Titler, Marita G. PhD, RN, FAAN*; Wilson, Deleise S. PhD, RN*; Resnick, Barbara PhD, CNRP, FAAN†; Shever, Leah L. PhD, RN‡
Use of research evidence to guide practice improves patient outcomes. Large gaps still exist, however, between recommended, evidence-based (EB) care and what is applied in care of patients and populations.1,2 The objectives of this study were to describe, as perceived by the Principal Investigators (PIs), the implementation strategies, challenges, successes, and lessons learned from conducting 5 implementation studies funded by the Interdisciplinary Nursing Quality Research Initiative (INQRI), and to present 2 case examples of other INQRI studies to illustrate dissemination strategies. Potential impact of study findings are set forth.
Dissemination and implementation are used to represent the process of bringing “evidence” into practice, originally defined as “diffusion.” Although using the terms dissemination and implementation to cover such a wide area can be very helpful in facilitating discussion, it does not allow for the division of this very complex diffusion process into smaller, more easily addressed areas of science that can develop a robust knowledge base. Thus, various agencies at the National Institutes of Health (NIH) (eg, National Institute of Mental Health, National Cancer Institute) distinguish between implementation and dissemination as part of their Funding Opportunities and Program Announcements.
Dissemination research is the systematic study of processes and factors that lead to widespread use of an EB intervention by the target population.3 Successful dissemination of EB recommendations for health care may differ depending on the targeted audience of key stakeholders (eg, consumers, clinicians, policymakers).4–8 Moving dissemination research forward requires studies that test the effectiveness of packaging and disseminating EB information to reach appropriate stakeholders and thereby improve public health and clinical care services.
Implementation science is the study of methods, interventions, and variables that promote the uptake and use of evidence based practices (EBPs) by individuals and organizations to improve clinical and operational decision making with the goal of improving health care quality.9–11 Findings from implementation science provide an empirical base for promoting EB health care practices in a variety of settings.9,12–35 Models of implementation to guide research and practice are plentiful.10,36–39 The same implementation intervention may meet with varying degrees of effectiveness when applied in different contexts and settings.10,30,35,40–44 This paper provides the unique perspectives of PIs to understand their perceptions about implementation and the success and challenges in doing such studies.
Qualitative descriptive methods were used to understand the challenges and opportunities experienced by PIs in conducting 5 implementation studies. An interview guide, developed by the primary author, elicited information about (1) the type and perceptions of implementation strategies used in their study; (2) the success, challenges, and lessons learned in doing the study; and (3) steps taken to sustain continued use of the program or EBPs following study completion (the interview guide is appended as Supplemental Digital Content 1, http://links.lww.com/MLR/A422). The study was exempt as reviewed by the University of Michigan’s Institutional Review Board (IRB).
The PI of each study was contacted through e-mail to elicit their participation. Mutually agreeable times were arranged to undertake a telephone interview with each PI. The interviews were conducted by a postdoctoral fellow and Master’s student, were tape recorded, and transcribed for content analysis. Transcripts were coded by the first author and research fellow using an inductive approach.45,46 Coding of the narrative and naming of themes were done individually, compared, and agreement about common themes was finalized in a discussion between the 2 individuals.45,46
To illustrate dissemination and study impact, investigators from 2 other research teams were asked to reflect on the following questions and write a case exemplar regarding dissemination of study findings and perceived impact. How were findings from your study disseminated? Have you been contacted about this study? If so, for what information? What are your perceptions of how study findings have impacted practice, public policy, or key stakeholder groups?
Four of 5 implementation studies were on clinical topics (falls; delirium; pain; substance abuse—screening, brief intervention, and referral) and 1 was on professional development of nurse managers; 4 were multisite studies. All studies were in acute care. Major themes regarding implementation strategies are presented first, followed by challenges, successes, and lessons learned, and sustainability of practices after study completion.
The major themes regarding implementation strategies were education, regular ongoing interaction with the sites, implementation tools, and visibility about the project in study units. All respondents discussed the importance of using education of clinicians, opinion leaders, change champions, and organizational leaders with the type and amount of education varying across studies. Educational strategies included train-the-trainer programs, on-line educational modules, a 5-day interactive workshop, and grand rounds. This is exemplified in the following.
At the beginning of the study “each group was brought to campus … and there was a group of experts that actually conducted the education. … So the education itself included all of the content that everyone needed to be successful. And we also videoed the presentations so that they could use them for training in their sites.”
We had a national expert … he did grand rounds for all of the physicians … he presented the evidence in a way that is almost indisputable. And it really had an effect in changing physicians’ minds on whether this would work or not. After he presented, there was a lot more physician buy-in here.
Regular ongoing interaction with the sites included site visits, list-serve, teleconferences, and Webinars. Respondents discussed the importance of building relationships with study sites and clinicians, as well as ongoing interactions to discuss progress and issues in implementation. One respondent noted: “I think what worked best is the constant interaction with the sites.” Another noted “An implementation strategy was the monthly synchronous meetings … where they could have questions answered about the implementation.”
The third major theme was the use of tools for implementation such as quick reference guides, toolkits, and check lists. This theme is exemplified by the following.
We provided them with lots of tools … when they came for the training. … They had an algorithm. So we gave them lots of tools that they could use for the implementation.
We provided them with a mock version of the toolkit—what we were thinking—and got their ideas. … The toolkit itself, we are quite excited about it. The units really liked it.
The fourth major theme focused on visibility about the project and desired practices in the study units. Some of these strategies were planned by the research team, whereas others were initiated by the staff in the study units. These strategies included use of local opinion leaders and change champions, development of a study logo, posting a series of key practice messages in the units or patient rooms, and audit and feedback of key practice data. This theme is illustrated by the following.
We identified leaders in the organization to work with and formal opinion leaders. We actively engaged staff at the medical center to become champions of the program.
We had a commercial artist develop a logo and that logo was on all of our materials, our workbooks, mugs, tote bags, and little badges that they could wear with their badge at work and with reminders of key points to remember as they go about their day as a manager. So we did a lot of branding, following the principles of translation science.
… one group [of nurses]did a lot of creative things about communication with use of whiteboards … and they developed structured messages where it said ‘your last pain medicine was given at …’ ‘your next available medicine is …’.
Challenge, Successes, and Lessons Learned
Major themes regarding challenges were IRB approvals, the timeframe for actual implementation, and study-specific challenges. IRB challenges included obtaining approval for multisite implementation studies which are not the typical types of studies reviewed by IRB boards. One respondent noted that “I guess the IRBs are not quite set-up to do this kind of research.” Another PI noted that: “Some of the challenges were truly the IRB approval process. I think for any other studies I do, I’m putting a regulatory specialist on my team.”
Time spent in actual implementation ranged from 4 to 12 months, with most being 4–6 months. Studies were funded for 18 months. This was troublesome for investigators as exemplified by the following.
The biggest challenge was … we had such a very, very short timeframe in terms of implementing the intervention … That was one of the things that was so hard was that it was such a hard timeframe to get this up and running to study the outcomes and also the processes.
I’m very worried that we didn’t give the units enough time to make changes.
Other challenges were study specific and included some planned implementation tools or strategies not being used (eg, list-serve), lag time between the training and use of the EB interventions by staff, key stakeholders (eg, pharmacists) not being engaged early enough in the implementation process, low response rate on return of questionnaires, and submission of follow-up data by hospitals.
In terms of successes, the major themes focused on enthusiasm and increased understanding about the study topic (eg, delirium), and tools for other hospitals to use for improving practice. The first theme, noted by all respondents, is exemplified in the following.
One of the successes is the excitement and engagement of site coordinators and nurses at the sites. I can’t tell you how much energy there is. … The nurses are so engaged and so excited … These are nurses who have never engaged in research before. This happened at multiple sites. So I think that is one of the exciting things.
Another success is at this point the people at the place where this is being implemented really do now kind of get how really serious delirium is. … now I think they have a greater appreciation of the fact that what they do on a daily basis is affecting patients and their family in the long run.
All respondents discussed that the studies resulted in tools and resources for other hospitals to use in improving practice as exemplified by the following.
We’re actually using the policy and procedure we developed through the study as part of a template for other hospitals … to do the ABCDE in their institution so they do not have to re-invent the wheel.
And of course we don’t have the results yet. But I do think this is an implementable intervention and one area in which nurses can take the lead in improving outcomes for people. … I am confident this can be spread broadly by what we have learned. … I think we are going to come out with a toolkit of what was successful so other people can use it.
Major themes regarding lessons learned focused on context, complexity of implementation, and communication. All respondents discussed the importance of context of practice for implementation as well as understanding contextual changes that may occur as a result of the implementation study. One respondent noted “So in implementation science it seems that context is so important. You know. … Obviously this is a big lesson.” Another noted “So this study… is also intended to understand the contextual changes that occurred during implementation of this study”. All respondents discussed the complexity of implementation noting that it requires changing multiple practice behaviors and use of multiple implementation strategies. The following are exemplars illustrating this theme.
Implementation is a complex process that takes time. … there were just so many practices embedded in this bundle that it was hard to get all of the pieces addressed. Changing practitioner behavior is hard.
We thought it would be a relatively simple process because the evidence was so strong behind it, but in the end it was a little bit more challenging than we thought.
Communication with clinicians and study sites was viewed by respondents as an essential part of implementation and a lesson learned as exemplified by the following:
I think one of the things we are going to do in the next study, we are actually going to script some of the communication to the staff or the site (site coordinator).
One of the lessons learned is to use multiple communication strategies with the sites to keep them engaged.
Ideas of how the EB interventions might be sustained following study completion included (1) integrating the EBPs into electronic health records; (2) imbedding the practice as part of the system (eg, policies and procedures); (3) presenting the study results to the practice sites so they can see their success; and (4) providing a training manual for use in educating other clinicians in their sites.
In summary, a variety of implementation strategies were used. Investigators freely shared the many challenges and success in doing these implementation studies, and the professional community looks forward to their results as the final data from these 5 studies are analyzed and disseminated.
Case Exemplars of Dissemination
Two case exemplars illustrate the potential impact and dissemination of findings from intervention and descriptive research funded by the INQRI program.
The Function Focused Care-Assisted Living (FFC-AL) Intervention Study
This study, led by B.R., tested the feasibility and effectiveness of the FFC-AL intervention. A Social Ecological Model and self-efficacy theory served as the basis of the intervention in conjunction with the Diffusion of Innovation Theory. The RE-AIM model was used to evaluate dissemination and implementation of FFC-AL in these communities. A total of 171 residents and 96 direct care clinicians consented to participate in the study. Study outcomes and implementation of the FFC-AL were disseminated through publications (Table 1 appended as Supplemental Digital Content 2, http://links.lww.com/MLR/A423) and presentations at numerous interdisciplinary scientific meetings.
B.R. is frequently interviewed about her research and this study is discussed as part of successful aging. Her team is currently doing a dissemination project in 20 AL sites and using a lighter touch model that includes an in-house champion. The team developed a comprehensive training package, funded by the Stulman Foundation, that is used with this dissemination project.
The impact of B.R.’s research sets forth the importance of optimizing function and physical activity in older adults. The team works to consistently translate function focused care into practice, and to assure that nurses assist older adults to perform functional and physical activity at their highest level. The team plans to test the effectiveness of function focused care (1) in acute care settings; and (2) with older adults who have moderate to severe dementia in AL settings.
Impact of System-Centered Factors and Processes of Nursing Care on Fall Prevalence and Injuries from Falls
This descriptive study, led by M.G.T. and L.L.S., investigated linkages among 2 National Quality Forum patient-centered outcome measures (fall prevalence and injury from falls), National Quality Forum system-centered measures (skill mix, nursing care hours per patient day, and practice environment), hospital structural factors (acute care bed capacity), and processes of care to prevent falls. Forty-eight hospitals and 188 adult medical-surgical units enrolled in the study.
The research design and methods influenced the study’s impact and subsequent changes in practice. Commitments from chief nursing officers for data access and enrollment of hospitals resulted in an unanticipated, high degree of enthusiasm with multiple sites seeking to participate. Active participation by nurses at each site was required to collect and submit study data. For many, this was a new experience and some sites implemented changes based on what was learned during data collection. For example, at some institutions, staff nurses completed chart audits looking for interventions related to fall prevention. Those nurses communicated with their colleagues that their documentation about fall prevention interventions needed to improve.
Study findings were disseminated through publications and presentations (Table 1 appended as Supplemental Sigital Content 2, http://links.lww.com/MLR/A423). Study results were also distributed to each site through e-mail followed by conference calls for discussion of findings. Discussions regionally and nationally focused on the need to do more for preventing falls than documentation of a fall risk score and implementing general fall prevention interventions (eg, colored wrist band, sign on the door). Findings regarding the lack of interventions addressing mobility were also discussed by multiple groups. These discussions culminated in a second RWJ INQRI study to implement fall prevention interventions that address patients’ specific risk factors. Findings about nurse managers’ limited knowledge of research evidence for fall prevention led to a second study to examine nurse managers’ knowledge and behaviors that facilitate adoption of EBPs, funded by the American Organization of Nurse Executives. Falls and falls with injury did not decrease in the first year after the 2008 CMS pay-for-performance initiative (treatment for injuries from a fall during hospitalization are not reimbursed). This finding can inform public policy.
The PIs’ discussions about their studies produced unique perspectives regarding implementation that are not typically included in publications of study findings. Multiple common implementation strategies (education, interaction with sites, tools, study visibility) were used across the 5 studies as recommended by others11,17,25,29,32,35,42,47–49 and these addressed key areas of importance in implementation—the nature of the EBP topic, engagement of clinicians, and communication.35,50,51 Strategies to address context of practice, an important component of implementation,35,50,51 were not used but noted as a lesson learned.
Challenges reported by the PIs are important for other investigators to note. These studies were funded for 18 months and the IRB challenges left less time for implementation, most being 4–6 months. This is worrisome as many investigators plan 12–24 months for implementation.15,17,22,24,28,29,35
PIs consistently remarked about the complexity of implementation as a lesson learned. Implementation interventions are, by their very nature complex.52,53 Complex interventions have several interacting components and are further characterized by number and difficulty in the practice behaviors that are being addressed, number of groups targeted by the intervention, number and variability of outcomes, and degree of flexibility permitted in implementation.52,53 This is challenging when reporting study results as space limitations may preclude full description of these complex implementation interventions.53
The respondents’ perceptions of success, such as creating excitement for research and development of tools for use by others, are important outcomes that are not typically captured or reported in implementation studies. These “secondary” study gains are important for improving quality of care. Although addressing sustainability was not central to these studies, the strategies reported herein are important as more research is needed in how to mitigate the “improvement-evaporation effect” and explicating factors associated with sustainability of gains achieved in improving care during implementation.54,55
Case Exemplars of Dissemination
The case examples illustrate study impact locally and nationally by drawing attention to issues in care of older adults. B.R.’s study drew attention to optimizing function and physical activity, whereas M.G.T. and colleagues increased awareness about fall prevention interventions that target patient-specific risk factors. Findings were used by the study sites to improve care, and results were disseminated through research meetings and publications. Studies led to additional funded research.
Impact of the INQRI Studies
The potential impact of all 7 studies is far reaching. They addressed important issues in health care and demonstrated how quality of care can be improved in pain management, delirium prevention and treatment, substance abuse screening and treatment, fall prevention, and optimizing function and physical activity in older adults. In addition, 2 studies addressed the importance of the nurse manager role in quality care, an area that needs further attention in health care delivery.
Limitations include small sample size, transcribed data were not returned to the investigators for review, and interviews were conducted before final analysis of data from the 5 studies. Exemplars of dissemination were from 2 studies and were based on perceptions of the investigators.
This study captures several nuanced perspectives from 5 PIs who were completing INQRI-funded implementation studies. Despite differences in topics, geographic regions of the United States, and study sites, common implementation strategies were described. IRB review and time for implementation were common study challenges. Common lessons learned included the complexity of implementation studies and the practice context. The nuanced perspectives shared by these PIs are important lessons for other scientists embarking on implementation research. The INQRI case examples illustrate important dissemination strategies and impact of study findings on quality of care. Collectively, these 7 INQRI-funded studies addressed important quality health care issues, and their impact is far reaching.
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