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The need to offer nutritional support to children and young people is commonplace for health professionals. This article explores the use and indication of nasogastric tubes (NGT) in children and young people, before explaining the process of inserting NGTs and the ongoing management of this method of nutritional support.

PurposeThe aim of this study was to describe the experiences of graduate students who participated in the community of practice (CoP) and identify areas for improvement to support academic success.Design/methodology/approachIn total, 19 graduate students engaged in a CoP to facilitate social interactions, knowledge sharing and learning within a culture of scholarship. A descriptive qualitative research study was conducted using semistructured interviews with eight participants who had attended the CoP meeting.FindingsAll participants were from the School of Nursing and perceived the CoP to be beneficial, particularly international students who had challenges in adapting to new academic and social environments. Areas for improvement include creating a group structure that enhances belonging and learning.Originality/valueThis is the first CoP that was implemented at the Faculty of Health Sciences at the authors’ university. It has been the authors’ experience that a CoP can benefit graduate students through networking, knowledge sharing, social support and learning. The finding of this research will be used to inform a new CoP to address the needs of graduate students. The authors will be adapting the CoP to the current context that includes a virtual platform during the COVID-19 pandemic and will include content specific for international students.

Background There is growing recognition among healthcare professionals that the sustainability of evidence-based practices (EBPs) within different settings is variable and suboptimal. Understanding why a particular EBP might be sustained in one setting and not another remains unclear. Recent reviews illustrate the need to identify and analyze existing frameworks/models/theories (F/M/Ts) that focus solely on the sustainability of EBPs in specific healthcare settings, such as acute care, to illuminate key determinants and facilitate appropriate selection to guide practice and research. Methods We conducted a systematic review to extract sustainability frameworks. This involved using two available syntheses of the literature and a systematic search of four databases from January 2015 to July 2018: CINHAL, MEDLINE, Embase, and ProQuest. We included studies published in English, and if they included sustainability F/M/Ts recommended for use in acute care or an unspecified healthcare organization/setting. F/M/Ts explicitly recommended for use in public health and or community settings were excluded. We then conducted a comparative analysis of F/M/Ts using a modified theory analysis approach, to understand the theoretical underpinnings of each F/M/T, their determinants and concepts hypothesized to influence the sustained use of EBPs within an acute care context. Results Of 2967 identified citations from the 2 available syntheses and the systematic review, 8 F/M/Ts met the inclusion criteria. We identified 37 core factors, of which 16 were recorded as common factors (occurring within 4 or more of the 8 included F/M/Ts). All factors grouped into 7 main themes: innovation, adopters, leadership and management, inner context, inner processes, outer context, and outcomes. Conclusions This systematic review is the first to include a comprehensive analysis of healthcare sustainability F/M/Ts for the sustained use of EBPs in acute care settings. Findings reveal insights into sustainability as a “process or ongoing stage of use” following initial implementation, suggesting this construct should be added to the definition of sustainability. Results provide a resource of available F/M/Ts and hypothesized factors to consider for acute care team members who are planning or currently implementing EBPs with the goal of improving patient outcomes. It also provides a basis for future research on sustainability in acute care.

Wendy Gifford,1 Ian D Graham,2,3 Mark G Ehrhart,4 Barbara L Davies,5,6 Gregory A Aarons7 1School of Nursing, Faculty of Health Sciences, University of Ottawa, ON, Canada; 2Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 3School of Epidemiology, Public Health and Preventive Medicine, Facility of Medicine, University of Ottawa, Ottawa, ON, Canada; 4Department of Psychology, San Diego State University, San Diego, CA, USA; 5Nursing Best Practice Research Center, University of Ottawa, Ottawa, ON, Canada; 6Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA; 7Child and Adolescent Services Research Center, University of California, San Diego, CA, USA Purpose: Leadership in health care is instrumental to creating a supportive organizational environment and positive staff attitudes for implementing evidence-based practices to improve patient care and outcomes. The purpose of this study is to demonstrate the alignment of the Ottawa Model of Implementation Leadership (O-MILe), a theoretical model for developing implementation leadership, with the Implementation Leadership Scale (ILS), an empirically validated tool for measuring implementation leadership. A secondary objective is to describe the methodological process for aligning concepts of a theoretical model with an independently established measurement tool for evaluating theory-based interventions.Methods: Modified template analysis was conducted to deductively map items of the ILS onto concepts of the O-MILe. An iterative process was used in which the model and scale developers (n=5) appraised the relevance, conceptual clarity, and fit of each ILS items with the O-MILe concepts through individual feedback and group discussions until consensus was reached.Results: All 12 items of the ILS correspond to at least one O-MILe concept, demonstrating compatibility of the ILS as a measurement tool for the O-MILe theoretical constructs.Conclusion: The O-MILe provides a theoretical basis for developing implementation leadership, and the ILS is a compatible tool for measuring leadership based on the O-MILe. Used together, the O-MILe and ILS provide an evidence- and theory-based approach for developing and measuring leadership for implementing evidence-based practices in health care. Template analysis offers a convenient approach for determining the compatibility of independently developed evaluation tools to test theoretical models. Keywords: leadership, implementation, evidence-based practice, template analysis, theoretical models, leadership development, knowledge translation

Background Networks are a vehicle for mobilizing knowledge, but there is little research about evidence-informed decision-making in community settings. Breastfeeding is a powerful intervention for population health; combined system and community interventions can increase exclusive breastfeeding rates by 2.5 times. This study examined evidence-informed decision-making within an interorganizational network, including the facilitators and barriers to achieving network goals. Methods A mixed method case study design was used. The primary sources of data were focus group discussion and questionnaire administration. Data were analyzed concurrently using framework analysis and social network analysis. Results Key findings were at the interorganizational and external levels: 1) Relationships and trust are connected to knowledge exchange 2) Need for multiple levels of leadership. Conclusions The findings of this study have potential implications for enhancing the use of evidence-informed decision-making as other networks work toward Baby Friendly Initiative (BFI) designation and also highlights the potential for network maps to be used as a knowledge mobilization tool.

Aim In this article, the authors discuss a multiphase approach for developing quality indicators based on pain practice guidelines, and the challenges associated with the process. The presentation is based on previously published reporting standards for guideline-based quality indicators. Methods The following steps of the indicator development process were undertaken: topic selection; guideline selection; extraction of recommendations; quality indicator selection and practice test. Results Eleven practice guidelines were reviewed for quality, and three high-quality guidelines were compared for pertinent recommendations. From these three guidelines, 12 recommendations were extracted and judged appropriate to examine the practice gap for nursing students and clinicians on an oncology and palliative care unit. Quality indicators were then identified by a consensus process, resulting in 24 discrete indicators that were included in the practice test. Conclusion Quality indicators can be used to examine gaps in pain management practice, and to evaluate change after guideline implementation. However, their development can be challenging, and guideline developers could facilitate uptake of guidelines by including clear, relevant quality indicators as part of guideline creation and presentation.

Background Research into evidence-based practice has been extensively explored in nursing and there is strong recognition that the organizational context influences implementation. A range of barriers has been identified; however, the research has predominantly taken place in Western cultures, and there is little information about factors that influence evidence-based practice in China. The purpose of this study was to explore barriers and facilitators to evidence-based practice in Hunan province, a less developed region in China. Methods A descriptive qualitative methodology was employed. Semi-structured interviews were conducted with staff nurses, head nurses and directors (n = 13). Interviews were translated into English and verified for accuracy by two bilingual researchers. Both Chinese and English data were simultaneously analyzed for themes related to factors related to the evidence to be implemented (Innovation), nurses’ attitudes and beliefs (Potential Adopters), and the organizational setting (Practice Environment). Results Barriers included lack of available evidence in Chinese, nurses’ lack of understanding of what evidence-based practice means, and fear that patients will be angry about receiving care that is perceived as non-traditional. Nurses believed evidence-based practice was to be used when clinical problems arose, and not as a routine way to practice. Facilitators included leadership support and the pervasiveness of web based social network services such as Baidu (百度) for easy access to information. Conclusion While several parallels to previous research were found, our study adds to the knowledge base about factors related to evidence-based practice in different contextual settings. Findings are important for international comparisons to develop strategies for nurses to provide evidence-based care. Electronic supplementary material The online version of this article (10.1186/s12912-018-0295-x) contains supplementary material, which is available to authorized users.

Background: Paediatric musculoskeletal matters (PMM-www.pmmonline.org) is a free, evidence-based and peer reviewed open e-resource for paediatric musculoskeletal (MSK) medicine targeting non-MSK specialists. Since launch (Nov-2014) PMM has reached 190 countries with >78,000 users, >244,500 hits. Users who have declared their training background on the website are mainly non-MSK specialists. Feedback from users has requested further content to reflect international healthcare systems. PMM India was developed in collaboration with the Indian Academy of Paediatrics (IAP; Sept-2015, >3,700 users, 16,000 hits to date) and showcases successful partnership with local clinicians in developing PMM with local context. Further ‘internationalisation’ is now ongoing with additional global partners to develop PMM International. Here, we describe the process for international development. Methods: Paediatric rheumatologists in 11 countries around the world were approached to peer-review and identify additional PMM content to reflect paediatric MSK medicine in their health care systems (e.g., case mix, clinical presentations, care pathways), with a focus on knowledge relevant for non-MSK specialists. New content was developed by local teams identified by the paediatric rheumatologist(s) who then collated and provided expert overview before submission for editorial review. All contributions were provided in English. Additional cases and images were included with appropriate consent. Results: PMM International additions to the original website brings new content predominately focused on infections/infection-related disease with MSK features or as differential diagnoses for rheumatic disease. Most content is in English with requests for translation of some content (e.g., pGALS which is available in 11 languages to date). PMM International will be further peer reviewed with open access to all. A PMM app is planned to facilitate access where internet capacity is limited. Conclusion: Rapid globalisation necessitates appropriate e-resources with content that reflect international health care contexts. PMM International targets non-MSK specialist audiences to raise awareness and early recognition of MSK pathology. Our work reflects strong collaborative global partnerships within the paediatric rheumatology community. PMM has been endorsed by the Paediatric Rheumatology European Association (PReS) as an educational resource. Implementation of PMM International has yet to be formally evaluated (i.e., change in knowledge, practice), but data thus far supports wide reach and positive uptake from the target audience user groups.

In Ontario, Canada, the Registered Nurses' Association promotes a Best Practice Spotlight Organization initiative to enhance evidence-based practice. Qualifying organizations are required to implement strategies, evaluate outcomes, and sustain practices aligned with nursing clinical practice guidelines. This study reports on the development and evaluation of a multifaceted implementation strategy to support adoption of a nursing clinical practice guideline on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital. Multiple approaches were employed to influence behavior, attitudes, and awareness around optimal pain practice (e.g., instructional resources, electronic reminders, audits, and feedback). Four measures were introduced to assess pain in communicating and noncommunicating children as part of a campaign to treat pain as the fifth vital sign. A prospective repeated measures design examined survey and audit data to assess practice aligned with the guideline. The Knowledge and Attitudes Survey (KNAS) was adapted to ensure relevance to the local practice setting and was assessed before and after nurses' participation in three education modules. Audit data included client demographics and pain scores assessed annually over a 3-year window. A final sample of 69 nurses (78% response rate) provided pre-/post-survey data. A total of 108 pediatric surgical clients (younger than 19 years) contributed audit data across the three collection cycles. Significant improvements in nurses' knowledge, attitudes, and behaviors related to optimal pain care for children with disabilities were noted following adoption of the pain clinical practice guideline. Targeted guideline implementation strategies are central to supporting optimal pain practice.

Aims The aim of this study was to determine the effects of an Action Learning intervention on nurses’ use of a fetal health surveillance (FHS) guideline during labor of women who were low risk on admission for delivery. Methods Using a pragmatic randomized controlled trial, nurses were randomized to Action Learning (n = 44) or Usual Care (n = 45). Low-risk women were assigned to either an Action Learning nurse (n = 122) or a Usual Care nurse (n = 148). Data on practices during an episode of care (nurses’ FHS practices from admission through to delivery in low-risk women) were collected at three trial time points: 1 month prior, during 6 months, and 1 month following. Guideline adherence, women's perception of birth experience, and enablers and inhibitors to intermittent auscultation (IA) were collected. Multivariate logistic regression determined the variables (chosen by the nurses) that predicted Action Learning nurses’ adherence to FHS practices. Findings Statistically significant change was not evident between nurses’ rate of FHS practices in the Action Learning group compared with Usual Care (Δ6.8%, odds ratio [OR] 0.16, 95% confidence interval [CI] 0.84–2.83). Postpartum, women reported high satisfaction with no significant difference by study group. Two labor events, epidural and narcotic analgesia, most influenced guideline appropriate care (p = .000, OR –4.04; p = .000, OR = 2.89) within the experimental group. Linking Evidence to Action Despite lack of between-group significant changes in FHS practices, Action Learning nurses, who chose areas of practice that presented obstacles to their guideline adherence ability (epidurals and narcotics), significantly changed their FHS practices. Researchers need to consider whether practice is long-standing acceptance of the evidence by healthcare providers, and the provider's intentions for implementation effectiveness when choosing an implementation strategy. Supportive nurses, Doppler availability, and clear policies support adherence to an IA guideline. Deimplementation of ineffective practice is warranted.

Objective The objective of this study was to determine the feasibility of Facebook as a dissemination strategy for the People Getting a Grip on Arthritis self-management program by arthritis health professionals to their patients. Methods The feasibility study comprised a single arm, pre-post design that included a convenience sample of 78 arthritis health professionals across Canada. Assessments were performed at baseline, two-weeks post-intervention, and at three-months follow-up using online questionnaires. The primary outcome measure was change in perceived usability of Facebook as a dissemination strategy for the People Getting a Grip on Arthritis program with patients at two-weeks post-intervention using an instrument based on an extended version of the Technology Acceptance Model 2. Comparisons with baseline were assessed using t -test analyses. Results Statistically significant improvements from baseline were seen for all items of the Technology Acceptance Model 2 domains: perceived ease of use (four items), intention to use (two items) and output quality (two items) domains. Variable results were seen for the job relevance , perceived usefulness , voluntariness , and result demonstrability domains of the Technology Acceptance Model 2. There were no statistically significant improvements for the subjective norm and image domains. Conclusions Facebook may provide arthritis health professionals with an additional option of how to best share evidence-based information to allow their patients to successfully self-manage their arthritis.

Aims and objectives To examine activities conducted, challenges encountered and supports used when sustaining nursing practice guideline implementation in multiple healthcare organisations over 3 years. Background Numerous models and frameworks exist to guide the implementation of guidelines, yet very few focus on sustaining improved practice changes. It is not known if one intervention or multiple interventions are required, nor the long-term activities, challenges and supports for sustaining improved practices. Design Qualitative descriptive study. Methods We conducted focus group interviews with steering committee members and individual interviews with leaders and direct care providers at the end of a 3-year guideline implementation study. The National Health Service Sustainability Model was used to guide data collection and analysis. Results The eight sites included three teaching hospitals, a community hospital, a long-term care facility, two community health agencies and a community health centre. Individual interviews were conducted with 36 leaders and 26 direct care providers. Focus group interviews were conducted with steering committee members (n = 70) at each site. Guideline implementation activities (n = 45) included developing new outcome monitoring systems, conducting chart audits, communicating progress to internal stakeholders, appointing interprofessional staff to steering committees, developing educational sessions and resources for staff and patients, revising policies and procedures, and developing partnerships with external organisations. Supports included lessons learned from previous and concurrent change initiatives, and commitment, involvement and positive attitudes of staff and leaders. Conclusion Activities identified by the participants addressed all 10 factors in the Sustainability Model in the three areas of process, staff and organisation. The challenges and supports encountered provide insights into the process of guideline implementation and sustainability. Relevance to clinical practice A multilevel action plan for staff, leaders and the organisation is recommended when introducing and sustaining practice changes.

Background Understanding the types of barriers that exist when implementing change can assist healthcare managers to tailor implementation strategies for optimal patient outcomes. Aim The aim of this paper is to present an organising framework, the Barriers Assessment Taxonomy, for understanding barriers to nurses' use of clinical practice guideline recommendations. Barriers to recommendations are illustrated using the Barriers Assessment Taxonomy and insights discussed. Method As part of a pilot implementation study, semi-structured interviews (n = 26) were conducted to understand barriers to nurses' use of nine guideline recommendations for diabetic foot ulcers. Content analysis of verbatim transcripts included thematic coding and categorising barriers using the Barriers Assessment Taxonomy. Results Nineteen barriers were associated with nine recommendations, crossing five levels of the health care delivery system. The Barriers Assessment Taxonomy revealed that all recommendations had individual and organisational level barriers, with one recommendation having barriers at all levels. Individual level barriers were most frequent and lack of knowledge and skills was the only barrier that crossed all recommendations. Implications for nursing management The Barriers Assessment Taxonomy provides a framework for nursing managers to understand the complexity of barriers that exist, and can assist in choosing intervention strategies to support improved quality care and patient outcomes.

UNLABELLED With funding from the Ontario Ministry of Health and Long-Term Care, the Registered Nurses' Association of Ontario (RNAO) established the Advanced Clinical Practice Fellowship (ACPF) program in 2000 to improve patient care and outcomes through advanced nursing knowledge and skills. This paper describes the perceptions of ACPF fellows regarding their influence on quality of care and patient outcomes, specifically, the types of practice change activities initiated, successful implementation and influence on outcomes, barriers encountered and strategies used to address them and influence change. METHODS Thirty telephone interviews were conducted with ACPF fellows after completing their fellowship. Interviews were analyzed using descriptive content analysis. RESULTS Fifty-one practice change activities were identified. Ratings for successful implementation (1 = not successful, 10 = extremely successful) were 7.2/10; ratings for successful influence on outcomes were 7.4/10. Barriers identified were (a) resistant attitudes, (b) time and workload, (c) lack of administrative support and (d) lack of mentor's involvement. Strategies proposed were (a) building a knowledge base, (b) negotiation and dialogue and (c) self-reliance and persistence. IMPLICATIONS The ACPF program is an innovative and highly utilized initiative. While this program supports strategic directions of government and nursing professional groups, further research will validate and expand on the specific ways in which the initiative influences professional development, healthcare delivery and patient outcomes.

Several studies found that renal transplant recipients with chronic kidney disease have untreated complications and do not attain recommended clinical targets. Using a before/after design with propensity score-matched controls, we evaluated whether an advanced practice nurse-led interprofessional collaborative chronic care approach could improve clinical outcomes for CKD transplant patients compared with a traditional physician-led model. The intervention included strategies for disease self-management, shared decision making, and healthcare system reorganization. The primary outcome was the proportion of patients attaining at least seven of nine targets as per published guidelines. A greater proportion of intervention patients achieved the outcome (68% vs. 10%; p = 0.0001) and had discussions about end-stage treatment options (88% vs. 13%; p = 0.0001) compared with controls. The intervention patients had significantly fewer emergency room visits (incidence rate ratio [IRR] 0.53; 95% CI 0.29-0.91; p = 0.02) and hospital admissions (IRR 0.34; 95% CI 0.16-0.68; p = 0.001) compared with the control patients. There were no significant differences found between the groups in systolic/diastolic blood pressure, carbon dioxide, hemoglobin, or phosphate parameters. An advanced practice nurse-led approach, based on the chronic care model, has the potential to improve clinical outcomes for renal transplant recipients and needs to be tested in a multicenter randomized controlled trial.

Background\ud We describe the collaborative development of an evidence based, free online resource namely ‘paediatric musculoskeletal matters’ (pmm). This resource was developed with the aim of reaching a wide range of health professionals to increase awareness, knowledge and skills within paediatric musculoskeletal medicine, thereby facilitating early diagnosis and referral to specialist care.\ud \ud Methods\ud Engagement with stakeholder groups (primary care, paediatrics, musculoskeletal specialties and medical students) informed the essential ‘core’ learning outcomes to derive content of pmm. Representatives from stakeholder groups, social science and web development experts transformed the learning outcomes into a suitable framework. Target audience representatives reviewed the framework and their opinion was gathered using an online survey (n = 74) and focus groups (n = 2). Experts in paediatric musculoskeletal medicine peer reviewed the content and design.\ud \ud Results\ud User preferences informed design with mobile, tablet and web compatible versions to facilitate access, various media and formats to engage users and the content presented in module format (i.e. Clinical assessment, Investigations and management, Limping child, Joint pain by site, Swollen joint(s) and Resources).\ud \ud Conclusions\ud We propose that our collaborative and evidence-based approach has ensured that pmm is user-friendly, with readily accessible, suitable content, and will help to improve access to paediatric musculoskeletal medicine education. The content is evidence-based with the design and functionality of pmm to facilitate optimal and ‘real life’ access to information. pmm is targeted at medical students and the primary care environment although messages are transferable to all health care professionals involved in the care of children and young people.

Aims and objectives. To examine the activities and resource implications for the initial cohort of healthcare organisations involved in the introduction of multiple nursing guidelines. Background. The Best Practice Spotlight Organization initiative was launched in 2003 as part of the Registered Nurses’ Association of Ontario’s Best Practice Guidelines programme. While previous research has evaluated improvements in patient care and outcomes, there has been limited research from an organisational perspective on the activities conducted to introduce nursing guidelines. Design. Secondary analysis of retrospective narrative data. Methods. We conducted a content analysis of the 2004–2006 annual reports from the seven participating sites. We used both deductive and inductive approaches to categorise the guideline implementation activities and their resource implications. Results. All sites reported implementing multiple guidelines (four to nine guidelines per site) and used a wide range of implementation activities that clearly addressed nine of the 10 NHS Sustainability dimensions. The dimension not reported was benefits beyond helping patients. All sites established steering committees that involved staff and senior leaders, reviewed selected guidelines and recommendations, reviewed existing policies and procedures and developed new policies and procedures, recruited champions or peer mentors, applied for additional external funding to support activities, developed relationships with external clinical partners, included guideline implementation in orientation, developed intra-agency web-based and print communications for the project, and evaluated practice changes. For each of these activities, the sites reported expenditures and resource usage. Conclusions. The organisational processes used for the introduction of new nursing guidelines in Canada are remarkably consistent with factors identified by leaders and change agents in the UK who developed the NHS Sustainability Model. Relevance to clinical practice. A multidimensional framework for sustainability is useful for planning successful guideline implementation across an organisation. Examples of specific activities and resource implications for organisational change are provided.

ignificance The importance of leadership to influence nurses’ use of clinical guidelines has been well documented. However, little is known about how to develop and evaluate leadership interventions for guideline use. Purpose The purpose of this study was to pilot a leadership intervention designed to influence nurses’ use of guideline recommendations when caring for patients with diabetic foot ulcers in home care nursing. This paper reports on the feasibility of implementing the study protocol, the trial findings related to nursing process outcomes, and leadership behaviors. Methods A mixed methods pilot study was conducted with a post-only cluster randomized controlled trial and descriptive qualitative interviews. Four units were randomized to control or experimental groups. Clinical and management leadership teams participated in a 12-week leadership intervention (workshop, teleconferences). Participants received summarized chart audit data, identified goals for change, and created a team leadership action. Criteria to assess feasibility of the protocol included: design, intervention, measures, and data collection procedures. For the trial, chart audits compared differences in nursing process outcomes. Primary outcome: 8-item nursing assessments score. Secondary outcome: 5-item score of nursing care based on goals for change identified by intervention participants. Qualitative interviews described leadership behaviors that influenced guideline use. Results Conducting this pilot showed some aspects of the study protocol were feasible, while others require further development. Trial findings observed no significant difference in the primary outcome. A significant increase was observed in the 5-item score chosen by intervention participants (p = 0.02). In the experimental group more relations-oriented leadership behaviors, audit and feedback and reminders were described as leadership strategies. Conclusions Findings suggest that a leadership intervention has the potential to influence nurses’ use of guideline recommendations, but further work is required to refine the intervention and outcome measures. A taxonomy of leadership behaviors is proposed to inform future research.

Objective To determine whether hospital‐based perinatal nurses with expertise in adolescent mother‐friendly care identify a need to improve inpatient nursing care of adolescent mothers and how well perinatal units support nurses' capacity to provide adolescent mother‐friendly care. Design/Setting/Participants: A key informant survey of nurses from eight perinatal units at three hospitals (four separate sites) in a Canadian city. Methods Perinatal nurses expert in the care of adolescent mothers were identified by their managers and colleagues. These nurses and all perinatal clinical educators were invited to participate. Twenty‐seven of 34 potential key informants completed the survey. Results Key informants rated their own skill in caring for adolescent mothers higher (median 8.0) than they rated the skill of other nurses (median 6.0) on their units. They attributed their expertise working with adolescent mothers to their clinical and life experiences and their ability to develop rapport with adolescents. A common reason for the assigned lower peer‐group ratings was the judgmental manner in which some nurses care for adolescent mothers. Key informants also identified that hospital‐based perinatal nurses lack adequate knowledge of community‐based resources for adolescent mothers, educational programs related to adolescent mother‐friendly care were insufficient, and policies to inform the nursing care of adolescent mothers were not available or known to them. Conclusion A minority of perinatal nurses have expertise in adolescent mother‐friendly care. There is a need for perinatal unit‐level interventions to support the development of nurses' skills in caring for adolescent mothers and their knowledge of community‐based resources. Peer mentoring and self‐reflective practice are promising strategies.

Objective: Workforce recruitment and retention challenges are being experienced in public health as in other Canadian health sectors. While there are many nurses working in public health, little research has been done about their job satisfaction. Job satisfaction is linked to recruitment, retention and positive client outcomes. The purpose of this research was to examine the relationships between three modifiable work environment factors (autonomy, control-over-practice, and workload) and Canadian public health nurses’ (PHNs) job satisfaction. Methods: Data were from the 2005 National Survey of the Work and Health of Nurses (response rate, 79.7%; 18,676 nurses). Bivariate and multivariate logistic regression analyses were used for this secondary analysis. Findings were discussed with practicing PHNs, policy-makers and researchers from across Canada at a knowledge translation (KT) ‘Think-Tank’. Results: Among the 271 PHNs, 53.5% reported being ‘very satisfied’ with their jobs. The interaction between autonomy and workload was a significant predictor of PHNs’ job satisfaction, (OR 0.97, 95% CI 0.96-0.99, p

Aims and objectives. To report on a three-year follow-up evaluation in Canada of nursing care indicators following the implementation of the Adult Asthma Care Best Practice Guideline and the Reducing Foot Complications for People with Diabetes Best Practice Guideline and to describe the contextual changes in the clinical settings. Background. The Registered Nurses’ Association of Ontario in Canada has developed and published more than 42 guidelines related to clinical nursing practice and healthy work environments. To date, evaluation has involved one-year studies of the impact of guideline implementation on the delivery of care in hospital and community settings, but little is known about whether changes in practice that were made during the initial implementation period have been sustained. Design. Longitudinal follow-up study. Methods. Site observations and interviews were conducted with key informants at two hospitals. Indicators of nursing care changes identified six months post-implementation were compared with indicators found during a retrospective chart audit at the same sites three years later. Fisher exact tests were used to compare outcomes for the two time periods. Results. Three out of 12 indicators related to asthma care remained consistently high (≥84% of audited charts) and four indicators declined significantly (p

Objectives We conducted a validation study on use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients ( N =3633). This survey sought to identify potential facilitators and barriers to an implementation policy that would allow nurses to clinically clear the c-spine of minor trauma patients. Methods We conducted a prospective quantitative survey of ED nurses in six hospitals. Questions were developed from a previous qualitative survey at the same validation study EDs. Results 158 ED nurses were surveyed and 137 (86.7%) responded. Nurses strongly endorsed potential facilitators for nursing clearance of the c-spine, including ‘Like to try new things at work' (96.4%) and ‘Easy for me to take on new responsibilities' (96.4%). Most respondents were comfortable applying the rule (89.1%). Nurses endorsed potential barriers but at much lower rates, with the most common being ‘Heavy workload makes it difficult to use the rule' (37.2%). Variation existed among hospitals for the facilitator ‘Use of the rule would be useful to my practice', ranging from 81.8% to 100% endorsement ( P =0.004). Conclusions This survey was an important step towards the goal of empowering ED nurses to clinically clear the c-spine of alert and stable trauma patients. There was a high rate of endorsement of facilitators and a low rate of endorsement of barriers. We found variation between hospitals, emphasizing the importance of understanding local beliefs when seeking to change clinical practice. We are conducting an implementation trial based on this feedback.

gifford w., davies b., tourangeau a. & lefebre n. (2011) Journal of Nursing Management 19, 121–132 Developing team leadership to facilitate guideline utilization: planning and evaluating a 3-month intervention strategy Background Research describes leadership as important to guideline use. Yet interventions to develop current and future leaders for this purpose are not well understood. Aim To describe the planning and evaluation of a leadership intervention to facilitate nurses’ use of guideline recommendations for diabetic foot ulcers in home health care. Method Planning the intervention involved a synthesis of theory and research (qualitative interviews and chart audits). One workshop and three follow-up teleconferences were delivered at two sites to nurse managers and clinical leaders (n = 15) responsible for 180 staff nurses. Evaluation involved workshop surveys and interviews. Results Highest rated intervention components (four-point scale) were: identification of target indicators (mean 3.7), and development of a team leadership action plan (mean 3.5). Pre-workshop barriers assessment rated lowest (mean 2.9). Three months later participants indicated their leadership performance had changed as a result of the intervention, being more engaged with staff and clear about implementation goals. Conclusions and implications for nursing management Creating a team leadership action plan to operationalize leadership behaviours can help in delivery of evidence-informed care. Access to clinical data and understanding team leadership knowledge and skills prior to formal training will assist nursing management in tailoring intervention strategies to identify needs and gaps.

To prevent complications from peripheral vascular access device (PVAD) therapy, the Infusion Nurses Society (INS) developed 2 scales to measure the extent and severity of phlebitis and infiltration in PVADs. This study evaluated the psychometric properties of these scales to validate them with respect to their interrater reliability, concurrent validity, feasibility, and acceptability. A total of 182 patients at 2 sites were enrolled, and 416 observations of PVAD sites were made. Two nurses independently rated each PVAD site for the presence or absence of phlebitis and/or infiltration by using the INS scales. The interrater reliability was calculated, as was the agreement of the observed versus charted incidence of phlebitis and infiltration (concurrent validity) and the ease of use of the scales (feasibility, acceptability). Interrater reliability for both the Phlebitis and Infiltration scales and concurrent validity were found to be statistically significant (P < .05). The study nurses reported the scales to be easy to use, taking an average of 1.3 minutes to complete both. The importance of valid measures for use in research cannot be underestimated. The INS Phlebitis and Infiltration scales have been shown to be easy to use, valid, and reliable scales.

Design and objective: This paper describes the protocol for a three-arm, single-blind, parallel design randomized controlled trial (RCT) to investigate the perceived usability of Facebook to share information from an evidence-based arthritis self-management program with patients compared with email or an educational website after two weeks. Study population Three-hundred and twenty-seven arthritis health professionals (i.e., nurses or physical/occupational therapists) registered with their regulatory body in Canada, currently practicing clinically defined as spending a minimum of 50% of their time (working week) in direct arthritis patient care. Interventions The proposed RCT will include three information and communication technology (ICT) intervention groups: Facebook, email, and an educational website. Outcome measures The primary outcome will be perceived usefulness by health professionals of using the ICT intervention to share information with their patients according to the technology acceptance model 2 (TAM2) questionnaire at two weeks post-intervention. Secondary outcomes will include other usability domains of the TAM2 questionnaire (i.e., perceived ease of use, result demonstrability, output quality, job relevance, image, voluntariness, subjective norm, and intention to use) at two weeks, three months, and six months post-intervention. Analysis: An analysis of variance will be conducted to compare TAM2 questionnaire scores of the Facebook group with the email and educational website groups.

To examine the determinants of nurses' intentions to practice continuous labor support.A descriptive survey based on the Theory of Planned Behavior.A large, urban Canadian hospital with 2 sites and 7,000 births per year.Ninety-seven registered nurses from 2 birthing units.Scores measuring nurses' attitudes, subjective norms, and intentions regarding continuous labor support for women with epidural analgesia were significantly lower than those for women without epidural analgesia (p.0001). Multiple regression analyses revealed that previous labor support courses, subjective norms, and perceived behavioral control explained 55% of the variance in nurses' intentions to provide continuous labor support to women without epidural analgesia while 88% of the variance in intentions to provide continuous labor support to women with epidural analgesia was explained by subjective norms and attitudes. Subjective norms made the most significant contribution to the variance in nurses' intentions to provide continuous labor support. Top perceived organizational barriers to continuous labor support included unit acuity and method of patient assignment.Nurses' intentions to provide continuous labor support are lower for women receiving epidural analgesia and are influenced by the perceived social pressures on their unit. Nurses view organizational barriers as important factors influencing their ability to provide continuous labor support.

This paper presents an overview of curriculum and program development activities at the four Canadian Regional Training Centres directed towards the goal of achieving increased knowledge to action. The RTCs have initiated learning opportunities to increase the skills of graduate students in conducting knowledge translation and exchange (KTE). The authors describe similar as well as unique approaches used at each centre to hone understanding and skills. RTC activities include the development of a new four-year residency program for doctoral students, new Web-based and real-time interactive theory courses and new linkages with departments of journalism. While formal evaluation is yet to be completed, interim feedback from participating graduate students has been encouraging.

This study developed and tested a chart audit tool to assess the implementation of evidence-based recommendations for vascular access nursing assessment and device selection. Chart audits of 71 patients were conducted in a home healthcare agency and a community hospital prior to guideline implementation. Observations of initial infusion therapy and chart audit documentation of 31 patients were also compared. Results from observations indicated that nurses provided care consistent with the recommendations, but findings from chart audits indicated that assessment and decisionmaking were poorly documented. Studies that use only precomparison and postcomparison by chart audit may miss changes in nursing practice.

Objective To determine if there was an improvement in nurses’ communication skills 5 months after a multiple component intervention to implement the Registered Nurses’ Association of Ontario best practice guideline ‘Establishing Therapeutic Relationships’. Methods A matched pair, before and after design was used. Eight client scenarios with corresponding client comments were read aloud to nurses who were asked to respond verbally, as though they were interacting with the client. Responses were audio-taped and transcribed. The frequency and quality of nurses’ active listening, initiating and assertiveness skills were measured pre- and post-implementation of the guideline. Results Twenty-two nurses responded at both time points. Active listening skills were most frequently used. There was a statistically significant decrease in the number of active listening skills used, but a statistically significant improvement in the quality of active listening and initiating statements and frequency of initiating skills. Conclusion Nurses demonstrated improvements in selected communication skills following the implementation of a multiple component intervention that included a best practice guideline. Practice implications A combination of strategies that support the implementation of a best practice guideline is described. Results indicate some improvement in communication skills that are essential to the establishment of therapeutic nurse–client relationships.

Objective To determine whether vulnerability factors (confidence with breastfeeding, postpartum depression, supplementation, and perceived adequacy of support) are associated with breastfeeding outcome at 6 weeks postpartum after controlling for age and education. Design Secondary analysis of a cross‐sectional telephone survey at 6 weeks postpartum. Setting Ottawa‐Carleton, Ontario, Canada. Participants A proportionate, consecutive sample of breastfeeding women from each of four hospitals in the region (526/554, 95% response rate). Methods Stratified bivariate analyses were used to examine the relationship between each factor and breastfeeding outcome. Multivariate logistic regression analyses examined relationships between all factors and breastfeeding outcome. Results In the logistic regression analyses, confidence with breastfeeding (odds ratio: 1.85, 95% confidence interval: 1.50‐2.27, p p = .007) were related to breastfeeding after controlling for age and education. Conclusions Support for breastfeeding should include assessment of maternal confidence with breastfeeding and postpartum depression. Evaluation of intervention strategies to address these vulnerability factors is a priority. JOGNN , 35, 87‐97; 2006. DOI: 10.1111/J.1552‐6909.2006.00005.x

The Family Court of Australia provides conciliation counselling to couples who are involved in disputes regarding their children following separation. In cases where domestic violence is involved, the appropriateness of providing counselling has been seriously questioned. This study is an extension of earlier work completed by the authors that specifically examined client satisfaction with counselling in cases involving domestic violence. This article examines client and counsellor perceptions of the counselling process and its outcomes. Language: en

The Family Court of Australia provides conciliation counselling to couples who are involved in disputes regarding their children following separation. In situations where domestic violence has occurred, the appropriateness of providing counselling to such couples has been seriously questioned This study examines the experience of clients attending counselling at the family court. Two groups of clients are studied--one group who reports domestic violence as a significant issue and a comparison group who does not report domestic violence. The results indicate that the two groups do not differ in their expressed level of satisfaction with the counselling they have received and that both groups consider counselling to have been helpful in resolving their issues. The preliminary results of this study have implications for the provision of postseparation counselling/mediation to couples when domestic violence has occurred. Language: en

Purpose This pilot study describes the evaluation of an 88-page Toolkit that was developed to guide nursing leaders, including advanced practice nurses, managers and steering committees, who were responsible for coordinating implementation of selected best-practice guidelines (BPG) in their respective agencies. Methods The self-administered questionnaire was mailed to all clinical resource nurses and steering committee members involved in implementing best-practice guidelines. The questionnaire evaluated the usefulness of the content of five chapters (and the case scenarios and worksheets included with each chapter). Results Sixty-eight percent of respondents returned the questionnaire. More than 85% of them found the Toolkit helpful during the implementation process; 83% reported using it, 80% said they would use it again. The Toolkit was used primarily to identify, analyze and engage stakehoLders, and to assess environmental readiness. Fifty-seven percent of respondents said they used the Toolkit to plan the implementation strategy. Conclusions The Toolkit assessed in this evaluation shows promise as a useful guide for those charged with BPG implementation. Like other guidelines that are based on evidence, the Toolkit will require occasional updates to ensure that the strategies proposed reflect current evidence. Nursing leaders have a responsibility to keep up to date and to provide efficient and effective healthcare services. Best-practice guidelines or clinical practice guidelines are useful tools that synthesize the latest evidence and provide recommendations for care providers aiming to improve the quality of patient care (Grol 2001). Many leaders are challenged to know how and when to implement the increasing numbers of practice guidelines. The purpose of this article is to describe a pilot study to evaluate a Toolkit that was developed to guide nursing leaders in implementing selected best-practice guidelines (BPGs) in their respective agencies.

The Canadian Medical Association (CMA) maintains a database of clinical practice guidelines (CPGs) developed or endorsed by Canadian organizations. The study purpose was to describe how these guidelines were developed, disseminated and evaluated. A survey was mailed to the developer of each CPG registered in the CMA Infobase between June 1996 and December 1999. Data were received for 730 unique guidelines (response rate of 70%) developed by 75 organizations. Of these, 72% were developed by committees that had a formal process for selecting their members. The scientific literature was reviewed for all of the guidelines, a computerized search undertaken for 88% and the search strategy included 34% of CPG documents. An attempt was made to grade the quality of the evidence underpinning 54% of the guidelines. For most guidelines, consensus about values or judgements was reached by expert opinion through open discussion (78% of guidelines). The most common strategies used to disseminate the guidelines were direct mailing of guidelines to members of the developing organization (80% of all guidelines), publishing guidelines in newsletters/journals (76%), direct mailing to others (73%), electronic dissemination (62%), educational or continuing medical education activities (50%), and providing information about guidelines to patients/consumers (47%). Overall, 5% of the guidelines have been evaluated to determine their impact on health outcomes. During the 5-year study period (1994-99), the more recent guidelines were more likely to use multidisciplinary development panels, report the literature search strategies and grade the quality of the evidence. The CPG development process in Canada is becoming more rigorous and reproducible, but there is still considerable room for improvement. In addition to encouraging Canadian guideline developers to use more rigorous and transparent methods, considerably more attention must be focused on using and identifying effective and cost-effective strategies to promote and facilitate the uptake of guidelines by practitioners and to evaluate the impact of guidelines on patient outcomes.

Objectives: The objectives of this study were to (1) determine how congruent community-provided leg ulcer care was with best practice for venous leg ulcers and (2) identify organizational and clinical factors associated with the provision of best practice for venous leg ulcers. Design: The practice variation study group was an audit of nursing agency client records to determine the provision of care. Setting and subjects: The study population was a home care cohort of persons with venous leg ulcers (n = 66) who received care from one Ontario home care nursing agency between March 1999 and November 1999. Instrument: The audit tool was developed with a checklist reflecting the common recommendations from 3 international practice guidelines, as well as organizational and clinical factors that may influence or reflect best practice. Results: Half of client records (35/66) included an identified etiology of the leg ulcer. An Ankle Brachial Pressure Index score was documented prior to the initiation of compression on fewer than half of the records (21/44). Regular ulcer measurement was done for 11% of the clients (7/64). Two thirds of the clients (44/66) were treated with compression. More than 60% of the clients (40/66) had been seen by either a dermatologist or a vascular surgeon. Topical antibiotics were prescribed for two thirds of clients (44/64). Fifteen percent of clients (10/66) were assessed for pain, and 17% (11/66) received some form of pain management. Documentation of client education specific to the leg ulcer was present on 3% of records (2/66). The mean number of different nurses providing leg ulcer care to each client was 19. A registered practical nurse was the classification of nurse assigned to 43.8% (29/66) of the clients. Conclusion: Several gaps were identified in the care provided. A standardized approach to care is needed that includes a comprehensive leg ulcer assessment to determine the ulcer etiology, determination of an Ankle Brachial Pressure Index score to screen for the presence of arterial disease, and compression for all clients who meet the criteria for venous disease. A reorganization of services is required, which includes an increased role for community nurses in leg ulcer assessment and management. Organizational and clinical factors influencing the delivery of best practice need to be identified and addressed. (J WOCN 2003;30:132-42.)

In light of the emphasis on increased efficiency in the delivery of hospital-based healthcare services in Canada, healthcare administrators need to advocate for greater care in the community. The implementation of an antenatal home-care program for women with high-risk pregnancies at the Ottawa Hospital presented the opportunity to develop a comprehensive framework to evaluate the value and outcomes of the new community-based program.

High quality research evidence for nursing practice is available from the Cochrane Library and in clinical practice guidelines produced by professional associations. The transfer of research evidence into practice is a complex process, and changing provider behavior is a challenge, even when the relative advantages are strong. An active approach with multifaceted interventions based on the assessment of barriers has been found most effective. An array of interventions for implementing research findings in practice is included, and promising organizational and theoretical perspectives on increasing the use of research evidence for nursing practice are described.

In the early stages of development and pilot implementation of the guidelines, it became apparent that organizations were struggling to identify ways to introduce and implement the guidelines. The majority of the pilot sites were providing education sessions to facilitate CPG utilization with little attention to other implementation strategies. Those charged with introducing the CPG into the clinical setting were soon faced with a myriad of implementation challenges for which they needed a solution. It became clear that a planned systematic approach to facilitate implementation of CPGs was needed.

Background Poor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms. Discussion We conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists. Summary Implementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.

OBJECTIVE The aims of this study were to field test and evaluate a series of organizational strategies to promote evidence-informed decision making (EIDM) by nurse managers and clinical leaders in home healthcare. BACKGROUND EIDM is central to delivering high-quality and effective healthcare. Barriers exist and organizational strategies are needed to support EIDM. METHODS Management and clinical leaders from 4 units participated in a 20-week organization-focused intervention. Preintervention (n = 32) and postintervention (n = 17) surveys and semistructured interviews (n = 15) were completed. RESULTS Statistically significant increases were found on 4 of 31 survey items reflecting an increased organizational capacity for participants to acquire and apply research evidence in decision making. Support from designated facilitators with advanced skills in finding, appraising, and applying research was the highest rated intervention strategy. CONCLUSIONS Results are useful to inform the development of organizational infrastructures to increase EIDM capacity in community-based healthcare organizations.

Objective. Despite many initiatives, advances in patient safety remain uneven in part because poor relationships among health professionals have not been addressed. The purpose of this study was to determine whether relationships between health professionals contributed to a patient safety climate, after implementation of an intervention to improve inter-professional collaboration. Design/Setting. This was a secondary analysis of data collected to evaluate the Interprofessional Model of Patient Care (IPMPC) at The Ottawa Hospital in Ontario, Canada, which consists of five sites. A series of generalized estimating equation models were generated, accounting for the clustering of responses by site. Participants. Thirteen health professionals including physicians, nurses, physiotherapists and others (n=1896) completed anonymous surveys about 1 year after the IPMPC was introduced. Intervention. The IPMPC was implemented to improve interdisciplinary collaboration. Main Outcome Measures. Reliable instruments were used to measure collaboration, respect, inter-professional conflict and patient safety climate. Results. Collaboration (β=0.13;P= 0.002) and respect (β=1.07;P=0.03) were significant independent predictors of patient safety climate. Conflict was an independent and significant inverse predictor of patient safety climate (β= −0.29; P=0.03), but did not moderate linkages between collaboration and patient safety climate or between respect and patient safety climate. Conclusions. Through the IPMPC, all health professionals learned how to collaborate and build a patient safety climate, even in the presence of inter-professional conflict. Efforts by others to foster better work relationships may yield similar improvements in patient safety climate.

Background Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice. Aim To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals’ use of evidence in clinical practice. Methods A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentee's needs; and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively. Results Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners’ knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals’ behaviors and impact on practitioners’ and patients’ outcomes: some outcomes improved, while others showed no difference. Linking Evidence to Action Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.

Background: Approximately 6-30% of Canadian women smoke during pregnancy. Prenatal care visits are an opportune time for Family Practice Nurses to provide evidence-based smoking cessation interventions. The purpose of this exploratory study was to describe: 1) Smoking cessation interventions by Family Practice Nurses during prenatal visits; 2) Family Practice Nurses' awareness and use of smoking cessation guidelines as well as the proportion of Family Practice Nurses who engage pregnant women who smoke in minimal interventions and intensive interventions; 3) the predictors of nurse-provided smoking cessation counseling for pregnant women and 4) the barriers to smoking cessation counseling. Methods: A previously validated questionnaire measuring smoking cessation counseling practices was modified and converted to an electronic format. A bilingual invitation was emailed to the members of Ontario Family Practice Nurses' interest group of the Registered Nurses' Association of Ontario, Canada. Descriptive and multivariate analyses were completed. Predictors investigated included nurses' age, beliefs about their role in smoking cessation, self-efficacy to provide effective counseling, smoking cessation training, and interest in updating smoking cessation knowledge. Eighty-nine Family Practice Nurses working in primary care settings across Ontario, Canada responded. Results: Nurses with higher levels of self-efficacy were more likely to provide smoking cessation counseling. Although nurses Ask, Advise and Assess, they are less likely to provide concrete assistance in the quitting process or arrange follow-up. The most commonly cited barriers to nurse-provided smoking cessation counseling included cost of medication, lack of time, and lack of knowledge. Fourteen percent of respondents reported that they never offer smoking cessation counseling to pregnant women. Conclusions: Family Practice Nurses are not consistently providing evidence-based smoking cessation interventions for pregnant women. Disseminating research outlining effective strategies to increase nurses' selfefficacy to provide effective smoking cessation interventions may increase the uptake of evidence-based recommendations.

To evaluate the effectiveness of a fetal monitoring education program in increasing nurses' knowledge and clinical skills.Multicenter randomized control trial.Twelve hospitals in eastern Ontario, Canada.One hundred nine volunteer registered nurses randomly assigned, within each hospital, to an experimental (n = 47) or control (n = 62) group. Ninety-six nurses (40 in the experimental group and 56 in the control group) completed the 6-month follow-up (88% retention).The experimental group participated in a 1-day fetal monitoring workshop and a review session 6 months later.Performance on a 45-item knowledge test and a 25-item skills checklist. The passing score was at least 75% correct on each test.The percentage of nurses in the experimental group passing both the knowledge and the clinical skills tests after the workshop was significantly higher (p0.01) than that of the nurses in the control group: 68.1% versus 6.5%, respectively. A large difference between the groups remained at the 6-month follow-up (experimental, 45%; control, 6.5%). The performance of the nurses in the experimental group improved to an 85% pass rate after they attended the 6-month review session.This comprehensive, research-based program is effective in increasing fetal monitoring knowledge and clinical skills.

Background Between November 2014 and March 2015, eight high level azithromycin resistant Neisseria gonorrhoeae (NG) isolates (MIC > 256 mg/l) were identified by Sexually Transmitted Bacteria Reference Unit Microbiology Services (STBRU) from our clinic. An Outbreak Control Team was established to actively manage the outbreak. We report the actions and outcomes of the clinical team. Immediate actions Clinicians reminded to take cultures from all exposed sites when NG suspected and before any treatment; first face-to-face contact is most effective in obtaining partner details; TOC at 2 weeks essential. Enhanced PN commenced. Where initial PN incomplete, or withheld, at least two further attempts of face-to-face interview or phone call. TOC non-attendees contacted by phone call and letter, giving further opportunity to pursue PN. Advice sought from STBRU about treating pharyngeal infections to avoid pressure on ceftriaxone by its use as monotherapy. Investigation of how the first eight cases were missed despite clinic systems in place for checking positive NG cultures. Outcomes By December 2015: 16 infected people identified with whole genome sequencing suggesting clonal outbreak. All were heterosexual, most aged 16–20 years. No ethnic or geographic clustering. 12/16 attended for TOC which were negative. 28 contacts disclosed, 16 traceable all attended - 3 NG negative, 13 NG positive, (12/13 azithromycin resistant, 1 NAAT positive but culture negative). PN identified 1 cluster of 4 and 3 clusters of 2 Lessons learned NG cultures and sensitivities remain essential to detect antimicrobial resistance. Despite enhanced PN there are many untraceable contacts in young heterosexuals. Clinics need robust administrative systems for timely detection of antimicrobial resistance

The study objective was to evaluate the reliability, validity, and reactivity of measures eliciting health risk attitudes toward smoking during pregnancy (HRAS). The authors' rationale for studying HRAS, including health expectations, values, and tradeoffs, evolved from interviews with pregnant smokers who stated that health was a primary consideration in the decision to quit smoking during pregnancy. The authors be