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Publications & Resources > The Standard > March 2006

   Last modified: March 2006

Translating Knowledge into Practice

One of the College’s roles is to assist nurses and their employers in creating and maintaining workplaces that support quality nursing practice. Last year, the College began an ambitious project to examine ways in which its standards and guidelines can best be applied in practice settings. Called Knowledge Translation Fellowship, the project involved the College, the School of Nursing at York University and six health care organizations. In this article, nurses from two regional cancer centres share their Fellowship experiences.

KNOWLEDGE TRANSLATION IS AN APPROACH based on an exchange between a knowledge producer (such as the College, which publishes practice standards and compiles statistical data) and knowledge users (such as nurses and the government). For knowledge translation to work, the knowledge producer must relay information in a meaningful way so the user can receive, address and apply it.

“The project examined new ways of embedding the College’s practice standards into workplaces,” explains Heather Campbell, RN, the College’s director of Practice and Policy. “When the College initiated the project in early 2005, we approached organizations that could propose projects with the potential for meaningful and positive practice changes for the caregivers at the facility. With the College’s support, participants used the standards to identify, address and develop solutions for practice and systemic problems in their workplaces to improve patient care.”

Lianne Jeffs, RN, a nursing practice and policy consultant, assisted the College in developing the framework for the process. “The College’s project is based in the philosophy of patient safety,” says Jeffs, who is also a doctoral student at the University of Toronto. “A patientsafety priority in health care calls for health care leaders to address systemic issues within their organizations, enabling individual and organizational learning, changes and improvements. Despite its priority as a health policy issue, there are still gaps in the transfer and translation of knowledge into practice. It is imperative that efforts be undertaken to bridge these gaps. The College’s project was structured to help participants identify new ways of working and adapting practice standards locally, at the point of care.”

Competing demands

Two regional cancer centres — at Kingston General Hospital and Credit Valley Hospital in Mississauga — were among the six organizations chosen to participate in the project. The College asked that at least one nurse from each facility act as the liaison between the facility and the College, and attend workshops and discussion sessions at the College. In turn, the College assigned a staff member to assist the facility in addressing the identified practice issues.

“Because of the competing demands that nurses face, practice issues do not always get addressed, no matter how pressing they may seem,” says Lisa Freeman, RN, a Practice Consultant at the College who worked with the nurses representing the two cancer centres. “This project enabled organizations to prioritize an issue and, with the College’s support, creatively work toward solutions.”

Esther Green, RN, the chief nursing officer and director of Health Human Resource Planning at Cancer Care Ontario, says there was “no hesitancy” on her part when the College asked her to participate. “Cancer Care Ontario’s mission is to improve the performance of the cancer system by driving quality, accountability and innovation in all cancer-related services,” says Green. “Part of this role is to set and implement quality standards that are consistent across the cancer care system. This initiative aligned with our goals, so it was important to us that we work with the College to share information and make improvements that will impact care.”

Cancer Care Ontario chose nursing documentation as its project. “Our provincial nursing group had already identified documentation in cancer settings as requiring attention,” says Green.

“From the College’s perspective, documentation was an excellent choice, as it is such an integral component of safe and effective nursing practice,” says Freeman. “Comprehensive and accurate documentation demonstrates nurses’ accountability and provides an account of nursing’s unique contribution to health care.”

Linda Robb-Blenderman, RN, and Marcie Flynn-Post, RN, were assigned as the organization’s leads. “We knew that documentation guidelines were not consistent across cancer care settings,” says Flynn-Post. “This was causing problems when clients were transferred between clinics but, because of competing priorities, we’d never been able to address the issues until we had the opportunity to participate in the project with the College.”

The perfect fit for everyone

For its Knowledge Translation Fellowship project, Saint Elizabeth Health Care in Toronto focused on the decisionmaking involved in matching clients receiving care in the community with the appropriate level of care provider.

“Community nursing is a unique area of practice but it represents a small fraction of the health care sector,” says Helene LaCroix, RN , who, as nursing practice officer at Saint Elizabeth, is accountable for professional practice and quality management. “It is often an area of practice that is poorly understood by policy-makers. Communitybased organizations spend considerable time translating regulators’ standards so they ‘fit’ into this practice setting.”

LaCroix’s initial project proposal encompassed the creation of knowledge tools to support nurses in making decisions about care providers. “We found early on that the plan was too large,” says LaCroix. “The aim changed to understanding how nurses applied the College’s practice standards, and increasing nurses’ comfort and knowledge levels so they could make more informed decisions.”

The project focused on a group of nurses at a single site. The College’s Professional Standards and documents related to unregulated care providers (UC Ps) provided the framework. With the College’s assistance, LaCroix compiled and analysed service-delivery data related to RN and RPN work distribution and conducted a nurse survey. “By conducting the analysis, the facility gained greater understanding of how nurses in the pilot site distribute their work,” says LaCroix. “We confirmed that nurses take a team approach to care delivery, and that most clients at the site received care from both RN s and RPNs. From the nurse survey, we learned that nurses are knowledgeable about determining the level of care provider that’s needed, but are less comfortable when making decisions to transfer care to UCPs.”

The College was pleased to find that the nurses demonstrated a high level of familiarity with its standards for determining the level of care provider. “There were also, however, responses that suggested that decisions to transfer clients from one level of care provider to another were driven by the diagnosis and treatment required by clients, rather than the concepts of stability and predictability,” says LaCroix.

This project continues under LaCroix’s direction. “Our next step will be to validate the findings of the survey, and to use knowledge-building strategies that I learned from my involvement in this project to deepen our knowledge of this issue. For example, it is still not clear how such terms as ‘stability’ and ’predictability’ are defined by nurses. Further work will help us to land working definitions of such terms and to enhance our ability to apply more consistent standards to these types of decisions.”

Two challenges

Two nursing documentation issues that Cancer Care Ontario faced were the large number of forms used across the organization, as well as the range of documentation systems — some outdated — used by facilities within the network. “There were also changes happening within the organization,” says Freeman. “For example, one of the participants had her cancer centre moved to new facilities partway through the project. This is why the College only agreed to partner with organizations that showed real dedication to the project and had organizational commitment from the top down. Projects promoting significant change can only succeed when management and nurses within the organization have been given designated roles and ownership of the issues.”

As with all nurses, time is an issue for Robb- Blenderman and Flynn-Post. “When we first entered into the project, I was concerned that we would not be able to accomplish what we wanted to because of our already demanding jobs,” says Robb-Blenderman. “It felt like meeting some of the project deadlines was going to become an obstacle, but having a colleague for support and to share the responsibility made them attainable.”

“Linda and I were totally committed to the project,” adds Flynn-Post. “But we were also conscious of our other priorities. Because the timelines were shared at the beginning, we were able to meet them. We were also fortunate to have the support of Esther Green and our hospitals.”

“A critical ingredient to the success of this project was the support of nursing leadership,” adds Campbell. “The chief nursing officer provided invaluable endorsement and support.”

A starting point

Identifying the current state of nursing documentation was Cancer Care Ontario’s project goal. “Documentation is a large task and has many facets, including nursing workloads and available tools,” says Robb-Blenderman. “Through the project, we were able to find a starting point — the development of a generic audit tool that can be used to identify safe nursing practices and nurse-sensitive outcomes.”

“Having an audit tool will help us gather the information we need to help us make practice changes that are consistent and sustainable,” says Flynn-Post. “Our intention is to use this audit tool across the continuum of cancer care — from in-patient to outpatient, from medical oncology to radiation oncology, right through to the chemotherapy suite.”

Throughout 2005, Flynn-Post and Robb-Blenderman collaborated with the College’s internal and external consultants to fashion the audit tool. Along with other participants, they met for workshops and seminars to share their progress, learn from each other and receive guidance from the College. “I was surprised by how beneficial the workshops and seminars were,” says Flynn-Post. “They helped us look at our project and see it in manageable pieces that we could plan around, develop, study and eventually implement. We were able to delve into the Documentation practice standard, in our case, and really see how it applies in practice.”

Building leadership capacity

Another goal of the project was to build leadership capacity in nurses. “One of our hopes was for the nurses to become champions for their projects back in their workplaces, and many of them did,” says Freeman.

“I now have greater insight into how changes can be effected and made sustainable,” says Flynn-Post. “What appealed most about the project was the opportunity it provided to enhance my skills on knowledge transfer concepts and how to put them to use in my practice. Knowledge translation strategies apply to all facets of nursing, from clinical skills to, in our case, documentation. I also appreciated the opportunity to work on a project outside of the hospital that would develop my knowledge and skills and allow me to bring some of that learning back into my practice setting.”

Deborah Tregunno, an assistant professor at the School of Nursing at York University in Toronto, is leading the project evaluation. “We used focus groups and interviews to understand how participants moved through the program and to gain insight into the ways in which each project unfolded to meet the needs of individual circumstances,” she says. “We wanted to capture and communicate stories about learning and innovation. Participants were pleased with the collegial learning environment and the opportunity to work together to address practice challenges in our increasingly complex work environments. As one participant said, ‘Professionally, it’s helped me a ton. Some of the stuff I learned I’ll never forget. It was a difficult project but a great opportunity.’”

Through the project, the College learned more about practice setting realities and the everyday challenges of nurses. It also provided insight into how nurses use the practice standards. “We learned that our practice standards and guidelines have to stay broad, so nurses can adapt them to their practice settings,” says Freeman. “We were also told of other supports that nurses need, such as e-learning. This feedback is helping inform what the College’s ongoing outreach consultation will look like in the future.”

Moving forward

Robb-Blenderman and Flynn-Post are now sharing the audit tool they developed through the project with other Cancer Care partners across the province. “At the inaugural meeting of the Cancer Care Ontario Oncology Nursing Program at the end of last year, we presented our work on the audit tool,” says Flynn-Post, proudly. “It stimulated a great deal of discussion, there was much interest in the tool, and volunteers from other sites came forward to help us move ahead in the area of oncology nursing documentation. For example, we are considering the creation of a ‘community of practice’ around documentation at a provincial level to develop solutions that can be applied across settings.”

“It is so exciting that Cancer Care Ontario is moving ahead with this,” says Freeman. “This result is exactly what the College was hoping for when it launched the project over a year ago.”

Reflecting on their Fellowship experience, both Flynn- Post and Robb-Blenderman expressed that they found it positive and would enter into such a partnership with the College again. “We were impressed with the dedication, knowledge and professionalism of the College staff,” says Flynn-Post. “It was a fabulous partnership!”

Thank you

The College would like to thank the following individuals for their support of the Fellowship project:

  • Claire Mallette, RN , PhD, Chief Nursing Officer and Director of Professional Practice, and Karima Karmali, RN , Professional Practice Leader, Workplace Safety and Insurance Bureau
  • Josie Walsh, RN , Vice-President, Programs, and Chief Nurse Executive, and Susan Jones, RN , Clinical Educator, Rehabilitation, Providence Healthcare\
  • Rani Srivastava, RN , Deputy Chief, Nursing Practice, and Angela McNabb, RN , Advance Practice Nurse, Centre for Addiction and Mental Health
  • Nancy Lefebre, RN , Chief Clinical Executive and Senior Vice- President, Knowledge and Practice, and Helene LaCroix, RN , Nursing Practice Officer, Saint Elizabeth Health Care
  • Joanne Greco, RN , and Elizabeth Villar-Guerreo, RN , Education- Orientation Coordinator, Community Care Access Centre, North York
  • Esther Green, RN , Chief Nursing Officer and Director of Professional Practice; Linda Robb-Blenderman, RN , Clinical Practice Leader; and Marcie Flynn-Post, RN , Nurse Manager, Cancer Care Ontario
  • Lianne Jeffs, RN , Health Care Consultant
  • Deborah Tregunno, RN , PhD, Assistant Professor, School of Nursing, York University

 

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