Main findings
Using a convergent parallel design, this MM study developed a comprehensive understanding of the impact of a Canadian ECHO program for CD management (ECHO-CD) on nurses’ competency development and clinical practice. The QUAN results (nurses’ self-efficacy, knowledge, attitude, participation, satisfaction and acceptability, and perception of clinical performance) were merged with the QUAL results (nurses’ experiences and perceptions about the competencies they developed and implemented in their clinical practice, and the factors that influenced this process) to produce greater insights into the conditions linked to the successful uptake and implementation of CD EBP in nursing care. Overall, our findings suggest that participating in ECHO-CD contributed to the nurses’ competency development and that this participation can, under certain conditions, result in effective and sustainable clinical practice changes. To interpret and discuss the main findings of this study, below we pinpoint a number of questions to highlight our findings’ contributions to the advancement of knowledge, and their implications for nursing education and practice, and future research.
What do the findings of this study add to our current knowledge of the ECHO model and what are their implications for research?
Based on social learning (52, 53) and behavior change (51) theories, both of which build on the premise that social interactions are essential conditions for effective learning and behaviour change to occur (75), one promising component of the ECHO model is the interprofessional environment that fosters collaborative learning. The ECHO model therefore endorses that sharing professional experiences improves and reinforces learning, while peer support enhances one’s motivation to and self-perception of being able to perform new behaviours in clinical practice (34). Consistently, our results indicated that peer-to-peer sharing of similar experiences and mentoring activities were essential conditions to normalize the nurses’ experience with CD management and provide emotional support in difficult clinical situations. Previous MM and QUAL research in the field of ECHO have also reported several benefits of the model’s interprofessional and collaborative component in terms of sharing EBP, empowering participants to manage complex clinical situations, and increasing their understanding of the roles played by each profession (76-80).
Moreover, our study contributes to advancing this evidence on the impact of the ECHO model by highlighting that the opportunity for practice and validation—as a “key educational condition” (81) of the ECHO model—seem beneficial to fostering nurses’ competency development and practice change. This finding is critical both for the field of nursing science and for future research on the ECHO model with regard to how continuing professional education is designed for, and tailored to needs of, the participants to help them further contextualize their learnings and improve their confidence in implementing relevant, evidence-based interventions in their practice. As the ECHO model can be characterized as a complex educational intervention, i.e., multiple interacting components within the intervention and with its context (82-84), further research is needed to elucidate which educational conditions and learning methods are better suited to foster successful uptake and implementation of CD EBP in nursing care through ECHO. For example, future studies could use a “blending” approach to adult learning theory/frameworks and design components of implementation research (85) and, in doing so, assess more specifically the clinical effects of ECHO on relevant outcomes (e.g., sustainable practice change and patients’ health), while systematically gathering and documenting the planned and unplanned strategies used during the research (86, 87) to improve the implementation and sustainability of EBP.
How do the findings of this study help increase our understanding of the ECHO model’s impact on nurses' competency development and practice change, and what are their implications for education and practice?
As outlined previously, our results showed that ECHO-CD provided opportunities for nurses to engage in ongoing learning and practice change, a process that includes two broad activities, namely practicing new acquired learnings and then receiving validation from peers and experts regarding the changes made in the workplace. This allowed nurses to share with other participants how they effectively—or not—implemented into their clinical practice their new learnings, which, in turn, helped strengthen their belief in their own ability to suitably manage CD or helped them find tangible solutions to deal with complex and adverse clinical situations. This process was an essential steppingstone in the nurses’ competency development in CD care, and most importantly, in clinical practice change. Thus, competency development and practice change occurred simultaneously, through both educational and workplace learning situations. These two environments aided the nurses to consolidate “critical learnings,” which, according to Tardif (88), are sustainable learnings that represent a “cognitive reorganization” or a crucial developmental stage.
These findings reinforce the idea that nurses learn and develop their competencies through experience, and that consequently, education and practice, must align and work interdependently (89). Indeed, the belief that nurses learn while practicing nursing is based on decades of evidence in nursing (90-94) and adult education (95-98). For example, Jantzen (94) finds, from a grounded theory, that refining nursing practice includes both formal and informal learning; however, significant nursing expertise is developed through “puzzling and enquiring”, an active, iterative process described as learning while nursing in the work setting, which requires self-consciousness and autonomy. In a related fashion, it has been asserted, as conceptualized in a systematic review by Davis et al (99), that working and learning must be understood as an integrated experience that enables nurses to implement contemporary, evidence-based, professional practice and continuously improve safe, quality patient care. Following along similar lines, a recent metasynthesis showed that contextualizing learning and placing it in close proximity to practice enhanced nurses’ motivation and engagement toward continuing professional development (100). Likewise, it has been robustly documented that fragmentation in continuing professional development initiatives should be actively avoided, and that this would require strong practice–education organizational partnerships and the promotion of learning in the practice setting (99, 100).
Another important finding from this MM study is that ECHO contributed to reinforce nurses’ positive attitudes about performing their professional role in complex and adverse situations, which further stimulated ongoing learning and practice renewal. This is congruent with adult learning theory and previous nursing education research showing that transformative learning helps to develop emancipated and responsible attitudes in nurses toward their own learning (101, 102). To this end, Hoggan (103) argues that a strong professional identity can have a powerful influence on behavior change because it prompts nurses to show receptiveness to new learning and openness to self-directed and reflexive learning, and to demonstrate accountability for their own professional development. Overall, the findings of this study corroborate the evidence from many existing knowledge syntheses (24, 100, 104-106) stating that building a culture of lifelong learning in the workplace, one that values continuing professional education and encourages nurses to grow professionally, is a key condition to maintain high standards of care through competent nursing practice (102, 104).
What theoretical insights do the findings of this study raise?
This study adds to the current literature on the ECHO model by shedding new light on the learning and educational processes that contribute to the successful uptake and implementation of CD EBP in nursing care. Indeed, although the ECHO model was built on the theoretical foundations of social learning theories, the findings of this study particularly resonate with transformational learning theory (107). Transformative learning is a process that facilitates the transition from a transmissive pedagogical standpoint to a transformative paradigm of learning and interdependence between continuing education and practice (89, 108). It advocates for democratic education for sustainable development, whereby learners are co-creators of their own learning through questioning, critical reflection, and creativity, in order to arrive at viewpoint changes that guide their actions (107). Transformative learning is dynamic and interactive, and, thus, it engages nurses to actively participate in their own learning and it enables the construction of contextualized knowledge that is useful for real-life professional setting (101). Transformative learning stimulates nurses to learn how to think independently. It develops their self-confidence and competence to meet the multifaceted healthcare needs of their patients, and to renew and adapt their practice in constantly shifting contemporary work environments (109).
In this MM study, we found that ECHO allowed nurses to actively engage in opportunities for practice and validation, which according to transformative learning, refers to an integrative process of making connections between concepts and experiences so that knowledge and skills can be reinvested into new, multifaceted clinical challenges (110). Congruent with our findings, Tsimane and Downing (101) report, from their concept analysis results, that the process of transformative learning in nursing education is facilitated through investigative, collaborative, inventive, and interactive learning activities which, together, constitute the educational processes that should be put forward in developing and implementing any potential continuing educational program.
This can have implications for the future implementation of ECHO-affiliated programs, as regards the extent of what, and in what ways, the original ECHO model can be adapted to the needs of end users to promote transformative learning. It also has implications for educators and/or facilitators (e.g., the ECHO interdisciplinary panel of experts) regarding their readiness to embrace roles as active knowledge translation agents, mentors, and learning coaches, rather than serving as a transmission channel for the passive dissemination of EBP.
What can be inferred from the findings of this study to improve future implementations of the ECHO model?
This study lays bare an important number of cultural, contextual, and organizational factors that negatively affected the nurses’ consistent participation in ECHO-CD (e.g., time constraints, access to technology, lack of contextualized educative content), as well as their capacity to implement new interventions in their patients’ care plan and to foster practice changes within multidisciplinary care teams (e.g., limited CD-specialized resources, lack of employer support toward practice changes) (55). Such barriers have also been uncovered in other ECHO programs addressing complex and chronic health topics, within the constraints of resource-scarce healthcare settings (30, 31). For example, Pagé et al (78) use a QUAL study design to explore the factors influencing healthcare providers’ uptake of an ECHO program for chronic pain management and find that expert recommendations and/or feedback were often “lost in translation,” which was mainly associated with insufficient multidisciplinary healthcare resources to offer gold-standard care. The same research group insists that ECHO programs should offer participants evidence-based guidance balanced between acknowledging the optimal therapeutic path for a given patient and what this patient can realistically have access to. This can have implications for the future implementation of ECHO-affiliated programs, as regards the extent of what, and in what ways, the original ECHO model can be adapted to the needs of end users. It also has implications for educators and/or facilitators regarding their readiness to embrace roles as active knowledge translation agents, mentors, and learning coaches, rather than serving as a transmission channel for the passive dissemination of EBP.
Similar to our findings, research has shown that nurses are often reluctant to leave or prevented from leaving the clinical setting to attend continuing professional education due to heavy workloads and a lack of relief coverage, use of personal time to undertake mandatory training, and organizational culture and leadership issues constraining the implementation of learning to benefit patients (104). Instead, as noted by Mlambo et al (100), relevant organizational support should prioritize both structural (e.g., allocation of time and funding for continuing education, adequate staffing, healthy workplace culture conducive to practice change) and moral support (e.g., explicit managerial support and recognition for professional development, encouragements from peers, experts, and mentors). Our results, however, highlight that concurrent with supportive environments, emotional support provided through peer-to-peer sharing and mentoring activities—as a key condition for the successful implantation of CD EBP in nursing care—should also be emphasized within the educational setting, to normalize nurses’ experience toward the many challenges they face in managing CDs.
Lastly, our results showed that a key condition for successful uptake and implementation of CD EBP was for nurses to attend ECHO with their co-workers. This facilitated knowledge sharing and practice changes, and it fostered a common, patient-centered vision in care team members. In the implementation science literature, a team-based approach has shown promising results for improving the implementation of evidence-based interventions in interprofessional primary healthcare settings and for overcoming barriers such as a lack of communication and unshared professional values (111, 112). As most ECHO participants are primary care providers who work in multidisciplinary teams, future studies should aim to evaluate the impact of ECHO on specific outcomes of care performance and/or care processes such as teamwork and collaborative skills. Research is also needed to deepen our understanding of the ECHO model’s influence on relational dynamics at work and to explore how it can be used or improved further to foster interdisciplinarity and create a healthy learning culture in the workplace.
Strengths and limitations
This MM study is unique in that it relies on an integrative conceptual framework (57) developed by taking inspiration from a social-constructivist worldview of science (58), stipulating that an in-depth inquiry arises from a ‘“looping effect” between QUAN and QUAL evidence that produces a “mixed kind” of evidence. Hence, the major strength of this study is its rigorous, thoughtfully planned MM design. In our MM convergent parallel design, both QUAN and QUAL methods were used concurrently, bolstering one other, and allowing us to develop a comprehensive understanding of the impact of an ECHO program for CD management on nurses’ competency development and clinical practice. In addition, we used a structured and systematic integration process, the PIP (73), to merge, compare, and contrast the QUAN with the QUAL results, which added value to either method in itself. This interwoven approach provided a fertile analytical ground to study the key conditions for successful implementation of EBP in CD nursing care with the ECHO model.
This MM study also has some limitations. First, the QUAN study relied on a prospective cohort study design without the use of a control group and the sample size available for analysis was small (n = 28). For this reason, causal inferences regarding exposure to the educational program and nurse-related outcomes could not be made. Second, our study was conducted in only one Canadian province, and the educational program was strongly contextualized to CD care in this area. Although this may well reflect specific contextual aspects, it can also make our results difficult to transfer to other settings or regions. We therefore provided, a detailed description of ECHO-CD, in accordance with reporting guidelines for EBP educational interventions (55, 56), which will facilitate its adaptation in other contexts. Third, we investigated outcomes and perspectives at the level of individual nurse participants. Outcomes and/or perspectives at the organizational and patient level warrant further exploration.
Finally, one important issue to consider in MM convergent design is the divergences (also called contradictions, discrepancies, dissonances, and differences) between QUAN and QUAL results that can arise during the integration process, constituting a potential threat to the reliability of the MM findings (59, 113). From a conceptual standpoint, however, some authors in the field of MM research argue that divergences in data/results can also stimulate rich theoretical questionings and shed new light on existing empirical knowledge (114). In this study, the divergences noticed during the integration process by the first author (GC) were systematically discussed with another researcher (JC), and then resolved by reviewing the preliminary MM interpretations and providing possible explanations, where appropriate. In addition, the PIP ensured rigor throughout the integration procedures, discrepancies being systematically addressed and documented, and its use further enhanced transparency in their reporting.