Objectives At the end of this session, participants will have: An introduction to the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guidelines Program –from concept to reality, and; –lessons learned along the way. A greater understanding of RNAO best practice guidelines – how they are developed, and; – how they can be used.

Multi-year funding support from the Government of Ontario RNAO Best Practice Guidelines Program

Program Mandate To develop, pilot implement, evaluate and disseminate nursing best practice guidelines.

Goals for Best Practices Improve patient care Reduce variation in care Transfer research evidence into practice Promote nursing knowledge base Assist with clinical decision making Identify gaps in research Stop interventions that have little effect or cause harm Reduce cost

Five Broad Areas of Focus 1. Gerontology 2. Primary Health Care 3. Home Health Care 4. Mental Health Care 5. Emergency Care

What are Best Practice Guidelines (BPG)? “Systematically developed statements (based on best available evidence) to assist practitioner and patient decisions about appropriate health care for specific clinical (practice) circumstances” (Field & Lohr, 1990)

Comparing Standards of Practice to BPG Standard Based on values, morals, legislation Minimum requirements for individual practitioner Basis for determining professional competence, misconduct & malpractice Emphasis on legal & ethical requirements BPG Based on evidence from a critical review of the literature Suggested guidelines for individuals and organizations Emphasis on synthesis of the literature

Comparing Standards of Practice to BPG (2) Standard Defines acceptable and unacceptable behaviour Defines process for making decisions BPG Provides extensive background information to make informed decisions

Program Phases Pilot Implementation Development Planning Evaluation Revision Dissemination

Planning/ Development

Guideline Development Methodology Getting started –Guideline topic selection –Panel recruitment and establishment –Search, retrieval and critical appraisal of evidence sources –Identification of existing clinical practice guidelines

Guideline Development Methodology (2) Defining the scope Guideline appraisal –Screen for inclusion criteria –Use of AGREE Instrument

AGREE Instrument : 6 Domains Scope & Purpose Stakeholder Involvement Rigor of Development Clarity & Presentation Applicability Editorial Independence

Guideline Development Methodology (3) Development of recommendations Evaluation indicators External stakeholder review Publication Revision Practice Recommendations Education Recommendations Organization & Policy Recommendations

BPG Table of Contents Summary of Recommendations Interpretation of Evidence Responsibility for Development Purpose & Scope Development Process Definition of Terms Background Context Practice Recommendations Education Recommendations Organization & Policy Recommendations Research Gaps & Future Implications Evaluation/Monitoring of Guideline Implementation Strategies Process for Update/Review of Guideline References Bibliography Appendices

Types of Evidence?

Levels of Evidence Ia Meta-analysis or systematic review of randomized control trials Ib At least one randomized controlled trial IIaAt least one well-designed controlled study without randomization. IIb At least one other type of well-designed quasi-exp. study without randomization III Well-designed non-exp. descriptive studies IV Expert committee reports or opinions and/or clinical experiences of respected authorities

Additional Sources of Evidence Qualitative Research Clinical Experience Patient Preferences Contextual Influence

Pilot Implementation

Toolkit: Implementation of Clinical Practice Guidelines Selecting a guideline Assessing the organization for environmental readiness Identifying, assessing and engaging stakeholders Implementing strategies Securing resources Evaluating outcomes

Implementation Strategies (in Healthcare) Generally EffectiveSometimes EffectiveLittle or no Effect  Educational outreach visits  Reminders  Interactive educational meetings  Multifaceted intervention including two or more of: audit and feedback, reminders, local consensus processes, marketing  Audit and feedback  Local opinion leaders  Local consensus processes  Patient mediated interventions  Educational materials  Didactic educational meetings RNAO (2002). Toolkit: Implementation of Clinical Practice Guidelines “ No Magic Bullets”

Evaluation

BPG Evaluation 50+ organizations across Ontario to pilot implement/evaluate BPGs Canadian Health Services Research Foundation (CHSRF) funded study: Sustained Use of Research Evidence (SURE) Development and testing of measures Monographs published containing developed and tested evaluation tools

Challenges/Barriers to Successful Implementation Attitudes: “we do it already” Workload: Interferes with education sessions Lack of continuity: Limited time with patients Limited resources: staff education, purchase of equipment Organizational constraints: use of agency nurses, staff changes Lack of prompts: Documentation not changed to prompt recording of intervention

Facilitators of Successful Implementation Support: Financial, ideas, information Collaboration: Education sessions with allied staff BPG Champions: Positive early experiences Administration involvement: buy-in from management, steering committees Clinical Resource Nurse: Dedicated role, availability Education: Tools, sessions, paid time Congruence with current practice, beliefs and values

Best Practice Research & Evaluation Unit On March 11, 2005, the RNAO and the University of Ottawa, School of Nursing partnered and launched a research unit. A major role of the unit will be to: –Evaluate the knowledge dissemination, transfer, translation and uptake of clinical practice guidelines and their impact on medium and long-term nursing practice; and –Promote greater collaboration and research exchange between and among researchers, decision-makers, doctoral students and health care organizations.

Dissemination

Website to remember Materials available for free download : –All published BPG (English and some in French) –Teaching materials, Evaluation tools –Toolkit:Implementation of Clinical Practice Guidelines –Educator’s Resource Kit –Inventory of Research Gaps –BPG newsletter

Ways of Introducing BPG to Others Website BPG on the website, CD, hard copy Best Practice Guidelines Newsletter Making it Happen video Best Practice Champions Network Biennial BPG International Conference Annual Best Practice Summer Institute (1 week residential)

Ways of Introducing BPG to Others (2) Advanced Clinical/Practice Fellowships (only in Ontario) RNAO Doctoral Fellowships ($25,000) Workshops Best Practice Spotlight Organizations

Using BPG in Practice Relevance to practice setting Relevance to client population Commitment of care providers to implementation Environmental support –Expert and educational –Administrative support including budget and materials

Using BPG Identify the priority recommendations for implementation Determine which recommendations students/staff can use to make decisions Prepare examples to explain how the recommendations could be used

Remember… Each BPG needs to be reviewed and applied, based on specific needs of the organization or practice setting, as well as the needs and wishes of the client  Not a “cookbook” but a tool for decision-making

Where can you go from here? What would you like to see happen now that you know more about BPG? How can educators and practitioners work together to reduce the knowledge-practice gap? What next steps can be implemented to achieve desired outcomes?

Closing Thoughts If you have a dream that doesn’t scare you… You don’t have a big enough dream!

References 1. DiCenso, A., Virani, T., Bajnok, I., Borycki, E., Davies, B., Ian, G. et al. (2002). A toolkit to facilitate the implementation of clinical practice guidelines in healthcare settings. Hospital Quarterly, 5, Edwards, N., Davies, B., Ploeg, J., Dobbins, M., Skelly, J., & Ralphs- Thibodeau, S. (2005). Evaluating best practice guidelines. Canadian Nurse, 101(2), Field, M.J. & Lohr, K.N. (eds). (1990). Guidelines for clinical practice: Directions for a new program. Institute of Medicine, National Academy Press, Washington, DC. 4. Grinspun, D., Virani, T., & Bajnok, I. (2001). Nursing best practice guidelines: The RNAO project. Hospital Quarterly, 4,(2) Registered Nurses’ Association of Ontario. (2002). Toolkit: Implementation of clinical practice guidelines. Toronto: Author.

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has. - Margaret Mead (anthropologist)