Newhouse, Robin P. PhD, RN, NEA-BC, CNOR
Author Affiliation: Assistant Dean, Doctor of Nursing Practice Program, Associate Professor, University of Maryland School of Nursing, Baltimore.
Correspondence: School of Nursing, University of Maryland, 655 West Lombard St, Baltimore, MD 21201 (firstname.lastname@example.org).
In this department, Dr Newhouse highlights hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss the practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the author discusses the importance of assessing the readiness of the organization in accelerating evidence-based practice initiatives and provides a description and references of potential instruments to measure organizational readiness.
A major goal of nurse executives is to embed evidence-based practice (EBP) into their systems of nursing care. It is common for nurse executives to assess problems and opportunities, create a strategic plan to address the identified gaps, implement the plan, and evaluate the outcomes. The same process is required before beginning to enhance EBP initiatives, create a culture of ownership by the staff and grow a mature program that informs and improves nursing processes and patient outcomes.
The first step before initiating strategies to build capacity for EBP is to conduct an assessment to identify if the organization is ready.1 The purpose of this article is to discuss the importance of assessing the readiness of the organization to develop or accelerate EBP initiatives and describe instruments that have been used to assess work context attributes needed for EBP.
The science on organizational adoption of new innovations supports the need for antecedents to be in place and the organization to be ready for the change.2-4 Antecedents are attributes of the organization that make the adoption of an innovation more likely.2,3 Readiness allows the organization to move in the right direction to promote adoption.2,3 Priming the organization is within the scope of responsibility of the nurse executive and leadership team. Building the infrastructure includes assuring that the antecedents are in place and that the organization is ready to move ahead. For implementation of an EBP program to be successful, both the human and material resources (antecedents) need to be in place and the organization must be ready to embrace the organizational change in terms of vision, culture, and processes.
Instruments to Measure Readiness for EBP
One of the first steps in creating a plan to enhance EBP is to assess the organizational context. One approach is to use a checklist to assess if the basic infrastructure (eg, literature search capability, peer-reviewed journals, mentors) is present.1 The leadership team planning the change can each compete the checklist, and results can be summarized and discussed to begin to plan for the infrastructure needed, particularly because there are budget implications at this stage of development.
In addition, understanding the perception of readiness by the nursing staff is foundational to their engagement and ownership of the process and outcome. Strategies will need to be based on anticipated barriers to their engagement in the organizational change. Using instruments with acceptable estimates of reliability and validity for the population and context is important in the measurement of the nursing staff's perception of readiness. Results will provide a wealth of information engaging nursing staff and providing direction for the implementation plan. Fortunately, there are a number of instruments available to choose from.
In a literature review of instruments that measure research utilization, research activity, knowledge management, and organizational learning, 18 tools met inclusion criteria.5 Three major organizational attributes were measured in the instruments (vision, leadership, and a learning culture) and 4 knowledge stages (need, acquisition of new knowledge, knowledge sharing, and knowledge use). Authors conclude that these concepts measure the absorptive and receptive capacity of organizations.5 This literature review is available as an open source document published in Implementation Science and will be useful to identify potential instruments and the instrument authors.
At a recent conference, authors presented the state of instrument development and psychometric testing for 3 instruments that measure context.6 The 3 instruments include the Context Assessment Instrument (CAI),7 Alberta Context Tool (ACT),8 and Organizational Readiness to Change Assessment (ORCA).9 All use the Promoting Action on Research Implementation in Health Services (PARIHS) framework as a foundation. The PARIHS framework includes the major concepts of evidence, facilitation, and context.10,11
Each instrument measures the readiness of the work context for EBP specifically. Table 1 includes the name of the instrument, description of the domains, the number of items, response format, and estimates of reliability and validity for each instrument. To facilitate contact to obtain permission for use and instructions for administration, variable and scale definitions, and scoring instructions of the tools, the most recent publications of each of the 3 authors of the tool are included in the reference list.7-9 Each will be briefly described.
Context Assessment Instrument7
The CAI contains 37 items with a 4-point Likert response format. A total score is calculated to represent an environment's receptivity to change. The 5 domains of the CAI include collaborative practice, evidence-informed practice, respect for persons, practice boundaries, and evaluation. Adequate estimates of reliability and validity are reported in European studies. It takes approximately 20 minutes for a respondent to complete the items on the CAI.
Alberta Context Tool8
The ACT contains 56 items with 5- and 6-point Likert response formats. The context dimensions included are intended to be modifiable by interventions. The eight core context dimensions in the ACT include: (1) leadership, (2) culture, (3) evaluation, (4) social capital, (5) structural and electronic resources, (6) formal interactions, (7) informal interactions, and (8) organizational slack (comprised of three sub-concepts: staffing, space, and time resources). Adequate estimates of reliability and validity are reported in Canadian studies, with the exception of low reliability for 4 subscales with Cronbach's α below .70. The instrument has also been used in European samples. It takes approximately 9 minutes online and 14 minutes in paper format for the respondent to complete the items on the ACT.
Organizational Readiness to Change Assessment9
The ORCA contains 77 items with 5-point Likert response formats. It was developed for use in quality improvement activities to assess the site readiness by researchers from the Veterans Affairs Ischemic Heart Disease Quality Enhancement Research Initiative. The 3 domains include evidence, context, and facilitation. Adequate estimates of reliability and validity are reported for most factors and subscales, with a few exceptions. Low reliability was estimated for 3 evidence subscales. Issues of construct validity were found for the facilitation and context factors. Of the 9 facilitation subscales, only 7 loaded on the facilitation subscale. In the context subscale, 5 of 6 loaded on the context factor. It takes approximately 15 minutes for respondents to complete the web-based version.
Successful adoption and acceleration of EBP within organizations are dependent on leadership's ability to assess if antecedents are in place and the organizational readiness. The nurse executive's role includes responsibility for creating environments that produce intended results.12 Using an instrument to measure the context before changes are implemented provides information needed to understand the nursing staff's perception of the readiness for them to engage. Results can be used to create a strategic plan based on the organizational goals to embed EBP, with focused efforts to break down barriers to engagement for nursing staff.
1. Newhouse RP. Establishing organizational infrastructure (chapter 3). In: Poe S, White KM, eds. Johns Hopkins Nursing Evidence-Based Practice Implementation and Translation
. Indianapolis, IN: Sigma Theta Tau International; 2010:56-72.
2. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q
3. Greenhalgh T, Robert G, Bate P, Macfarlane A, Kyriakidou O. Diffusion of Innovations in Health Service Organizations: A Systematic Literature Review
. Malden, MA: Blackwell Publishing Ltd; 2005.
4. Newhouse RP. Creating infrastructure supportive of evidence-based nursing practice: leadership strategies. Worldviews Evid Based Nurs
6. McCormack B, Estabrooks CA, Squires J, et al. Evaluating context using different lenses. Presented at: Knowledge Utilization Colloquium; June 10, 2010; Halifax, Nova Scotia, Canada.
7. McCormack B, McCarthy G, Wright J, Slater P, Coffey A. Development and testing of the context assessment index (CAI). Worldviews Evid Based Nurs
8. Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton PG. Development and assessment of the Alberta context tool. BMC Health Serv Res
9. Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implement Sci
10. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci
11. Rycroft-Malone J. The PARIHS framework-a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual
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