Starting Out: qualitative perspectives of new graduate nurses and nurse leaders on transition to practice.

AIM: To describe new graduate nurses' transition experiences in Canadian healthcare settings by exploring the perspectives of new graduate nurses and nurse leaders in unit level roles. BACKGROUND: Supporting successful transition to practice is key to retaining new graduate nurses in the workforce and meeting future demand for healthcare services. METHOD: A descriptive qualitative study using inductive content analysis of focus group and interview data from 42 new graduate nurses and 28 nurse leaders from seven Canadian provinces. RESULTS: New graduate nurses and nurse leaders identified similar factors that facilitate the transition to practice including formal orientation programmes, unit cultures that encourage constructive feedback and supportive mentors. Impediments including unanticipated changes to orientation length, inadequate staffing, uncivil unit cultures and heavy workloads. CONCLUSIONS: The results show that new graduate nurses need access to transition support and resources and that nurse leaders often face organisational constraints in being able to support new graduate nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations should ensure that nurse leaders have the resources they need to support the positive transition of new graduate nurses including adequate staffing and realistic workloads for both experienced and new nurses. Nurse leaders should work to create unit cultures that foster learning by encouraging new graduate nurses to ask questions and seek feedback without fear of criticism or incivility.

A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study.

BACKGROUND: Best practice guidelines are a tool for narrowing research-to-practice gaps and improving care outcomes. There is some empirical understanding of guideline implementation in nursing settings, yet there has been almost no consideration of the longer-term sustainability of guideline-based practice improvements. Many healthcare innovations are not sustained, underscoring the need for knowledge about how to promote their survival. PURPOSE: To understand how a nursing best practice guidelines program was sustained on acute healthcare center nursing units. METHODS: We undertook a qualitative descriptive case study of an organization-wide nursing best practice guidelines program with four embedded nursing unit subcases. The setting was a large, tertiary/quaternary urban health center in Canada. The nursing department initiated a program to enhance patient safety through the implementation of three guidelines: falls prevention, pressure ulcer prevention, and pain management. We selected four inpatient unit subcases that had differing levels of program sustainability at an average of almost seven years post initial program implementation. Data sources included 39 key informant interviews with nursing leaders/administrators and frontline nurses; site visits; and program-related documents. Data collection and content analysis were guided by a framework for the sustainability of healthcare innovations. RESULTS: Program sustainability was characterized by three elements: benefits, routinization, and development. Seven key factors most accounted for the differences in the level of program sustainability between subcases. These factors were: perceptions of advantages, collaboration, accountability, staffing, linked levels of leadership, attributes of formal unit leadership, and leaders' use of sustainability activities. Some prominent relationships between characteristics and factors explained long-term program sustainability. Of primary importance was the extent to which unit leaders used sustainability-oriented activities in both regular and responsive ways to attend to the relationships between sustainability characteristics and factors. CONCLUSIONS: Continued efforts are required to ensure long-term program sustainability on nursing units. Persistent and adaptive orchestration of sustainability-oriented activities by formal unit leadership teams is necessary for maintaining best practice guidelines over the long term. Leaders should consider a broad conceptualization of sustainability, beyond guideline-based benefits and routinization, because the development of unit capacity in response to changing circumstances appears essential.

Nursing unit leaders' influence on the long-term sustainability of evidence-based practice improvements.

AIM: To describe how actions of nursing unit leaders influenced the long-term sustainability of a best practice guidelines (BPG) program on inpatient units. BACKGROUND: Several factors influence the initial implementation of evidence-based practice improvements in nursing, with leadership recognized as essential. However, there is limited knowledge about enduring change, including how frontline nursing leaders influence the sustainability of practice improvements over the long term. METHODS: A qualitative descriptive case study included 39 in-depth interviews, observations, and document reviews. Four embedded nursing unit subcases had differing levels of program sustainability at 7 years (average) following implementation. RESULTS: Higher levels of BPG sustainability occurred on units where formal leadership teams used an integrated set of strategies and activities. Two key strategies were maintaining priorities and reinforcing expectations. The coordinated use of six activities (e.g., discussing, evaluating, integrating) promoted the continuation of BPG practices among staff. These leadership processes, fostering exchange and learning, contributed to sustainability-promoting environments characterized by teamwork and accountability. CONCLUSIONS: Unit leaders are required to strategically orchestrate several overlapping and synergistic efforts to achieve long-term sustainability of BPG-based practice improvements. IMPLICATIONS: As part of managing overall unit performance, unit leaders may influence practice improvement sustainability by aligning vision, strategies, and activities.

An organizational perspective on the long-term sustainability of a nursing best practice guidelines program: a case study.

BACKGROUND: Many healthcare innovations are not sustained over the long term, wasting costly implementation efforts and often desperately-needed initial improvements. Although there have been advances in knowledge about innovation implementation, there has been considerably less attention focused on understanding what happens following the early stages of change. Research is needed to determine how to improve the 'staying power' of healthcare innovations. As almost no empirical knowledge exists about innovation sustainability in nursing, the purpose of our study was to understand how a nursing best practice guidelines (BPG) program was sustained over a long-term period in an acute healthcare centre. METHODS: We conducted a qualitative descriptive case study to examine the program's sustainability at the nursing department level of the organization. The organization was a large, urban, multi-site acute care centre in Canada. The patient safety-oriented BPG program, initiated in 2004, consisted of an organization-wide implementation of three BPGs: falls prevention, pressure ulcer prevention, and pain management. Data were collected eight years following program initiation through 14 key informant interviews, document reviews, and observations. We developed a framework for the sustainability of healthcare innovations to guide data collection and content analysis. RESULTS: Program sustainability entailed a combination of three essential characteristics: benefits, institutionalization, and development. A constellation of 11 factors most influenced the long-term sustainability of the program. These factors were innovation-, context-, leadership-, and process-related. Three key interactions between factors influencing program sustainability and characteristics of program sustainability accounted for how the program had been sustained. These interactions were between: leadership commitment and benefits; complementarity of leadership actions and both institutionalization and development; and a reflection-and-course-correction strategy and development. CONCLUSIONS: Study findings indicate that the successful initial implementation of an organizational program does not automatically lead to longer-term program sustainability. The persistent, complementary, and aligned actions of committed leaders, in a variety of roles across a health centre department, seem necessary. Organizational leaders should consider a broad conceptualization of sustainability that extends beyond program institutionalization and/or program benefits. The development of an organizational program may be necessary for its long-term survival.

The sustainability of healthcare innovations: a concept analysis.

AIM: To report on an analysis of the concept of the sustainability of healthcare innovations. BACKGROUND: While there have been significant empirical, theoretical and practical contributions made towards the development and implementation of healthcare innovations, there has been less attention paid to their sustainability. Yet many desired healthcare innovations are not sustained over the long term. There is a need to increase clarity around the concept of innovation sustainability to guide the advancement of knowledge on this topic. DESIGN: Concept analysis. DATA SOURCES: We included literature reviews, theoretical and empirical articles, books and grey literature obtained through database searching (ABI/INFORM, Academic Search Complete, Business Source Complete, CINAHL, Embase, MEDLINE and Web of Science) from 1996-May 2014, reference harvesting and citation searching. METHODS: We examined sources according to terms and definitions, characteristics, preconditions, outcomes and boundaries to evaluate the maturity of the concept. RESULTS: This concept is partially mature. Healthcare innovation sustainability remains a multi-dimensional, multi-factorial notion that is used inconsistently or ambiguously and takes on different meanings at different times in different contexts. We propose a broad conceptualization that consists of three characteristics: benefits, routinization or institutionalization, and development. We also suggest that sustained innovations are influenced by a variety of preconditions or factors, which are innovation-, context-, leadership- and process-related. CONCLUSION: Further conceptual development is essential to continue advancing our understanding of the sustainability of healthcare innovations, especially in nursing where this topic remains largely unexplored.

Advanced practice nursing, health care teams, and perceptions of team effectiveness.

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP.

BACKGROUND: Making evidence-based practice (EBP) a reality throughout an organization is a challenging goal in healthcare services. Leadership has been recognized as a critical element in that process. However, little is known about the exact role and function of various levels of leadership in the successful institutionalization of EBP within an organization. AIMS: To uncover what leaders at different levels and in different roles actually do, and what actions they take to develop, enhance, and sustain EBP as the norm. METHODS: Qualitative data from a case study regarding institutionalization of EBP in two contrasting cases (Role Model and Beginner hospitals) were systematically analyzed. Data were obtained from multiple interviews of leaders, both formal and informal, and from staff nurse focus groups. A deductive coding schema, based on concepts of functional leadership, was developed for this in-depth analysis. RESULTS: Participants' descriptions reflected a hierarchical array of strategic, functional, and cross-cutting behaviors. Within these macrolevel "themes," 10 behavioral midlevel themes were identified; for example, Intervening and Role modeling. Each theme is distinctive, yet various themes and their subthemes were interrelated and synergistic. These behaviors and their interrelationships were conceptualized in the framework "Leadership Behaviors Supportive of EBP Institutionalization" (L-EBP). Leaders at multiple levels in the Role Model case, both formal and informal, engaged in most of these behaviors. LINKING EVIDENCE TO ACTION: Supportive leadership behaviors required for organizational institutionalization of EBP reflect a complex set of interactive, multifaceted EBP-focused actions carried out by leaders from the chief nursing officer to staff nurses. A related framework such as L-EBP may provide concrete guidance needed to underpin the often-noted but abstract finding that leaders should "support" EBP.

Redefining self: patients' decision making about treatment for multiple sclerosis.

The treatment of multiple sclerosis (MS) has become possible with the advent of disease-modifying therapies, but little is known about patients' experiences when faced with a complex array of treatment options. The purpose of this phenomenological study was to explore the lived experience of making a first decision about treatment with disease-modifying therapies for relapsing-remitting MS. Nine participants shared their perspectives on negotiating the decision to accept, refuse, or delay treatment. All individuals described a core theme in which decision making about treatment was part of a process of coming to a "redefined self." This core theme included reflections about self-image, quality of life, goals, and being a person with MS. Six common themes supporting this core theme were (a) weighing and deciding what's important, (b) acknowledging the illness as part of oneself, (c) playing the mental game, (d) seeking credible resources, (e) evaluating symptoms and fit with quality of life, and (f) managing the roles and involvement of family. The findings of this study provide a greater understanding about the experience of making a therapeutic choice for those with MS and offer insights for nurses when supporting patients faced with options about treatment.

Clinical nurse specialists in Canada: why are some not working in the role?

Clinical nurse specialists (CNSs) are advanced practice nurses. They contribute to the quality and safety of patient care by providing an advanced level of clinical care to patients and families and by supporting healthcare team members to deliver evidence-based care. CNSs help to reduce healthcare costs when the roles are fully deployed and all the dimensions of the CNS role are implemented. The dimensions of the CNS role include clinical care, organizational leadership, research, education, professional development and consultation to provide patient care. There is a paucity of research on CNSs in Canada. We conducted the first Canada-wide survey of CNSs and asked each nursing regulatory body to identify the CNSs in their registration database. One-quarter (n=196/776) of the regulator-identified CNS respondents whom we contacted for the study were no longer or had never been a CNS. Currently, adequate mechanisms are lacking to identify and track CNSs in Canada, and little is known about the factors that influence CNSs' decisions to leave their role. The non-employed CNS respondents in our survey highlighted that the lack of role clarity, their inability to find employment as a CNS and the inability to implement all the dimensions of the CNS role were key factors in their decision not to work as a CNS. These findings have important implications, given that these factors are potentially modifiable and amenable to decisions made by nursing leaders in organizations and regulatory bodies. Mechanisms to identify and track CNSs in Canada are needed to develop an effective workforce plan and maximize the integration of CNSs in the workforce.

Practice patterns and perceived impact of clinical nurse specialist roles in Canada: results of a national survey.

BACKGROUND: Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists. OBJECTIVE: To identify the practice patterns of clinical nurse specialists in Canada. DESIGN: A descriptive cross-sectional survey. PARTICIPANTS: Self-identified clinical nurse specialists in Canada. METHODS: A 50-item self-report questionnaire was developed, pilot-tested in English and French, and administered to self-identified clinical nurse specialists from April 2011 to August 2011. Data were analyzed using descriptive and inferential statistics and content analysis. RESULTS: The actual number of clinical nurse specialists in Canada remains unknown. The response rate using the number of registry-identified clinical nurse specialists was 33% (804/2431). Of this number, 608 reported working as a clinical nurse specialist. The response rate for graduate-prepared clinical nurse specialists was 60% (471/782). The practice patterns of clinical nurse specialists varied across clinical specialties. Graduate-level education influenced their practice patterns. Few administrative structures and resources were in place to support clinical nurse specialist role development. The lack of title protection resulted in confusion around who identifies themselves as a clinical nurse specialist and consequently made it difficult to determine the number of clinical nurse specialists in Canada. CONCLUSIONS: This is the first national survey of clinical nurse specialists in Canada. A clearer understanding of these roles provides stakeholders with much needed information about clinical nurse specialist practice patterns. Such information can inform decisions about policies, education and organizational supports to effectively utilize this role in healthcare systems. This study emphasizes the need to develop standardized educational requirements, consistent role titles and credentialing mechanisms to facilitate the identification and comparison of clinical nurse specialist roles and role outcomes internationally.

Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness.

AIM: This article describes a new conceptual framework for acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness. BACKGROUND: Acute care nurse practitioners contribute positively to patient care by enacting an expanded scope of practise. Researchers have found both positive and negative reactions to the introduction of acute care nurse practitioners in healthcare teams. The process of role enactment, shifting role boundaries, and perceptions of team effectiveness has been studied disparately. A framework linking team structures and processes to desirable outcomes is needed. DATA SOURCES: Literature was obtained by searching CINAHL, PsycInfo, MedLine, PubMed, British Nursing Index, Cochrane Library, JSTOR Archive, Web of Science, and Google Scholar from 1985-2010. A descriptive multiple-case study was completed from March 2009-May 2009. DISCUSSION: A new conceptual framework describing how role enactment and boundary work affect perceptions of team effectiveness was developed by combining theoretical and empirical sources. The framework proposes proximal indicators used by team members to assess their team's performance. IMPLICATIONS FOR NURSING: The framework identifies the inter-related dimensions and concepts that different stakeholders need to consider when introducing nurse practitioners in healthcare teams. Further study is needed to identify team-level outcomes that reflect the contributions of all providers to quality patient care, and explore the patients' and families' perceptions of team effectiveness following the introduction of acute care nurse practitioners. CONCLUSION: The new framework can guide decision-making and research related to the structures, processes, and outcomes of nurse practitioner roles in healthcare teams.

How are acute care nurse practitioners enacting their roles in healthcare teams? A descriptive multiple-case study.

BACKGROUND: In many countries, acute care nurse practitioners contribute to patient care through an expanded scope of practice that includes nursing and medical activities. There have been calls across nations to establish better understanding of how nurse practitioners enact their roles in healthcare teams. The 2006 introduction of cardiology nurse practitioners in Quebec, Canada provides an opportunity to examine this process more closely. OBJECTIVES: The purpose of the study is to understand how nurse practitioners enact the medical and expanded nursing portions of their role in healthcare teams. DESIGN: A descriptive multiple-case study design was used. SETTINGS: The study was conducted in two university-affiliated teaching hospitals in Quebec. DATA SOURCES: Data were collected from March 2009 to May 2009. Data sources included interviews (N=59), field notes, documents, and a time and motion study (N=108 h 53 min) of nurse practitioner activities using a validated observation tool. METHODS: The interviews were conducted individually or in groups. Content analysis was used to analyse the qualitative data. Descriptive statistics were generated for the time and motion study. RESULTS: The clinical role component, including nursing and medical activities, occupied the largest portion of the nurse practitioners' work time. The pace of nurse practitioner work activities was faster in the first half of the workday in response to patient care demands. The enacted nurse practitioner scope of practice was sensitive to the local context, and the needs of team members, patients and families. Nursing and medical leadership, and the transfer of prescriptive authority and decision-making autonomy affected how nurse practitioners enacted the medical and expanded nursing portions of their roles. Participants believed the pace of work influenced the nurse practitioners' ability to develop relationships with team members, and enact all the components of their role. CONCLUSIONS: The practitioners' scope of practice changed in response to pressures inside and outside healthcare teams or a lack of healthcare system structures. The study findings appear to be applicable to nurse practitioners working in other specialties, and in other countries. Future research needs to examine how the pace of work affects the nurse practitioners' ability to provide care.

Boundary work and the introduction of acute care nurse practitioners in healthcare teams.

AIM: This article is a report of a study of boundary work following the introduction of an acute care nurse practitioner role in healthcare teams. BACKGROUND: Acute care nurse practitioners enacting their roles in healthcare teams have faced a number of challenges including a mix of positive and negative views of the acute care nurse practitioner role from healthcare team members and acute care nurse practitioner roles crossing the boundaries between the medical and nursing professions. Understanding the process by which the boundaries between professions changed following the introduction of an acute care nurse practitioner role was important since this could affect scope of practice and the team's ability to give patient care. METHODS: The study was conducted in two university-affiliated teaching hospitals in Canada. A descriptive multiple case study design was used. Data were collected from March to May 2009. RESULTS: Participants (N = 59) described boundary work as a process that included: (1) creating space; (2) loss of a valued function; (3) trust; (4) interpersonal dynamics; and (5) time. The development of trust among team members was essential. The co-location of team members working on common projects, and medical and nursing leadership facilitated boundary work. CONCLUSION: The micro-level processes of boundary work in healthcare teams have important implications for the development of full scope of practice for acute care nurse practitioners, effective inter-professional teamwork and the integration of new roles in healthcare systems. Future research needs to be undertaken in different contexts, and with patients and families.

Does the sequence of data collection influence participants' responses to closed and open-ended questions? A methodological study.

BACKGROUND: The sequence used for collecting quantitative and qualitative data in concurrent mixed-methods research may influence participants' responses. Empirical evidence is needed to determine if the order of data collection in concurrent mixed methods research biases participants' responses to closed and open-ended questions. OBJECTIVES: To examine the influence of the quantitative-qualitative sequence on responses to closed and open-ended questions when assessing the same variables or aspects of a phenomenon simultaneously within the same study phase. DESIGN: A descriptive cross-sectional, concurrent mixed-methods design was used to collect quantitative (survey) and qualitative (interview) data. The setting was a large multi-site health care centre in Canada. METHODS: A convenience sample of 50 registered nurses was selected and participated in the study. Participants were randomly assigned to one of two sequences for data collection, quantitative-qualitative or qualitative-quantitative. ANALYSIS: Independent t-tests were performed to compare the two groups' responses to the survey items. Directed content analysis was used to compare the participants' responses to the interview questions. RESULTS: The sequence of data collection did not greatly affect the participants' responses to the closed-ended questions (survey items) or the open-ended questions (interview questions). CONCLUSIONS: The sequencing of data collection, when using both survey and semi-structured interviews, may not bias participants' responses to closed or open-ended questions. Additional research is required to confirm these findings.

Patient and nurse staffing characteristics associated with high sitter use costs.

AIM: This paper is a report of a study of the relationships between patient health conditions, nurse staffing characteristics and high sitter use costs. BACKGROUND: Increasing recourse to patient sitters is a major cost concern to hospitals. To reduce these expenses, we need to understand better the factors associated with high sitter use costs. METHODS: From a cohort of 43,212 medical/surgical patients admitted to an academic health centre in Montreal (Canada) in 2007 and 2008, all 1151 patients who received a sitter were selected. We applied multivariate logistic regression, using the Generalized Estimating Equation framework, to estimate the relationships between patient health conditions, nurse staffing characteristics and being in the upper two quintiles of sitter costs, vs. the lower three. RESULTS: The median sitter cost per patient, in Canadian dollars, was $772·35 (IQR = $1737·84); and $2397·00 (IQR = $3085·03) among the patients with high sitter use costs. In multivariate analyses, dementia, delirium and other cognitive impairments (OR = 1·49; 95% CI = 1·01-2·22) and schizophrenia and other psychoses (OR = 2·42; 95% CI = 1·08-5·76) increased the likelihood of high sitter use costs. In addition, every additional worked hour per patient per day by Registered Nurses (OR =0·33; 95% CI = 0·27-0·39) and by patient care assistants (OR = 0·11; 95% CI = 0·08-0·15) reduced the likelihood of high sitter use costs. Conclusion. Circumstances of understaffing and patients having psycho-geriatric conditions are associated with high sitter use costs. Improving staffing and providing additional resources to support the care of psycho-geriatric patients may lower these expenses.

Advanced practice nursing, health care teams, and perceptions of team effectiveness.

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

Registered nurses' job demands in relation to sitter use: nested case-control study.

BACKGROUND: Increases in overtime and absenteeism among registered nurses (RNs), in conjunction with a workforce having less experience, have resulted in high RN job demands. At the same time, there has been an increase in hospitals' use of patient sitters (i.e., unskilled attendants), but it is not known if these two changes are correlated. OBJECTIVE: The aim of this study was to determine if indicators of RN job demands, specifically overtime, absenteeism, and experience, are related to greater sitter use. METHOD: A nested case-control study design was used. All patients who were assigned a sitter (cases) were selected from a cohort of 43,212 medical and surgical patients who had been admitted to an academic health center in Montreal (Canada) in 2007 and 2008. For each case (n = 1,179), up to four controls (n = 4,167) were selected randomly among patients who did not receive a sitter. Multivariate logistic regression, within a generalized estimating equation framework, was used to assess the association between RN job demand indicators and sitter use, while controlling for other risk factors for sitter use. RESULTS: Compared with controls, patients who were assigned sitters had been subject to high rates of RN overtime and absenteeism and lower RN cumulative experience in the period prior to sitter use. Each additional hour of RN overtime increased the likelihood of sitter use by 108% (odds ratio = 2.08, 95% confidence interval = 1.32-3.29). Every 5 years of collective RN experience reduced the odds of sitter use by 23% (odds ratio = 0.77, 95% confidence interval = 0.66-0.89). Absenteeism was not associated with sitter use. DISCUSSION: High RN overtime and collective inexperience are associated with greater sitter use. A possible explanation is that sitters are used to palliate failures to meet high job demands. Further research is required to assess the impact of sitter use on patient outcomes.

Intervention patterns of pivot nurses in oncology.

The Pivot Nurse in Oncology (PNO) is a health care professional dedicated to providing patients with cancer and their families with continuing and consistent supportive care throughout the care trajectory. The purpose of this paper is to describe the variation and frequency of nursing interventions delivered by 12 PNOs at our health centre. An administrative analysis over a three-year period revealed a total of 43,906 interventions that were grouped into 10 categories. This analysis provided a description of the intervention frequency and these interventions were further collapsed into the four role functions of the PNO. Coordination/continuity of care and the assessment of needs and symptoms were identified as the dominant practice domains of the PNO in the professional cancer navigator role.

Individual nurse and organizational context considerations for better Knowledge Use in Pain Care.

Nurses are involved in many of the painful procedures performed on hospitalized children. In collaboration with physicians, nurses have an exceptional responsibility to have knowledge to manage the pain; however, the evidence indicates this is not being done. Issues may be twofold: (a) opportunities to improve knowledge of better pain care practices and/or (b) ability to use knowledge. Empirical evidence is available that if used by health care providers can reduce pain in hospitalized children. Theory-guided interventions are necessary to focus resources designated for learning and knowledge translation initiatives in the area of pain care. This article presents the Knowledge Use in Pain Care (KUPC) conceptual model that blends concepts from the fields of knowledge utilization and work life context, which are believed to influence the translation of knowledge to practice. The four main components in the KUPC model include those related to the organization, the individual nurse, the individual patient, and the sociopolitical context. The KUPC model was conceptualized to account for the complex circumstances surrounding nurse's knowledge uptake and use in the context of pain care. The model provides a framework for health care administrators, clinical leaders, and researchers to consider as they decide how to intervene to increase knowledge use to reduce painful experiences of children in the hospital.

Institutionalizing evidence-based practice: an organizational case study using a model of strategic change.

BACKGROUND: There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice. METHODS: A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization. RESULTS: The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP-related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP. CONCLUSION: Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively.