Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings

Abstract

BackgroundLittle is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.MethodsA 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.ResultsWhile 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.ConclusionImplementation 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.

Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries

“…205,207,209,211,212,215 Of these, two publications reported on 1 year postpartum outcomes 212, 215 and a third reported on 15-year outcomes from the Swedish SPAWN Study. 207 One study, evaluating weight change from immediately after delivery to 9 months postpartum, found no difference.…”

“…A second, evaluating weight change from the first prenatal visit to 1 year postpartum, also found no differences. 209 The two studies that evaluated weight change from a prepregnancy measure to weight at 1 year, 212, 215 18 months, 211 and 15 years 207 all reported statistically significant differences favoring greater intensity of breastfeeding.…”

“…Ten studies defined breastfeeding in terms of duration, 203,204,206,208,209,213,[217][218][219]221 but their measurement of outcomes varied. Three of 10 studies reported weight change between an early postpartum period (1 to 14 days after delivery) to later in the postpartum period (12 to 24 months).…”

“…208 One of 10 studies reported on weight change between early pregnancy (first prenatal visit) and 1 year postpartum and found a greater and statistically significant weight reduction. 209 The remaining 6 of 10 studies reported on weight change from prepregnancy weight to postpartum weight measured at time points ranging from 6 months to 8 years postpartum. 204,206,[217][218][219]221 Of these, 3 reported no statistically significant differences, 204,206,217 and 1 reported a difference only for the group with the longest period of exposure (20 weeks or more).…”

“…Of these, 7 cohort studies that examined postpartum weight changes in relation to exclusive breastfeeding were included in the prior 2007 AHRQ review; 205,207,[209][210][211][212][213][214][215] short-212, 215 and long-term 207 outcomes were reported for the Stockholm Pregnancy and Women's Nutrition Study (SPAWN) in three publications. The searches for this update review identified 10 additional relevant publications.…”