| ObjectiveThis study aimed to explore the systematic methods to implement the evidence-based nursing intervention for the post-stroke dysphagia patients,which was applied in clinical practice settings and focused on improving the outcome of the stroke survivors.MethodsBased on the Post-Stroke Dysphagia Evidence-Based Practice Program(PSD-EBPP)constructed by the research team,this evidence-based implementation program utilized the Consolidated Framework for Implementation Research(CFIR),Replicating Effective Programs Framework(REP)and Reach,Efficacy,Adoption,Implementation,and Maintenance Framework(RE-AIM)as the theoretical guide to identify the factors influencing the clinical practice and evaluate the implementation effect of PSD-EBPP separately.The research involves the following: From 51 hospitals in China,hospitals which meet recruitment conditions of implementing PSD-EBPP were selected for our implementation.1.Evaluation of the determinants in the application of evidence-based practice for dysphagia.Based on the CFIR,neurology,neurosurgery,and cerebrovascular disease departments as the experimental subjects,we used a quantitative survey to approach the implementation readiness,structure,organizational culture described in the domain of inner setting;as the nurses were the experimental subjects,knowledge and skill level in the domain of characteristics of individuals were surveyed;and as the managers and nurses were the experimental subjects,the adaptability of the evidence in the domain of intervention characteristics were explored.The constructs in the domain of intervention characteristics,characteristics of individuals,inner setting and outer setting were assessed using qualitative interviews to identify specific determinants in the application of PSD-EBPP,and to provide the formulation basis of implementation scheme.2.Develop evidence-based implementation scheme of rehabilitation nursing care for post-stroke dysphagia patients.Based on the determinants identified,we analyzed literature and held brainstorming sessions to develop the implementation scheme of PSD-EBPP.3.Implementation and effect evaluation of evidence-based practice program were conducted.From August 2019 to February 2020,the selected relevant departments of thehospital as the experimental site,the implementation of PSD-EBPP was designed as a stepped wedge cluster randomized trials and convenience sampling method was used to apply evidence-based practice program for post-stroke dysphagia rehabilitation care in real-world.The evaluation was from two aspects of process and outcome.We adopted the dimensions of the adoption and implementation of the RE-AIM to evaluate the process of implementation in hospital departments and their nurses who were in evidence-based practice programs.We used the efficacy dimension of the RE-AIM framework to evaluate the outcomes of nurses and patients after the implementation of the intervention.The questionnaire survey method was used to evaluate the changes of organizational culture,nurses’ knowledge,skills and behaviors.The patients’ health outcome indicators included swallowing function(main indicator)and oral hygiene,etc.ResultsSuccessfully recruited 7 departments in 4 hospitals as the implementation sites of PSD-EBPP,numbered S-1,S-2,S-3,S-4.1.We recognized the determinants of 4 hospitals’ departments to disseminate and implement PSD-EBPP.Facilitators included: Nurses surrounded in good organizational culture;clinical practices had the basis for the implementation of PSD-EBPP;most of the evidences were good apply in the contexts.Barriers included: Patients’ knowledge related to dysphagia were insufficient;patients only had weak willingness to attach themselves to rehabilitation for dysphagia;differences between clinical practices and PSD-EBPP hindered the dissemination of evidences;organizational support still needed to be strengthened;lack of knowledge and skills about dysphagia in nurses;and implementation methods needed to be clarified.2.We developed a scheme included a set of strategies suitable for localized implementation,including the establishment of an implementation team and training for nurses;clarification of dysphagia care procedures etc.The program mainly embodied the six categories of evidences for swallowing function screening and evaluation from the aspects of intervention implementers and methods;it also included dysphagia screening and evaluation sheets,diet care record sheets and other 12 tools.3.(1)Process evaluation: The adoption rate of 4 hospitals were 63.63%～90.90%,35.71%～71.43%,58.62%～96.55%,77.77%～100.00%,respectivily.The implementation rate of dysphagia screening and evaluation in the 4 hospitals is 85.71%～100.00%.The implementation rate of other interventions is at least 42.60%～58.30% for oral care,andthe highest is nutrition risk screening with 96.20%～100.00%.(2)Evaluation of outcomes : At the organizational level,the score of the organizational culture after the evidence-based implementation was higher than before the application in S-1 hospital and S-3 hospital(P <0.05),while there was no significant difference in S-2 hospital,S-4 hospital.At the practitioner level,there was no significant difference between the nurses’ knowledge and skill total scores before and after implementation in S-4 hospital(P >0.05),while nurses’ knowledge was improved than those before the intervention in S-1 hospital and S-3 hospital,and skill scores also improved in S-3 hospital(P <0.05).And after implementation nurses’ behavior scores was higher than those(P <0.05).At the patient level,339 patients from 4 hospitals were included and analyzed.Swallowing function: The intervention group had a lower score than the control group(P <0.05).Risk of malnutrition:The score of risk of malnutrition decreased over time(P <0.05).Oral hygiene: The oral hygiene score was lower in the intervention group than in the control group,and the difference between different time points was statistically significant(P <0.05).Length of hospital stay: There was no significant difference between the intervention group and the control group.Patients in the intervention group had higher scores on knowledge related to dysphagia and quality of life than those in the control group(P <0.05).There were no significant differences between the intervention group and the control group in terms of pneumonia and asphyxia.ConclusionThe scheme constructed in this study can effectively and partly improve the organizational culture of the clinical department,effectively promote the nurses’ practice of dysphagia,and effectively improve patients’ swallowing function,oral hygiene,level of dysphagia related knowledge and quality of life.Adopting the CFIR framework and the RE-AIM framework would help to promote the construction and application of evidence-based practice programs that are highly operable,and to evaluate the effect of implementation.This study provided the scientific and systematic method of the application of evidence-based practice programs for post-stroke dysphagia rehabilitation nursing care,and also provided a demonstration for the application of implementation science to guide evidence-based practice in other nursing areas. |
PDF Full Text Request