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When Implementation Fails: The Case of a Nursing Guideline for Fall Prevention

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Abstract:

Background: Implementing guidelines can be very difficult. No magic bullet or step-by-step implementation plan is available, neither is any single implementation strategy superior. At the Academic Medical Center (AMC) in Amsterdam, a nursing guideline was developed in 1993 on prevention of patient falls. Falls decreased by 30% on six wards, yet an effort to implement the guideline into daily practice throughout the hospital failed. A renewed effort was made to implement the guideline in two wards (neurology and internal medicine) in 1999.

Implementing the Guideline: Preparations were made for implementation in the two wards. Barriers to change were identified and solutions were translated into day-to-day activities in the wards. The intervention period covered 18 months (January 2000–June 2001). A mix of implementation strategies was used, including a local consensus process, educational activities, and active support and feedback to management and staff.

Results: In the internal medicine ward, the target incidence of 6% was met for four of the 18 months in the intervention period. In the neurology ward, the incidence target of 11% was met in five months.

Discussion: Barriers to change and enabling factors may only become apparent during the implementation process itself. A strongly perceived need to change daily practice, a simple guideline, the hospital board's support, an understanding of local barriers, monitoring of outcomes, a locally tailored multifaceted implementation strategy, and voluntarily cooperating nurses are no guarantees for success.

Document Type: Research Article

Publication date: 2006-03-01

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