A Systematic Review of the Effectiveness of Knowledge Translation Interventions to Promote Evidence-Informed Decision Making Among Nurses in Tertiary Care

Purpose: To improve the quality of client care, nurses are increasingly expected to engage in evidence-informed decision making (EIDM); the use of research evidence along with information about patient preferences, clinical context and resources, and clinical expertise in decision making (American Nurses Association; Canadian Nurses Association, 2013; DiCenso, Ciliska, & Guyatt, 2005; Kitson, 2004; Nursing & Midwifery Council, 2008; Sigma Theta Tau International Honor Society of Nursing, 2005). It is believed, however, that the use of research evidence by nurses is not optimal (Squires et al., 2011). Knowledge translation (KT) interventions, such as education, reminders, and champions, have been identified as ways to increase EIDM among health care professionals, including nurses (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012). Previous systematic reviews, however, have largely focused on the effectiveness of these interventions among physicians and allied health professionals.  Only one systematic review (Thompson, Estabrooks, Scott-Findlay, Moore, & Wallin, 2007) has considered the effect of KT interventions upon nurses’ research use. As such, there is a lack of synthesized evidence in regards to the effectiveness of KT interventions among nurses, especially in regards to promoting EIDM knowledge and skills. To address this gap and inform the real-world questions of decision makers who are in a position within their organizations to influence the uptake of the findings to promote EIDM, the objectives of this project were to determine: 1) if KT interventions are effective for promoting EIDM knowledge, skills, and behaviours among nurses, 2) if KT interventions for promoting EIDM knowledge, skills, and behaviours among nurses effective for changing client outcomes; and 3) what contextual factors which shape the effectiveness of the interventions.

Methods: To address these objectives, a systematic review was conducted. Using an integrated KT approach, the research team engaged partners from two academic health centres in Ontario and an advisory committee which included frontline practitioners (nurses, advanced practice nurses) and nurse decision makers (nurse managers, nurse educators) from these health centres, as well as representatives from provincial and national organizations (Canadian Nurses Association and the Registered Nurses Association of Ontario) (Canadian Institutes of Health Research, 2013). The partners and advisory committee members provided input into the methodology of the systematic review. A search strategy for published and unpublished literature identified relevant articles. This strategy included a search of electronic bibliographic databases, handsearching of the references lists of included studies and key journals, and searches of key sources of grey literature (i.e. Open Grey (http://www.opengrey.eu/);  National Institutes of Health Science of Dissemination and Implementation conferences (http://obssr.od.nih.gov/scientific_areas/translation/dissemination_and_implementation), and Joanna Briggs Institute (http://joannabriggs.org/). Articles retrieved from the search were screened independently by two reviewers. Articles were deemed relevant if they: 1) focused on nurses, defined as registered nurses and advanced practice nurses (including clinical nurse specialists, nurse practitioners), 2) were conducted in tertiary care, 3)  implemented any KT intervention; a list of KT interventions was compiled from a review of previous systematic reviews in KT, 4) considered the outcomes of EIDM knowledge, skills, and behaviour, and patient outcomes as a result of EIDM behaviours, and 5) was a systematic review, randomized controlled trial (RCT), cluster RCT, non-randomized controlled trial, cluster controlled trial, interrupted time series design, or prospective cohort study, qualitative study (i.e. descriptive, phenomenology, grounded theory), or mixed methods study.  A third reviewer was available to resolve discrepancies not achieved through consensus, as agreement was necessary for inclusion during full-text screening. Risk of bias assessments and data extraction were performed by two independent reviewers, with a third reviewer to resolve discrepancies. Cochrane Risk of Bias was used to assess quantitative studies (Higgins et al, 2011) and The Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI) was used to assess qualitative studies (The Joanna Briggs Institute, n.d.). For mixed methods studies, assessment of methodological quality was completed separately for quantitative methods and the qualitative methods using the aforementioned criteria. Included studies were synthesized using narrative and meta-analytic methods.

Results: Of the 44, 608 articles screened, 33 articles met the inclusion criteria (five RCTs, six cluster RCTs, five non-randomized controlled trials, five cluster controlled trials, eight qualitative descriptive studies, and two grounded theory studies, and two mixed methods studies. Although the original intent was to include systematic reviews and prospective cohort studies, the research team and partners determined that due to differences in the questions and objectives of the systematic reviews retrieved that they would only be included to inform the search and that given the relatively large number of high-level studies that met the inclusion criteria (i.e. RCTs, cluster RCTs, non-randomized controlled trials, and cluster controlled trials) that the prospective cohort designs representing low-level evidence would not be included in the synthesis. The included studies were conducted in various countries and within different clinical areas within tertiary care. The majority of KT interventions implemented were multifaceted and, with the exception of the two single component interventions that implemented either computerized decision support or access to a library system, the interventions included an educational  aspect. Educational meetings were implemented most often, followed by educational materials, and educational outreach visits. A range of innovative KT interventions unique to nursing, not captured well within traditional categorizations of KT interventions, were also identified. While none of the included studies examined the effect of the KT interventions on EIDM knowledge and skills, they did evaluate the implementation of interventions to promote engaging in EIDM behaviours (i.e., searching for the best available evidence, critically appraising research evidence) or the use of research evidence (i.e., an evidence-informed guideline, protocol, pathway) for practice change, as well as patient outcomes as result of nurses use of research evidence. While the majority of the studies were synthesized narratively, a meta-analysis of two studies identified that  EIDM behaviours did not significantly increase as a result of a multifaceted intervention which involved educational meetings and mentorship [mean difference 2.7, 95% CI (-1.7 to 7.1)]. Findings from qualitative and mixed methods studies identified barriers and facilitators to implementation consistent with the literature. Context and leadership were determined to be important factors influencing the implementation of KT interventions for supporting the use of research evidence in practice. Across all of the included studies there was  variation in the clinical areas, interventions (i.e. components, intensity), and measurement of the outcomes which prevented conclusions about the relative effectiveness single or multifaceted KT interventions, as well as  aspects of multifaceted KT interventions.While further work is needed to determine the most effective intervention to promote EIDM among nurses in tertiary care,  some of the KT interventions identified in this systematic review do show promise.

Conclusion: This systematic review addressed a gap in the literature and was also relevant, timely, and useful for the partners involved. Interventions to enhance the EIDM behaviours and patient outcomes among nurses in tertiary care are being implemented and evaluated. Although the recommendations for the implementation of specific KT interventions cannot be drawn, decision makers can refer to the synthesis of the included studies to assist in selecting KT interventions which may be able to be applied to their local context in order to promote evidence-informed nursing practice for the delivery of quality client care. Furthermore, recommendations for nursing research and nursing education became apparent during the synthesis of the included studies. Nurses engaging in formal research projects and quality improvement projects are encouraged to enhance the reporting the details of the KT intervention being implemented. In addition, methodologies such as interrupted time series studies and mixed methods designs would improve the rigour of the evaluations being undertaken and further an understanding of the context in which KT interventions “work”.