policies, protocols and procedures, although the terms are sometimes used interchangeably, which suggested that practitioners do not fully understand the differences between them (Jankowski, 2001). Guidelines provide a specific set of instructions to guide the care of patients with specific conditions (Woolf, et al., 2000a) and their main aim is to improve the quality of patient care (Woolf, et al., 2000b; Larson, 2003). Guidelines are designed to assist practitioners in making decisions about patient care, and are considered to be guidance, but if they are not followed, without a rationale for this decision, there may be professional consequences (Hewitt-Taylor, 2003a,b). Some consider this to be a threat to autonomy and accountability and the Medical Defence Union has stated that national guidelines, at least, are rigorously developed and are based on the best and most up- to-date research and knowledge and practitioners should only deviate from these with good (and documented) cause (Colbrook, 2002). It is the research basis of guidelines that lends weight to the need to use them in practice (Duff,et al., 1996). While guidelines can lead to the standardisation of care, this is not always viewed as a benefit to patients, but rather as a means of denying their individuality and removing professional nurses’ autonomy (Hewitt-Taylor, 2003a,b). This has been contested by those who support the guideline movement, as untrue, since the use of evidence in practice (including guidelines) requires that consideration be given to patients’ values and preferences and that patients are viewed as individuals. Hewitt-Taylor (2003a,b)

is more concerned with a ‘blanket approach’ to care that is guideline-based, without consideration. This has the potential to return nursing to the days of ritualistic or routine care that is provided in an unthinking manner and from which nursing has fought hard to distance itself (Walsh & Ford, 1989; Holland, 1993; Ford & Walsh, 1994).

Most national guidelines (those produced by the National Institute for Health and Clinical Excellence in England and Wales, SIGN in Scotland and the Royal College of Nursing throughout the UK) are developed by large multi-disciplinary groups, according to a lengthy and rigorous process. The validity and acceptability to practitioners of the guideline will, in part, depend on the composition of this group (Duff, et al., 1996; Cheater & Closs, 1997). Since guidelines are designed to be specific, the process begins with a specific clinical question and although it varies according to the body involved, the guideline is developed around a research or evidence hierarchy with recommendations built around the strength of the evidence (SIGN, 2002).

Although the most research has been undertaken into the development and use of national guidelines, review of the literature demonstrates that there are many local guideline development programmes in place, for example, Mank and Van der Lelie (2003). Von Degenberg (2001) highlights the risks of practitioners undertaking the development process locally, not least, the cost, the time taken and the need for specialist critical appraisal skills to ensure the quality of the finished product. Without good quality, appropriate material as the basis for guidelines, they risk either not being used, or if they are adopted into practice there may be issues relating to the quality of care. The studies undertaken by Thompson, et al. (2001a,b) have shown that many of the sources of evidence available to nurses in the clinical area, were not in fact, evidence, or research based. The other danger of local development is that of duplication (Von Degenberg, 2001). Poor inter-organisational communication may mean that there is considerable duplication of effort when it comes to guideline development. The resources required in terms of time and finance, would suggest that duplication is costly and inefficient. A review of the literature relating to guideline implementation has shown that it remains a considerable challenge to all practitioners and that a review of the strategies for implementation suggests that since most studies

have focussed on medical staff, it is not possible to make recommendations that would readily translate into nursing practice (Richens, et al., 2004). However, it was possible to conclude that while a strategy for implementation is important (Duff,et al, 1996), it must take account of several key principles which address aspects of the complex process and no single definitive strategy could be recommended from a systematic review of the literature relating to guideline implementation in nursing (Richens,et al.,2004).

Once the guideline is complete it is disseminated widely prior to the implementation process. However, it is the local adaptation and implementation of guidelines that continues to be the most considerable challenge of the process (Davenport, 2000; Richens,et al., 2004) as the development of good guidelines alone does not guarantee their use in practice (Feder, et al., 2000). National guidelines need local adaptation prior to application in the local context and this is the responsibility of each organisation (Foord-Kelcey, 2001; SIGN, 2002). Achieving ‘local ownership’ of national guidelines is an important, but not straightforward issue in securing their application to practice in the local setting (Ring, et al., 2005, 2006). In a review of literature relating to dissemination and implementation of guidelines, Cheater and Closs (1997) found that enabling practitioners to discuss national guidelines could influence their use in practice. Hedley, et al., (2003) believe that people will support an initiative, if they are involved in the development process. However, even the approach taken by the NMPDU in Scotland of involving local nurses in a national development process, did not guarantee wide-spread dissemination or use in practice (Ring, et al., 2005; Ring, et al., 2006). The complexity of the process of implementation is often under-estimated as the focus has traditionally been on the development of the guideline rather than on EBPI.

EBPI

If implementation concerns change (Mulhall & Le May, 1999) then ‘change is the raison d’etre of EBN [evidence-based nursing].’ (Flemming & Cullum, 1997). Understanding EBPI requires an acknowledgement that the focus is on processes of change.

In nursing the concept of EBPI grew from the notion of RU. In the early days of interest in RU, there was a belief that if nurses understood that they should be using research or evidence in practice, then they would do so. This was reflected in a statement from the international council of nurses, which suggested that once nurses knew about research, they would use it in their practice (ICN, 1996a,b). However, this was not the case and many of the initiatives put in place, such as research facilitators, were not based on a full understanding of what the problems were and what suitable remedies would be (Hunt, 1996). Hunt saw these attempts as simplistic and flawed because they failed to take account of the complexity of the process involved and the situations in which implementation would occur (Hunt, 1996). For many, the focus was on dissemination of research findings, which involved presenting research findings and circulating them within organisations, without any additional attempts to encourage the actual use of the research (Walter, et al., 2003). While effective dissemination has been recognised as a prerequisite of EBPI (Dickson, 1996; Smith & Masterton, 1996), this often resulted in overload of information, but little else in the way of practical implementation (Knott & Wildavsky, 1980; Nutley & Davies, 2000a). The circulation of research, without any active measures to facilitate EBPI has been shown to be ineffective (Bero, et al., 1998). There has been a growing understanding that EBPI is not the simple linear process that it is often thought to be, but a complex endeavour that may be iterative and unpredictable in outcome (Dopson, et al., 2002; Stetler, et al., 2006; Nutley, et al., 2007). There are clearly differences between the processes, purposes and outcomes of dissemination, which is concerned with communicating evidence or research and implementation, which brings about a change in practice as a result of theuseof research and evidence (Mulhall & Le May, 1999; Nutley,et al., 2007). However, the process has been acknowledged as one that has particular challenges as a result of the investment required at all levels of an organisation and the need for multiple strategies to tackle the complex process (Pearson, 2004).

In the same way that Stetler (1994) identified three different types of RU, conceptual, instrumental and symbolic or persuasive use, (also described as active and latent research use by Bartholemew and Collier (2002)), this has been more widely recognised, but much of the effort in healthcare has been on increasing instrumental use. Although not specifically stated, this is likely to be seen as the way in which the

greatest patient benefit will result. There are increasing policy demands for the demonstration of quality and benefit from health care systems (Marshall, 2001; Mannion, et al., 2001) and instrumental use of research will be more amenable to measurement and evaluation than the other types.

Originally seen as the responsibility of the individual practitioner (Hunt, 1981), there has been a growing awareness that making changes to practice is often beyond the ability of unsupported individuals who may lack the knowledge and skills to do so. There are a number of other factors that have a substantial impact on the circumstances, which facilitate or impede EBPI. These impact at individual, team and organisational level (Redfern & Christian, 2003; Rycroft-Malone, et al., 2004a,b; Ring, et al., 2005). The importance of other variables in RU/EBP was gradually recognised and the need to take account of organisational structure, personal factors and EBPI processes came to the fore (Luckenbrill Brett, 1989). Increasingly, there has been a move away from seeing the individual practitioner as key in the process; instead the organisations in which they work are viewed as having a greater influence on the ability to be successful in implementing EBP (Halliday & Bero, 2000). The context in which EBPI is taking place is seen as one of the most significant factors, but contexts vary widely and strategies for implementing EBP in one context will not necessarily be effective in another (Nutley, et al., 2000; McCormack, et al., 2002; Greenhalgh,et al., 2004; Dopson,et al., 2005; Walter,et al., 2005; Dopson, 2006). If context is seen as the setting in which EBPI will take place, within this there are other key factors, which influence the success of EBPI. These include organisational culture; the type of evidence; social factors; and the management of change process selected to facilitate the application of evidence to practice (Bucknell, 2004).

Work led by the Royal College of Nursing into the EBPI process has developed an explanatory framework (Kitson, et al., 1996; 1998; Rycroft-Malone, et al., 2002; Kitson,et al.,2008). Focussing on three elements that are seen as the most significant in the process, evidence, context and facilitation, each of these has been further researched to determine their impact (McCormack, et al., 2002a,b; Harvey, et al., 2002; Rycroft-Malone, et al., 2004a). While many of these factors have long been recognised as problems to be overcome, this has not necessarily led to effective management of them (Thomson, 1998). With the early focus being on the individual

practitioner, many of the implementation strategies, were seen as ‘bottom-up’, that is, change would begin at practice level and would spread upwards (and outwards) through an organisation. However, many of the more recent EBP initiatives, such as national guidelines and best practice statements, enter the organisation at senior nurse level and are disseminated downwards (top-down) to practice level. A combination of both methods is seen as important (Nutley,et al.,2007).

The role of context is seen as key to effective EBPI and the necessity of undertaking a diagnostic analysis (Kitson,et al., 1996; Kitson,et al., 1998; Rycroft-Malone, et al., 2002; McCormack,et al.,2002a; Rycroft-Maloneet al.,2004a; Dopson & Fitzgerald, 2005) is recognised as an important first step to understanding both the context and the role of individuals within it, as well as identifying the readiness for change (Richardson, 1999, 2000; Harvey, et al., 2002). Specific processes (and occasionally key staff with specific skills) need to be put in place to enable EBPI to take place and these need to actively involve practitioners (Perala, 2000; Newhouse, et al., 2005; 2007).

One aspect of context that occurs with increasing frequency and relates to the success of EBPI, is that of management support, administrative commitment and autonomy to make changes to practice. For example, Wallin, et al., (2006) found in a survey of contextual factors influencing the uptake of quality initiatives, that support and commitment from management and enough autonomy for nurses to make changes to practice were crucial factors. Likewise, an overview of qualitative approaches to studying RU, highlighted the importance of management support and autonomy for nurses to make research and evidence-based changes to care (Tripp-Reimer & Doebbeling, 2004). A UK-wide review of EBP progress undertaken between 1994 and 2000 also showed that management and leadership were crucial to effective EBPI, not only by the promotion of positive research cultures, but also by active involvement in supporting practitioners, through the development of specific roles and by fostering autonomy for nurses. Their role in building and maintaining positive relationships with other professions, within the wider organisational context was also seen as significant (Foundation of Nursing Studies, 2001). Studies of change in health care have continued to demonstrate the significance of context in mediating change (Pettigrew,et al., 1992a,b; Ferlie,et al., 1998; Iles & Sutherland, 2001).

One related factor features in the literature relating to change and evidence use in practice - that of culture. While it is acknowledged that culture is a complex and contested notion (Scott, et al., 2003a, b; Mannion, et al., 2005; Scott-Findlay & Estabrooks, 2006), it is nonetheless one that has some significance in understanding EBPI and nurse managers. Studies of culture have shown that it has an impact on many aspects of health care, including performance and research use (Scott, et al., 2003a,b; Sheaff,et al., (2003); Hyde & Davies, 2004; Mannion, et al., 2005; Scott- Findlay & Estabrooks, 2006). Pettigrew, et al. (1992) in their study of strategic change in the health service found that there was not one, but many cultures within the organisation and this has also been noted by other authors as significant. Traynor (1994), Mulhall and Le May (1999) and Thompson and Learmonth (2002) assert that not only does each professional group have its own culture, but so too does each clinical area, ward or unit, each directorate or clinical grouping and each hospital within a Trust. The relationship between context and culture is not clear, but both impact on each other (Pettigrew,et al., 1988b; Tod,et al., 2004; Pepler,et al., 2006). Culture has been identified as a barrier to EBP and RU and managers are thought not only to have a considerable role in influencing culture, but also to have the potential to ameliorate problems arising from organisational culture (Nolan,et al., 1998; Sitzia, 2001; Estabrooks, et al., 2002). Nurse managers have a role in shaping or informing organisational and nursing cultures and recognise that to an extent, this happens through the priority or importance that NMs attribute to aspects of practice and their wider roles (Kane-Urrabazo, 2006; McSherry, 2006; Biron,et al., 2007).

It is clear that EBPI is a complex and multifaceted process. However, certain factors have emerged that are significant in facilitating the evidence use, not least the role of context and more specifically, in relation to nursing, the part played by managers in this. Before going on to look at this in greater detail in the final section, a review of EBPI models and then strategies will be provided as a means of indicating the different ways in which evidence has been or is being implemented and to illustrate the potential ways in which nurses or NMs seeking to embark on the EBPI process, have at their disposal.

Implementation models

As outlined above, evidence and research use in practice are highly complex processes, involving many factors at all levels of health care organisations. Despite this, many attempts to conceptualise and instrumentalise the process have been undertaken. This section presents the main models that have been used to guide or underpin EBPI. Many of these were originally designed for RU, as they preceded the introduction of EBP, but nonetheless, they have the same goal and therefore they have been included. Some of the older models have been updated to reflect changes in thinking and understanding regarding implementation and the advent of EBP. This section is intended to give an overview of EBPI models and is not exhaustive. Although brief details are given in Box 2.1, fuller explanations of the models follow in the text.

Box 2.1: Examples of models used to explain and facilitate EBPI Organisational models

Conduct & Utilisation of Research in Nursing (CURN) (Horsley,et al., 1978) Iowa model (Titler,et al., 1994)

Titler & Everett model (2001) based on the diffusion of innovations

Stetler & Marram model (1976), updated in 1985, with further refinements by Stetler in 1994 and 2001.

Tyler collaborative model (Olade, 2003)

Organisational model (Kitson, et al., 1996) revised and expanded in 1998 and named Promoting Action on Research in Health Services (PARIHS). Further refinements in 2002 (Rycroft-Malone,et al.; Kitson,et al.,2008)

Organisational excellence model (Walter,et al., 2004)

Organisational and/ or individual models

Modified diffusion of innovations model (Dobbins,et al.,2002) Burrows and McLeish, research-based practice model (1995) Jack & Oldham model (1997)

Framework to assist EBP (McInnes,et al., 2001)

Research-based practitioner model (Walter,et al., 2004) Embedded research model (Walter,et al., 2004)

Explanatory models

Pipeline model ( Glasziou, 2004; 2005; Glasziou & Haynes (2005)

It is clear that the number of models conceptualising the evidence into practice process is increasing and in addition there has been a greater focus on the mechanics of EBPI than in some of the earlier models, which has led to further refinements of these over time. While models have something to add to understanding the process, many, particularly those that focussed specifically on research use, were simplistic and did not capture the complexity of the process. Many were linear in form, which failed to acknowledge that there is more likely to be a non-linear, or iterative progression through the stages from knowledge or awareness of evidence, to EBPI (Nutley,et al.,2007). Many of the earlier models failed to take account of the barriers to EBPI and presented an overly optimistic account of the process. These were built