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To evaluate the clinical effectiveness of a Nurse Practitioner led procedural support service for children with procedural anxiety, and identify facilitators and barriers to its sustained implementation and optimisation.
An effectiveness–implementation hybrid type 3 study used a prospective mixed methods evaluation approach.
From December 2022 to May 2023, data were collected from children, parents and clinicians using a nurse practitioner-led service at a quaternary paediatric hospital in Brisbane, Australia. A prospective audit assessed clinical outcomes, while qualitative interviews explored implementation barriers and facilitators.
The clinical audit (n = 40) confirmed the service was effective and safe, ensuring procedural completion with minimal distress. Descriptive statistics indicated low pain and anxiety scores. There was a moderate negative relationship between pain scores and the use of distraction techniques. Interviews with thirty-three participants showed the service improved access to procedural care, reduced the need for physical restraint and general anaesthesia, and enhanced clinical workflow through preadmission assessments.
Utilising a Nurse Practitioner support service represents a safe and effective strategy to enhance access for paediatric patients with procedural anxiety.
This study underscores the significance of specialised nursing roles in managing paediatric procedural anxiety, offering a replicable model to enhance procedural outcomes and mitigate medical trauma across healthcare settings.
Minimising pain and distress is important in all clinical encounters with children to reduce the risk of medical-related trauma and the future avoidance of healthcare.
The report of study outcomes was guided by the Standards for Reporting Implementation Studies (StaRI) initiative.
Patients or the public were not included in the design, conduct or reporting of the study.
To evaluate the impact of a participatory, action-oriented implementation study, guided by the integrated Promoting Action on Research Implementation in Health Services framework, for optimising pain care processes in a tertiary paediatric emergency department.
Hybrid type 3 implementation effectiveness.
A collaborative appraisal of the context and culture of pain care informed two interdependent action cycles: Enabling nurse-initiated analgesia and involving families in pain care. The Kids Pain Collaborative, an authentic clinical–academic partnership, was central to facilitating successful implementation. Summative evaluation explored the impact of implementation on processes of pain care using an interrupted time series analysis and emotional touchpoint interviews with families.
Staff achieved clinically important and sustained improvements in the rate of nurse-initiated analgesia and pain assessment. Family involvement in pain care shifted from task-orientated practices towards more person-centred ways of working and decision-making. As capacity for collective leadership developed, frontline staff found ways to integrate the KPC approach into ED systems to lead pain care innovation beyond the life of the research project.
The Kids Pain Collaborative, as the overarching implementation strategy, created a practitioner-led coalition for change. Successful implementation was facilitated by working with four interdependent principles: Collaborative and authentic engagement; enabling context for cultural transformation; creating safe spaces for critical reflection and workplace learning; and embedding sustainable practice change.
A multi-level model of internal–external facilitation enabled sustained improvement in pain care practice. An embedded researcher was pivotal in this process.
Authentic engagement of clinicians and families was pivotal in transforming systems of pain care and enabling a culture where "it is not ok for children to wait in pain"
The principles underpinning the Kids Pain Collaborative are transferable to other emergency department and acute care contexts.
Standards for Reporting Implementation Studies checklist.
To implement strategies to improve the care of patients with acute pain in the emergency department (ED).
Pre–post implementation study using a Type 2 hybrid effectiveness–implementation design.
Implementation strategies were introduced and monitored through the Ottawa Model of Research Uses' assessment, monitoring and evaluation cycles, supported by focused and sustained facilitation.
Improvements in time-to-analgesia within 30 min (21%–27%), administration of nurse-initiated analgesia (NIA) (17%–27%) and measurement of pain (65%–75%) were achieved post-implementation. NIA was the strongest predictor of receiving analgesia within 30 min. Adoption of pain interventions into practice was not immediate yet responded to sustained facilitation of implementation strategies.
Collaboration with local clinicians to introduce simple interventions that did not disrupt workflow or substantially add to workload were effective in improving analgesia administration rates, and the proportion of patients receiving analgesia within 30 min. The assessment, monitoring and evaluation cycles enabled agile and responsive facilitation of implementation activities within the dynamic ED environment. Improvements took time to embed into practice, trending upward over the course of the implementation period, supporting the sustained facilitation approach throughout the study.
Sustained adoption of evidence-based pain interventions into the care of people presenting to the ED with acute pain can be achieved through sustained facilitation of implementation. NIA should be at the centre of acute pain management in the ED.
This study addressed the lingering gap between evidence and practice for patients with acute pain in the ED. Implementation of locally relevant/informed implementation strategies supported by focused and sustained facilitation improved the care of patients with acute pain in the ED. This research will have an impact on people presenting to EDs with acute pain, and on clinicians treating people with acute pain in the ED. Relevant equator guidelines were followed and the StaRI reporting method used.
No Patient or Public Contribution in this study.
To explore the implementation contexts and strategies that influence the uptake and selection of alternative peripherally inserted central catheter (PICC) materials and design.
Qualitative evaluation of end user perspectives within a randomized control trial of different PICC materials and design.
Semi-structured interviews with key stakeholders were undertaken via an adapted, rapid-analytic approach using the Consolidated Framework for Implementation Research. Outcomes were mapped against the Expert Recommendations for Implementing Change (ERIC) tool for strategies to guide innovation in PICC practice.
Participants (n = 23) represented a combination of users and inserters/purchasers, from adult and paediatric settings. Dominant themes included intervention characteristics (intervention source), inner setting (structural characteristics) and individuals involved (self-efficacy). Strategies emerging to support a change from ERIC mapping (n = 16) included promotion of intervention adaptability, inclusion of staff and consumer perspectives and sufficient funding. Implementation contexts such as inner setting and individuals involved equally impacted PICC success and implementation effectiveness and enabled a greater understanding of barriers and facilitators to intervention implementation in this trial.
Trial evidence is important, but healthcare decision-making requires consideration of local contexts especially resourcing. Implementation contexts for Australian healthcare settings include a practical, strategic toolkit for the implementation of alternative PICC materials and designs.
This study adhered to COREQ guidelines.
No patient or public contribution.
Paediatric patients with complex or acute conditions may require a central venous access device, however, almost one-third of these devices have associated complications (e.g. infections). Implementation of evidence-based practices regarding central venous access devices can reduce and potentially prevent complications.
This scoping review aimed to explore recent interventional research in CVAD management through an implementation lens.
This scoping review used the Arksey and O'Malley framework. Studies were included if they were written in English, published in 2012 to July 2023, involved children and were relevant to the study aims. Risk of bias was appraised by the Mixed Methods Appraisal Tool.
Searches were undertaken in EMBASE, CINAHL (Ebsco), PubMed, Web of Science and Cochrane Library (CENTRAL).
Of the 1769 studies identified in a systematic search, 46 studies were included. Studies mostly focused on health professionals and central venous access device maintenance and had quantitative pre-post study designs. Adherence to implementation frameworks was lacking, with many studies employing quality improvement approaches. Implementation strategies were typically multipronged, using health-professional education, bundles and working groups. Bundle compliance and reductions in central line-associated bloodstream infections were the most featured outcomes, with most studies primarily focusing on effectiveness outcomes.
Translation of evidence-based practices to the clinical setting is difficult and current adoption of implementation frameworks (apart from ‘quality improvement’) is limited. Implementation strategies are diverse and dependent on the local context, and study outcomes typically focus on the effectiveness of the physical intervention, rather than measuring the implementation effort itself.
Future intervention research requires a more uniform and deliberate application of implementation frameworks and strategies.
Greater exploration of relationships between frameworks and strategies and implementation and service outcomes is required to increase understanding of their role in maximizing resources to improve health care.
Adhered to best reporting guidelines as per PRISMA-ScR (Tricco et al., 2018).
No patient or public contribution.
To assess barriers and facilitators to the implementation of guidelines for the prevention of inadvertent perioperative hypothermia in orthopaedic patients.
Systematic review.
Nine databases: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, ProQuest Dissertations and Theses, Scopus, Web of Science and Trip Clinical Evidence Database.
Primary studies published in English between January 2008 to July 2022 were screened. Study selection, quality assessment, and data extraction were completed independently by researchers. Data were extracted using the Consolidated Framework for Implementation Research and mapped to the Expert Recommendations for Implementing Change strategies.
Eighty-seven studies were included in the review. The most frequently reported barriers and facilitators related to evidence strength, relative advantage, and cost of implementing perioperative hypothermia prevention guidelines. The top four ERIC strategies were: Identify and prepare champions; Conduct educational meetings; Assess for readiness and identify barriers and facilitators; and Inform local opinion leaders.
This review provides synthesized evidence regarding barriers and facilitators to perioperative hypothermia guidelines for patients undergoing orthopaedic surgery.
Our work provides theory guided strategies to promote implementation of perioperative hypothermia prevention to assist nurses caring for patients undergoing orthopaedic surgery.
Findings provide professionals caring for patients undergoing orthopaedic surgery with theory-informed strategies to improve perioperative hypothermia prevention. Reducing perioperative hypothermia will improve outcomes for patients undergoing orthopaedic surgery.
The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.
Due to the study design, no patient or public consultation took place.
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