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

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

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

4. Overview thesis content Guideline project 1993-97 Data collection Followup1998 RCT Guideline Implementation 2001-03 3 papers 1 paper (so far) Wallin L, Boström AM, Harvey G, Wikblad K, Ewald U. National guidelines for Swedish neonatal care. Evaluation of the clinical application.International Journal for Quality in Health Care 2000;12(6):465-474 Wallin L, Boström AM, Wikblad K, Ewald U. Sustainability in changing clinical practice promotes evidence based nursing care. Journal of Advanced Nursing 2003; 41(5):509-518. Wallin L, Ewald U, Wikblad K, Arnetz B. Predictors of organisational improvement in neonatal care - staff perceptions as compared with objective measures. (Manuscript 2003) Wallin L, Boström AM, Harvey G, Wikblad K, Ewald U. Progress of unit based QI: An evaluation of a support strategy. Quality and Safety in Health Care 2002;11(4):308-314. Lars Wallin KU03

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

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

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

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

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

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

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

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

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

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

15. Results – aggregated level Target levels % Lars Wallin KU03

16. Predictors Lars Wallin KU03

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

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

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