Authors: Cassidy C, Harrison MB, Godfrey C, and Graham ID, On behalf of the Implementation Strategies in Nursing Systematic Review Working Group
Presenter: Dr. Christine Cassidy
Institution: Dalhousie University
Practice guidelines can reduce variations in nursing practice and improve patient care. However, implementation of practice guidelines is complex and inconsistent in practice. It is unclear which strategies are effective at implementing clinical guidelines in nursing practice. The purpose of this review was to to determine the effectiveness and feasibility of implementation strategies to facilitate the uptake of guidelines focused on nursing care.
We conducted a systematic review of five electronic databases in addition to the Cochrane Effective Practice and Organization of Care (EPOC) Group specialized registry up to September 30th, 2020. Randomized controlled trials were included if the implementation strategy was aimed at implementing guidelines in nursing and reported assessments of the process or outcome of care provided by nurses. Two reviewers independently screened studies, assessed study quality, extracted data, and coded data using the EPOC taxonomy of implementation strategies. For those strategies not included in the EPOC taxonomy, we inductively categorized these strategies and generated additional categories. We conducted a narrative synthesis to analyze results.
Of the 38,172 citations screened, 46 papers reporting on 41 studies met the inclusion criteria. The methodological quality varied but the majority had low or unclear risk of bias. Most implementation strategies were multi-component and included a combination of educational materials and educational meetings (n=36). A number of studies employed implementation strategies not listed within the EPOC taxonomy, including adaptation of practice guidelines to local context (n=9), external facilitation (n=14), changes to organizational policy (n=3), as well as theory-based approached (n=17). Review findings show that multicomponent implementation strategies that include educational meetings, in combination with other educational strategies, report positive effects on professional practice outcomes, professional knowledge outcomes, patient health outcomes, and resource use/expenditures. Participatory approaches also show positive trends in patient, provider, and health system outcomes.
Nursing is advancing the science on implementation strategies. A key finding in this review is the identification of important implementation strategies used in the nursing trials not found in the EPOC taxonomy, including participatory approaches such as facilitation, adaptation and organizational changes. Nursing and other disciplines that work primarily in teams may benefit from using participatory-based implementation strategies. Further research is needed to understand how different implementation strategy components work in a nursing context and to what effect. As the field is still emerging, future reviews should also explore guideline implementation strategies in nursing in quasi or non-experimental research designs and qualitative research studies.