Background
Methods
Design
Participants and setting
Tailoring the intervention
Data collection
Data analysis
Results
Intervention delivery
Targeted barriers | Theory-based KT strategy | Proposed mechanisms of action | KT activities |
---|---|---|---|
Lack of teamwork, trust, and communication | Increased levels of interaction Strengthened relations Improved understandings between professionals groups and managers | Facilitating regular dialogue meetings between a selected group of professionals and managers (the Learning Lab group) | |
Lack of knowledge regarding HAI, patient outcome and HH performance | Audit and feedback [60] | Increased motivation and commitment Internal drive for seeking knowledge and change | Visualization of patient outcome data and behavioral feedback Mindful observations of one’s own and one’s peers’ HH practice Facilitated problem-based learning Co-creation of printed information material Reviewing “My five moments for hand hygiene” |
Skepticism about the value of HH and AT | “Celebrating” resistance Challenging basic assumptions [46] | Decreased skepticism about the evidence in support of HH and AT Increased commitment to change | Workshop welcome and encouraging participants’ diverse perspectives Facilitators actively seek to understand and address hesitation, questions and resistance in a respectful way Reviewing the evidence for HH and AT in relation to invasive procedures Co-producing printed evidence-based information on HH |
Lack of tailoring of the clinical guidelines to the OR context | Relevant and meaningful HH and AT routines | Step 1: Welcome and promote innovative new ideas; sense, probe, respond and reflect in an iterative process in the Learning Lab group Step 2: Involve OR staff in the testing, reflection and refining of standardized operational procedures | |
Lack of role models and opinion leaders | Role modeling from credible and trusted sources | Strive to create honest relationships between facilitators and participants Lab participant as change agents | |
Deficits in clinical leadership and change management skills | Facilitating development of clinical leadership skills [46] | Increased ability to understand and manage implementation in complex environments Increased awareness of the importance of leadership in change processes | Interactive mini-lectures on leadership, implementation and change management |
The goals of the first learning laboratory and workplace-based meeting |
• Open up for dialogue • Create awareness about the problem of the lack of HH and AT in the OR and postoperative infections among patients undergoing hip-fracture surgery. • Start the process of creating a shared sense of urgency within the organization • Learn more about post-operative infections and how to create chance and co-create new knowledge • Clarifying roles, goals, and working methods |
Issues and central questions addressed in the learning laboratories, exemplified by quotations |
“Is there really any evidence in support of HH and AT?”
“How can we involve all our co-workers in the OR?”
“How to move away from telling someone that they are wrong or failing to see this as an opportunity for learning away from shame and blame?”
“How can we create awareness around our own practices?”
“Will this be another project without physician engagement, that will fail?”
“What is the right way to do it…?”
“We don’t have the time to talk about or observe each other doing this [HH] during work.” |
Between the labs
Fidelity to the intervention
Profession & Role | Attendance rates/participants during 11 Labs |
---|---|
Nurse assistant | 8 |
Nurse assistant | 9 |
OR nurse | 10 |
OR nurse and clinical instructor | 7 |
Nurse anesthetist | 6 |
Nurse anesthetist | 10 |
Anesthesiologist and clinical chief physician | 8 |
Anesthesiologista | 6 |
Orthopedic surgeonb (senior) | 4 |
Orthopedic surgeon (junior) | 6 |
Intensive care nurse and OR ward manager | 6 |
Nurse anesthetist and OR front-line nurse manager | 7 |
The complexity and emergence of knowledge translation
Over-arching theme | Knowledge translation - a complex and emergent process | |
---|---|---|
Themes | 1. Deterrents to knowledge translation | 2. Catalysts for learning and change |
Subthemes
|
1.1 Balancing conflicting goals and system ambiguities
1.2 Unknown patient consequences
1.3 Doubts that HH and AT prevent HAI
1.4 Strong boundaries, hierarchies, and distrust.
1.5 A culture of right and wrong
|
2.1 Facilitation as an iterative process of creating trusting relationships
2.2 The creation of a shared sense of urgency
2.3 Co-creation and iterative prototyping
2.4 A growing awareness of the workplace culture and one’s own practices
2.5 Increased psychological safety through dialogue
|
Deterrents to knowledge translation
Balancing conflicting goals and system ambiguities
Unknown patient consequences
Doubts that HH and AT prevent HAI
“There’s no evidence that hand hygiene will reduce the risks of infection.”
Nursing staff as a group tended to more easily accept the evidence base as sufficient when presented to them by the facilitators. Conversely, the anesthesiologists needed to engage in repeated discussion and debates rather than the intended dialogue. One participant highlighted the issue of the source of the information:“Until there’s a double blind RCT study showing this, I’m going to carry on as usual.”
“If we want to convince the physicians that this is important, they’ll need to hear the evidence from a peer [rather than from another profession].”
Actively encouraging expressions of hesitation and the challenging of evidence gave the facilitators the ability to tailor the presentation and discussion of evidence in relation to all the participating professional groups. However, the facilitators were not able to fully create the conditions required for true dialogue within some of the professional groups, due to lack of access and the limited time allocated. Hence, some participants remained hesitant towards change throughout the study period.“We know that you [the RN/facilitator] are an expert in this field, but that’s not enough.”
Strong boundaries, hierarchies, and distrust
A culture of right and wrong
Catalysts for learning and change
Facilitation as an iterative process of creating trusting relationships
The creation of a shared sense of urgency
“Now that I see [the lack of HH], I cannot un-see.”
From being a peripheral problem caused by people other than themselves, the lack of HH became central. The will to change was enacted, and the observations gave rise to many ideas for improving practice. For nurse anesthetists, the need to maintain the safety of patients was ever-present in their daily work, but the lack of HH and AT was not previously viewed as a safety issue. During the intervention there was a slow shift in perspective and a growing interest in finding solutions to address the inadequacies.“Now I see it all the time, and it makes me frustrated.”
Co-creation, situated learning and iterative prototyping resulting in mind-changing turning points
“It takes more time to work in this way [co-creation and prototyping], but it’s worth it because change comes so much easier.”