In the past few years several major reports highlighted the gap between our knowledge of effective treatments and services currently being received by consumers. These reports agree that we know much about interventions that are effective but make little use of them to help achieve important behavioral health outcomes for children families and adults nationally. This theme is repeated in reports by the Surgeon General (United States Department of Health and Human Services 1999; 2001) the National Institute of Mental Health [NIMH] National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment (2001) Bernfeld Farrington & Leschied (2001) Institute of Medicine (2001) and the Presidents New Freedom Commission on Mental Health (2003). The authors call for applied research to better understand service delivery processes and contextual factors to improve the efficiency and effectiveness of program implementation at local state and national levels. Our understanding of how to develop and evaluate evidence-based intervention programs has been furthered by on-going efforts to research and refine programs and practices to define "evidence bases" and to designate and catalogue "evidence-based programs or practices". However the factors involved in successful implementation of these programs are not as well understood. Current views of implementation are based on the scholarly foundations prepared by Pressman & Wildavskys (1973) study of policy implementation Havelock & Havelocks (1973) classic curriculum for training change agents and Rogers (1983; 1995) series of analyses of factors influencing decisions to choose a given innovation. These foundations were tested and further informed by the experience base generated by pioneering attempts to implement Fairweather Lodges and National Follow-Through education models among others. Petersilia (1990) concluded that "The ideas embodied in innovative social programs are not self-executing." Instead what is needed is an "implementation perspective on innovation--an approach that views postadoption events as crucial and focuses on the actions of those who convert it into practice as the key to success or failure". (excerpt)

Implementation research: a synthesis of the literature.

Stroke is a leading cause of disability in the United States.1 The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15 000 veterans are hospitalized for stroke each year (VA HSR&D, 1997).

Forty percent of stroke patients are left with moderate functional impairments and 15% to 30% with severe disability.2 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and reduce potential costly long-term care expenditures.

There are only 45 rehabilitation bed units (RBUs) in the VA today. Many veterans who have a stroke and are admitted to a VA Medical Center will find themselves in a facility that does not offer comprehensive, integrated, multidisciplinary care. In a VA rehabilitation field survey published in December 2000, more than half of the respondents reported that the “rehabilitative care of stroke patients was incomplete, fragmented, and not well coordinated” at sites lacking a RBU (VA Stroke Medical Rehabilitation Questionnaire Results, 2000).

In Department of Defense (DoD) medical treatment facilities, approximately 20 000 active-duty personnel and dependents were seen in 2002 for stroke and stroke-related diagnoses according to ICD-9 coding.3 Comprehensive treatment for stroke patients in DoD medical facilities is given primarily at medical centers. Smaller DoD community hospitals may have limited resources to see both inpatients and outpatients, relying more on the TRICARE network for ongoing stroke rehabilitation services.

A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke.4–6 The VA/DoD Stroke Rehabilitation Working Group only focused on the post–acute stroke rehabilitation care.

Duncan and colleagues7 found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded “compliance …

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Management of Adult Stroke Rehabilitation Care: a clinical practice guideline.

Background
Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

Objectives
To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

Search methods
We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

Selection criteria
Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

Data collection and analysis
Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

Main results
Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 11.95: 95%CI 4.72 to 30.30). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results.  An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.

Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

Authors' conclusions
Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

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Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

Jo Rycroft-Malone, Gill Harvey, Kate Seers, Alison Kitson, Brendan McCormack and Angie Titchen

An exploration of the factors that influence the implementation of evidence into practice

To screen or not to screen for adult malnutrition

With the Government promoting ﬂexible and ‘family-friendly’ policies within the NHS, an increase in the number of part-time nurses is imminent, particularly in view of current pro-active recruitment drives in this area. Research, however, indicates that it is mainly female employees who continue to utilise such policies with few male nurses employed on a part-time or ﬂexible basis. Working part-time and taking career breaks, usually because of caring commitments, results in female nurses falling behind male colleagues in terms of career development and promotion prospects, with managers selecting males over females (particularly those who work part-time) regarding functional role allocation in the hospital setting. Based on a recent study of full-time and part-time nurses and their managers in three Outer London NHS Trusts, this paper argues that so-called ‘family-friendly’ policies must target both sexes and that the underlying attitudes of men to childcare and the domestic division of labour must change before the sexes can compete on equal terms in the workplace. Until this happens men will continue to advance the development of their nursing careers more rapidly than women. Already, in a female-dominated area of employment, male nurses form a disproportionate percentage of those in higher grades and management posts.

'The tender trap': gender, part-time nursing and the effects of 'family-friendly' policies on career advancement

Quality of life (QoL) is increasingly recognised as an important healthcare outcome, especially for those living with enduring disability. Stroke is a major source of long-term disablement and many aspects of life after stroke have been explored. Little attention has been paid to nutritional issues despite the cultural and hedonistic importance of food and eating, and the deleterious effects of malnutrition. The present study employed an epidemiological survey to investigate the contribution of dietary and nutritional factors in relation to QoL after stroke. The participants were 206 survivors of a cohort of acute stroke patients consecutively admitted to a National Health Service trust hospital in South London, UK, between March 1998 and April 1999. They were interviewed in their homes at 6 months post-stroke. Cognitively or communication-impaired patients were precluded from interview except where a live-in carer participated as a proxy (n = 10). The participation rate for those who were eligible and could be contacted was 206 out of 218 (94%). Participants were assessed using standardised, validated tools for functional abilities in activities of daily living and eating, cognition and mood state, social support and economic indices, nutritional status, dietary intake, and QoL. Overall group scores demonstrated relatively minor degrees of physical disablement; exclusion of those with limited cognition and communication precluded assessment of a small subgroup with greater disablement at hospital discharge. Nonetheless, the overall assessment results were not dissimilar to other reported groups. Indices of poor nutritional status and substantial dietary inadequacy were revealed, linked with reduced appetite and depression. Multiple regression analyses revealed the dominant impact of mood state in relation to QoL scores; additional significant effects were identified for social support, eating-related disabilities and age. The effects of mood and social support are well-recognised, whilst nutrition-related effects have previously received little attention. Intervention in these areas might achieve improvements in survivors' perceived QoL.

An exploration of nutrition and eating disabilities in relation to quality of life at 6 months post-stroke.

Nutritional support in acute stroke: the impact of evidence-based guidelines

Background. Stroke is a common and enduring problem, producing a wide range of effects that may impact on all aspects of life. One area that has seldom been investigated is the effects of stroke on ability to eat and, particularly, stroke survivors’ subjective experiences of eating-related difficulties.

Aim. To investigate stroke survivors’ reports of eating-related experiences 6 months after stroke.

Methods. Participants were 206 survivors of acute stroke who were admitted to hospital between March 1998 and April 1999. Those able to communicate and who gave informed consent participated in a semi-structured interview and assessment of eating abilities in their homes 6 months after their stroke. Interviews were tape recorded and transcribed and 113 interviews with eating disabled participants were entered onto QSR NUD*IST 4 for thematic analysis. Analyses were later checked independently.

Findings. At 6 months, 34%, 61% and 5% had no, slight and moderate eating disablements, respectively. A range and variety of difficulties were discussed, but relationships between degrees of disablement and handicap were not straightforward; effects seemed more closely related to participants’ responses than objective difficulties. Eating and related activities were clearly important aspects of life for these stroke survivors, socially and psychologically, as well as functionally. Prestroke activities were sometimes maintained, with considerable effort.

Conclusions. Findings indicated issues of relevance for those involved with early rehabilitation interventions and highlighted aspects of continuing care service delivery that warrant review. The relative lack of attention paid to eating-related aspects of care is an important oversight.

Susan McLaren

Papers

'The tender trap': gender, part-time nursing and the effects of 'family-friendly' policies on career advancement

An exploration of nutrition and eating disabilities in relation to quality of life at 6 months post-stroke.

Nutritional support in acute stroke: the impact of evidence-based guidelines

Eating difficulties after stroke

Coping and adaptation at six months after stroke: experiences with eating disabilities.