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Planning for Implementation of Evidence-Based Practice

Planning for Implementation of Evidence-Based Practice - Clinical Hub, Nursing Hub, Nursing Practice Tools and Resources, Bedside Shift Report, Resources


JONA
Volume 42, Number 4, pp 222-230
Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Planning for Implementation of
Evidence-Based Practice
Laura Cullen, MA, RN, FAAN
Susan L. Adams, PhD, RN
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.
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 implementationstrategies
varies over the course of the EBP process. Assisting
nurses at the point of care in leading EBP projects
16
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
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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.
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.
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.
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.
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 programs
20
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
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.
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
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to learn from their colleagues
29-31
is to engage and
train change agents. There are many different change
agent roles
32
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, mi-
crobiology 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
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,
coveringmanyshifts,planfor2to3weekstohelp
clinicians gain sufficient knowledge and to garner
their commitment to the practice change. This phase
Table 1. Change Agent Roles
Name Perspective Educational Role Impact
Change champion Focus is local and is from
inside the organization
Review evidence, design practice
change (eg, policy), assist with
creating resources for
implementation, train peers
Assists project leader and links
evidence with reality of
clinical practice
Core group Focus is local and is from
setting adopting the EBP
Review key evidence, train,
role model, reinforce, and
trouble shoot with colleagues
Point-of-care learning
EBP facilitator/mentor Broad program focus may
be from inside or outside
the organization
Provide leadership throughout
EBP process
Mentoring of or functioning as
project director
Knowledge broker Broad program focus from
outside the organization
Assess facilitators and barriers,
locate best evidence, train,
network, mentor, and
report results
Leading and connecting with
project director(s)
Opinion leader Focus is on the program and
across the continuum
of care from inside
the organization
Review evidence and judge fit,
peer education, influence
practice of others
Peer influence
Thought leader Focus is local and may be
from inside or outside
the organization
Provide educational sessions Program preparation influences
practice change of the
educator; little impact on
audience is anticipated
Emerging concept yet to be
tested in healthcare
Dobbins et al,
33
Doumit et al,
34
Greenhalgh et al,
32
Russell et al,
35
Stetler et al,
36
and Titler.
37
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of implementation should be clearly articulated
with a designated go-live date approaching in the
future.
Promoting Action and Adoption
After raising awareness, promoting positive atti-
tudes, and building knowledge about the change,
the next imperative is to change behavior and put
recommendations into practice. What has been
described as the implementation phase of an EBP
process is essentially the behavior change point in
the multiple phases of implementation. Interven-
tions to promote action or adoption need to move
from active to interactive and target the clinicians
so they develop skills in use of the practice change.
Training, role modeling, and mentoring by change
agents are essential elements of the implementation
plan.
16,20,36,42-44
Follow-up from unit leaders and
project change agents is needed for troubleshoot-
ing, reinforcing the desired behavior, and providing
recognition at the point of care for correctly and
consistently applying practice recommendations.
Practical strategies such as practice prompts pro-
mote behavior change by providing timely remind-
ers in the practice setting at the point of care. Practice
prompts can be sophisticated clinical information
system reminders incorporated in the electronic
health record (EHR) or as simple as a pocket guide
with a logo containing key talking points.
45-47
As
EHR technology develops, additional innovations
will create ways to hardwire provision of some clin-
ical practice recommendations (eg, influenza vacci-
nations or medication infusion dosages) by requiring
justification of variations in practice (eg, skipping
timed pediatric immunizations). Creating patient re-
minders, clinical checklists, and standing orders builds
support in the system and effectively sets parameters
for successful use of EBP.
48-52
The action and adoption phase of implemen-
tation will require several weeks to complete. Dur-
ing this phase, clinicians are testing practice changes,
finding ways to integrate new practices into work-
flow, adapting the practice for unique patient circum-
stances, and doing small-scale evaluation.
53
Several
weeks are needed for progressive uptake of the EBP
when change agents are actively promoting adoption,
and practitioners are trying the change. Continued
use of implementation strategies must occur through-
out this phase as early and late adopters progress at
varying rates. Participation can be encouraged by
having early adopters provide timely feedback on
positive results. Active implementation strategies
may be used more sporadically after early adopters
create sufficient momentum promoting the practice
change. Audits with actionable and timely data
feedback of results are essential and highly effective
for both adoption and integration of practice change
by building support in the organizational system.
54,55
Timing should allow for trying and using the EBP
change before full evaluation of process and outcome
indicators.
Some clinicians lag in action and adoption.
Highly interactive and individualized feedback will
be needed for clinicians working through adoption
while the group is moving toward integration and
sustainability of practice changes. Late adopters
will be watching the early adopters’ progress and
slowly become active adopters. Clear expectations
and administrative follow-up through the perfor-
mance evaluation process will facilitate action. If a
small group of clinicians are slower to adopt prac-
tice recommendations, we have found that involv-
ing a group leader from the late adopters in planning
and troubleshooting implementation early may be
helpful. Late adopters may provide important in-
sights into issues and propose possible solutions
when designing and localizing clinical practice rec-
ommendations. In the end, noncompliance becomes
the responsibility of administrators.
Pursuing Integration and Sustainability
In order to achieve a return on investment from
working through the EBP process, it is essential to
realize integration and sustained use of the EBP
change.
26,56,57
Celebrating successes through senior
leadership recognition in public forums supports shif-
ting expectations and group norms or standard
operating procedures. Creating peer-to-peer discus-
sions articulating expectations (ie, peer influence)
and using comparative data are likely to be ef-
fective. Reinfusion will be needed through the early
months of integration to sustain the gains already
achieved. Updating postings and practice reminders
keep the message fresh and in the forefront. Posters
left for extended periods tend to become invisible,
so content and strategies must be updated to attract
the attention of busy clinicians (eg, update pictures
and key points, add names of successful staff).
Early and active planning for reinfusion and sustain-
ability is highly recommended to prevent slippage,
loss of early progress, or loss of momentum for chang-
ing practice.
Integration of clinical practice recommendations
into daily care requires additional strategies by the
clinical team and senior leaders, including strategies
built in the social system matching the organizational
culture. Reporting results of project implementa-
tion and revisions based on evaluative data and
practitioner feedback can facilitate additional com-
mitment to sustained use of new practices. Graphic
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displays of key indicators may be helpful.
58
Reporting
and feedback of trended data support progressive
integration and positive reinforcement for practi-
tioners
59,60
and assist with quick identification of
the need to reinfuse the EBP.
After trying and implementing the practice
change, final revisions in policies, procedures, or
protocols are needed.
25,61
Project leader reporting
of activity and results should target committees in
the infrastructure responsible for policy approval,
documentation, staff education, quality improve-
ment, EBP, and product inventory.
27,62,63
Reports
to senior leaders should include the project pur-
pose; use of the EBP process; impact or return on
the investment; link between the project results,
organizational priorities, and infrastructure sup-
porting the EBP change. Communicating with senior
leaders is strategic for garnering reinforcement, rec-
ognition, and future resources.
Building the practice change in the organiza-
tional system requires use of additional strategies
to promote sustainability. Financial incentives,
64,65
awards, recognition,
66,67
and support establish the
new norms for practice. Incorporating the practice
change in the competency review process and ob-
taining individual commitments to 1 or 2 actions
during staff performance evaluations help to sup-
port unit goals and create continuous reinfusion
and momentum. Building responsibility for ongoing
EBP work in a new or existing unit or organizational
Table 2. Implementation Strategies Used in Different Clinical Area Projects
Planning Phase
Strategies Used for Perioperative EBP Strategies Used for Emergency Department EBP
Implementing Preoperative
Screening for Sleep Apnea
Thermoregulation for
Adult Trauma Patients
Create awareness
and interest
& Highlight the advantages and
anticipated impact
& Highlight the advantages and anticipated impact
& Staff meetings
& Slogan and logo
& Unit in-services
& Staff meetings
& Postings
& Unit in-services
& Postings
Build knowledge
and commitment
& Education & Education
& Link with quality improvement priorities & Link practice change with stakeholders priorities
& Change champion & Change agents
& Integrate with other policies & Disseminate credible evidence
& Clinician input & Gap assessment
& Local adaptation & Clinician input
& Case study & Match the practice change with equipment
& Teamwork & Resource manual
& Trouble shooting implementation & Teamwork
& Informed organizational leaders & Troubleshoot use of the protocol
& Action planning & Inform organizational leaders
& Action planning
Promote action
and adoption
& Educational outreach & Educational outreach
& Clinical reminders & Reminders or practice prompts
& Demonstrating workflow & Decision algorithm
& Feedback evaluation results & Skill competency
& Trying the change & Incentives
& Multidisciplinary teamwork and discussions & Trying the practice change
& Report progress and updates & Reporting progress
& Change agents & Change agents
& Troubleshooting by change champions at the
point of care
& Role modeling practice change
& Documentation changes
& Change agents provide trouble shooting and
recognition at point of care
& Rounding by unit leaders & Audit and feedback of evaluative data
& Report into quality improvement program & Rounding by unit leaders
& Report to senior leadership & Report into the quality improvement program
Pursue integration
and sustained use
& Recognition for change & Personalize the messages
& Update reminders & Peer influence
& Report within quality improvement program & Update practice reminders
& Trend results & Report to senior leaders
& Presenting at educational programs & Project responsibility within unit quality
improvement committee
& Present in educational programs
Used with permission from Block et al
22
and Dolezal et al.
68
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committee will keep responsibility for the work clear
and a priority supported in the infrastructure. Mul-
tiple strategies are needed to move from awareness
to integration and should target clinicians, organi-
zational leaders, and the social system.
How to Select Implementation Strategies
When planning for EBP implementation, a nursing
leader should ask several questions:
� What EBP changes have been successfully im-
plemented previously?Howwerethoseprac-
tice changes implemented?
� Who are stakeholders or others who might
be interested in this EBP? What is the po-
tential impact or advantage for them? What
are their priorities, and how can those be ad-
dressed? How can the process be simplified
and built into the system to make adoption
easier for them?
� What are barriers and facilitators to adoption
of EBP? What creative solutions can address
the barriers and/or optimize the facilitators?
� What information or data are the clinicians
and stakeholders accustomed to seeing? What
information or data are typically shared with
EBP changes?
� How can we make this fun?
� How can we design messages for clinicians
and leaders describing the EBP that includes
credible evidence, why the change is impor-
tant, what the EBP change will look like, and
what are the expected outcomes?
Answers to these questions provide direction
for choosing from among the implementation strat-
egies listed. Choose and use implementation strat-
egies cumulatively from the early phases through
the implementation process. Highlighting the poten-
tial advantage, key evidence, project logo, and results
of a gap analysis throughout the implementation
process helps busy clinicians stay focused. These ques-
tions can be revisited while adding strategies across
each phase of the implementation process. EBP projects
in various clinical areas may use different implemen-
tation strategies; flexibility is key (Table 2).
22,68
Implementation is fluid, complex, highly inter-
active, and impacted by contextual variations. Pre-
scriptive and rigid timing of strategies may never be
appropriate.
69
Critical thinking skills of nurses in
evaluating and adapting strategies to the chang-
ing conditions in the clinical setting will continue
to be required. Team leaders will almost certainly
need to adjust or add implementation strategies as
the work progresses. Wensing et al
69
describe se-
lection of implementation strategies as an ‘‘art,’’ stat-
ing that ‘‘research-based evidence can provide some
guidance but cannot show decisively which inter-
vention is most appropriate,’’ yet a structured ap-
proach to selecting implementation strategies may
be helpful.
69(pE85)
Conclusion
Implementation science is an emerging field with
few randomized controlled trials across healthcare
settings where nurses work. However, there is a
growing body of important research showing the
impact of a variety of implementation strategies on
nurse-sensitive outcomes.
28,51,57,69,70
Implementing
EBP change is difficult; consequently, nursing leaders
mustuseeffectiveimplementation strategies to en-
gage clinicians and promote adoption of evidence-
based care delivery to improve patient outcomes.
Using the Evidence-Based Practice Implementation
guide to select implementation strategies adds clarity
to a critical and often undeveloped step in the EBP
process. While gaps remain in our knowledge, this
guide offers a valuable addition to practice by pro-
viding an application-oriented approach for planning
implementation using evidence-based implementa-
tion strategies.
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