Improving clinical practice in intensive care: Implementation of an evidence based protocol for bowel management

Abstract

There are numerous practice areas within the intensive care environment that are important for ensuring quality of care and evidence based practice. Complications associated with poor bowel management for critically ill patients include, increased ventilation times and length of stay. Bowel management protocols can improve patient outcomes by prompting clinicians and standardising care. Evidence-based implementation strategies are more likely to increase the update of guidelines or protocols into practice than merely providing copies to clinicians. Theories can broaden the understandings of clinician behaviour change interventions. The theory of planned behaviour explains the influences of attitude and beliefs on behaviour intention. The overall aim of the research reported in this thesis was to investigate the use of an evidence-based implementation strategy to effect clinician behaviour change and to improve a neglected area of clinical practice in the intensive care environment. The research comprised of two linked studies and three data collection phases. Study one used a telephone survey to describe the current guidelines and practices in Intensive Care Units (ICUs) within New South Wales (NSW) for eleven practice areas and aimed to identify an area of neglected practice for the focus of the remainder of the research. Results from study one found that the use of guidelines and informal routine procedures for the eleven practice areas within NSW ICUs was variable. Bowel management was identified by participants as a neglected area of practice within their units (n=28, 86%). The aim of study two was to evaluate the effect of a targeted implementation strategy to introduce a bowel management protocol into intensive care on patient outcomes; clinician practices; clinician knowledge, attitudes, beliefs and behaviour intentions. Two data collection phases were employed in study two; a staff survey and a retrospective medical record audit. The theory of planned behaviour informed the staff survey. Items to measure the TPB constructs were composed according to the manual on constructing questionnaires based on the TPB by Francis et al (Francis et al., 2004a). Validity of the theory of planned behaviour questionnaire items for use to evaluate the behaviour of interest, bowel management practices, was demonstrated. Development of a bowel management protocol and targeted implementation strategy was informed by previous protocols and the relevant evidence based literature. The developed multifaceted implementation strategy included education sessions, a printed fact sheet and reminders. Following implementation of the bowel management protocol, the staff survey in study two determined that nursing and medical staffs’ knowledge regarding bowel management improved (overall mean knowledge scores pre-implementation = 17.64, post implementation = 19.25). However, this increase in knowledge did not translate into more positive attitudes or beliefs related to bowel management for intensive care patients. Clinicians’ behaviour intentions toward three bowel management practices did not increase after the implementation strategy. There was no significant improvement in clinician practices or patient outcomes, namely the incidence of constipation and diarrhoea detected in the medical record audit following the implementation strategy did not decrease. The overall research aims, questions and significance are presented in the first chapter and the relevant literature is discussed in the second chapter. The thesis presents the specific aims, methods and results of the two linked studies inside manuscripts that have been either published, accepted for publication or under editorial review. The final chapter synthesises the results from the two linked studies and provides a discussion in the context of previous research. Initiating clinician behaviour change in the intensive care setting appears to be difficult to achieve when implementing a bowel management protocol. The theory of planned behaviour can provide useful insight into the predictors of clinician behaviour intention and a questionnaire based on the theory constructs can be used in the evaluation of behaviour change interventions.