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The article cites a study assessing the impact of hybrid electronic paper environments. Methods used in the study were two stimulated environments, the hybrid and paper environments participated by thirty-five new nurses. In the analysis, substantial differences were found out and the modified cognitive load were revealed. Conclusions from the study were drawn ascertaining the effect of hybrid environments to the information assaying aspects of novice nurse and asserting the need for further exploration of other effects of the stated environments.

The purpose of this study was to investigate the effects of a hybrid electronic-paper patient record environment upon health professional information seeking (i.e. amount of information accessed, choice of key sources of information, type of information and use of information seeking tactics). A within group, laboratory, experimental study was conducted using two simulation environments (i.e. a paper patient record and a hybrid or electronic-paper environment). Thirty-five novice nurses participated in this within group, laboratory based study. Findings revealed significant differences between the paper and hybrid environments in terms of their effects upon information seeking. Subjects: (1) accessed less data in the hybrid than the paper environment, (2) accessed more non-electronic sources than electronic sources of information in the hybrid environment, and (3) used more passive information seeking tactics in the hybrid than the paper environment. Findings from the cued recall data revealed subjects experienced increased cognitive load in the hybrid environment. Implications for the design of hybrid environments are discussed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Patient involvement in health service planning and evaluation is considered important yet not widely practiced. This study explored stakeholder beliefs about patient participation in performance indicator selection to better understand hypothesized barriers. METHODS: Interviews with 30 cancer patients and health professionals from two teaching hospitals were analyzed qualitatively. RESULTS: All groups believed patients, not members of the public, should be involved in the selection of indicators. Ongoing, interactive methods such as committee involvement, rather than single, passive efforts such as surveys were preferred. Health professionals recommended patients assume a consultative, rather than decision-making role. Older patients agreed with this. CONCLUSION: Variable patient interest, health professional attitudes, and a lack of insight on appropriate methods may be limiting patient involvement in this, and other service planning and evaluation activities. More research is required to validate expressed views among the populations these stakeholders represent, and to establish effective methods for engaging patients. PRACTICE IMPLICATIONS: Efforts to encourage a change in health professional attitude may be required, along with dedicated organizational resources, coordinators and training. Methods to engage patients should involve deliberation, which can be achieved through modified Delphi panel or participatory research approaches. [ABSTRACT FROM AUTHOR]

Integrated delivery systems that promote learning and flexibility will be better prepared to face the challenges imposed by a complex and competitive environment. The integration of learning into these systems requires a shared vision, facilitative leadership, and highly functioning communication channels within an organic structure. Strategies that promote positive attitudes toward change are necessary for learning as is the provision of resources, training, incentives, and rewards that support learning, and feedback on how new administrative and clinical practices advance the mission and goals of the system. [ABSTRACT FROM AUTHOR]

Clinician-managers (CMs) are becoming increasingly responsible for resource allocation decisions, decisions that can spawn ethical issues when resources are scarce. The purpose of the study on which this article is based was to determine which factors would predict CMs' satisfaction with organizational practices that assist them with ethical issues arising from resource allocation decisions. [ABSTRACT FROM AUTHOR]

Abstract Background Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines. Methods A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team. Results The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic. Conclusions Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

Abstract Background One way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care. Methods We used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents. Results The context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time. Conclusions We conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.

Abstract Background Practice guidelines can improve health care delivery and outcomes but several issues challenge guideline adoption, including their intrinsic attributes, and whether and how they are implemented. It appears that guideline format may influence accessibility and ease of use, which may overcome attitudinal barriers of guideline adoption, and appear to be important to all stakeholders. Guideline content may facilitate various forms of decision making about guideline adoption relevant to different stakeholders. Knowledge and attitudes about, and incentives and capacity for implementation on the part of guideline sponsors may influence whether and how they develop guidelines containing these features, and undertake implementation. Examination of these issues may yield opportunities to improve guideline adoption. Methods The attributes hypothesized to facilitate adoption will be expanded by thematic analysis, and quantitative and qualitative summary of the content of international guidelines for two primary care (diabetes, hypertension) and institutional care (chronic ulcer, chronic heart failure) topics. Factors that influence whether and how guidelines are implemented will be explored by qualitative analysis of interviews with individuals affiliated with guideline sponsoring agencies. Discussion Previous research examined guideline implementation by measuring rates of compliance with recommendations or associated outcomes, but this produced little insight on how the products themselves, or their implementation, could be improved. This research will establish a theoretical basis upon which to conduct experimental studies to compare the cost-effectiveness of interventions that enhance guideline development and implementation capacity. Such studies could first examine short-term outcomes predictive of guideline utilization, such as recall, attitude toward, confidence in, and adoption intention. If successful, then long-term objective outcomes reflecting the adoption of processes and associated patient care outcomes could be evaluated.

Abstract Background This paper focuses on measuring the efficiency and effectiveness of two diagramming methods employed in key informant interviews with clinicians and health care administrators. The two methods are 'participatory diagramming', where the respondent creates a diagram that assists in their communication of answers, and 'graphic elicitation', where a researcher-prepared diagram is used to stimulate data collection. Methods These two diagramming methods were applied in key informant interviews and their value in efficiently and effectively gathering data was assessed based on quantitative measures and qualitative observations. Results Assessment of the two diagramming methods suggests that participatory diagramming is an efficient method for collecting data in graphic form, but may not generate the depth of verbal response that many qualitative researchers seek. In contrast, graphic elicitation was more intuitive, better understood and preferred by most respondents, and often provided more contemplative verbal responses, however this was achieved at the expense of more interview time. Conclusion Diagramming methods are important for eliciting interview data that are often difficult to obtain through traditional verbal exchanges. Subject to the methodological limitations of the study, our findings suggest that while participatory diagramming and graphic elicitation have specific strengths and weaknesses, their combined use can provide complementary information that would not likely occur with the application of only one diagramming method. The methodological insights gained by examining the efficiency and effectiveness of these diagramming methods in our study should be helpful to other researchers considering their incorporation into qualitative research designs.

Abstract Background Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. Methods Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12). Results After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. Conclusion Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.

Background: This paper focuses on measuring the efficiency and effectiveness of two diagramming methods employed in key informant interviews with clinicians and health care administrators. The two methods are 'participatory diagramming', where the respondent creates a diagram that assists in their communication of answers, and 'graphic elicitation', where a researcher-prepared diagram is used to stimulate data collection.Methods: These two diagramming methods were applied in key informant interviews and their value in efficiently and effectively gathering data was assessed based on quantitative measures and qualitative observations.Results: Assessment of the two diagramming methods suggests that participatory diagramming is an efficient method for collecting data in graphic form, but may not generate the depth of verbal response that many qualitative researchers seek. In contrast, graphic elicitation was more intuitive, better understood and preferred by most respondents, and often provided more contemplative verbal responses, however this was achieved at the expense of more interview time.Conclusion: Diagramming methods are important for eliciting interview data that are often difficult to obtain through traditional verbal exchanges. Subject to the methodological limitations of the study, our findings suggest that while participatory diagramming and graphic elicitation have specific strengths and weaknesses, their combined use can provide complementary information that would not likely occur with the application of only one diagramming method. The methodological insights gained by examining the efficiency and effectiveness of these diagramming methods in our study should be helpful to other researchers considering their incorporation into qualitative research designs. [ABSTRACT FROM AUTHOR]

Background: The impact of efforts by healthcare organizations to enhance the use of evidence to improve organizational processes through training programs has seldom been assessed. We therefore endeavored to assess whether and how the training of mid- and senior-level healthcare managers could lead to organizational change., Methods: We conducted a theory-driven evaluation of the organizational impact of healthcare leaders' participation in two training programs using a logic model based on Nonaka's theory of knowledge conversion. We analyzed six case studies nested within the two programs using three embedded units of analysis (individual, group and organization). Interviews were conducted during intensive one-week data collection site visits. A total of 84 people were interviewed., Results: We found that the impact of training could primarily be felt in trainees' immediate work environments. The conversion of attitudes was found to be easier to achieve than the conversion of skills. Our results show that, although socialization and externalization were common in all cases, a lack of combination impeded the conversion of skills. We also identified several individual, organizational and program design factors that facilitated and/or impeded the dissemination of the attitudes and skills gained by trainees to other organizational members., Conclusions: Our theory-driven evaluation showed that factors before, during and after training can influence the extent of skills and knowledge transfer. Our evaluation went further than previous research by revealing the influence--both positive and negative--of specific organizational factors on extending the impact of training programs.

Support is considered an important factor for realizing the benefits of health information technology (HIT) but there is a dearth of research on the topic of support, especially in primary care. We conducted a qualitative multiple case study of 4 family health teams (FHTs) and one family health organization (FHO) in Ontario, Canada in an attempt to gain insight into users' expectations and needs, and the realities of end-user support for primary care electronic medical records (EMRs). Data were collected by semi-structured interviews, documents review, and observation of training sessions. The analysis highlights the important role of on-site information technology (IT) staff and super-users in liaising with various stakeholders to solve technical problems and providing hardware and functional ('how to') support; the local development of data support practices to ensure consistent documentation; and the gaps that exist in users' and support personnel's understanding of each other's work processes.

Research Problem: Tutorials and user manuals are important forms of impersonal support for using software applications including electronic medical records (EMRs). Differences between user- and vendor documentation may indicate support needs, which are not sufficiently addressed by the official documentation, and reveal new elements that may inform the design of tutorials and user manuals., Research Question: What are the differences between user-generated tutorials and manuals for an EMR and the official user manual from the software vendor?, Literature Review: Effective design of tutorials and user manuals requires careful packaging of information, balance between declarative and procedural texts, an action and task-oriented approach, support for error recognition and recovery, and effective use of visual elements. No previous research compared these elements between formal and informal documents., Methodology: We conducted an mixed methods study. Seven tutorials and two manuals for an EMR were collected from three family health teams and compared with the official user manual from the software vendor. Documents were qualitatively analyzed using a framework analysis approach in relation to the principles of technical documentation described above. Subsets of the data were quantitatively analyzed using cross-tabulation to compare the types of error information and visual cues in screen captures between user- and vendor-generated manuals., Results and Discussion: The user-developed tutorials and manuals differed from the vendor-developed manual in that they contained mostly procedural and not declarative information; were customized to the specific workflow, user roles, and patient characteristics; contained more error information related to work processes than to software usage; and used explicit visual cues on screen captures to help users identify window elements. These findings imply that to support EMR implementation, tutorials and manuals need to be customized and adapted to specific organizational contexts and workflows. The main limitation of the study is its generalizability. Future research should address this limitation and may explore alternative approaches to software documentation, such as modular manuals or participatory design.

Purpose: To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI)., Method: This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified., Results: Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies., Conclusions: Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level., Implications for Rehabilitation: • Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

The aim of this study was to better understand care protocol implementation, including the influence of organizational-contextual factors on implementation approaches, in long-term care homes operating in Ontario. We surveyed directors of care employed in all 547 Ontario LTC homes, and combined survey data with secondary organizational data on rural/urban location, nursing home size, chain membership, type of ownership, and accreditation status. Motivations for the use/selection of care protocols in nursing homes primarily derived from beliefs in continuous improvement and in evidence-based care. Protocol selection was largely participative, involving management and staff. External information sources were important for protocol implementation, and in-service education was the chief means of training and educating staff. Significant differences in approaches to implementation were evident in association with differences in ownership. Three key success factors for implementation were identified: contextualizing the practice change, adequately resourcing for implementation, and demonstrating connections between practice change and outcomes.

Objectives: To evaluate the effectiveness of a nurse retention strategy, the "70% Full-Time Commitment", in retaining part-time and casual nurses in Ontario's nurse profession., Methods: Using the College of Nurses of Ontario database, a longitudinal dataset for all nurses registered with the college from 1993 to 2006 was created (N=216,353). One-year transition probabilities of nurse employment status (full-time, part-time and casual) were conducted (1993-2009) to generate trends of nurses' likelihood to stay in, switch or leave their full-time, part-time or casual position in Ontario's nurse profession., Results: After the 70% Full-Time Commitment (2004-2009) was initiated, most full-time (89.7%), part-time (76.6%) and casual (62.5%) nurses stayed in their employment position. A slightly larger proportion of part-time nurses (13.6%) switched to full-time compared to casual nurses (8.6%). However, a similar proportion of young part-time (24.5%) and casual (23.3%) nurses switched to full-time. A smaller proportion of part-time (3.2%) and casual (7.1%) nurses left the profession., Conclusion: Part-time and casual nurses have different employment switching patterns. The "70% Full-Time Commitment" was not an effective mechanism in retaining part-time and casual nurses. It might be more effective as a recruitment initiative for young nurses., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To describe the structure of informal networks for individuals with spinal cord injury (SCI) living in the community, to understand the quality of relationship of informal networks, and to understand the role of informal networks in the prevention and management of secondary health conditions (SHCs)., Design: Mixed-method descriptive study., Setting: Ontario, Canada Participants: Community-dwelling adults with an SCI living in Ontario Interventions/methods: The Arizona Social Support Interview Survey was used to measure social networks. Participants were asked the following open-ended questions: (1) What have been your experiences with your health care in the community? (2) What have been your experiences with care related to prevention and/or management of SHCs?, (3)What has been the role of your informal social networks (friends/family) related to SHCs?, Results: Fourteen key informant interviews were conducted (6 men, 8 women). The overall median for available informal networks was 11.0 persons (range 3-19). The informal network engaged in the following roles: (1) advice/validating concerns; (2) knowledge brokers; (3) advocacy; (4) preventing SHCs; (5) assisting with finances; and (6) managing SHCs. Participants described their informal networks as a "secondary team"; a critical and essential force in dealing with SHCs., Conclusions: While networks are smaller for persons with SCI compared with the general population, these ties seems to be strong, which is essential when the roles involve a level of trust, certainty, tacit knowledge, and flexibility. These informal networks serve as essential key players in filling the gaps that exist within the formal health care system.

To mitigate nurse shortages, health care decision makers tend to employ retention strategies that assume nurses employed in full-time, part-time, or casual positions and working in different sectors have similar preferences for work. However, this assumption has not been validated in the literature. The relationship between a nurse's propensity to exit the nurse profession in Ontario and employment status was explored by building an extended Cox Proportional Hazards Regression Model using a counting process technique. The differential exit patterns between part-time and casual nurses suggest that the common practice of treating part-time and casual nurses as equivalent is misleading. Health care decision makers should consider nurse retention strategies specifically targeting casual nurses because this segment of the profession is at the greatest risk of leaving. Nurse executives and nurse managers should investigate the different work preferences of part-time and casual nurses to devise tailored rather than "one-size fits all" nurse retention strategies to retain casual nurses.

Purpose: The purpose of this scoping review was to identify research priority areas related to secondary complications and associated health care use for individuals with spinal cord injury (SCI)., Data Sources: Peer-reviewed journals were identified using CINAHL, MEDLINE, PubMed, Embase, Social Sciences Abstracts, Social Works Abstract and PsycInfo search engines. Key references were hand searched., Study Selection: A total of 289 abstracts were identified from the initial search strategy. We removed studies that did not measure health care and those that did not involve analytical investigation., Data Extraction: The selected 31 studies were reviewed in detail using a coding template based on the domains and sub-components of the Andersen model (i.e. environmental, population characteristics, health behavior and outcome)., Results: Most studies measured predisposing characteristics (e.g., age, gender) and need characteristics (e.g., level of injury). There was a notable absence of environmental characteristics (e.g., health system, neighborhood variables), enabling characteristics and health behaviors (beyond diet and nutrition)., Conclusions: We identified a gap in the SCI literature. Future research should focus on longitudinal study designs with more representation of non-traumatic spinal cord injury, as well as utilizing more advanced statistical analyses (i.e., multivariate level) to adjust for confounding variables.

Background: In primary care settings, users often rely on vendors to provide support for health information technology (HIT). Yet, little is known about the vendors' perspectives on the support they provide, how support personnel perceive their roles, the challenges they face and the ways they deal with them., Objective: To provide in-depth insight into an electronic medical record (EMR) vendor's perspective on end-user support., Methods: As part of a larger case study research, we conducted nine semi-structured interviews with help desk staff, trainers and service managers of an EMR vendor, and observed two training sessions of a new client., Results: With a growing client base, the vendor faced challenges of support staff shortage and high variance in users' technical knowledge. Additionally, users sometimes needed assistance with infrastructure, and not just software problems. These challenges sometimes hindered the provision of timely support and required supporters to possess good interpersonal skills and adapt to diverse client population., Conclusion: This study highlights the complexity of providing end-user support for HIT. With increased adoption, other vendors are likely to face similar challenges. To deal with these issues, supporters need not only strong technical knowledge of the systems, but also good interpersonal communication skills. Some responsibilities may be delegated to super-users. Users may find it useful to hire local IT staff, at least on an on-call basis, to provide assistance with infrastructure problems, which are not supported by the software vendor. Vendors may consider expanding their service packages to cover these elements.

Background: Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines., Methods: A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team., Results: The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic., Conclusions: Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

Background: Support is often considered an important factor for successful implementation and realising the benefits of health information technology (HIT); however, there is a dearth of research on support and theoretical frameworks to characterise it., Objective: To develop and present a comprehensive, holistic, framework for characterising enduser support that can be applied to various settings and types of information systems., Method: Scoping review of the medical informatics and information systems literature., Results: A theoretical framework of end-user support is presented. It includes the following facets: support source, location of support, support activities, and perceived characteristics of support and support personnel., Conclusion: The proposed framework may be a useful tool for describing and characterising enduser support for HIT. it may also be used by decision makers and implementation leaders for planning purposes.

Using a multiple case study design, this article explores the translation process that emerges within Ontario long-term care (LTC) homes with the adoption and implementation of evidence-based clinical practice guidelines (CPGs). Within-organization knowledge translation is referred to as knowledge application. We conducted 28 semi-structured interviews with a range of administrative and care staff within 7 homes differentiated by size, profit status, chain membership, and rural/urban location. We further undertook 7 focus groups at 5 locations, involving a total of 35 senior clinical staff representing 15 homes not involved in earlier structured interviews. The knowledge application process that emerges across our participant organizations is highly complex, iterative, and reliant upon a facility's knowledge application capacity, or absorptive capacity to effect change through learning. Knowledge application capacity underpins the emergence of the application process and the advancement of knowledge through it. We find that different elements of capacity are important to different stages of the knowledge application process. Capacity can pre-exist, or can be acquired. The majority of the capacity elements required for successful knowledge application in the LTC contexts we studied were organizational. It is essential for managers and practitioners therefore to conceptualize and orchestrate knowledge application initiatives at the organization level; organizational leaders (including clinical leaders) have a vital role to play in the success of knowledge application processes., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: One way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care., Methods: We used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents., Results: The context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time., Conclusions: We conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.

Lowe and Chan's proposal for the development of common work environment metrics is long overdue. The authors' healthy work environment (HWE) framework is evidence based and illustrates the relationships between HWEs and organizational-level outcomes in a succinct yet comprehensive manner. The challenges we face in implementing their framework are related not so much to a fear of change but to a willingness to engage with multiple stakeholders and levels of government in coordinating our efforts. To date, we have lacked, at the policy level, a belief that HWEs can reduce operating costs, improve human resource utilization and, ultimately, lead to higher-quality patient care. We need a framework that will allow us to compare organizational performance in the area of health human resources in the same manner as we compare organizational outcomes in other areas. Such comparisons would allow us to further our understanding of the relationships among care providers, workplaces and organizational outcomes.

Background: Practice guidelines can improve health care delivery and outcomes but several issues challenge guideline adoption, including their intrinsic attributes, and whether and how they are implemented. It appears that guideline format may influence accessibility and ease of use, which may overcome attitudinal barriers of guideline adoption, and appear to be important to all stakeholders. Guideline content may facilitate various forms of decision making about guideline adoption relevant to different stakeholders. Knowledge and attitudes about, and incentives and capacity for implementation on the part of guideline sponsors may influence whether and how they develop guidelines containing these features, and undertake implementation. Examination of these issues may yield opportunities to improve guideline adoption., Methods: The attributes hypothesized to facilitate adoption will be expanded by thematic analysis, and quantitative and qualitative summary of the content of international guidelines for two primary care (diabetes, hypertension) and institutional care (chronic ulcer, chronic heart failure) topics. Factors that influence whether and how guidelines are implemented will be explored by qualitative analysis of interviews with individuals affiliated with guideline sponsoring agencies., Discussion: Previous research examined guideline implementation by measuring rates of compliance with recommendations or associated outcomes, but this produced little insight on how the products themselves, or their implementation, could be improved. This research will establish a theoretical basis upon which to conduct experimental studies to compare the cost-effectiveness of interventions that enhance guideline development and implementation capacity. Such studies could first examine short-term outcomes predictive of guideline utilization, such as recall, attitude toward, confidence in, and adoption intention. If successful, then long-term objective outcomes reflecting the adoption of processes and associated patient care outcomes could be evaluated.

Healthcare has undergone many transformations over the past several decades including increased diagnostic sophistication, shorter in-hospital stays and day surgeries as well as greater home-based treatments such as intravenous therapy, dialysis and palliation. Despite their rigorous evidence-based underpinnings and the demonstrated benefits of these advances, the sustainability of new clinical practices in healthcare organizations continues to present a challenge to practitioners and researchers alike.

A within group, laboratory, experimental study of nurse information seeking was conducted. As a part of the study, 35 novice nurses assessed and planned the care of two patients in two simulation environments: a paper (PR) environment and a hybrid (HY) environment [i.e., part of the environment was made available in electronic form via an electronic patient record (EPR) and part of it was paper-based]. Subjects were asked to "think aloud" in each environment and participated in a cued recall session following participation in the simulations. Subjects' verbalizations and actions were audio and video recorded and then transcribed. In the first phase of the study audio and video data were qualitatively coded using Model Based Coding with concepts from Newcomer Information Seeking Theory (NIST). This paper presents the qualitative results of this study with a focus upon the types of information used by novice nurses during the assessment and planning of patient care. Qualitative findings revealed novice nurses used referent, relational and appraisal information (as predicted by NIST theory and research) including information composed of more than one type of information (e.g., referent-relational). Two new types of information emerged from the qualitative data - situational task and situational organization information.

Objectives: Knowledge exchange is thought to enhance research utilization by decision-makers but there is little guidance on appropriate methods. This study evaluated the effectiveness of a research planning exercise utilizing technical (ranking, rating) and interpretive strategies (interdisciplinary workshop deliberation)., Methods: Participants were surveyed to establish research priorities and professional roles. Observation was used to examine actual contribution and outcomes. Semi-structured interviews with participants elicited perceived outcomes, commitment, contribution and learning. Survey data was reported with summary statistics. Transcripts were analyzed qualitatively., Results: Stakeholders were satisfied with the overall process, gaps in research were prioritized, and research questions were proposed, but anticipated intermediate or lateral outcomes were not achieved. Identifying differing perspectives and establishing relationships were unanticipated outcomes. Barriers included group dynamics, lack of clarity on objectives and processes, and minimal experience or interest in interpretive activities., Conclusions: A conceptual framework for evaluating factors influencing knowledge exchange outcomes had not been previously investigated. Strategies for overcoming identified barriers include better facilitation, involving a critical volume of non-clinicians, in-person sharing of background information, and incentives for decision-makers. Further research is required to examine the effectiveness of different forms of knowledge exchange, and the degree to which they are currently being practiced.

Purpose: The purpose of this paper is to show that performance data use could be promoted with a better understanding of the type of indicators that are important to different stakeholders. This study explored patient, nurse, physician and manager preferences for cancer care quality indicators., Design/methodology/approach: Interviews were held with 30 stakeholders between March and June 2004. They were asked to describe how they would use a cancer "report card", and which indicators they would want reported. Transcripts were reviewed using qualitative analysis., Findings: Role (patient, nurse, physician, manager) influenced preferences and perceived use of performance data. Patients and physicians were more skeptical than nurses and managers; patients and managers expressed some preferences distinct from nurses and physicians; and patients and nurses interpreted indicators more broadly than physicians and managers. All groups preferred technical process over outcome or interpersonal process indicators., Research Limitations/implications: Expressed views are not directly applicable beyond this setting, or to the general public but findings are congruent with attitudes to performance data for other conditions, and serve as a conceptual basis for further study., Practical Implications: Strategies for maximizing the relevance of performance reports might include technical process indicators, selection by multi-stakeholder deliberation, information that facilitates information application and customizable report interfaces., Originality/value: Performance data preferences have not been thoroughly examined, particularly in the context of cancer care. Factors were identified that influence stakeholder views of performance data, and this framework could be used to confirm findings among larger and different populations.

Unlabelled: The purpose of this study was to investigate the effects of a hybrid electronic-paper patient record environment upon health professional information seeking (i.e. amount of information accessed, choice of key sources of information, type of information and use of information seeking tactics). A within group, laboratory, experimental study was conducted using two simulation environments (i.e. a paper patient record and a hybrid or electronic-paper environment). Thirty-five novice nurses participated in this within group, laboratory based study. Findings revealed significant differences between the paper and hybrid environments in terms of their effects upon information seeking., Subjects: (1) accessed less data in the hybrid than the paper environment, (2) accessed more non-electronic sources than electronic sources of information in the hybrid environment, and (3) used more passive information seeking tactics in the hybrid than the paper environment. Findings from the cued recall data revealed subjects experienced increased cognitive load in the hybrid environment. Implications for the design of hybrid environments are discussed.

The Dementia Care Networks Study investigated 4 community-based, not-for-profit dementia care networks in Ontario, Canada. Investigators examined whether sociodemographic and health characteristics, type of support network, and amount of service use among care recipients and caregivers (n = 267 dyads) were associated with experiences with care processes. The process-of-care constructs were: family physicians' awareness of services; experiences with health care workers, and assessment and placement activities. The findings highlighted that family physicians' understanding of dementia and their ability to work with the dyad to become aware of and accept services, was an important component in the dyad's satisfaction. If caregivers received home support and the care recipients received emotional support from their social support network, they were more likely to be satisfied with their experiences with health care workers. In summary, increased awareness and provision of services were associated with more positive perceptions of network effectiveness.

Should the same evidence lead to the same decision outcomes in different decision-making contexts? In order to improve comprehension of this issue, this study considers how context influences evidence utilization in the development of health policy recommendations. We used an embedded multiple case study design to study how four expert groups formulated policy recommendations for breast, cervical, colorectal, and prostate cancer screening in Ontario, Canada. We interviewed expert group members and analysed meeting agendas/minutes, interim/final reports and other case-related documents. Our analyses revealed varying policy objectives; the use, neglect, or overextended consideration of three key decision support tools; the varying skills/abilities of expert group members in using different decision support tools; the varying impact of effect modifiers, resource constraints and political interests; and the differing development/consideration of context-specific evidence to address uncertainty in the external decision-making context. While more work is needed to determine if these findings are generalizable beyond cancer screening policy, we believe the central challenge for evidence-based policy is not to develop international evidence, but rather to develop more systematic, rigorous, and global methods for identifying, interpreting, and applying evidence in different decision-making contexts. Our analyses suggest that identification of evidence must distinguish between different policy objectives in order to link a broad conceptualization of evidence to appropriate policy questions. Interpretation of evidence must acknowledge the varying nature of evidence for different policy objectives, balancing existing emphasis on evidentiary quality with more sophisticated methods for assessing the generalizability of evidence. The application of evidence must also acknowledge different policy objectives, appropriately employing rule-based grading schemes and agreement-based consensus methods that are sensitive to the nature of the evidence and contexts involved.

This review of health care team effectiveness literature from 1985 to 2004 distinguishes among intervention studies that compare team with usual (nonteam) care; intervention studies that examine the impact of team redesign on team effectiveness; and field studies that explore relationships between team context, structure, processes, and outcomes. The authors use an Integrated Team Effectiveness Model (ITEM) to summarize research findings and to identify gaps in the literature. Their analysis suggests that the type and diversity of clinical expertise involved in team decision making largely accounts for improvements in patient care and organizational effectiveness. Collaboration, conflict resolution, participation, and cohesion are most likely to influence staff satisfaction and perceived team effectiveness. The studies examined here underscore the importance of considering the contexts in which teams are embedded. The ITEM provides a useful framework for conceptualizing relationships between multiple dimensions of team context, structure, processes, and outcomes.

This commentary addresses four of the paradoxes proposed by Huerta et al.--resourcing, synergy, defragmentation and evaluation--and uses recent evidence from the Ontario Regional Stroke Strategy and the Dementia Care Networks Study to explore the challenges identified in greater depth. Seven strategies are also proposed to advance the practice and research agendas related to network development and evaluation: developing a shared vision of care for particular groups of care recipients/clients, products and services that goes beyond a single sector (e.g., acute care only); identifying the aspects of care that will most likely benefit from a network structure; embedding networks within broader strategies; developing both clinical and management leadership and collaborations at the organizational and network levels; developing mechanisms to understand care-recipient flow and where gains can be achieved through interactions of key organizations and service providers; using administrative and information mechanisms to increase efficiencies within networks; and acknowledging that, even with a centralized strategy, variations will exist between similar networks.

We apply the theoretical frameworks of knowledge transfer and organizational learning, and findings from studies of clinical practice guideline (CPG) implementation in health care, to develop a contingency model of innovation adoption in long-term care (LTC) facilities. Our focus is on a particular type of innovation, CPGs designed to improve the quality of LTC. Our interest in this area is founded on the premise that the ability of LTC organizations to adopt and sustain the use of innovations like CPGs is contingent on the initial capacity these institutions have to learn about them, and on the presence of factors that contribute to capacity building at each stage of innovation adoption. Based on our review of relevant theory, we develop a set of fifteen testable propositions that relate factors operating at the guideline, individual, organizational, and environmental levels in LTC institutions to stages of guideline adoption/transfer. Our model offers insights into the complexities of adopting and sustaining innovations in LTC facilities particularly, in health care organizations specifically, and in service organizations generally.

Purpose: The Dementia Care Networks' Study examined the effectiveness of four community-based, not-for-profit dementia networks. The study involved assessing the relationship between the types of administrative and service-delivery exchanges that occurred among the networked agencies and the network members' perception of the effectiveness of these exchanges., Design and Methods: With the use of a case-study method, the evolution, structure, and processes of each network were documented. Social network analysis using a standardized questionnaire completed by member agencies identified patterns of administrative and clinical exchanges among networked agencies., Results: Differences were found between the four networks in terms of their perceptions of service-delivery effectiveness; perceptions of administrative effectiveness did not factor significantly. Exchanges between groups of agencies (cliques) within each of the four networks were found to be more critical than those between individual agencies within each network., Implications: Integration-measured by the types of exchanges within as opposed to across networks-differentiated the four networks studied. This research contributes to our understanding of the use of multiple measures to evaluate the inner workings of service delivery and their impact on elder health and elder health care.

Background: Quality-of-work-life (QWL) includes broad aspects of the work environment that affect employee learning and health. Canadian health care organizations (HCOs) are being encouraged to monitor QWL, expanding existing occupational health surveillance capacities., Aim: To investigate the understanding, collection, diffusion and use of QWL indicators in Canadian HCOs., Methods: We obtained cooperation from six diverse public HCOs managing 41 sites. We reviewed documentation relevant to QWL and conducted 58 focus groups/team interviews with strategic, support and programme teams. Group interviews were taped, reviewed and analysed for themes using qualitative data techniques. Indicators were classified by purpose and HCO level., Results: QWL indicators, as such, were relatively new to most HCOs yet the data managed by human resource and occupational health and safety support teams were highly relevant to monitoring of employee well-being (119 of 209 mentioned indicators), e.g. sickness absence. Monitoring of working conditions (62/209) was also important, e.g. indicators of employee workload. Uncommon were indicators of biomechanical and psychosocial hazards at work, despite their being important causes of morbidity among HCO employees. Although imprecision in the definition of QWL indicators, limited links with other HCO performance measures and inadequate HCO resources for implementation were common, most HCOs cited ways in which QWL indicators had influenced planning and evaluation of prevention efforts., Conclusions: Increase in targeted HCO resources, inclusion of other QWL indicators and greater integration with HCO management systems could all improve HCO decision-makers' access to information relevant to employee health.

Background: Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia., Methods: Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12)., Results: After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU., Conclusion: Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.

Effective health services rely on a foundation of research-based evidence. While quality care improvements are dependent on the application of evidence, incorporating them into practice may be challenging. This article presents the results of a study of the diffusion of a complex evidence-based innovation initiated by the Heart and Stroke Foundation of Ontario.