Translating Evidence into Practice: The Case of Dementia Guidelines in Specialized Geriatric Services

Abstract

This paper describes a process of identifying best practice guidelines for non-pharmacological management for individuals with dementia and disseminating them to a group of frontline practitioners in specialized geriatric services. Our dissemination plan involved early participation of practitioners, development of a chart summarizing five guidelines showing commonalities, contrasts, and gaps in the guidelines, and their interpretation, colour-coded for the strength of the evidence on which they were based. Two sequential workshops were held in which recommendations for action were developed. Outcomes of the process included a resource manual, a network of practitioners, and action recommendations based upon survey data. An early follow-up evaluation showed increased adoption of guidelines.

Full text

Translating Evidence into Practice: The Case of Dementia Guidelines
in Specialized Geriatric Services
Lewis, David L.
Jewell, David.
Turpie, Irene D.
Patterson, Chris, 1964-
Canadian Journal on Aging / La Revue canadienne du vieillissement,
Volume 24, Number 3, Fall/automne 2005, pp. 251-260 (Article)
Published by University of Toronto Press
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Translating Evidence into Practice: The Case
of Dementia Guidelines in Specialized
Geriatric Services
David L. Lewis,
1,2
David Jewell,
1,3
Irene Turpie,
2,4
Christopher Patterson,
2,5
Barbara McCoy,
6
and Julia Baxter
4,7
RE
´
SUME
´
Cette e
´
tude de
´
crit un processus qui consiste a
`
de
´
terminer des pratiques exemplaires pour le traitement non
pharmacologique des individus atteints de de
´
mence et a
`
les diffuser aupre
`
s d’un groupe de praticiens de premie
`
re
ligne en services ge
´
riatriques spe
´
cialise
´
s. Notre plan de diffusion comportait une participation des praticiens de
`
s les
premie
`
res e
´
tapes, l’e
´
laboration d’un diagramme re
´
sumant les cinq lignes directrices et expliquant les points communs,
les contrastes et les lacunes de ces lignes directrices, ainsi que leur interpre
´
tation, au moyen de codes de couleur selon
la ponde
´
ration des preuves sur lesquelles elles e
´
taient fonde
´
es. Deux ateliers se
´
quentiels, au cours desquels des
mesures ont e
´
te
´
recommande
´
es, ont e
´
te
´
organise
´
s. Un manuel de ressources, un re
´
seau de praticiens ainsi que des
recommandations fonde
´
es sur les donne
´
es de l’e
´
tude ont e
´
te
´
tire
´
s de ce processus. Une e
´
valuation de suivi effectue
´
e
peu apre
`
sare
´
ve
´
le
´
une connaissance accrue des lignes directrices.
ABSTRACT
This paper describes a process of identifying best practice guidelines for non-pharmacological management for
individuals with dementia and disseminating them to a group of frontline practitioners in specialized geriatric services.
Our dissemination plan involved early participation of practitioners, development of a chart summarizing five
guidelines showing commonalities, contrasts, and gaps in the guidelines, and their interpretation, colour-coded for the
strength of the evidence on which they were based. Two sequential workshops were held in which recommendations
for action were developed. Outcomes of the process included a resource manual, a network of practitioners, and action
recommendations based upon survey data. An early follow-up evaluation showed increased adoption of guidelines.
1 Regional Geriatrics Program central, Hamilton
2 Division of Geriatrics, Department of Medicine, Faculty of Health Sciences, McMaster University
3 Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University
4 St. Joseph’s Healthcare Hamilton
5 Hamilton Health Sciences
6 Alzheimer Society of Hamilton & Halton
7 Halton Geriatric Mental Health Outreach Program
* We are grateful to members of the Regional Geriatrics Program central for their participation in the conferences and workshops.
Jennifer Horvat coordinated the conferences and workshops, assisted in the research, and was generally invaluable. Rhonda
Barron assisted in the education components and assisted in the research, and was likewise generally invaluable.
Manuscript received: / manuscrit rec¸u : 27/04/04
Manuscript accepted: / manuscrit accepte
´
: 08/02/05
Mots cle
´
s: mise en pratique des lignes directrices; diffusion des connaissances/acquisition de connaissances; de
´
mence
Keywords: practice guidelines; knowledge dissemination; dementia; aging
Requests for offprints should be sent to: / Les demandes de tire
´
s-a
`
-part doivent e
ˆ
tre adresse
´
es a
`
:
David Lewis, Ph.D.
Regional Geriatrics Program Central
88 Maplewood Avenue
Hamilton, ON L8M 1W9
(lewisda@mcmaster.ca)
Canadian Journal on Aging / La Revue canadienne du viellissement 24 (3) : 251 - 260 251

Introduction
A workshop convened by the Canadian Health
Services Research Foundation in 1999 recommended
that regional agencies should ‘‘establish forums aimed
at identifying and articulating the demand for
evidence around themes that are relevant to the
users of research results and decision makers’’
(Canadian Health Services Research Foundation,
1999). In 2001, the Regional Geriatric Program of
Central South Ontario (RGPc), one of the five Ontario
regional geriatric programs, established a Best Practice
Task Group to identify the learning needs of staff
working in specialized geriatric services (SGSs) in the
seven areas served by RGPc. In Ontario, specialized
geriatric services are defined as ‘‘services provided
by geriatricians and geriatric psychiatrists (both
indirect and hands-on-service provision) and services
provided in affiliation with at least one of these
medical specialists’’ (Regional Geriatric Program
central, 2002). Specialized geriatric services include
geriatric assessment units, geriatric rehabilitation
services, in-patient consultation, geriatric day hospi-
tals, outpatient clinics, and outreach teams.
Integrating research findings into practice remains
a serious challenge. Our goal was to explore strategies
and processes that promote evidence-based practice
and decision-making among staff in SGSs. Clinical
practice guidelines (CPGs) are ‘‘systematically devel-
oped statements designed to assist the decision
making of practitioners and patients about appropriate
health care for specific clinical circumstance’’ (Field &
Lohr, 1992). Our key objectives were to increase staff
understanding of how CPGs are formulated, to
develop strategies to encourage the adoption of CPGs
into clinical practice, and to identify key areas for
improved practice. In recent years many guidelines
have been developed by specialist and other
advocacy groups to guide practitioners in the care of
patients. Many guidelines are not based on evidence
but on expert opinion. Even when CPGs are founded
on evidence-based practice principles, adoption and
implementation of those guidelines remains a problem
(Michaud, McGowan, van der Jagt, Wells, & Tugwell,
1998). For example, a review of evidence-based medi-
cine studies (Booth et al., n.d.) showed that between 3
per cent and 58 per cent of medical interventions are
not supported by evidence. The exact percentage
depended upon the definition of evidence and the
specialty being examined. A chart review (Michaud
et al.) of a Canadian general internal medicine depart-
ment found that 65 per cent of interventions were
supported by randomized or ‘‘head to head’’ clinical
trials, while for 7 per cent there was evidence that
alternative therapies were more effective than the ones
selected. There are no studies specific to geriatric care.
Clinical practice guidelines are not consistently
adopted in practice (Auriat, 1998; Davis & Howden-
Chapman, 1996; Lomas & Anderson, 1989). Adoption
depends in part on individual and possibly occupa-
tional traits of the health care professionals them-
selves, timeliness and perceived quality of the
guidelines, organizational factors such as the type of
practice setting, extent of favourable incentives,
reinforcement by regulatory agencies, and ‘‘patient’’
factors (Davis & Taylor-Vaisey, 1997).
In addition, strategies to promote adoption of CPGs
show varying success. A review by Davis and Taylor-
Vaisey (1997) indicated that direct dissemination of
guidelines by publication, didactic mechanisms like
lectures, and traditional continuing medical education
and mailings were weak strategies. Audit and feed-
back, especially rapid feedback targeted to specific
providers and delivered by colleagues or respected
leaders, was moderately effective. Reminder systems,
academic detailing, and multiple interventions were
strongest (see also Bradley et al., n.d.).
The task group focuses on increasing adoption of
specific ‘‘best practices’’ in targeted clinical settings.
Some avenues of dissemination are closed to the group;
however, it does not directly affect the occupational,
regulatory, organizational, and incentive environ-
ments, for example, and lacks sufficient resources to
conduct academic detailing. Likewise, the task group
does not produce CPGs, but it can condense, merge,
and simplify those that already exist.
Task group members recognized that ideal guidelines
would
. summarize data to inform the care of patients
. define the strategies used to identify the evidence
. provide clear grading of recommendations
. be short and straightforward
. be locally applicable (Central West Health Planning
Information Network, 2000)
Goals and Objectives
The Best Practice Task Group decided to use CPGs as
the evidence source to be adopted into practice, and
this paper describes the approaches that we used to
disseminate CPGs for the management of dementia to
staff working in SGSs.
Methods
Figure 1 shows the steps followed by the task group;
in addition to preliminary work and future plans, this
was a five-step process.
252 Canadian Journal on Aging 24 (3) D.L. Lewis

Step 1
A learning-needs assessment survey, intended to
involve staff of SGSs early in the process, was
e-mailed to selected SGS practitioners as a ‘‘snowball’’
survey. Methods and results have been reported
elsewhere (Jewell, Turpie, Patterson, Lewis, &
Baxter, 2003). The greatest learning need identified
by respondents was management of dysfunctional
behaviour in dementia. This topic became a focus for
a dissemination strategy because challenging care
situations related to dementia are frequently the
reasons for admission to long-term care (LTC) and a
common reason for referral to SGSs (Cohen-Mansfield
& Werner, 1998; Orell, 1996).
Step 2
We performed a literature review to locate CPGs on
the management of behavioural disturbance in
dementia. The search was confined to the (U.S.)
National Guideline Clearinghouse (n.d.) and the
Canadian Medical Association’s Clinical Practice
Guidelines InfoBase (n.d.). We identified five CPGs:
the American Academy of Family Physicians (AAFP;
Cummings et al., 2002), the American Academy of
Neurology (AAN; Doody et al., 2001), the American
Psychiatric Association (APA; Working Group on
Alzheimer’s Disease and Related Dementias, 1997),
the Canadian Consensus Conference (CCC) on the
Management of Dementia (1999), and the Scottish
Intercollegiate Guidelines Network (SIGN, 1998).
Individual recommendations were then assessed for
quality. We selected CPGs on the basis of evidence,
which addressed the non-pharmacological manage-
ment of behaviour disorder in dementia.
Step 3: Development of Provider Evidenced-Based
Guidelines (PEG)
The next step for the Best Practice Task Group was to
determine the most effective means of disseminating
CPGs to improve adoption in clinical practice.
While there are many strategies for dissemination,
we chose to use the framework developed by the
National Health Service in the U.K. (NHS Centre
for Reviews and Dissemination, 1999) and based a
resource manual upon this framework. The dissemi-
nation strategy included
1. the origin of the research and/or the dissemination
strategy
2. the substantive nature of the research findings
3. the feasibility of implementing findings
4. the transmission strategy used to communicate the
research findings
5. the relations between researcher and user
6. the user’s characteristics
7. the environmental characteristics
Items 1 and 2 were covered in Steps 1 and 2 of this
project, and items 5 to 7 were used for subsequent
steps. The task group concentrated on item 4, the
transmission strategy, as the most amenable to change.
Preliminary Work:
Task Group forms,
sets goals and
objectives
Step 2: Literature
review of relevant
CPG's
Step 1:
Learning needs
assessment
Step 4: Workshop I
Step 3: Provider
evidence-based
guidelines
developed &
disseminated
Step 5: Workshop II
Future: Prepare & disseminate poster,
collaborate with regulators & compliance
advisors to increase adoption,
Re-administer survey of guideline adherence
CPG's = Clinical practice guidelines
Figure 1: Flow chart of strategy design for implementation of guidelines for management of dysfunctional behaviour
in dementia CPGs
Evidence into Practice La Revue canadienne du vieillissement 24 (3) 253

To maximize utility, relevant content of each CPG was
abstracted and presented in a table. This was an
iterative process, deconstructing information so that it
could be summarized meaningfully for staff. We felt
that staff would be more easily persuaded to review
and act on CPGs if they were supported by multiple
sources of evidence. Rankings of evidence followed
established guidelines (West et al., 2003), and sections
of the chart were colour-coded to reflect levels of
evidence (1, 2, 3).
1
These guidelines are available at
www.rgpc.ca/best/best_practices.html
Process for Engaging Staff
The resource manual was developed to include colour-
coded charts for non-pharmacological intervention
for behavioural management in dementia, two articles
on knowledge transfer, all five unedited CPGs, and
a summarized pharmacological intervention chart
for behavioural management in dementia. A letter
outlining the educational strategy was mailed to
administrators of SGSs (geriatric medicine and
psychiatry settings) in the target area. The letter
asked organizations to identify staff opinion leaders
who could influence their peers in the promotion of
best practices. The letter was followed up with a
personal phone call to reinforce the importance of
this initiative. Managers from all targeted regions
identified front-line clinical staff for this project.
Ultimately, two staff members from each region were
selected (by local managers and medical directors)
to participate in two relevant workshops; almost all
were nurses. Psycho-geriatric resource consultants
(PRCs)
2
and administrators from long-term care
settings were also invited.
Step 4
Workshop 1
The first workshop was held for 34 staff from 14 SGS
organizations in February 2003. Participants were
front-line clinical staff working in geriatric medicine
and psychiatry outpatient programs. The goals were
to (1) provide members with a primer on levels of
evidence, (2) introduce the process and objectives of
the initiative, (3) provide practical examples of the use
of CPGs summarized in the colour-coded charts, and
(4) introduce the development of an RGPc network of
SGSs dedicated to fostering evidence-based practice
and promoting a culture of research.
Homework
Participants were provided with the resource manual
and were asked to compare the approaches of their
teams on non-pharmacological interventions in the
management of dementia, with the CPG recommen-
dations. Respondents in each team used a Likert scale
(Trochim, 2000) to rank the frequency with which
specific recommendations were followed in their
organizations. Team members were also asked to
comment on barriers (Figure 2) and facilitators to
the implementation of guidelines into their practice
settings.
0246810121416182
0
Lack of resources, staff
Role confusion, strain
Lack of specific services
Access limited by geography
Pharmaceutical firms' over-involvement in education
Incentives that inhibit change
Inconsistent practices
Communications gaps
Limits of physical plant
Referral process
Staff turnover
Waiting list
Inability to do home visits
Attitudes, no buy-in
Lack of knowledge
Reliance on pharmacological options
Lack of discussion about guidelines
Outside mandate
Too much detail in summary
Too few details in summary
Recommendations not followed
Need for more antipsychotics
Number of res
p
onses
Structural
Organizational
Personal
Guideline content
Figure 2: In your setting what makes it harder to implement guidelines?
254 Canadian Journal on Aging 24 (3) D.L. Lewis

Step 5
Workshop 2
A second workshop was held 8 weeks later.
Participants were provided summary feedback on
their team response to the exercise described above.
They provided further feedback on the experience of
reviewing the CPGs as a team.
Follow-up Evaluation
Finally, a follow-up evaluation questionnaire was
circulated to participants (Figure 3) by e-mail. The
questionnaire was designed as a semi-structured
self-report document.
Results
Prior to the second workshop, participants were
asked to return a questionnaire using a Likert scale
(Trochim, 2000) to rank the frequency with which the
recommendations listed in the workbook (Table 1)
were followed in their organizations; a 95 per cent
response rate was achieved.
These responses indicate that there was wide varia-
tion in adherence to guideline recommendations,
depending on the specific item (Table 1). For Level 1
recommendations, such as asking family members or
other caregivers for information about an individual’s
behaviour or for evaluating suicidality and propensity
to violence, 11 organizations (representing 79% of
organizations surveyed) report adherence to guide-
lines at least 75 per cent of the time. On the other
hand, only 3 organizations (21%) often adhered to
recommendations on use of restraints or on structur-
ing a facility to accommodate the needs of demented
elders with behavioural problems. Levels 2 and 3
recommendations generally displayed a low level of
adherence.
Of the 34 participants at the second workshop, 28
people representing 11 organizations (80%) submitted
a response to our request for information about
facilitators and barriers to guideline adoption in their
organizations. These respondents listed 92 barriers to
CPG adherence, divided into ‘‘structural’’, ‘‘organiza-
tional’’, and ‘‘individual’’ factors, as well as factors
related to the CPGs themselves. Structural factors
(e.g., shortages of resources, staff, and specific services)
were the most frequently cited, mentioned 33 times.
Organizational factors were listed 25 times and
included factors such as inconsistent practices, com-
munication gaps, limits of the physical plant, and
problems with referral and other processes. Personal
factors, such as ‘‘attitudes’’ and lack of ‘‘buy-in’’ or
lack of knowledge were listed 18 times. Finally, the
guidelines as presented by RGPc were listed as a
barrier 16 times: Many wanted more discussion, and
some found them too detailed or not detailed enough.
Identified barriers to the adoption of the CPGs are
included in Figure 2.
Participants listed 89 factors that they felt facilitated
CPG adherence (not shown). These were mainly
organizational (49 of 89), including the qualities of
the teams both within and outside of participants’
units, organizational support for team education, and
standardized practice. Structural facilitators included
the existence of specialist units and facilities, and the
psycho-geriatric resource consultants.
At the second workshop, participants were presented
with these data and asked to divide into teams.
Each team was asked to produce no more than five
strategies for an educational work plan to increase
CPG adherence. The teams identified 17 separate
strategies, which were transcribed and circulated.
Participants, this time as individuals, then scored as
many as 5 strategies from ‘‘5’’ (most important) to ‘‘1’’
(least important). Those results were collated and
presented as a graph at the end of the workshop
(Figure 3).
Adoption of Guidelines
Representatives of 10 of the 11 organizations that
participated in the workshops responded to the
follow-up evaluation questionnaire (Figure 4). All
reported greater awareness of guidelines in general.
In addition, 9 of 10 reported that their organizations
1. Have you been using the existing clinical practice guidelines as outlined in your
resource manual, i.e., the chart or unedited version?
2. Have you been using clinical practice guidelines in general?
3. Are you more aware of existing clinical practice guidelines?
4. Now that some time has passed since your feedback at the workshop, do you have
any further suggestions on how to improve the delivery and adoption of clinical practice
guidelines?
Figure 3: Follow-up evalution questionnaire
Evidence into Practice La Revue canadienne du vieillissement 24 (3) 255

Table 1: Number of respondents reporting adherence to guidelines in 75% or more of applicable cases and in less
than 50% of applicable cases
Number
> ¼75%
Adherence
Per Cent
> ¼75%
Adherence
Number
<50%
Adherence
Per Cent
<50%
Adherence
Level 1 Recommendation
Ask caregivers 11 78.6
Evaluate suicidality, violence 11 78.6
Rule out physical causes 10 71.4
Make safety recommendations 10 71.4
Treat general medical conditions 9 64.3
Provide thorough evaluations 9 64.3
Watch for abuse 9 64.3
Help plan financial arrangements 9 64.3
Assess regularly 8 57.1
Assess periodically 8 57.1 1 3.6
Schedule frequent visits 8 57.1 1 3.6
Advice from Alzheimer’s Society 8 57.1 3 10.7
Advise on driving 8 57.1
Provide behaviour modification for incontinence 8 57.1 2 7.1
Modify environment, behaviour first 7 50.0 2 7.1
Help family anticipate future 5 35.7
Restructure LTCs to meet needs of demented residents 3 21.4 1 3.6
Use restraints if imminent risk only 3 21.4 5 17.9
Use restraints as last resort 3 21.4 5 17.9
Document restraints 3 21.4 1 3.6
Level 2 Recommendation
Identify ‘‘triggers’’ of behaviours 7 50.0 1 3.6
Educate caregivers 7 50.0 1 3.6
Provide stimulation 5 35.7 2 7.1
Educate LTC staff to reduce use of antipsychotics 3 21.4
Provide supportive psychotherapy 2 14.3 1 3.6
Avoid cognition therapy 2 14.3 2 7.1
Offer reminiscence therapy
Provide validation, sensory integration
Level 3 Recommendation
Provide routine, familiar clothes, etc. 8 57.1
Speak simply, offer music, etc. 8 57.1 1 3.6
Maintain a safe environment 7 50.0
Provide day care, respite programs 7 50.0
Provide adult day program 7 50.0
(continued)
256 Canadian Journal on Aging 24 (3) D.L. Lewis

had begun to use CPGs in general, and 8 of 10 that
they had adopted the specific CPGs contained in the
workshops’ resource manual.
Staff employed in SGSs do not usually have
the opportunity to discuss activities outside their
program area. This initiative brought staff together
from many areas for face-to-face discussions, large
group interaction, and the opportunity for ongoing
communication.
Ad hoc groups have since formed to
. develop an educational poster outlining evidence for
management of dementia, to be used for training and
education with health professionals, patients, and
caregivers
. collaborate with regulatory and funding compliance
advisors to determine how the guidelines can be
incorporated into best practice in long-term care settings
Discussion
Adherence to specific CPGs recommendations prior
to the workshops (Table 1) appeared to reflect the
credibility attributed to them by levels of evidence.
The highest levels of adherence were reported for
recommendations supported by one or more random-
ized controlled trials (RCTs). High-quality RCTs
can be difficult or even impossible in health services
research (West et al., 2003), yet the evidence from
other high-quality research was far less influential,
Table 1: Continued
Number
> ¼75%
Adherence
Per Cent
> ¼75%
Adherence
Number
<50%
Adherence
Per Cent
<50%
Adherence
Ensure a homelike setting 4 28.6 1 3.6
Offer graded assistance, practice, etc. 3 21.4 3 10.7
Develop special care units 3 21.4 1 3.6
Provide reality orientation, validation 2 14.3 1 3.6
Offer short-term hospitalization 2 14.3 2 7.1
Offer electronic networks for caregivers 3 10.7
LTC: Long-term care facility
0 102030405060
More literature relevant to recommendations
Ensure our organizations are aware of RGPC
Look at specific guidelines and how to start
Look at applicability and flexibility of adapting guidelines (i.e., LTC)
How can BP influence re-write of LTC facility standards?
Make consensus statements sensitive and palatable to LTC
Measurement and evaluation of practice – tools we used
Share successes, areas of improvement to increase continuity in group
Series of steps for guidelines for geriatric assessment – flow chart
Guidelines should be part of orientation binders
Find guidelines relevant to practice and organize by team interests
Develop poster for cues
Fact sheets to support non-pharmacological intervention
Incorporate BP in PIECES curriculum
BP Guidelines in curriculum for PSW/aides
Incorporate BP in performance appraisals
Introduce guidelines to LTC, universities, colleges, etc.
BP: Best practice guidelines
LTC: Long-term care facility
CPG: Clinical practice guidelines
PSW: Personal support worker
PIECES: "Physical, Intellectual, Emotional, Capabilities, Environment,Social;" an element of the Ontario Alzheimer Strategy aimed at teaching best practices
Figure 4: Q-sort strategies, best practices workshop, April 2003
Evidence into Practice La Revue canadienne du vieillissement 24 (3) 257

often less than recommendations based on expert
consensus.
Moreover, only a few Level 1 recommendations were
widely followed. Recommendations for minimizing
use of restraints are notable for the lack of adherence
they gain. In general, it appears that CPGs are
accepted if they are specific; if they can be followed
on the treatment site, especially as part of an
assessment; and if they are aimed at reducing the
risk of physical harm to the resident. Clinical practice
guidelines are less likely to be accepted if they require
sustained interventions or ongoing assessment; if
they involve contacts outside the organization (such
as with the Alzheimer’s Society); if they require
consideration of social and psychological factors; or
if they necessitate changes to the organization or its
physical plant.
These tendencies were echoed by the participants
themselves, who reported that barriers to guideline
adherence were largely organizational or structural
(Figure 3), and that the presence of ‘‘resources’’ – in
general and/or specifically – made adherence easier.
One interpretation of these results is that participants
are willing to implement CPGs in order to improve
practice, but believe they lack the means to do so. On
the other hand, the results may mean that participants
did not see CPG adherence as a routine ‘‘part of the
job’’, and expect that the health care system will
devote additional energy to the creation of specialized
units and teams. If either of these is the case, no
amount of ‘‘translating’’ will increase adoption.
From a process perspective, this exercise has been
useful in developing a network of staff, discovering
leadership potential, and obtaining a commitment
from organizations to invest their staff in disseminat-
ing best practices. Each guideline we reviewed
suggested that as a first step practitioners try
non-pharmacological approaches to behaviour man-
agement in dementia, which is in part a recognition
that most care is provided by professionals other
than physicians. Even so, the evidence on which
these non-pharmacological CPGs is based is com-
paratively sparse. There is far more evidence for
medical and pharmacological approaches, and con-
sequently a tendency to downplay the value of other
interventions.
Participants desired material that was highly synthe-
sized and simplified as a one-page fact sheet or
algorithm. While they enjoyed the process of compar-
ing their current practices with guidelines, this activity
was not sustainable over the long term. Participation
in the development of educational packages and
posters – that is, more concrete tools – was seen as a
distinct advantage with a tangible outcome.
Participants further suggested that having access to
other SGS sites has been rewarding. Their perspective
on the system of services has changed, and working
0246810
Using CPG’s in resource
manual?
Using CPG’s in general?
More aware of CPG’s?
Suggestions?
Number yes
CPG’s = Clinical practice guidelines
Figure 5: Adoption and awareness of CPG’s (N ¼10)
258 Canadian Journal on Aging 24 (3) D.L. Lewis

side-by-side with medicine and psychiatry was seen
as ‘‘seamless’’ and client-centred.
Within the CPG, staff noted information that was
often dated, revealing the work entailed in producing
such guidelines and keeping them current. This
project involved a literature search for CPGs and for
the most effective means of dissemination, compila-
tion of a resource binder, and two half-day work-
shops, and it consumed considerable time and effort.
However, it is expected that participating groups may
be more easily engaged with new projects in the
future. In addition, early feedback shows that almost
all participants found the process useful, are more
aware of CPGs, and are using them more often.
Finally, note that adoption of guidelines (Figure 5)
was evaluated by response to semi-structured surveys
conducted after the workshops. This approach is
imprecise, may be subject to affirmation bias, and in
any case does not show whether any effects persist.
Re-administration of the ‘‘adherence to guidelines’’
survey awaits 1-year follow-up.
Notes
1 A Level 1 recommendation is supported by at least one
high-quality randomized controlled trial, Level 2 by
other high-quality research, and Level 3 by expert
consensus. For more detail, see www.rgpc.ca/best/
best_practices.html
2 Psycho-geriatric resource consultants (PRCs)
provide consultation to long-term care facilities
and other agencies that serve elderly people
who exhibit challenging behaviour. Their mandate
is to enhance local knowledge and skills in
psycho-geriatric care.
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