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Evidence-based practice guidelines: A burden and a blessing

Goossens, A.

Publication date2004

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Citation for published version (APA):Goossens, A. (2004). Evidence-based practice guidelines: A burden and a blessing.

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Download date:01 May 2021

AA failed model-based attempt to

implementt an

evidence-basedd nursing guideline for fall prevention

AstridSemin-GoossensAstridSemin-Goossens '', Jelle (H) M.J. van der Helm2, Patrick M.M. Bossuyt'

DepartmentsDepartments of Clinical Epidemiology & Biostatistics' and Patient Care 2

AcademicAcademic Medical Center at the University of Amsterdam

JNursJNurs Care Qua! 2003 Jul-Sep;18(3):217-25

Abstract t

Background.Background. An evidence-based nursing guideline had been locally developed in 1993

too reduce fall incidence rates, creating a 30% reduction. Implementation had failed

though.. Between 1999 and 2001 the guideline was updated. A multifaceted intervention

wass chosen based on a model for implementing change.

Method,Method, The study was performed on two wards. Recommendations of Grol's five-step

implementationn model were followed. The aim was a reduction in fall incidence of 30%

withinn a year. Data on falls were extracted from nursing records and Incidence Report

Formss (IRF).

Results.Results. In a pilot study an average of 9 falls per 1000 patients per day had been

recordedd in the department of internal medicine and 16 the neurology ward. Given the

desiredd reduction of 30%, the target averages were 6 and 11 falls respectively. During

thee intervention year the average incidences were 8 and 13 falls (95% CI: 6-11 and 10-

15).. There was a changeable pattern over time without any declining trend. The

percentagee filled in IRF's varied strongly with an average of 52% in the department of

internall medicine and 60% in the neurology department.

Conclusion.Conclusion. There has been no durable decrease in monthly falls despite the use of a

model-basedd procedure for implementing change. Neither did we observe any

improvementt in filling in IRF's. It can be questioned if the nurses themselves did

experiencee patient falls to be troublesome enough. Investigating this is difficult though.

Althoughh the most successful strategy still appears to be changing attitudes of nurses in

orderr to increase fall prevention, there is no clear strategy on how to create this

successfully. .

112 2

Introduction n

Clinicall guidelines are considered to be essential tools in reducing practice variation and

improvingg effectiveness. There exists an extensive literature on effective implementation

off medical guidelines (Bero eta/. 1995: Solberg eta/. 2000). We now know that, to

overcomee barriers to their adoption, clinical guidelines should be simple (Grilli eta/.

1994)) and supported by active implementation strategies (Grimshaw eta/. 1993: Oxman

eta/.eta/. 1995). Single intervention strategies are often not effective in creating change. The

widespreadd use of educational materials and mailed information appears to have limited

effects,, whereas combined interventions (including personal educational visits, posters,

reminders,, incentives) are reported to be more effective (Grol 2001). Despite the

increasee in knowledge, a "magic bullet" for implementation has not been identified. For

everyy single guideline project the implementer has to decide on what an effective

strategyy to introduce the guideline into practice will be.

Overr the last years, the use of a multi-faceted approach has been advocated for

changingg doctors' behavior. Grol and colleagues have developed a well-formulated

modell for implementing change (Grol 1997).This model has shown to be effective in

changingg the behavior of general practitioners and doctors (Grol et al. 2000, Grol 2001).

Stilll little is known about the effectiveness of implementing guidelines that target

changess in nurses' behavior (Waddell 1991, Ripouteau 2000). In this paper we report an

attemptt to implement a nursing guideline for fall prevention in a large academic teaching

hospitall with the use of Grol's model.

Background Background

Inn the Academic Medical Center in Amsterdam, a teaching hospital with 1000 beds, an

evidence-basedd nursing guideline had been locally developed in 1993 to reduce fall

incidencee rates. The guideline primarily existed of filling in risk-scales daily, labeling

patientss with an increased risk and taking some protective actions like lowering the bed.

Thee motive for the development of the guideline was the number of patient falls reported

annuallyy to the Incidence Reporting Committee. A 30% reduction in falls had been

observedd during a period in which the guideline was applied in a pilot study, an effect

comparablee to similar interventions elsewhere (Oliver et al. 2000). Despite this

encouragingg outcome the subsequent introduction of the guideline in daily practice had

failed.. The implementation strategy had been rather simple. The guideline developers

113 3

hadd invited interested nurses to ask for a copy of the guideline to be sent to them. Few

nursess had done so.

Inn 1999 the hospitals' Incident Report Committee received reports on 322 falls

makingg this the second largest category of incidents. From the 1993 project we had

learnedd that only 40 to 50% of all fall accidents are actually reported to the committee.

Realizingg that this number was far too high, we desired to introduce an updated version

off the existing guideline for fall prevention. As nurses had not embraced the guideline at

thee time, we were aware that accomplishing a real change did require an active

approachh (Nadler 1981, Bero eta/1998). We therefore choose to create a multifaceted

interventionn based on Grol's model for implementing change (Grol 1997). This model has

shownn to be effective in changing the behavior of general practitioners and doctors (Grol

2001,, Grol et a/2001). That model had never been applied with nursing guidelines.

Doctorss differ from nurses. Nursing is a practice-oriented profession, even more so than

medicinee is, with nurses often relying on individual intuition or collective tradition as a

basiss for intervention. Nurses are not used - yet - to operate on the basis of evidence and

ass nursing research itself advances, a gap has developed and continues to persist

betweenn the publication of research findings and the dissemination and use of these

findings. .

Onee way of promoting nursing research usage is by offering nurses evidence-

basedd guidelines. Considering the traditional basis of the nursing profession, it is obvious

thatt some exertion is needed to make them work accordingly to a guideline, especially

whenn the guideline contains behavioural adaptations. We therefore tried to create

changee by applying a model that is capitalized on positive factors for implementation.

Grol'ss model consists of five steps to help implementers to create change in a planned

andd structured way. Repeatedly people who are in the midst of an implementation

processs are unexpectedly faced with numerous factors that they have to attend to. Using

aa theoretical and well-tested implementation model makes it possible to anticipate to

somee of these factors. It appears to be a solid framework to start of with. The main

objectivee of the present study was to implement an evidence-based nursing guideline to

achievee a reduction in fall incidence of 30% within a year.

114 4

Method d

Thee study was performed in two voluntary cooperating wards who both suffered from a

highh number of fall incidents: a 32-bed neurology ward that employed 33 nurses and had

8500 admissions per year and a 32-bed internal medicine ward with 34 nurses 1500

admissionss per year. Since the aim of the project was to improve quality of care no

permissionn was needed from the Medical Ethics Committee.

Thee project started with a three-month pilot study (July-September 1999),

followedd by a pre-intervention period (October-November 1999). In December 1999 the

guidelinee itself was finalized and disseminated. The actual intervention year was from

Januaryy to December 2000 and was followed up by an evaluation (January-July 2001).

Dataa on falls were extracted from nursing records during the entire 25-month period. A

falll was defined as 'an untoward event in which the patient comes to rest unintentionally

onn the floor'.

Inn the method used we followed the recommendations of Grol's five-step

implementationn model which can be used as a framework. The first step is to develop a

proposall of how one wants to create the change, followed by the identification of

obstacless to change and linking the right intervention to overcome the obstacles. The

fourthh and last steps are the development of a proper plan to work with and to evaluate

duringg the process if the intervention works and if not to readjust ones plan.

1.1. Develop a change proposal

Thee first recommendation is to use a guideline that is based on evidence, comes from a

crediblee source, is low in complexity, tested in practice, and adapted to the local needs. It

shouldd not involve much extra work.

Wee did not believe in a top-down strategy so we involved the nurses in re-writing

andd implementing the guideline. To do so a project team of 11 was formed: four

memberss of the nursing staff of both wards, four nurses, the research nurse who had

helpedd develop the original guideline in 1993, a clinical epidemiologist (ASG), and a

consultantt for quality improvement projects (JH). This team convened weekly in the pre-

interventionn period and monthly afterwards. An updated version of the original guideline

wass developed by the project team based on recent developments (Oliver eta/. 1997:

Evanss e?a/.1999) and in consultation with the rest of the nurses involved. The renewed

guidelinee focused on the identification of fall-prone patients based on three main risk

115 5

factors:: a recent fall (less than six months ago), unrest or disorientation and refusal to

exceptt guidance or orders from nurses. The following actions were recommended for

patientss with one or more risk factors: preventive measures (moving the bed to the

lowestt position and raising siderails); noting the increased risk in the nursing file;

informingg patient and relatives about the increased risk and measures taken. In case of

unrestt or agitation relatives were asked to help in structuring the environment (e.g.

puttingg the bell within reach, making sure the patients shoes where nearby etc.) A

restrainingg waist belt could be used.

Onn request of the nurses we explicitly did not shape the guideline too much in the

formm of a protocol but choose - together with the project team - to give space to the

nursess to decide what actions had to be taken in particular circumstances, based on their

professionall experience. The actions that were included in the guideline were all

extractedd from the literature on fall prevention. Most of them were rather obvious,

commonsensee interventions. This way the revised guideline really was a guideline and

nott a fixed set of instructions. The decision to use a restraining belt, for example, was left

upp to the responsible nurses for cases in which they considered a waist belt to be

appropriatee for a particular patient.

Thee guideline also contained general instructions for the nursing staff, including

organizingg a check-up of equipment and setting up evaluation meetings. In these

meetingss particular fall incidences were discussed among the nurses in order to detect if

thee guideline had been applied properly and to judge if this kind of accident could be

avoidedd in the future.

Thee guideline was finalized in November 1999 and presented as a plastic A6-

sizedd document with an attractive layout (see Figure 1). It was disseminated in

Decemberr 1999 in both wards.

116 6

Guidelinee for fall prevention < & &

DefinitionDefinition of a fall: (Nearly) hitting the floor

accidentallyy and unintentionally

JudgmentJudgment of increased fall risk: AA patient has an increased risk of falling if hee or she minimally has one of the followingg risk factors:

Experienced a fall in the last 6 monthss (see intake form)

Unrest and/or disorientation Refusal to except guidance or

orderss from nurses

Actions: Actions: (1)) For the nurses:

Notate the risk for falling ones on thee patients' intake form, ones in thee nursing record (under 'planning'),, and daily in the correspondingg electronic databasee with patient records

In case of increased risk: take actionss according to the advices givenn in the 'list of nursing interventions'' (see other side)

(2)) The managementteam is responsible for: :

Initiation of monthly discussions of falll accidents with the nurses

Debriefing their managers about thee fall incidence on their ward

Looking after the necessary equipmentt for fall prevention

InIn case of a fall accident: fill in an Incidence Report Form and

sentt it to the Incidence Report Committee e

always stay alert and try to prevent thee patient getting into a possibly dangerouss situation

ListList of nursing interventions for high risk patients: patients:

Informing the patient and its relatives aboutt the fall risk and preventive actionn taken

QQ Preventive actions to be taken: position n

oo the bed at the right hight oo siderails oo bell within reach andd offer help regularly

aa Notate increased fall risk in patient record d

aa In case of confusion or agitation: structuree the patients environment as muchh as possible and ask relatives for help p

aa Use a restraint belt if really necessary

aa Make extra observation rounds

Figuree 1. The revised guideline to enhance Fall Prevention, printed double sided on A6-format

117 7

2.2. Identify obstacles to change

Stepp two recommends to find out possible obstacles and to decide how to approach

these.. During our frequent sessions with the project team it became obvious that the

nursess wanted environmental hazards like slippery floors, low toilet seats and loose

televisionn cables on the floor to be tackled. To study this annoyance the nurses of the

projectt team interviewed their colleagues during the pre-intervention period to create a

"Topp 10" list of situations that were perceived as hazardous on the working floor. So we

tookk Grol's advice about tracing obstacles very literally with the aim to eliminate as many

off these obstacles as possible and to check if necessary resources, such as well-

functioningg side rails, were lacking.

Thee nurses were displeased with two elements of the original guideline which

weree risk scales that had to be filled in and putting identification stickers on patients'

bedss who were fall prone. They also were unhappy with format of the standard hospital

Incidencee Report Form (IRF).

3.3. Link intervention to obstacles This step promotes the use of a multifaceted approach

too tackle problems on various levels. We used a variety of strategies. During the

introductionn phase we used marketing principles (Kotler etal. 1998) such as an attractive

layy out of the guideline itself. To increase awareness all nurses received a small torch

withh the imprint "Fall Prevention 2000" to use during night shifts. Pivotal staff members

andd the hospital board were sent a luxurious pen with the same inscription. Huge posters

containingg the guideline and the goals of the project were displayed in all nurses' coffee

rooms.. Those involved were provided with the latest monthly figures on fall incidences.

Ann article announcing the implementation was published in the hospitals' weekly

periodical l

Nursess expressed adversity towards two elements of the original guideline. They

statedd that to them these were important reasons in 1993 not to implement the guideline

att the time. Firstly, filling in a risk scale daily in order to identify fall-prone patients. We

discardedd the risk scale, aiso considering the quality of the evidence on their predictive

valuee (Innes eta/A983, Cox etalA988). Secondly, the original guideline prescribed that

fall-pronee patients should receive an orange sticker on their bed frame (Fife etal. 1984).

Thesee stickers were judged to be unnecessarily stigmatising and without convincing

evidencee of their effectiveness (Evans etal. 1999) they were also eliminated.

Thee nurses uttered annoyance with the standard hospital Incidence Report Form

(IRF)) and requested a more simple form to report accidents. This led to the adjustment of

118 8

thee standard IRF. They especially expressed a need to have more open space to write

downn the nature of the incident. We simplified the form and made it easier to mail it to the

committee.. Reasons for not filling in IRF's were regularly discussed within the project

team.. To create more awareness and cognitive input the possible avoidance of falls was

discussedd repeatedly by and with the nurses.

4.4. Develop a plan

Thee model recommends the carefull planning of all chosen interventions and their

distributionn over time. In the regular meetings with the project team, needs and ideas

weree extensively analyzed. The actions undertaken are already described in the former

section.. We constantly tried to respond to the needs expressed by the nurses in order to

createe a positive implementation environment. For instance, in the course of the

interventionn year the neurology ward asked for large alarm bells for patients with

coordinationn problems. These bells were bought. Intermediate targets were set such as

increasingg the number of falls reported with an IRF. The question "Does this patient have

ann increased risk for falling" was added to the routine patient history form. Outside of the

regularr meetings feedback was given to the nurses during informal visits.

5.5. Evaluate the process

Thee last step entails checking if the interventions are effective and to adjust the plan if

necessary.. We tried to keep track of the changes taking place by introducing several

indicatorss on measurable activities. In the regular meetings, we sought for new ideas and

solutions.. The most important target was to make the nurses fill in the IRF's. It was

regularlyy emphasized that proper data collection was a prerequisite for monitoring

reductionn of falls. We presented all intermediate results on fall incidence and IRF's

regularlyy and explicitly addressed all issues raised by the participants.

DataData collection

Dataa on falls was collected in two ways. IRF's were the primary source. Since we already

kneww that less than half of the actual fall accidents are reported by an IRF, we introduced

aa second method. A research nurse extracted data on fall incidents from all nursing

records.. Since nearly 100% of the fall accidents actually are reported in these records

thiss was considered the "gold standard" for determining fall incidences. We determined

thatt this labor-intensive hand searching could be omitted once at least 90% of the falls

weree reported on the regular IRF's.

119 9

Afterr the intervention year a questionnaire was developed to evaluate the

implementationn process. The questionnaire consisted of eight items checking the nurse's

actuall knowledge of the guideline and inquiring about their behavior regarding how often

theyy used the guideline. Nurses were also asked for their opinion on 20 statements

aboutt fall prevention, beliefs and disbeliefs, and perceived importance of the problem.

Too detect a possible trend with respect to the fall incidences we kept recording

dataa on falls by continuing reading the nursing records during the evaluation period as

welll as during the last half of 2001.

DataData analysis

Statisticall analysis included descriptive statistics on the number of falls that had been

documentedd in the nursing records, on the IRF's that had been filled in and on the

questionnaire.. Fall incidences over different time spans and their 95% confidence

intervall were calculated.

Results s

FaFa I f incidences extracted from the nursing records

Inn 25 months, 2670 patients were hospitalised on the two wards for 23 876 days out of

whichh 159 patients experienced 238 falls.

Inn the pilot study an average of 9 falls per 1000 patients per day had been

recordedd in the department of internal medicine. Given the desired reduction of 30%, the

targett average was 6 falls per 1000 patient-days. We observed an average incidence of

88 falls during the intervention year (95% CI: 6-11). After the intervention year the average

incidencess were 7 and 9 falls for the first and second half of 2001 respectively.

Onn the neurology ward the average incidence was 16 falls in the pilot study. The

targett was 11 falls per 1000 patient per day. There were 13 falls in the intervention year

(95%% CI: 10-15) and 16.5 and 16 falls afterwards. Figure 2 shows the incidence of falls,

revealingg a capricious pattern over time without any declining trend.

120 0

> 1 1

ro ro D D

C C 0) )

ra ra o. . o o o o o o T --

L_ _

0) ) D. .

(/> > c c o o > > d> >

30 0

25 5

20 0

15 5

10 0 targett neuro

targett int. med.

AA S O N

Figuree 2. Number of monthly falls per 1000 patients per day (extracted from the nursing records) andd their 95% confidence intervals on the neurology department and department of internal medicine,, from January till December 2000.

AnalysesAnalyses of Incident Report Forms

Thee percentage of falls reported to the Incident Report Committee varied from 25% to

100%% per month compared to those read in the nursing records, with an average of 52% %

inn the department of internal medicine and 60% in the neurology department. The

targetedd increase in the IRF reporting to 90% was not reached. No change over time

couldd be observed.

Questionnaire Questionnaire

Duringg the evaluation period after the intervention year a questionnaire was handed out

too all 67 nurses. The response rate was 78%. The average age of the responding nurses

wass 35 years (range 18-54), with an average of 5 years of working experience on their

wardd (range <1-34). For 64% nursing school was the highest level of education. Despite

thee fact that 96% of the nurses reported to have received the guideline, and no more

121 1

thann 11% had lost it, only 19% could give the stated definition of a fall. Only 65% of the

nursess said to experience falls as a real problem and 62% felt responsible for the

reductionn of fall accidents. The external circumstances on the ward, such as shower

chairss and proper siderails were judged not to be good enough by 63%. The inevitability

off patients falling was stated by 82%. Although the majority felt satisfied with the

guidelinee itself (57%) most nurses stated they had not changed their behavior because

off it (80%).

Discussion n

Inn this guideline development and implementation project, we have not been able to

achievee an enduring decrease in monthly falls through the planned introduction of a

nursingg guideline despite the use of a model-based procedure for implementing change.

Twoo years of work did not produce any lasting change in fall incidence. Neither did we

observee an improvement in filling in IRF's. This failure caused us to re-examine the

nursess as a target group and the implementation model itself. Although we adhered to a

triedd and tested model for change, we may have failed to take the truly necessary steps.

Itt is possible that we have underestimated the amount of behavioural change required

fromm the nurses. During the intervention period we found out that their daily practice

regularlyy differed from the way they were supposed to work according to the protocols.

Patientt history forms are not always filled out. In nearly half of the cases a fall was not

reportedd in an IRF. So risk management and reporting all falls - intermediate steps in our

implementationn process - was more labour intensive than we had anticipated.

Despitee the emphasis on instrumental tools as a means for achieving change, the

philosophyy of evidence-based guidelines itself can be questioned based on this project.

Itt is generally accepted that guidelines are more convincing when based on evidence

(Groll et al. 1998). In our project the evidence base, namely that patient falls are often

patternedd and predictable events did not seem to be very relevant for our target group.

Nursess from the neurology ward frequently stated that it was simply impossible to

preventt patients from falling. Falling was recurrently considered to be an inevitable part

off aging, of hospitalisation and illness and therefore seen as an unavoidable accident,

ratherr then something predictable and often preventable. These feelings of helplessness

didd not change during our intervention. So it is possible that nurses are less susceptible

122 2

too evidence than doctors and by focusing first and primarily on the available evidence we

mayy have overestimated its impact.

Withh respect to Grol's model our study shows that it is applicable in a nursing

settingg but also has some drawbacks. It gives useful guidelines on how to approach a

changee process in a structured way. But application is no guarantee for success.

Althoughh most models are broadly defined, the main problem we came across is that this

modell appeared to be too general. Despite the fact that the model does structure the

implementationn process, it is during the process itself that one comes across many

unexpectedd obstacles on different layers in the organization. The model does not give

specificc advices so one still has to sort out lots of unanticipated obstructions. For

instance,, since the wards did volunteer to participate in this study we expected the

nursess to be determined in reducing the number of falls. We have taken the nurses'

requestss on several levels seriously and the project team fulfilled most of the nurses

needs.. Although we made very clear that adequate reporting of falls was essential in this

studyy in order to ascertain changes in the fall incidences this did not make them report

accidentss any better. It was during the intervention that we discovered that there

probablyy were various psychological aspects, which intervened with our request for IRF's

too be filled in and which were hard to tackle. Fear of the large numbers of falls, the

avoidabilityy of falls that might be revealed from accurate reporting or the fear of legal

actionn are all possible explanations for the maintenance of reporting fall rates

inconsistently. .

Anotherr aspect of the generality of the model is that professionals often agree

thatt a problem exists but that they not always put their words into actions by actually

changingg their behavior. That was also the main result on our questionnaire: finding that

thee answers did not correspond with the actual behaviour we have observed may

indicatee that to be one of the obstacle problems. The sad thing is that despite the many

risk-scaless and fall-prevention programs that have been developed over the last 20

years,, the most successful strategy still appears to be changing attitudes of nurses

(Morsee 1993). The fact that we did not even discover a Hawthorne effect, a kind of

placeboo effect, looks like a manifestation of the fact that we failed to do so. If one wants

too investigate to which extend the target group is the real stakeholder of a problem, just

askingg for this in a questionnaire will give rise to socially desirable, and thus misleading,

answers.. The model does not provide alternatives. An option could be the use of

financiall incentives such as a bonus for a specific reduction in falls at the end of the year.

Thiss is something that might be worth trying in future projects.

123 3

Iff we were to repeat this project there are other things that we would do

differently.. First of all, related to what we just stated, we did not investigate at the start of

thee project to which extend the nurses truly experienced patient falls to be troublesome.

Itt was our assumption that the willingness of the head nurses and members of staff to

cooperatee in this project would be enough. But obviously it is crucial that there is some

certaintyy as to whether the target group as a whole welcomes a change. If this is not the

casee then one should think of other strategies like working with incentives. Secondly it

mightt be useful to investigate to which extend a department is already used to work with

evidencee based guidelines or protocols. If it is not, then one can expect the process to be

moree complicated and time consuming than when the department does work according

too standards. And last but not least, it might take some more adjustments from the

organizationn as a whole to create an environment in which it is easier to implement

changess like these. In our case, efforts to reach and involve the people higher in the

hierarchyy such as the medical chiefs and nursing managers were not successful. These

peoplee stated that they subscribed to the problem but that there were other problems that

neededd to be solved to which they gave priority.

Wee spent two years in an attempt to implement a simple guideline without

success.. Although we know already that a "magic bullet" does not exist and we try to

implementt with shotguns, it is useful to realize that even with a shotgun it is possible to

misss ones target.

Acknowledgements s Wee are grateful to Anneke Tutuarima for undertaking the retrospective chart review and

too all the nurses working on the neurology ward and the ward of internal medicine for

theirr effort in trying to make this guideline work. We thank professor Rob J. de Haan for

hiss comments on earlier drafts of this paper.

Funding.Funding. This project was funded by the Hospital Board of Directors through the Center

forr Practice Guidelines of the Academic Medical Center at the University of Amsterdam.

CompetingCompeting interests: None declared

124 4

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