;)
Figure: Lynn Gallagher-Ford (left) and Sharon Tucker critique student attempts to develop PICO-T questions in an evidence-based practice (EBP) immersion program at the Lucile Packard Children's Hospital in Palo Alto, California. Photo courtesy of the Fuld Institute for EBP.
Evidence-based practice (EBP) has become a standard for the delivery of safe, quality care and the achievement of optimal patient outcomes. Patients, families, payers, and regulatory agencies expect that care delivery will be based on the most current and best available evidence. Numerous models and frameworks exist to guide practitioners in delivering EBP. Nurse and health care staff participation in intensive EBP immersion programs is growing rapidly, and undergraduate and graduate nursing programs are embedding EBP in their curricula.
Despite this important progress, bringing evidence to routine clinical care remains an elusive, challenging, and often underresourced goal.1 To address this well-recognized gap, research and quality improvement (QI) efforts have focused on implementation and translation models and strategies that can promote the successful uptake and sustainability of EBP. This article introduces a new series focused on the implementation step of EBP. Using the research literature on implementation science, models, and strategies, we will present case studies that are designed to inform readers and practitioners about how to minimize barriers and leverage facilitators (such as unit champions or mentors) to achieve success in implementing and sustaining EBP changes.
This new series builds on the previous EBP series published in AJN from 2009 to 2011. That series describes the seven steps of EBP, giving nurses the knowledge and skills needed to implement EBP at their institutions. It also contains some of the most popular and downloaded AJN articles, reflecting a sense of urgency among nurses, other health care practitioners, and organizations to use the best evidence to provide safe and high-quality care.
EBP: STEP BY STEP
The seven steps of EBP are well established in nursing and other disciplines and present a standardized approach to EBP. As described in the previous AJN series, they are:
- Step Zero: Cultivate a spirit of inquiry and an EBP culture
- Step 1: Ask clinical questions in PICO-T (population, intervention, comparison, outcome, and, if appropriate, time) format
- Step 2: Search for the best evidence
- Step 3: Critically appraise the evidence and recommend a practice change
- Step 4: Integrate the evidence with clinical expertise and patient/family preferences and values
- Step 5: Evaluate the outcomes of the practice decisions or changes based on the evidence
- Step 6: Disseminate the results of the EBP change
The widespread endorsement of these EBP steps, along with numerous models and resources, has led to the establishment of EBP competencies for health care providers.2, 3 These competencies reflect a minimum set of attributes, such as knowledge, skills, attitudes, abilities, and judgment, that enable a clinician to meet practice standards. Examples of EBP competencies include understanding how to formulate a clinical question in PICO-T format, critically appraising the evidence, and incorporating patient preferences into the implementation of a practice change.
IMPLEMENTATION—THE MOST CHALLENGING STEP
Great progress has been made in recent years in standardizing EBP. However, Step 4, the implementation step, in which evidence is integrated with clinician expertise and patient/family preferences and values, remains perhaps the most challenging. The reasons for this are multifactorial and interrelated: the involvement of numerous and diverse stakeholders, resource intensity (such as pulling staff away from patient care to lead the practice change, or the necessity of certain equipment and supplies for the practice change), a fast-paced and constantly changing hospital environment, evolving regulatory and payer demands, resistance to change, and lack of time and effort dedicated to “hard-wiring” evidence-based change over time (making the change sustainable and embedded in the system and culture).
Implementation of EBP is thus a complex and resource-intensive step, and the time and effort needed are often underestimated and underresourced. Recognition of the research-to-practice gap was described in 2000 by Balas and colleagues, who published a landmark paper in which they noted it takes an average of 17 years to translate a scientific discovery (such as an evidence-based recommendation) into real-world clinical practice and settings.4 Since this gap was made transparent, an entire scientific field—implementation or translation science—has emerged, providing models, insight, and strategies to inform and expedite the uptake of EBPs.5 Nilsen published a summary of implementation models and theoretical approaches, categorizing them as follows: models that direct or guide the process of research into practice, frameworks for understanding and/or exploring influences on implementation, classic theories largely related to change processes, specific implementation models, and evaluation approaches.6 In this EBP series, we'll use the concepts and features of several of these models, suggesting a simplified approach to implementation to guide nurses and other health care practitioners.
SUCCESSFUL STRATEGIES
We will guide readers to think of implementation of an initiative as occurring in phases of change, using select strategies best aligned with each phase. Strategies will address organizational culture, leadership structure and support, EBP resources, patient populations and settings, technical and data needs, educational needs, reminders and reinforcement, mentors and champions, QI tools, and data trending, among other topics. Early phases of change might address potential obstacles such as staff support for the status quo, beliefs that the current practice is working fine, and a general lack of recognition or openness to exploring a practice change. Later phases of change might reflect a readiness for a practice change, widespread rollout, and efforts to institute sustainable change over time.
For each phase of the implementation step, we will introduce strategies to keep the initiative moving toward a successful practice change. These strategies will be based on the work of several researchers, including Grol and Grimshaw,7 Grimshaw and colleagues,8 Powell and colleagues,9 and Cullen and colleagues.10, 11 The two papers coauthored by Jeremy Grimshaw propose that EBP changes need to be supported by an assessment of the barriers and facilitators to applying the evidence in a specific context or setting; the best evidence should then be used to select the implementation strategies.7, 8 These strategies include, among others, the use of educational materials, reminders, computerized decision support, performance feedback, opinion leaders, multiprofessional collaboration, and mass media campaigns.7
The paper by Powell and colleagues is based on a compilation of 73 implementation strategies identified by an expert panel.9 The panel believed these strategies to be useful building blocks for the multifaceted, multilevel strategies used in the implementation of EBP changes in mental health service settings (transferrable to other specialties) and for comparative effectiveness research.
Finally, to guide our discussion of implementation strategies, we'll turn to the work of Cullen and Adams, who recommend strategies aligned with the phases of implementation and target two distinct groups: clinicians, organizational leaders, and key stakeholders, and the organizational system of support.10 They also highlight the importance of change agent roles, such as those of change champions, EBP mentors, and opinion leaders.10 This work led to the production and publication of a useful resource guide—Evidence-Based Practice in Action: Comprehensive Strategies, Tools, and Tips from the University of Iowa Hospitals and Clinics—which includes 63 implementation strategies, each presented with a definition, benefits, procedure, case example, and supporting references.11
SUSTAINABLE CHANGE
Implementation is a major step in the EBP process, but because its challenges are often underappreciated, implementation efforts are often underresourced. It's therefore not surprising that the translation of evidence into practice is often a slow process that may never fully occur or cannot be sustained. In this series, we will focus on the development of competency among nurses, nursing leaders, and other health care providers in implementing EBP. We will use published models and strategies to help readers better understand how to successfully tackle the implementation of EBP. Moreover, we'll illustrate how others have applied these implementation strategies—with various outcomes, whether successful, partially successful, or stalled and delayed—by inviting EBP experts to tell their stories. These examples will be presented along with our commentary, in which we'll detail the principles and strategies used, highlighting those that can best lead to sustainable change.
REFERENCES
1. Li SA, et al. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review Syst Rev 2018 7 1 72
2. Albarqouni L, et al. Core competencies in evidence-based practice for health professionals: consensus statement based on a systematic review and Delphi survey JAMA Netw Open 2018 1 2 e180281
3. Melnyk BM, et al. The first U.S. study on nurses’ evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes Worldviews Evid Based Nurs 2018 15 1 16 25
4. Balas EA, Boren SA Managing clinical knowledge for health care improvement Yearb Med Inform 2000 1 65 70
5. Dearing JW, Kee KF Brownson RC Historical roots of dissemination and implementation in science Dissemination and implementation research in health: translating science to practice 2012 New York, NY Oxford University Press 55 71
6. Nilsen P Making sense of implementation theories, models and frameworks Implement Sci 2015 10 53
7. Grol R, Grimshaw J From best evidence to best practice: effective implementation of change in patients’ care Lancet 2003 362 9391 1225 30
8. Grimshaw JM, et al. Knowledge translation of research findings Implement Sci 2012 7 50
9. Powell BJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project Implement Sci 2015 10 21
10. Cullen L, Adams SL Planning for implementation of evidence-based practice J Nurs Adm 2012 42 4 222 30
11. Cullen L, et al.
Evidence-based practice in action: comprehensive strategies, tools, and tips from the University of Iowa Hospitals and Clinics. Indianapolis, IN: Sigma Theta Tau International; 2018.
