A quantitative analysis of the impact of a computerised information system on nurses' clinical practice using a realistic evaluation framework

Objective: To explore nurses' perceptions of the impact on clinical practice of the use of a computerised hospital information system. Design: A realistic evaluation design based on Pawson and Tilley's work has been used across all the phases of the study. This is a theory-driven approach and focuses evaluation on the study of what works, for whom and in what circumstances. These relationships are constructed as context-mechanisms-outcomes (CMO) configurations. Measurements: A questionnaire was distributed to all nurses working in in-patient units of a university hospital in Spain (n = 227). Quantitative data were analysed using SPSS 13.0. Descriptive statistics were used for an overall overview of nurses' perception. Inferential analysis, including both bivariate and multivariate methods (path analysis), was used for cross-tabulation of variables searching for CMO relationships. Results: Nurses (n = 179) participated in the study (78.8% response rate). Overall satisfaction with the IT system was positive. Comparisons with context variables show how nursing units' context had greater influence on perceptions than users' characteristics. Path analysis illustrated that the influence of unit context variables are on outcomes and not on mechanisms. Conclusion: Results from the study looking at subtle variations in users and units provide insight into how important professional culture and working practices could be in IT (information technology) implementation. The socio-technical approach on IT systems evaluation suggested in the recent literature appears to be an adequate theoretical underpinning for IT evaluation research. Realistic evaluation has proven to be an adequate method for IT evaluation. (C) 2009 Elsevier Ireland Ltd. All rights reserved

The Toowoomba adult trauma triage tool

Since the introduction of the Australasian Triage Scale (ATS) there has been considerable variation in its application. Improved uniformity in the application of the ATS by triage nurses is required. A reproducible, reliable and valid method to classify the illness acuity of Emergency Department patients so that a triage category 3 by one nurse means the same as a triage category 3 by another, not only in the same ED but also in another institution would be of considerable value to emergency nurses. This has been the driving motivation behind developing the Toowoomba Adult Trauma Triage Tool (TATTT). It is hoped the TATTT will support emergency nurses working in this challenging area by promoting standardisation and decreasing subjectivity in the triage decision process

Mental health nurses’ attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder:systematic, integrative literature review

Aims and objectives To establish whether mental health nurses responses to people with borderline personality disorder are problematic and, if so, to inform solutions to support change. Background There is some evidence that people diagnosed with borderline personality disorder are unpopular among mental health nurses who respond to them in ways which could be counter-therapeutic. Interventions to improve nurses’ attitudes have had limited success. Design Systematic, integrative literature review. Methods Computerised databases were searched from inception to April 2015 for papers describing primary research focused on mental health nurses’ attitudes, behaviour, experience, and knowledge regarding adults diagnosed with borderline personality disorder. Analysis of qualitative studies employed metasynthesis; analysis of quantitative studies was informed by the theory of planned behaviour. Results Forty studies were included. Only one used direct observation of clinical practice. Nurses’ knowledge and experiences vary widely. They find the group very challenging to work with, report having many training needs, and, objectively, their attitudes are poorer than other professionals’ and poorer than towards other diagnostic groups. Nurses say they need a coherent therapeutic framework to guide their practice, and their experience of caregiving seems improved where this exists. Conclusions Mental health nurses’ responses to people with borderline personality disorder are sometimes counter-therapeutic. As interventions to change them have had limited success there is a need for fresh thinking. Observational research to better understand the link between attitudes and clinical practice is required. Evidence-based education about borderline personality disorder is necessary, but developing nurses to lead in the design, implementation and teaching of coherent therapeutic frameworks may have greater benefits. Relevance to clinical practice There should be greater focus on development and implementation of a team-wide approach, with nurses as equal partners, when working with patients with borderline personality disorder

A realistic evaluation of the impact of a computerised information system on clinical practice : the nurses' perspective.

The aim of this study is to explore nurses' perceptions of the impact in clinical practice of the use of a computerised hospital information system. Design: A realistic evaluation design based on Pawson and Tilley's work has been used across all the phases of the study. It is a theory driven approach and focuses evaluation on the study of what works, for whom and in what circumstances. These relationships are constructed as context-mechanisms-outcomes configurations (CMO). Methods: A self-developed questionnaire containing both closed and open-ended questions was piloted and distributed to all nurses working in in-patient units of the Clinica Universitaria of Navarra (n= 227). Quantitative data were analysed using SPSS 13.0. Descriptive statistics were used for an overall overview of nurses' perception. Inferential analysis, including both bivariate and multivariate methods (path analysis), were used for cross-tabulation of variables searching for CMO relationships. Content analysis of open-ended questions was used to identify major themes in nurses' responses. Results: 179 nurses participated in the study (78.8% response rate). Overall satisfaction with the IT system is positive and only 7.5% of the nurses wanted to go back to paper records. Mechanisms and outcomes are highly correlated. Comparisons with context variables show how users' characteristics, except attitude towards the introduction of technology, did not have a significant influence on perceptions while the nursing unit context had greater influence. Path analysis illustrated that the influence of unit context variables are on outcomes and not on mechanisms. Six main themes emerged from open-ended questions: information, communication, patient care, documentation processes, work dynamics and running of the program. Some differences in relation to the unit context were observed

Stakeholder perspectives on new ways of delivering unscheduled health care: the role of ownership and organisational identity

<b>Rationale, aims and objectives</b>: To explore stakeholder perspectives of the implementation of a new, national integrated nurse-led telephone advice and consultation service (NHS 24), comparing the views of stakeholders from different health care organisations. <b>Methods</b>: Semi-structured interviews with 26 stakeholders including partner organisations located in primary and secondary unscheduled care settings (general practitioner (GP) out-of-hours co-operative; accident and emergency department; national ambulance service), members of NHS 24 and national policymakers. Attendance at key meetings, documentary review and email implementation diaries provided a contextual history of events with which interview data could be compared. <b>Results</b>: The contextual history of events highlighted a fast-paced implementation process, with little time for reflection. Key areas of partner concern were increasing workload, the clinical safety of nurse triage and the lack of communication across the organisations. Concerns were most apparent within the GP out-of-hours co-operative, leading to calls for the dissolution of the partnership. Accident and emergency and ambulance service responses were more conciliatory, suggesting that such problems were to be expected within the developmental phase of a new organisation. Further exploration of these responses highlighted the sense of ownership within the GP co-operative, with GPs having both financial and philosophical ownership of the co-operative. This was not apparent within the other two partner organisations, in particular the ambulance service, which operated on a regional model very similar to that of NHS 24. <b>Conclusions</b>: As the delivery of unscheduled primary health care crosses professional boundaries and locations, different organisations and professional groups must develop new ways of partnership working, developing trust and confidence in each other. The results of this study highlight, for the first time, the key importance of understanding the professional ownership and identity of individual organisations, in order to facilitate the most effective mechanisms to enable that partnership working

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background: Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research. Methods: We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically. Results: 79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact. Conclusions: Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation

Achieving change in primary care—causes of the evidence to practice gap : systematic reviews of reviews

Acknowledgements The Evidence to Practice Project (SPCR FR4 project number: 122) is funded by the National Institute of Health Research (NIHR) School for Primary Care Research (SPCR). KD is part-funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Research and Care West Midlands and by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR. This paper presents independent research funded by the National Institute of Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Funding This study is funded by the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR).Peer reviewedPublisher PD

A pragmatic cluster randomised trial evaluating three implementation interventions

Background Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting. Methods A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients' experiences, and stakeholders' experiences of implementation, including influences. ANOVA was used to test differences over time and interventions. Results Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility. Conclusions This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions' impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance. Trial registration ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE