The programmes developed by the Knowledge Translation Unit aim to standardise and improve care delivered at primary level by nurses (or other non-physician clinician equivalents), doctors and lay health workers. Each programme consists of a clinical practice guideline and an implementation strategy and is underpinned by five principles:
- The guideline aligns with policy and where feasible, is evidence-based.
- Engagement with decision-makers and end-users improves uptake.
- The implementation strategy of educational outreach can change practice. (1, 2, 3)
- Training in primary care teams facilitates task-sharing. (4)
- A cascade model of training allows for rapid scale-up.
The guidelines are designed to be concise and easy to use. A standardised format of algorithms and checklists simplifies the approach to the patient. The content is locally tailored and prioritises the care of common chronic conditions, both infectious and non-communicable. Guideline development and revision is collaborative, drawing on clinicians, patient advocacy groups, policy makers and end-users. This process invariably involves tackling policy issues like prescribing restrictions, scope of practice, discrepancies in recommendations and resource constraints.
A training strategy is more likely to result in practice change if time is limited between training and clinical decision-making, learning and practice are alternated, and training occurs over a prolonged period (5) – our educational outreach training sessions are short (1½ hours), on-site and multiple (eight sessions over 2–3 months). This minimises disruption to clinical services. Training is interactive, case-based and involves all facility staff; the team approach promoting functional integration of clinical care.
A cascade model of implementation allows for rapid scale-up and integration of the programme into the health system. The on-site training is delivered by nurses drawn from the health system (clinicians, managers, trainers) who are trained by master trainers during a facility trainers’ workshop. Workshop activities mirror an on-site training session. Facility trainers with leadership qualities and managerial support are selected as master trainers. A support programme for trainers and end-users establishes a community of practice (6) to provide a forum for problem solving and opportunities to reinforce training methodology and guideline use.
- Fairall L, Zwarenstein M, Bateman ED, Bachmann OM, Lombard C, Majara B, Joubert G, English RG, Bheekie A, van Rensburg HCJ, Mayers P, Peters AC, Chapman RD. Educational outreach to nurses improves tuberculosis case detection and primary care of respiratory illness: a pragmatic cluster randomized controlled trial BMJ. 2005; 331:750-754
- Zwarenstein M, Bheekie A, Lombard C, Swingler G, Ehrlich R, Eccles M, et al. Educational outreach to general practitioners reduces children’s asthma symptoms: a cluster randomised controlled trial. Implement Sci. 2007;2:30.
- Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004 Feb;8(6):iii–iv, 1–72.
- Stein, J., S. Lewin, L. Fairall, P. Mayers, R. English, A. Bheekie, E. Bateman, and M. Zwarenstein. Building Capacity for Antiretroviral Delivery in South Africa: A Qualitative Evaluation of the PALSA PLUS Nurse Training Programme. BMC Health Services Research 8, no. 1 (November 18, 2008): 240. doi:10.1186/1472-6963-8-240.
- O’Brian, M. Rogers, S. et al. 2007. Educational outreach visits: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, Issue 4.
- Smith, M. K. (2003, 2009) ‘Communities of practice’, the encyclopedia of informal education, www.infed.org/biblio/communities_of_practice.htm.