Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

Document Type : Original Article

Authors

1 School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

2 Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden

3 Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden

4 Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden

5 Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

6 School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden

7 Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden

8 Mörby Academic Primary Healthcare Center, Stockholm County Council, Stockholm, Sweden

9 International Health Systems Research, Departments of Learning, Informatics, Management, Ethics and Public Health Sciences, Karolinska Institutet, Solna, Sweden

10 Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden

11 Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada

Abstract

Background
Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation.
 
Methods
Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a fourmonth leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention.
 
Results
Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation.
 
Conclusion
Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

Keywords

Main Subjects


  1. Cummings GG, Estabrooks CA, Midodzi WK, Wallin L, Hayduk L. Influence of organizational characteristics and context on research utilization. Nurs Res. 2007;56:S24-S39. doi:10.1097/01.NNR.0000280629.63654.95
  2. Gifford W, Davies B, Edwards N, Griffin P, Lybanon V. Managerial Leadership for Nurses’ Use of Research Evidence: An Integrative Review of the Literature. Worldviews on EvidenceBased Nursing. 2007;4:126-145. doi:10.1111/j.1741-6787.2007.00095.x
  3. Dannapfel P, Peolsson A, Nilsen P. What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden. Implement Sci. 2013;8:31. doi:10.1186/1748-5908-8-31
  4. Kristensen HK, Borg T, Hounsgaard L. Aspects affecting occupational therapists’ reasoning when implementing research-based evidence in stroke rehabilitation. Scand J Occup Ther. 2012;19:118-131. doi:10.3109/11038128.2011.556197
  5. Jennings BM, Scalzi CC, Rodgers JD 3rd, Keane A. Differentiating nursing leadership and management competencies. Nurs Outlook. 2007;55:169-175.
  6. Birken SA, Lee SY, Weiner BJ. Uncovering middle managers’ role in healthcare innovation implementation. Implement Sci. 2012;7:28. doi:10.1186/1748-5908-7-28
  7. Davies BL. Sources and models for moving research evidence into clinical practice. J Obstet Gynecol Neonatal Nurs. 2002;31:558-562.
  8. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50. doi:10.1186/1748-5908-7-50
  9. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence and future implications. J Contin Educ Health Prof. 2004;24 Suppl 1:S31-S37. doi:10.1002/chp.1340240506
  10. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies--a synthesis of systematic review findings. J Eval Clin Pract. 2008;14:888-897. doi:10.1111/j.1365-2753.2008.01014.x
  11. Socialstyrelsen. Nationell utvärdering 2011 - Strokevård - Delrapport: Landstingens insatser. (National Assessment 2011 – Stroke Care – County Council Assessment). http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18350/2011-6-3.pdf. Accessed October 11, 2015. Published 2011.
  12. Socialstyrelsen. Nationella riktlinjer för Strokesjukvård (National Guidelines for Stroke Care). http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/17790/2009-11-4.pdf. Accessed October 11, 2015. Published 2009.
  13. Donnellan C, Sweetman S, Shelley E. Implementing clinical guidelines in stroke: a qualitative study of perceived facilitators and barriers. Health Policy. 2013;111:234-244. doi:10.1016/j.healthpol.2013.04.002
  14. Walker MF, Fisher RJ, Korner-Bitensky N, McCluskey A, Carey LM. From what we know to what we do: translating stroke rehabilitation research into practice. Int J Stroke. 2013;8:11-17. doi:10.1111/j.1747-4949.2012.00974.x
  15. Gifford WA, Davies BL, Graham ID, Tourangeau A, Woodend AK, Lefebre N. Developing leadership capacity for guideline use: a pilot cluster randomized control trial. Worldviews Evid Based Nurs. 2013;10:51-65. doi:10.1111/j.1741-6787.2012.00254.x
  16. Hodnett ED, Kaufman K, O’Brien-Pallas L, Chipman M, Watson-MacDonell J, Hunsburger W. A strategy to promote research-based nursing care: effects on childbirth outcomes. Res Nurs Health. 1996;19:13-20. doi:10.1002/(SICI)1098-240X(199602)19:13.0.CO;2-O
  17. Gifford W, Davies B, Tourangeau A, Lefebre N. Developing team leadership to facilitate guideline utilization: planning and evaluating a 3-month intervention strategy. J Nurs Manag. 2011;19:121-132. doi:10.1111/j.1365-2834.2010.01140.x
  18. Gifford WA, Davies B, Edwards N, Graham ID. Leadership strategies to influence the use of clinical practice guidelines. Nurs Leadersh (Tor Ont). 2006;19:72-88.
  19. Yukl G, Gordon A, Taber T. A hierarchical taxonomy of leadership behavior: integrating a half century of behavior research. Journal of Leadership & Organizational Studies. 2002;9:15.
  20. Yukl G. Leadership in Organizations. 8th ed. Boston: Pearson; 2013.
  21. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. doi:10.1136/bmj.a1655
  22. Moore GF, Audrey S, Barker M, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258.
  23. Palmcrantz S, Tistad M, Eldh AC, et al. Assessing feasibility and acceptability of study procedures: getting ready for implementation of national stroke guidelines in out-patient health care. BMC Health Serv Res. 2015;15:517.
  24. Forsetlund L, Bjorndal A, Rashidian A, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009;15:CD003030. doi:10.1002/14651858.CD003030.pub2
  25. Manley K, McCormack B. Practice development: purpose, methodology, facilitation and evaluation. Nurs Crit Care. 2003;8:22-9.
  26. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci. 2008;3:1. doi:10.1186/1748-5908-3-1
  27. Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs. 2004;13:913-924. doi:10.1111/j.1365-2702.2004.01007.x
  28. Rycroft-Malone J, Kitson A, Harvey G, et al. Ingredients for change: revisiting a conceptual framework. Quality & Safety in Health Care. 2002;11:174-180. doi:10.1136/qhc.11.2.174
  29. Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13-24. doi:10.1002/chp.47
  30. Seers K, Linck P, McCarthy G, McCormack B, et al. FIRE (Facilitating Implementation of Research Evidence): a study protocol. Implement Sci. 2012;7:25. doi:10.1186/1748-5908-7-25
  31. Spradley J P. Participant Observation. New York: Holt, Rinehart and Winston; 1980.
  32. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008;62:107-115. doi:10.1111/j.1365-2648.2007.04569.x
  33. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105-112. doi:10.1016/j.nedt.2003.10.001
  34. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26-33. doi:10.1136/qshc.2004.011155
  35. Chuang E, Jason K, Morgan JC. Implementing complex innovations: factors influencing middle manager support. Health Care Manage Rev. 2011;36:369-379. doi:10.1097/HMR.0b013e3182100cc2
  36. Kirchner JE, Parker LE, Bonner LM, Fickel JJ, Yano EM, Ritchie MJ. Roles of managers, frontline staff and local champions, in implementing quality improvement: stakeholders’ perspectives. J Eval Clin Pract. 2012;18:63-69. doi:10.1111/j.1365-2753.2010.01518.x
  37. Birken SA, Lee SY, Weiner BJ, Chin MH, Chiu M, Schaefer CT. From strategy to action: how top managers’ support increases middle managers’ commitment to innovation implementation in health care organizations. Health Care Manage Rev. 2015;40:159-168. doi:10.1097/HMR.0000000000000018
  38. Ovretveit J. Leading improvement. J Health Organ Manag. 2005;19:413-430. doi:10.1108/14777260510629661
  39. Morrow E, Robert G, Maben J. Exploring the nature and impact of leadership on the local implementation of the Productive Ward Releasing Time to Care. J Health Organ Manag. 2014;28:154-176. doi:10.1108/JHOM-01-2013-0001
  40. Collins DB, Holton EF. The effectiveness of managerial leadership development programs: A meta-analysis of studies from 1982 to 2001. Human Resource Development Quarterly. 2004;15:217-48. doi:10.1002/hrdq.1099
  41. Carlfjord S, Lindberg M, Bendtsen P, Nilsen P, Andersson A. Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory. BMC Fam Pract. 2010;11:60. doi:10.1186/1471-2296-11-60
  42. Ploeg J, Davies B, Edwards N, Gifford W, Miller PE. Factors influencing best-practice guideline implementation: lessons learned from administrators, nursing staff, and project leaders. Worldviews Evid Based Nurs. 2007;4:210-219. doi:10.1111/j.1741-6787.2007.00106.x
  43. Eldh AC, Fredriksson M, Halford C, et al. Facilitators and barriers to applying a national quality registry for quality improvement in stroke care. BMC Health Serv Res. 2014;14:354. doi:10.1186/1472-6963-14-354
  44. Kristensen HK, Hounsgaard L. Implementation of coherent, evidence-based pathways in Danish rehabilitation practice. Disabil Rehabil. 2013;35:2021-2028. doi:10.3109/09638288.2013.768301