Two prior research columns have addressed locating evidence for use in clinical practice and the interpretation of research articles (Sharts-Hopko, in press-a, in press-b). After assessment is made about the available evidence, nurses may find that they want to use the evidence to change the way they practice. With that decision, they must then plan how the evidence will be used to change practice in their settings, and how change will be evaluated. This is one aspect of what biomedical scientists call implementation science, the systematic assessment of clinical outcomes of practices developed through research in various routine clinical settings. It is a subset of translation science, which refers to the translation of basic research findings in controlled environments to application in clinical settings.
Phases in Implementation of Evidence-Based Practice
Early in the movement to encourage implementation of best practices as identified through research, experts assumed that knowledge of the scientific evidence would be sufficient to induce clinicians to apply cutting-edge information to their practices. In the 1960s and 1970s, considerable resources were directed toward helping nurses read, interpret, and conduct research to answer clinical questions. A continuing problem in health care delivery in the United States has been the lag between scientific discovery of knowledge and its adoption in practice. Rather than being the final solution to improving the quality of health care practice, we now understand that locating and evaluating scientific evidence for relevance to practice is better thought of as the first phase of implementation.
Kitson et al. (2008) have observed that whereas the spread of evidence was previously viewed as a linear process at the level of the individual, it is now recognized that organizational change is required for the complex and multifaceted process of using evidence in practice. They understand that the process requires stakeholders to negotiate and evolve toward a shared understanding of the benefits and risks associated with changing practice. System change to implement new practice guidelines can be considered as the second phase.
Kitson et al. (2008) as well as Titler (2010) have identified another critically important factor for the implementation of evidence-based practice, and that is context. Context refers to the institutional culture, infrastructure for evaluation, social climate, leadership, and amount of interaction with outside organizations, as well as characteristics of the professionals involved in the change and their attitudes toward research.
Tansella and Thornicroft (2009) have observed that a third phase in evidence-based practice exists: the ongoing routine practice over time that is consistent with what the scientific evidence demonstrated. They distinguished between early implementation, the result of phase two, and persistence of implementation. Examples of strategies for ensuring fidelity over time are the inclusion of the practice revision in the education and certification of new professionals and the orientation of newly hired clinicians, as well as the incorporation of feedback systems nationally and within individual institutions and to determine the extent to which practice has truly been changed.
A Model for Implementation
Various models exist to guide health professionals in the revision of clinical guidelines and policies based on current scientific evidence regarding best practice. The Iowa Model of Evidence-based Practice is one well-known and highly regarded example in the nursing literature (Titler, 2002). First, the model requires a comparison of current practice with the proposed revisions. Proposed revisions to practice originate from various triggers. These could include the publication of new research; changes in professional standards and guidelines emanating from professional organizations or federal agencies; or a shift in the philosophy underlying practice, such as a desire to be more family-centered or community-based. Problem-focused triggers include concerns arising from such sources as internal quality assessment processes, financial data, or the emergence or identification of a specific clinical problem (Titler, 2002, 2007).
If it is determined that a practice guideline or policy warrants change based on the assessment of the scientific evidence, then a pilot or demonstration project is designed for implementation on a circumscribed scale involving a few clinicians and a small number of patients. Outcome measures need to be identified prior to implementation and may include clinical outcomes, patient and family as well as staff satisfaction, environmental impact, and the effect of the clinical change on direct and indirect costs of care. In addition, the time frame for the trial implementation is determined in advance. Need for further revision in the practice guideline may be identified during this initial pilot phase.
As an example of the initial pilot phase of a revision, 30 years ago, I was married to a research and development scientist at the chemical company that introduced nonstick skillets. A problem with original pans was that the nonstick coating eventually flaked off into food that was being cooked. When the next generation of nonstick coating was developed in the laboratory, prototype skillets were distributed to employees of the company for routine use and scrubbing over a period of months. The skillets were then retrieved for analysis, users were surveyed, and the product was further refined on the basis of this initial limited trial.
After the practice guideline is refined, it can be piloted on a larger scale. Outcome data need to be collected from everyone affected by the change. Changes in the practice guideline will be adopted (or not) based on data from the pilot study. Because of the recent identification of the phase three (concern with fidelity of the evidence-based practice over time in routine clinical use), it is important to monitor outcomes associated with the effect of the revised practice guideline for a period of time.
Fostering Staff Support for Change
Stakeholders need to be involved from the inception of the implementation project. It may be necessary for a person acting in the role of change facilitator to work over a period of time with clinical staff to discuss concerns related to the change, individually or in group meetings. In addition, staff members need assurance that quality measures are in place; timely feedback about the process and associated outcomes of the practice change are warranted. Recognition for their accomplishments during assessment and then implementation can help staff appreciate the value of changing to an evidence-based practice. Two extremely rewarding results of a change implementation project for clinical staff would be for those who were involved to present their work to groups within the institution and at external professional meetings, and to publish an article describing their accomplishments. As more institutions consider seeking Magnet designation, these activities are proving to be advantageous for the organization as well as the individuals involved. Various professional organizations such as the Association of Nurses in AIDS Care, Sigma Theta Tau International, and many regional research societies specifically elicit presentations about implementation of evidence-based practice. Some nurses who are advancing their education may find that the implementation of evidence-based practices dovetail with academic requirements. While negotiation of ownership of the project is important when multiple staff members are involved, this can also add to the intrinsic value of the process.
Examples in HIV Care
The Journal of the Association of Nurses in AIDS Care has published examples of implementation projects at various stages. For example, Dawson Rose, Gutin, and Reyes (in press) published an article evaluating the evidence about Positive Prevention strategies for people living with HIV in the United States for its adaptation and use in Mozambique. The need to conduct a trial in the very different context presented by Mozambique was clear, but the existing evidence provided a theoretically sound base from which to work.
Cook, McCabe, Emiliozzi, and Pointer (2009) applied a considerable amount of evidence supporting the use of telephonic nurse counseling to improve medication adherence to the specific case of antiretroviral therapy among persons living with HIV. It would be easy for casual reviewers to ignore this article as an example of piloting evidence-based practice, because the authors did not identify it as such. Yet the literature on telephonic counseling to help people with treatment regimens is vast and long-standing. The particular strategy used in this study did prove to be a promising tactic to improve antiretroviral therapy adherence, although the authors recommended testing the strategy in a larger randomized controlled trial.
When the need for change in a clinical practice becomes apparent either because of concerns arising from within the institution or because of scientific advances, knowledge of the current research is important, but it has proven to be insufficient to ensure that practice will change. An implementation project requires the identification of desired outcomes, outcomes assessment, and the way that change will be introduced on a limited scale. Feedback will be used to refine the change, and it will be assessed for a defined period of time. It is important that communication with the staff involved be open, that the clinical outcomes are shared, and that concerns be addressed. Recognition of staff for their accomplishments in systematically implementing a change in practice serves as a powerful motivator and should contribute to quality and morale in the organization as a whole.
The author reports no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.
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