Guideline adherence by clinicians is sub-optimal and patients can miss out on proven treatments. An Australian audit of adherence to stroke evidence-based guidelines showed that 87% of patients did not receive thrombolysis as recommended (Stroke Foundation, 2017). The organisational context of clinical settings can play a vital role in facilitating adherence to guidelines (Squires et al., 2015). The use of clinical guidelines is higher in settings where clinicians report working in a positive organisational context (Estabrooks et al., 2015; Forberg et al., 2014; Knopp-Sihota et al., 2015). The organisational context of a clinical setting can consist of workplace culture, leadership, teamwork, feedback processes and available resources.
The T3 trial, a cluster randomised controlled trial of triage, treatment and transfer of patients with stroke in the Emergency Department (ED), used a theory-based implementation strategy to introduce stroke care evidence-based protocols in participating EDs. Prior to introducing the protocols, organisational context of participating EDs was assessed to identify contextual factors that could potentially hinder the implementation of the protocols.
Aims
- To assess nurses’ perceptions of organisational context of Emergency Departments (EDs) enrolled in the T3 trial prior to introduction of protocols.
- To examine the relationship between nurse and hospital characteristics and measures of organisational context.
Methods
Organisational context of the 26 EDs participating in the T3 trial was assessed by the Alberta Context Tool (ACT) (Estabrooks et al., 2009). Higher scores on the ACT indicate an organisational context that fosters guideline implementation or research use by staff. The ACT captures 10 concepts rated on a 5-point Likert scale: leadership, culture, feedback processes, connections among people, structural and electronic resources, time, space, staffing, informal interactions and formal interactions. A mean score is generated for each individual concept (Estabrooks et al., 2009).
We used stratified sampling with proportional allocation to identify ED nurses from the enrolled 26 participating hospital sites was recruited. Casual staff were excluded. Stratification was by hospital size, full-time/part-time status and whether an enrolled or registered nurse. Paper-based surveys consisting of the ACT and 10 questions about nurse characteristics including age, gender, full-time or part-time work and length of qualification, were distributed by the site contact and returned to the site contact in a sealed envelope or via reply-paid envelope to the T3 researchers. Return of the survey implied consent to participate. The survey was completed prior to the hospitals being randomized to the intervention and control arms of the T3 trial.
Hospital characteristics: the number of hospital beds, number of ED beds and location (metropolitan, urban, remote) for the participating hospitals were obtained from the Stroke Foundation 2013 audit of acute stroke services.
Mean context scores for each concept were calculated. Associations between mean context scores and nurse/hospital characteristics were examined using correlations and linear regression. Hospital clusters were accounted for by using a general estimation equation model for the regression analysis. Since no overall context score can be generated, a regression analysis was undertaken for each of the 10 concepts.
Results
558 ED nurses participated with a 94% response rate. Seventy-four per cent (n = 413) were female, almost half were between 25 and 34 years old; 84% worked rotating shifts and 55% (n = 306) worked part-time. The highest mean context score were obtained for connections among people (4.06; SD 0.44), culture (3.81; SD 0.58), leadership (3.77; SD 0.68) and feedback processes (3.39; SD 0.73). Mean scores close to the average scale rating were obtained for staffing, space, time, informal interactions and resources, while the lowest score was for formal interactions with a mean of 1.79 (SD = 0.95).
Regression showed 38 hospital and nurse characteristics were significantly associated with higher or lower context scores across the 10 concepts. Some of the significant associations were as follows:
- Nurses in urban district hospitals had significantly lower perceptions of staffing (-1.171; p=0.013) compared to those in metropolitan hospitals.
- Nurses in middle-sized hospitals (351-550 beds) had significantly lower perceptions of staffing (-0.637; p=0.004) compared to those in smaller hospitals (≤ 350 beds).
- Senior nurses had significantly higher perceptions of formal interactions (0.236; p= 0.013) and staffing (0.3; p=0.020) than junior nurses.
- Nurses aged >30 years had significantly lower perceptions of staffing (-0.218; p=0.005), informal interactions (-0.4; p=0.007) and formal interactions (-0.293; p=0.001) compared to nurses aged 29 and below.
- Nurses working shift work had significantly lower perceptions of informal interactions (-0.805; p=0.005) and formal interactions (-0.407; p=0.013) compared to those not working shifts.
Implications
ED nurses in this study had positive perceptions of organisational context about connections among people, their work culture, leadership and feedback processes. However, perceptions of staffing and formal and informal interactions was variable depending on the size of hospital and nurse characteristics of age, seniority and whether or not they did shift-work.
The implications of these findings are that: i) assessment of organisational context can provide crucial information about factors that may facilitate or hinder adherence to guidelines and evidence-based practice; ii) to foster a climate conducive to implementation of evidence-based practice, hospital managers should consider assessing organizational context and involve clinicians in developing strategies for addressing modifiable aspects of context prior to implementing changes.