| This sandwich thesis presents the findings of a qualitative nested case study that explored the introduction of medical directives into clinical practice within a southern Ontario teaching hospital. The purpose of this study was to describe and explore the factors influencing the development and implementation of medical directives in the hospital. In-depth, semi-structured interviews were conducted with a purposive sample of 7 physicians, 9 nurses, 2 allied healthcare professionals, 6 administrators, 2 regulatory body representatives and 1 consultant. Eleven documents including 3 medical directives, 4 legal perspectives and 4 policies were purposively chosen for analysis. The analytic process revealed that medical directives are being developed to standardize care, handle liability issues, provide increased scope of practice for other health providers, improve timeliness of care and to cope with physician resource shortages. Implementation of medical directives is influenced by nurse confidence and willingness to assume increased responsibility, the amount of new learning needed to carry out the directive, additional paperwork required, perceived usefulness of the directive, physician support of nurses' use of the directives and the frequency of encounter with the type of patient described in the directive. The process of developing a medical directive was facilitated by organizational support, physician leadership, stakeholder involvement, and perceived appropriateness of the medical directive. The process was impeded by the use of technical language and the absence of important stakeholders in the crafting of the directive. Increased understanding of these factors will assist regulatory bodies, administrators and healthcare professionals to develop and implement medical directives that potentially lead to timely, efficient and effective provision of care to patients in the hospital. Drawing from the study findings, as well as the literature on clinical practice guidelines and change management, a conceptual framework for successful development and implementation of medical directives is presented. |
