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Theme 3: Selecting, tailoring and evaluating effectiveness and efficiency of KT interventions

3.1 Addressing Vertebral Osteoporosis Incidentally Detected to prevent future fractures

Investigators:
Majumdar, Johnson, McAlister, Rowe
Duration:
0-36 months
Targets:
Physicians
MRC Phase:
3

Background

Osteoporosis leads to decreased bone mass, skeletal fragility, and fractures. Osteoporosis affects at least 1.4 million Canadians, 25% of women and 12% of men ≥60 years of age. The most common osteoporotic fractures are vertebral (spinal), two-thirds of which are asymptomatic. Irrespective of symptoms, these "silent" fractures cause disability, deformity, and death. Compared to those with normal bones and no fracture, the patient with osteoporosis and vertebral fracture has a 20-fold increased risk of future fracture. These fractures are costly and painful and lead to deformity, disability and perhaps death. Guidelines recommend aggressive treatment of osteoporosis because rate of repeat fracture is 20% within 1 year and treatment reduces risk by 40-50%. Guidelines do not, however, recommend population screening for vertebral fractures. We reported (Arch Intern Med, 2005) that chest radiographs performed in the ED detected "incidental" fractures in 16% of elderly patients, although only 25% were treated for osteoporosis.

Objectives

To improve the quality of care for elderly patients with osteoporosis and vertebral fractures incidentally detected by a chest radiograph in the Emergency Department (ED).

Specific Aims:

To determine whether exposure to a physician-directed quality improvement intervention can-

  1. Aim #1. Increase rates of osteoporosis treatment in patients with newly recognized vertebral fracture(s);
  2. Aim #2. Increase patients' self-reported diagnosis of osteoporosis and other related knowledge;
  3. Aim #3. Be further augmented by the addition of patient-activation.

Methods

A multi-center (3 EDs) prospective nonrandomized controlled trial with blinded (allocation-concealed) ascertainment of outcomes comparing the proposed physician-directed intervention to usual care controls. We define usual care as notification of the patients' primary care physician of chest radiograph results. Allocation will be on the basis of an alternate-week time series design, with the proposed intervention "on" for all patients for one week, followed by the intervention being "off" (i.e., usual care) the next week. After 3 months, controls will be offered the physician-intervention plus patient-activation, with outcomes recollected 3 months later. Eligible patients will be ≥60 years of age who: (1) have a chest radiograph reporting the presence of a vertebral fracture, (2) are not taking prescription osteoporosis treatment, and (3) are discharged home from the ED. The primary outcome is the proportion of patients starting new prescription osteoporosis treatment within 3 months of fracture recognition; secondary outcomes include BMD testing and self-reported diagnosis of osteoporosis. The intervention is expected to increase the primary outcome by at least 20% (absolute) over usual care new start rates of 10%. With alpha=0.05, beta=0.80, 20% losses-to-followup, plus additional sample size/power to address potential center-effects, evaluate the influence of patient-activation, and explore secondary outcomes, the required total sample size is 300 patients.

Significance

To our knowledge, no studies examining strategies to improve care for this vulnerable and high-risk population exist, and our results should be important regardless of findings. If "negative" it will provide evidence that more costly and laborious interventions will be needed to overcome clinical inertia; if positive, however, our intervention should be widely applicable. In addition, positive results can be easily extended to other related populations (e.g., routine chest radiographs for admission to nursing homes) and can be adapted for implementation via other modalities (e.g., computerized decision support or telemedicine).

3.2 Effectiveness of a web-based teaching curriculum for implementing a clinical pathway

Investigators:
Johnson, Klassen, Benzies, Grimshaw
Duration:
0-60 months
Targets:
HCP
MRC Phase:
2-3
Community Partners:
Calgary Health Region, AB rural physicians action plan (RPAP), Southern AB child & youth network SACHYN

Background

The Calgary Health Region (CHR) is developing a series of clinical pathways for the management of common paediatric problems in emergency departments and urgent care centres (ED/CC) that will be implemented using interactive teaching sessions and reminder systems. We are evaluating this initiative using an interrupted time series (ITS) as part of a CIHR funded Team Grant in Pediatric Emergency Care. The interventions were chosen because of evidence of their effectiveness in other settings (O'Brien 2001, Garg 2006, Grimshaw 2004). However the uptake of educational sessions within knowledge translation activities is limited due to 'time pressures', and an inability to fit fixed-scheduled teaching sessions into their busy daily lives. A web-based, teaching curriculum designed for primary care health providers may effectively supplement interactive teaching sessions, because it offers physicians the opportunity to access the modules at their convenience. In this application we seek additional funds to develop and evaluate a web based teaching curriculum for family physicians as an adjunct intervention for the proposed clinical pathway on the management of gastroenteritis. This is the commonest reason for children and their parents to seek urgent health care (King). There are ongoing concerns about overuse of intravenous rehydration requiring unnecessary inpatient admission given that the majority of children can be safely cared for at home using oral rehydration (American Academy of Pediatrics; Bellemere).

Objectives

To determine if the addition of a web-based curriculum to an interactive teaching session and reminder system enhances the implementation of a clinical pathway that addresses the management of childhood gastroenteritis in emergency.

Methods

Intervention:

We will develop the clinical pathway, face-to-face educational session and reminders. In addition, we will create a modular web-based curriculum using a case based format and incorporating audiovisual files of ill and injured children, and hyperlinks to pathophysiology and pharmacology, and the primary evidence that has established 'best practice' to create a flexible learning environment for multidisciplinary users with differing learning needs and styles.

Design:

We will use an interrupted time series (ITS) design with multiple baselines. ITS designs attempt to detect whether an intervention has had an effect significantly greater than the underlying trend (Shaddish, Cook and Campbell, Ramsay). Data are collected at multiple time points before and after the intervention; the multiple time points before the intervention allow the underlying trend to be estimated, the multiple time points after the intervention allow the intervention effect to be estimated accounting for the underlying trend. Such designs are appropriate in evaluating implementation strategies when it is difficult to randomise or identify a suitable control group - as with the regional introduction of a clinical pathway. The introduction of the intervention will be staggered across the different ED/UCC centres over an 18 month period. In order to understand month-to-month and seasonal changes in rates over time, we will derive utilization rates and practice patterns for 7 years divided into 84 one month periods. Data will be collected on all children in the CHR evaluated in a CHR ED/UCC who have a discharge diagnosis of gastroenteritis by linkage and analysis of health care administrative databases, retrospective chart audit to assess the change in health care utilization rates, medical practice patterns, and the psychosocial burden of the disease on their families after implementation of clinical pathways for gastroenteritis within the CHR. An economic analysis will be performed based on a societal perspective.

Sample size and analysis:

The power of ITS designs is a function of the stability of the estimates of the slopes before and after the intervention. In general, greater than 50 repeated observations seem necessary to adequately control type 1 errors and provide adequate power of intervention effect detection. In the analysis we will analyse individual time series curves for each ED/UCC using Box-Jenkins ARIMA analysis and pool data across ED/UCCs to examine overall effect of intervention.

Significance

If this intervention is found to be effective, it will be tested across multiple sites within KT Canada in a randomized trial. It will advance the knowledge of the effectiveness of online continuing education.

3.3 Promoting Shared decision making for the management of acute respiratory illnesses - feasibility study

Investigators:
Légaré, Godin, Labrecque, Laurier, Thivierge, Grimshaw, O'Connor, Stacey, Straus, Sales
Duration:
0-24 months
Targets:
Patients, HCP
MRC Phase:
2

Background

Acute respiratory infections (ARI) are the most frequently reported reasons for consulting primary care.114 Although the majority of these infections are viral in nature,115;116 over 60% of patients receive unnecessary antibiotics increasing health care costs to patients and health care systems and risk of antibiotic resistance.117;118 Shared decision making (SDM) is a promising strategy for effective KT between patients and their health providers and particularly so in contexts of uncertainty.119 SDM refers to a process by which a healthcare choice is made by practitioners together with the patient, based on the best available evidence and in line with what an informed patient would value. However, it is not clear how SDM can be implemented in clinical practice. We have completed a series of small scale feasibility studies in a small sample of family physicians (FPs) in Québec City of a multifaceted intervention to implement SDM for management of ARI (DECISION+). This involved three 3.0 hour interactive workshops for FPs (focusing on probabilistic nature of the diagnosis in the context of ARI, the scientific evidence on the risks/benefit of treatment options including antibiotics for ARIs and strategies to foster active patient participation in decision making), bi-weekly brief, paper reminder of key issues highlighted in the workshops, feedback on the level of agreement between patients' and providers' level of decisional comfort and printed educational material targeting patients. DECISION + led to 1) reductions in decisions to use antibiotics for ARI by both patients and providers 2) improved agreement between the patient' and provider's perception of decisional comfort and 3) improved intentions of providers to engage in SDM in future clinical encounters.120-122

Objectives

We plan a definitive trial of DECISION + in 3 provinces delivered in both official languages but believe additional feasibility work is needed to demonstrate the feasibility of: 1. delivering the intervention in English in diverse primary care settings 2. dyadic outcome measurement involving patients and FPs and 3. FP recruitment across 3 provinces.

Methods

This study will be a prospective, multi-center, mixed method, exploratory trial conducted in Québec, Ottawa and Calgary over a 2 year period.

For objective 1 and 2 (months 0-18)

We will engage in translation and back translation of the existing DECISION+ program materials and all relevant self-administered questionnaires for patients and providers based on the guidelines for cross-cultural adaptation of self-reported measures.123 We will pilot test the educational workshops on 4-6 English speaking FPs in Ottawa and Calgary (recruited through family practice teaching networks). FPs will be recruited by the team of investigators with help from research assistants at each site. All pilot interactive workshops will be audiotaped and transcribed verbatim. Content analysis will be performed to assess the fidelity of the English workshops to the French workshops. Outcome measurements include: at the time of consultation - the Dyadic Decisional Conflict Scale (D-DCS) (FP and patient), the Decision to use antibiotic (FP and patient) and Intention to engage in SDM in future clinical encounters (FP only);124 and 2 weeks following the index consultation - the Decisional regret scale (FP and patient).75 In order to pilot test the adapted English questionnaires and assess their reliability 40 dyads of FPs and patients will be recruited using a procedure that was successfully used in the past by team members.121 The reliability and validity of the translated measures will be assessed using standard approaches.125 We anticipate that the sample size for a definitive trial will be around 120-160 family physicians.

For objective 3 (months 16 – 24)

We will approach family practices in and around Quebec City, Ottawa and Calgary. Each practice will be provided with a detailed description of the planned trial and implications for participants and asked about their potential interest in participation. FPs who are potentially interested will be contacted by phone to discuss their willingness to participate. Based on previous experience, we plan to approach between 250-300 family physicians to achieve our target.

Deliverables

DECISION + intervention toolkit and core measures available within both official languages, 2-3 peer reviewed publications, grant application for definitive randomised trial of DECISION + intervention

3.4 Development and pilot evaluation of an individualized feedback tool designed to increase appropriate use of treatments among family physicians

Investigators:
Brehaut, Poses, Shojania, Hing, Ramsay, Grimshaw, Handfield-Jones
Duration:
36-60 months
Targets:
HCP
MRC Phase:
1-2
Community Partners:
CMA

Background

The problem of inappropriate use of existing treatments is a significant challenge for KT researchers. There is mounting evidence that a wide variety of treatments are either under- or over-used, and that this misuse causes significant burden to the Canadian health and social welfare system. For example, treatment of pharyngitis with antibiotics has been reported for between 57% and 74% of patients, yet the literature shows very little evidence of the effectiveness of these treatments in terms of speed of symptom resolution, or lower rates of adverse events. In a science methods protocol, we argued that part of the explanation of these inappropriate treatment decisions stems from misunderstandings on the part of individual physicians about the likelihood of different treatment outcomes; for example, underuse of warfarin in patients with atrial fibrillation stems from overestimation of harms and underestimates of benefits. We developed a vignette-based task administered by postal survey based on social judgment analysis and showed that there is a close association between treatment decisions and judgments of the likelihood of outcomes and, that inaccurate outcome judgments can be attributed to too much attention paid to aspects of the vignettes that are unrelated to the treatment outcomes, and not enough attention paid to vignette cues that are related to outcomes. In this proposal, we plan to develop an online tool designed to show individual physicians the extent to which they over- or under-weight certain aspects of the decision, and examine whether such feedback can change subsequent decisions. This project will serve as pilot work for a definitive RCT evaluating the usefulness of the online vignette-based task as an intervention to encourage physician behaviour change.

Objectives

To develop, and evaluate an online, vignette-based educational tool that evaluates how individual physicians make common treatment decisions, and provides them with feedback on how their strategies compare to that of an 'optimal' strategy suggested by empirically-derived guidelines;

Methods

Phase 1

Phase 1 of this project will involve the development of an online, immediate-feedback version of the task developed for the previous project. A series of written vignettes about the use of antibiotics for treatment of pharyngitis has been developed. The primary goal of this series of vignettes is to measure the specific factors that drive individual clinicians' judgments and treatment decisions. The task involves asking physicians to respond to 16 realistic case vignettes. Several clinical variables are varied systematically across the 16 cases, according to a partial factorial design. The variables have been chosen based on previous work outlining the factors (both correct and incorrect) known to affect physician decisions in this specific clinical case(i.e. age, gender, ethnicity, cough presence/absence, cough productive of green sputum, fever, nasal discharge, smoking, tonsillar exudate, tender lymph nodes). By asking physician respondents to indicate what management decision they would choose for each combination of clinical variables, as well as the likelihood they would choose that management decision given 100 cases like it, we will be able to identify which variables have the greatest effect on physician judgments, and whether judgments are affected by non-predictive cues, or unrealistic expectations of appropriate cues. After presenting and recording responses to each of the 16 vignettes, the program will feedback the 'judgment strategy' indicated by the participants' responses. This judgment strategy can be represented as a linear regression model, with standardized regression weights describing the relative importance of each cue in determining the physician's diagnosis. Feedback on the participant's judgment strategy will be fed back immediately after completing the vignettes, and will be presented along with an 'ideal' strategy suggested by evidence-informed guidelines (i.e. the Centor criteria).

Phase 2

Phase 2 will involve an iterative development process known as User-Centered Design (UCD). Data collection for this objective will involve expert and user testing. Three experts in the clinical area, and another three experts in computer usability will work through the format and structure of the tool to ensure that the clinical vignettes are realistic, and that the format of the tool conforms to basic principles of good design. Following the expert sessions, an updated version of the tool will be subjected to a series of 'user tests'. These user tests involve participants 'talking aloud as they use the tool. User tests will be videotaped and evaluated for user misunderstandings, expressions of frustration or confusion, and the specific areas of the tool where these occurred. These 'usability problems', as well as areas suggested for improvement by multiple users, will become target areas for improvements on subsequent iterations. The decision aid will be revised after each iteration, which will consist of user tests on 5-6 participants. These iterative user tests provide (in the first iteration) baseline measures of user satisfaction and performance (time required to read, comprehension, misunderstandings), as well as (in later iterations) measures of the degree to which the current version of the tool meets the pre-specified usability goals.

Phase 3

Phase 3 will be a pilot study examining whether the new tool changes physician decision-making about these vignettes, in an attempt to determine the feasibility of a randomised trial examining its effects on actual physician behaviour. Participant physicians will complete a pre-feedback series of vignettes as described above. Participants will then be assigned by alternation to receive either 1) feedback of their judgment patterns as compared to an 'ideal' pattern as described above, or 2) simple information on the guideline itself. After this feedback phase, all participants will complete another, post-feedback series of vignettes. Primary outcomes measured will include change in performance from the first series (as summarized by change in absolute beta weights across all clinical variables), and overall deviation from the ideal pattern (overall absolute deviation of all clinical variables from ideal pattern). Sample size calculation was based on detecting a 10% change on a summary deviation score between pre-and post-feedback weights assigned to all clinical variables; after running a 50,000 iteration simulation, detecting a 10% difference on a continuous outcome. Results of the simulation showed that a sample size of 40 individuals yields a proportion of rejecting the null when it is true of 0.048 (i.e. alpha level is approximately .05), while the proportion of incorrectly accepting the null hypothesis is less than .01 (i.e. power is greater than 0.99). We will also record qualitative information on people's impressions of the usefulness of both types of feedback as applied to the completed vignettes, and to their real-world practice.

Signficance

This will result in the creation of an online vignetted based educational tool targeted towards health care professionals. It will be further evaluated in a randomised trial that will be completed across multiple sites within KT Canada.

3.5 Improving Management of Diabetic patients on Waiting Lists

Investigators:
Haynes, Hunt, Gerstein
Duration:
0-24 months
Targets:
Patients, HCP
MRC Phase:
1-2
Community Partners:
Hamilton HS Diabetes Care & Rx Ctre

Background

Less than 50% of diabetic patients achieve treatment goals [Gaede P et al, 2003] because of problems in the quality of care they receive and/or their adherence to treatment recommendations. Patients in primary care failing to achieve treatment goals are commonly referred for specialty diabetic care. However specialty diabetic clinics often have waiting lists for non urgent patients; for example, the Diabetes Care and Research Centre at Hamilton Health Sciences in Southern Ontario has a typical delay of 6-9 months. We have developed a computerized decision support system (CDSS-D; Hunt DL, Haynes RB, 2001) that can support patients (and their family physicians) while they are on the waiting list by providing personalised treatment recommendations based on evidence-based diabetes guidelines to both the patient and the referring practitioner. This could reduce any negative impact of the waiting list and may reduce waiting lists if patients respond to the treatment recommendations and no longer need specialty referral. This may result in more timely and effective management of the patient's diabetes-related problems, while freeing up scarce specialty clinic time.

Objectives

  1. To perfect the feasibility and acceptability of delivering the intervention, practice and patient recruitment, and outcome measurement to plan for a future definitive randomised trial.
  2. To estimate if the addition of a diabetes CDSS-D at the time of referral results in improved control of diabetes and implementation of diabetes-related recommendations (eg, for eye care, foot care, smoking cessation, exercise, diet), and increased satisfaction of patients and referring physicians.

Intervention

We have developed a CDSS-D that is being tested in CIHR funded randomised trial focussing on community-volunteer patients, with physician participation optional. The CDSS-D uses responses from a patient questionnaire and hemoglobin A1c to generate evidence-based recommendations based on current Canadian Diabetes Association recommendations and details of local resources (e.g. CDA office, Diabetes Hamilton) and services (how to obtain free glucometers, access benefits to offset the cost of needed care, etc).

Methods

The CDSS-D is a complex intervention and we will follow recommended procedures for Phase I and II development and testing (Campbell et al, 2007). Initially, an abbreviated Phase I "modelling" study will be conducted with a convenience sample of newly referred patients and their referring physicians. We already have some experience with the intervention in community volunteer patients (for which the involvement of the patient's physician is at the discretion of the patient); the key issues for using the CDSS-D for newly referred patients are 1) the engagement of the physician and 2) interaction of the patient and physician, based on the recommendations that are generated by CDSS-D. The Phase I investigation will assess the acceptability and feasibility of the study procedures, including preferred options for completing the questionnaires for the patients (mailed, telephone interview, online and the proportions of patients who prefer or require each), format and nature of the advice generated by the CDSS-D, and acceptability and perceived actionability of the recommendations for each of the patient and physician pairs. Following the modeling study, a Phase 2 exploratory or pilot study will be undertaken with a before-after, single group design, to assess the measurement properties of the study data and estimate the effects of the of the intervention (see Analysis below). Referred patients will be asked, at the time of initial referral, to complete a questionnaire (see Appendix) and will submit a filter-paper blood specimen for hemoglobin A1c determination. They will also be given access to an office-hours "helpline" for additional support until the time of their diabetes clinical visit, at which time the questionnaire responses and A1c will be re-determined.

Recruitment:

For Phase I, we will recruit a convenience sample of referred patients and their physicians, and continue this phase until we have "saturation" of recommendations from patients and physicians to the study procedures. We do not expect that we will need more than about 30 patients and referring physicians for this phase, given the experience we've had in IN-CHARGE. For Phase II, we plan to recruit at least 100 patients spontaneously and newly referred from at least10 clinical practices. These patients are expected to be older, with more comorbidity and urgent treatment issues than the volunteer sample in IN-CHARGE.

Outcome measures:

We will assess the acceptability and usability of the service, and suggestions for improvements for referred patients and referring physicians in Phase 1, by analysing patients' responses to the questionnaire and using post-questionnaire and post-recommendation debriefing of patients, and post-recommendation debriefing of physicians, using telephone interviews. Interviews will be qualitative, with an interview schedule directed to the components of the questionnaires and recommendations, and an open invitation for suggestions for improvement in any of these elements, proceeding until saturation. In Phase II, we will assess control of diabetes and cardiovascular risk factors by assessing baseline patient status for the 18 care recommendations in CDSS-D (assessed by questionnaire – see Appendices) and hemoglobin A1c (collected using the Via Post Filter Paper Card TM that is marketed by ROCHE, with a precision <4.4% at all levels), and changes in the number of recommended care items that are completed by the date of the diabetes clinic appointment (repeat baseline questionnaire and A1c). Relevant data collected by this questionnaire includes: a) self-blood glucose monitoring; b) the last measured A1c level; c) use of glucose lowering drugs; d) blood pressure, cholesterol and albuminuria monitoring; e) smoking status; f) foot care behaviours; g) number of visits to the primary health care provider or diabetes educator; h) self-reported physical activity and weight; i) use of ACE inhibitor, angiotensin receptor blocker, "statin", aspirin, diuretic, beta blocker, and influenza immunization; j) cholesterol measurement; k) time since the eyes were last checked. Responses to the items that are deemed to indicate optimal self-management according to CDA recommendations will be assigned a score of 1; other responses will be assigned a score of 0. Patient and physician satisfaction will be also be assessed by qualitative interviews.

Analysis:

For Phase 1, sampling will continue until saturation as noted in Recruitment above. The sample size for Phase II will be at least 10 clinical practices and at least 100 patients. This will allow us to estimate (using simple descriptive statistics), with reasonable confidence, eg, 95% confidence intervals of +/- 10%, the proportion of patients who implement 2 or more recommendations during the interval from initial referral to initial clinic visit, and provide even more precise estimates for the mean number of recommendations and variance from the CDSS-D per patient at baseline; the mean number and variance of recommendations implemented from time of initial referral to first clinic visit and related time-to-implementation indices; improvements in control of diabetes (based on the mean A1c difference and variance between baseline and first diabetes clinic visit); and the intraclass correlations for the referring clinics for these measures, all essential for proper planning of an eventual cluster RCT.

Significance

This study is a natural progression of our current investigations and shifts the focus to the patients most likely to be in need. It tests a computerized decision support system that targets both patients and practitioners, to date, an understudied innovation that is more likely to be effective than targeting either group alone. It also tests a potential solution for waiting lists for specialty care. If successful, the intervention will be formally trialled in other KT Canada Network sites and Canadian settings, and additional CDSSs can be prepared for other chronic disease conditions.

3.6 Coaching Workshop to Promote Knowledge Utilization in Long Term Care: Development and Pilot Testing

Investigators:
Cummings, Sales, Estabrooks, Laschinger, Wong
Duration:
13-36 months
Targets:
HCP
MRC Phase:
2
Community Partners:
Regional Health Authorities

Background

Attention has been directed to the role of nursing leaders in advancing change in healthcare organizations to create healthier and safer practice environments for both nurses and patients. Avolio and colleagues (2004) have proposed that authentic leadership is the root component of effective leadership needed to build trust and healthier work environments that promote patient safety, excellence in care and the retention of nurses. This leadership model focuses on the positive role modeling of honesty, integrity and high ethical standards to develop leader-follower relationships and may be a contributor to effective KT through its promotion of evidence use. In this study we will pilot-test the effect of a leadership intervention (Coaching for Impressive CARE) that develops coaching and communication skills, designed to increase longterm care (LTC) managers' authentic leadership behaviours. This program was developed by the Institute for Healthcare Communication to teach organizational leaders how to coach staff in dealing with complex patient care issues.

Objectives

  1. To determine the impact of a leadership intervention on nursing staff workplace attitudes, knowledge use, authentic leadership behaviours of managers, and work outcomes; and,
  2. To analyze relationships among managers' AL behaviours and staff nurse workplace attitudes (trust in manager, empowerment, and communication satisfaction), perceived quality of worklife and work outcomes (knowledge use, role performance, speaking up behaviour, job satisfaction and perceived quality of care).

Methods

An intervention study using a 1-group pretest-posttest-follow-up design will be implemented in longterm care facilities in Alberta. Survey data from nursing staff will be collected at baseline, within 6 weeks of the leadership coaching intervention and 6 months later. In month 15, three focus groups, one with managers who attended the program, and two with nursing staff, will be conducted to better understand the effect of the intervention and to identify potential program problems.

Study Sample:

The sample includes 18 managers from long term care in Calgary who will participate in the coaching leadership workshop. Survey data regarding the effectiveness of the workshop will be collected from unit staff reporting to managers on the Calgary site. We will approach all fulltime and part-time permanent nursing staff (registered, licensed practical nurses and nurse aides) on these study units which is approximately 400 nursing staff. A sample size of 53 individuals, each participating at all three data collections, was determined to detect a medium effect size (r2 = .12) with 80% power and a .05 level of significance (Cohen, 1988).

Data Collection:

A modified Dillman approach, with 2 mailings per data collection will be used to distribute the survey to nurses (Dillman, 1991).

Intervention:

One Coaching for Impressive CARE workshop (6.5 hours) will be offered for the managers. The program provides managers with specific skills and techniques that will support and reinforce efforts by employees to improve health care services. The workshop will be offered during month 3.

Data Analysis:

Quantitative:

Descriptive statistics and reliability estimates will be computed for all study variables. Repeated Measures Analysis of Variance will be used to assess for differences in outcomes across the 3 data points. A total sample size of at least 200 subjects is recommended as sufficient (Hu & Bentler, 1995).

Qualitative:

All focus group data will be transcribed and analyzed for significant themes within each group and across groups. The content of all qualitative data will be analyzed thematically and inductively. Data analysis will commence following the first focus groups.

Significance

This study will create new knowledge about developing relationships between managers and staff in the workplace that support staff performance and quality outcomes for patients, and empirical evidence for the efficacy of a leadership development intervention to enhance coaching and communication skills for front-line leaders.

References

  1. Avolio, B.J., Gardner, W.L., Walumbwa, F.O., Luthans, F., & May, D.R. (2004). Unlocking the mask: A look at the process by which authentic leaders impact follower attitudes and behaviours. Leadership Quarterly, 15, 801-823.
  2. Dillman, D. A. (1991). The design and administration of mail surveys. ¬Annual Review of Sociology, 17, 225-249.
  3. Hu, L., & Bentler, P. (1995). Evaluating model fit (pp. 76-99). In R. Hoyle, (Ed.) Structural equation modeling: Concepts, issues, and applications. Newbury park, CA: Sage Publications.
  4. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press
  5. Institute of Medicine (IOM). (2004). Keeping patients safe - Transforming the work environment of nurses. Washington, DC: National Academy Press.