METHODOLOGICAL CONSIDERATIONS

We used various research methods to address our research questions. These included a systematic literature review, quantitative cross-sectional questionnaire studies, a qualitative interview study, and a pre-experimental study. Within each study, specific strengths and limitations were discussed. In this paragraph, we will discuss general methodological considerations for this thesis.

The first consideration relates to the model used as a framework for this thesis: the model for effective implementation that uses a stepwise approach to accomplish practice improvement [33]. The handover study (chapter 6) followed this stepwise model from identification of the guideline to be implemented (step 1), up to the execution of the implementation strategy (step 5), which leaves only step 6 (continuous evaluation on process and outcome) unaddressed. All other studies represent important aspects of one step of the model, with a focus on the analysis of the target group, current practice and setting. Results from these studies provide input for the next steps of the model. The model was useful to assess guideline adherence from different points of view, to design our studies, and to structure this thesis. Another reason to use this generic model was the absence of a model specific for the prehospital and emergency care field. To assist future implementation, it might be useful to develop such a model.

A strength of this thesis is the use of quantitative and qualitative research designs. Due to this multi-method approach, a broad spectrum of influencing factors emerged, and the results of the studies were complementary to each other.

A weakness may be that this thesis did not cover/include the patient perspective, although the Federation of Patients and Consumer

Organizations in the Netherlands (NPCF) was invited to participate in the steering group. The perspective of the patient did not emerge from the interviews, and we also did not add this in our questionnaires. In emergency care the perspective of the patient is generally underexposed, as the contact between patient and professional often is short, and patients require urgent diagnostics and treatment. Nevertheless, it is inevitable that patients with acute needs have opinions and expectations about guideline adherence. Recent studies showed that ‘care provision’ and ‘quality of care’ are features of patients’ expectations of ED care [63,64].

The inclusion of ambulance and emergency nurses from the Netherlands, and a focus on Dutch national protocols, might involve a threat to the external validity of the studies in this thesis. In the Netherlands, ambulance and emergency nurses have several years of clinical experience, are highly trained, and have followed additional (inter)national and local training programs. This staffing of ambulances with highly trained nurses is common in other countries such as Belgium, Finland and Sweden, but uncommon for countries that staff ambulances with paramedics or emergency medical technicans [65]. Furthermore, the protocols under study in this thesis, the NPAC and NPED, are specifically designed for the Dutch setting. By including these nurses and focusing on these protocols, we might have identified factors influencing adherence related to the nurses’ specific backgrounds, or the characteristics of the Dutch protocols. Therefore, our results may be of somewhat limited value for other settings and countries.

Specifically for the systematic review in chapter 2 the first methodological consideration is the heterogeneity in designs, methods, professionals, settings, quality, and guidelines of the studies included. This heterogeneity also made it impossible to conduct a meta-analysis. The second

consideration concerns our choice to include studies on adherence in the emergency medical dispatch, prehospital EMSs, and EDs. While these three settings are often regarded as the chain of emergency care, they differ with regard to personnel, scopes of practice, education, capabilities, and status of guidelines and protocols. Despite these differences, the underlying rationale is that all professionals, irrespective of setting, are expected to provide care as described in guidelines and protocols.

For the quantitative studies reported in chapters 3 and 4, some overlapping methodological considerations exist. Both studies used questionnaires on which the ambulance and emergency nurses could report their adherence on a self-rating scaling from 0%-100%. This self-report method comes with the risk of overestimation. Our questionnaires were developed on the basis of existing instruments, literature, and expert opinion. Validity and reliability were only tested on a small scale. In addition, the use of questionnaires to identify influencing factors depends on the perceptions of the nurses. Since non-adherence might not completely occur conscious, these perceptions may not accurately reflect the magnitude of the reported influencing factors. The studies reported in chapters 3 and 4 might have suffered from selection and sampling bias. The emergency nurses who received the questionnaire were all members of the Dutch Emergency Nurses Association (DENA). The members of the DENA themselves may be a selected population with characteristics that differ from non-members, such as opinion and awareness about guidelines and protocols. Also, all nurses and physicians in chapter 5 were selected through self-selection or snowball sampling, therefore it might be possible that only professionals with a strong opinion about protocol adherence were interviewed. Furthermore, all studies identifying influencing factors focused on factors as perceived by professionals. These perceived factors may not reflect the whole range of influencing factors.

The handover study reported in chapter 6 might have suffered from the socially desirable behaviors of the observed professionals, as observations were not hidden from the professionals. This may have resulted in

overestimation on the degree of adherence, or observation of other barriers than normally would have occurred. As the ambulance service in the handover study was familiar with blended learning, a blended-learning intervention was considered for this study. Within the ‘blended learning’ concept, e-learning is used in combination with face-to-face educational meetings [66]. However, due to organizational restrictions, execution of a blended-learning intervention was not possible.

Finally, the studies described in this thesis focus on the chain of ambulance and ED settings. Although the description of the chain of emergency care in the Netherlands also includes general practitioners and the helicopter emergency medical service sometimes, which we did not include in our studies, we do think that a positive point of the current thesis is our focus on at least one part the chain of emergency care instead of just one single setting. This focus is reflected in incorporating professionals from ambulance

and ED settings in the same study, the guidelines under study (handover guideline), the intervention used (e-learning program), and multi-disciplinary composition of steering groups and committees with representatives of all professionals from the chain of emergency care. This focus provided the opportunity to study adherence to guidelines in the chain of emergency care, thus contribute to improving patient care. The focus on the total chain increased the awareness of different cultures and interests between the different departments, and the necessity of communication and integration.