SPECIAL FEATURES: CLINICAL CONCEPTS

Adaptation of a Best Practice Guidelineto Strengthen Client-Centered Care inPublic HealthLorraine Athwal, R.N., M.P.H., C.C.H.N.(C),* Brenda Marchuk, R.N., B.Sc.N., C.C.H.N.(C),1

Yvette Laforet-Fliesser, R.N., M.Sc.N., C.C.H.N. (C),2,3 Joyce Castanza, R.N., B.Sc.N.,4 Lori Davis, R.N.,B.Sc.N., C.C.H.N.(C),1 and Marg LaSalle, R.N., B.Sc.N., I.B.C.L.C., C.C.H.N.(C)11Family Health Services, Middlesex-London Health Unit, London, Ontario; 2Edellys Training Corporation, London, Ontario; 3Arthur LabattFamily School of Nursing, Western University, London, Ontario; and 4Environmental Health and Chronic Disease Prevention Services,Middlesex-London Health Unit, London, Ontario

Correspondence to:

Brenda Marchuk, Middlesex-London Health Unit, 50 King St. London, ON, Canada N6A 5L7. E-mail: brenda.marchuk@mlhu.on.ca

ABSTRACT Best practice guidelines (BPGs) were developed by the Registered Nurses Association ofOntario (RNAO) to support evidence-based nursing practice. One Ontario public health unit chose toimplement the BPG on client-centered care (CCC). A critical review of this BPG revealed issues thatwould hinder successful implementation within a public health setting. These included a focus on theclient as an individual, the predominance of acute care exemplars and training resources that were notrepresentative of public health nursing practice, and the need to reconcile the enforcement roles of pub-lic health with the BPG principles. The purpose of this article is to describe the process of adapting theCCC BPG to more accurately reflect the broad scope of public health nursing practice. A model for CCCin public health nursing context is presented and processes for implementing, evaluating, and sustainingCCC are described.

Key words: best practice guidelines, client-centered care, evidence-based practice, public healthnursing practice, relationships.

Holistic, relationship-centered practice is a well-established belief and value in nursing science.Nursing theorists like Peplau (1991), Rogers(1970), Newman (1979), Watson (1988) and Parse(1998) have included this principle as a centraltenet in their frameworks. In professional publichealth nursing practice, the nurse–client relation-ship “promotes maximum participation and self-determination of the individual, family, group,community or population” (Community HealthNurses of Canada [CHNC], 2011; p. 16). Worldwide

standards of practice and competencies for com-munity and public health nurses (PHNs) clearlyarticulate the importance of the client relationshipand set the expectation that nurses will engagewith and be respectful of clients and their choices(CHNC, 2011; Community Nurses Special InterestGroup, Western Australia and Department ofHealth, Western Australia, 2001; Keller, Strohsch-ein, & Schaffer, 2011; Nursing and MidwiferyCouncil, 2004; and Quad Council PHN Competen-cies, 2003).

In addition to being client-centered, it isexpected that PHNs will practice according to thebest available evidence (Public Health Agency ofCanada, 2007). Best practice guidelines (BPGs) are

*Lorraine Athwal is a former employee of the Middlesex-London HealthUnit

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a tool that can assist nurses in providing evidence-based client care. In Ontario, Canada, the RegisteredNurses’ Association of Ontario (RNAO), with fund-ing from the Ministry of Health and Long TermCare, Ontario, 2008 launched a multiyear projectto develop, evaluate, and disseminate BPGs fornurses (Ploeg, Davies, Edwards, Gifford, & Miller,2007). Since 1999, a total of 47 guidelines, anImplementation Toolkit and educational resourceshave been published and have received interna-tional attention (RNAO, 2006).

The purpose of this article is to describe howone Ontario public health unit adapted the con-tent of the RNAO Client-Centered Care BPG (CCCBPG) to reflect public health nursing practice withindividuals, families, groups, and populations indiverse settings. We propose an adaptation of theMinnesota Public Health Intervention (PHI)model (Keller, Strohschein, Lia-Hoagberg, &Schaffer, 2004) that illustrates our revisions ofthe values, beliefs, and core processes for client-centered care in a community and public healthnursing context. The processes for implementa-tion, evaluation, and sustaining CCC will also bediscussed.

BackgroundIn Ontario, Canada, legislation mandates the healthservices provided by personnel in public healthunits. [Middlesex-London Health Unit] is one of36 official health agencies funded by both the pro-vincial government and the municipal tax base todeliver public health programs to an urban-ruralcommunity of approximately 400,000 people. Anautonomous board of health, generally composedof elected officials who represent the municipaltaxpayers, is the governing body of each healthunit. Over 100 PHNs work on interprofessionalteams in one of several service areas or depart-ments of the [Middlesex-London Health Unit] suchas family health, communicable disease manage-ment and control, sexual health promotion, andchronic disease and injury prevention.

The Director of Family Health Services acts asthe agency’s Senior Nurse Leader (SNL) or ChiefNursing Officer. She is a member of the NursingPractice Council (NPC) that contributes to qualityassurance in nursing practice and a quality workenvironment, and excellence in practice by identify-ing and responding to professional nursing issues.

The NPC strives to support excellence in nursingthrough engaging nurses in evidence-based, andreflective practice by facilitating their capacity toprovide care according to professional standards.Membership on the Council includes at least fourstaff nurse representatives from several ServiceAreas, at least three managers who are nurses fromseveral Service Areas, the SNL, the CommunityHealth Nursing Specialist, the nurses’ union localpresident or designate, and the manager of HumanResources and Labor Relations.

As a result of the Best Practice Guidelines ini-tiative, the SNL engaged and supported a numberof nurse managers and PHNs to become BPGChampions. Champions are considered changeleaders who assume different roles such as bringingawareness of best practices to staff nurses andorganizational leaders, facilitating the training anddevelopment of professional staff in BPG imple-mentation, and fostering organizational changes toreinforce implementation of guidelines (Davies,Edwards, Ploeg, & Virani, 2008; Edwards et al.,2005; Ploeg et al., 2010). Since 2003, two manag-ers and more than 12 staff have completed thetraining. These BPG Champions have contributedto the health unit’s successful implementation andevaluation of several other BPGs, such as support-ing smoking cessation and screening for womanabuse. The NPC and SNL endorsed the implemen-tation of the Client Centered Care BPG across theorganization, and an implementation team wasformed.

The implementation team for CCC consisted offive PHNs from three program areas (chronic dis-ease and injury prevention, maternal and childhealth, and school health), the community healthnursing specialist, and a program manager. TheRNAO Toolkit: Implementation of Clinical PracticeGuidelines (2002) guided the team’s process andspecific elements are described below.

Reviewing the Original Best PracticeGuidelines

The implementation team conducted a search forother nursing evidence-based practice guidelines onclient-centered care. As none were identified, onlythe RNAO BPG was reviewed. Designated membersof the implementation team then appraised theCCC BPG and considered how each of the BPG rec-

Athwal et al.: Client-Centered Care in Public Health 135

ommendations would work in this public healthsetting (RNAO, 2002, 2006).

The Implementation Toolkit recommends usingthe AGREE tool (AGREE Collaboration, 2000) toassess the quality of a BPG (RNAO, 2002). TheAGREE instrument is a tool that assesses the meth-odological rigor and transparency in which a guide-line is developed. It contains 23 items organizedunder six quality domains: (1) scope and purpose,(2) stakeholder involvement, (3) rigor of develop-ment, (4) clarity of presentation, (5) applicability,and (6) editorial independence. Two additionalitems address the overall quality of the guidelineand the recommended use of the guideline in prac-tice (AGREE Collaboration, 2000).

Each item is ranked on a seven-point Likert-type scale ranging from ‘strongly disagree’ (1) to‘strongly agree’ (4). For each item, a score isassigned depending on completeness and qualityof reporting. Scores increase as more criteria aremet and considerations are addressed (AGREECollaboration, 2000). It is recommended that atleast two appraisers, preferably four, assess eachguideline.

Using the AGREE tool presented some chal-lenges. The guideline evaluation instrument focusedon BPGs that addressed management of clinicalconditions rather than philosophies of care. Forexample, assessment domains inquired whether theBPG considers “health benefits, side effects andrisks” (AGREE Collaboration, 2000, p. 11) as wellas “different options for management of the condi-tion” (p. 15). Additionally, the tool lacked educa-tional supports to guide the scoring and process ofevaluation. In the end, the AGREE tool was used asa reference to guide discussions about the qualityof the BPG for public health practice.

Upon completion of the review, contextualissues were identified that would hinder successfulimplementation within a public health setting.These included the focus of client as an individual,the predominance of acute care exemplars andtraining resources that were not representative ofpublic health nursing practice, and the need to rec-oncile the enforcement roles of public health withthe BPG principles. For example, the videos,assigned readings, and sample case studies in theTeaching-Learning Activities were all focused onpractice with an unwell individual in a health careinstitution.

Adapting the Best Practice Guideline

Client-centered care is defined as “an approach inwhich clients are viewed as whole; it is not merelyabout delivering services where the client is located.Client centered care involves advocacy, empower-ment, and respecting the client’s autonomy, voice,self-determination, and participation in decisionmaking” (RNAO, 2002, p. 12). In the BPG, the termclient is inclusive of individuals, families, communi-ties, and populations (RNAO, 2006). However, asnoted earlier, there is a predominant focus of theclient as an individual in the BPG narrative andsupporting resources.

The RNAO (2006) recommends that practicesettings adapt these guidelines in user-friendly for-mats for daily use. Adaptation of the supportingmaterials within a guideline for a specific work con-text is a common diffusion strategy involved in theimplementation of BPGs (Ploeg et al., 2010).

Values and beliefsThe values within the BPG are based on thosefound in the Code of Ethics for Registered Nurses(Canadian Nurses Association, 2008) and the Ethi-cal Framework for Registered Nurses and Regis-tered Practical Nurses in Ontario (College of Nursesof Ontario, 2009). These values inform every aspectof client care and service (RNAO, 2006). To deter-mine whether these reflected the uniqueness andscope of public health nursing practice, we con-ducted a review of key public health nursing docu-ments in Canada and beyond. We selected andconsulted several influential papers that addressedpublic health nursing ethics (Canadian NursesAssociation, 2006, 2008), Canadian leaders in pub-lic health practice (Falk-Rafael, 2000; Hartrick,2002), regulating bodies (College of Nurses ofOntario, 2009), and foundational public healthpapers (CHNC, 2009; Public Health Agency of Can-ada, 2013; World Health Organization, 1998).

Based on central themes in the literature, thevalues and beliefs were modified to capture the var-ious dimensions of public health nursing practice.Consultation with nurse researchers knowledgeablein CCC and in community and public health nurs-ing helped us to further refine the changes. Table 1compares the original RNAO CCC BPG values andbeliefs and our revisions for public health nursingpractice.

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Core processesThe BPG stipulates four core processes in becom-ing client-centered. By practicing these core pro-cesses, the CCC values and beliefs can be achieved(RNAO, 2006, p. 20). These core processes are (1)Identifying Concerns or Needs, (2) Making Deci-sions, (3) Caring and Service, and (4) EvaluatingOutcomes (p. 20). A number of nursing activitiesand example questions that invite client participa-tion and are reflective of the values and beliefs arealso identified in the guideline.

At the health unit, the titles of the four coreprocesses remained unchanged. However, we usedthe same methods as described above, to articulatenursing activities that better reflected public healthnursing practice. The majority of these activitieswere informed by the CCC BPG and the CanadianCommunity Health Nursing Standards of Practice(CHNC, 2011). Examples are found in Table 2.

Model of client-centered care in public healthnursing practiceUpon further reflection, the implementation teamidentified a need to conceptualize the relationshipbetween the values and beliefs and core processesand levels of public health nursing practice. Webecame aware of the Minnesota PHI Model. Thismodel visually integrates three distinct and equallyimportant components: The population basis of allPHIs; the three levels of public health practice; and17 PHIs (Keller et al., 2004). With permission of theauthors, this model inspired a visual depiction of cli-ent-centered care in public health nursing practice.

The same visual concept was used, but theinterventions in the outer circle of the originalmodel were replaced with the values and beliefs ofCCC that inform all levels of nursing practice(Fig. 1). The core processes of CCC were placed atthe hub of the wheel. The wheel spokes are

TABLE 1. Comparison Between RNAO CCC BPG Values and Beliefs and Public Health Nursing Values and Beliefs

RNAO CCC BPG valuesand beliefs Public health nursing CCC values and beliefs

RespectHuman dignity

Caring: is based on the principles of social justice and respect for clients’ wishes, concerns,values, priorities, perspectives, and strengths, and includes both respect and human dignity.Caring is essential and universal and acknowledges the physical, spiritual, emotionalcognitive nature of individuals, families, groups, and communities (CHNC, 2011)

Clients are expertsfor their own livesClients as leaders

Partnership: While clients know themselves best, both the client and the PHN bring expertiseto the partnership. Clients are active partners in decisions that affect their health andwell-being. They define their own health issues, set their own priorities among health goals,control the choice of actions, and evaluate their efforts. The PHN does not impose, but ratheroffers expertise

– Multiple Ways of Knowing: Recognizes the diverse evidence for practice that evolves andcreates effective action with the client (CHNC, 2011). It encourages the exploration ofpossibilities, creativity in practice and contributes to the transformative power of client andPHN working together (Falk-Rafael, 2005)

Clients’ goals coordinatecare of the healthcare team

Clients’ Goals Shape the Service Plan: The PHN and client mutually explore the meaning ofthe situation, the provision of information and the development of skills that will enableclients to gain great control over their health. PHNs foster the power and energy withinclients through relationships that support clients to reach their full potential (Hartrick, 2002)

Continuity andconsistency ofcare and caregiver

Continuity and Consistency of Service and Provider: Essential to the health care process isestablishing a foundation for the relationship within CCC values and beliefs and coreprocesses

– Determinants of Health: Public health is fundamentally concerned with action and advocacyto address a range of potentially modifiable determinants of health (Public Health Agency ofCanada, 2013; Public Health Agency of Canada, 2007). PHNs consider the impact of thecomplex sociopolitical environment on the health of individuals and communities(CHNC, 2011)

Timeliness Timeliness: The needs of clients and communities deserve a prompt response (RNAO, 2006)Responsiveness anduniversal access

Responsiveness & Universal Access: Care that is offered to clients is universally accessibleand responsive to their wishes, values, priorities, perspectives, and concerns (RNAO, 2006)

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bi-directional arrows to illustrate how the PHNinteracts with individuals, families, communities,and systems in a fluid manner. The levels of prac-tice are reflective of the Canadian CommunityHealth Nursing Standards of Practice (2011).

Implementing the Adapted Client-Centered Care Best PracticeGuideline

Nursing best practice guidelines are successfullyimplemented only when there is adequate planning,resources, organizational and administrative sup-port, as well as appropriate facilitation (RNAO,2006). Ploeg et al. (2007) identified several factorsat individual, organizational, and environmentallevels that influenced effective implementation.Facilitators at the individual level included learningabout the guideline through group interaction andhaving positive staff attitudes and beliefs. Leader-ship support, the use of champions, teamwork, andcollaboration were identified as important organiza-tional enablers. Access to professional association

TABLE 2. Adaptation of Core Processes for Public Health Nursing Practice

Coreprocesses Examples of adaptations for public health nursing

Identifyingconcerns/needs

Collaborate with client and other stakeholders in conducting holistic assessments of strengthsand needs of the client ensuring that the client’s perspective is clarified and understood(CHNC, 2011; RNAO, 2006)Support the clients as they represent their perspective when making recommendations to others,that is, the healthcare team, the project team, or the community group (RNAO, 2006)Use a variety of information sources to access date and research findings related to health at thenational, provincial/territorial, regional, and local levels (CHNC, 2011)

Makingdecisions

Collaborate with the client in his/her decision making in planning for care and services. Spendtime with the client to understand the situation from his/her perspective. Follow the client’s leadregarding his desire for participation in decision making (RNAO, 2006)Assist the client to make informed choices about protective and preventative health measures suchas immunization, birth control, breastfeeding, modifiable risk factors, and healthy publicpolicy (CHNC, 2011)

Caring andservice

Maximize the client’s capacity for taking responsibility and managing their health needs accordingto resources and skills available (CHNC, 2011)Make decisions using ethical standards/principles, taking into consideration the tension betweenindividual versus societal good and the responsibility to uphold the greater good of all peopleor the population as a whole, that is, communicable disease control, environmental hazards,tobacco legislation (CHNC, 2011)

Evaluatingoutcomes

Engage the client in evaluating care delivery and health-related outcomes (RNAO, 2006)Evaluate and modify population health promotion programs in partnership with the client andother stakeholders (CHNC, 2011)Monitor and evaluate changes and progress in accessing determinants of health and appropriatecommunity services (CHNC, 2011)

Figure 1. Model of Client-Centered Care in Pub-lic Health Nursing

Adapted with permission from Keller et al. (2004)

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support and interorganizational collaboration andnetworks were also significant facilitators. The facil-itators which were incorporated into our planningare described below.

Organizational leadershipPloeg et al. (2007) identified that support fromnurse managers and administrators at all levels ofthe organization, from the chief executive officerto the frontline nurse managers, was a key facilita-tor for successful guideline implementation. Ourcorporate commitment to evidence-based practiceand to the vision of CCC facilitated nursing staffand managers’ interest and fostered positive atti-tudes toward the project. Through regular commu-nication with nurses and frequent feedback ondifferent stages of planning, our NPC representa-tives demonstrated positive attitudes about theCCC project. The Community Health Nursing Spe-cialist had dedicated time to promote, coordinateand deliver on different implementation, evalua-tion, and sustainability initiatives. The implemen-tation team met every 2 weeks to discussmodifications to the BPG, to plan staff educationsessions, and to initiate sustainability activities.This leadership cultivated a positive atmospherefor the initiative.

Learning through group interactionThe RNAO Client Centred Care Best PracticeGuideline (2006) provided an educational programoutline that consisted of eight-two-hour classes heldat weekly intervals. This educational interventionwas considered too time-intensive for nurses in ourorganization. Instead, a 2-hour training session wasdeveloped for all nursing and interested allied pub-lic health staff in the spring of 2010.

The goals of the training session for staff werethe following: to increase their understanding ofthe principles of CCC, provide an opportunity toreflect on their practice, and to increase confidenceand comfort in changing aspects of their care tobecome more client-centered. One strategy includedthe use of brief video clips of a popular main-stream movie. Critical questions related to the clipswere posed by the facilitators to stimulate discus-sion. For example, nurses were asked to identifythe effectiveness of the main character in usingprinciples of client-centered care. In small groupdiscussions, nurses identified a time when they felt

the care they had received was not client-centered,to describe how this made them feel, and how theywould have changed this experience. They were alsoasked to identify two changes they might make toimprove their practice.

A self-learning package was developed and dis-tributed to staff at the training session. It containedreferences, a copy of our model with explanations,and practice scenarios with reflective questions.The package could be used individually or collec-tively at future team meetings. The practice scenar-ios described a home visit, prenatal education, anda health promotion intervention. In the health pro-motion example, nurses were asked to identify whatwas most important from the community’s perspec-tive, and how they would evaluate intervention out-comes according to the CCC core processes. At theend of the session, a challenge was issued to shareexperiences and examples of specific practicechanges incorporating client-centered care at futureall nurse meetings.

The effectiveness of the training session wasassessed with a simple “stop sign” evaluation. Par-ticipants were asked to indicate using a red, green,or yellow token about their readiness to fullyembrace CCC in their practice. Index cards wereavailable to capture broader feedback. Red symbol-ized “Not interested/relevant,” yellow “Not sure.Need more information/support. Here is what Ineed,” and green symbolized “Let’s go!” Evaluationsrevealed that overall staff felt “ready to go” with theimplementation of the BPG.

In follow-up, a number of activities to promoteadoption of CCC principles were introduced. Eachteam was presented with a tabletop card that listedthe values and beliefs and core process of CCC as avisual reminder. Members of the implementationteam facilitated discussions when possible. Somemanagers required staff to complete an online CCCself-learning module, available through RNAO. Oth-ers used the prepared sample dialogues and prac-tice scenarios with critical reflection questions,found in the self-learning education package, atseveral team meetings. The implementation teamaddressed additional staff questions promptly ine-mail messages called “Centered Conversations: Q& A with the Client-Centered ImplementationTeam.” For example, the first Q & A addressed thefollowing concern: “I still don’t know how this willapply to our work. More application needed for

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individual teams.” The team responded with an e-mail to all participants with information andresources that included exemplars of CCC in spe-cific program teams. Such resources included sam-ple client interactions and scenarios as reflectivepractice exercises. These are from a variety of per-spectives including health promotion, school health,and home visiting. Sample client interactions couldbe analyzed using a Critical Reflection DialogueWorksheet developed by the team. The scenariosincluded reflective questions to stimulate group dis-cussion. Individual program teams were encour-aged to review these exercises and explore potentialapplications collectively. Additionally, it was recom-mended that nurses share an actual experiencefrom their own practice and discuss some of theethical dilemmas associated with the situation.

Evaluating Knowledge Transfer

Six months after the training session, an onlineevaluation was designed to measure the usefulnessof the resources to help staff provide CCC. The timelapse between the workshop and the online evalua-tion provided adequate opportunity to review theself-learning education package at an individual orteam level. Staff rated the team discussions, thesample scenarios, and dialogues, as well as the self-learning package as the most beneficial. Barriers toincorporating CCC into practice were related toorganizational factors (e.g., time constraints, teamorganization, and working on a multidisciplinaryteam) and external systems issues (e.g., differing

philosophies of partner organizations, governmentrequirements for service delivery, etc.).

In the spring of 2011, PHNs gathered again torevisit the challenge launched at the initial trainingsession. Individuals were asked to reflect on thebenefits of CCC practice and to share examples ofhow they incorporated the BPG into their practice.The dialogue revealed changes in nursing activitiesat all levels of client care. For example, at a systemslevel, modifications were made in communicationsto the public. Additionally, nurses were more con-scious of the client representing an individual,small group, or community. Documents and healthpromotion materials were altered to include moreCCC language and included target populations dur-ing revisions. Prior to small group teaching, thegroup’s learning needs and goals were assessed. Ifthe client was an individual or family, some staffstated that they focused on client-driven conversa-tions rather than the completion of checklists.Table 3 provides an example of how a scenario andthe critical thinking questions from the trainingsession led to observable and sustainable changesin practice.

Sustaining Change

Formal strategies for sustaining changes in practicefrequently rely on performance evaluations, jobdescriptions, staff orientations, and policy. Duringthe implementation of the CCC BPG, the organiza-tion’s job descriptions and performance evaluationwere being revised in a concurrent process. Using

TABLE 3. Example of Critical Thinking Dialogue

Practice example scenario Critical thinking questions Actual outcomes

“My family is a traditional one. Everyonewas very excited about this baby. Thefirst grandchild to be born in Canada.I wanted to learn as much as I could, soI signed up for the Health Unit prenatalclasses. Everything seems so differenthere. I was surprised to see so manyhusbands in class. My husband camewith me to the first class - my mothercame with us as well. We were veryuncomfortable being there. There wasa lot of discussion about the femalebody. Back home that wouldn’t bediscussed in front of men.”

As the prenatal instructor, how willyou use the values and beliefs ofclient-centered care to guide yourpractice with this family?Are there resources or services thatcould be modified within yourteam to be more client-centered?How would you proceed if you werethe staff facilitating this session?Consider individual participants,the class as whole and differentfamily units.What organizational changes wouldsupport CCC for this situation?

The Prenatal Coordinator revisedthe prenatal curriculum to ensurethat language was client-centredand culturally sensitiveAltered language in communicationmessages to the public to ensure thatthey were client-centered andculturally sensitiveFocus on client-driven conversationsrather than completion of checklistsduring one-to-one interactions

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the language and concepts from the seminal docu-ments mentioned previously, many of the core pro-cesses and values and beliefs were integrated intothe revised performance evaluations and jobdescriptions. This led to a stronger reflection ofCCC values and beliefs and the core processes inthese agency documents. For instance, the new jobdescription includes points that reflect the first stepin CCC core processes: identifying needs and con-cerns. The job description states that an expecta-tion of the PHN is to facilitate “the communities’involvement in identifying health needs andstrengths” (Middlesex-London Health Unit, 2012a,b).

The performance appraisal is organizedaccording to levels of experience and skill. For thePHN who “implements public health programs,policies, and services,… with assistance”, theexpectation is that the PHN “plans and designsprograms in collaboration with individuals, fami-lies, groups and/or communities, and/or developspolicies, to address specific public health issuesand determinants of health” (Middlesex-LondonHealth Unit, 2012a,b). Again, this expectation isconsistent with the core processes, identifyingneeds, and the value and belief that clients’ goalsshape the service plan.

Discussion

Implementation barriers and lessons learnedMany barriers to implementation at this health unitwere consistent with those reported by Ploeg et al.(2007). For instance, time constraints, working inmultidisciplinary teams and system level changescreated challenges for us. Other barriers identifiedby staff were differing philosophies of partner orga-nizations and government requirements for servicedelivery. Changes in leadership, including theretirement of the nurse manager and the CHNS’leave of absence, interrupted and slowed down theimplementation of the project.

For implementation team members, consider-able time was initially taken to understand the ori-ginal BPG CCC within the context of our healthunit. Once we realized that the BPG required signif-icant changes, more time and resources wereneeded to make the necessary modifications. Dis-cussions about the current work setting and anhonest appraisal of resource implications would

have likely lengthened the time frame for imple-mentation and evaluation. Additionally, having amember with content expertise on the implementa-tion team would have facilitated understanding andtranslating the guideline to PHN principles moreefficiently. Previous BPG implementation teams inour organization did have a clinical expert and wereable to implement in less time.

Critical reviewRecently, the literature has reported concernsregarding the use of evidence-based knowledge.Mitchell (2009) purports that evidence cannot builda knowledge base for nursing practice, but exists toassist individuals to make decisions about theircare. Furthermore, she states that evidence-basedpractice should not be applied to the nurse–clientrelationship that is based on values and theoreticalprinciples, and not merely data (Mitchell, 2009,p. 272). Holmes, Murray, Perron, and McCabe(2008) believe that the best practice guidelines andevidence-based movement in nursing “are a danger-ous technology by which health care organizationsseek to discipline, govern and regulate nursingwork” (p. 394). They argue that evidence-basednursing practices defines evidence too narrowly,and interferes with nurses ability to think critically,thus threatening the nurse–client relationship(Holmes et al., 2008).

The current experience of evidence-based prac-tice in this local health unit does not support theseconcerns. The organizational philosophy of knowl-edge embraces the integration of different patternsof knowing through critical reflection, and a broadinterpretation of knowledge (Chinn & Kramer,2008). Within this public health unit, best practiceguidelines are rarely adopted without criticalappraisal of their applicability. In the case of theadoption of the RNAO Client Centred Care BestPractice Guideline (2006), considerable effort wasmade to resolve specific contextual challenges. Thisincluded the narrow definition of client as an indi-vidual, the need to reconcile the enforcement rolesof public health with the Guideline principles, andthe predominance of acute care supporting litera-ture that was not representative of public healthnursing practice. This example disputes the notionthat the adoption of best practice guidelines innursing impedes critical thinking, and obstructsethical and social responsibilities of the profession

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(Holmes et al., 2008). Critical thinking is imperativeto ensure nurses combine rational evidencewith the intuitive, especially when adoptingso-called ready-made practices (Birx, 2006).

Future directionsWhile nursing staff and managers have reportedchanges in client-centered practices, it would beprudent to evaluate client(s)’ perceptions of theircare. Research has shown that practitioners are notnearly as client-centered as is generally believed(Dunst, Trivette, & Hamby, 2008). Another publichealth unit in Ontario has developed a validatedtool that measures clients’ perception of client-cen-tered practices with families (Algoma Public Health,2011). We could build upon this work and possiblycollaborate with several health units in developingstandardized tools to assess CCC practices with avariety of populations and levels of practice. Moreformal research would help measure the organiza-tional impact of CCC provided by PHNs and otherpublic health disciplines. Such research would sus-tain the organization’s commitment and passion forclient-centered practice and shape professionaldevelopment opportunities for nurses and otherpublic health staff.

The RNAO Best Practice Guidelines are utilizedby nurses and allied health professionals aroundthe world. They provide evidence-based informa-tion that is easily accessible to the practicing nurse.The process of first tailoring this CCC BPG for pub-lic health nursing practice and then diffusing thework through education programs, documentationpolicies and sustainability measures, extended overa period of almost 4 years. Critical review andthoughtful revisions have resulted in changes in theway PHNs practice with individuals, families andcommunities. Sustaining these changes requirescontinuous quality improvement of agency humanresource materials, refining more client-focusedpolicies, and ongoing dialogue on CCC philosophywith staff.

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