The Role of Nursing Best Practice Champions
in Diffusing Practice Guidelines: A Mixed
Methods Study
Jenny Ploeg, RN, PhD, Jennifer Skelly, RN, PhD, Margo Rowan, PhD, Nancy Edwards, RN, PhD, Barbara Davies, RN, PhD, Doris Grinspun, RN, MSN, PhD, O.ONT, Irmajean Bajnok, RN, PhD, Angela Downey, PhD
A B S T R A C T
Background:While the importance of nursing best practice champions has been widely promoted in the diffusion of evidence-based practice, there has been little research about their role. By learning more about what champions do in guideline diffusion, the nursing profession can more proactively manage and facilitate the role of champions while capitalizing on their potential to be effective leaders of the health care system.
Aim: To determine how nursing best practice champions influence the diffusion of Best Practice Guideline recommendations.
Methods:A mixed method sequential triangulation design was used involving two phases: (1) key
informant interviews with 23 champions between February and July 2006 and (2) a survey of champions (N=191) and administrators (N=41) from September to October 2007. Qualitative findings informed the development of surveys and were used in interpreting quantitative information collected in phase 2.
Results: Most interview and survey participants were female, employed full-time, and had worked in practice for over 20 years. Qualitative and quantitative findings suggest that champions influence the use of Best Practice Guideline recommendations most readily through: (1) dissemination of information about clinical practice guidelines, specifically through education and mentoring; (2) being persuasive practice leaders at interdisciplinary committees; and (3) tailoring the guideline implementation strategies to the organizational context.
Conclusions and Implications:Our research suggests that nursing best practice champions have
a multidimensional role that is well suited to navigating the complexities of a dynamic health system to create positive change. Understanding of this role can help service organizations and the nursing profession more fully capitalize on the potential of champions to influence and implement evidence-based practices to advance positive patient, organizational, and system outcomes.
KEYWORDSnurse champions, guidelines, best practice champions, knowledge transfer, knowledge diffusion,
evidence based practice, change agents
Jenny Ploeg,Associate Professor, McMaster University, School of Nursing, Hamilton, ON;Jennifer Skelly,Associate Professor, McMaster University, School of Nursing, Hamilton, ON;
Margo Rowan,Principal, Rowan Health Policy Consulting, and Assistant Professor, Department of Family Medicine, University of Ottawa, Ottawa, ON;Nancy Edwards,Professor, University of Ottawa, School of Nursing, Ottawa, ON;Barbara Davies,Associate Professor, University of Ottawa, School of Nursing, Ottawa, ON;Doris Grinspun,Executive Director, Registered Nurses’ Association of Ontario (RNAO), Toronto, ON;Irmajean Bajnok,Director, IABPG Program & Centre for Professional Nursing Excellence, Registered Nurses’ Association of Ontario, Toronto, ON;Angela Downey,Associate Professor, University of Victoria, Business and Economics Building, Victoria, BC, Canada.
Address correspondence to Jenny Ploeg, McMaster University, School of Nursing, 1200 Main Street West, Room HSc3N28G, Hamilton, ON Canada L8N 3Z5; [email protected]
Accepted 19 July 2010
Copyright©2010 Sigma Theta Tau International doi: 10.1111/j.1741-6787.2010.00202.x
INTRODUCTION
F
or the past decade, the nursing profession has em-braced evidence-based practice to optimize patient care. Best Practice Guidelines (BPGs) have emerged as an important tool to facilitate knowledge transfer of credible research evidence (Thompson et al. 2006). Nursing best practice champions have been suggested as central to help introduce or implement and maintain the use of BPGs in the workplace (Santos 2007; Grinspun 2008). While the importance of champions in evidence-based practice has been widely promoted, there has been little research about the dimensions of their role and what they see as rele-vant activities and why (Soo et al. 2009). Greenhalgh et al. (2005) found only two survey-based studies (O’Loughlin et al. 1998; Valois & Hoyle 2000) and three case studies (Meyer & Goes 1988; Backer & Rogers 1998; Riley 2003) that supported the role of health services champions in im-plementing innovations but none of these studies focused on nurse champions. Given the potentially valuable role of champions and their perceived impact on nursing practice, it is vital to better understand how they influence the use of BPGs. As Markham (1998) suggests “knowing how cham-pions contribute to projects is critical to understanding, managing, and facilitating innovation and to training oth-ers how to champion projects” (p. 490–491). The purpose of this paper is to describe the results of a mixed methods study that examined the role of nurse champions who were trained to support the diffusion of BPGs in diverse clinical settings. We used Rogers’ (2003) definition of diffusion as the “process by which an innovation is communicated through certain channels over time among the members of a social system” (p. 11).Greenhalgh et al. (2005) defined champions as “indi-viduals who dedicate themselves to supporting, market-ing, and ‘driving through’ an innovation” (p. 126). Cham-pions have been referred to by a variety of terms such as change agents, opinion leaders, sponsors, and inter-nal entrepreneurs (Locock et al. 2001; Greenhalgh 2005). Greenhalgh et al. (2005) explain that champions are not necessarily opinion leaders as the latter may or may not support an innovation. The concept of champions was im-plied in Rogers’ (2003) seminal book on diffusion of in-novations in which he described the “change agent” as an individual who “influences clients’ innovation-decisions in a direction deemed desirable by a change agency” (p. 366). Rogers identified seven change agent roles includ-ing: (1) developing a need for change, (2) establishing an information exchange relationship, (3) diagnosing prob-lems, (4) creating an intent to change in the client, (5) translating an intent into action, (6) stabilizing adoption and preventing discontinuance, and (7) achieving a
ter-minal relationship. In a concept analysis, Thompson et al. (2006) concluded that opinion leaders, facilitators, cham-pions, linking agents, and change agents were essentially all knowledge transfer agents with different conceptual la-bels. However, there were conceptual differences among the five roles. For example, champions were perceived to maintain ongoing relationships within the organization to support their role as influential advocates, whereas change agents formed short-term relationships to foster change in the organization.
The role of champions is relatively new to nursing, although it has been studied extensively in the manage-ment and medical literature (Maidique 1980; Shane 1995; Thompson et al. 2006). Furthermore, the influence of med-ical opinion leaders in the diffusion and adoption of medi-cal innovations has been recognized for almost half a cen-tury (Borbas et al. 2000). The literature suggests that when implementing change, leadership needs to involve change agents such as local champions or clinical opinion lead-ers to influence the practice of their pelead-ers (Doumit et al. 2007). Clinical opinion leaders tend to be those individuals who are “respected sources of information” (Curran et al. 2005, p. 700) and are able to exert influence over others’ decision making, not as innovators but as early adopters who are well integrated with their peers. These are infor-mal leaders who are neither authority figures nor working in administrative roles, but practicing nurses who “walk in their [colleagues] shoes” (Borbas et al. 2000, p. 26S). They influence patterns of practice, potentially leading to higher quality care and patient outcomes, and they may accelerate the uptake of knowledge (Majumdar et al. 2007).
The literature on the role of nurse champions in facil-itating evidence-based practice is mixed (Seto et al. 1991; Hodnett et al. 1996; Solberg et al. 2000; Rycroft-Malone et al. 2004; Campbell 2008) and the nature of their role remains unclear. For example, Campbell (2008) studied the impact of nurse volunteer champions on intensive care unit nurses’ compliance with sepsis screening protocols and found improved compliance but no changes in patient outcomes. Nurse champions were trained about the role, but there is no description of what champions actually did in their roles. Hodnett et al. (1996) studied the impact of “educational influentials (EIs)” nurses who were identified by other nurses as caring nurses with expert clinical and teaching skills. EIs received a 2-day workshop, developed strategic plans to increase the amount of support their colleagues provided to women in labor, and had ongoing assistance from project staff. EIs reported using a number of strategies (range 3–8, mode =5), tailored to the hos-pital norms, to support colleagues. They viewed informal, spontaneous small group interactions as most effective and formal presentations and distribution of printed material
as least effective. However, the intervention resulted in no improvement in patient outcomes such as episiotomy rates. Finally, Seto et al. (1991) reported on the impact of opinion leaders who were staff nurses who assisted with in-service education for infection control. Head nurses nom-inated nurses who had good knowledge and/or interest in the subject and were able to communicate the new guide-line to the ward staff and effectively influence them to com-ply with recommendations. Opinion leaders participated in discussing controversial issues related to the guideline, approving the guideline and providing demonstration tu-torials to staff nurses. Findings suggest that information transmission by opinion leaders was superior to continu-ing education lectures in terms of influenccontinu-ing patient care practices consistent with the guideline. While the results of these studies help us to understand the potential impact of nurse champions, they have limitations in helping us to understand what champions did to facilitate these results. None of the studies asked the champions themselves about the roles they played in relation to the guidelines. Further, all three studies were conducted in only acute care settings; two studies were conducted in only one hospital (Seto et al. 1991; Campbell 2008), which limits the generalizability of results to other settings and health care sectors such as community and long-term care.
Context
This project is one of five in a program of research enti-tled: “Evidence Informed Nursing Service Delivery Mod-els” funded by the Canadian Health Services Research Foundation. [Correction added after online publication 17 Sep 2010: program title updated.] The program aims at bet-tering our understanding of the capacity of health systems to adopt innovative, evidence-informed models of nurs-ing service delivery. The opportunity arose to examine the best practice champion initiative of the Registered Nurses’ Association of Ontario (RNAO), Canada (Grinspun et al. 2001; Scarrow 2008; RNAO 2009a).
Since 1999, the RNAO has led the promotion and preparation of nursing best practice champions as crit-ical to the implementation of nursing BPGs (RNAO 2009b).Champions are considered change leaders. Within their employing organization they assume different roles such as bringing awareness of best practices to staff nurses and organizational leaders, facilitating the training and de-velopment of professional staff in BPG implementation, and fostering organizational changes to reinforce imple-mentation of guidelines (Edwards et al. 2005; Davies et al. 2008; RNAO 2009b). Champions volunteered and/or were designated this role by their employing organization. The champions invited to participate in this study attended a 1- or 2-day interactive learning workshop sponsored by
RNAO. The workshop content focused on three key areas: (1) evidence-based practice and the RNAO BPGs program, (2) the role of a champion, and (3) application of RNAO’s guideline implementation toolkit which outlines a practice change process.
The toolkit describes a six-phase process of guideline implementation including: (1) selection of the guideline, (2) identification of resources, (3) stakeholder identifica-tion and analysis, (4) assessment of environmental readi-ness, (5) implementation, and (6) evaluation. Workshop sessions assisted champions to plan for this process of change, beginning with the identification of an area of con-cern to nurses and patients. Champions were also assisted to plan for an assessment of current practice; to compare current practice with guideline recommendations; and to select recommendations that address important gaps in practice, ensuring that guideline implementation strategies fit the reality of the environmental context. Workshops ad-dressed generic guideline implementation strategies and resource materials as well as guidance on strategies that are tailored to the organizational context and priority prac-tice changes. Sessions also focused on how champions can implement guidelines by working with other stakeholders such as team members, managers, other professionals, and other champions. The focus and substantive content of the workshops was quite consistent from 2002 to 2006, with some updates reflecting new guideline recommendations.
Study Purpose
The aim of this study was to determine how nursing best practice champions influence the diffusion of BPG recom-mendations. A future paper will describe our analysis of the facilitators and barriers to the role of the champion, and the impact of champions on systems change through guideline spread.
METHODS
DesignA mixed methods sequential triangulation design (Creswell & Clark 2007) was used consisting of a qualita-tive phase followed by a quantitaqualita-tive phase (see Figure 1). Qualitative data from interviews were used to inform the development of items for survey instruments. At the inter-pretation stage, both quantitative and qualitative data were considered.
Phase 1 — Qualitative Interviews
Sampling. We used purposeful sampling, in particu-lar maximum variation sampling, to capture diverse per-spectives of participants (Sandelowski 1995). Champi-ons were identified from one of two groups: Group A
Figure 1. Study design: mixed methods sequential triangulation design. comprised champions from Ontario, Canada, who
at-tended a 2-day RNAO BPG workshop between June 2002 and June 2004. Group B were champions from across Canada who attended a similar 1-day workshop from February to March 2004. Participants from Groups A and B were purposively sampled on the basis of holding different positions. They included front-line nurses, educators, and administrators, and represented various practice settings including acute, community, and long-term care (LTC). Additionally, Group B was purposively sampled to repre-sent different areas of Canada (east, west, and north). A program assistant from RNAO identified potential research participants from its database of workshop participants. An e-mail was sent to 54 possible participants in Group A and 106 in Group B with a study information letter and consent form asking them to contact RNAO if they were interested in participating in the study. Once approval was received from the participant, his or her contact information and de-mographic information was released to the research assis-tant. If there was no response from potential participants, the RNAO staff member followed up with either an e-mail reminder or a telephone call. Sampling ceased when the pre-established number of participants was reached (20– 25). We estimated the sample size based on the described aim and type of sampling (Sandelowski 1995) and other published examples of mixed methods studies (e.g., Stacey et al. 2005).
Data collection. Based on the literature review sum-marized above, and previous work of team members on BPG projects (Edwards et al. 2005; Ploeg et al. 2007; Davies et al. 2008), a semi-structured interview guide (available from authors) was developed by the research team and sent to participants before the interview. Participants were asked to describe: (1) their work and roles as champi-ons, (2) factors affecting the promotion or
implementa-tion of best practices, (3) how they influenced diffusion of BPG recommendations, (4) perceived impact they had on best practices, (5) resulting changes in practices, and (6) role barriers and facilitators. This paper is focused on the roles of champions, the strategies they reported using to influence diffusion of guideline recommendations, and perceptions of the success of their BPG-related strategies. Interviews were conducted by telephone from February to July 2006 and audio-taped. A trained Masters-prepared bilingual research assistant conducted interviews in En-glish and French.
Data analysis. Audiotapes were transcribed verbatim in the source language. The French language transcripts were then translated to English by a trained translator. Transcriptions were reviewed and cleaned by a research assistant. A coding framework was developed based on the interview questions (e.g., roles, activities). This was fol-lowed by line-by-line reading of the text and revision of the coding framework to reflect the data. A principal inves-tigator and a research associate developed the initial cod-ing categories. Two research assistants coded three or four transcripts and worked with the principal investigator and research associate to further refine these categories, which were then applied to all transcripts. Main categories and sub-categories were identified through review of the data within and across codes and were reviewed by a third team member. Inconsistencies were solved through consensus among coders.
Phase 2 — Quantitative Surveys
Survey development. The literature on diffusion of in-novations informed the constructs underlying the survey, while codes and categories from the Phase 1 qualitative analysis were used to develop the items. Items were re-viewed by team members for face and content validity
and further refined through pilot testing with a small sample of champions and administrators. Pilot data were not used in the final analysis. The survey had six main areas (i.e., characteristics of champions and their organizations, guidelines implemented, champions’ role, critical mass of champions, impact of champions, and facilitators and bar-riers to champion activities). Survey items described in this paper used one of two formats, each with a five-point Likert scale response option: (1) “Please rate the extent to which you as an RNAO best practice champion have been successful in applying the following strategies to fa-cilitate the use of best practice guidelines” (1=not at all successful to 5 = very successful), and (2) “Please rate the extent to which the following practice changes have occurred because of your work as an RNAO Best Practice Champion” (1=not changed at all to 5=changed to a large extent). Other questions were dichotomous, multiple choice or open-ended.
Sampling. All champions (N =894) who had com-pleted RNAO’s champions’ workshop between June 2002 and December 2006 and administrators (N=110) from their organizations were included in the sampling frame developed by RNAO from its database of workshop par-ticipants. The sampling frame for the survey participants included participants in Group A of the qualitative inter-views. However, since there were no personal identifiers included on the survey, matching the responses of those who participated in both the survey and interviews was not possible. RNAO sent an e-mail invitation to all who were listed in the sampling frame inviting them to complete the survey. Nine e-mail addresses for champions bounced back leaving a total of 885 potential respondents for that group. The invitation provided an online link to an En-glish version of the survey. Participants could complete the survey using Survey Monkey or they could download or request the survey and mail or fax their responses. The survey was available online from September to October 2007. Reminder e-mails were sent to all respondents 1 and 2 weeks after the initial recruitment.
Data analysis. Data captured in Survey Monkey were downloaded into Excel and then exported into SPSS and analyzed using descriptive statistics. Independent t tests were used to compare mean survey item ratings be-tween champions and administrators. We then coded the champions into three groups (i.e., administrators, educa-tors/clinicians such as Clinical Nurse Specialists and Nurse Practitioners, and front-line staff) and conducted one-way ANOVAs to compare mean survey item ratings among these three groups. Qualitative information was compared against the quantitative information collected in Phase 2 to help interpret the overall findings.
Ethics
The University of Ottawa Health and Social Sciences Ethics Board and the McMaster University Research Ethics Board provided ethics approval for this study. All participants re-ceived information letters about the study. Participants in qualitative interviews signed consent forms while comple-tion of quantitative surveys implied consent of participa-tion in Phase 2.
FINDINGS
Participant CharacteristicsA total of 23/26 (88.5%) champions participated in the qualitative interviews, 12 from Group A (2-day workshop from Ontario only) and 11 from Group B (1-day workshop pan-Canada). A total of 191/885 (21.6%) champions and 41/110 (37.3%) administrators completed the quantitative survey. Most interview and survey participants were fe-male, employed full-time, and had worked in nursing for over 20 years (See Table 1). A higher percentage of survey respondents worked in the acute and long-term care sec-tors than in the community sector. The three BPGs most commonly implemented were risk assessment and pre-vention of pressure ulcers, assessment and management of pain, and prevention of falls and fall injuries in older adults.
Diffusion Strategies of Best Practice Champions
Overall, the qualitative and quantitative findings indicate that champions are change agents who take on multi-dimensional roles, such as educator, facilitator, mentor, leader, policy developer, and evaluator, to diffuse a guide-line. Champions use many strategies at multiple organiza-tional levels, attending to various stakeholder groups and tailoring their diffusion strategies to the unique organi-zational context. Three main categories and related sub-categories related to champions’ diffusion strategies were identified (see Table 2) and are described below. Partici-pant quotations from qualitative interviews are identified by group and health care sector.
Dissemination of information about clinical practice guidelines. Champions disseminated information about clinical BPGs primarily to nursing staff. This information included the rationale for using BPGs in nursing, guide-line specific recommendations and how to apply them, suggestions for problem solving related to guideline imple-mentation, and communicating about guideline resources. Champions described education and awareness activities, and acting as a resource to support and mentor other nurses in their organization. Both champions and administrators rated the integration of BPGs into ongoing programs and educational activities as lower than the provision of BPG-focused activities (see Table 3).
TABLE 1
Demographic description of respondent groups
RESPONDENT GROUPS
PHASE 1 PHASE 2 PHASE 2
CHAMPIONS CHAMPIONS ADMINISTRATORS
INTERVIEWS SURVEY SURVEY
ITEM (N=23) (N=191) (N=41) Gender Female 21(91%) 174(91%) 35(85%) Male 2(9%) 8(4%) 2(5%) Missing — 9(5%) 4(10%) License RN 23(100%) 163(85%) 34(83%) RPN — 13(7%) — Missing — 15(8%) 7(17%)
Highest level of education
Diploma 6(26%) 72(33%) 8(15%)
Baccalaureate degree in Nursing 9(39%) 56(26%) 13(24%)
Certificate post BScN — 15(7%) 6(11%)
Master degree (nursing or other) 5(22%) 49(23%) 11(20%)
PhD (nursing or other) 3(13%) 13(6%) 12(22%)
Missing — 18(8%) 4(7%)
Length of time in practice or Nursing (Years)
0–10 3(13%) 23(12%) 2(4%) 11–20 5(9%) 49(26%) 6(15%) 21–30 8(35%) 58(30%) 12(29%) >30 7(30%) 46(24%) 13(32%) Missing — 15(8%) 8(20%) Setting Acute 7(30%) 99(52%) 17(41%) Community 9(39%) 27(14%) 3(7%) Long-term care 7(30%) 54(28%) 13(32%) Other — 2(1%) 4(10%) Missing — 9(5%) 4(10%) Current position Staff nurse 6(26%) 54(28%) — Team leader 2(9%) 9(5%) — Manager 5(22%) 15(8%) 5(12%) CNS 3(13%) 24(13%) — Nurse practitioner — 11(6%) — Clinical educator 3(13%) 27(14%) — Director or administrator 4(17%) 26(14%) 17(41%) Coordinator — 14(7%) 17(41%) Other — — 15(37%) Missing — 11(6%) 4(10%) Employment Full time 20(87%) 157(82%) 36(88%) Part time 3(13%) 18(9%) 1(2%) Other or missing — 16(8%) 4(10%) (Continued)
TABLE 1
(Continued)
RESPONDENT GROUPS
PHASE 1 PHASE 2 PHASE 2
CHAMPIONS CHAMPIONS ADMINISTRATORS
INTERVIEWS SURVEY SURVEY
ITEM (N=23) (N=191) (N=41)
Length of time in current organization or agency (years)
0–5 8(35%) 50(26%) 20(49%) 6–10 6(26%) 31(16%) 9(22%) 11–20 4(17%) 54(28%) 5(12%) 21–30 4(17%) 29(15%) 1(2%) >30 1(4%) 11(6%) 1(2%) Missing — 16(8%) 5(12%) TABLE 2
Diffusion strategies of champions
Dissemination of information about clinical practice guidelines: Education and awareness
Acting as a resource to support and mentor nurses Champions as persuasive practice leaders:
Working through committees
Participating in and leading interdisciplinary teams
Tailoring guideline implementation strategies to the organizational context:
Exploring, auditing, monitoring of best practices Documentation changes to incorporate best practice
recommendations
Education and awareness. In qualitative interviews, champions described actively raising awareness about BPGs through the use of formal and informal education strategies. They viewed this as a core feature of their role in guideline diffusion. Most efforts were directed at orga-nizing or delivering face-to-face, group education sessions, workshops, or presentations to educate staff. “We do skills day a couple times a year. . .we’ve made sure that anybody attending knows about best practices, either generically or focused on a best practice, so that information is get-ting out there” (A104, Acute). Several champions provided electronic or video-based learning, for example, through an “interactive web-based learning CD (with) links to RNAO and other wound care sites” (A109, Acute). Champions
TABLE 3
Mixed methods results of champions diffusion methods: dissemination of information about BPGs
CHAMPIONS ADMINISTRATORS
QUANTITATIVE RESULTS N MEAN SD MEDIAN N MEAN SD MEDIAN pVALUE
Qualitative Category i) Education and Awareness:
Raising awareness∗ 117 3.94 0.89 4 29 3.86 0.88 4 0.67
Sharing information∗ 116 3.97 0.88 4 29 3.83 0.80 4 0.45
Providing education∗ 115 3.82 0.94 4 28 3.71 1.05 4 0.61
Integration of BPGs into staff orientation∗∗ 113 3.45 1.15 3 26 3.58 1.03 4 0.67 Integration of BPGs into ongoing education∗∗ 114 3.44 1.12 3 26 3.77 0.86 4 0.16 Qualitative category
ii) Acting as a Resource to Support and Mentor Nurses:
Mentoring staff∗ 108 3.94 1.08 4 28 3.71 1.05 4 0.33
Role modeling for staff∗ 114 3.89 1.08 4 29 3.93 1.00 4 0.87
∗Quantitative item format: Please rate the extent to which you as an RNAO Best Practice Champion have been successful in applying the following strategies
to facilitate the use of BPGs (1=not at all successful, 5=very successful).∗∗Quantitative item format: Please rate the extent to which the following practice changes have occurred because of your work as an RNAO Best Practice Champion (1=not changed at all, 5=changed to a large extent).
TABLE 4
Mixed methods results of champions’ diffusion methods: champions as persuasive practice leaders
CHAMPIONS ADMINISTRATORS
QUANTITATIVE RESULTS N MEAN SD MEDIAN N MEAN SD MEDIAN pVALUE
Qualitative Category
(i) Working through Committees:
Working through existing committees∗ 97 3.55 1.32 4 24 3.62 1.10 4 0.79
Qualitative category
(ii) Participating in and Leading Interdisciplinary Teams:
Leading interdisciplinary teams∗ 115 3.82 0.94 4 27 3.33 1.14 3 0.46
Participating in interdisciplinary teams∗ 109 3.72 1.19 4 28 3.79 0.92 4 0.77
∗Quantitative item format: Please rate the extent to which you as an RNAO Best Practice Champion have been successful in applying the following strategies to facilitate the use of BPGs (1=not at all successful, 5=very successful).
were strong advocates for the education of all staff related to the guidelines: “I ensured that my team had one hun-dred percent taken the e-learning” (A102, Community). Staff members were most commonly made aware of the work of champions and the guidelines through posters, postings, newsletters, journals, or bulletins.
In many cases education was described as ongoing and designed to “continuously reinforce. . .best practices” (B111, LTC). Timing was also strategic, for example, to orient new nurses: “the new employees all get the com-plete session” (B102, Community). At other times training was reactive, for example, if there was a change in pol-icy or procedure based on the guideline: “You send out the new policy and procedure. . .If it’s a major change, then we make sure there’s an educational component that accompanies it” (B112, Community). Quantitative data from champions and administrators (see Table 3) suggest that providing education and raising awareness were per-ceived as successful strategies due to their relatively high ratings (3.71 to 3.94 on a five-point scale). Quantitative ratings of the success of ongoing education and staff ori-entation efforts were slightly lower varying from 3.44 to 3.77.
Acting as a resource to support and mentor nurses.
There were many ways in which champions acted as valu-able resources to facilitate guideline diffusion within an organization. Most commonly, they were perceived to be knowledgeable or experts about the guidelines: “I am used as a resource in my workplace and so what I learn from the best practice guidelines, I can pass on to other peo-ple” (B113, Community). They often provided leadership for guideline implementation: “I’m one of the clinical lead-ers.. . .That’s in my job description and I guess that’s one of my passions. . .to ensure that the residents in our facility are being cared for with best practices, and evidence-based practice” (B110, LTC). Champions frequently described how they helped and supported nurses through their role
as a resource on BPGs: “So I’m sort of trying to support the nurses any way I can to bring their practice up and ensure that they know what the best practices are” (B110, LTC). Mentoring and/or role modeling was a key feature of their resource function, “mentoring in terms of, you know, really trying to emphasize the whole idea of evi-dence based practice that it wasn’t just okay [to say], ‘This is the way I do it.’ [Instead we were encouraging nurses to say] we do it this way because the evidence suggests (so)” (A113, Community). In the quantitative surveys (Table 3), champions and administrators perceived that champions had been quite successful in using role modeling and staff mentoring to facilitate the use of BPGs, as evidenced in ratings of 3.71 and higher.
Champions as persuasive practice leaders. The sec-ond main category describing the diffusion strategies used by champions involved their role as persuasive practice leaders (Table 4). Champions worked with staff, peers, other professionals, and senior managers on a variety of groups and committees to persuasively advocate for evidence-based practice through BPG utilization. Most commonly, they worked through existing committees and interdisciplinary teams.
Working through committees. Champions often de-scribed how they worked through a complex and inter-linked system of organizational groups and committees to advocate for best practices. One champion described this process as: “. . .you start with the working group. . .The multidisciplinary team that works on it, once they reach a consensus, the working group brings the documents to a key person. That person will go around and present things to the committees, there is a medical consultation committee. . .there’s the research committee, there’s the ethics committee, and. . .they all have to be approved by everyone involved after the baseline work” (B104, Acute). Although champions identified several types of
committees that were pivotal for the BPG diffusion pro-cess in their organization, guideline-related committees were mentioned most often. Nursing executive committee, nursing practice councils, and research committees were also frequently identified. Quantitative results (Table 4) suggest that working through committees was viewed by both champions and administrators as a successful cham-pions’ strategy to facilitate guideline diffusion (rating 3.55 and 3.62, respectively).
Participating in and leading interdisciplinary teams.
Champions indicated that although their team work in-volved mostly nurses, they also interacted with a host of other interdisciplinary team members, particularly phys-iotherapists, dieticians/nutritionists, occupational thera-pists, physicians, and pharmacists to facilitate guideline diffusion. Many of their teams were involved in various activities related to the BPG including informing others about guideline implementation activities and providing regional leadership on guideline usage. Most notably, the team brought best practice matters to various people and committees for discussion and/or approval, “anything re-lating to OT (Occupational Therapy) or Physio (Physio-therapy), our members of the team would then take that back to those people and discuss things that were going on.. . .We spoke with [nurses] on the floor” (A109, Acute). Quantitative results (Table 4) suggest that the champions’ role in leading or participating in interdisciplinary groups was a successful strategy in guideline diffusion (average ratings for administrators were 3.33 and for champions were 3.82). It is important to note that champions and ad-ministrators were not from the same organizations so we cannot infer that champions had more negative or posi-tive perspecposi-tives of success of BPG implementation than administrators.
Tailoring Guideline Implementation Strategies to the Organizational Context
The third main category describing the diffusion strate-gies used by champions involved their role in tailoring the guideline implementation strategies to the organizational context. We use the term tailoring as it relates to Rogers’ (2003) statement that “change agents should be aware of their clients’ felt needs and adapt their change programs to them” (p. 375). Study results suggest that champions adapted some of the supporting materials contained within the guideline or the toolkit for their work context. For ex-ample, champions collaboratively made decisions about which guideline recommendations to implement, which educational strategies to use, and which assessment tools to put in place. The two strategies used most commonly to adapt change to the organizational context were explor-ing, auditexplor-ing, and monitoring best practices, and policy
and documentation changes to incorporate BPG recom-mendations.
Exploring, auditing, and monitoring of best practices.
In the qualitative interviews, champions described their roles in exploring, auditing, and monitoring best practices. Champions most often explored the literature to iden-tify relevant guidelines and to make comparisons among guidelines. For example, they searched for available guide-lines to appraise the evidence and decide which one to use: “I would go to the web. . .and start looking for best prac-tice guidelines and what can we do to incorporate that into our practice. It’s based on what the population need is at the time” (B101, LTC). Assessing guideline use was also an important activity for champions, primarily in the form of “audits”: “We audit certain what I’ll call nursing-specific clinical indicators and there were four that we targeted at that point in time and continue to target now” (A110, Acute). Some champions monitored changes in guideline knowledge as a result of education. Champions monitored practice gaps or needs in the organization that could be addressed through guideline use: “our department will be looking at that data and identifying areas of gaps and it will be my responsibility along with some of my colleagues here to develop protocols for figuring out how we’re going to fix that and how we’ll bring our quality up” (B101, LTC).
Finally, some champions used feedback strategies to re-inforce the positive patient outcomes resulting from guide-line implementation within the organization: “So during Nurses’ Week. . .I talked about. . .what our prevalence and incidence rates are in skin breakdown. . .I talked about what strategies had been implemented in the last year, and talked about the difference between last year’s results and this year’s. So there’s some reinforcement that the changes that they are making at the bedside are really translat-ing into good patient outcomes” (A110, Acute). Results of the quantitative surveys (see Table 5) indicate that both champions and administrators assessed that champions had been quite successful in providing feedback about out-comes resulting from implementation of BPGs (ratings of 3.31 and 3.3, respectively).
Policy and documentation changes to incorporate BPG recommendations. Many champions were involved in de-veloping organization-specific policies and documents to help diffuse BPGs within their setting. These were most fre-quently labeled by respondents as “policies,” “procedures,” “protocols,” “practices,” or “standards.” These changes were made, most commonly, to set the expectations about the standard of care and therefore “harmonize” the prac-tice: “One thing that was really important was to get every-body on the same pain scale, because of the five different buildings [where our health care organization is located]
TABLE 5
Mixed methods results of champions diffusion methods: tailoring guideline implementation strategies to the organizational context
CHAMPIONS ADMINISTRATORS
QUANTITATIVE RESULTS N MEAN SD MEDIAN N MEAN SD MEDIAN pVALUE
Qualitative Category
i) Exploring, Auditing, Monitoring of Best Practices:
Providing feedback related to outcomes∗ 106 3.31 1.27 3 27 3.30 1.07 3 0.96
Qualitative Category
(ii) Policy and Documentation Changes to Incorporate Best Practice Recommendations:
Integration of BPGs into organizational policies∗∗ 113 3.48 1.23 4 26 3.92 1.06 4 0.09 Integration of BPGs into organizational documentation∗∗ 114 3.37 1.17 3 26 3.58 1.03 4 0.40
∗Quantitative item format: Please rate the extent to which you as an RNAO Best Practice Champion have been successful in applying the following strategies to facilitate the use of BPGs (1=not at all successful, 5=very successful).∗∗Quantitative item format: Please rate the extent to which the following practice changes have occurred because of your work as an RNAO Best Practice Champion (1=not changed at all, 5=changed to a large extent).
we were not all on the same pain scale. So now, everybody is on the 0 to 10. And that meant working with forms commit-tee and some of these other groups to be able to change the documentation. . .” (B105, Acute). A few champions sug-gested that documentation about the guideline also served as a “reminder,” “trigger,” or “reinforcer” for staff: “We actually changed how we documented or what our chart looked like to trigger staff to be looking for things that they need to be looking for” (A101, Acute). Standard doc-umentation supported consistent data collection which, as one respondent described about pain management for res-idents, led to improved quality of care: “Documentation was really not [consistent] and the residents were suffer-ing.. . .Having that data [on frequency of vocalization] is really helpful to nurses to present to the doctor [to]. . .find what. . .kind of medication can be implemented [so] that residents [are] less suffering the pain” (A106, LTC). In the quantitative survey, champions and administrators rated the extent to which, due to the work of the champion, BPGs were integrated into documentation at the organi-zational level (3.37 and 3.58, respectively) and integrated into policy at the organizational level (3.48 and 3.92, re-spectively) (see Table 5). These results suggest that these were important diffusion strategies used by champions.
Group Differences
We found no statistically significant differences on mean survey item ratings between champions and administra-tors (see Tables 3–5). We had hypothesized that the mean survey item ratings by champions in more formal leader-ship roles with some referent power, such as managers and educators/clinicians, might differ from the mean ratings of champions who were front-line staff with less authority. However, we found no statistically significant differences between the mean survey item ratings of these three groups of champions on any of the survey items.
Study Limitations
Study strengths include the mixed methods design and our triangulation of findings, approaches validated in the nursing literature (Foss & Ellefsen 2002; Halcomb & An-drew 2005). Another important study strength was the inclusion of participants from multiple sites and sectors of health care (e.g., acute, long term and community care). However, there are several limitations. Of primary concern is the low response rate for the quantitative survey for both administrators (37.3%) and champions (21.6%). It is pos-sible that those who responded were enthusiastic about their role as champions because they had been success-ful in guideline implementation, while those who did not respond were unable to implement and sustain an active champion role in their institution after the workshop and, therefore, declined to participate.
Despite these low response rates, triangulation of sur-vey data with interview information identified consistent categories for the roles of champions. This suggests that both types of data sources were necessary but insufficient on their own to defensibly and meaningfully understand and explain the phenomena under study. In accordance with our ethics protocol, the data collection method was designed to protect the anonymity of nurse champions and administrators listed in the RNAO database. Therefore, it was not possible to identify survey non-respondents and to compare them to respondents. It was also not possible to identify whether champions and administrators who answered the survey were from the same institution or site nor was it possible to identify any overlap between champions completing the survey and those involved in qualitative interviews. We do not have any data indicating the circumstances through which these champions took on the champion role, that is, whether they volunteered or were designated by their sponsoring agency. There may be a self-selection bias here in that those nurses who are
more confident in their role, empowered by their man-agers, and able to work more effectively with leaders in their organization are more likely to agree to take on the role of champion. If this is the case, there may be fewer differences among champions holding formal positions at different system levels than one would find if nurses were randomly assigned to the champion role. We do not advo-cate for the latter approach, believing that it is likely more cost-effective to begin with champions with demonstrated leadership qualities, but this assumption requires further study. Other study limitations include: (1) the potential for socially desirable responses, given the relationship of research team members with the RNAO; and (2) the lack of linkage of self-reports to any patient outcome data. In view of these study limitations, we acknowledge the tenta-tive nature of the study findings and the need for further research in this area.
DISCUSSION
This study fills a gap in the literature on the roles of nurs-ing best practice champions in the diffusion of BPGs. Our research findings indicate that champions held multiple roles with different functions and aims. These findings partly support the work of Thompson et al. (2006), who viewed champions as one of five conceptually unique yet overlapping knowledge diffusion roles. First, champions were active knowledge disseminators of clinical informa-tion to nurses. In this role they were trained educators who offered support and mentoring to peers and staff. They were comparable to the “facilitator” role described by Thompson et al. (2006): “Facilitators are active and dy-namic, concerned with helping, enabling, and developing a learning process” (p. 694, citing Macneil 2001; Harvey et al. 2002). This champions’ role was also similar to the change agent roles described by Rogers (2003) of devel-oping a need for change and establishing an information exchange relationship.
Secondly, champions were persuasive practice leaders who worked with various disciplines in all types and lev-els of positions to explain, convince, and help ensure that guideline implementation and recommendations sat-urated the organization. The complex web of committees and working groups they had to engage was particularly challenging in acute care settings. They worked under the assumption that interpersonal contact that cuts across interdisciplinary boundaries improves the likelihood of wider behavioral change. Functioning in this way, they were comparable to the “opinion leader” role as “influen-tials. . .having the ability to persuade others” (Thompson et al. 2006, p. 693). This role of champions was related to Rogers’ (2003) change agent roles of creating an intent
to change and translating that intent into action. Other researchers have identified this role as effective in achiev-ing behavior change in health care (Grimshaw et al 2001; Locock et al. 2001).
Finally, champions were adapters who tailored the BPG implementation strategies to the organizational context. They did this by exploring, auditing, and monitoring their practices to improve care delivery and patient outcomes. Champions attempted to contextualize BPGs to make them more accessible and applicable to staff and patients/clients by preparing site-specific policies and procedures. In this capacity they were similar to “linking agents [who] direct their actions at improvement of individual or institutional performance. . .[and] use knowledge or knowledge-based products and services as key instruments for improve-ment” (Thompson et al. 2006, p. 695–696). Indeed, Rogers (2003) claims that “change agents’ success in securing the adoption of innovations by clients is positively related to the degree to which a diffusion program is compatible with clients’ needs” (p.375).
Does tailoring guideline implementation strategies to unique organizational contexts have a risk of potential de-viation from the “evidence base” in the guideline? In many ways, introducing a guideline is similar to how Denis et al. (2002) explain diffusion patterns for complex health care innovations: “Each innovation has a hard-core element that is well defined and fixed and a soft periphery that is less clear and more flexible to manipulate by the adopting system” (p. 65–66). Further research is needed to under-stand how different actors, including champions, negotiate the meaning of guidelines around the soft periphery.
Research indicates that no matter how compelling the evidence, changing clinical practice, as in the case of BPGs, requires multiple strategies tailored to organizational con-texts (Gifford et al. 1999). As potential leaders of a multi-faceted change strategy inherent in implementing BPGs, the nurse champions’ role needs to be multidimensional, involving, for example, education of staff, organizational policy development, and outcome evaluation. It is ex-pected that the important different roles held by champi-ons would be negotiated and adapted to the organizational context and setting in which BPGs are implemented.
Clarifying concepts related to knowledge transfer agents, such as champions and opinion leaders, is impor-tant to remove the ambiguity of these concepts and enable readers to make valid comparisons across studies. This re-search has attempted to elucidate the concept of nursing best practice champions based on the belief that under-standing this role is important in continuing to move to evidence-informed nursing practice. However, there are differences in how some of the leading authors on diffu-sion of innovations approach these concept boundaries.
For example, Greenhalgh et al. (2005) are cognizant of role distinctions and suggest “the literature on champi-ons (as distinct from opinion leaders) in implementing innovations in health service delivery and organizations is sparse” (p.129). Moreover, Rogers (2003) does not re-fer to the concept of champions, instead using the more general classification of change agents. Indeed, the issue of exploring potential differences or overlap among the various knowledge transfer agents is an area worth further discussion and research.
IMPLICATIONS FOR PRACTICE AND
RESEARCH
Results of our research support the importance of nursing best practice champions in bringing about evidence-based awareness and practice to health care organizations. To maximize the potential contribution of their roles, there is a need for adequate training of champions. Such training would address a broad range of knowledge and skills such as knowledge transfer, policy development, research and evaluation, leadership, and mentorship. Further, champi-ons are likely to require ongoing education and support to be effective in their roles.
There are a number of unanswered research areas and questions about nursing champions that were identified in conducting this research. First, we do not know if certain characteristics of champions (e.g., position in the orga-nization, credibility among their peers, experience in the role, reasons for taking the champions workshop, previ-ous committee or work group membership) are associated with their effectiveness. For example, are nurse educa-tors or nurse managers, because of their position within the organization, more effective than front-line nurses in navigating the complex system requirements for guideline diffusion? What criteria should be used to select nursing champions? Future research should include more sensi-tive measures that specifically examine the power, span of control, and authority of champions in these positions and the relationships between each of these elements of power and authority to the work of the champions. Second, we do not know which organization supports are required for success of the nursing champions’ role, and if some organi-zational supports are more important than others. For ex-ample, how important is managerial or leadership support, or formal or informal recognition of the champions’ role, to their success? Buchanan et al. (2007) stated that “the more change agents and influencers there are dispersed across the organization in positions not normally considered as leadership roles, the more likely are changes influenced by them to be sustained” (p. 150). Thus, a third area of pos-sible research is related to identifying what constitutes a
“critical mass” of champions within a unit or organization that is required for optimal impact of champions’ roles and how a critical mass of champions can successfully lever-age support from an organization for practice changes. Fourth, it would be interesting to study further the types of decision-making associated with “tailoring” guideline implementation strategies in terms of using common ap-proaches to change versus building unique apap-proaches for unique populations and settings. Furthermore, it would be useful to differentiate the types of tailoring by considering, for example, tailoring an implementation strategy to fit a local context or to fit multiple sites to enhance adoption of a guideline.
Finally, a prospective intervention study with a control group could be used to examine the impact of champions’ roles and strategies on a range of client, nursing practice, organizational and system outcomes. This study design could include interviews with champions before and after their training, following them for a 1-year period to exam-ine more fully how their role evolves over time. Multiple interview points with timing closer to the champions’ ac-tual implementation of specific strategies could provide a rich description of when and under what circumstances certain strategies are used or not used. As part of this assessment, it would be useful to include measures of pre-existing roles on decision-making committees within their work organization and externally. Types of outcomes to be assessed could include: client outcomes specific to the BPG recommendations implemented; nursing practice changes such as guideline-related patient assessment and education activities; organization outcomes such as improved inter-professional collaboration on guideline-related topics; and system outcomes such as the development of collaborative community partnerships related to the BPG. Social net-work mapping might be used to examine how champions link with and the strength of their ties with both peers and those in positions of authority. A wait list control group of nurses targeted for future champion training could be considered.
CONCLUSIONS
By learning more about what nursing champions do, ser-vice organizations, academia, and the nursing profession can more fully capitalize on their leadership potential to in-fluence, implement, and sustain evidence-based decisions and practices to advance positive patient, organizational, and system outcomes. Our research suggests that nurs-ing best practice champions may be well positioned to promote an evidence-based culture and respond to the needs of point of care nurses and other health profes-sionals in adopting evidence-based practices. Although the
champions’ role is a challenging one, involving multi-dimensional and multi-level strategies, it is well suited to navigating the complexities of our dynamic health sys-tem to create positive change. However, more research is needed to extend our understanding of not only the roles and strategies used by champions to diffuse guidelines, but also the impact of these roles and strategies at patient, nursing practice, organization, and systems levels.
ACKNOWLEDGEMENTS
This project is part of a larger program of research entitled “Evidence-Informed Nursing Service Delivery Models,” funded by the Canadian Health Services Research Founda-tion under its Research, Exchange and Impact for System Support (REISS) competition. Some of Phase 1 interviews were funded by Office of Nursing Policy, Health Canada. We gratefully acknowledge the work of statistician Noori Ahktar-Danesh who provided support for the quantitative analysis. We are most appreciative of the qualitative coding conducted by research assistants Marie-Jos´ee Perrier and Lyndsay Pouliotte-Beneteau. Finally, we thank Nathalie Lapierre for her involvement in question development, re-cruitment, interviews, and preliminary data analysis for the qualitative study. Funding for the RNAO workshops in Ontario was provided by the Ontario Ministry of Health and Long-Term Care. The pan-Canadian workshops were funded by Health Canada. Dr. Ploeg holds a career award from the Ontario Ministry of Health and Long-Term Care. Dr. Edwards holds a Nursing Chair funded by the Cana-dian Health Service Research Foundation, the CanaCana-dian Institutes of Health Research and the Government of On-tario.
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