Clostridium difficile infection (CDI) prevention is of high priority. We reviewed clinical practice guidelines (CPGs), and conducted an individual participant data meta-analysis (IPMDA) of randomized controlled trials (RCTs) to assess effectiveness and safety of probiotic prophylaxis. For CPGs, we rated quality, summarized recommendations with their strength and author-reported evidence, then re-evaluated evidence. For the IPDMA, we pooled RCTs investigating probiotics versus control for CDI prevention among antibiotic consumers, using generalized linear mixed models. Our outcomes were CDI and serious adverse events (SAEs). We adjusted for age, sex, hospitalization status, and exposure to high risk antibiotics. We assessed study risk of bias and confidence in estimates of effect. Five international guidelines were evaluated, and all scored poorly for applicability, stakeholder involvement, and rigor of development. Recommendations were not always linked to evidence, and guideline authors were not transparent about how evidence limitations impacted their decisions. None of the guidelines recommended probiotics. Fourteen studies contributed data, with one pending. Probiotics reduced CDI among all studies and the adjusted model. No covariates were significantly associated with CDI. Subgroups suggested that high incidence did not affect probiotic effectiveness, and high-dose, multi-strain probiotics were more beneficial. Our estimate was robust to sensitivity analyses. Probiotics did not significantly affect SAE odds among all studies and the adjusted model. Increasing age was a significantly associated with SAEs. No SAEs were reportedly probiotics-related. For both outcomes, estimates were similar from data of obtained and not obtained studies. Confidence in estimates was moderate for both outcomes, due to low event rates. Current guidelines on CDI prevention did not adhere well to validated standards for development and reporting, most notably due to insufficient links between recommendations and supporting evidence. Our preliminary analysis suggests that probiotic prophylaxis is useful and safe for CDI prevention. / Thesis / Master of Science (MSc) / Clostridium difficile infection (CDI) is a common hospital-associated infection, and prevention is of high priority. We reviewed clinical practice guidelines on CDI prevention to summarize their recommendations, and assess the quality of guideline development and reporting. Furthermore, we analysed patient data from randomized clinical trials to obtain an overall estimate (meta-analysis) of whether using a novel strategy, probiotic prophylaxis, is effective and safe. The guidelines had several limitations, importantly that authors were not transparent about how recommendation were developed, and recommendations were not always linked to evidence. Although no guideline recommended using probiotics to prevent CDI, our advanced analysis of previously conducted trials suggested that it was an effective intervention, reducing infections by approximately 76%, and was not associated with differences in serious adverse events compared to participants not receiving probiotics. In summary, guidelines on CDI prevention should be improved, and probiotics may be considered as an additional strategy.

Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms experienced when an infant has been exposed to certain substances (e.g., opioids) in-utero, resulting in health challenges for infants. Previous studies have reported substantial variations in the clinical management of NAS, suggesting that some infants may not be receiving optimal care. High-quality clinical practice guidelines are crucial to support optimal patient outcomes and standardize care. In response, I conducted a systematic review and quality appraisal of available NAS guidelines and recommendations using the AGREE-II and AGREE-REX tools. I also developed and piloted a tool to measure family-centred care in guidelines. Most guidelines received low-quality appraisal scores on the AGREE-II and the AGREE-REX appraisals (16/20 and 10/20, respectively) and have conflicting pharmacological recommendations. Findings will improve clinicians’ awareness of the variation in the quality of guidelines and assist them to make care decisions that are from the best available evidence and family-centred.

This research was undertaken to study the impact of single and multicomponent knowledge translation interventions (KTIs) on barriers to the integration of Clinical Practice Guidelines (CPG) into Clinical Decision Making (CDM) in the context of physical therapists (PTs) and find out which of the two KTIs was more effective. A literature review showed that research knowledge (e.g. CPG) in the field of PT (Physical Therapy) is not being integrated in to clinical practice (e.g. CDM), thus leading to a research-practice (R-P) gap in other words CPG-CDM gap. It is suggested in the literature that the management and behavioural aspects of PTs might be acting as barriers hindering the integration of the research knowledge into clinical practice consequently affecting the delivery of optimum patientcare. Remedial measures, namely KTIs, are suggested to address those barriers and to bridge the R-P gap. However, the phenomenon of the R-P gap, the causes of it and the possible interventions are not well understood concepts in the literature, particularly in the context of PTs. CPG for Venous Thromboembolism (VTE) in PT was chosen as the example of research knowledge. It was argued that barriers have the potential to affect CDM which in turn can affect the CPG-CDM gap. Lack of knowledge about CPG-CDM gap is a major limitation in the literature that is affecting the integration of CPG into CDM. Other gaps found in the literature that have the potential to affect CPG-CDM gap include management and behavioural variables as probable causes of CPG-CDM gap (or barriers), use of KTIs to bridge the CPG-CDM gap and, KTIs. Furthermore, lack of knowledge about relationship between barriers and CPG-CDM gap, KTIs and barriers, KTIs and CPG-CDM gap and the impact of KTIs (effectiveness) in bridging CPG-CDM gap were the other gaps found in the literature that had potential implications to CPG-CDM gap. These gaps were addressed in this research to some extent. Relationships between the independent variables (lack of knowledge of PTs in CPG, lack of favourable attitude of PTs towards CPG and lack of self-efficacy and motivation of PTs to integrate CPG into CDM) and the dependent variables (CDM and CPG-CDM gap) were defined and models were proposed. Further, it was posited that KTIs could impact barriers based on theories and models found in the literature that provided some basis to create the linkage between KTIs and management and behavioural barriers. Education material (EM) and virtual communities of practice (VCoP) were chosen as of the KTIs in this study. The models of Cabana et al. (1999) and Fischer et al. (2016), primarily, were used to ground the conceptual models represented by figures and equations. Methodologically, a positivist approach with an objective ontological stance was employed and a deductive approach and quantitative research method were used to address the research gaps. The research design included a longitudinal element and survey questionnaire. The target population was licensed PTs in the USA. Random sampling was used. Two groups of PTs were identified namely EM-group and VCoP group. Data was collected from the groups before and after administering the KTIs. The results showed that single and multicomponent KTIs impacted barriers in different ways. EM impacted lack of favourable attitude of PTs towards CPG, and lack of self-efficacy and motivation of PTs to integrate CPG into CDM as barriers and narrow the CPG-CDM gap. VCoP was found to impact the combination of four barriers and narrow CPG-CDM gap. In addition, barriers in groups of two were also impacted by VCoP and narrowed the CPG-CDM gap. Furthermore, a CPG knowledge score card and a corresponding CDM score card developed by the researcher were used to test the change behaviour of PTs in integrating CPG into CDM. This experiment showed that barriers existed and caused CPG-CDM gap and KTIs could narrow the CPG-CDM gap. The findings indicate that this research has contributed to knowledge in many ways, including unearthing the relationship between CPG-CDM gap and barriers, better understanding of KTIs, their relationship with CPG-CDM gap and barriers, gaining knowledge about the impact of single and multicomponent KTIs on single and multiple barriers and identification of methods to bridge the CPG-CDM gap.

The prescription rate of antipsychotics in patients with dementia varies between 20% and 50% for the common and troubling neuropsychiatric symptoms experienced by patients with dementia. The use of these antipsychotic medications has been linked with increased risk of morbidity and mortality due to associated Parkinsonism, over sedation, gait disturbances, cognitive decline, and cardiovascular adverse events. The purpose of this project was to assess whether development of an evidence-based clinical practice guideline (CPG) for a long-term care facility would increase awareness about issues that govern the safe use of antipsychotic medications. The conceptual framework for the project was Watson's model of caring. The Fineout-Overholt tool was used to rank and score information retrieved following an extensive literature review. An expert panel made up of 2 medical doctors and 4 nurse practitioners had 100% agreement that objectives were clear; content was relevant and easy to understand; the CPG was well-organized and easy to follow; and knowledge learned would be used in practice. From 66.6% to 83.3% agreed that the CGP led to an improved understanding of dementia, neuropsychiatric symptoms, medication adverse events, and nonpharmacologic interventions. The expert panel agreed to launch the CPG upon implementation of an educational program for frontline nursing staff and a behavioral log to track occurrence and frequency of behaviors and the use of nonpharmacologic interventions and their effectiveness in managing behaviors. Safe implementation of this CPG might be adapted to other long-term facilities to optimize dementia care, which would bring about a positive social change.

PURPOSE: To describe 1) smoking cessation (SC) interventions by Family Practice Nurses (FPN) during prenatal visits, and 2) the predictors and barriers of FPN-provided SC counselling for pregnant women. DESIGN: Non-experimental, descriptive, correlational design. Onetime, cross-sectional questionnaire using a previously validated questionnaire, modified and converted to electronic format. METHODS: Descriptive and multivariable analysis. Predictors investigated included nurses’ age, beliefs about their role in SC, self-efficacy to provide effective counselling, SC training, and interest in updating SC knowledge. PARTICIPANTS: Eighty-nine members of the Ontario Family Practice Nurses’ interest group (18% response rate) working in primary care settings across Ontario. RESULTS: Nearly one quarter (21.5%) of respondents never offer SC counselling to pregnant women. Nurses with higher levels of self-efficacy were more likely to provide SC counselling. Nurses are less likely to provide concrete assistance in the quitting process or arrange follow-up. The most commonly cited barriers included lack of time and cost of medication. CONCLUSIONS: FPNs are not consistently providing evidence-based SC interventions for pregnant women. Training to enhance self-efficacy may increase the frequency, efficiency and quality of FPN-provided SC interventions.

Organizational learning through experience has been found to be associated with enhanced firm performance. Organizational experiments are a method of experiential learning that enable organizations to learn from experience and gain context-specific knowledge of how and why to implement new knowledge. Pilot projects, a type of organizational experiment, involve making intentional, systematic efforts to gather and analyze feedback in order to accurately assess the action-outcome relationships of adopting new knowledge prior to embarking on full-scale implementation. Despite the popularity of pilot projects used to test products, programs, and services as well as reports on the outcomes of such experiments, there is a dearth of research focusing on how organizational learning occurs during organizational experiments, and on the processes and structural mechanisms of organizational experiments that contribute to organizational learning. A qualitative, multiple-case study of eight pilot projects was carried out within nursing units across five acute health care organizations during Fall 2008. Interviews were conducted with 32 individuals, including pilot project leaders, nursing program managers and direct care nurses. An inductive approach to data analysis was applied and themes identified. Results were compared to 14 propositions that were developed based on the knowledge transfer, innovation diffusion, and organizational learning literature, and which were bracketed before data analysis to allow findings to emerge from the data. The findings advance existing organizational learning, innovation diffusion, and knowledge transfer models by illuminating the complexity of organizational learning processes. Several processes and structural mechanisms of organizational experiments were found to facilitate single-loop organizational learning, leading to incremental changes to meet existing goals and objectives. Although double-loop organizational learning, which may result in fundamental changes in an organization’s assumptions, norms, policies, goals and objectives was not observed, the study revealed a number of processes and structural mechanisms that have the potential to encourage this type of learning. Studies of organizational experiments are rare. Future directions for research and theory development are suggested to build on the findings of this study. Practical implications are offered to organizations in any industry interested in realizing the potential that organizational experiments have for double-loop learning and enhanced organizational performance.

PURPOSE: To describe 1) smoking cessation (SC) interventions by Family Practice Nurses (FPN) during prenatal visits, and 2) the predictors and barriers of FPN-provided SC counselling for pregnant women. DESIGN: Non-experimental, descriptive, correlational design. Onetime, cross-sectional questionnaire using a previously validated questionnaire, modified and converted to electronic format. METHODS: Descriptive and multivariable analysis. Predictors investigated included nurses’ age, beliefs about their role in SC, self-efficacy to provide effective counselling, SC training, and interest in updating SC knowledge. PARTICIPANTS: Eighty-nine members of the Ontario Family Practice Nurses’ interest group (18% response rate) working in primary care settings across Ontario. RESULTS: Nearly one quarter (21.5%) of respondents never offer SC counselling to pregnant women. Nurses with higher levels of self-efficacy were more likely to provide SC counselling. Nurses are less likely to provide concrete assistance in the quitting process or arrange follow-up. The most commonly cited barriers included lack of time and cost of medication. CONCLUSIONS: FPNs are not consistently providing evidence-based SC interventions for pregnant women. Training to enhance self-efficacy may increase the frequency, efficiency and quality of FPN-provided SC interventions.

Organizational learning through experience has been found to be associated with enhanced firm performance. Organizational experiments are a method of experiential learning that enable organizations to learn from experience and gain context-specific knowledge of how and why to implement new knowledge. Pilot projects, a type of organizational experiment, involve making intentional, systematic efforts to gather and analyze feedback in order to accurately assess the action-outcome relationships of adopting new knowledge prior to embarking on full-scale implementation. Despite the popularity of pilot projects used to test products, programs, and services as well as reports on the outcomes of such experiments, there is a dearth of research focusing on how organizational learning occurs during organizational experiments, and on the processes and structural mechanisms of organizational experiments that contribute to organizational learning. A qualitative, multiple-case study of eight pilot projects was carried out within nursing units across five acute health care organizations during Fall 2008. Interviews were conducted with 32 individuals, including pilot project leaders, nursing program managers and direct care nurses. An inductive approach to data analysis was applied and themes identified. Results were compared to 14 propositions that were developed based on the knowledge transfer, innovation diffusion, and organizational learning literature, and which were bracketed before data analysis to allow findings to emerge from the data. The findings advance existing organizational learning, innovation diffusion, and knowledge transfer models by illuminating the complexity of organizational learning processes. Several processes and structural mechanisms of organizational experiments were found to facilitate single-loop organizational learning, leading to incremental changes to meet existing goals and objectives. Although double-loop organizational learning, which may result in fundamental changes in an organization’s assumptions, norms, policies, goals and objectives was not observed, the study revealed a number of processes and structural mechanisms that have the potential to encourage this type of learning. Studies of organizational experiments are rare. Future directions for research and theory development are suggested to build on the findings of this study. Practical implications are offered to organizations in any industry interested in realizing the potential that organizational experiments have for double-loop learning and enhanced organizational performance.

Diss. (sammanfattning) Linköping : Linköpings universitet, 2004. / Härtill 4 uppsatser.

Thesis (Ph. D.)--University of Alabama at Birmingham, 2008. / Title from first page of PDF file (viewed Feb 11, 2009). Includes bibliographical references (p. 73-94).