Planning for Implementation of Evidence-Based Practice
Expectations for evidence-based healthcare are growing, yet the most difficult step in the process, implementation, is often left to busy nursing lead- ers who may be unprepared for the challenge. Se- lecting from the long list of implementation strategies and knowing when to apply them are a bit of an ‘‘art,’’ matching clinician needs and organizational context. This article describes an application- oriented resource that nursing leaders can use to plan evidence-based practice implementation in complex healthcare systems.
Nurses in leadership positions have responsibility for provision of evidence-based healthcare that meets the expectations of patients, families, regulators and others.1-3 Research shows that use of evidence is inconsistent. Basic practices from hand hygiene to early ambulation are difficult to implement. Nurs- ing leaders are expanding use of evidence-based care delivery to improve patient and organizational out- comes by developing the infrastructure, defining the processes, strategically planning for implementation, and reporting results.Planning for Implementation of Evidence-Based Practice
One of the 1st steps when defining the pro- cess is to select an evidence-based practice (EBP) model.4,5 Several models have been developed to
guide organizational and project leaders through the steps of the EBP process.6-10 Most of these pro- cess models include similar steps such as identifying a problem, critiquing the evidence, implementing evidence-based recommendations, evaluating the change, and disseminating results. Despite exten- sive use of EBP process models, it is understood that additional guidance may be needed at each step. Re- cent attention is now focusing on the indistinct step of implementation.11-14
Failure to provide guidance for use of effective implementation strategies promotes the use of in- effective strategies, or worse, no strategy at all. This results in ‘‘reduced patient care quality and raises costs for all, the worst of both worlds.’’15(p380) It has been demonstrated that change happens over time; the literature provides little direction for nurses re- garding when to use specific strategies. Insights from implementation science and successful EBP work in- dicate that application of implementation strategies varies over the course of the EBP process. Assisting nurses at the point of care in leading EBP projects16 Planning for Implementation of Evidence-Based Practice
has led to creation of a 4-phase approach for plan- ning implementation.16
This article provides clinicians and nursing lead- ers with an application-oriented approach to orga- nize, plan, and select strategies for implementation of EBP changes. This guide is meant to supplement EBP process models, not replace them. It is designed to be simple and intuitive.
Implementation Strategies for Evidence-Based Practice
The Implementation Strategies for Evidence-Based Practice guide (Figure 1) is organized to assist nurses responsible for EBP in selecting implementation strategies to help practitioners and clinical teams
222 JONA � Vol. 42, No. 4 � April 2012
Author Affiliations: Evidence Based Practice Coordinator (Ms Cullen), Department of Nursing Services and Patient Care, University of Iowa Hospital and Clinics; Investigator (Dr Adams), Comprehensive Access and Delivery Research and Evaluation Center, Iowa City VA Medical Center. Planning for Implementation of Evidence-Based Practice
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the De- partment of Veterans Affairs.
The authors declare no conflict of interest. Correspondence: Ms Cullen, Department of Nursing Services
and Patient Care, 200 Hawkins Dr, RM T100 GH, Iowa City, IA 52242-1009 (Laura-cullen@uiowa.edu).
DOI: 10.1097/NNA.0b013e31824ccd0a
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
move clinical practice recommendations into routine workflow in practice. Strategies are selected and po- sitioned to enhance the movement through 4 phases of implementation: creating awareness and interest, building knowledge and commitment, promoting
action and adoption, and pursuing integration and sustainability to promote application by nursing and team leaders. Planning for Implementation of Evidence-Based Practice
The implementation phases are displayed as col- umns progressing from awareness to integration.
Figure 1. Evidence-Based Practice Implementation guide. *Implementation strategy supported by some empirical evidence.
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Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Each column includes strategies based on the goal for that implementation phase. Implementation strat- egies also target 2 distinct groups and are arranged in rows accordingly. The 1st section specifically targets the practitioners and organizational leaders, includ- ing key stakeholders. The 2nd section builds support for the practice change in the organizational system or context. Project leaders select implementation strat- egies that are appropriate for their particular unit and organization as the EBP initiative progresses across phases. Although the guide is diagrammed in a linear format for ease of use, the process is not directly linear and is fluid across implementation phases. In a clinical team, practitioners may be in different phases or move forward or back across phases in a nonlinear manner. Multiple strategies added cumulatively from each phase will need to be carried over for use throughout the process to keep implementation progressing. Planning for Implementation of Evidence-Based Practice
A large list of strategies is included (Figure 1), and with varying amount of evidence to support them. The implementation strategies with empirical evidence in healthcare are marked with asterisks. Few strategies have empirical evidence using rig- orous study designs with additional support from reported application in practice or exclusively ad- dressing nursing; therefore, other practical but less well-tested strategies to support application are in- cluded as well. Because research evaluation of strat- egies across a variety of healthcare settings and with various healthcare workers is lacking, a simplified system of identification is used instead of an exten- sive grading schema.
Creating Awareness and Interest
Implementation begins by focusing on strategies to create awareness and interest among clinicians and stakeholders (column 1, Figure 1). These suggested strategies should be started early in the EBP pro- cess and will likely be needed to some degree during the implementation and sustainment phases. Interest wanes over time because of competing demands and staff turnover. Multifaceted, ongoing strategies are needed to keep the practice change in the forefront. Planning for Implementation of Evidence-Based Practice
Highlighting the positive characteristics of an EBP change such as the anticipated advantage of the change and the compatibility with group values can promote awareness and interest among clini- cians.17-19 Staff attendance at continuing educa- tional programs20 increases awareness and interest in practice updates in general. Nurse leaders can continue garnering resources to support these pro- fessional development activities with application for practice. Integrating a journal club into the im- plementation process by choosing multiple, high-
quality, project-related articles can serve a dual purpose: expanding nurses’ interest and knowledge regarding the desired practice change while ad- vancing article critiquing skills.21 Journal club re- view of articles on a single clinical topic can be used to guide policy updates, staff education, and auditing of important indicators to improve care.
Although empirical evidence is limited, creating slogans and logos can be a successful and fun way to grab the attention of busy clinicians.22,23 Creating a contest to generate ideas for project slogans can get staff involved, increasing their awareness and com- mitment to practice changes. Strategically placing project logos and slogans on project-related materials throughout implementation (eg, resource manual or materials, reminders, and data feedback) helps busy clinicians quickly refocus on the EBP and their role in promoting adoption of the practice change.24 Planning for Implementation of Evidence-Based Practice
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Posting announcements may generate awareness of a particular practice update, but require additional reinforcement, for example, supplementing with dis- cussions during unit in-services or staff meetings.
Involve senior executives early in the EBP process. Senior leaders want to be supportive of clinician- driven EBP and need sufficient information about the purpose, resource needs, and anticipated return on investment. Leadership from senior executives has a demonstrated impact on uptake and sustained use of EBP recommendations.1,25-27 Announcements from senior leaders create an urgency about an issue, articulate an organizational commitment, and dem- onstrate the availability of resources and support that an impact is expected matching organizational priorities. Planning for Implementation of Evidence-Based Practice
Building Knowledge and Commitment
Interventions that increase practitioner’s knowl- edge of and commitment to try a clinical practice recommendation are designed to build on the aware- ness and interest raised in phase 1. For example, comparing organizational outcomes to those de- scribed in the literature through a gap assessment and discussed during unit meetings or journal clubs from phase 1 increases clinician’s knowledge and commitment by highlighting the gap in desired performance. Like raising awareness and interest, increasing knowledge and commitment requires mul- tifaceted ongoing attention.
Educational sessions are a necessary step in raising knowledge and commitment but must be combined with other strategies to be effective.28
Educational sessions can use a variety of methods from unit in-services, readings, or online learning modules to simulation training. One method of in- teractive education that leverages nurses’ preference
224 JONA � Vol. 42, No. 4 � April 2012
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to learn from their colleagues29-31 is to engage and train change agents. There are many different change agent roles32 described in the literature, including internal and external facilitators, change champions, core groups, knowledge brokers, thought leaders, and opinion leaders (Table 1).32,34-37 In general, the change agent role involves sharing information and supporting practice changes with colleagues and may vary based on the size of the unit. Our experience indicates that the roles are not well understood by clinicians. Identifying change agents early, obtaining their support, providing education regarding the practice change, and clarifying their roles facilitate effective use of team members’ strengths and con- nections in the organization.
Identifying change agents from each discipline relevant to the clinical topic at hand can build com- mitment to change. For example, if the goal is to increase hand hygiene, including change agents from infection prevention specialists or epidemiology, microbiology personnel, nurses, nursing assistants, phy- sicians, and someone from inventory supply would be helpful. Including facility services, the unit sec- retary, and housekeeping may be important so that the correct equipment (ie, a full dispenser) is always readily available and positioned in accordance with safety standards. Core group members can serve as Planning for Implementation of Evidence-Based Practice
change agents.37 Having a core group of trained change agents available to cover all shifts meets clinicians’ needs and builds expertise as clinicians seek answers through interactions with colleagues.
Unlike strict research protocols, clinical prac- tice guidelines are designed to be locally adapted to individual settings. Teams can modify them for use to create a local practice protocol.38-40 Focusing on key steps that are critical promotes adoption by sim- plifying the change.18,41 Articulating how the EBP was simplified to assist clinician users can promote commitment to practice changes.
Building knowledge and commitment provides an essential foundation for promoting action and adoption of the EBP change. Planning for implemen- tation should be based on a timeline allowing for a focused effort, building practitioners’ knowledge and commitment before proceeding to the next phase of implementation. If the clinical practice recommen- dations are to be piloted in a setting that involves a small number of practitioners (eg, a rural clinic), it may be possible to move more quickly through this phase. If the practice change involves a large number of practitioners from multiple disciplines, covering many shifts, plan for 2 to 3 weeks to help clinicians gain sufficient knowledge and to garner their commitment to the practice change Planning for Implementation of Evidence-Based Practice
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