Efficacy of the Facilitation Intervention for Practice (FLIP) program for increasing adherence to clinical practice guidelines (CPG) relating to the management of the clinical deterioration of patients.

The intervention group ward nursing staff will receive the standard implementation of Clinical Practice Guidelines (CPGs) plus the Facilitation Intervention for Practice improvement (FLIP). The Australian Commission on Safety and Quality in Health Care published a CPG titled "A guide to support implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration". This CPG will be dissemination to all wards (both intervention and control wards). All wards will receive standard education support provided by the hospital related to this topic. Standard education consists of in-service presentations during work time to update staff on policy or practice changes, information on the CPG, its availability online as well as notification of the free online educational courses available to increase their knowledge and understanding about the identification and management of deteriorating patients. Information will be disseminated via posters on ward noticeboards and emails sent by the Nurse Unit Manager to all nursing staff. In addition to the standard implementation, the intervention wards will receive additional educational support (FLIP) specifically targeting identified areas requiring practice improvement. FLIP comprises individuals in facilitator roles using facilitation methods (face to face contact) and processes in a flexible way to tailor implementation strategies to the local ward context, according to identified barriers and enablers. There will be two types of facilitator roles: hospital facilitators (HFLIP) and ward facilitators (WFLIP). A hospital facilitator (HFLIP) will be appointed to cover 4 or 5 intervention wards in each of the four hospitals, acting as the overall facilitation lead and a coordinator and mentor for the ward facilitators. In each intervention ward, two ward facilitators will be appointed to support and enable ward nurses to implement the CPGs into practice. Each HFLIP will work with 8-10 WFLIPs. The intervention wards will receive half a day per week support from the HFLIP for 6 months, reviewing barriers and enablers to implementing CPGs into practice during the intervention period and in discussion with the WFLIPs. The HFLIP will also review ward specific systems, processes, routines and audit practices in order to align systems of care to enable implementation of CPGs into daily practice. Training and a toolkit of methods and techniques will be given to all FLIPs to promote the transfer of CPGs into daily practice. At ward level, the 2 WFLIPs will work with the HFLIP to audit practice, identify barriers, strategies and areas for improvement; they will provide cover for each other during leave and support ward staff during practice hours, receiving one day per fortnight of protected time for conducting audits and meeting with the HFLIP to agree to tailored strategies to improve adherence to guidelines. The intervention will commence following the completion of training and when the HFLIPs can commence on the wards in the role. The intervention will last 6 months. HFLIPs will have prior experience (e.g. in practice development or an education role) so that they can support and mentor the WFLIPS and deal with the more challenging contextual barriers that may arise. Standardised procedure manuals will be provided to all facilitators with specific detail on roles and responsibilities. All facilitators will undergo monitoring procedures to ensure intervention fidelity. All Hospital and Ward FLIPs will receive training for a single day together and then the HFLIPs will continue for a further two days on advanced facilitation skills. Training will be conducted jointly by an investigator and a nurse educator. They will also receive mentoring and support during the trial consisting of monthly teleconferences for an hour with an investigator and support via a discussion blog asynchronously throughout the intervention period. The intensity of intervention will be assessed and monitored across sites. Examples of practices in the CPGs include documenting clinical assessments accurately; completing scope of practice activities such as administering medications; escalating care to the appropriate staff. All facilitators will enter data into the Electronic Activity and Communication Log (eACL). Data will be collected at time of activity and throughout the duration of the intervention on ward communication. Data captured will include methods and techniques outlined in the Facilitator Manuals, enablers and barriers, and measures of impact.