Received: 9 June 2020 | Revised: 19 August 2020 | Accepted: 27 August 2020 DOI: 10.1111/jan.14598 PROTOCOL Impact of the implementation of best practice guidelines on nurse’s evidence-based practice and on nurses' work environment: Research protocol Silvia Esteban-Sepúlveda1,2 | Albert Sesé-Abad3 | Laia Lacueva-Pérez1,2 | Manuela Domingo-Pozo4,5,6 | Sergio Alonso-Fernandez7,8,9 | 10,11 12,13 Marta Aquilue-Ballarin | Ana Isabel Barcelo-Martinez | 14 15,16 Estíbaliz Cristobal-Dominguez | Jesús Bujalance-Hoyos | 17 18 Consuelo Dossantos-Sanchez | Manuel Angel Pascual-Pascual | 19 20 Elisabeth Garcia-Arteaga | Maria Galisteo-Gimenez | Gemma Mas-Dalmau21 | Maria Pilar Heredia-Reina22 | Silvia Roca-Marti23 | María Perez Riart1 | Laura Albornos-Muñoz24,25 | Esther Gonzalez-Maria24,26 | Juan Carlos Fernández-Domínguez27,28 1 Methodology, Quality and Nursing Research Department, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain 2 Research Group in Nursing Care (GRECI), Hospital del Mar Institute of Medical Research (IMIM), Barcelona, Spain 3 Faculty of Psychology, Balearic Islands University, Palma, Spain 4 Hospital General Universitario de Alicante, Alicante, Spain 5 Nursing Department, Universidad de Alicante, Alicante, Spain 6 Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Alicante, Spain 7 Catalan Institute of Health, Germans Trias i Pujol University Hospital, Barcelona, Spain 8 Fundamental Care and Medical-Surgical Nursing Department, School of Nursing, University of Barcelona, Barcelona, Spain 9 Health Sciences Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain 10 Hospital Comarcal de Vinarós, Castello, Spain 11 Universitat Jaume I, Castellón de la Plana, Spain 12 Facultad de Enfermería, Universidad Católica de Murcia, Murcia, Spain 13 Hospital General Universitario Santa Lucía de Cartegena, Murcia, Spain 14 Osakidetza IHO Araba, Vitoria-Gasteiz, Spain 15 Grupo de Investigación en Cuidados de Málaga (INVESCUIDA), Instituto de Investigación Biomédica – IBIMA, Malaga, Spain 16 Hospital Regional Universitario de Málaga, Malaga, Spain 17 Hospital Universitario Lucus Augusti, Lugo, Spain 18 Hospital de Guadarrama, Madrid, Spain 19 Fundació Hospital de Puigcerdà, Puigcerda, Spain 20 Hospital Clínic de Barcelona, Barcelona, Spain 21 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain 22 Hospital Universitario de Fuenlabrada, Madrid, Spain 23 Consorci Sanitari de l'Anoia, Igualada, Barcelona, Spain 24 Nursing and Healthcare Research Unit (Investén-isciii), Instituto de Salud Carlos III, Madrid, Spain 25 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2020 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd 448 |  wileyonlinelibrary.com/journal/jan J Adv Nurs. 2021;77:448–460. | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ESTEBAN-SEPÚLVEDA et al. 449 26 Centro de Investigación Biomédica en Red, Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain 27 Faculty of Nursing and Physiotherapy, Balearic Islands University, Palma de Mallorca, Spain 28 Research Group of Care, Chronicity and Evidence in Health, Balearic Islands Health Research Institute (IdSIBa), Palma de Mallorca, Spain Correspondence Silvia Esteban-Sepúlveda, Consorci Parc Abstract de Salut MAR de Barcelona. Methodology, Aim: To determine the impact of the Best Practice Spotlight Organization® initia- Quality and Nursing Research Department. Barcelona, Spain. tive on nurses’ perception of their work environment and their attitudes to evidence- Email: 88119@parcdesalutmar.cat based practice. Funding information Design: Quasi-experimental, multicentre study. The intervention is the participation This study is founded by the Barcelona in Best Prectice Spotilight Organizations to implement Best Practice Guidelines. Registered Nurse's Official College (COIB) (https://www.coib.cat/ca-es/inici.html) for Methods: The study will include seven centres in the interventional group and 10 3 years (record PR-259/18) with 4,605.37£ in the non-equivalent control group, all of them belonging to the Spanish national for the run-in costs (questionnaires, shipping costs), and for travel expenses health system. The Practice Environment Scale of the Nursing Work Index, and the related to dissemination of results. Health Sciences Evidence-Based Practice Questionnaire will be administered to a Likewise, the Strategic Plan for Research and Innovation in Health 2016–2020 sample of 1,572 nurses at the beginning of the programme and at 1 year. This 3-year (PERIS) of the Catalonia Health Department study started in April 2018 and will continue until December 2021. Statistical analy- (http://salut​web.gencat.cat/ca/ambits_ actua​cio/linies_dactu​acio/recer​c a/peris​ ses will be carried out using the SPSS 25.0. This project was approved by the Drug -2016-2020) is funding the study for 2 years Research Ethics Committee of the Parc de Salut Mar and registered in Clinical Trials. (record SLT008/18/00006) with 81,666.14£ for the full-time contract of the principal Discussion: The study findings will show the current state of nurses’ perception investigator, acquisition of services (online of their work environment and attitudes to evidence-based practice, and possible platform for data entry, statistical software), meetings with the rest of investigators, and changes in these parameters due to the programme. other expenses related to dissemination of Impact: The findings could provide a strong argument for health policymakers to results. Both funding sources conducted an independent peer review of the trial scale up the Best Practice Spotlight Organization® initiative in the Spanish national protocol and application. health system. KEYWORDS evidence-based practice, implementation, midwives, nurses, nursing, practice guidelines, quasi-experimental study, work environment Why is this research or review needed? How should the findings be used to influence • There are still barriers to excellence in health care, es- policy/practice/research/education? pecially in the field of nursing care. This implies the ex- • If the findings of this study reveal that the Best istence of variability in nursing practice and, therefore, Practice Spotlight Organization® program improves differences in health outcomes. nurses’ perception of their working environment and/ • The application of evidence through the Best Practice or leads to better attitudes to evidence-based practice, Spotlight Organization® is a new initiative in Spain. they would provide a strong argument for strengthen- There is a need to identify the direct impact of this ini- ing state policy in extending the initiative to all centres tiative on nurses’ work environment and on their atti- in Spain, and to other international settings that could tudes to evidence-based practice. apply the programme. 1 | I NTRO D U C TI O N it has become an important paradigm in health care, as it provides The term evidence-based medicine was coined in Canada by Sackett a framework for the resolution of problems encountered in daily et al. (1996) in the mid-1990s and is defined as “the conscientious, clinical practice. Although this paradigm originated in the field of explicit, judicious and reasonable use of modern, best evidence in medicine, the application of its basic principles has spread to allied making decisions about the care of individual patients”. Since then, professions, giving rise to the broader concept of evidence-based | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 450 ESTEBAN-SEPÚLVEDA et al. practice (EBP) and, in the case of nursing, to that of evidence-based earmarked as a key element in the quality of health interventions nursing (EBN). to reduce variability in clinical practice. Several authors have stated The construct of EBP consists of a process of five steps or that EBP can improve clinical practice and help health profession- aptitudes initially delineated by Sackett et al. (1997) and consol- als stay up to date (Sackett et al., 1997), and that clinical practice idated in the Sicily Declaration (Dawes et al., 2005), which are should be based on the most current, reliable and valid evidence routinely conducted in clinical practice (Johnson, 2008). This pro- drawn from research (Trinder & Reynolds, 2008). Almost 20 years cess involves the following: the formulation of answerable and later, a meta-analysis confirmed that patients receiving EBN inter- clinically relevant clinical questions based on problems arising in ventions had better outcomes than those receiving standard care clinical practice; the search for and retrieval of the best available (Heater et al., 1988). Thus, although it has been proven that EBP evidence with which to answer these questions; critical appraisal allows more individualized, effective, rational and dynamic care of the evidence for validity and clinical relevance; application of (Youngblut & Brooten, 2001), it has also been revealed that its im- the appraised evidence in clinical practice; integration of the ev- plementation is complex and difficult because nursing practice has idence with clinical experience and patients’ perspective; and, historically been based more on intuition and/or experience than on finally, assessment of the effects of the intervention on individ- research (Brown et al., 2010), which has led to high variability in clin- uals. The conceptualization of the construct of EBP has evolved, ical practice. This was demonstrated in several studies performed in including patient health status and the availability of resources in the 1990s showing that 20%–25% of nursing care was unnecessary an organization, which are constantly changing and differ in each or potentially harmful and that 30–40% of patients did not receive situation. Thus, the current concept of EBP encompasses the in- care based on the results of research (Schuster et al., 1998). tegration of individual clinical experience, patients’ preferences Several studies have described the elements believed to be bar- and actions, their clinical circumstances, and the best available riers to the use of research in nursing practice: the quality of the external evidence drawn from systematic reviews to guide clinical available research, organizational characteristics, the difficulty of decision-making in the best possible way, with the aim of improv- finding and reviewing evidence, lack of time and autonomy, the dif- ing the effectiveness of healthcare delivery, and consequently, pa- ficulty of understanding statistical concepts, and nurse-specific fac- tient outcomes (Cullen et al., 2008; DiCenso et al., 2005). tors such as predisposition and skills (De Pedro-Gómez et al., 2012; The work environment is another element considered to be key Kajermo et al., 2010; Solomon & Spross, 2011; Squires et al., 2011). for the quality of health interventions, and there is sufficient evi- Thus, decades after the introduction of the concept of EBP, nurses dence to state that it influences patients’ health outcomes. As long are not putting into practice the evidence obtained from research ago as the 1930s, it was stated that work satisfaction largely de- or are only doing so in a partial or limited way (Kajermo et al., 2010). pended on group behaviour and the relationships of the individuals Therefore, there is generally a gap between the results of research in the group, with greater emphasis placed on cooperation and the and their application in practice. feeling of being of importance, than on physical conditions and fi- Concerning the work environment in the case of nurses, Sleutel nancial incentives. Later, leadership style was linked to the organiza- (2000) defined a set of factors that influence work satisfaction: tional setting or climate, and the importance of the environment on autonomous practice in which nurses participate in decision-mak- staff behaviour. In the 1960s, it was believed that people's behaviour ing and have control; the status and value of nursing throughout depended on both individual perception of their environment and in- the institution assigned by administration and physicians; and sup- dividual components when adapting to it. Litwin and Stringer (1968) portive relationships with colleagues, physicians and administra- concluded that, by varying the leadership style, different organiza- tion, characterized by mutual respect and mutual concern for the tional climates with stable characteristics could be rapidly created, quality of care. The American Association of Colleges of Nursing which could have significant effects on motivation, performance and (2002) identified the dimensions that describe the characteristics work satisfaction. Based on the conclusions of several authors who of the practice environment and that best support professional have developed the concept, the work climate or environment can nursing practice, allowing nurses to work at their maximum poten- be defined as the shared perceptions of an organization's members tial: a philosophy of clinical care that emphasizes quality, safety, about organizational processes in the broadest sense, which en- interdisciplinary collaboration, continuity of care and professional compass different aspects such as leadership styles, interpersonal responsibility, promotion of executive nurse leadership, and main- relationships, remuneration, the organizations’ policies or strategic tenance of clinical progress programmes based on education, cer- lines and the mechanisms it uses to carry them out, etc., and which tification and advanced training, among other factors. There is a directly influence the people composing the organization. demonstrated relationship between better nurse-perceived work environments and better health outcomes among patients (Cho et al., 2016), and with a more favourable perception of the qual- 1.1 | Background ity of care received (Aiken et al., 2012). It has even been found that a reduction in the patient-nurse ratio is strongly associated Concerning the implementation of EBP in daily clinical practice, with health outcomes only in adequate work environments (Aiken since the 1970s with the work of Archibald Cochrane, EBP was et al., 2011). | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ESTEBAN-SEPÚLVEDA et al. 451 To overcome the above-mentioned difficulties, and given the cur- 1.1.1 | International relevance rent high variability in clinical practice, and the results of several pa- tient health indicators, in the last few years there has been growing This study is the first on the topic and could be replicated in all interest in applying healthcare quality policies based on the best avail- settings applying for the Best Practice Spotlight Organization® able evidence and several institutions have been created to meet this Program around the world. aim. Currently, one of the maximum exponents is the Joanna Briggs Institute, which was joined by Spain in 2004 through the Spanish Centre for Evidence-based Health Care: a Joanna Briggs Institute 2 | TH E S T U DY Centre of Excellence. This Centre forms part of the Joanna Briggs International Collaboration and is situated in the Health Care Research 2.1 | Aim Unit (Investén-isciii) of the Instituto de Salud Carlos III. Its mission is to promote and support the synthesis, transfer, and utilization of evi- To determine whether the Best Practice Spotlight Organisation® dence through the identification of practices that are feasible, appro- initiative in Spain has an impact on nurses’ work environment and priate, understandable, and effective in improving health outcomes. their attitude to EBP. In 2010 the Health Care Research Unit (Investén-isciii), with the agreement of the Registered Nurses’ Association of Ontario (RNAO), started the process of translating the RNAO Best Practice Guidelines 2.2 | Objectives to allow their use in the Spanish context and joined the Best Practice Spotlight Organisation® (BPSO®) initiative as the instigators and 2.2.1 | General objective coordinators of its implementation in Spain. The RNAO Programme for the Implementation of Best Practice Guidelines in BPSO® To determine whether the implementation of the Best Practice (named Centres Committed to Excellence in Care in Spain), encour- Guidelines in the context of the initiative for the implementation ages, facilitates and supports the implementation, assessment and of Registered Nurses’ Association of Ontario in the Best Practice maintenance of scientific evidence in health care by supporting and Spotlight Organisation® improves perception of the work environ- mentoring the institutions involved, seeking improvements in pa- ment in nurses in participating centres and attitudes and behaviour tient, provider, organization, and health system outcomes. regarding EBP in nursing care. To do this, the knowledge-to-action conceptual framework is used (Straus et al., 2009), which is based on six components: iden- tification of the problem and selection of the evidence, adaptation 2.2.2 | Specific objectives to the context, assessment of barriers and facilitators, selection of the interventions to be implemented, monitoring and assess- 1. To identify the socio-occupational and professional character- ment, and sustainability, including an entire series of indicators istics of nurses working in organizations participating in the to measure care process and patient health outcomes for each of study. the guidelines implemented. Thus, to achieve the implementation 2. To describe the characteristics of the work environment and be- of recommendations, follow-up is continuous, as described in the liefs-attitudes and behavioural profile regarding the EBP of nurses literature (Ploeg et al., 2010). Centres participating in this pro- working in organizations participating in the study. gramme commit to implementing, assessing and maintaining the 3. To determine whether there are differences in the perception of implementation of at least three Best Practice Guidelines of the the work environment and beliefs-attitudes and behavioural pro- RNAO for an initial period of 3 years and to subsequently add to file regarding EBP at 12 months post-implementation between the number of guidelines, scaling them up to the entire institu- the intervention group and the control group. tion and undergoing the process of gaining designation as a Best 4. To assess whether there are differences between the baseline data Practice Spotlight Organisation®, which signifies recognition by obtained in the phase prior to the study and at 12 months after the Health Care Research Unit (Investén-isciii), the Spanish Centre the implementation of the RNAO Best Practice Guidelines in the for Evidence-based Health Care and RNAO that the institution is perception of the work environment, beliefs-attitudes and behav- involved in the application, assessment and maintenance of Best ioural profile regarding EBP in the intervention group according to Practice Guidelines. nurses’ training profile and sociodemographic characteristics. The first cohort of participants was initiated in 2012, the second 5. To determine whether there are differences between the baseline in 2015, and the third in 2018. To carry out the programme, a leader data obtained in the phase prior to the study and at 12 months was selected in each institution, and the figure of champion, who are after the implementation of the RNAO Best Practice Guidelines less directly involved in the program. This programme encourages among nurses directly involved in the program (leaders, champi- both EBP and nurse participation, multidisciplinary work, and an in- ons) and nurses in the intervention group not directly involved in stitutional-level philosophy of care. the initiative. | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 452 ESTEBAN-SEPÚLVEDA et al. 2.3 | Hypotheses Intervention group Six healthcare organizations included in the third cohort of the 2.3.1 | Main hypothesis 1 BPSO® Program, located in five different regions. Three are teach- ing urban hospitals, having between 500 and 1,000 beds, 1 is a long- The implementation of Best Practice Guidelines in the context of the term conditions rehabilitation hospital, and 2 are integrated care Registered Nurses’ Association of Ontario Best Practice Spotlight organizations that involves teaching hospital and primary healthcare Organisation® initiative will significantly improve attitudes and centres in urban and rural settings. behaviour regarding EBP among nurses employed in participating institutions. Control group Seven healthcare organizations not included in the BPSO® Program, located also in five different regions, that include four teaching urban 2.3.2 | Main hypothesis 2 hospitals having between 500 and 900 beds, and three more (having be- tween 40 and 400 beds) hospitals that attend both urban and rural zones. The implementation of Best Practice Guidelines in the context of the Registered Nurses’ Association of Ontario Best Practice Spotlight Organisation® initiative will significantly improve perception of 2.4.2 | Study participants and recruitment the work environment among nurses employed in participating institutions. Inclusion criteria Nurses who work in institutions participating in the study and who decide to participate voluntarily. 2.3.3 | Secondary hypotheses Exclusion criteria • The implementation of Best Practice Guidelines in the context of Nurses who, at the time of data collection, are not occupationally the RNAO BPSO® initiative will significantly improve attitudes active. and behaviour regarding EBP among nurses working in participat- Recruitment will be carried out in person by the member of the ing institutions. research team in each centre. Individual nurses working in cen- • Nurses working in institutions involved in the RNAO BPSO® ini- tres participating in the study will be recruited consecutively until tiative will show, at 12 months post-implantation, a significantly achievement of the calculated sample size. greater improvement in their perception of the work environment than nurses working in institutions not involved in the initiative. • There is an association between the training profile and the de- 2.4.3 | Sample size gree of involvement and the change generated after the imple- mentation of the Best Practice Guidelines in the context of the The sample size has been calculated for independent means of the RNAO BPSO® initiative. measurements both for the control group and for the intervention group. Considering a bilateral contrast and accepting an alpha risk of 0.05 and a beta risk of 0.20 for both groups, and assuming a change 2.4 | Design and methods in the EBP construct with a standardized effect size (Cohen's) of 0.2, a minimum of 786 participants will be required in each group to Multicentre quasi-experimental pre-post study with a non- make up a total of 1,572 participants. The sample size of each centre equivalent control group, in the context of the third Spanish co- has been calculated proportional to the size of the centre (number of hort of the BPSO® participating in the Best Practice Guidelines beds), resulting in a mean of 112 nurses in each intervention centre Implementation Program of the RNAO. Outcomes will be meas- and 78 in each control centre. ured at two-time points: baseline and one year after the begin- ning of the intervention (Figure 1). This protocol will follow the SPIRIT 2013 Statement guidelines according to the design (Chan 2.5 | The intervention et al., 2013). The main components of the intervention, implementation of Best Practice Guidelines in Best Practice Spotlight Organizations 2.4.1 | Setting (González-María et al., 2020), is described in Table 1. In the institutions composing the control group, there is no uni- Healthcare organizations in the intervention and in the control form method to implement the Best Practice Guidelines. In some group belong to the Spanish National Health System. It is public and centres, protocols have been designed by experts working in that universal access, managed by regions. centre. In others, healthcare management have decided which | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ESTEBAN-SEPÚLVEDA et al. 453 Recruitment of participant institutions Intervention group: T0: Group Control group: 6 institutions assignation 7 institutions Baseline Baseline measurements T1: Data 1 measurements (N = 786 nurses) (N = 786 nurses) Introduce intervention: Implementation of the T2: Start of the Routine way Best Practice Spotlight Intervention Organisation® Program Final measurements T3: Data 2 Final measurements (N = 786 nurses) One year after T2 (N = 786 nurses) FIGURE 1 Study flow diagram protocols will be implemented based on recommendations. However, and applicability in distinct practice environments (Lake, 2007) and a common element is that none of the control group centres will im- has acceptable metric properties: appropriateness (content validity), plement the strategy followed by the intervention group, based on structure, good adjustment (construct validity), discriminatory abil- the involvement and training of participating professionals, with a ity for magnet hospitals (discriminatory ability), concurrent validity uniform method of registering indicators, with external monitoring (association with patient health outcomes and with nurses´ self- and an accreditation system that should be updated every 5 years. esteem and mental health) (Bonneterre et al., 2008). This question- naire has been validated in the Spanish context in the framework of the RN4CAST-España Project (Fuentelsaz-Gallego et al., 2013), and 2.6 | Instruments and measures has 31 questions structured in five factors: staffing and resource ad- equacy (4 items), collegial nurse-physician relations (3 items), nurse 2.6.1 | Sociodemographic and labour data manager ability, leadership and support of nurses (5 items), nursing foundations for quality care (10 items), and nurse participation in Participants’ demographic information, including age, gender, mari- hospital affairs (9 items). tal status, educational level and employment status, will be collected through an ad hoc questionnaire. Additional data related to workplace, job satisfaction, experience with research and the institution's attitude 2.6.3 | Beliefs-attitudes and behaviour to EBP and research perceived by nurses will be provided (Table 2). regarding the evidence-based practice questionnaire The Health Sciences Evidence-Based Practice questionnaire, 2.6.2 | Nurses’ work environment designed and validated in 2017 by Fernández-Domínguez et al. (2017), is the only currently available instrument in the The Practice Environment Scale-Nursing Work Index is the most Spanish setting that overcomes the limitations of the previous useful instrument in terms of comprehension, validity, reliability, questionnaires. These questionnaires evaluate the construct of | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 454 ESTEBAN-SEPÚLVEDA et al. TA B L E 1 Components of the intervention “Implementation of Best Practice Guidelines in Best Practice Spotlight Organizations” Component Description Theory and rationale Best Practice Guidelines implementation is based on the conceptual framework Knowledge to Action (Straus et al., 2009), aiming to achieve a best-practice culture in healthcare organizations. Implementation involves a systematic change process in organizations as well as in professionals leaded by nurses. According to implementation science, this change has more possibilities to occur under an iterative cycle in which the specific context elements are considered for tailoring the interventions Procedures and materialsa Organizations joining a new BPSO® cohort will set up an implementation committee and will assign a registered nurse as implementation leader. They will receive group in-person training on implementation methodology provided by the Spanish Program coordinators during a week, following the standardized international program themes, materials and procedures consisting of a workshop with open discussions and case studies based on the experience of previous cohorts. As the final workshop result, leaders will develop an implementation plan of Best Practice Guidelines selected in their organization Leaders will attract multiprofessional champions in their organization and will replicate afterwards the implementation training (Cascade training model) with the same method, materials, and support tools for all BPSO®, provided by Program coordinators. Champions will work in groups that meet in-person periodically for decision-making and development of the implementation activities according to the plan, scaling up the recruitment of new champions and involving them on activities Core activities across organizations will be the dissemination of the program and progression, continuous training, peers support, evaluation, and feedback, delivered in a combined way Providers, modes, and Spanish program coordinators will be Train the Trainers for implementation and evaluation in the International frequency of delivery Program. They will deliver the initial training to leaders and will supervise the process over time Involvement in BPSO® cohort, setting up committees and selection of the leader will be promoted by nurses and supported by the managerial board The leader and committees will be mostly registered nurses to be multiprofessional. They will deliver implementation training; involve, support, and coordinate the champions' group activities, monitor the program progress and report to Program coordinators. They will meet and review the implementation plan periodically Champions will be nurses and other health professionals, as physicians, physiotherapists, midwives, as well as other staff, depending on the Best Practice Guideline implemented. They will meet periodically by workgroups to review the gap between practice and Best Practices Guidelines, to analyse the context and stakeholders to plan actions for implementing the recommendations selected, including the update of protocols and procedures. They will deliver specific training related to Best Practices Guidelines implemented and will act as peer mentors supporting to promote best practices and adequate clinical records, usually by short meetings, clinical sessions, and boosters. They will give feedback to the leader and committees and contribute to the dissemination of the Program, (Ploeg et al., 2010) The time established to have the Best Practice Guidelines implemented is 3 years Modifications The components of the implementation will be cyclic. Thus, along the implementation they will be revised and updated, to adapt strategies to the progression that is reached in the organization, and to add cycles of quality improvement Onsite activities related to specific Best Practice Guidelines will have to be adapted at each organization's characteristics, expressed in protocols and procedures Assessment of adherence Program coordinators will monitor the process. Monthly online meetings with each organization team will be performed, to support and monitor the progress, as well as an annual onsite audit. At least once a year there will be a joint meeting with all the cohort to review procedures and fidelity Leaders and committees will monitor the process at their institution by meetings, reports, and evaluation, and will report to program coordinators quarterly For core activities, all BPSO® will use the same forms. Implementation will be evaluated with a common method, with a specific structure, process, and outcome indicators. Evaluation data will be collected monthly, through an online platform, to assess the impact on patients, professionals, and the organization. The information gathered will be used, among others, for proving frequent feedback Note: Adapted from TIDieR checklist. a Registered Nurses’ Association of Ontario. (2012) Toolkit: Implementation of best practice guidelines (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario. Available at: https://rnao.ca/sites/​rnao-ca/files/​RNAO_ToolK​it_2012_rev4_FA.pdf). EBP focusing on assessing the components of the results of sci- Bishop, 2009), and show weaknesses in psychometric validation entific research (McEvoy et al., 2010; Upton & Upton, 2006), (for and content validity or do not provide evidence of the measure- example, in Fresno's test and its modified versions) (McCluskey & ment model or factorial structure (De Pedro Gómez et al., 2009; | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ESTEBAN-SEPÚLVEDA et al. 455 TA B L E 2 Study measurements Independent variables Collected data Range Demographic data Gender Male, female Age Years Marital status Single, couple, divorced/separated Number of children Number of patients under care Qualifications Diploma, Bachelor's degree, Master´s degree, PhD Labour data Years working as a nurse Years Type of workplace unit Surgical units, medical units, critical care, emergency department, others Weekly work hours <20, 21–35, full time Professional profile Ward nurse, researcher, manager, teacher Continuous training data Type of training that is of interest Continuing education linked to the institution, continuing education not linked to the institution, postgraduate, masters, doctorate, none Research courses taken Yes/no Evidence-based practice courses taken Yes/no Research-related data Congress attendance in the last 4 years Number Congress participation Number of posters, oral communication, presentation Reading of scientific journals Number and journal name Nurses’ knowledge of Research support figure Yes/no/don't know institutional research- Availability of hours within working hours related resources Training in research available Encouragement of evidence- and research-based care Dependent variables Job satisfaction Degree of satisfaction with current job One Likert-type question rated from “very dissatisfied” to “very satisfied” Nurses’ perception of the Staffing and resource adequacy Thirty-one Likert-type questions rated from “Strongly work environment Collegial nurse–doctor relations Disagree” to “Strongly Agree” Nurse manager ability, leadership and support Nursing foundations for quality care Nurse participation in hospital affairs Nurses’ relationship with Beliefs-Attitudes Sixty Likert-type questions rated from minimum evidence-based practice Results of scientific research agreement to maximum agreement Development of professional practice Assessment of results Barriers-Facilitators McEvoy et al., 2010; Upton & Upton, 2006). Other instruments validity in relation to other constructs (attitudinal resistance to have obtained unsatisfactory results in terms of their psycho- change, burnout, and quality of professional life) and validity metric properties in some of their dimensions (De Pedro Gómez based on response processes (ceiling-floor effect). The instru- et al., 2009; Upton & Upton, 2006), and these limitations are ment has 60 items presented in enunciative-declarative forms mentioned in recent systematic reviews (Leung et al., 2014). and assessed on a Likert-like scale scored 1-10 according to the Validation of the Health Sciences Evidence-Based Practice ques- degree of agreement (the higher the score the greater the agree- tionnaire includes evidence of reliability (internal consistency), ment). Responses are classified in five dimensions (Fernández- apparent and content validity, validity based on internal struc- Domínguez et al., 2016): beliefs and attitudes (12 items); results ture (confirmatory models), convergent validity (with respect to of scientific research (14 items); development of professional the Evidence-Based Practice Questionnaire-19), decision valid- practice (10 items); assessment of results (12 items), and barri- ity (with respect to the participant's level of training on EBP), ers/facilitators (12 items). | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 456 ESTEBAN-SEPÚLVEDA et al. TA B L E 3 Study measure notes After baseline 1 year Up to 1 year after Outcomes (measures) Baseline from baseline baseline Inclusion criteria Demographic and labour x x data Primary outcomes Nurses’ relationship x x with evidence-based practice, HS-EBP Nurses’ perception of the work environment, PES-NWI Job satisfaction Secondary outcomes Continuous training data x x Research-related data Nurses’ knowledge of institutional research- related resources Intervention: BPSO® x program Abbreviations: HS-EBP, Health Science Evidence Based Practice Questionnaire; PES-NWI, Practice Environment Scale-Nursing Work Index. 2.7 | Data collection will be duly informed by the coordinating group of the project about the procedure for codifying and collecting data before the start of Before data collection, an identification code will be assigned to the study. The principal investigator will carry out the follow-up, each participating centre. In each of these centres there will be a unification and cleaning of the database. Once the information has member of the research team, who will know the code assigned to been introduced, the principal investigator will centralize and store that centre and who will be responsible for explaining the study all the original questionnaires, and the informed consent forms, as to nurses, distributing and collecting the data collection dossier specified in the European Union data protection regulation of 27 (the Practice Environment Scale-Nursing Work Index, the Health April 2016. Only the coordinating team will have access to all the Sciences Evidence-Based Practice questionnaire, and ad hoc ques- questionnaires and informed consent forms and with the sole aim of tionnaires) and the informed consent form in a separate document. achieving objectives 4 and 5 of the study. Each questionnaire will be identified with the code of the assigned In all participating centres, baseline data collection will be centre and the unit where the nurse responding to the dossier works conducted before implementation of the Best Practice Spotlight (Emergency department, Critical care; Surgical units, Medical units, Organisation® Program. Post-intervention data collection will be Others), and the numerical order in which it has been distributed. performed 12 months after the start of the implementation in all The same code will appear in the document (of the informed con- participating centres and will be carried out by the member of the sent) so that no personal identification data will appear in either the research team in charge of data collection in the first phase. Study dossier or the informed consent. Thus, first the project will be ex- measurement notes are showed in Table 3. plained, the dossier will be distributed and informed consent will be obtained, which will be sent to the principal investigator. Second, after approximately 1 week, the dossier will be collected and the 2.7.1 | Data analysis information will be entered in the database. Each member of the research team will have access only to information from his or her A univariate descriptive analysis will be performed of all variables. centre. Only the principal investigator and the coordinating group Qualitative variables will be expressed as frequency and percent- will have access to the information from all the centres. age and exploratory data analysis will be performed of quantitative The information will be registered in a database specifically de- variables, and tests of normality (Kolmogorov–Smirnov or Shapiro- signed for the study. Quality control mechanisms will be developed Wilk depending on the sample size). We will attempt not to use any both by participating centres and centrally to guarantee that, at all method of imputation of missing values and will apply pairwise data times, the information is gathered according to the stipulations of processing to maximize the information in the data matrix. the study protocol and that the established norms are followed in For comparison of the pre- and post-intervention phases in each all processes. To this end, all persons responsible for data collection study group with respect to EBP dimensions/construct factors and | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ESTEBAN-SEPÚLVEDA et al. 457 the work environment, the Student t-test will be used for independent objectives 4 and 5. The study will adhere to current legislation as samples, or the Mann–Whitney U-test if the data follow non-normal expressed in Regulation 2016/679 of the European Parliament, 27 distribution. The effect size will be estimated through Cohen's d and the April 2016. This study protocol has been registered in Clinical Trials 95% confidence interval of the pre-post difference of the means in the (ClinicalTrials.gov Identifier: NCT04199065). dimensions/factors of the Health Sciences Evidence-Based Practice questionnaire and the Practice Environment Scale-Nursing Work Index. The presence of differences in baseline values between the two 2.8 | Validity and reliability study groups will be determined using parametric tests (Student t-test for independent samples) or non-parametric tests (Mann–Whitney The Health Sciences Evidence-Based Practice questionnaire and the U-test, depending on the results of the goodness-of-fit tests). We Practice Environment Scale-Nursing Work Index, will be the main will perform a repeated measures ANOVA of two factors using time study measurements. Both have adequate metric properties and (pre- and post) and group (intervention group and control group) as have been validated in the Spanish context. variables. In variables showing statistically significant differences be- The progress of the intervention will be audited periodically. The tween groups in baseline measurements, pre-intervention values will quality control mechanisms will be applied by the participating cen- be included as a potential covariable (ANCOVA) to adjust the effect. tres and by the research coordinator to guarantee that the informa- The effect size will be estimated through Cohen's d and the 95% con- tion is collected as stipulated in the study protocol. This monitoring fidence interval of the difference of the means in the dimensions/fac- will also ensure that the established standards are followed through- tors of the Health Sciences Evidence-Based Practice questionnaire and out the entire process. the Practice Environment Scale-Nursing Work Index. We will also con- This study will be carried out in clinical practice and under real duct a differential analysis of profiles in the dimensions of the Health conditions. Furthermore, the number and size of the institutions in- Sciences Evidence-Based Practice questionnaire, including sociode- volved are high. These characteristics will provide external validity. mographic, training and research variables, implementation time, type of involvement, and perception of the work environment. Inferential analyses will be conducted through statistical models for comparison 3 | D I S CU S S I O N of means, whether parametric (t-test, ANOVA) or non-parametric in the case of non-normally distributed variables (Mann–Whitney U-test, Health professionals familiar with research have more open atti- Kruskal–Wallis H test). tudes to EBP and knowledge of this approach (González-Torrente Last, we will also apply multivariate models, such as multiple re- et al., 2012). In turn, better practice environments facilitate EBP gression, path analysis, or structural equations with latent variables to (Lake, 2007). However, there is no published evidence on whether model the relationships of interdependence between the main study the inverse is true, that is: whether an institutional policy that ap- variables: EBP and perception of the nurse work environment. The plies evidence-based care improves attitudes and behaviour to- multivariate analysis will be performed through the MPlus Program wards research and EBP and enhances perception of the work and we will use standard criteria established by the scientific commu- environment among nurses. If this were the case, the enhancement nity to assess the quality of model adjustment, and the most appropri- in the perception of work environment achieved by implementing ate model for estimating the performance of the variance/covariance Best Practice Guidelines could feed back into attitudes to EBP, matrix and the nature of the variables involved. The data will be anal- generating a ripple effect and consequently improving health out- ysed and processed using the SPSS v.22 statistical package. comes. Moreover, in environments that are difficult to change, the application of evidence-based care through the RNAO Program for the Implementation of Best Practice Guidelines in BPSO® is a strat- 2.7.2 | Ethical considerations egy to generate changes and improvements in the perception of the work environment, and to achieve greater proactivity concerning The study has been approved by the Barcelona Drug Research research and the use of research results by nurses, that is: an im- Ethical Committee of the Parc de Salut Mar (CEIm-Parc de Salut provement in nurses’ behavioural profile regarding EBP. This means Mar 2018/8087/I), although approval will also be sought from the that the implementation of the RNAO Best Practice Guidelines ethics committees of participating centres if deemed appropri- through the BPSO® Program acts as a motor for change in the be- ate. The dossier will be identified with a code without identifying haviour of nursing professionals, and could be considered a key ele- personal data and will be collected in a closed envelope to ensure ment to generate better health outcomes, acting both directly on confidentiality. the patient and indirectly on nursing staff. This is in consonance Only members of the research team involved in data analysis with recently published results revealing that, in unfavourable will have access to individual tracing due to the codification of the economic contexts, Nursing Foundations for Quality Care and data collection file and informed consent and no datum will be made Nurse Participation in Hospital Affairs is associated with a better public that could be linked to individuals. Tracing will only be per- perception of the nursing work environment (Esteban-Sepúlveda formed to demonstrate possible individual changes, as described in et al., 2019). | 13652648, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.14598 by Readcube (Labtiva Inc.), Wiley Online Library on [12/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 458 ESTEBAN-SEPÚLVEDA et al. 3.1 | Bias control, limitations, and strengths AC K N OW L E D G E M E N T S Authors gratefully acknowledge both funding institutions: Catalonia High nurse turnover in institutions prevents an exclusively longitudi- Health Department and Barcelona Registered Nurse's Official nal design that would allow comparison in the entire study population College. The authors also thank the participating institutions for of the data from the same participants over time. Consequently, the their willingness to take part in the study. study unit will not initially be nurses but rather institutions and the settings where the intervention has been performed. However, given C O N FL I C T O F I N T E R E S T that overall health outcomes are aggregate and not individual-level The principal investigator has no conflict of interest in relation to the measures, it is also pertinent to determine whether there is a change study itself. Two of the authors are the coordinators of the Program in the variables studied among nurses, both overall and by work units, for the Implementation of Best Practice Guidelines in Best Practice after an institutional-level intervention. Regardless, the total time that Spotlight Organisation® in Spain. each nurse stays in the unit implementing each of the Best Practice Guideline will be collected, so that the analysis of the post-interven- PEER REVIEW tion results (in the intervention group) will only include the values of The peer review history for this article is available at https://publo​ those professionals who have remained active in the unit for at least ns.com/publo​n/10.1111/jan.14598. 3 months after the start of the implementation of the guideline. Even so, we will also perform an analysis of the same character- ORCID istics as those mentioned for the subgroup of professionals in whom Silvia Esteban-Sepúlveda https://orcid.org/0000-0002-0627-0680 we were able to perform paired measurements through participant Sergio Alonso-Fernandez https://orcid.org/0000-0001-6969-9380 traceability (codification of informed consent and the data collection Estíbaliz Cristobal-Dominguez https://orcid.org/0000-0001-7165-5723 dossier), while respecting at all times participant anonymity so that no Silvia Roca-Marti https://orcid.org/0000-0001-9667-4824 identifiable individual can be linked to the responses obtained. Data collection may be hampered by geographical dispersion, differences T WITTER in participating institutions, and distinct rhythms of implementation. Silvia Esteban-Sepúlveda @Silviaestebans3 Consequently, it is envisaged that a person will be designated to fulfil this function in each of the participating institutions. 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AACN Clinical Issues, 12(4), 468–476. https://doi. org/10.1097/00044​067-20011​1000-00003 The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to ­advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and ­theoretical papers. 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