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AnteayerWorldviews on Evidence-Based Nursing

Administration of 3% Sodium Chloride Through Peripheral Intravenous Access: Development and Implementation of a Protocol for Clinical Practice

Abstract

Background

Patients with traumatic brain injury, cerebral edema, and severe hyponatremia require rapid augmentation of serum sodium levels. Three percent sodium chloride is commonly used to normalize or augment serum sodium level, yet there are limited data available concerning the most appropriate route of administration. Traditionally, 3% sodium chloride is administered through a central venous catheter (CVC) due to the attributed theoretical risk of phlebitis and extravasation injuries when hyperosmolar solution is administered peripherally. CVCs are associated with numerous complications, including arterial puncture, pneumothorax, infection, thrombosis, and air embolus. Peripherally infused 3% sodium chloride may bypass these concerns.

Aims

To explore the evidence for peripherally infused 3% sodium chloride and to implement the findings.

Methods

The Iowa Model of Evidence‐Based Practice (EBP) was used to guide the project. A multidisciplinary team was established, and they developed an evidence‐based protocol for the administration of 3% sodium chloride using peripheral intravenous catheters (PIVs), identified potential barriers to implementation, and developed targeted education to implement this practice change in a large academic medical center.

Results

Of the 103 patients in this project, only three (2.9%) identified adverse events. Two were associated with continuous infusions, and one was associated with a bolus infusion.

Linking Action to Evidence

This is the first study to describe a multidisciplinary protocol development and implementation process for the administration of 3% sodium chloride peripherally. Utilizing a multidisciplinary team is critical to the success of an EBP project. Implementing an evidence‐based PIV protocol with stringent monitoring criteria for the administration of 3% sodium chloride has the potential to reduce adverse events related to CVC injury.

Implementation Science: Application of Evidence‐Based Practice Models to Improve Healthcare Quality

Abstract

Background

Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence‐based practice (EBP) models can guide implementation, contributing to the knowledge‐to‐practice gap.

Aim

This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes.

Methods

The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice.

Linking Evidence to Action

Knowledge of implementation science can help clinicians adopt high‐quality evidence into their practices. Application‐oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge‐to‐action gap.

Validation of the Implementation Climate Scale in Nursing

Abstract

Background

One critical factor in effective implementation of evidence‐based practices (EBPs) in nursing is an organizational context that facilitates and supports implementation efforts. Measuring implementation climate can add useful insights on the extent to which the organizational context supports EBP implementation.

Aims

This study cross‐validates and examines the psychometric properties of the Implementation Climate Scale (ICS), which measures nurses’ perceptions of their unit’s climate for EBP implementation.

Methods

This study analyzed ICS data from two cross‐sectional studies, including 203 nurses from California and 301 nurses from Florida. Analyses included evaluation of internal consistency, multilevel aggregation statistics, and confirmatory factor analyses.

Results

The 18‐item ICS demonstrated comparable psychometric properties to the original measure development paper in both samples. Confirmatory factor analyses provided support for the scale’s factor structure in both samples.

Linking Evidence to Practice

The ICS is a pragmatic measure that can be used to assess unit implementation climate in nursing contexts. Results from the ICS from nurses and nurse leaders can provide insights into implementation‐specific barriers and facilitators within the organizational context.

Use of Pain Management Champions to Enhance Guideline Implementation by Care Workers in Nursing Homes

Abstract

Background

Underutilization of evidence‐based pain management in nursing homes (NHs) is common. Evidence toward effective approaches to improve adoption of evidence‐based practices in NHs is limited. Application of theory in evaluation approaches can increase understanding of implementation challenges.

Aim

To get a better understanding of the impact of implementation strategies by exploring the underlying mechanisms using behavioral theory.

Methods

This mixed‐methods study is embedded in an implementation‐effectiveness study of a pain management guideline in four Swiss NHs. To evaluate our implementation strategies, training workshops were held, and trained pain champions were introduced. We also developed a conceptual framework. Based on Bandura’s self‐efficacy theory, we hypothesized how our implementation strategies might affect changes in care workers’ behavior. Care workers’ questionnaire surveys were conducted at baseline (n = 136), after 3 months (n = 99), and after 6 months (n = 83) to assess self‐efficacy in pain management and self‐reported guideline adoption. We computed linear mixed‐effect models to assess changes over time in self‐efficacy and logistic regressions to assess associations between self‐efficacy and guideline adoption. Concurrently, we conducted focus groups with care workers (n = 8) to explore their response to the implementation strategies.

Results

Overall, there was a significant increase in self‐efficacy at both time points (p < .001). We found significant associations between self‐efficacy and adoption of two guideline components, that is, performing a comprehensive pain assessment and using observational pain assessment tools in cognitively impaired residents. Qualitative findings showed that implementation strategies were received positively by care workers. Focus group participants reported more attentiveness to residents’ pain experience. The participants also reported increases in assessment and documentation of pain with more detail than before.

Linking Evidence to Action

Our findings highlighted that the training and use of pain champions increased self‐efficacy and thereby induced behavior change leading to guideline adoption. Regarding persistent implementation challenges, a theory‐based conceptual model contributes to the overall understanding.

An Examination of the Factors Associated With Implementation of Evidence‐Based Management Practices for Improving Nurse Work Environments

Abstract

Background

Evidence‐based management practices (EBMPs) that improve nurses’ work environments have been linked to improvements in patient outcomes such as patient satisfaction and mortality. Yet, the extent to which nurse managers implement these EBMP or the factors associated with their implementation is not known.

Aims

Guided by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework, we examined individual, evidence, and organizational characteristics associated with nurse managers’ implementation of the five EBMPs.

Methods

A cross‐sectional, correlational, survey design was used. Nurse managers from 10 public hospitals in New York City were recruited. Evidence and contextual variables were measured with the Organizational Readiness for Change Assessment instrument. EBMPs were measured with a modified version of the Practice Environment Scale of the Nursing Work Index. All multi‐item scales were validated with confirmatory factors analysis in the studied sample. Additionally, the scales had Cronbach’s alpha reliability greater than .8. A multivariate linear regression analysis with robust standard error correction was used to analyze the data and to adjust for clustering of managers in hospitals.

Results

A total of 331 nurse managers responded for a 47.4% response rate. Bachelor’s degree, number of staff supervised, managers’ personal experience with evidence for EBMPs, staff culture, and organizational resources were significant predictors of nurse managers’ implementation of EBMPs for NWE improvement (p < .05).

Linking Evidence to Action

Staff culture was positively associated with implementation of all five EBMPs for improving nurses’ work environments. Managers should prioritize nursing unit culture that encourages staff to innovate and change in order to improve care.

The Importance of Context and Organization Culture in the Understanding of Nurses’ Barriers Against Research Utilization: A Systematic Review

Abstract

Background

Numerous studies have explored nurses’ perceived barriers to research utilization. In this study, considerations of how to break down the barriers are discussed in order to find new ways to develop and strengthen evidence‐based practice.

Aims

The objective of the study was to identify nurses’ perceptions of barriers to research utilization in clinical practice between the years of 2000 and 2018 and across continents by reviewing studies that used the Barriers to Research Utilization (BARRIERS) scale (Appl Nurs Res, 4, 1991, 39).

Design

A systematic review of observational studies based on Joanna Briggs specific guidelines.

Methods

A systematic search to identify and select eligible studies was conducted in PubMed, CINAHL, PsycInfo, and SCOPUS during January 2019. Google Scholar was also searched to identify additional studies using the Funk et al. (Appl Nurs Res, 4, 1991, 39) BARRIERS scale. An instrument for quality appraisal was constructed for this paper by combining two similar and previously used cross‐sectional study checklists (Int J Sociol Soc Policy, 23, 8, 2003; Implement Sci, 5, 32, 2010). Descriptive statistics were performed using IBM SPSS Statistics (version 25).

Results

The 27 included studies were conducted in 16 countries across five continents and 11,276 nurses participated. Seven of the top 10 barriers were comprised of organizational factors. These organizational barriers were consistent over time and the five continents, with 56% of the listed top 10 barriers falling under the organizational category. From the year 2000 to 2008, the majority of the studies were conducted in Europe and Australia. However, for the next 10 years (2008–2018), the majority of studies were conducted in Asia, Africa, and North America.

Linking Evidence to Action

To break down the nurses’ barriers to research utilization, our future practice and research focus will be to conduct intervention studies focusing on the effect of facilitators and contextual environment, as well as developing nursing research cultures in clinical practice with support from the nursing management.

Development of a Cadre of Evidence‐Based Practice Mentors for Nurses: What Works?

Abstract

Background

Development of a critical mass of evidence‐based practice (EBP) mentors for healthcare professionals is pivotal in facilitating and sustaining system‐wide implementation of evidence‐based care, especially for nurses. Empirical evidence shows that organizational factors are strongly associated with EBP. However, the understanding of organizational support to promote EBP competency is found lacking, especially in Mainland China.

Aims

The purposes of this study were to (1) establish a baseline assessment of EBP nursing leadership and work environment support as well as EBP competency for EBP mentors of nurses in Western China, and (2) explore how nursing leadership and work environment impact the EBP competencies of mentors.

Methods

A cross‐sectional study was conducted. The study population was 286 EBP mentors for nurses from six urban general hospitals in Xi’an City, Shanxi Province. The EBP Nursing Leadership Scale and the EBP Work Environment Scale were used to evaluate their perceived organizational support. EBP competency was measured by the Evidence‐Based Practice Questionnaire.

Results

There was insufficient time for EBP mentors of nurses to engage in EBP. Lack of experts in EBP and educational offerings about EBP were identified as the two lowest workplace organizational supports for EBP. The respondents reported themselves as not competent in EBP, especially for the knowledge/skills. EBP nursing leadership and work environment support were key predictors of the self‐reported EBP competency in the stepwise multiple linear regression models (β = .211–.345, p < .01).

Linking Evidence to Action

It is imperative to provide EBP mentors for nurses with the knowledge and skills to achieve the expected level of EBP competency. Strategies for developing a cadre of EBP mentors for nurses who have competency in EBP need to be multipronged and target the cultivation of an organizational culture that supports EBP.

Animal‐Assisted Therapy as an Intervention for Older Adults: A Systematic Review and Meta‐Analysis to Guide Evidence‐Based Practice

Abstract

Background

Animal‐assisted therapy (AAT) can ameliorate diverse health problems in older adults. However, applications of AAT have been limited because of the lack of intervention guidelines for older adults.

Aims

This study aimed to explore applications of AAT to older adults, analyze its health effects, and provide evidence for future interventions.

Methods

A systematic review and meta‐analysis were conducted based on the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses checklist. Data were analyzed based on both a narrative synthesis and a meta‐analysis specifically for depression.

Results

A total of 47 studies were selected for analysis. About 45% focused on older adults with diseases such as dementia, and 57.4% selected dog(s) as an intervention animal. About 34.0% delivered interventions once a week, and the behavioral outcome domain was the most frequently investigated. The meta‐analysis showed that the effect sizes of the AAT group were −1.310 (95% CI [−1.900, −.721]).

Linking Evidence to Action

This review provides evidence for AAT as an intervention in the physiological, psychosocial, cognitive, and behavioral domains of older adults. When planning interventions for older adults, nurses should consider intended health outcomes, appropriate therapeutic animals, and the consequent intervention contents.

A Mobile Healing Program Using Virtual Reality for Sexual Violence Survivors: A Randomized Controlled Pilot Study

Abstract

Background

Many young women suffer from sexual violence, but few practice self‐healing activities.

Aims

This study evaluated the feasibility and preliminary effects of a mobile virtual intervention, Sister, I will tell you!©, to heal young women after sexual violence in South Korea.

Methods

A mobile virtual intervention, Sister, I will tell you!©, was developed based on a literature review and preliminary studies. In collaboration with sexual violence survivors and experts, eight modules for reflective writing and six modules for mindfulness meditation were included in this 4‐week mobile virtual intervention. Thirty‐four female sexual violence survivors were randomly assigned to either experimental (n = 19) or control groups (n = 15). The experimental group practiced reflective writing and mindfulness meditation, guided by the mobile virtual intervention. The control group practiced audio‐guided mindfulness meditation. Pretest, posttest, and post‐4‐week evaluations with standardized instruments measured perceived support, negative impact from sexual violence, and suicidal ideation. Descriptive and inferential statistics were used to analyze survey data and content analysis to analyze reflective writing.

Results

Among 34 enrolled participants, 26 completed the 4‐week intervention and posttest evaluations; 24 completed post‐4‐week evaluations. Significant improvements were found among participants in the areas of perceived support, negative impact from sexual violence, and suicidal ideation. The effect size of the intervention was moderate. Four themes that emerged from reflective writings were objectifying sexual violence, healing beginning with action, confronting issues, and sharing experiences.

Linking Evidence to Action

The intervention showed potential for initiating young women’s engagement in healing from sexual violence. A simple mobile audio intervention without human interaction could benefit sexual violence survivors.

Effectiveness of Multidisciplinary Care for Chronic Kidney Disease: A Systematic Review

Abstract

Background

Chronic kidney disease (CKD) is a common chronic disease. As this disease is extremely complex, multidisciplinary care (MDC) is needed to provide complete and continuous care.

Aim

A systematic literature review was performed to examine the constituents of MDC, the content of MDC interventions, and the health outcomes in CKD patients receiving MDC.

Methods

Searches of five Chinese and English databases for studies of CKD patients who had received MDC from 2007 to 2019 revealed 11 studies, which comprised 16,066 CKD patients. The Physiotherapy Evidence Database scale (Physiotherapy Evidence Database, 2017) was used to appraise study quality for randomized controlled trials, and the Joanna Briggs Institute Critical Appraisal tools (Joanna Briggs Institute, 2017) were for cohort studies.

Results

The MDC teams that provided comprehensive medical care for these patients included nephrologists, nurses, surgeons, general practitioners, pharmacists, psychotherapists, social workers, nutritionists, and other specialists. The literature review revealed that MDC for CKD slows the decline in estimated glomerular filtration rate and decreases patient mortality, the risk of renal replacement therapy, the need for emergent dialysis, and annual medical costs. Analyses of biochemical markers in the CKD patients showed that MDC improves control of serum levels of calcium and phosphate, improves control of parathyroid hormone, and reduces proteinuria and fasting blood glucose values. However, further studies are needed to determine the effects of MDC on all‐cause mortality, blood pressure control, hospitalization rate, hospitalization for cardiovascular or infection events, medications use, and other biochemical markers in CKD patients.

Linking Evidence to Action

Cross‐disciplinary collaboration of healthcare professionals is needed to ensure that patients undergo regular follow‐up and periodic assessment of clinical status, in addition to ensuring that relevant resources and assistance are provided in a timely manner. A follow‐up period of at least 2 years is also needed to ensure sufficient time to observe MDC results.

Evidence‐Based Practice: A New Dissemination Guide

Worldviews on Evidence-Based Nursing, Volume 18, Issue 1, Page 4-7, February 2021.

Effectiveness of Evidence‐Based Practice (EBP) Education on Emergency Nurses’ EBP Attitudes, Knowledge, Self‐Efficacy, Skills, and Behavior: A Randomized Controlled Trial

Abstract

Background

Emergency care clinicians are expected to use the latest research evidence in practice. However, emergency nurses do not always consistently implement evidence‐based practice (EBP). An educational intervention on EBP was implemented to promote emergency nurses’ use of EBP, and the effectiveness of it was evaluated.

Aims

This study aimed to evaluate the effectiveness of an EBP educational intervention on emergency nurses’ EBP attitudes, knowledge, self‐efficacy, skills, and behavior. The study also examined learners’ satisfaction with the EBP educational intervention.

Methods

A randomized controlled trial with parallel groups with evaluations before the education, immediately after it, and 6 and 12 months after the education was conducted at four emergency departments in two university hospitals. The experimental group (N = 40) received EBP education while the control group (N = 40) completed self‐directed EBP education. The primary outcomes were emergency nurses’ EBP attitudes, knowledge, self‐efficacy, skills, and behavior, while the secondary outcome was satisfaction with the EBP education.

Results

Thirty‐five participants of an experimental and 29 participants of a control group completed the study. There were no statistically significant (p < .05) improvements and differences between groups in EBP attitude, self‐efficacy, or behavior immediately after the EBP education. At the 6‐month measurement point, the experimental group showed significantly better EBP attitudes, behavior, knowledge, and self‐efficacy than the control group. At the 12‐month measurement point, the improvements began to decrease. The groups also differed significantly in terms of participant satisfaction with how the teacher encouraged learners to ask clinical questions.

Linking Evidence to Action

The EBP educational intervention implemented in this study had a positive effect on emergency nurses’ EBP attitudes, knowledge, self‐efficacy, skills, and behavior. The effects of the education appeared the best 6 months after the education. After this point, the results began to decrease and approached baseline levels. EBP educational interventions designed for emergency nurses should apply various teaching strategies to improve their EBP attitude, knowledge, self‐efficacy, skills, behavior, and satisfaction with the education.

Is It Possible for Registered Nurses and Physicians to Combine Research and Clinical Work to Facilitate Evidence‐Based Practice?

Abstract

Background

Evidence‐based patient care requires clinicians to make decisions based on the best available evidence and researchers to provide new scientific knowledge. Clinician‐scientists (i.e., registered nurses [RNs] and physicians with a PhD) make important contributions to health care; yet, their roles are not fully understood, supported, or recognized by healthcare leaders. Only a few studies have addressed the factors that enable RNs and physicians to simultaneously pursue both clinical work and research after earning a PhD.

Aim

To explore what factors have a bearing on the ability of RNs and physicians to pursue research and clinical work simultaneously after earning a PhD.

Methods

The study used a qualitative design based on open‐ended, in‐depth interviews. Data were analyzed using conventional content analysis.

Results

Analysis of the data yielded a broad range of factors that RNs and physicians perceived to either facilitate or hinder continued research while simultaneously undertaking clinical work. Most of the perceived barriers were due to factors external to the individual. Several factors applied to both professions yet differed in impact. Factors mentioned as fundamental to continued research were financial support and allocated time for research. Maintenance of a good relationship with academia and support from management were also considered to be important. In addition, personal factors, such as motivation to pursue a research career after obtaining a PhD, were influential.

Linking Evidence to Action

A supportive infrastructure is important for enabling clinician‐scientists to pursue research after earning a PhD. Creating favorable conditions for RNs and physicians to combine research with clinical work can facilitate evidence‐based practice. This information can be used for interventions aimed at improving the conditions for clinician‐scientists.

Translation, Cross‐Cultural Adaptation, and Psychometric Analysis of the Attitudes Towards Homelessness Inventory for Use in Sweden

Abstract

Background

Homelessness is an increasing problem worldwide, and the origins of homelessness in high‐income countries are multifaceted. Due to stigma and discrimination, persons in homelessness delay seeking health care, resulting in avoidable illness and death. The Attitudes Towards Homelessness Inventory (ATHI) was developed to cover multiple dimensions of attitudes toward persons in homelessness and to detect changes in multiple segments of populations. It has, however, not previously been translated to Swedish.

Aims

The aim of the present study was to translate, cross‐culturally adapt, and psychometrically test the ATHI for use in a Swedish healthcare context.

Methods

The project used a traditional forward‐ and back‐translation process in six stages: (1) two simultaneous translations by bilingual experts; (2) expert review committee synthesis; (3) blind back‐translation; (4) expert review committee deliberations; (5) pre‐testing with cognitive interviews including registered nurses (n = 5), nursing students (n = 5), and women in homelessness (n = 5); and (6) psychometric evaluations. The final ATHI questionnaire was answered by 228 registered nurses and nursing students in the year 2019.

Results

The translation process was systematically conducted and entailed discussions regarding semantic, idiomatic, experiential, and conceptual equivalence. Confirmatory factor analysis was used to examine if the collected data fitted the hypothesized four‐factor structure of the ATHI. Overall, it was found that the model had an acceptable fit and that the Swedish version of ATHI may be used in a Swedish healthcare context.

Linking Evidence to Action

The ATHI has been shown to be a psychometrically acceptable research instrument for use in a Swedish healthcare context. The systematic and rigorous process applied in this study, including experts with diverse competencies in translation proceedings and testing, improved the reliability and validity of the final Swedish version of the ATHI. The instrument may be used to investigate attitudes toward women in homelessness among nursing students and RNs in Sweden.

Issue Information

Worldviews on Evidence-Based Nursing, Volume 18, Issue 1, Page 1-3, February 2021.

Evaluation of the Perceived Barriers and Facilitators to Timely Extubation of Critically Ill Adults: An Interprofessional Survey

Abstract

Background

Spontaneous breathing trials (SBTs) are an evidence‐based way of identifying patients ready for mechanical ventilation (MV) liberation. Despite their effectiveness, global SBT performance rates remain suboptimal, and many patients who demonstrate the ability to breathe on their own remain on MV. The factors that influence clinicians’ decision to discontinue MV following a successful SBT remain unclear.

Aims

The aim of this study was to explore the underlying causes of extubation delays in the intensive care unit (ICU) from an interprofessional perspective.

Methods

An exploratory, descriptive, cross‐sectional design was used. An online survey was administered in December 2019 to clinicians practicing in three ICUs at a single medical center in the U.S. Survey questions focused on clinicians’ perceptions of current MV liberation practices and perceived barriers or facilitators to timely extubation after a successful SBT.

Results

Of 425 eligible clinicians, 135 completed the survey (31.7% response rate). The majority of clinicians believed the current SBT and extubation process took too long (n = 108; 80.0%) and that this delay negatively affected patient outcomes. While professional groups differed in their rankings of importance, factors perceived to contribute to extubation delays most commonly included SBT timing, low provider confidence levels in making extubation decisions, and patient‐specific factors. Potential strategies to overcome these barriers included developing an automated extubation protocol, performing SBTs when the provider responsible for final extubation decisions is physically present, and decreasing clinician perception of reprimand or condemnation for failed extubations.

Linking Evidence to Action

The MV liberation process is complex and dependent on the decisions of various ICU professionals. Clinicians perceive a number of potentially modifiable provider‐ and organizational‐level factors that cause extubation delays in everyday practice. Understanding and addressing these barriers is essential for improving ICU quality and patient outcomes. Future research should explore the effect of nurse and respiratory therapist‐driven extubation protocols on MV liberation rates.

Implementation and Evaluation of a Standardized Nurse‐Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care

Abstract

Background

Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse‐administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care.

Aim

This study aimed to implement and evaluate the interRAI AC assessment system using a multi‐strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i‐PARIHS) framework.

Methods

This nurse‐led quality improvement study was piloted in a 200‐bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE‐AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance).

Results

In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre‐implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed.

Linking Evidence to Action

Despite challenges to implementing a system‐wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

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