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Nurses' perceptions of consensus reports containing recommendations for practice
Nurses' Perceptions of Consensus Reports Containing Recommendations for Practice Sheila T. Fitzgerald, CRNP, PhD M a r t h a N. Hill, RN, PhD Barbara Santamaria, RN, MPH, CFNP Cheryl Howard, M P H Rose Jadack, PhD, RN
Consensus reports providing guidelines designed to alter clinical practice are being disseminated with increasing frequency by professional associations, the government, and voluntary health agencies. The purpose of this study was to examine nurses"perceptions of consensus reports that contain recommendations designed to alter clinical practice, including the extent to which consensus reports offer relative advantage over other more traditional sources of practice-related information. Strategies for encouraging the use of consensus reports are discussed.
T
he m a n n e r in w h i c h nurses learn new information and make decisions to change their practice behaviors is a topic of considerable research and clinical interest. Consensus statements and reports have been issued with increasing frequency to disseminate new information to health care practitioners with the goat of influencing practice, tn addition, they are intended to serve as a primary reference for policy development, including setting priorities for research.l. 2 Groups of experts are being brought together by sponsors such as the National Institutes of Health (NIH), the Agency for Health Care Policy and Research (AHCPR), and professional associations such
Nurs Outlook 1997;45:229-35. Copyright © 1997 by Mosby-Year Book, Inc. 0029-6554/97/$5.00 + 0
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as the American Nurses' Association (ANA) to reach agreement on state-of-the-art practice and publish consensus reports containing practice guidelines. Sponsors of these consensus reports, who are commonly guided by social science theory, including Rogers' diffusion of innovation theory, 3assume that the report guidelines and recommendations will be salient and readily adopted by the target audience. In addition, consensus reports are developed to serve as useful resources in defining criteria, norms and standards, and health care expenditure determinants. 4 Increasingly, guideline development by consensus is seen as an essential step in assessing and improving the quality of health care. Research on the diffusion of innovations shows that factors other than the content of the information itself is important in determining whether people will adopt
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the innovation or ideas contained within consensus reports. 58 The extent to which the target audience receives and uses information and changes behavior according to recommendations is influenced by the scientific credibility of the source(s) of the information and the importance of the information) According to Rogers, 3 several underlying dimensions of innovations have been shown to be important, including ( 1 ) relative advantage (the degree to which an innovation is perceived as better than the idea it supersedes); (2) compatibility (the degree to which the innovation is perceived to be consistent with existing values); (3) complexity (the degree to which the innovation is perceived to be difficult to understand and use); (4) trialability (the degree to which an innovation may be ex-
Increasingly, guideline development by consensus is seen as an essential step in assessing and improving the quality of health care.
perimented with on a limited basis); and (5) observability (the degree to which the results of an innovation are visible to others). Thus the perceptions of consensus reports held by the target audience directly influence whether the recommendation will be considered and used in practice. Fitzgerald et al.
229
AAOHN
(266 members) Nurse characteristics Female Caucasian Certification Occupational health nursing" Adult nurse practitioner* Family nurse practitioner" No certification* Educational level (highest degree) Associate degree Diploma program* Baccalaureate* Masters* Nurse practitioner* Doctorate Non-nursing Nursing Practice setting Occupational* Private practice/H MO/ community health agency" Hospital" Other"
ANA (535 members) N %
N
%
261 243
98.1 91.4
513 509
96.2 95.9
167 9 6 70
62.8 3.4 2.3 26.3
10 116 183 51
1.7 20.2 31.9 8.9
42 169 91 20 17
15.8 63.5 34.2 7.5 6.4
57 175 465 443 267
9.9 30.5 81.0 77.2 46.5
0 0
0.0 0.0
33 18
6.2 3.4
246 7
92.5 2.6
41 172
7.7 32.1
2 11
0.8 4.1
162 160
30.3 29.9
*Chi-square analysis significant, p < 0.0125, after Bonferroni correction for multiple comparisons. *Chi-square analysis significant, p < 0.007, after Bonferroni correction for multiple comparisons.
Hill and Weisman 9 examined physicians' perceptions of consensus reports and found that physicians reported generally positive or neutral views. On an investigator-developed seven-point semantic differential scale of 17 descriptive adjectives (with 1 being most positive and 7 being least positive), 595 physicians most positively perceived consensus reports as credible (mean = 2.25; standard deviation [SD] = 1.1) and reliable (mean = 2.41; SD = 1.1). Physicians' least positive perception was a neutral assessment of consensus reports as biased (mean = 3.79; SD = 1.6). Factor analysis revealed three factors: compatibility, complexity in understanding, and complexity in use. The compatibility dimension was rated significantly more favorably than complexity in understanding and complexity in use. The relative advantage of consensus reports compared with more traditional methods of learning also was assessed by Hill and Weisman. 9 Physicians strongly or somewhat agreed that the availability of consensus reports was better than each practitioner need230
Fitzgerald et al.
ing to find out the information from colleagues (85%), textbooks (73%), and staff meetings (68%). Fewer physicians agreed that consensus reports offered relative advantage over journals (60%) and continuing education (58%). Physicians also were asked to what extent they perceived as influential the three sources of consensus reports that contained guidelines for practice. Results showed that 46%, 38%, and 26% of physicians reported professional associations, the federal government, and voluntary health agencies, respectively, as very influential sources of consensus reports. We have not identified any research reports that examine nurses' perceptions or views of consensus reports, use of consensus report information, and behavior based on relevant information contained in a particular consensus report. N o r have nurses' perceptions of the relative advantage of consensus reports over other sources of practice-related information been identified. Yet consensus guidelines developed by multidisci-
plinary groups and disseminated with the intent of influencing nursing and medical practice are proliferating. T h e release of the Expert Panel Report on Guidelines for the Diagnosis and Management of Asthma provided an opportunity to examine nurses' perceptions of consensus reports in general, as well as their awareness and use of a nationally promulgated consensus report containing guidelines for care of patients with asthma. L°lz This Report was endorsed by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee of the National Heart, Lung, and Blood Institute (NHLBI). The A N A and the American Association of Occupational Health Nurses (AAOHN), who belong to the Committee, endorsed the Report. Dissemination efforts included articles in official publications featuring the guidelines, announcements with instructions about how to obtain a copy, and featured presentations at annual meetings. Copies of the Report were not mailed to members of each organization because of cost constraints, but they were available on request. The awareness and use of the Report 1 year after its release by occupational health nurses (OHNs) is reported elsewhere. 13 The purpose of this study was to examine nurses' perceptions of consensus reports. A secondary purpose was to further evaluate the instrument that assesses perceptions of consensus reports. The assumptions underlying the study were that consensus reports are thought to be influential in changing nurses' behavior to the extent that clinicians are familiar with them and perceive them as being compatible with current values; that the reports are thought to offer advantage relative to other credible sources of information; and that they are thought to be sponsored by influential sources. The extent to which specific perceptual dimensions that emerged are compatible with diffusion of innovation theory was also examined. The following six research questions were explored: (1) What are nurses' perceptions of consensus reports as a general source of clinical information? (2) Do A A O H N and A N A members have different perceptions of consensus reports? (3) Do RNs and MDs have different perceptions of consensus reports?
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(4) What are nurses' perceptions of the relative advantage of consensus reports compared with other sources of information ? (5) What is the perceived influence of consensus report sources (government, professional organizations, and voluntary health organizations) ? (6) What level of awareness of, familiarity with, and use of consensus reports do nurses have 1 year after dissemination? METHODS
Sample and Procedures A pretest-posttest design was used to survey nurses who work with patients who have asthma and to examine their perceptions of consensus reports in general and their awareness of and use of asthma management consensus reports 1 year after their release. The sample was drawn from two sources: the A A O H N and the A N A . These associations were selected to provide the study population because they belong to the NAEPP Coordinating Committee and their members are likely to be caring for adults with asthma. Moreover, these associations endorsed the Expert Panel Report on Guidelines for the Diagnosis and Management of Asthma. Limited resources precluded national surveys of both organizations. A regional A A O H N sample was chosen because the concentration of members in the mid-Atlantic region offered a "best case" assessment opportunity. Nurses in the mid-Atlantic region who were members of the A A O H N and nurse practitioners, clinical nurse specialists, and community health nurses who were members of the A N A were surveyed. The pretest survey was conducted 1 month prior to the publication and dissemination of the Expert Panel Report. 12 Questionnaires were mailed to 1788 nurses. After a second mailing to nonresponders, a total of 1107 (61.9%) surveys were returned. Of the responders, 207 (18.7%) were determined to be ineligible for the study because they were retired members of the professional organizations or were not involved with patient care. One person did not fully complete the questionnaire. Thus a 57% adj usted response rate (899 responders/1581 mailed surveys) was obtained in the month available for data collection prior to publication of the report. Finally, because an important purpose of this study was to comNURSING OUTLOOK
Item pairs
Overall (N = 801) Mean (SD)
Factor 1: Compatibility* Credible-not credible* Helpful-harmful* Reliable-not reliable* Valuable-worthless* Influential-not influential* Necessary-unnecessary* Scientific-not scientific Authoritative-not authoritative
23.4 2.7 2.8 2.8 2.9 3.0 3.0 3.1 3.2
Factor 2: Complexity" Easy to understanddifficult to understand* Easy to use-difficult to use* Straightforward-confusing* Simple-complex* Practical-impractical* Time saving-time consuming* Precise-vague*
24.9 (6.7) 3.5 (1.3)
Factor 3: Bias Biased-impartial
3.6 3.5 4.0 3.2 3.5 3.6
(7.7) (1.2) (1.1) (1.2) (1.2) (1.3) (1.3) (1.4) (1.3)
(1.2) (1.2) (1.3) (1.2) (1.2) (1.2)
4.0 (1.4)
AAOHN (N = 266) Mean (SD) (7.8) (1.3) (1.2) (1.3) 3.3 (1.2) 3.3 (1.3) 3.3 (1.3) 3.3 (1.4) 3.4 (1.3)
ANA (N = 535) Mean (SD)
25,9 3.1 3.1 3.2
22.1 2.5 2.6 2.6 2.7 2.8 2.9 3.1 3.1
27.1 (6.9) 3.9 (1.3)
23.8 (6.3) 3.3 (1.2)
4.0 3.9 4.3 3.6 3.7 3.8
(1.2) (1.2) (1.4) (1.2) (1.2) (1.2)
4.1 (1.4)
3.4 3.4 3.8 3.0 3.3 3.5
(7.4) (1.1) (1.1) (1.1) (1.1) (1.2) (1.3) (1.3) (1.3)
(1.1) (1.2) (1.3) (1.2) (1.1) (1.2)
4.0 (1.4)
Respondents rated item pairs on 7-point scales (1 = positive descriptor of pair, 7 = negative descriptor of pair). The two subscale scores were computed by adding the individua/items. For compatibility there was a possible high score of 48. For complexity there was a possible high score of 49. "Significant between-group difference, p < 0.003, after Bonferroni correction. pare nurses affiliated with the A N A and nurses affiliated with the A A O H N , 98 persons were dropped from analyses because (1) they reported being members in both organizations (n = 64), or (2) they reported that they currently belonged to neither organization (n = 34). Therefore the final pretest sample of 801 respondents consisted of 266 nurses from the A A O H N and 535 nurses from the ANA. Table 1 shows the demographic characteristics of the survey responders at time 1. The responders were predominantly white women with a mean age of 46.9 years (SD = 8.7). The A A O H N and A N A respondents were representative of organizational member demographics on age, gender, and higher degree earned. A higher proportion of A A O H N members were certified and were practicing in occupational health settings. A N A members were significantly more likely to be masters prepared, employed in traditional health care
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settings, and report more time spent with patients with asthma than OHNs. Nurses' perceptions of consensus statements that contain recommendations for general clinical practice were measured with use of a 16-item semantic differential scale adapted from Hill and Weisman2 Respondents rated 16 item pairs on a 7-point Likert scale. These descriptor pairs included (1) credible-not credible, (2) reliable-not reliable, (3) simple-complex, (4) helpful-harmful, (5) scientific-unscientific, (6) biased-impartial, (7) authoritative-not authoritative, (8) easy to understand-difficult to understand, (9) valuable-worthless, (10) practical-impractical, ( 11 ) necessary-unnecessary, (12 ) influential-not influential, (13) straightforward-confusing, (14) time saving-time consuming, (15) precise-vague, and (16) easy to use-difficult to use. For each item pair, a score of 1 indicated the most positive view of consensus reports and a score of 7 indicated the most negative view. Fitzgerald et al.
231
Nurse ranking Item pairs Item pairs
Factor loading
Factor 1: Compatibility Credible-not credible Reliable-not reliable Scientific-not scientific Valuable--worthless Authoritativenot authoritative Influential-not influential Necessa ry-u n necessary Helpful-harmful
0.86 0.85 0.78 0.64
0.86 0.82 0.80 0.83 0.66 0.64 0.54
Factor 3: Biased Biased-not impartial
0.95
Question stem: "In general, consensus statements or reports that contain recommendations are ."
Next, respondents were asked the extent to which they agreed that the availability of consensus reports offered relative advantage to practitioners in comparison with learning about state-of-the-art recommendations from each of five sources: colleagues, continuing educational programs, journals, textbooks, and staff meetings. For each of these sources of clinical information, the respondent was asked to rate the relative advantage of consensus reports on a 4-point scale (1 = strongly disagree and 4 = strongly agree). The perceived influence of consensus report sources was measured by asking respondents to indicate their opinion of how influential each of the following is as a source of consensus report statements: federal government agencies (e.g., NIH), professional associations, and voluntary health associations. For each of these three sources of consensus reports, the respondent was asked to rate the influence on a 3-point
232
Fitzgerald et al.
Compatibility descriptor pairs Credible-not credible Reliable-not reliable Helpful-harmful Necessary-unnecessary Authoritative-not authoritative
1 2 3 4 5
2.66 2.79 2.80 2.99 3.17
(I .2) (I .2) (I .2) (I .3) (1.3)
I 2 3 4 3
2.25 2.41 2.62 2.88 2.62
(1.1) (I .I) (I .2) (I .4) (1.2)
1 2 3 4 5
3.22 3.45 3.53 3.61 3.64
(1.2) (1.2) (1.2) (1.2) (1.2)
3 4 2 1 3
3.41 3.56 3.18 2.90 3.41
(1.5) (1.3) (1.4) (1.4) (1.3)
Complexity descriptor pairs 0.78 0.67 0.62 0.57
Factor 2: Complexity Easy to understanddifficult to understand Easy to use-difficult to use Straightforward-confusing Simple-complex Practical-impractical Time saving-time confusing Precise-vag ue
Nurses Physician Physicians (N = 899) ranking (N = 595) Mean (SD) Mean (SD)
Practical-impractical Time saving-time consuming Straightforward-confusing Easy to use-difficult to use Precise-vague
Physician data from Hill MN, Weisman CS. Physicians' perceptions of consensus reports. Int J Technol Assess Health Care 1991 ;7:35. Copyright 1991 by the Cambridge University Press. Reprinted with permission. Respondents rated item pairs on 7-point scales (1 = positive descriptor of pair, 7 = negative descriptor of pair).
scale (1 = not at all influential and 3 = very influential). Persons who responded at time 1 were mailed a second questionnaire at time 2, 1 year after the Report was released. A total of 655 surveys were returned, resulting in a response rate of 72.8%. A t time 2, respondents were asked about their awareness and use of the asthma guidelines in the past year. Respondents were asked in a yes/no format whether they were aware of the guidelines, from what source they received the guidelines, and whether they believed they were generally familiar with the guidelines. O n a 5-point scale, respondents were asked how often they refer to guidelines in practice and to what extent their care of patients/employees with asthma is based on recommendations in the guidelines.
RESULTS In general, nurses in this study reported positive to neutral views of consensus statements that contain recommendations for clinical practice. The means and standard deviations of the 16 descriptor item pairs are shown in Table 2. Mean scores ranged between 2.7 and 4.0 on a 7-point scale (1 = positive perception and 7 = negative perception). Respondents viewed consensus reports as credible (mean = 2.7, SD = 1.2) and helpful (mean =
2.8, SD = 1.1). The consensus report descriptors that nurses rated least positively were biased (mean = 4.0, SD = 1.4), precise (mean = 3.6, SD = 1.2) and simple (mean = 4.0, SD = 1.3). In addition, evidence existed that some nurses perceived the reports as somewhat difficult to use, vague, and confusing. With use of a paired t test, means for the most favorably rated descriptor--credible and the least favorably rated descriptor biased~ were significantly different (t[801] = - 22.76, p < 0.001). A principal components factor analysis with an oblique rotation was conducted on the 16 item pairs (see Table 3). A n oblique rotation was chosen because it was anticipated that the resulting factors might not be unrelated to one another. Three factors emerged. Eight items loaded on the first factor, which was entitled "compatibility," and seven items loaded on the second factor, which was entitled "complexity." Only one item loaded on the third factor, entitled "bias." Because this item was the only negatively scored item pair among the 16 item pairs, it is unclear whether this item loaded onto a separate factor because it was a uniquely different factor or because it was the only negatively scored item. Therefore this factor was dropped from subsequent analyses. The two subscales showed good internal
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consistency. Reliability testing yielded a standardized alpha score of 0.89 for compatibility and 0.90 for complexity. Items for the compatibility and complexity subscales were summed. The mean scores for the compatibility and complexity subscales are shown in Table 2. Again, nurses reported neutral views with respect to the compatibility and complexity of consensus reports. For compatibility, respondents had a mean score of 23.4 (SD = 7.7; range = 8-56). For complexity, the mean score was 24.9 (SD = 6.7; range = 7-49). Significant professional association group differences with regard to the factor scores emerged. Nurses from the A N A perceived that consensus reports had significantly greater compatibility than nurses from the A A O H N (t[799] = 6.50, p < 0.001). Likewise, nurses from the A N A perceived that consensus reports had significantly less complexity than nurses from the A A O H N (t[799] = 7.11, p < 0.001). Results of these analyses were compared with those from previous work conducted with physicians, using the same scale to assess perceptions of consensus reports in general? Several differences emerged. First, the factor analysis of descriptor items produced a different factor solution, in that the complexity factor broke into two separate complexity factors: complexity in understanding and complexity in use. In the present study, nurses did not rate the descriptors in such a way to distinguish between complexity in understanding and complexity in use. Second, although nurses generally rated the descriptors of consensus reports in a similar fashion, the mean scores were generally more neutral (see Table 4). Participating nurses were asked to rate the relative advantage of consensus reports as a source of practice recommendations over other sources of information (see Table 5). Overall, respondents believed that the availability of consensus reports was better than each practitioner having to find out the information from colleagues. Availability of consensus reports was believed to offer relative advantage over textbooks, staff meetings, journals, and continuing education programs. Comparisons of source data were made between the A N A and A A O H N groups. One group difference appeared. A N A members, to a significantly greater extent than A A O H N members, believed that consensus reports were a better source of practice informaNURSING OUTLOOK
Information source Colleagues Continuing education programs Journals Textbooks* Staff meetings
Overall (N = 801) Mean (SD)
AAOHN (N = 266) Mean (SD)
ANA (N = 535) Mean (SD)
p
3.11 (0.68) 2.76 (0.83)
3.13 (0.70) 2.76 (0.90)
3.11 (0.68) 2.76 (0.79)
NS NS
2.72 (0.79) 3.01 (0.79) 3.02 (0.81)
2.76 (0.78) 2.88 (0.80) 2.93 (0.83)
2.70 (0.79) 3.08 (0.78) 3.06 (0.79)
NS 0.001 0.032
Data are from the question, "To what extent do you agree that the availability of consensus statements that contain recommendations for state-of-the-art practice is better than each practitioner receiving this information from .... " Respondents rated each item on a 4-point scale (1 = strongly disagree, 4 = strongly agree). "Significant between-group difference, p < 0.01, after Bonferonni correction.
Federal government (e.g., NIH, National Heart, Lung and Blood Institute)
2.74
(I .00)
2.74 (0.74)
2.73 (1.1 O)
Professional associations
2.65 (0.79)
2.60 (0.51)
2.67 (0.90)
Voluntary health organizations 2.43 (1.07) (e.g., American Heart Association)
2.40 (0.70)
2.44 (1.22)
Data are from the question, "In your opinion, how influential is each of the following as a source of consensus statements?" Respondents rated each item on a 3-point scale (1 = not at all influential, 3 = very influential).
tion than textbooks. Inspection of the means, however, show differences that may not have clinical significance. Overall, respondents believed that the federal government, professional associations, and voluntary health organizations were influential sources of consensus reports (see Table 6). No significant professional group differences emerged. Lastly, analyses were conducted to examine nurses' awareness, familiarity, and use of consensus reports 1 year after dissemination. Of 655 returned questionnaires, 13 were dropped from the analyses because of incomplete data. Similar to the data analyses conducted at time 1, 60 persons were dropped from time 2 analyses because they either reported being members of both the A N A and A A O H N or reported belonging to neither
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the A N A or the AAOHN. Therefore, time 2 analyses were conducted with a final sample of 582 nurses. A full 75.1% (n = 437) of the nurses returning complete questionnaires reported not being aware of the NHLBI guidelines 1 year after the Report's dissemination. A significant professional group difference existed. One hundred n i n e t e e n A N A nurses (30.2%) and 26 A A O H N nurses (13.8%) reported awareness of the guidelines (X2[1, N = 582] = 17.37, p < 0.0001). Nurses were asked how often they referred to the guidelines for asthma practice on a 5-point scale, and they reported infrequent use. Data are reported for the 145 respondents who reported awareness of the guidelines. Of the nurses who were aware of the guidelines at time 2, 66 Fitzgerald et al.
233
(45.5%) had access to a copy of the guidelines, 57 (39.3%) did not have a copy available to them, and 20 (13.8%) did not know whether a copy was available to them. The 66 nurses who had a copy of the Report referred tO it infrequently. The nurses reported an overall mean of 2.09 (SD = 1.1 ), where 0 = never referred to guidelines and 4 = referred to guidelines very often. No group differences emerged. Nurses who were aware of the guidelines were also asked on a 4.point scale to what extent their care of patients with asthma was based on the guidelines (1 = not at all and 4 = a great deal}. Overall the nurses reported moderate use (mean = 2.64, SD = 1.09). A significant group difference existed. A N A nurses reported basing care on the guidelines to a greater extent than did A A O H N nurses (t[135] = -3.61, p < 0.001). DISCUSSION Roger's theoretical model of innovation diffusion and adoption that guided the consensus report dissemination effort was useful in identifying variables that are likely to affect nurses' perceptions and behavior. In the case of the consensus report studied here, the 1991 Expert Panel Report on The Diagnosis and Management of Asthma, nurses' perceptions of NHLBI-sponsored consensus reports are evaluated for the first time. Generally positive views were reported by nurses in this study. Two factors were identified, which were labeled "compatibility" and "complexity." Compatibility was rated most favorably, and complex-
Interestingly, the nurses in this study also considered consensus statements or reports to be moderately biased.
ity was rated somewhat less favorably. Overall, however, nurses' ratings were positive to neutral. Interestingly, the nurses in this study also considered consensus statements or reports to be moderately biased. This opinion may reflect nurses' perception of a proconsensus bias on the part of the sponsors and sources (i.e., the implication of most consensus report sponsors that the recommendations are important guide. lines that should be disseminated and 234
Fitzgerald et al.
adopted by all nurses). Nonetheless, the bias-unbiased paired item did not load in the factor analysis. The results of the facto r analysis in this study differed from the results seen in an earlier study of physicians' perceptions of consensus reports. Hill and Weisman 9 observed three factors that were consistent with Roger's theory. The observation of only two factors in this study required evaluation of the extent to which nurses' perceptions of consensus reports differed with that of physicians. The implications of these differences highlights the importance of looking concurrently at nurses' and physicians' perceptions, particularly in a time of rapid change in health care policy. The implications also raise questions about the type of practice-guiding information that needs to be tailored for different professional disciplines. The nurses in this study seemed to be aware of the sponsors' intent to produce a document that meets the sponsors' need to communicate a particular message about clinical practice with respect to asthma. The nurses agreed to differing degrees that consensus reports offer relative advantage to practitioners in comparison to learning about state-of-the-art recommendations from other information sources. Relatively few nurses agreed that consensus reports as a source of information offer relative advantage over continuing education and journals. This may be explained by responses to other questions in the survey in which they indicated that journals were the most important source of new information and that journals and continuing education, meetings, courses, and conferences were the most useful sources in assessing the validity of new clinical information. Differences between participants who were members of A N A versus A A O H N may be explained by educational level in that A N A members were predominantly baccalaureate and master's prepared. In addition, members of A N A held positions in clinical settings where they managed client caseloads, some of which included patients with asthma. Occupational health is not a setting where primary care is provided, and as a result, the O H N may be aware that an employee has asthma but does not assume a role in management or education of the person with asthma. In addition, the increased importance of journals and continuing education pro-
grams as sources of clinical information may explain the diminished frequency with which colleagues have been reported as primary sources of new, useful, and state-of-the-art recommendations during the past few decades. This finding is consistent with trends during the past several decades, since Coleman et al. s documented that dissemination of information about a new antibiotic was by word of mouth from physician to physician. Subsequent studies identified professional journals and continuing education as physicians' major inf o r m a t i o n s o u r c e s . ~416 As nurses have become more specialized, colleagues might be less informed about state-of-the-art recommendations for a particular condition. In addition, nurses in the role of "opinion leaders" or experts who make information available through journals and continuing education programs are perceived differently than "colleagues."
The process of selecting topics about which consensus and~or changes in practice are needed should include a needs assessment based on current practice.
The process of selecting topics about which consensus and/or changes in practice are needed should include a needs assessment based on current practice. The assumptions that the same innovations in practice are needed by nurses and physicians and that these innovations will occur if they have neutral or positive attitudes toward consensus development and information sources have not been met. In the cases of consensus development as an innovation to change medical practice as studied by Hill et al. 6 and Kanouse et al., ~ it is not the diffusion and adoption of innovation theory that is inappropriate; rather, it is the assumptions of the consensus development and dissemination process that seems to be inappropriate. Future research on the diffusion and use of consensus guidelines should take into account organizational constraints, for example, explicit requirements for or against the use of practice guidelines, which are never independent of context, as well as individual practitioner factors. Perhaps the rationale
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for this approach to changing medical practice needs to be reconsidered. In 1992 the A H C P R ~7 published an extensive annotated bibliography designed to facilitate access of policymakers and health care practitioners to conceptual work and empirical dissemination of clinical information and innovation. A review of this document identified no research on the d i s s e m i n a t i o n of i n n o v a t i o n and change of practice behavior among nurses. Recognition is growing that distribution of information alone is insufficient to ensure adoption of new practice behaviors or their use in health delivery. 18,19Rogers 3 reports that a strategy to increase the rate of an adoption of an innovation is to identify opinion leaders in an organization and to direct promotional efforts toward them so as to indirectly encourage peer communication about the innovation. A n example of this strategy is the efforts that the Nurses' Asthma Group, a subcommittee of the NAEPP, are making to enlist adult nurse practitioners in the Baltimore area to adopt management and educational recommendations described in Nurses: Partners in Asthma Care, 2° a document published by NHLBI that incorporates the Expert Panel guidelines for nurses. These efforts include telephone consultation, case study discussions, formal presentations, and mailed information on asthma management that are designed to disseminate practice guidelines and increase peer communication among nurses caring for persons with asthma. A meta-analysis of 23 studies of practitioners' compliance with practice guidelines found that (1) relatively more complex guidelines had less compliance, and (2) relatively more reliable guidelines (with regard to the degree to which an innovation can be utilized) had greater compliance. 2' Another study published by Brown et al. 2z described the results of efforts to translate the A H C P R Guidelines for the Treatment of Depression in Primary Care for use by clinicians in a large health maintenance organization. The guidelines were abridged, condensed, reorganized, and reformatted by a local committee without altering the scientific integrity of the original document. Knowledge of organizational structure and culture, economic forces, and personalities facilitated the translation of the science-oriented national
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g u i d e l i n e by the c o m m i t t e e i n t o user-oriented documents tailored to local audiences. In addition, other benefits included improved lines of communication and debate between primary care clinicians, as well as a group of local clinicians and managers well informed on current recommendations for the management and treatment of depression. In summary, the data reported in this article represent a methodology for evaluating nurses' perceptions and use of consensus reports. Additional research on strategies for effective dissemination of reports to nurses and the incorporation of guidelines into clinical practice is needed. • We thank Theodore Buxton, MPH, National Heart, Lung, and Blood Institute staff, for the assistance he provided during the implementation and conduct of this study.
REFERENCES 1. KanouseDE, Winkler ID, KosecoffJ. Changing medical practice through technology assessment: an evaluation of the NIH consensus development process. Ann Arbor (MI): Health Administration Press; 1989. 2. Perry S. The NIH consensus development program. N EnglJ Med 1987;317:485-8. 3. Rogers EM. Diffusionof innovations. 4th ed. New York: Free Press; 1995. 4. DonabedianA. Criteria, norms,and standards of quality: What do they mean? Am J Public Health 1981;7l:409-12. 5. ColemanJ, MenzelH, Hatz E. Socialprocesses in physicians' adoption of a new drug. J Chronic Dis 1959;9:1-19. 6. Hill MN, LevineDM, Whelton PK. Awareness, use,and impactofthe 1984JointNationalCommittee consensusreport on high bloodpressure. Am J PublicHealth 1988;78:1190-4. 7. Kanouse DE, Jacoby I. When does information change practitioners' behavior? Int J Technol Assess Health Care 1988;4:27-33. 8. Retchin SM, Fletcher RH, Buescher PC, Waugh RA, Buttaglini SW. The application of policy: prophylaxis recommendations for patients with mitral valve prolapse.Med Care 1985;23:1156-62. 9. Hill MN, Weisman CS. Physicians' perceptions of consensus reports, lnt J Technol Assess Health Care 1991;7:30-41. 10. National Asthma Education Program Expert Panel. Guidelines for the diagnosisand management of asthma. J Allergy Clin Immunol 1991;88:425-534. 11. National Asthma Education Program Expert Panel. Guidelines for the diagnosisand management of asthma. Pediatr Asthma Allergy Immunol 1991;5:57-187. 12. National Asthma Education Program Expert Panel. The expert panel report on the guide-
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lines for the diagnosis and management of asthma. Bethesda (MD): National Institutes of Health; 1991. 13. FitzgeraldS, Hill MN, Santamaria B, Howard C, Jaldack RA. Occupational health nurses' awareness and use of the practice guidelines for the diagnosisand management of asthma. Am Assoc Occup Health Nurse J 1996;44: 78-83. 14. Stinson ER, Mueller DA. Survey of health professionals' information habits and needs. JAMA 1980;243:140-3. 15. Stross JK, Harlan WR. The dissemination of new medical information. JAMA 1979;241: 2622-4. 16. Stross JK, Harlan WR. Dissemination of relevant information on hypertension. JAMA 1981;246:360-2. 17. Agency for Health Care Policy and Research. Annotated bibliography:informationdisseminationto healthcarepractitionersandpolicymakers. Washington(DC): Dept. of Health and Human Services (US); 1992 Apr. AHCPR Pub. No. 92-0030. 18. Kaegi I.. Nurses leading the charge to take national AHCPR guidelines into local settings. J Qual Improvement 1995;21:5-21. 19. WarneckeRB, Johnson TP, KuluznyAD, Ford LG. The community clinical oncology program: its effect on clinical practice. J Qual Improvement 1995;21:336-9. 20. National Asthma Education and Prevention Program. Nurses: partners in asthma care. Washington (DC): Dept. of Health and Human Services (US); 1995 Oct. NIH Pub. No. 95-3308. 21. Grilli R, LomasJ. Evaluatingthe message:the relationshipbetweencompliancerate and the subject of practice guidelines. Med Care 1994;32:202-13. 22. Brown JB, Shye D, McFarland B. The paradox of guideline implementation: how AHCPR's depression guideline was adapted at Kaiser Permanente Northwest Region. J Qual Improvement 1995;21:5-21.
SHEILA 1". FITZGERALD is an assistant professor at The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Md. MARTHA N. HILL is a professor at The Johns Hopkins University School of Nursing, Baltimore, Md. BARBARA SANTAMARIA is a nurse practitioner in Hospital-based Home Care at Baltimore Veterans Administration Hospital, Md. CHERYL HOWARD is a data analyst at The National Heart, Lung, and Blood Institute, Bethesda, Md. ROSE JADACK is an assistant professor at Ohio State University College of Nursing, Columbus.
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235
Consensus reports providing guidelines designed to alter clinical practice are being disseminated with increasing frequency by professional associations, the government, and voluntary health agencies. The purpose of this study was to examine nurses"perceptions of consensus reports that contain recommendations designed to alter clinical practice, including the extent to which consensus reports offer relative advantage over other more traditional sources of practice-related information. Strategies for encouraging the use of consensus reports are discussed.
T
he m a n n e r in w h i c h nurses learn new information and make decisions to change their practice behaviors is a topic of considerable research and clinical interest. Consensus statements and reports have been issued with increasing frequency to disseminate new information to health care practitioners with the goat of influencing practice, tn addition, they are intended to serve as a primary reference for policy development, including setting priorities for research.l. 2 Groups of experts are being brought together by sponsors such as the National Institutes of Health (NIH), the Agency for Health Care Policy and Research (AHCPR), and professional associations such
Nurs Outlook 1997;45:229-35. Copyright © 1997 by Mosby-Year Book, Inc. 0029-6554/97/$5.00 + 0
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35/1/83625
as the American Nurses' Association (ANA) to reach agreement on state-of-the-art practice and publish consensus reports containing practice guidelines. Sponsors of these consensus reports, who are commonly guided by social science theory, including Rogers' diffusion of innovation theory, 3assume that the report guidelines and recommendations will be salient and readily adopted by the target audience. In addition, consensus reports are developed to serve as useful resources in defining criteria, norms and standards, and health care expenditure determinants. 4 Increasingly, guideline development by consensus is seen as an essential step in assessing and improving the quality of health care. Research on the diffusion of innovations shows that factors other than the content of the information itself is important in determining whether people will adopt
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the innovation or ideas contained within consensus reports. 58 The extent to which the target audience receives and uses information and changes behavior according to recommendations is influenced by the scientific credibility of the source(s) of the information and the importance of the information) According to Rogers, 3 several underlying dimensions of innovations have been shown to be important, including ( 1 ) relative advantage (the degree to which an innovation is perceived as better than the idea it supersedes); (2) compatibility (the degree to which the innovation is perceived to be consistent with existing values); (3) complexity (the degree to which the innovation is perceived to be difficult to understand and use); (4) trialability (the degree to which an innovation may be ex-
Increasingly, guideline development by consensus is seen as an essential step in assessing and improving the quality of health care.
perimented with on a limited basis); and (5) observability (the degree to which the results of an innovation are visible to others). Thus the perceptions of consensus reports held by the target audience directly influence whether the recommendation will be considered and used in practice. Fitzgerald et al.
229
AAOHN
(266 members) Nurse characteristics Female Caucasian Certification Occupational health nursing" Adult nurse practitioner* Family nurse practitioner" No certification* Educational level (highest degree) Associate degree Diploma program* Baccalaureate* Masters* Nurse practitioner* Doctorate Non-nursing Nursing Practice setting Occupational* Private practice/H MO/ community health agency" Hospital" Other"
ANA (535 members) N %
N
%
261 243
98.1 91.4
513 509
96.2 95.9
167 9 6 70
62.8 3.4 2.3 26.3
10 116 183 51
1.7 20.2 31.9 8.9
42 169 91 20 17
15.8 63.5 34.2 7.5 6.4
57 175 465 443 267
9.9 30.5 81.0 77.2 46.5
0 0
0.0 0.0
33 18
6.2 3.4
246 7
92.5 2.6
41 172
7.7 32.1
2 11
0.8 4.1
162 160
30.3 29.9
*Chi-square analysis significant, p < 0.0125, after Bonferroni correction for multiple comparisons. *Chi-square analysis significant, p < 0.007, after Bonferroni correction for multiple comparisons.
Hill and Weisman 9 examined physicians' perceptions of consensus reports and found that physicians reported generally positive or neutral views. On an investigator-developed seven-point semantic differential scale of 17 descriptive adjectives (with 1 being most positive and 7 being least positive), 595 physicians most positively perceived consensus reports as credible (mean = 2.25; standard deviation [SD] = 1.1) and reliable (mean = 2.41; SD = 1.1). Physicians' least positive perception was a neutral assessment of consensus reports as biased (mean = 3.79; SD = 1.6). Factor analysis revealed three factors: compatibility, complexity in understanding, and complexity in use. The compatibility dimension was rated significantly more favorably than complexity in understanding and complexity in use. The relative advantage of consensus reports compared with more traditional methods of learning also was assessed by Hill and Weisman. 9 Physicians strongly or somewhat agreed that the availability of consensus reports was better than each practitioner need230
Fitzgerald et al.
ing to find out the information from colleagues (85%), textbooks (73%), and staff meetings (68%). Fewer physicians agreed that consensus reports offered relative advantage over journals (60%) and continuing education (58%). Physicians also were asked to what extent they perceived as influential the three sources of consensus reports that contained guidelines for practice. Results showed that 46%, 38%, and 26% of physicians reported professional associations, the federal government, and voluntary health agencies, respectively, as very influential sources of consensus reports. We have not identified any research reports that examine nurses' perceptions or views of consensus reports, use of consensus report information, and behavior based on relevant information contained in a particular consensus report. N o r have nurses' perceptions of the relative advantage of consensus reports over other sources of practice-related information been identified. Yet consensus guidelines developed by multidisci-
plinary groups and disseminated with the intent of influencing nursing and medical practice are proliferating. T h e release of the Expert Panel Report on Guidelines for the Diagnosis and Management of Asthma provided an opportunity to examine nurses' perceptions of consensus reports in general, as well as their awareness and use of a nationally promulgated consensus report containing guidelines for care of patients with asthma. L°lz This Report was endorsed by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee of the National Heart, Lung, and Blood Institute (NHLBI). The A N A and the American Association of Occupational Health Nurses (AAOHN), who belong to the Committee, endorsed the Report. Dissemination efforts included articles in official publications featuring the guidelines, announcements with instructions about how to obtain a copy, and featured presentations at annual meetings. Copies of the Report were not mailed to members of each organization because of cost constraints, but they were available on request. The awareness and use of the Report 1 year after its release by occupational health nurses (OHNs) is reported elsewhere. 13 The purpose of this study was to examine nurses' perceptions of consensus reports. A secondary purpose was to further evaluate the instrument that assesses perceptions of consensus reports. The assumptions underlying the study were that consensus reports are thought to be influential in changing nurses' behavior to the extent that clinicians are familiar with them and perceive them as being compatible with current values; that the reports are thought to offer advantage relative to other credible sources of information; and that they are thought to be sponsored by influential sources. The extent to which specific perceptual dimensions that emerged are compatible with diffusion of innovation theory was also examined. The following six research questions were explored: (1) What are nurses' perceptions of consensus reports as a general source of clinical information? (2) Do A A O H N and A N A members have different perceptions of consensus reports? (3) Do RNs and MDs have different perceptions of consensus reports?
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(4) What are nurses' perceptions of the relative advantage of consensus reports compared with other sources of information ? (5) What is the perceived influence of consensus report sources (government, professional organizations, and voluntary health organizations) ? (6) What level of awareness of, familiarity with, and use of consensus reports do nurses have 1 year after dissemination? METHODS
Sample and Procedures A pretest-posttest design was used to survey nurses who work with patients who have asthma and to examine their perceptions of consensus reports in general and their awareness of and use of asthma management consensus reports 1 year after their release. The sample was drawn from two sources: the A A O H N and the A N A . These associations were selected to provide the study population because they belong to the NAEPP Coordinating Committee and their members are likely to be caring for adults with asthma. Moreover, these associations endorsed the Expert Panel Report on Guidelines for the Diagnosis and Management of Asthma. Limited resources precluded national surveys of both organizations. A regional A A O H N sample was chosen because the concentration of members in the mid-Atlantic region offered a "best case" assessment opportunity. Nurses in the mid-Atlantic region who were members of the A A O H N and nurse practitioners, clinical nurse specialists, and community health nurses who were members of the A N A were surveyed. The pretest survey was conducted 1 month prior to the publication and dissemination of the Expert Panel Report. 12 Questionnaires were mailed to 1788 nurses. After a second mailing to nonresponders, a total of 1107 (61.9%) surveys were returned. Of the responders, 207 (18.7%) were determined to be ineligible for the study because they were retired members of the professional organizations or were not involved with patient care. One person did not fully complete the questionnaire. Thus a 57% adj usted response rate (899 responders/1581 mailed surveys) was obtained in the month available for data collection prior to publication of the report. Finally, because an important purpose of this study was to comNURSING OUTLOOK
Item pairs
Overall (N = 801) Mean (SD)
Factor 1: Compatibility* Credible-not credible* Helpful-harmful* Reliable-not reliable* Valuable-worthless* Influential-not influential* Necessary-unnecessary* Scientific-not scientific Authoritative-not authoritative
23.4 2.7 2.8 2.8 2.9 3.0 3.0 3.1 3.2
Factor 2: Complexity" Easy to understanddifficult to understand* Easy to use-difficult to use* Straightforward-confusing* Simple-complex* Practical-impractical* Time saving-time consuming* Precise-vague*
24.9 (6.7) 3.5 (1.3)
Factor 3: Bias Biased-impartial
3.6 3.5 4.0 3.2 3.5 3.6
(7.7) (1.2) (1.1) (1.2) (1.2) (1.3) (1.3) (1.4) (1.3)
(1.2) (1.2) (1.3) (1.2) (1.2) (1.2)
4.0 (1.4)
AAOHN (N = 266) Mean (SD) (7.8) (1.3) (1.2) (1.3) 3.3 (1.2) 3.3 (1.3) 3.3 (1.3) 3.3 (1.4) 3.4 (1.3)
ANA (N = 535) Mean (SD)
25,9 3.1 3.1 3.2
22.1 2.5 2.6 2.6 2.7 2.8 2.9 3.1 3.1
27.1 (6.9) 3.9 (1.3)
23.8 (6.3) 3.3 (1.2)
4.0 3.9 4.3 3.6 3.7 3.8
(1.2) (1.2) (1.4) (1.2) (1.2) (1.2)
4.1 (1.4)
3.4 3.4 3.8 3.0 3.3 3.5
(7.4) (1.1) (1.1) (1.1) (1.1) (1.2) (1.3) (1.3) (1.3)
(1.1) (1.2) (1.3) (1.2) (1.1) (1.2)
4.0 (1.4)
Respondents rated item pairs on 7-point scales (1 = positive descriptor of pair, 7 = negative descriptor of pair). The two subscale scores were computed by adding the individua/items. For compatibility there was a possible high score of 48. For complexity there was a possible high score of 49. "Significant between-group difference, p < 0.003, after Bonferroni correction. pare nurses affiliated with the A N A and nurses affiliated with the A A O H N , 98 persons were dropped from analyses because (1) they reported being members in both organizations (n = 64), or (2) they reported that they currently belonged to neither organization (n = 34). Therefore the final pretest sample of 801 respondents consisted of 266 nurses from the A A O H N and 535 nurses from the ANA. Table 1 shows the demographic characteristics of the survey responders at time 1. The responders were predominantly white women with a mean age of 46.9 years (SD = 8.7). The A A O H N and A N A respondents were representative of organizational member demographics on age, gender, and higher degree earned. A higher proportion of A A O H N members were certified and were practicing in occupational health settings. A N A members were significantly more likely to be masters prepared, employed in traditional health care
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settings, and report more time spent with patients with asthma than OHNs. Nurses' perceptions of consensus statements that contain recommendations for general clinical practice were measured with use of a 16-item semantic differential scale adapted from Hill and Weisman2 Respondents rated 16 item pairs on a 7-point Likert scale. These descriptor pairs included (1) credible-not credible, (2) reliable-not reliable, (3) simple-complex, (4) helpful-harmful, (5) scientific-unscientific, (6) biased-impartial, (7) authoritative-not authoritative, (8) easy to understand-difficult to understand, (9) valuable-worthless, (10) practical-impractical, ( 11 ) necessary-unnecessary, (12 ) influential-not influential, (13) straightforward-confusing, (14) time saving-time consuming, (15) precise-vague, and (16) easy to use-difficult to use. For each item pair, a score of 1 indicated the most positive view of consensus reports and a score of 7 indicated the most negative view. Fitzgerald et al.
231
Nurse ranking Item pairs Item pairs
Factor loading
Factor 1: Compatibility Credible-not credible Reliable-not reliable Scientific-not scientific Valuable--worthless Authoritativenot authoritative Influential-not influential Necessa ry-u n necessary Helpful-harmful
0.86 0.85 0.78 0.64
0.86 0.82 0.80 0.83 0.66 0.64 0.54
Factor 3: Biased Biased-not impartial
0.95
Question stem: "In general, consensus statements or reports that contain recommendations are ."
Next, respondents were asked the extent to which they agreed that the availability of consensus reports offered relative advantage to practitioners in comparison with learning about state-of-the-art recommendations from each of five sources: colleagues, continuing educational programs, journals, textbooks, and staff meetings. For each of these sources of clinical information, the respondent was asked to rate the relative advantage of consensus reports on a 4-point scale (1 = strongly disagree and 4 = strongly agree). The perceived influence of consensus report sources was measured by asking respondents to indicate their opinion of how influential each of the following is as a source of consensus report statements: federal government agencies (e.g., NIH), professional associations, and voluntary health associations. For each of these three sources of consensus reports, the respondent was asked to rate the influence on a 3-point
232
Fitzgerald et al.
Compatibility descriptor pairs Credible-not credible Reliable-not reliable Helpful-harmful Necessary-unnecessary Authoritative-not authoritative
1 2 3 4 5
2.66 2.79 2.80 2.99 3.17
(I .2) (I .2) (I .2) (I .3) (1.3)
I 2 3 4 3
2.25 2.41 2.62 2.88 2.62
(1.1) (I .I) (I .2) (I .4) (1.2)
1 2 3 4 5
3.22 3.45 3.53 3.61 3.64
(1.2) (1.2) (1.2) (1.2) (1.2)
3 4 2 1 3
3.41 3.56 3.18 2.90 3.41
(1.5) (1.3) (1.4) (1.4) (1.3)
Complexity descriptor pairs 0.78 0.67 0.62 0.57
Factor 2: Complexity Easy to understanddifficult to understand Easy to use-difficult to use Straightforward-confusing Simple-complex Practical-impractical Time saving-time confusing Precise-vag ue
Nurses Physician Physicians (N = 899) ranking (N = 595) Mean (SD) Mean (SD)
Practical-impractical Time saving-time consuming Straightforward-confusing Easy to use-difficult to use Precise-vague
Physician data from Hill MN, Weisman CS. Physicians' perceptions of consensus reports. Int J Technol Assess Health Care 1991 ;7:35. Copyright 1991 by the Cambridge University Press. Reprinted with permission. Respondents rated item pairs on 7-point scales (1 = positive descriptor of pair, 7 = negative descriptor of pair).
scale (1 = not at all influential and 3 = very influential). Persons who responded at time 1 were mailed a second questionnaire at time 2, 1 year after the Report was released. A total of 655 surveys were returned, resulting in a response rate of 72.8%. A t time 2, respondents were asked about their awareness and use of the asthma guidelines in the past year. Respondents were asked in a yes/no format whether they were aware of the guidelines, from what source they received the guidelines, and whether they believed they were generally familiar with the guidelines. O n a 5-point scale, respondents were asked how often they refer to guidelines in practice and to what extent their care of patients/employees with asthma is based on recommendations in the guidelines.
RESULTS In general, nurses in this study reported positive to neutral views of consensus statements that contain recommendations for clinical practice. The means and standard deviations of the 16 descriptor item pairs are shown in Table 2. Mean scores ranged between 2.7 and 4.0 on a 7-point scale (1 = positive perception and 7 = negative perception). Respondents viewed consensus reports as credible (mean = 2.7, SD = 1.2) and helpful (mean =
2.8, SD = 1.1). The consensus report descriptors that nurses rated least positively were biased (mean = 4.0, SD = 1.4), precise (mean = 3.6, SD = 1.2) and simple (mean = 4.0, SD = 1.3). In addition, evidence existed that some nurses perceived the reports as somewhat difficult to use, vague, and confusing. With use of a paired t test, means for the most favorably rated descriptor--credible and the least favorably rated descriptor biased~ were significantly different (t[801] = - 22.76, p < 0.001). A principal components factor analysis with an oblique rotation was conducted on the 16 item pairs (see Table 3). A n oblique rotation was chosen because it was anticipated that the resulting factors might not be unrelated to one another. Three factors emerged. Eight items loaded on the first factor, which was entitled "compatibility," and seven items loaded on the second factor, which was entitled "complexity." Only one item loaded on the third factor, entitled "bias." Because this item was the only negatively scored item pair among the 16 item pairs, it is unclear whether this item loaded onto a separate factor because it was a uniquely different factor or because it was the only negatively scored item. Therefore this factor was dropped from subsequent analyses. The two subscales showed good internal
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consistency. Reliability testing yielded a standardized alpha score of 0.89 for compatibility and 0.90 for complexity. Items for the compatibility and complexity subscales were summed. The mean scores for the compatibility and complexity subscales are shown in Table 2. Again, nurses reported neutral views with respect to the compatibility and complexity of consensus reports. For compatibility, respondents had a mean score of 23.4 (SD = 7.7; range = 8-56). For complexity, the mean score was 24.9 (SD = 6.7; range = 7-49). Significant professional association group differences with regard to the factor scores emerged. Nurses from the A N A perceived that consensus reports had significantly greater compatibility than nurses from the A A O H N (t[799] = 6.50, p < 0.001). Likewise, nurses from the A N A perceived that consensus reports had significantly less complexity than nurses from the A A O H N (t[799] = 7.11, p < 0.001). Results of these analyses were compared with those from previous work conducted with physicians, using the same scale to assess perceptions of consensus reports in general? Several differences emerged. First, the factor analysis of descriptor items produced a different factor solution, in that the complexity factor broke into two separate complexity factors: complexity in understanding and complexity in use. In the present study, nurses did not rate the descriptors in such a way to distinguish between complexity in understanding and complexity in use. Second, although nurses generally rated the descriptors of consensus reports in a similar fashion, the mean scores were generally more neutral (see Table 4). Participating nurses were asked to rate the relative advantage of consensus reports as a source of practice recommendations over other sources of information (see Table 5). Overall, respondents believed that the availability of consensus reports was better than each practitioner having to find out the information from colleagues. Availability of consensus reports was believed to offer relative advantage over textbooks, staff meetings, journals, and continuing education programs. Comparisons of source data were made between the A N A and A A O H N groups. One group difference appeared. A N A members, to a significantly greater extent than A A O H N members, believed that consensus reports were a better source of practice informaNURSING OUTLOOK
Information source Colleagues Continuing education programs Journals Textbooks* Staff meetings
Overall (N = 801) Mean (SD)
AAOHN (N = 266) Mean (SD)
ANA (N = 535) Mean (SD)
p
3.11 (0.68) 2.76 (0.83)
3.13 (0.70) 2.76 (0.90)
3.11 (0.68) 2.76 (0.79)
NS NS
2.72 (0.79) 3.01 (0.79) 3.02 (0.81)
2.76 (0.78) 2.88 (0.80) 2.93 (0.83)
2.70 (0.79) 3.08 (0.78) 3.06 (0.79)
NS 0.001 0.032
Data are from the question, "To what extent do you agree that the availability of consensus statements that contain recommendations for state-of-the-art practice is better than each practitioner receiving this information from .... " Respondents rated each item on a 4-point scale (1 = strongly disagree, 4 = strongly agree). "Significant between-group difference, p < 0.01, after Bonferonni correction.
Federal government (e.g., NIH, National Heart, Lung and Blood Institute)
2.74
(I .00)
2.74 (0.74)
2.73 (1.1 O)
Professional associations
2.65 (0.79)
2.60 (0.51)
2.67 (0.90)
Voluntary health organizations 2.43 (1.07) (e.g., American Heart Association)
2.40 (0.70)
2.44 (1.22)
Data are from the question, "In your opinion, how influential is each of the following as a source of consensus statements?" Respondents rated each item on a 3-point scale (1 = not at all influential, 3 = very influential).
tion than textbooks. Inspection of the means, however, show differences that may not have clinical significance. Overall, respondents believed that the federal government, professional associations, and voluntary health organizations were influential sources of consensus reports (see Table 6). No significant professional group differences emerged. Lastly, analyses were conducted to examine nurses' awareness, familiarity, and use of consensus reports 1 year after dissemination. Of 655 returned questionnaires, 13 were dropped from the analyses because of incomplete data. Similar to the data analyses conducted at time 1, 60 persons were dropped from time 2 analyses because they either reported being members of both the A N A and A A O H N or reported belonging to neither
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the A N A or the AAOHN. Therefore, time 2 analyses were conducted with a final sample of 582 nurses. A full 75.1% (n = 437) of the nurses returning complete questionnaires reported not being aware of the NHLBI guidelines 1 year after the Report's dissemination. A significant professional group difference existed. One hundred n i n e t e e n A N A nurses (30.2%) and 26 A A O H N nurses (13.8%) reported awareness of the guidelines (X2[1, N = 582] = 17.37, p < 0.0001). Nurses were asked how often they referred to the guidelines for asthma practice on a 5-point scale, and they reported infrequent use. Data are reported for the 145 respondents who reported awareness of the guidelines. Of the nurses who were aware of the guidelines at time 2, 66 Fitzgerald et al.
233
(45.5%) had access to a copy of the guidelines, 57 (39.3%) did not have a copy available to them, and 20 (13.8%) did not know whether a copy was available to them. The 66 nurses who had a copy of the Report referred tO it infrequently. The nurses reported an overall mean of 2.09 (SD = 1.1 ), where 0 = never referred to guidelines and 4 = referred to guidelines very often. No group differences emerged. Nurses who were aware of the guidelines were also asked on a 4.point scale to what extent their care of patients with asthma was based on the guidelines (1 = not at all and 4 = a great deal}. Overall the nurses reported moderate use (mean = 2.64, SD = 1.09). A significant group difference existed. A N A nurses reported basing care on the guidelines to a greater extent than did A A O H N nurses (t[135] = -3.61, p < 0.001). DISCUSSION Roger's theoretical model of innovation diffusion and adoption that guided the consensus report dissemination effort was useful in identifying variables that are likely to affect nurses' perceptions and behavior. In the case of the consensus report studied here, the 1991 Expert Panel Report on The Diagnosis and Management of Asthma, nurses' perceptions of NHLBI-sponsored consensus reports are evaluated for the first time. Generally positive views were reported by nurses in this study. Two factors were identified, which were labeled "compatibility" and "complexity." Compatibility was rated most favorably, and complex-
Interestingly, the nurses in this study also considered consensus statements or reports to be moderately biased.
ity was rated somewhat less favorably. Overall, however, nurses' ratings were positive to neutral. Interestingly, the nurses in this study also considered consensus statements or reports to be moderately biased. This opinion may reflect nurses' perception of a proconsensus bias on the part of the sponsors and sources (i.e., the implication of most consensus report sponsors that the recommendations are important guide. lines that should be disseminated and 234
Fitzgerald et al.
adopted by all nurses). Nonetheless, the bias-unbiased paired item did not load in the factor analysis. The results of the facto r analysis in this study differed from the results seen in an earlier study of physicians' perceptions of consensus reports. Hill and Weisman 9 observed three factors that were consistent with Roger's theory. The observation of only two factors in this study required evaluation of the extent to which nurses' perceptions of consensus reports differed with that of physicians. The implications of these differences highlights the importance of looking concurrently at nurses' and physicians' perceptions, particularly in a time of rapid change in health care policy. The implications also raise questions about the type of practice-guiding information that needs to be tailored for different professional disciplines. The nurses in this study seemed to be aware of the sponsors' intent to produce a document that meets the sponsors' need to communicate a particular message about clinical practice with respect to asthma. The nurses agreed to differing degrees that consensus reports offer relative advantage to practitioners in comparison to learning about state-of-the-art recommendations from other information sources. Relatively few nurses agreed that consensus reports as a source of information offer relative advantage over continuing education and journals. This may be explained by responses to other questions in the survey in which they indicated that journals were the most important source of new information and that journals and continuing education, meetings, courses, and conferences were the most useful sources in assessing the validity of new clinical information. Differences between participants who were members of A N A versus A A O H N may be explained by educational level in that A N A members were predominantly baccalaureate and master's prepared. In addition, members of A N A held positions in clinical settings where they managed client caseloads, some of which included patients with asthma. Occupational health is not a setting where primary care is provided, and as a result, the O H N may be aware that an employee has asthma but does not assume a role in management or education of the person with asthma. In addition, the increased importance of journals and continuing education pro-
grams as sources of clinical information may explain the diminished frequency with which colleagues have been reported as primary sources of new, useful, and state-of-the-art recommendations during the past few decades. This finding is consistent with trends during the past several decades, since Coleman et al. s documented that dissemination of information about a new antibiotic was by word of mouth from physician to physician. Subsequent studies identified professional journals and continuing education as physicians' major inf o r m a t i o n s o u r c e s . ~416 As nurses have become more specialized, colleagues might be less informed about state-of-the-art recommendations for a particular condition. In addition, nurses in the role of "opinion leaders" or experts who make information available through journals and continuing education programs are perceived differently than "colleagues."
The process of selecting topics about which consensus and~or changes in practice are needed should include a needs assessment based on current practice.
The process of selecting topics about which consensus and/or changes in practice are needed should include a needs assessment based on current practice. The assumptions that the same innovations in practice are needed by nurses and physicians and that these innovations will occur if they have neutral or positive attitudes toward consensus development and information sources have not been met. In the cases of consensus development as an innovation to change medical practice as studied by Hill et al. 6 and Kanouse et al., ~ it is not the diffusion and adoption of innovation theory that is inappropriate; rather, it is the assumptions of the consensus development and dissemination process that seems to be inappropriate. Future research on the diffusion and use of consensus guidelines should take into account organizational constraints, for example, explicit requirements for or against the use of practice guidelines, which are never independent of context, as well as individual practitioner factors. Perhaps the rationale
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for this approach to changing medical practice needs to be reconsidered. In 1992 the A H C P R ~7 published an extensive annotated bibliography designed to facilitate access of policymakers and health care practitioners to conceptual work and empirical dissemination of clinical information and innovation. A review of this document identified no research on the d i s s e m i n a t i o n of i n n o v a t i o n and change of practice behavior among nurses. Recognition is growing that distribution of information alone is insufficient to ensure adoption of new practice behaviors or their use in health delivery. 18,19Rogers 3 reports that a strategy to increase the rate of an adoption of an innovation is to identify opinion leaders in an organization and to direct promotional efforts toward them so as to indirectly encourage peer communication about the innovation. A n example of this strategy is the efforts that the Nurses' Asthma Group, a subcommittee of the NAEPP, are making to enlist adult nurse practitioners in the Baltimore area to adopt management and educational recommendations described in Nurses: Partners in Asthma Care, 2° a document published by NHLBI that incorporates the Expert Panel guidelines for nurses. These efforts include telephone consultation, case study discussions, formal presentations, and mailed information on asthma management that are designed to disseminate practice guidelines and increase peer communication among nurses caring for persons with asthma. A meta-analysis of 23 studies of practitioners' compliance with practice guidelines found that (1) relatively more complex guidelines had less compliance, and (2) relatively more reliable guidelines (with regard to the degree to which an innovation can be utilized) had greater compliance. 2' Another study published by Brown et al. 2z described the results of efforts to translate the A H C P R Guidelines for the Treatment of Depression in Primary Care for use by clinicians in a large health maintenance organization. The guidelines were abridged, condensed, reorganized, and reformatted by a local committee without altering the scientific integrity of the original document. Knowledge of organizational structure and culture, economic forces, and personalities facilitated the translation of the science-oriented national
NURSING OUTLOOK
g u i d e l i n e by the c o m m i t t e e i n t o user-oriented documents tailored to local audiences. In addition, other benefits included improved lines of communication and debate between primary care clinicians, as well as a group of local clinicians and managers well informed on current recommendations for the management and treatment of depression. In summary, the data reported in this article represent a methodology for evaluating nurses' perceptions and use of consensus reports. Additional research on strategies for effective dissemination of reports to nurses and the incorporation of guidelines into clinical practice is needed. • We thank Theodore Buxton, MPH, National Heart, Lung, and Blood Institute staff, for the assistance he provided during the implementation and conduct of this study.
REFERENCES 1. KanouseDE, Winkler ID, KosecoffJ. Changing medical practice through technology assessment: an evaluation of the NIH consensus development process. Ann Arbor (MI): Health Administration Press; 1989. 2. Perry S. The NIH consensus development program. N EnglJ Med 1987;317:485-8. 3. Rogers EM. Diffusionof innovations. 4th ed. New York: Free Press; 1995. 4. DonabedianA. Criteria, norms,and standards of quality: What do they mean? Am J Public Health 1981;7l:409-12. 5. ColemanJ, MenzelH, Hatz E. Socialprocesses in physicians' adoption of a new drug. J Chronic Dis 1959;9:1-19. 6. Hill MN, LevineDM, Whelton PK. Awareness, use,and impactofthe 1984JointNationalCommittee consensusreport on high bloodpressure. Am J PublicHealth 1988;78:1190-4. 7. Kanouse DE, Jacoby I. When does information change practitioners' behavior? Int J Technol Assess Health Care 1988;4:27-33. 8. Retchin SM, Fletcher RH, Buescher PC, Waugh RA, Buttaglini SW. The application of policy: prophylaxis recommendations for patients with mitral valve prolapse.Med Care 1985;23:1156-62. 9. Hill MN, Weisman CS. Physicians' perceptions of consensus reports, lnt J Technol Assess Health Care 1991;7:30-41. 10. National Asthma Education Program Expert Panel. Guidelines for the diagnosisand management of asthma. J Allergy Clin Immunol 1991;88:425-534. 11. National Asthma Education Program Expert Panel. Guidelines for the diagnosisand management of asthma. Pediatr Asthma Allergy Immunol 1991;5:57-187. 12. National Asthma Education Program Expert Panel. The expert panel report on the guide-
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lines for the diagnosis and management of asthma. Bethesda (MD): National Institutes of Health; 1991. 13. FitzgeraldS, Hill MN, Santamaria B, Howard C, Jaldack RA. Occupational health nurses' awareness and use of the practice guidelines for the diagnosisand management of asthma. Am Assoc Occup Health Nurse J 1996;44: 78-83. 14. Stinson ER, Mueller DA. Survey of health professionals' information habits and needs. JAMA 1980;243:140-3. 15. Stross JK, Harlan WR. The dissemination of new medical information. JAMA 1979;241: 2622-4. 16. Stross JK, Harlan WR. Dissemination of relevant information on hypertension. JAMA 1981;246:360-2. 17. Agency for Health Care Policy and Research. Annotated bibliography:informationdisseminationto healthcarepractitionersandpolicymakers. Washington(DC): Dept. of Health and Human Services (US); 1992 Apr. AHCPR Pub. No. 92-0030. 18. Kaegi I.. Nurses leading the charge to take national AHCPR guidelines into local settings. J Qual Improvement 1995;21:5-21. 19. WarneckeRB, Johnson TP, KuluznyAD, Ford LG. The community clinical oncology program: its effect on clinical practice. J Qual Improvement 1995;21:336-9. 20. National Asthma Education and Prevention Program. Nurses: partners in asthma care. Washington (DC): Dept. of Health and Human Services (US); 1995 Oct. NIH Pub. No. 95-3308. 21. Grilli R, LomasJ. Evaluatingthe message:the relationshipbetweencompliancerate and the subject of practice guidelines. Med Care 1994;32:202-13. 22. Brown JB, Shye D, McFarland B. The paradox of guideline implementation: how AHCPR's depression guideline was adapted at Kaiser Permanente Northwest Region. J Qual Improvement 1995;21:5-21.
SHEILA 1". FITZGERALD is an assistant professor at The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Md. MARTHA N. HILL is a professor at The Johns Hopkins University School of Nursing, Baltimore, Md. BARBARA SANTAMARIA is a nurse practitioner in Hospital-based Home Care at Baltimore Veterans Administration Hospital, Md. CHERYL HOWARD is a data analyst at The National Heart, Lung, and Blood Institute, Bethesda, Md. ROSE JADACK is an assistant professor at Ohio State University College of Nursing, Columbus.
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