Diffusion of Innovation in Long Term Care: A Bedside Clinical Direction Model for Implementing Heart Failure Evidence-Based Practice Protocols in Frail Elders

Deborah A. Lekan-Rutledge, MSN, RNC, Eleanor S. McConnell, PhD, RN, APRN-BC, and Cristina C. Hendrix, DNS, RN, GNP. Graduate Program, Gerontological Nursing, Duke University School of Nursing, Durham, NC, USA

Duke University School of Nursing received a yearlong grant from GlaxoSmithKline to develop and implement an interdisciplinary disease management model to improve clinical outcomes for residents in long term care facilities. The model, known as Bedside Clinical Direction, uses a gerontological advanced practice nurse to serve as a direct linkage between medical providers, the interdisciplinary team, senior RN nursing leadership and direct caregiving paraprofessional staff (LPNs and CNAs) to implement evidence-based care practices for residents with the selected medical problem. Heart failure was selected as the clinical focus because of its prevalence among older adults and because it is the leading cause of hospitalization among persons over the age of 65. Early recognition and treatment of acute heart failure in long term care can reduce morbidity and mortality, prevent deconditioning and functional losses associated with acute illness and hospitalization, and improve overall medical management and quality of life.
We used the diffusion of innovation framework to guide the development of educational initiatives to improve recognition, assessment, treatment and monitoring of frail elders at high risk for acute heart failure. In contrast to traditional classroom teaching, we implemented novel teaching strategies including unit-based teaching with bedside clinical assessments of residents with heart failure, job aides, peer teaching (CNAs, LPNs), role play, cardiovascular models and simulations. This paper discusses how the diffusion framework informed the design and delivery of a comprehensive education program for paraprofessional staff with attention to cultural diversity, limited literacy issues, staff work culture, and adult learning principles. Program evaluation included staff interview, performance evaluation, self-assessment, and chart audit. The Bedside Clinical Direction model was a highly visible, effective approach to building capacity among paraprofessional staff to implement protocols for early recognition, treatment and monitoring of acute heart failure.

Learning Objective #1: Describe how the diffusion of innovation framework can be used to design a heart failure evidence-based practice program to paraprofessional staff.
Learning Objective #2: Describe the Bedside Clinical Direction model for teaching paraprofessional staff early recognition of heart failure in high risk frail elders.