| Objectives:① To understand the general situation of the promotion of community hospitals,the baseline situation of evidence-based practice programs for stroke and dysphagia;To analyze the barriers and facilitators affecting the scaling up of evidence-based program;②To verify the applicability of existing evidence and formulate implementation strategies,action strategy plans based on the best available evidence and combined with priority obstacles and facilitators;③To carry out community clinical practices to further promote the successful implementation of previous programs in the new environment,improve patient outcomes,improve nurse service quality,and strengthen evidence-based culture.Methods:This research was based on the WHO/Expandnet extension model as a theoretical framework and carried out following the implementation research steps.①Contextualizing implementation research issues:Observation and interviews with key insiders were used to clearly promote the general situation and available resources of the pilot community hospitals.Evidence review and questionnaires were used to understand the acceptability and availability of evidence in the community,the baseline situation of patients and nurses,and the gap between the current state of community practice and the evidence;The we used a stakeholder-based concept mapping method to comprehensively analyze the obstacles and facilitators for the implementation of the program,and give priority factors.② Developing an implementation research proposal:Based on the best available evidence and existing obstacles and facilitators,literature research methods and expert meeting were performed to formulate one-to-one implementation strategies and action strategy plans using available resources.③ Planning and conducting an implementation research project:implemented the strategies and plans,evaluated the effectiveness of the implementation of the program at the level of nurses,patients,implementation outcomes.Results:①Common situation of the community:The hospital is well located,with a large base of patients;Baseline survey of the protocol:based on the previous 9 pieces of evidence,14 clinical status review indicators were constructed.The implementation rate of 93%indicators was poor or not implemented,and 7%indicators were fully implemented.The overall acceptability score of the scheme was 40.71 ± 2.26,and the overall adoptability score was 32.00±1.89.The adoptability of each item was less than the acceptability;Community nurses baseline:The average score for evidence-based practice abilities was 14.24 ± 10.25,the average score for dysphagia-related knowledge was 35.06 ± 13.23,and the satisfaction score for dysphagia-related work was 76.30 ± 14.20.Community patients baseline:SWAL-QOL average score was 120.43± 25.23,dysphagia-related knowledge test average score was 41.36± 11.56,and the average score for patients’satisfaction was 97.22 ±2.47;The obstacles and facilitators affecting the scaling up of the program included:4 primary factors,10 secondary factors and 61 three-level factors.②A total of 3 guidelines,1 was an expert consensus,and 2 were evidence summaries were included in the formulation of the plan.We adjusted and supplemented the screening time,screening tools,treatment methods,nutrition risk screening,graded management,remote stroke rehabilitation,TCM nursing technology and other contents of the previous protocol for dysphagia;updated the best evidence and priority after adjustment obstacles and facilitators,developed implementation strategies and action strategy plans.③The program was implemented through the steps of establishing a community promotion team,pre-implementation material preparation,promotion and implementation of education and training,promotion start-up meeting,promotion and implementation of the plan,supervision of the promotion process,evaluation of promotion effect,and continuous quality improvement.The patients SWAL-QOL score,dysphagia knowledge score,and patient satisfaction were improved(P<0.05);the nurses’ evidence-based practice abilities,dysphagia-related knowledge level,and dysphagia-related work satisfaction were improved,and the differences were statistically significant(P<0.05);the acceptability and the adoptability of the protocol were increased,so did the execution rates;new project-related management documents,operating procedures,educational materials and knowledge manuals have been added in the community,and the implementation of evidence-based program improved evidence-based culture.At the same time our project provided an idea for the evidence-based"hospital-community" sinking linkage model.Conclusions:①It was clear that the community could provide a certain basis for the scaling up;The overall implementation rate of the review indicators was poor.There was a gap between the community situation and evidence.Nurses needed to enhance evidence-based practice abilities,dysphagia knowledge,and work satisfaction.Patients needed to raise the quality of life,dysphagia knowledge level and satisfaction;the overall protocol was acceptable with poor adoptability.When the program was scaled up to the community,evidence should be adjusted in order to match the community hospital and improve its adoptability.The main factors affecting scaling up included evidence levels(reliability of evidence,evidence of Advantages,easy transfer or placement of evidence),community levels(community implementation capacity,community demand balance),resource team levels(scale and stability of resource teams,necessary skills for resource teams),scaling up strategy levels(Organization process of scaling up,funding resources,Continued monitoring and evaluation).②The cross-agency adjustment of evidence-based practices must be based on the core elements of evidence-based care,and all needed to find the best balance between evidence,professionals,patients and context.Dynamically updated,adjusted,and optimized programs to better match the characteristics of community institutions.Developing specific and feasible implementation strategies and action strategy plans should consider the priority obstacles and facilitators.③ The project implementation needed to have a clear project planning table,including:establishing a project implementation team,task allocation,determination of the implementation site,implementation content determination,implementation time planning,data collection process,effect evaluation and other aspects,and targeted at different stages Specific clinical problems are continuously adjusted and revised action strategies to effectively promote the continuous and efficient implementation of the program promotion.Scaling up the evidence-based practice program could promote the improvement of patients’ quality of life,dysphagia-related knowledge level,and patients’ satisfaction;improve nurses’evidence-based practice abilities,dysphagia-related theoretical knowledge,and dysphagia-related work satisfaction;help building the culture of evidence-based organizations,improving the acceptability and adoptability of the program,and the implementation rate;also provide a reference to the evidence-based "hospital-community"sinking linkage nursing model. |
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