Diedrick, Lee A. MAN, RN, C-NIC; Schaffer, Marjorie A. PhD, RN; Sandau, Kristin E. PhD, RN, CNE
Nurse leaders are expected to implement changes in practice based on evidence. Moving evidence from knowledge to implementation in clinical practice relies on the ability of leaders to communicate effectively.1-3 When changes involve infrequently seen patient populations, information may be difficult to retain. The pace of change within the healthcare environment also contributes to an inability to retain new information.4,5 Pressure on nursing leaders to increase staffing productivity may not support time for retrieval and retention of new information by staff.
Practical solutions are needed for the entire change process, including the initial introduction to the change, adequate information to understand the change, and access to reference material when the information is needed.6 Barriers to nurse utilization of evidence-based practice (EBP) abound in the literature, but much of the focus has been on the process of finding and critiquing the evidence rather than the implementation process.7-9 EBP literature increasingly emphasizes the role nurse leaders have as facilitators of EBP changes, which includes dissemination of information during implementation of the new practice.1-3 Ultimately, the best patient care practices rely on nurse leaders to function as agents of change, moving evidence into clinical practice via effective communication.
The neonatal ICU (NICU) of a metropolitan children's hospital was identified as having no consistent method for communication of EBP changes. Changes and updates in practice were noted to average 4 per month. These were primarily communicated via e-mail and unit newsletters, which were archived. Information was not easily accessible for reference past initial implementation. Electronic reference materials were located in multiple computer files, including a department-specific drive and the organizational intranet site. Search functionality was rated as nonexistent on the department drive to less than adequate for the intranet. Nurses used colleagues for guidance, thus information was inconsistent. Variation in practice was a common complaint in patient/family surveys. Unit leaders reported slow progress with the adoption of new practices, disagreements among staff regarding procedures for skills, and concern about variations in competence. Leaders determined that a new and consistent method for communication of practice changes was needed.
Application of Rogers' Theory
Change theory is frequently associated with EBP. Rogers' diffusion of innovations model breaks the change process into 5 stages: knowledge, persuasion, decision, implementation, and confirmation.10 Communication is critical to all stages, beginning with the need to provide comprehensive information about the change during the knowledge stage. One key to adoption of a change is sufficient knowledge about the change so the process can move forward into the persuasion stage.
Rogers suggests that 3 types of knowledge-(1) awareness (what), (2) directions (how), and (3) principles (why)-are involved in effective change. Communication from Rogers' perspective is information exchanged between 2 or more individuals and cycled back and forth, in a nonlinear fashion. The information about the change can be disseminated top-down or diffused laterally. Communication is an active exchange between individuals as information is shared, thus reducing uncertainty. Interactive communication to implement change takes more time and effort but has empirical support as a positive contributor to effective implementation of EBP changes.4,11,12 A search of the literature for evidence-based strategies for implementing EBP found that participatory 2-way communication is often combined with programmatic or top-down communication.13 Ideas are solicited from stakeholders to shape the change, typically through surveys or a task force. Subsequently, the developed guidelines are communicated top-down from organization to staff member in a systematic manner.
A quasi-experimental single group before-after design was used to compare staff nurse satisfaction before and after implementation of a consistent communication strategy of practice changes. The survey (Supplemental Digital Content 1, http://links.lww.com/JONA/A59) was designed with 3 purposes. The primary purpose was to foster participatory/interactive involvement of the RN in development of the communication strategy. This was accomplished at the study site by requesting practical suggestions for communication methods using free text and multiple-choice options during the survey process. A 2nd purpose was to obtain demographic data to ensure all shifts, ages, years of service, scheduled hours, and educational levels within the study unit were represented in development of the strategy. The 3rd purpose was to obtain presatisfaction and postsatisfaction data for the implementation of a new communication strategy using a 4-point Likert-type scale. The project targeted RNs working in a 56-bed level III NICU in a free-standing, community, not-for-profit, tertiary care pediatric hospital and teaching facility. Institutional review board approval was obtained. The survey is available in Supplemental Digital Content 1, http://links.lww.com/JONA/A59.
Review of more than 30 EBP and nurse satisfaction surveys did not reveal a suitable previously validated and reliable survey, thus a survey to measure RN preferences for a consistent communication strategy was developed (Supplemental Digital Content 1, http://links.lww.com/JONA/A59). Content validity was established by internal experts including the NICU clinical nurse specialist, the director of nursing research, and a faculty member with research expertise. Internal consistency reliability before and after surveys was calculated for the 4-point Likert-type scale, with resulting good reliability (Cronbach α = .824).
A nonrandomized convenience sample of 214 staff nurses of the NICU was accessed via an e-mail link to an online survey site. Consent was implied by voluntary completion of the survey, and all results were anonymous.
The presurvey response rate was 48.6% (n = 104). No significant demographic differences were noted among respondents. The 3 most frequently chosen communication suggestions from the presurvey information were incorporated into the design of the communication strategy for the project (Table 1). Free text suggestions were categorized, tallied, and incorporated in the design. The top 3 suggestions for effective communication of EBP changes were (1) give rationale for the change, (2) notify nurses in advance of the change, and (3) place information in a designated folder in the electronic reference book. In response to the query about ideal timing for advanced notification, 61.5% of staff RNs requested notification of practice changes 2 to 4 weeks before the change.
In the free text section of the survey, nurses complained about the frequency of change and the amount of e-mail communication. Participants stated "we are inundated with e-mails" and "we get so many e-mails with conflicting information." Free text suggestions or comments that complained about computer reliance for information were minimal. Nurses made suggestions for technology enhancement, with the most frequent suggestion being the creation of a single place to look for communication of changes.
New Communication Strategy Plan
An Excel spreadsheet was developed from presurvey information with the date of the change, what was changing, why the change was being implemented, and information about the practice change. In the new strategy, information about the practice change often included a direct link to a written document, PowerPoint, video, or computer learning module (Table 2). The communication spreadsheet was limited to the size of the computer screen to eliminate the need to scroll. The spreadsheet was labeled with a date and placed in the unit electronic reference book under a new folder entitled Updates and New Information. The spreadsheet was updated 1 to 2 times a month, with e-mail notification to the staff when changes were made.
Evidence from the literature about implementation science and communication influenced the design of the spreadsheet. One goal of the communication strategy was to address the lack of time frequently cited as a barrier by nurses in the adoption of EBP changes.8,14,15 Hall and Walton's5 review of communication literature recommends filtering and culling information, thus streamlining and decreasing the volume of information. Tailored and targeted messages were recommended based on a randomized controlled trial of implementation of practice guidelines in the healthcare setting.16 The emphasis on communicating only relevant information is consistent with previous findings that relative advantage is by far the top reason for adoption of any change.17
Literature regarding information overload was helpful in development of the communication spreadsheet (Table 2). Eppler and Mengis4 proposed 7 steps to reduce information overload and improve communication: (1) timeliness; (2) brief overview that includes why and to whom; (3) simple diagrams or visuals; (4) consistent structure for messages; (5) tailoring to the recipient; (6) 2-way or interactive communication; and (7) increased accessibility through metaphors, analogies, or stories to reach a diverse audience. Decreasing extraneous information enables the end user to be attentive to important communication. The spreadsheet implemented in the study enabled filtering, tailoring, and targeting of information to the unit-specific nurses. Timeliness was enhanced by advanced notice of the proposed change. Providing a brief explanation of the reason for the change was important for supporting implementation of the change. Designed with staff nurse input, the format of the spreadsheet was a brief, easy to read colored table.
Communication of the New Strategy
The implementation for the consistent communication strategy was in itself a communication challenge. This validated the need to improve information delivery. Initially, the communication about the new strategy was presented to the NICU unit council (shared governance model) for their buy-in and critique. The information was then sent to all NICU nurses via e-mail. Presentations were made to the unit-based nurse committees, and the unit newsletter and Web site contained the information about the new strategy. A few weeks later, the unit clinical educators spent time 1-on-1 with nursing staff to ensure they were aware of the communication of the electronic folder with practice changes and how to access it. It was apparent during these sessions that most of the nurses had not yet looked at the new electronic folder or were aware of its existence. Communication about the new communication strategy was reinforced through e-mail.
The postsurvey information was identical to the presurvey information, giving respondents the opportunity to select a preferred communication strategy. The top 3 suggestions for effective communication of EBP changes were the same as that of the presurvey: (1) give rational for the change, (2) notify nurses in advance, and (3) place information in a designated folder in the electronic reference book. In the postsurvey information, the most frequently identified suggestion for improving communication of EBP changes, among all demographic groups, was establishment of the designated electronic folder for current changes. Postsurvey free text comments reiterated the desire to have 1 consistent place to look for information.
The postsurvey was completed 7 months after the presurvey. Response rate was 50% (n = 106). χ2 and Fisher exact tests were used for comparison of the presurvey and postsurvey results for staff nurse satisfaction with the communication strategy intervention. Survey respondents ranked satisfaction in 4 aspects of communication: (1) amount, (2) frequency, (3) method, and (4) ease of finding information. Regarding the amount of communication after the intervention, nurses who were somewhat or completely satisfied moved from 49 (51%) to 81 (77.2%), χ23, 201 P < .001. Satisfaction with frequency of communication increased from 55 (56.4%) to 78 (74.3%) nurses somewhat or completely satisfied, χ23, 203 P < .014. Method of communication moved from 53 (54.7%) to 82 (78.1%) nurses, somewhat or completely satisfied, χ23, 202 P < .001. For the item, how easy it is to find information, the presurvey showed 39 (38.3%) nurses were completely or somewhat satisfied, which increased to 67 (65.1%) in the postsurvey, χ23, 205 P = .001 (Table 3).
Demographic comparisons of satisfaction presurvey and postsurvey demonstrated few differences. The most significant was the lack of improvement in satisfaction in all measures for the evening shift (3-11 PM) nurses. The 11 PM to 7 AM shift had less improvement in satisfaction for method, frequency, and ease of finding information in comparison to the 7 PM to 7 AM night shift nurses and the day shift nurses (Table 4). Age group demographics indicated different satisfaction levels for the question how easy is it to find information. All age groups, younger than 30, 30 to 39, 40 to 49, and older than 49 years, were noted to have increased satisfaction in finding information in the postsurvey; however, satisfaction did not increase as markedly among the 2 older age groups.
Discussion of Results
The lack of increased satisfaction among 8-hour night shift nurses was not a surprise, as isolation is frequently a complaint of this shift. Night shift reported having less frequent contact with unit and organizational leaders. It was surprising that evening shift nurses reported no increased satisfaction with the new system, especially when their hours of work overlapped with the 12-hour day and 12-hour night nurses who did demonstrate a significant increase in satisfaction. Results indicated that compared with other shifts, evening shift nurses more often suggested 1-on-1 communication (rounding) as a preferred communication strategy. This difference in selection of preferred communication strategies did not reach statistical significance but provides insight into the lack of improvement in evening shift satisfaction. A review of the 1-on-1 rounding log noted that the evening shift was underrepresented, with only 25% of evening shift nurses approached one-on-one to communicate the new strategy, compared to more than 50% of nurses on the other shifts. The research team concluded that the evening shift had not been adequately introduced to the new communication strategy, which could have negatively affected their satisfaction levels.
The number 1 rating for establishment of a consistent electronic folder in the postsurvey was taken as affirmation of the new communication strategy. Of note, older nurses (defined as those older than 49 years for purposes of this study) were as likely to request the computer reference material as younger nurses. Further study is indicated regarding generational differences in computer literacy among staff nurses.
Free text comments provided insight into communication strategy preferences. Comments from the postsurvey that the electronic reference material was not accessible from home, but e-mail notification was accessible, prompted continued e-mail notification of additions to the communication spreadsheet. Although many RNs reiterated that they receive too many e-mails, it was apparent that e-mail communication should not be abandoned until the electronic reference material could be accessed outside the organization.
A frequent challenge in studies of EBP, change theory, and implementation science literature is that of confounding variables. Internal and external contextual factors make it difficult to distinguish the effects of the intervention from outside factors.11 For example, between the presurvey and postsurvey, the organization implemented a streamlined method of communication of practice changes via e-mail with links resembling the communication spreadsheet that was developed for this study, which could have had an impact on the outcome.
A 2nd limitation occurred when nurse union negotiations took place between the presurveys and postsurveys resulting in a 1-day strike and vote for open-ended strike. During this time, members of the organization were not focused on business as usual and the number of practice changes to be implemented dropped to 0 for 3 months of the study period. Although the second survey was delayed, there was no way to empirically gauge when tension levels returned to baseline. The 2nd survey may reflect the unsettled environment during labor negotiations and the decrease in number of practice changes.
The diversity of suggestions among the staff nurses about their preferences for communication made it difficult to honor them all. Free text suggestions were frequently contradictory. Choosing the top 3 suggestions in designing the strategy meant some nurse needs were not met, which may have affected satisfaction results. And finally, self-reports of satisfaction do not necessarily translate to actual change in practice. Further studies are needed to measure the impact of a consistent communication strategy on actual adoption rates of change and patient outcomes. Similar studies should be replicated in other settings and units.
Leadership support is essential for implementation of EBP, including time for development and maintenance of a consistent system of communication. The ideal process elicits staff nurse suggestions and participation in evaluation to ensure development of a communication strategy that will actually be used, fits workload constraints, and supports a preferred communication style. Once developed, the communication of practice changes could have the potential to save resources through increased efficiency, convenience, and accessibility to all. The electronic spreadsheet communication tool took little time to develop and maintain and could be updated by support staff if supervised by a knowledgeable clinician. We found that the most challenging aspect of communicating change is for leaders themselves to be aware of upcoming changes.
The spreadsheet provided 3 unintended benefits for leaders. The 1st involved the ease for clinical educators and managers to provide up-to-date information about unit changes for nurses returning from maternity and medical leaves. The list of all changes with a link to the education materials saved nurse leader time and supported a smoother transition for the returning nurse. The 2nd benefit was the recording of a timely history of the implementation of EBP changes for accrediting agencies and the organizational risk manager. Data from the spreadsheets were used as supporting information for the reaccreditation of Magnet® status. A final unexpected benefit was a documented record of practice change and accompanying education strategy. Measurement of adoption rates for EBP changes and patient outcomes can be compared with implementation and education strategies to determine the most effective approach and be matched with resulting trends in performance.
Establishment of a consistent communication strategy for implementation of EBP changes, developed with input from the staff and based on evidence, improved nurse satisfaction. Awareness raising and access to available resources are considered key success factors for the implementation of practice changes.18 This was accomplished by designing a single place to look for communication of practice changes. The new communication strategy provided a practical "gateway" for information to all nursing staff members.5
The authors thank Kristin McCullough, RN, MSN, CNS; Mari Akre, RN, PhD; Mike Skobba, RN, MSN; and Nancy Schult, RNC, for their support. The authors also thank the RNs of Children's Hospitals and Clinics of Minnesota St Paul campus NICU for their survey contributions, Cari O'Connor for technical support, and Meixia Liu, MS, for statistical analysis.
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