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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.

Interprofessional exchanges such as workshops are common activities in international development programs. The authors describe processes used to select, implement, and evaluate six collaborative workshops held in Tianjin, China, between 1990 and 1995. These workshops targeted curricular change for a baccalaureate nursing program in Tianjin Medical University. Our experience highlights the importance of understanding the assumptive base for change, developing an institutional memory in both partner universities, introducing interactive teaching methods congruent with Chinese value systems, and using a formative evaluation strategy to foster cross-cultural dialogue and mutual understanding among project partners.

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

To describe the attitudes of nulliparas (women who have never given birth) about caesarean delivery on maternal request, and to examine their characteristics, perceptions and fears related to vaginal birth and caesarean delivery.Cross-sectional survey.Canadian nulliparas, 18 to 24 years of age, attending an educational institution.A previously developed questionnaire was adapted, evaluated for validity and pretested. The questionnaire was presented in class by a research assistant. Participants placed questionnaires in a box to maintain confidentiality. The main outcome measure was participants' attitudes toward caesarean delivery on request. Descriptive, bivariate and multivariate regression statistical analyses were done.Of 260 women invited, 140 (53.8%) participated. Participants' mean age was 20.4 years, and 95 per cent were born in Quebec. The majority (63.3%) had heard about caesarean delivery on maternal request, but only 28.6 per cent had a favourable attitude toward it. Having fears about vaginal birth (p0.001), thinking that caesarean delivery was less stressful than vaginal birth (p = 0.042) and that vaginal birth had more negative consequences for the mother (p = 0.014) and a positive attitude of peers (p = 0.013) were four factors associated with a favourable attitude. For this group of respondents, these four factors would successfully predict attitudes to caesarean section upon maternal request 66.5 per cent of the time.

To examine the activities and resource implications for the initial cohort of healthcare organisations involved in the introduction of multiple nursing guidelines.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.Secondary analysis of retrospective narrative data.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.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.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.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.

Research describes leadership as important to guideline use. Yet interventions to develop current and future leaders for this purpose are not well understood.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.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.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.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.

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

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.

Objectives: The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospect ively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses. Methods: We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied im mobilization and completed a data form. Results: Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%‐100.0%) and specificity of 43.4% (95% CI 42.0%‐45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%‐ 95.0%) and a specificity of 43.9% (95% CI 42.0%‐46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinic ally by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases. Conclusion: Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.

A 4-year curriculum project (2004-2008) to integrate patient decision support into an existing curriculum was guided by the Knowledge-to-Action process model. The purpose of this project was to integrate a patient decision support theoretical framework and associated evidence-based resources throughout a four-year baccalaureate nursing curriculum. Interventions designed to adapt knowledge to local context and overcome barriers to knowledge use included faculty workshop to increase awareness, instructional resources designed for courses and core content, curricular blueprint of key threads to be included within courses, shared resources on the school of nursing internal website, and development of decision support resources in French. Curricular change and sustained use of knowledge was evidenced by repeated use of guest lecturers, assignments, and problem-based scenarios in courses, and students' evaluations on the tutorial and assignments.

Purpose To describe new mothers' experiences with family-centered maternity care in relation to their confidence level and to determine how care could have been more responsive to their needs. Study design and methods Using data from a prospective Canadian survey of 596 postpartum women, a subsample of women with low and high confidence (N = 74) was selected. Data were analyzed using descriptive statistics and content analysis. Results Women with both high and low confidence expressed negative experiences with similar frequency (n = 47/74, 64%). Women wanted more nursing support for breastfeeding and postpartum teaching and education. Women who reported a language other than English or French as their first language were significantly less confident than English- and French-speaking women (p Clinical implications A multilevel framework about family-centered care is presented for healthcare providers in prenatal, labor and birth, and postpartum care. It is recommended that nurses ask new mothers about their confidence level and give special consideration to cultural background in order to provide supportive care in hospital and community settings.

To quantify practice changes associated with implementing a clinical practice guideline for the second stage of labor in term nulliparous women with epidural anesthesia and to describe the lessons learned about knowledge translation. The main clinical practice guideline recommendation was waiting up to 2 hours before pushing after full dilatation.Pre- and post-evaluation of clinical outcomes and knowledge translation strategies associated with implementing the second stage of labor clinical practice guideline at two birthing units within a large teaching hospital.The implementation of the clinical practice guideline resulted in a significant increase in median waiting time before pushing of 33 minutes at Site 1. This change was also reflected in the twofold increase in the proportion of women waiting longer than 120 minutes before pushing at this site. There was no change in waiting time at Site 2. The duration of the second stage did not change significantly at either site. The median pushing time decreased at both sites but was only statistically significant at Site 1.Bringing about practice change in obstetrics is complex. The measured change in this study was less than we expected. Greater success might have been achieved by enhancing feedback to care providers and more frequent audits of practice. We need to better understand the subtle influences in attitude and culture that prevented successful implementation in one site. For units considering a similar process, we recommend a commensurately greater level of presence in the units to encourage compliance with the clinical practice guideline in order to achieve the desired level of practice change.

OBJECTIVES To explore the use of policies and procedures as a tool to support the implementation of clinical guidelines and to determine the relationship between organizational support and stability with nurses' perception of policy change. DESIGN Secondary analysis of qualitative and quantitative data collected in the post-intervention phase of the study entitled Evaluation of the Dissemination and Utilization of Best Practice Guidelines by Registered Nurses in Ontario. SETTING Eleven agencies across Ontario, Canada. PARTICIPANTS Fifty nursing staff, 32 nurse administrators and 22 clinical resource nurses (90% response) participated in semi-structured interviews. A total of 316 randomly selected nursing staff from 23 participating units in 11 agencies completed questionnaires (65% response). METHODS Qualitative data from semi-structured interviews were examined to determine whether participants had modified their policies and procedures as part of the implementation of clinical guidelines. Using SPSS 11.0 for Windows, the authors assessed, using independent t-tests, the relationship between the perception of modification of policies and procedures and the perceptions of organizational support an organisational stability. RESULTS While modifications to policies and procedures were made at each agency as part of the implementation of clinical guidelines, 27% of staff disagreed that modifications had been made. Nursing staff who agreed that changes had been made to policies and procedures were significantly more likely to report positive organizational support for clinical guideline implementation. CONCLUSION Findings suggest the need to increase nursing staffs' awareness of changes to policies and procedures during clinical guideline implementation. Furthermore, results indicate that organizational support may have a positive influence on modifications to policies and procedures that are guided by research-based clinical guideline recommendations.

Background Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings. Methods A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation. Results While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance. Conclusion Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.

Background: Clinical practice guidelines are promising tools for closing the research evidence-practice gap, yet effective and timely implementation of guidelines into practice remains fragmented and inconsistent. Factors influencing effective guideline implementation remain poorly understood, particularly in nursing. A sound understanding of barriers and facilitators is critical for development of effective and targeted guideline implementation strategies. Aim: This paper reports the perceptions of administrators, staff, and project leaders about factors influencing implementation of nursing best practice guidelines. Methods: Twenty-two organizations, in clusters of two to five, implemented one of seven guidelines in acute, community and long-term care settings. The topics were client centered care, crisis intervention, healthy adolescent development, pain assessment, pressure ulcers, supporting and strengthening families and therapeutic relationships. Fifty-nine administrators, 58 staff and 8 project leaders participated in post implementation semi-structured telephone interviews. Qualitative thematic analysis was conducted. Findings: Factors at individual, organizational and environmental levels were identified as influencing guideline implementation. Facilitators included learning about the guideline through group interaction, positive staff attitudes and beliefs, leadership support, champions, teamwork and collaboration, professional association support, and inter-organizational collaboration and networks. Barriers included negative staff attitudes and beliefs, limited integration of guideline recommendations into organizational structures and processes, time and resource constraints, and organizational and system level change. Similarities and differences in perceptions of these factors were found among staff, project leaders and administrators. Implications/Conclusions: Best practice guideline implementation strategies should address barriers related to the individual practitioner, social context, and organizational and environmental context, and should be tailored to different groups of stakeholders (i.e., nursing staff, project leaders and administrators). Health care administrators need to recognize the “real” costs and complexity associated with successful implementation of guidelines and the need to ensure corporate commitment at the onset.

Objective To describe care provider attitudes towards multidisciplinary collaborative maternity care in Canada and the factors influencing such care from the perspective of members of national professional associations of care providers. Methods A qualitative descriptive approach was used. Leaders of national associations nominated key members, who were invited to participate in semi-structured telephone interviews. Results Twenty-five participants from six national care provider associations (family physicians, obstetricians, registered midwives, registered nurses, nurse practitioners, and rural physicians) were interviewed. Participants described at least one of two main benefits of collaborative maternity care: a partial solution to the human resources shortage in maternity care, and improved maternity care for women. Despite their belief that collaboration is needed, participants expressed concern about the effects of collaboration on their practice. In particular, some participants were concerned about how collaborative models could support woman-centred care or respond to local community needs and promote continuity of care. Significant barriers to collaboration include structural factors (fee structure, liability issues) and interdisciplinary rivalry between groups of providers (turf protection, lack of mutual respect). Strategies to promote collaboration that were supported by the participants include strong national leadership and interdisciplinary education. Conclusion Representatives of professional associations of care providers believe that multidisciplinary collaborative maternity care is needed to sustain the availability of care providers and to improve access and women's choices for maternity care in Canada. However, they perceive that strong leadership and education are needed to address significant structural and relational barriers to collaborative practice.

Background Integration of research evidence into clinical nursing practice is essential for the delivery of high-quality nursing care. Leadership behaviours of nurse managers and administrators have been identified as important to support research use and evidence-based practice. Yet minimal evidence exists indicating what constitutes effective nursing leadership for this purpose, or what kinds of interventions help leaders to successfully influence research-based care. Aims (1) To describe leadership activities of nurse managers that influence nurses' use of research evidence; and (2) to identify interventions aimed at supporting nurse managers to influence research use in clinical nursing practice. Methods A search of electronic databases was conducted for studies on behaviours or activities of nurse managers/administrators and the use of research evidence by nurses. Sifting, screening, and quality assessments were done by two reviewers. Results were synthesized by study type (quantitative and qualitative) and reported. Results Twelve studies met inclusion criteria (eight quantitative, four qualitative). Three activities were found in quantitative studies that influenced nurses' use of research: managerial support, policy revisions, and auditing. Qualitative studies showed organizational issues as barriers to managers' abilities to affect research use, while role modeling and valuing research facilitated research use. Four studies, one of which was experimental, included an intervention to support managers, but all had insufficient information about leadership development. Conclusions To date, important descriptive work highlights the strategic role managers have in research transfer. Both facilitative and regulatory activities appear to be necessary for managers to influence research use. These findings have important implications for evolving theoretical models describing factors that affect the process of research utilization. It is time to move the science forward and test a hypothesis linking leadership to outcomes. Qualitative methods are essential for understanding the process of leadership for research transfer.

Support from nursing managers and administrators, together with the role of a dedicated project Lead, are consistently identified as important strategies for nurses to be able to use research evidence in their practice. However, little is known about the key behaviours and activities required to successfully implement and sustain research-based innovations in practice. This study describes the leadership behaviours and activities that influenced nurses' use of clinical practice guidelines. A secondary analysis of qualitative data was conducted to investigate factors that contributed to sustaining (or not) the use of clinical guidelines two and three years after implementation as part of the Registered Nurses Association of Ontario Best Practice Guidelines project. Grounded theory techniques were used to develop a theoretical model of Leadership. Findings indicated a different pattern of leadership in organizations that sustained guidelines, when compared to those that did not. Three broad leadership strategies emerged as central to successfully implementing and sustaining guidelines: (1) facilitating staff to use the guidelines, (2) creating a positive milieu of best practices and (3) influencing organizational structures and processes. Leadership for guideline implementation was found to include such behaviours as support, role-modelling commitment and reinforcing organizational policies and goals consistent with evidence-based care.

Background Recent advances in the management of paediatric and adolescent rheumatology have developed the need for highly specialist nurses within the multidisciplinary team. This has resulted in nurses working in shared care within other health care settings (e.g. community care, primary care, general paediatrics and adult rheumatology) demanding an enhanced knowledge base and new skill set. There is an important role for education and support for not only nurse specialists but also nursing colleagues. Objectives This study aims to establish the essential “core” learning needs of nurses delivering care to children and young people with rheumatic disease within a variety of health care settings. Methods Multi-method research was conducted using online survey, focus groups and interviews with key nursing stakeholder groups including clinical nurse specialists (CNS, n=28), nursing students (n=15), health visitors (n=3) and nurses from general paediatrics (n=2), community (n=7), research (n=5) and adult rheumatology (n=4). An online survey of CNS within the British Society for Paediatric and Adolescent Rheumatology (BSPAR) (response rate: 77%, with 27/35 respondents) ascertained expert opinion about educational needs based on experience, knowledge and skills, and how these mapped to the needs of different nursing groups. The survey results informed the questions for focus groups and 1-1 interviews, which were recorded and transcribed to further explore the educational needs of nurses working outside of the specialism. Transcripts were analysed qualitatively using thematic analysis. This study had ethical approval with informed consent from all participants. Results Four core themes emerged: (1) Need for Increased Awareness about Rheumatic Disease, (2) Impact of Personal Experience and Nursing Role, (3) Need for Increased Knowledge about Rheumatic Disease and Management, and (4) Design Components for an Impactful Learning and Information Resource. The level of knowledge needed was stratified by what would be expected within the different nursing roles. The key topics include understanding of conditions and how they may present, treatment and medications, impact of disease and treatment on the child/young person and family, available support for themselves as health care providers, and access to resources to support patients and families, along with contemporary information and research to enable them to be well informed. Conclusions This study has identified “core” learning needs for all nursing groups. These learning needs appear dependent on past experience and what would be expected within the spectrum of nursing roles, and the level of knowledge required ranged from novice to expert. Future work will develop resources to meet these educational requirements. Disclosure of Interest None declared

Background: To implement best practice in restraint use, healthcare providers and decision makers require current, accurate, and easily accessible information about restraint practices in their setting. There is a need for a reliable and valid instrument that is feasible for use in these settings to rapidly assess physical restraint use. Method: Two instruments to assess physical restraint use were developed and tested: an observation tool and a chart audit. The instruments were tested in complex continuing care units and rehabilitation units at two healthcare organizations. The restraint use observation tool was administered by trained observers in a series of five observations over a 2-week period. Chart audits were conducted for a sample of residents. Inter-rater agreement of the observation tool and chart audit was assessed. Point prevalence estimates were obtained for each site. The time required to use the observation tool and complete chart audits as well as the comparability of findings from the two data sources were described. Findings: Restraint use observations were completed for 289 patients and chart audits were completed for 207 patients. Prevalence and patterns of restraint use varied between sites and across time periods. Observations took an average of 2.6 (Site A) and 0.6 (Site B) minutes per patient. There was excellent inter-rater agreement for most items on the observation tool with the exception of whether or not the patient was able to release or loosen the restraint. There was significant concordance but as expected, not complete agreement between paired estimates of prevalence using the observational tool and the chart audit. Conclusion: The observation and chart audit tools are feasible to use and reliably assess physical restraint use in healthcare organizations. The patient's physical capacity to move independently, the patient's waking status, and the restraint's restriction of mobility are items that should be added to the observation tool. The tools are complementary and should be used in tandem to capture the multifaceted complexity of restraint use in health service organizations. Worldviews on Evidence-Based Nursing 2006; 3(2):73–85.

The management of the second stage of labour remains controversial, and there are very few comprehensive evidence-based clinical practice guidelines to assist care providers. We describe an approach to developing a local clinical practice guideline that included extensive review of the literature; use of a guideline appraisal instrument to assess methodological rigour, content, clarity and applicability; use of a recommendation matrix; drafting a local guideline; obtaining formal feedback; making revisions; and designing an implementation and evaluation plan. Recommendations from this guideline include timelines for the total length of second stage, waiting time, and pushing time. Positioning of the woman, use of oxytocin, and fetal assessment are also discussed. This guideline is not intended to be used for women with multiple gestation and women attempting vaginal birth after Caesarean (VBAC) or in clinical situations where little evidence on best practice exists and management is individualized. We advocate an approach to the second stage of labour that enhances patient safety through team planning, communication, and documentation.

In early 2004, an evidence-based prenatal care workshop was held for community health nurses working in First Nations communities in British Columbia. The purpose of the workshop was to begin a dialogue on the use of evidence to improve prenatal care in First Nations communities. Specifically, selected models of knowledge transfer to improve care were introduced and discussed. Of the 81 nurses who participated, 52 completed a feedback questionnaire. Most of the participants (73%) were community health nurses. They worked across diverse geographic settings and health-care administration models (federally managed, band managed, tribal council managed). Seventy-three per cent of the nurses reported that a participatory model of knowledge transfer was important or very important. They also identified priority target audiences (stakeholders) for knowledge transfer strategies. Exploring stakeholders' views, values and priorities related to prenatal care and creating informal dialogue among these groups was identified as a next step in participatory transfer and exchange of knowledge to improve prenatal care in First Nations communities.

Poor access to prenatal care for Aboriginal people is well documented, and is explicated as an unethical barrier to care resulting from colonial and neocolonial values, attitudes, and practices. A postcolonial standpoint, participatory research principles, and a case study design were used to investigate 2 Aboriginal organizations' experiences improving care for pregnant and parenting Aboriginal people. Data were collected through exploratory interviews and small-group discussions with purposefully selected community leaders, providers, and community members. The study found that safety in healthcare relationships and settings, and responsiveness to individuals' and families' unique experiences and capacities must be brought into the forefront of care. Results suggest that the intention of care must be situated within a broader view of colonizing relations to improve early access to, and relevance of, care during pregnancy and parenting for Aboriginal people.

Clinical practice guidelines are developed with the purpose of improving patient care. The Registered Nurses Association of Ontario (RNAO) Nursing Best Practice Guidelines (BPG) Project was implemented in 1999. It has resulted in the development, implementation and evaluation of 17 BPGs with agencies in different healthcare sectors. This article describes the process, challenges and lessons learned by the team responsible for evaluating the BPGs.