Abstract
Quality initiatives such as clinical guidelines can improve knowledge and support nurses in providing effective assessment and treatment of patients. However, managed change in the effective development, dissemination and implementation of guidelines is complex and involves many educational and organisational issues requiring strong leadership, resource provision and cohesive organisational aims. This study was designed to implement and evaluate the impact of evidence-based guidelines for the promotion of continence in primary care and to examine the place of guidelines within a clinical governance agenda. It was one part of a multi-centre project The South Thames Evidence-based Practice project (STEP) that aimed to compare similar studies in a variety of clinical settings. This study employed the principles of action research with a quasi-experimental design in which the practice, role, knowledge and attitudes of community nurses (n=244) in the promotion of continence for elderly people in the community was examined before, during and after the development and implementation of clinical guidelines. Guidelines were developed and introduced into an implementation group (n=140), supported by educational interventions and comparisons made with a control group (n=104) within the same community Trust. Quantative and qualitative data was collected using a range of methods and triangulation of data sources: nurse questionnaire (n=244); interviews (n=29), document survey (n=41/109); and focus groups (n=29). At the outset, the community nurses operated within a system structured primarily towards palliative management of continence problems, which was frustrating for those who had skill in more proactive care. Most had not received comprehensive training in continence care; felt that they did not have adequate knowledge to care for people effectively; demonstrated a limited knowledge base; and many held assumptions about the inability of elderly patients to be successfully treated. Documented continence assessments were incomplete. Nevertheless it was accepted that district nurses held the key role in continence care within primary care and were committed to developing their practice. Following educational support and implementation of guidelines, 68% of nurses in the implementation group were influenced to change their practice. Statistically significant improvements occurred in the implementation group compared to the control group in documentation of continence assessments; knowledge about causes, assessment and treatment; and in attitude towards equitable opportunities for care for elderly people. Differences between groups could be attributed to the interventions employed. Although changes in clinical practice resulting from the study affected a relatively small group of patients initially, the framework for sustained improvement was established and their value were acknowledged at all levels of the organisation; and the role of nurses in proactive promotion of continence as well as the management of incontinence was recognised. This study has demonstrated that district nurses are well-placed to perform assessments and conservative treatment of continence problems in older people, but that their capacity to perform this role may be limited by individual and organisational factors.