Associate Professor Jennifer Medves, School of Nursing, Queen's University, Kingston, ON, K7L 3N6, Canada. Email: email@example.com
Aim To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.
Methods Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.
Results Initial search revealed 12 083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.
Conclusion Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.
Healthcare delivery is becoming more and more complex. Healthcare providers who in the past worked in silos are recognising the inefficiencies of that approach. An emerging aspect has been the demand for an increase in collaborative care as evidenced by task force reports and governmental policies internationally at both federal and provincial/state level.1–7 Collaborative care and education have received increasing attention in order to deal with the complexity.1 Professional organisations have sought clarity for their members by defining collaborative care. The Canadian Association of Occupational Therapists defines collaborative care as ‘the positive interaction of two or more health professionals, who bring their unique skills and knowledge, to assist patients/clients and families with their health decisions'.8 For interprofessional teams of healthcare providers this means working collaboratively in the provision of integrated and continuous healthcare. Team-based healthcare and practice has been widely argued to provide not only improved efficiency and quality of service,3,7,9 but also cost reductions,4 and increased job satisfaction.3,6,9
With collaborative care there has also been a recognition that working in a team from evidence-based guidelines should make team decisions more straightforward. There is emerging evidence that it improves patient care and outcomes, and second, there is an association with cost-effectiveness and increased job satisfaction.10–12 Clinical decision-making informed by evidence has increased with development and utilisation of practice guidelines.13 Guidelines are defined by Field and Lohr as ‘systematically developed statements to assist practitioner decisions about appropriate healthcare for specific clinical circumstances’ (p. 38).14 Using guidelines to inform practice improves the effectiveness and efficiency of healthcare while reducing inappropriate variations in practice.
Collaborative team practice and the implementation of practice guidelines are promising approaches in healthcare delivery. In both areas challenges exist. West and colleagues report that in order to ensure effective collaboration, teams require explicit, appropriate tasks and goals and clear meaningful roles for each individual; criteria that could be accomplished through the implementation of clear and systematic guidelines to assist in practitioner decision-making.15 Further research is needed to evaluate various implementation and dissemination strategies and their effectiveness. Grimshaw et al. examined the effectiveness and efficiency of guideline dissemination and implementation strategies in the medical profession.16 Their findings highlighted the need for decision-makers to carefully consider the environment into which the guideline may be implemented, the benefits and costs to be incurred through both the implementation strategy, and changes in provider behaviour. They noted that despite an increased interest in guidelines, uncertainty pertaining to the effectiveness behind some of the different implementation strategies remained. Similarly, a systematic review by Thomas and colleagues17 focused on the implementation and dissemination of practice guidelines in nursing and professions allied to medicine (i.e. physiotherapists, occupational therapists, midwives, dentists, hygienists, pharmacists and other healthcare professionals), and has been updated by the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) group18 and is under review. The dissemination and implementation strategies identified by the EPOC group included distribution of educational materials, educational meetings, local consensus process, educational outreach visits, local opinion leaders, patient mediated, audit and feedback, reminders, marketing, mass media, patient incentives, evidence of revision of professional roles, clinical multidisciplinary teams, continuity of care, communication and discussion between distance health professionals, and changes in medical record systems. Patient and process outcomes are interventions for practitioners, interventions for patients, change in knowledge, change in practice and change in economic outcomes.
To date, no systematic review could be found that evaluated the effectiveness of guideline implementation for team-based, collaborative practice. The current trend towards collaborative practice clearly indicates the need to evaluate guideline implementation and dissemination strategies and their appropriateness for team-based healthcare setting. Practice guidelines are those documents that present the best evidence for a given protocol of treatment or care. Implementation and dissemination are those methods utilised to encourage uptake of evidence by practitioners to improve patient outcomes. Team-based practice is a way of working with colleagues from different professional groups to ensure any patient or client receives the care from the most appropriate individual while working in a collaborative manner that respects each person's individual skill base and knowledge. This systematic review was undertaken to describe and identify the effectiveness of different practice guideline implementation and dissemination strategies on team-based practice and/or patient outcomes.
The review protocol was developed to mirror the reviews carried out by Grimshaw and colleagues,16 Thomas and colleagues17 and the update.19 It was registered with Joanna Briggs Institute (JBI) and feedback was incorporated before the start of the review. The authors knew that a narrative analysis was all that could be done as in all likelihood the mixed methods of many of the original studies would preclude a quantitative analysis and the types of interventions and dissemination strategies were unlikely to be comparable across studies.
Search and retrieval of studies
We sought research studies of the effectiveness including randomised controlled trials (RCTs) and other research designs, such as quasi-randomised controlled trials, before and after studies, prospective studies, time series and observational studies, were all considered for inclusion in a narrative summary to enable the identification of current best evidence. Studies investigating the economic efficiency of dissemination and/or implementation of interventions were also considered.
Studies were included if healthcare teams collaborated in an activities to promote guideline implementation. If multiple professions being studied were simply following the same guideline then the article was excluded. There had to be explicit identification of working together as a team. Studies that include team-based practices, that is, practices including two or more professions or disciplines (e.g. medicine, nursing, occupational therapy, physical therapy, dietetics/nutrition, speech language therapy, social work, dentists/hygienists, laboratory services, pharmacy, health administration), were included. We were guided by definitions from the Canadian Health Services Research Foundation19 and the organisational literature defines team as ‘a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational borders’.20
In recognition of the variety of terms used for guidelines, we did not insist that the term ‘guideline’ be explicitly used as long as the intervention in question met the essence of Field and Lohr's definition.14 In addition to the term ‘guidelines’ we included ‘protocol’, ‘standard’ and ‘clinical pathway’. Studies were included if they used any objective measure of change in provider behaviour and/or patient outcome resulting from the assimilation of the practice guideline specific to the implementation/dissemination strategy. Outcome measures included change in knowledge, change in practice, change in patient outcomes and a change in economic outcomes. Where changes were reported, statistically significant findings are further identified as defined by the authors of the original studies, no further analysis was conducted by the authors of this review article.
The search strategy is summarised in Figure 1 and more details can be found at the Joanna Briggs website. Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological rigour before inclusion in the review using the standardised critical appraisal instruments from the JBI Meta Analysis of Statistics Assessment and Review Instrument. Disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. At each stage at least two reviewers read each paper, although it was not necessarily the same reviewer at each stage of the review. This was because some of the reviewers were employed for a limited time. The review of the papers took over 6 months because of the number that met the first criteria. Of the included papers in the final review two reviewers read each paper and checked the tables for accuracy. Dissemination strategies were quantified using the taxonomy defined by EPOC (Table 1) and data extraction tools developed for the Nursing and Professions Allied to Medicine (PAMS) study.19
Table 1. Effective Practice and Organisation of Care (EPOC) taxonomy
(1) Distribution of education materials: Distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audiovisual materials and electronic publications. The materials may have been delivered personally or through mass mailings.
(2) Educational meetings: Healthcare providers who have participated in conference, lectures, workshops or traineeships.
(3) Local consensus process: Inclusion of participating providers in discussion to ensure that they agreed that the chosen clinical problem was important and the approach to managing the problem was appropriate.
(4) Education outreach visits: Use of a trained person who met with providers in their practice settings to give information with the intent of changing the providers practice. The information given may have included feedback on the performance of the provider(s).
(5) Local opinion leaders: Use of providers nominated by their colleagues as ‘educationally influential’. The investigators must have explicitly stated that their colleagues identified the opinion leaders.
(6) Patient mediated interventions: New clinical information (not previously available) collected directly from patients and given to the provider, for example, depression score from an instrument.
(7) Audit and feedback: Any summary of clinical performance of healthcare over a specified period of time. The summary may also have included recommendations for clinical action. The information may have been obtained from medical records, computerised databases or observations from patients.
(8) Reminders: Patient or encounter specific information, provided verbally, on paper or on computer screen, which is designed or intended to prompt a health professional to recall information. This would usually be encountered through their general education; in the medical records or through interactions with peers, and so remind them to perform or avoid some action to aid individual patient care. Computer-aided decision support and drugs dosage are included.
(9) Marketing: Use of personal interviewing, group discussion (focus group), or a survey of targeted providers to identify barriers to change and subsequent design of an intervention that addresses identified barriers.
(10) Mass media: (i) varied use of communication that reached great numbers of people including television, radio, newspapers, posters, leaflets and booklets, alone or in conjunction with other interventions; (ii) targeted at the population level.
(1) Patient incentives: Patient received direct or indirect financial reward or benefit for doing or encouraging them to do specific action.
(1) Revision of professional roles: Also known as ‘professional substitution’, ‘boundary encroachment’, and includes the shifting of roles among health professionals. For example, nurse midwives providing obstetrical care; pharmacists providing drug counselling that was formally provided by nurses and physicians; nutritionists providing nursing care; physical therapists providing nursing care. Also includes expansion of role to include new tasks.
(2) Clinical multidisciplinary teams: Creation of a new team of health professional of different disciplines or additions of new members to the team who work together to care for patients.
(3) Continuity of care: Including one or many episodes of care for inpatients or outpatients. Arrangement for follow up. Case management (including coordination of assessment, treatment and arrangement for referrals).
(4) Communication and case discussion between distant health professionals: e.g. telephone links, telemedicine; there is a television/video link between specialist and remote nurse practitioners.
(1) Changes in medical records systems: e.g. changing from paper to computerised records, patient tracking systems.
Types of studies
A total of 88 studies comprised the final set from a total of 12 083 papers initially identified. The following databases were searched: AMED, CINAHL, Cochrane Database of Systematic Reviews, Centre of reviews and Dissemination (CRD), EMBASE, ERIC, Healthstar, MEDLINE, PsycINFO, Clinical Pharmacology, Clinical Reference Systems, Current Contents, Biomed Central, PubMed, Turning Research into Practice. The time period was from 1994 to 2007. Figure 1 displays exclusion and inclusion processes that guided the development of the final set of studies. The 88 studies were predominately from the USA (53.4%) and the UK (11.4%), with a further eight Canadian and four Australian studies. Other countries are represented by three or less studies. The total number of countries was 17.
The majority of the 12 083 papers screened described a multi- or interprofessional approach to development of guidelines rather than implementation and uptake of guidelines, the focus of this review. The studies ranged in design with 28 (31.4%) RCTs, 34 (38.2%) descriptive/case series and 27 (30.3%) comparable cohort studies.
Overall significant changes in knowledge, practice, patient and/or economic outcomes were reported in 64 of the 88 studies (72.7%). Every study utilised at least one dissemination and implementation strategy from a list of 10 and some used as many as six with one using eight strategies (see Table 2).
Table 2. Dissemination and implementation strategies
Number of studies
Number of significant findings
Frequency of significant studies
Distribution of educational materials
Local consensus processes
Educational outreach visits
Local opinion leaders
Audit and feedback
Teams that implemented and disseminated guidelines ranged from two professional groups to a maximum of eight, the vast majority had four professional groups or less for a total of 76. Eighty-one studies involved physicians as part of the team, 80 studies involved nurses, 23 pharmacists, 15 dietitians, 12 respiratory therapists, 12 physiotherapists, 9 social workers and 3 occupational therapists. Seventy-three studies had both physicians and nurses. There seemed to be no pattern of increasing numbers of healthcare professionals in the team to improve the likelihood of significant findings of the guideline. We could not identify a pattern over the time period 1995–2007 of an increasing number of professionals involved in teams associated with improved dissemination and implementation strategies or significant outcomes.
Dissemination and implementation strategies or approaches
Ten dissemination and implementation strategies aimed at healthcare professionals were identified in the 88 studies. The most common strategy was distribution of educational materials and the least common being mass media information. Educational materials included the guideline in paper or electronic version, small laminated cards, posters available where care was delivered and short versions of the guideline posted. Sixty of 89 studies used distribution of educational materials. Of these 60, 44 (73.3%) reported significant findings, although it is not possible to determine that distribution of educational materials was directly responsible for the significant findings. Educational meetings included any discussion of teaching and learning sessions for staff that were involved in increasing their knowledge about the standards outlined in the guideline as well as meetings to discuss process issues of dissemination and managing logistic changes to the organisation. Sixty-three studies used educational meetings. Of these 63, 47 (74.6%) reported significant findings, although it is not possible to determine that educational meetings directly responsible for the significant findings.
Local consensus processes involved any process where a guideline developed by a third party was discussed and adapted for local use and could include meetings, development of site-specific materials and agreement of guidelines for patients who met the criteria for inclusion in the study. Thirty-five studies used local consensus processes to disseminate and implement practice guidelines. Of these 35 studies, 23 (65.7%) reported significant findings, although it is not possible to determine that local consensus processes were directly responsible for the significant findings. Educational outreach visits are those visits where a team of healthcare professionals came from another institution or organisation and provided education to healthcare professionals; sometimes this was in addition to providing direct care to patients at the research site. Only 12 of 89 studies utilised educational outreach visits as part of their strategy, and 8 (66.6%) reported significant findings although it is not possible to determine that these visits were directly responsible for the significant findings.
Local opinion leaders are healthcare providers or experts in a given area who provide ongoing support for use of the guideline and may assist practitioners in providing best evidence practice. Local opinion leaders were usually employed by the research site or had a specific role as a clinician in the site outside of the research project. Specifically describing the input from local opinion leaders was described in 16 of 89 studies, with 13 (81.3%) having significant findings. While this is encouraging, it is not possible to determine that these opinion leaders based locally were directly responsible for the significant findings. Utilisation of a leader who has change management skills was highlighted as contributing to success in implementing nutritional support for stroke patients.21 Visibility of a pharmacist, as they visited the ward daily, was viewed as strengthening the likelihood of changing patients from intraveneous to oral antibiotics as recommended by guidelines.22
Patient-mediated interventions are those where the patient provides information that was not previously available to the team. This new information in turn has an effect on the timing of the intervention. Patient-mediated input was described in 14 of 89 studies, with 9 (64.3%) reporting significant findings. Although it is not possible to determine that patient-mediated input was directly responsible for the significant findings. All the studies that examined protocols to wean patients off mechanical ventilations had to use guidelines only when the patient's condition was sufficiently improved so new information became available during the time of the intervention.23–27 Other studies required the patients to provide permission to be enrolled in a practice driven by the best evidence.28
Audit and feedback are mechanisms where healthcare providers receive information about the guideline dissemination and implementation during the study period. This may come as a count of patients in the previous month that received adequate care according to the guideline. Audit and feedback could be provided to individuals or the team as a whole. By understanding how close or not close to targets team members were in an approach to either celebrate success, or examine issues that may be preventing adequate adherence to a guideline. Audit and feedback were the third most often cited professional strategy for dissemination and implementation in 46 of the 89 studies, and 38 (82.6%) reported significant findings. It is not possible to attribute that the audit and feedback was the factor that is directly responsible for the significant findings.
Reminders are those episodes that healthcare providers receive at the point of care at the appropriate time. Unlike educational materials reminders are patient specific and can be electronic pop-ups that appear on the screen when a chart is opened or a paper reminder placed in the chart, such as a pharmacist note advising clinicians that a patient requires blood tests to ensure toxicity is not an issue with a drug, or that a particular medication may be better for a patient based on best evidence. Reminders are more targeted and less passive than general educational materials, which the healthcare provider may not realise are important to a particular patient. Reminders to healthcare professionals were described in 28 of 89 studies and 24 (85.7%) of these studies reported significant findings. It is not possible to directly report that reminders to providers account for the significant findings.
Marketing includes all approaches that businesses would normally be used to encourage people to use their materials. Marketing techniques were utilised by 18 of 89 studies and in 14 (77.7%) of papers there were significant findings, and included focus groups. The results cannot be directly attributed to marketing. Marketing is not always evidence based as described in the study of best practice of atrial fibrillation where marketing of a drug by the pharmaceutical company meant physicians chose that drug over the one recommended in the guidelines.29 Marketing and making appealing food choices to patients was one approach to improve dietary intake in a Danish study that was trying to ensure adequate nutritional intake to patients on four units.30 Marketing of a guideline to both experimental and control groups was utilised in smoking cessation studies as the guidelines were freely available. As such it was a passive approach to dissemination and implementation.31,32 All women attending a paediatric clinic were invited to pick up a smoking cessation flyer and if they did they were then invited to participate in a study.33
Mass media uses print press, posters, televisions advertising, magazine inserts to inform the total population of best practice when monitoring, managing and treating a particular disorder or disease. One study utilised newsletters and conference calls to all healthcare providers of the program at all sites to provide information and updates.34 While some of these methods could also be attributed to audit and feedback, the study used newsletters a priori to get general information disseminated to all sites.
Overall, utilising multiple approaches to dissemination and implementation seems to be useful when working with teams, with distribution of educational materials, educational meetings, and audit and feedback being the most commonly used strategies. Of the studies that reported strategies those with significant findings used local opinion leaders, audit and feedback, and reminders had in excess of 80% significant findings.
Patient incentives are those that may directly affect whether a person would be more likely to undertake a particular healthcare plan and includes both financial encouragement or penalisation and healthcare insurance considerations. Patient incentives were reported in five studies and ranged from two studies on tobacco cessation,32,33 asthma management,35 hand washing36 and palliative care.37 The incentives are not comparable and were small in number. All the studies were based in the USA with the exception of the hand washing study in Taiwan. It is included in this section as the parents were encouraged to participate in hand washing so that infection rates were minimised.
Seven studies explicitly outlined revision of a, or some, professional roles as part of the study protocol and or to address a perceived need in order to appropriately disseminate and implement a guideline. We carefully distinguished between those studies that utilised a healthcare provider in a different role as a researcher and those where the role was revised. A new position as a diabetes disease manager coordinator was utilised,38 while an asthma study identified a nurse as the lead in a new role.35 A dietitian and a nurse were designated as lactation consultants to assist in the low birthweight study and were responsible only as consultants and not direct patient care.39 Registered nurses assumed the role of infection manager to work with nephrologists to minimise the effect of infections experienced by patients who had tunnelled cuffed catheters in place for haemodialysis.40 Screening for atrial fibrillation was conducted by a pharmacist who had the requisite skills to determine drug therapy that was most appropriate for each patient and then a team decision was taken before start of the medication.29 To reduce the number of patients who are physically restrained in long-term care settings, the nursing assistant was designated as case manager as they were the provider group who knew the elderly person best.41 The set of studies that revised professional roles to disseminate and implement guidelines was heterogeneous and therefore not comparable. Costs associated with changing roles may or may not have been included in the studies and are hard to distinguish from other costs.
All the studies reported clinical multidisciplinary teams were provided with some type of dissemination and implementation strategy to ensure guidelines were utilised appropriately. This was a focus of this systematic review. In addition where studies had local adaptation of a guideline it was usually undertaken by a multidisciplinary team. One study identified where a team approach was not taken using a key professional in developing the protocols meant that there was not sufficient uptake of the guideline in practice.42
A continuity of care plan was explicitly defined in eight studies although it implicitly seemed to be a component of many of the team approaches.34,43–49 Continuity of care in the EPOC taxonomy includes arrangements for follow up and case management. Many studies included notions of continuity of provider, continuity of team plan and appropriate follow up without being explicit. Teamwork interventions can improve continuity of care or coordination and help to improve quality of care.20
Communication and discussion includes utilisation of tele-health links, where there are synchronous or asynchronous links between specialists and practitioners over distance. These links can be for direct advice on patient care but are also useful to discuss case studies in the abstract that may help a given practitioner with clinical decision-making in the future. As a technique it was reported in three studies.35,50,51 All three studies reported significant changes in knowledge or practice or outcomes.
Redesign of medical or health record systems was identified in six studies.38,46,49,52–54 Electronic health record redesigns were described,46,49,53,54 or records that allowed clinicians from multiple sites to access results.38,52 While the number of studies that described the details was small, part of team effectiveness is the ability of all team members to be able to access patient information simply and on time. Other studies described global health records but were not specific about whether the changes were made before dissemination and implementation of the study guideline or whether there was a change in how information was recorded.
Patient and process outcomes
Team literature has been clear that in order to affect changes all the professional groups have to be involved early in the process. One study highlighted this concept and started to implement and disseminate a guideline of pain management for infant circumcision.55 As the obstetricians were not involved they did not change their preoperation orders; once the process started again they were more engaged and some changes were then seen.
Interventions for patients were defined as those strategies specifically targeted at them rather than for the practitioners who were going to implement the guidelines. They were infrequently reported, 15 studies from a total of 88 (17%). The types of intervention were distribution of educational materials29,34,45,47,56–60 and educational meetings.29,34,39,45,47–49,58,59,61–63
Assessment of knowledge of the practitioners was reported in 37 of studies, of which 12 were deemed to be significant.23,31,32,46,52,54,64–69 Some studies described a change in knowledge as there was a change in practice but did not describe how they assessed knowledge and so are not included in the 12 significant findings studies. Different approaches were taken to test the change in knowledge. Understanding of the written protocol by conducting a pre- and post-test survey showed significant change in knowledge.23,32,64–66 Healthcare providers self-reports of satisfaction with access and communication with specialist diabetes staff increased following an education program and changes to practice to ensure patients were monitored appropriately.52
Guidelines including pre-printed orders for adult patients following surgery were significantly more likely to be used.70 The education program targeted at teams of nurses, physicians and pharmacists helped to increase the likelihood of discussion of pain management with other healthcare providers.65 Developing a recall system improved the likelihood a patient would be monitored for diabetes markers as recommended by guidelines.52 Qualitatively, staff recognised patients did not get lost in the system and having one clinic for all diabetic patients ensured their care was monitored appropriately; communication and documentation also improved.
Twelve studies considered economic outcomes. Of these six reported significant findings.24,27,61,71–73 Utilisation of a guideline, through distribution of educational material and reminders, produced a cost saving of $11 000 per patient in a cohort of those with pressure ulcers.71 Laboratory testing costs were reduced by using an asthma guideline in a children's hospital in the USA.72 The Dutch study of patients who required intensive treatment of musculoskeletal disorders analysed costs at 2, 6 and 12 months.61 Although there were some significant differences at the conclusion of the study the difference between the two groups was negligible, but the authors recommend that as other patient outcomes improved it is worthwhile to continue with a team approach to care for these patients. Utilisation of mechanical ventilation weaning guidelines reduced hospital costs.24,27 Guidelines to control the use of antibiotics in a team led by pharmacists in Switzerland helped to save money for the hospital.73 In all of these studies the dissemination and implementation strategy of the guideline was closely monitored so that the organisations could assign costs. The variety of measures was not the same and so an effect of cost monitoring cannot be attributed to dissemination and implementation strategies. One study where cost savings were not reported passed on the profit from the unit to the employees in use of a hand-washing protocol.36 There were no differences in types of dissemination and implementation strategies used by the researchers that demonstrated a cost savings compared to those where there was no cost saving. Small sample size was hypothesised as the reason for lack of significant cost savings.25 However, in a large-sample-size study of patients with bipolar disorder the mean time for improved mental status to be achieved was 6 weeks shorter using a team approach while being cost neutral.34,59
Limitations of the review
In any systematic review there are always limitations because the review is based on a specific topic and in order to synthesise the information the balance between inclusion and exclusion has to be set a priori to ensure the protocol is replicable. There may be many studies that examine the effect of team use of guidelines with positive or negative outcomes that were not included as the discussion of implementation and/or dissemination was excluded.
The heterogeneous sample included articles not described due to limited space in this article;74–110 however, they are included in the reference list. We were not able to compare and contrast and provide a definitive list of those strategies that should always be considered. There was significant variation in the number of strategies used by researchers.
This review sought to synthesise the evidence of healthcare team implementing guidelines. Development of a guideline with multiple professions is one of the criteria for assessing the quality of a guideline.111 There is emerging evidence about the next step of implementing guidelines into practice. It was challenging and resource intensive to hone in studies of interprofessional teams implementing with more than 16 000 hits resulting in 88 studies relevant for the review. The evidence is equivocal about the effectiveness of strategies but the review showed a range of approaches currently being used to guide implementation within teams. In order for a team to work together, especially if the team is interprofessional, receiving similar dissemination and implementation strategies makes sense. It provides the team with opportunities to discuss the local context and evaluate if changes in processes need to be undertaken.
Team development takes time. For teamwork to be effective common understandings of patient care need to be established so that patients receive consistent and evidence-based information and practice. The decision to integrate and utilise practice guidelines that may have been established nationally and then adapted for local use seems to be an effective way to improve knowledge, practice and outcomes.112 The 88 studies in this study were only included as the authors provided strategies for dissemination and implementation of the guideline; there may be many more studies that used a team approach to integrate guidelines into practice. In addition, to be included studies had to provide results that could be attributed to the team, and not individual professional groups. The review has provided evidence that a multiple approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes. When compared with the uniprofessional reviews16,17,19 it does seem as though a team approach to dissemination and implementation has a higher percentage of significant findings. The analysis of this comparison is in development by the authors of this review. Ensuring guidelines are utilised has been a challenge to all practitioners and understanding why it does not occur is a frustration to guideline developers. With team-based practice there seems to be a higher uptake than targeting only one profession with dissemination and implementation strategies.
Researchers interested in investigating the uptake of guidelines in teams will have many areas of implementation strategies to evaluate. It is not clear which type is the most successful, nor is it clear how many strategies are required. While team practice may become the norm in healthcare it will be very important to understand better ways to encourage utilisation of evidence-based guidelines to maximise the best outcomes for patients. We did review the articles to see if there was a temporal change in uptake and could find no pattern. That is, we examined the articles written in the 1990s and compared them with those written in the last few years. From other work we have conducted in examining how teams learn to work together, we would conclude that having buy in from all the team members on plans of care for patients/clients is important, and sharing the practice guideline with each other, understanding and providing time to discuss the implications of a guideline, can only help team members work more cohesively.
Implications for practice, research and education
If team practice is the norm in a given setting, it makes sense that utilising best practice derived from evidence and presented as guidelines is more effective if the whole team is involved and receives similar dissemination strategies. The review has provided exemplars that those in practice can use to help them decide what strategies should be used. From a practice setting it is probably wise to include all professional groups, and the recipients of care when planning to make a change in normal care processes and procedures. Without full understanding of the practice guidelines it is unlikely that all team members and the recipients of care would abide by the guidelines.
More work is needed to understand how teams and the day-to-day functioning can affect knowledge translation and dissemination. If we understood the components of effective dissemination in teams this would help in multiple clinical settings to encourage healthcare providers to implement evidence-based practice.
While we prepare new practitioners and provide continuing professional development opportunities educators can be assured that this is some evidence that team approaches work. Healthcare providers need to be given the educational background in why evidence-based practice is important and strategies to increase uptake may be tailored depending on setting and substantive area. People learn differently and learners should be aware of how they learn best. This will then assist them in developing techniques for themselves that will promote keeping themselves updated on new knowledge and findings. Educators should explore with learners how they best learn and offer material in a variety of formats.
Dissemination and implementation strategies for healthcare teams and team-based practice were identified in 88 studies from 1995 to 2007. Team approaches were found across varied populations. The study designs were heterogeneous utilising randomised control, descriptive/case series or comparable cohort/case control study methods. Statistical meta-analysis was not possible as the studies were not alike in strategies and outcomes used to make meaningful comparisons. A descriptive analysis showed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and or outcomes for 72.7% of the studies. Many of the studies provided caveats to explain how or why the strategies did or did not show improvements. Overall, authors described complex healthcare requiring increasingly complex approaches to ensure evidence-based guidelines were utilised into practice, including using multiple dissemination and implementation strategies. Team-based healthcare is one way to ensure patients receive optimum assistance to manage complex health problems. The use of guidelines ensures teams have a similar approach to care in a given population and receiving multiple approaches to dissemination and implementation there is an increased likelihood of positive results in knowledge, practice and or outcomes.
The review was partially funded by the Queen's University Inter Professional Patient-centred Education Direction (QUIPPED) grant (Health Canada) and supported by the Queen's Joanna Briggs Collaboration funded by the Ontario Ministry of Health and Long Term Care. Paola Durando was granted partial time by Bracken Library at Queen's University to undertake the complex search strategy for the review. All authors gave much of their own time to complete the review. Ian Graham, Vice President, Canadian Institute of Health Research is thanked for providing help and guidance during the development of the protocol and for identifying the gap in the review literature of this topic.