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Integration of Best Practice Guidelines (BPGs) Into an Undergraduate Nursing Curriculum Muhammad Arsyad Subu
November 23, 2011

The RNAO launched the BPGs program in November 1999. The purpose of this program is to support Ontario nurses by providing them with

Best Practice Guidelines for client care (RNAO, 2011).

BPGs is a developed statements (based on best available evidence) to assist

practitioner and patient decisions about appropriate healthcare for specific clinical (practice) circumstances (Field & Lohr, 1990).









implementation; and 16 are available in Chinese, Italian, Japanese, and Spanish in addition to English and French (RNAO, 2011).
In Excellent Care for All Act, Bill 46 (Chapter 14 Statutes of Ontario, 2010).it is

a legal requirement that healthcare organizations consider the use of the best
available scientific evidence in healthcare in Ontario.


In clinical settings, many studies show that BPGs improved patient

outcomes, impacts patient referrals, creates partnership & offers cost savings (Brouwers, et al, 2004; Campbell, et al, 2010; Coutts, 2003; Delvin, et al, 2002); Ellis, et al, 2007; Higuchi, et al, 2011; Hogan &

Logan, 2004; MacLeod, et al, 2002; & Ploeg, 2004).

Many studies described knowledge translation (KT) & Knowledge

Utilization (KU) strategies of evidence-based.

KT, (Davis et al., 2003; Dobbins, et al, 2002; Glasgow, et al., 2003;

Jacobson, et al., 2003; Nutley, et al, 2003; Ohlsson, 2002)

KU, (Backer, 199; Greenhalgh, et al, 2005; Larsen, 1986; Grol, 2000;

Grol & Grimshaw, 2003; Rogers, 2005).

However, how these strategies used in nursing curriculum development

are still unknown.


Sustainability of BPGs implementation in an

undergraduate curriculum is essential in order to

achieve a high level in a nursing education program.

Some studies have been conducted to investigate

the implementation of BPG in clinical settings; but after an intensive literature search, nothing has been said that BPGs are systematically integrated in an

undergraduate nursing curriculum.

How the BPGs recommendations are integrated in

overall curriculum design (theory and clinical courses) in undergraduate nursing program?
What are the barriers and facilitators of BPGs

implementation in undergraduate nursing

How the curriculum changes have been sustained

based on BPGs recommendations ?

NHS sustainability model will be used as a framework to guide the

It is developed by NHS Institute for Innovation and Improvement in UK

& widely used of diverse disciplines around the world (Australia, Chile, Italy, Jamaica, Malta, South Africa, UK and the USA).
It is intended to provide a user-friendly practice-based guide to the key

factors that need to be considered for sustained organizational change (NHS, 2010).
It consists of ten factors related to:

process, staff and

organizational issues, which play a very important role in sustaining

change in healthcare (Higuchi, et al, 2011).

Sustainability is the degree to which an innovation continues

to be used. It is when new ways of working and improved outcomes become the norm and the continuation of

programs (Rogers, 2005; Shediac-Rizkallah & Bone,1998;

Monitoring systems and data feedback mechanisms are

needed to determine relevant process and outcome factors

to assess sustainability. Four degrees of sustainability are absent, precarious, weak, and routinization (Pluye, et al.,

2004) .

Sustainability Model (Maher, et al, 2007; 2010)

Nursing must be the discipline that uses knowledge and evidence from multiple

sources as an integral part of evidence-based nursing recommendations (Carper, 1978).

EBP has a popular movement and well-established in influencing nursing

knowledge development in educational & clinical practice (Higuchi et. al., 2006, Ritchie, et. al., 2010, de Cordova, et. al., 2008, Eaton, et. al., 2007, Miner Ross

et. al., 2010, and Stone & Rowles, 2007).

In bill 46 (Chapter 14 Statutes of Ontario, 2010) under point (12.c.) that the

functions of the Council are to promote healthcare that is supported by the best available scientific evidence by making recommendations to health care organizations and other entities on standards of care in the health system, based on or respecting clinical practice guidelines and protocols, making recommendations, based on evidence and with consideration of the

recommendations (The Legislative Assembly of Ontario, 2010).

The steps to plan the learning event (RNAO, 2005):

Integrate BPG contents into the curricula of an academic or practice

Identify facilitators and driving forces to integration of BPG content;

Identify barriers to integrating BPG content and strategies to

overcome them;
Identify partnerships for BPG education; Facilitate the integration of BPG content into learning events; Identify & allocate resources necessary for a successful learning

Plan for content and develop a learning plan; and Plan for contingencies

Integrate BPGs into nursing curriculum (RNAO, 2005).

The curriculum, whether in the academic setting or as the learning

strategy for a practice setting, is the overall plan for the education of learners in the institution or program
BPGs integration in curriculum must be planned in relation to present

content and context, experience and motivation. & possible disruptions require a contingency plan.
The integration of BPG into curricula will promote student acceptance

of the philosophy and underlying BPGs values as a natural part of their approach to nursing profession.
However, it is still unknown how the BPGs recommendations are


BPGs into theory courses (academic):

Some authors describe implementation of evidence-based in

curriculum undergraduate program to ensure students competencies (Ciliska, 2005, Melnyk & Fineout-Overholt, 2011; Mazurek- Melnyk, 2011).
Plan for BPG integration in theory and clinical courses (the type of

courses being taught) as well as motivation of the learners.

Plan the learning event: assessment of the facilitators that can help

create an impetus for change and allow integration of BPG and identify potential barriers in BPG implementation & strategies to overcome them (RNAO, 2005).

BPGs into clinical courses (practice):

It is essential that nursing curriculum in academic setting must reflect

nursing in practice settings.

Strategies to integrate BPG content into the practice setting will be

different from approaches for the academic setting.

Planning for BPG integration includes: staff with knowledge of BPG

(learned in basic education, in service exposure, post graduate courses with BPG in curriculum); and staff without previews BPG knowledge.
Identify facilitators and potential barriers in BPG implementation &

strategies to overcome these barriers (RNAO, 2005).

The barriers in integrating BPGs:

The challenge of translating research findings into clinical practice has

been an explicit concern to the discipline and profession of nursing for decades (Newton, 2009).
Barriers to effective use of research include the gap between research

and practice goals; the relevance or perceived relevance of research; poor access to research or not having time to absorb it; and researchunfriendly organizational settings (Hemsley-Brown, 2004).
The most commonly reported barriers of BPGs implementatuion in

clinical settings are: (1) staff time, workload and resource constraints; (2) lack of access to equipment and resources; and (3) staff resistance to change (Ploeg, et al., (2007).

The facilitators in integrating BPGs:

In clinical settings, 4 most common facilitators: (1) presence of

change champions, local facilitators, local leaders and/or specialist nurses; (2) staff training, education, and problem solving related to guidelines; (3) strong unit or organizational leadership; & (4) collaboration with multidisciplinary teams (Ploeg, et al., 2007).
The RNAO (2005) predicted some facilitators in any setting: 1)

accreditation expectations; 2) professional practice standards: 3) changes to entry practice requirements; 4) increased awareness and appreciation of evidence-based practice (EBP); 5) social accountability for quality outcomes; and 6) fiscal accountability for

quality outcomes.


Case study is one approach that supports deeper and more detailed

investigation of the type that is normally necessary to answer (how, what and why) questions (Yin, 2004, 2008; Clardy, 1997; Shavelson & Townes, 2002).
It investigates a phenomena within its real life context, especially when the

boundaries between phenomenon and context are not clearly evident (Merriem, 1998).
Stake (1995): intrinsic (understand the particulars of a case); Instrumental

(understand something more general); collective (combine multiple cases into a

single study).
The primary advantage of a case study is that it provides much more detailed

information than what is available through other methods (Neale, Thapa, &
Boyce, 2006).

Process in conducting a case study:

Follows the same general process as is followed for other

research: Plan, Develop Instruments, Train Data Collectors (if necessary), Collect data, Analyze data, Disseminate

findings ( Neale, Thapa & Boyce, 2006, Yin, 2008).

The six elements of a case study:
Determine and define the research questions, elect the

cases and determine data-gathering and analysis techniques, prepare to collect data, collect data in the field, evaluate and analyze the data, and prepare the report(Merriam, 1998).


A case study is suitable and fit to my research (especially my research

questions) It used when: the type of research question is typically to answer how, what or why questions (Yin, 2008; Clardy,1997; Shavelson & Townes, 2002; & Merriam, 1998).
A case study provides rich and significant insights into events and

behaviours and contribute uniquely to our knowledge of individual, organizational, and social, phenomena (Yin, 2004).
It provides descriptive details about how the workplace function, and

increases understanding of a particular phenomenon and a holistic view of a situation (Yin, 2008).


Inclusion criteria: Site or setting is a nursing program that has integrated BPG recommendation in undergraduate curriculum (theory and clinical courses).

Purposive sampling - Purposive sampling is popular in case study qualitative research (subjects are selected because of some characteristic ; i.e. snowball or chain - identifies

cases of interest from people who know, people who know what cases are information-rich,
that is, good examples for study, good interview subjects (Patton, 2002) SETTING:

The BPGs program has been implemented in some nursing schools in Canada and the United States. This study will be conducted at one nursing school that has implemented BPGs in undergraduate nursing curriculum in Ontario .


Participants in this study will be the faculty, program leaders (administrative leaders),
clinical partners representative, and students.

DATA COLLECTION METHOD A case study allows to present data collected from multiple methods (i.e., surveys,

interviews, document review, and observation) to provide the complete story or

information (Neale, Thapa, & Boyce, 2006).

Semi structured interview:

Data will be collected from faculty, program leaders (administrative leaders),

clinical partners representative, and students.

The semi-structured interview guide provides a clear set of instructions for

interviewers and can provide reliable, comparable qualitative data. Semistructure interviews can provide reliable, comparable qualitative data. Questions can be prepared ahead of time (allows the interviewer to be prepared and appear competent during the interview). It also allows informants

the freedom to express their views in their own terms (Bernard (1988).

Documents review:
Documents comprise a variety of written, visual, and physical material.

Documents are by-products of human activity that document their activity over time (Merriam (1998).
Document review will include: syllabus (theory, clinical/lab), assignments,

minutes meeting, and report to the RNAO. Observation:

Observation involves looking and listening carefully that allow to study people

in their natural setting without their behaviour being influenced by the presence of a researcher. Data usually consist of detailed information about

particular groups or situations (Kibler & Langley, 1988).

Observation will be focused on teaching-learning processes (during classes,

clinical, and lab sessions).

Data collected will be analyzed by using NVivo software. NVivo is a software for qualitative data analysis (QDA)

package produced by QSR International.

It is widely used and allows researchers to classify, sort

and arrange information; examine relationships in the data;

and combine analysis with linking, shaping, searching, and


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