When implementation fails: the case of a nursing guideline for fall prevention.
BACKGROUND
Implementing guidelines can be very difficult. No magic bullet or step-by-step implementation plan is available, neither is any single implementation strategy superior. At the Academic Medical Center (AMC) in Amsterdam, a nursing guideline was developed in 1993 on prevention of patient falls. Falls decreased by 30% on six wards, yet an effort to implement the guideline into daily practice throughout the hospital failed. A renewed effort was made to implement the guideline in two wards (neurology and internal medicine) in 1999. IMPLEMENTING THE GUIDELINE: Preparations were made for implementation in the two wards. Barriers to change were identified and solutions were translated into day-to-day activities in the wards. The intervention period covered 18 months (January 2000-June 2001). A mix of implementation strategies was used, including a local consensus process, educational activities, and active support and feedback to management and staff.


RESULTS
In the internal medicine ward, the target incidence of 6% was met for four of the 18 months in the intervention period. In the neurology ward, the incidence target of 11% was met in five months.


CONCLUSIONS
Barriers to change and enabling factors may only become apparent during the implementation process itself. A strongly perceived need to change daily practice, a simple guideline, the hospital board's support, an understanding of local barriers, monitoring of outcomes, a locally tailored multifaceted implementation strategy, and voluntarily cooperating nurses are no guarantees for success.
van der Helm
Jelle
J
Academic Medical Center, University of Amsterdam, The Netherlands. h.m.vanderhelm@AMC.UVA.nl
Goossens
Astrid
A
Bossuyt
Patrick
P
D000046:Academic Medical Centers; D000058:Accidental Falls / Q000517:prevention & control*; D004059:Diffusion of Innovation; D019317:Evidence-Based Medicine; D017408:Guidelines as Topic; D006801:Humans; D009426:Netherlands; D009732:Nursing Care / Q000592:standards*; D017751:Safety Management / Q000458:organization & administration*