An intervention to improve compliance with guidelines for prevention of venous thromboembolism improves the proportion of hospitalised patients receiving appropriate prophylaxis
- Correspondence to: W G Kernohan
Institute of Nursing Research, School of Nursing, University of Ulster, Newtownabbey, Co Antrim, Northern Ireland BT37 0QB, UK;
Implications for practice and research
▪ Addressing the specific barriers to evidence-based practice can have a significant effect on key performance indicators.
▪ In prevention of blood clots, four barriers were found: motivation, support, knowledge and evidence.
▪ Four strategies were used to address deficits: audit, decision support, education and policy development.
▪ The evidence is not enough: overcoming barriers helps, but there is still room for improvement. Nursing researchers need to build and evaluate methods to achieve much higher proportions of patients receiving risk assessment thereby to increase the number receiving prophylaxis against coagulation.
Blood is a remarkable bodily fluid that provides nutrients and oxygen to all human tissues and simultaneously carries away waste. Special features provide immunity against foreign cells and coagulation in response to injury. It is this latter feature which can contribute to problems in acute care settings where intended or accidental injury results in coagulation and potentially dangerous clots. Nurses are in a good position to prevent this from becoming a serious concern through the appropriate use of evidence-based practice. This implementation study took place in a large metropolitan private hospital where (before the study) half the patients received prophylaxis against coagulation.
Cycles of practice improvement were designed with four types of intervention: audit and feedback, introduction of documentation and decision-support aids, education sessions, and guidelines supported by hospital policy development. Two key performance indicators were collected: proportion of adult inpatients receiving appropriate prophylaxis against coagulation and proportion of adult inpatients that were risk assessed. Significance was examined using Fisher's exact test for difference in proportions.
Statistically significant improvements were seen in the key performance indicators which suggest that addressing individual and systemic barriers to the implementation of evidence-based practice goes some way to solve the issue of low rates of risk assessment and low rates of prophylaxis against coagulation.
Of the five stages of evidence-based practice – questioning, searching, appraisal, implementation and quality assurance – implementation is arguably the greatest challenge. The presentation of evidence-based nursing as a linear process is a simplification that is helpful for the graduate learner but fails to take account of the complexities of practice, areas where evidence is in short supply or where resources are thin on the ground. Implementation of evidence can be particularly complex and is exposed as it is to the vagaries of history, personality, culture and context.
Even in a fairly well-defined and well-accepted area of care such as prevention of deep vein thrombosis, lately referred to as venous thromboembolism (VTE), evidence-based practice remains a challenge for implementation, requiring careful attention to, and understanding of the context, the preferred approach to practice development, as well as a deep understanding of the evidence itself.
As Duff and colleagues point out, only half of those who are at risk of VTE receive evidence-based prophylaxis, even in the face of strong evidence and national guidelines.1 They note the need for multiple strategies for implementation. This can work albeit with some inefficiency. However, they refine the multiple-strategy approach usefully by identifying four main specific barriers for attention, namely, lack of motivation to change, lack of system support, knowledge/awareness deficits and disputed evidence. It is helpful to use an implementation of change model to design a response to these.
Commendably, Duff and colleagues attempt to address each barrier with a variety of specific interventions, including routine dissemination activities as well as some highly innovative ones, such as a Mock Newspaper containing a collection of recent news articles on VTE. They then proceed to apply an uncontrolled practice development design (with preaudits and postaudits) to show they can achieve key measures of improvement. Their tools for assessing and managing risk and for audit of performance are likely to be useful to many who struggle to prevent VTE and avoid the real killer: pulmonary embolism. They see significant improvement to their practice, noting distinct differences between outcomes comparing medical with surgical patients.
Such a focus on the ‘barriers’ to evidence-based practice is recognised as a useful approach and can certainly go some way towards delivery of best practice.2 However, an exclusive attention to barriers, rather than a broader approach that also identifies positive facilitators that exist in practice settings, is incomplete. Indeed, a simple practice development framework emphasises three aspects: understanding of the context, expert facilitation and high-quality evidence.3
Focusing on barriers tends to highlight (important) weakness. But equally, perhaps to balance the efforts, attention is needed on areas of existing strengths. One might argue that, in a challenging environment, building upon strengths would be more likely to succeed. The use of a change model is helpful but not infallible.4
Implementation is a vital part of evidence-based practice – arguably the most difficult and complex part of practice development. Examining and addressing barriers to good practice are actions to be commended. However, those who are working in practice development need to also consider positive aspects of the context and thereby identify opportunities, facilitators and existing supports. Tackling barriers and promoting facilitation are important, if not vital, in the implementation stage of evidence-based nursing. Not all barriers are easy to remove, so the identification of facilitators should form part of every practice development strategy.