title: Cluster randomized controlled trial of the effectiveness of audit and feedback and educational outreach on improving nursing practice and patient outcomes.
abstract: BACKGROUND
  Current understanding of implementation methods is limited, and research has focused on changing doctors' behaviors.
  
  
  OBJECTIVE
  Our aim was to evaluate the impact of audit and feedback and educational outreach in improving nursing practice and patient outcomes.
  
  
  METHODS
  Using a factorial design, cluster randomized controlled trial, we evaluated 194 community nurses in 157 family practices and 1078 patients with diagnosis of urinary incontinence (UI) for nurses compliance with evidence-linked review criteria for the assessment and management of UI and impact on psychologic and social well-being and symptoms. In the outreach arms, nurses' self-reported barriers informed development of tailored strategies.
  
  
  RESULTS
  In comparison with educational materials alone, the implementation methods tested did not improve care at 6 months follow-up. Moderate rates of improvement (10-17% of patients) in performance for the assessment of UI and greater rates of improvement (20-30% of patients) for the management of care were found but effects were similar across arms. Improvement in patient outcomes was more consistently positive for educational outreach than for audit and feedback but differences were not significant. Adjustment for caseload size, severity or duration of UI and patients' age did not alter results.
  
  
  CONCLUSIONS
  Printed educational materials alone may be as effective as audit and feedback and educational outreach in improving nurses' performance and outcomes of care for people with UI. Greater understanding of the underlying processes in improving performance within multidisciplinary teams through further, theory-driven studies with "no intervention" control groups and longer follow-up are needed.
authors.affiliation: School of Healthcare, University of Leeds, Leeds, and Leicestershire & Rutland Healthcare NHS Trust, Gorse Hill Hospital, Leicester, United Kingdom. f.m.cheater@leeds.ac.uk
authors.forename: Francine M
authors.initials: FM
authors.lastname: Cheater
authors.forename: Richard
authors.initials: R
authors.lastname: Baker
authors.forename: Stuart
authors.initials: S
authors.lastname: Reddish
authors.forename: Nicola
authors.initials: N
authors.lastname: Spiers
authors.forename: Allan
authors.initials: A
authors.lastname: Wailoo
authors.forename: Clare
authors.initials: C
authors.lastname: Gillies
authors.forename: Noelle
authors.initials: N
authors.lastname: Robertson
authors.forename: Catherine
authors.initials: C
authors.lastname: Cawood
mesh_terms: D004509:Education, Nursing, Continuing; D005163:Factor Analysis, Statistical; D005194:Family Practice; D005246:Feedback; D019983:Guideline Adherence; D006801:Humans; D009731:Nursing Audit; D009732:Nursing Care / Q000458:organization & administration*; D017063:Outcome Assessment, Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D011787:Quality of Health Care / Q000458:organization & administration; D014549:Urinary Incontinence / Q000451:nursing; D016526:Workload