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When it came to the 'knowing how' aspect of practice change, the project teams made extensive use of their own and others' practical knowledge.
To successfully measure policy effects, rates of practice change should also be measured with targeted water quality parameters.
The reasons for this lack of practice change are unclear.
Furthermore, it is not yet clear whether customized facilitators of practice change, adapted to local barriers, are more effective than generic facilitators of practice change [ 4].
The effect of practice change implementation will be measured using ongoing data collection within each network.
These indicators will measure the short-term impact of practice change.
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Therefore, 'grouping' the results of these nursing-sensitive outcomes may make implementation of practice changes easier and monitoring more straightforward during quality improvement activities.
Further assessment of practice changes over a longer time period (2 years) is required and a more detailed investigation of the factors that influence the sustainability of pain practice improvements, including examination of child and organization related contextual factors.
The final steps of working with individual physicians to facilitate or reinforce change through discussion and subsequent confirmation of practice changes have not been previously reported for the PAR program.
Prospective, adequately powered before-after studies may be most suitable for evaluation of practice changes and cluster-randomized trials are conceivably the best study designs to evaluate the effect of implementation strategies on outcome improvements [ 42].
Further, several aspects of implementation deserve further evaluation, as this review shows that these issues in implementation have lacked attention, such as cultural aspects pertaining to the medical ICU team, nurse-physician interaction and establishing sustainability of practice changes [ 12].
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