Development and Evaluation of a Leadership Intervention to Influence Nurses' Use of Clinical Guideline Recommendations

Leadership is important to quality improvement initiatives in healthcare. However, few studies have evaluated leadership interventions to enhance nurses’ use of guideline recommendations in the field of knowledge translation.

Purpose: To develop and evaluate an intervention designed to operationalize a leadership strategy composed of relations, change, and task-orientated leadership behaviours, and to examine its influence on nurses’ use of guideline recommendations in home-care nursing.

Design: Sequential mixed methods pilot study with post-only cluster randomized controlled trial.

Methods

Phase I: Intervention Development

1. A participatory approach was used at a community healthcare organization with 23 units across the province of Ontario, Canada. The guideline selected was developed by the Registered Nurses’ Association of Ontario for the assessment and management of foot ulcers for people with diabetes.

2. Integrative literature review, qualitative interviews, and baseline chart audits were conducted.

3. Four units were randomized to control or experimental groups.

4. Clinical and management leadership teams participated in a 12-week intervention consisting of printed materials, interactive workshop, and teleconferences. Participants received summarized chart audit data, identified priority indicators for change, and created a team leadership action plan to address barriers and influence guideline use.

Phase II: Evaluation

5. Chart audits compared differences in nursing process and patient outcomes. Primary outcome: eight-item nursing assessment score.

6. Qualitative interviews evaluated the intervention and leadership behaviours.

Results: No significant difference was found in the primary outcome. A significant difference was observed in nurses’ documentation of five priority indicators chosen by the experimental groups (p=.02). Gaps in care included: 53%, 76%, and 94% of patients not assessed for ulcer depth, foot circulation, or neuropathy (respectively); 75% and 93% did not receive wound debridement or hydrogel dressings.

Receiving data to identify priority indicators for change and developing a leadership action plan were reported as useful to guideline implementation. The experimental group described using more relations-oriented leadership behaviours conducting audit and feedback, and sending reminders.

Conclusion: Findings from this pilot study suggest that leadership is a team process involving relations, change, and task-oriented behaviours enacted by managers and clinical leaders. A leadership model is proposed as a beginning taxonomy to inform future leadership intervention studies.