Medical champions can make a difference in initiating culture change.

Abstract

Evidence-based medicine is the basis for quality improvement, but if it is to make a difference in clinical practice it needs to be applied in partnership with patients 1. It is very common to have a long time gap between sufficient research evidence and a change in practice. For example, the use of phototherapy 2 and antenatal corticosteroids 3 was appropriately applied several years, or even decades, after the evidence was provided about their effectiveness. Because even such simple therapies can be difficult to implement, the challenge understandably becomes bigger when it comes to complex clinical interventions 4, such as skin-to-skin contact between parents and infants or family-centred care. The evidence about the benefits of Kangaroo care had already been summarised in a Cochrane report by 2000 5, but there are still considerable worldwide variations in uptake in developed and developing countries and even within countries. After sufficient evidence has been provided, the implementation of evidence-based practices such as skin-to-skin contact and breastfeeding, the element of Kangaroo care, is dependent on contextual factors and facilitation 6. Facilitators are crucial in translating the evidence into clinical practice, as shown by Soni et al. in this issue of Acta Paediatrica 7. They showed that two doctors were the key facilitators in promoting skin-to-skin contact in neonates admitted to an Indian neonatal intensive care unit. Although any professional, or volunteer, working in a neonatal unit could take on the role of a facilitator, the two doctors were the strong promoters of skin-to-skin contact in this unit. In neonatal units, the involvement of all professionals in the team is required to make a practice change. This has been shown, for example, in infant pain management, where one study found that effective collaboration between doctors and nurses was the strongest predictor for successful pain management 8. After the practice change, the next challenge is to secure the sustainability of the new practice, which requires a change in the care culture of the unit. The change can be regarded as successful when it has reached all individual staff members. Thereafter, the risk of regressing back to old practices becomes smaller, even if some individuals moved away. According to the study reported in this issue 7, breastfeeding remained at the same level even after the champion doctors had moved to other units. However, some of the elements required for sustainability in the everyday practice of skin-to-skin contact had not been reached, as there was a significant decrease in the skin-to-skin practice after the champions had moved away. The stable rate in breastfeeding suggested that the difference was not in the mothers' presence. There has been far too little research about the key components and mechanisms that are needed to effect sufficient culture change to ensure the sustainability of new practices 9, especially the elements of successful leadership. To learn more about successful culture change, the evaluation of complex interventions is needed together with follow-up to evaluate the final patient outcomes. The quantification of the elements of Kangaroo care, that is skin-to-skin contact and breastfeeding separately, is a strength of this study and should be encouraged in future studies 7. The paper by Soni et al. 7 provides us with information about one mechanism that can be used to initiate culture change. The team work between the doctors, nurses and parents was shown to reach the desired goal when the champion doctors provided enthusiastic support for the team, in order to help the parents to provide skin–skin contact for their baby. Even if there are big challenges, we should find ways to support the sustainability of these opportunities for better care.