Evidence-Based Practice Implementation

Chapter 7. The Evidence for Evidence-Based Practice Implementation Marita G. Titler

Background Overview of Evidence-Based Practice

Evidence-based health care practices are available for a number of conditions such as asthma,

heart failure, and diabetes. However, these practices are not always implemented in care delivery, and variation in practices abound.1–4 Traditionally, patient safety research has focused on data analyses to identify patient safety issues and to demonstrate that a new practice will lead to improved quality and patient safety.5 Much less research attention has been paid to how to implement practices. Yet, only by putting into practice what is learned from research will care be made safer.5 Implementing evidence-based safety practices are difficult and need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and— ultimately—changing health care cultures to be evidence-based safety practice environments.5

Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6– 9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated by Nightingale,10 the nursing profession has more recently provided major leadership for improving care through application of research findings in practice.11

Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.12–15 Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decisionmaking is derived principally from nonresearch evidence sources such as expert opinion and scientific principles.16 As more research is done in a specific area, the research evidence must be incorporated into the EBP.15

Models of Evidence-Based Practice

Multiple models of EBP are available and have been used in a variety of clinical settings.16–36 Although review of these models is beyond the scope of this chapter, common elements of these models are selecting a practice topic (e.g., discharge instructions for individuals with heart failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient care and provider performance, and consideration of the context/setting in which the practice is implemented.15, 17 The learning that occurs during the process of translating research into practice is valuable information to capture and feed back into the process, so that others can adapt the evidence-based guideline and/or the implementation strategies.

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A recent conceptual framework for maximizing and accelerating the transfer of research results from the Agency for Healthcare Research and Quality (AHRQ) patient safety research portfolio to health care delivery was developed by the dissemination subcommittee of the AHRQ Patient Safety Research Coordinating Committee.37 This model is a synthesis of concepts from scientific information on knowledge transfer, social marketing, social and organizational innovation, and behavior change (see Figure 1).37 Although the framework is portrayed as a series of stages, the authors of this framework do not believe that the knowledge transfer process is linear; rather, activities occur simultaneously or in different sequences, with implementation of EBPs being a multifaceted process with many actors and systems.

Steps of Evidence-Based Practice

Steps of promoting adoption of EBPs can be viewed from the perspective of those who conduct research or generate knowledge,23, 37 those who use the evidence-based information in practice,16, 31 and those who serve as boundary spanners to link knowledge generators with knowledge users.19

Steps of knowledge transfer in the AHRQ model37 represent three major stages: (1) knowledge creation and distillation, (2) diffusion and dissemination, and (3) organizational adoption and implementation. These stages of knowledge transfer are viewed through the lens of researchers/creators of new knowledge and begin with determining what findings from the patient safety portfolio or individual research projects ought to be disseminated.

Knowledge creation and distillation is conducting research (with expected variation in readiness for use in health care delivery systems) and then packaging relevant research findings into products that can be put into action—such as specific practice recommendations—thereby increasing the likelihood that research evidence will find its way into practice.37 It is essential that the knowledge distillation process be informed and guided by end users for research findings to be implemented in care delivery. The criteria used in knowledge distillation should include perspectives of the end users (e.g., transportability to the real-world health care setting, feasibility, volume of evidence needed by health care organizations and clinicians), as well as traditional knowledge generation considerations (e.g., strength of the evidence, generalizability).

Diffusion and dissemination involves partnering with professional opinion leaders and health care organizations to disseminate knowledge that can form the basis of action (e.g., essential elements for discharge teaching for hospitalized patient with heart failure) to potential users. Dissemination partnerships link researchers with intermediaries that can function as knowledge brokers and connectors to the practitioners and health care delivery organizations. Intermediaries can be professional organizations such as the National Patient Safety Foundation or multidisciplinary knowledge transfer teams such as those that are effective in disseminating research-based cancer prevention programs. In this model, dissemination partnerships provide an authoritative seal of approval for new knowledge and help identify influential groups and communities that can create a demand for application of the evidence in practice. Both mass communication and targeted dissemination are used to reach audiences with the anticipation that early users will influence the latter adopters of the new usable, evidence-based research findings. Targeted dissemination efforts must use multifaceted dissemination strategies, with an emphasis on channels and media that are most effective for particular user segments (e.g., nurses, physicians, pharmacists).

End user adoption, implementation, and institutionalization is the final stage of the knowledge transfer process.37 This stage focuses on getting organizations, teams, and individuals

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to adopt and consistently use evidence-based research findings and innovations in everyday practice. Implementing and sustaining EBPs in health care settings involves complex interrelationships among the EBP topic (e.g., reduction of medication errors), the organizational social system characteristics (such as operational structures and values, the external health care environment), and the individual clinicians.35, 37–39 A variety of strategies for implementation include using a change champion in the organization who can address potential implementation challenges, piloting/trying the change in a particular patient care area of the organization, and using multidisciplinary implementation teams to assist in the practical aspects of embedding innovations into ongoing organizational processes.35, 37 Changing practice takes considerable effort at both the individual and organizational level to apply evidence-based information and products in a particular context.22 When improvements in care are demonstrated in the pilot studies and communicated to other relevant units in the organization, key personnel may then agree to fully adopt and sustain the change in practice. Once the EBP change is incorporated into the structure of the organization, the change is no longer considered an innovation but a standard of care.22, 37

In comparison, other models of EBP (e.g., Iowa Model of Evidence-based Practice to Promote Quality of Care16) view the steps of the EBP process from the perspective of clinicians and/or organizational/clinical contexts of care delivery. When viewing steps of the EBP process through the lens of an end user, the process begins with selecting an area for improving care based on evidence (rather than asking what findings ought to be disseminated); determining the priority of the potential topic for the organization; formulating an EBP team composed of key stakeholders; finding, critiquing, and synthesizing the evidence; setting forth EBP recommendations, with the type and strength of evidence used to support each clearly documented; determining if the evidence findings are appropriate for use in practice; writing an EBP standard specific to the organization; piloting the change in practice; implementing changes in practice in other relevant practice areas (depending on the outcome of the pilot); evaluating the EBP changes; and transitioning ongoing quality improvement (QI) monitoring, staff education, and competency review of the EBP topic to appropriate organizational groups as defined by the organizational structure.15, 40 The work of EBP implementation from the perspective of the end user is greatly facilitated by efforts of AHRQ, professional nursing organizations (e.g., Oncology Nursing Society), and others that distill and package research findings into useful products and tools for use at the point of care delivery.

When the clinical questions of end users can be addressed through use of existing evidence that is packaged with end users in mind, steps of the EBP process take less time and more effort can be directed toward the implementation, evaluation, and sustainability components of the process. For example, finding, critiquing, and synthesizing the evidence; setting forth EBP recommendations with documentation of the type and strength of evidence for each recommendation; and determining appropriateness of the evidence for use in practice are accelerated when the knowledge-based information is readily available. Some distilled research findings also include quick reference guides that can be used at the point of care and/or integrated into health care information systems, which also helps with implementation.41, 42

Translation Science: An Overview

Translation science is the investigation of methods, interventions, and variables that influence adoption by individuals and organizations of EBPs to improve clinical and operational decisionmaking in health care.35, 43–46 This includes testing the effect of interventions on

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promoting and sustaining adoption of EBPs. Examples of translation studies include describing facilitators and barriers to knowledge uptake and use, organizational predictors of adherence to EBP guidelines, attitudes toward EBPs, and defining the structure of the scientific field.11, 47–49

Translation science must be guided by a conceptual model that organizes the strategies being tested, elucidates the extraneous variables (e.g., behaviors and facilitators) that may influence adoption of EBPs (e.g., organizational size, characteristics of users), and builds a scientific knowledge base for this field of inquiry.15, 50 Conceptual models used in the translating-research- into-practice studies funded by AHRQ were adult learning, health education, social influence, marketing, and organizational and behavior theories.51 Investigators have used Rogers’s Diffusion of Innovation model,35, 39, 52–55 the Promoting Action on Research Implementation in Health Services (PARIHS) model,29 the push/pull framework,23, 56, 57 the decisionmaking framework,58 and the Institute for Healthcare Improvement (IHI) model59 in translation science.

Study findings regarding evidence-based practices in a diversity of health care settings are building an empirical foundation of translation science.19, 43, 51, 60–83 These investigations and others18, 84–86 provide initial scientific knowledge to guide us in how to best promote use of evidence in practice. To advance knowledge about promoting and sustaining adoption of EBPs in health care, translation science needs more studies that test translating research into practice (TRIP) interventions: studies that investigate what TRIP interventions work, for whom, in what circumstances, in what types of settings; and studies that explain the underlying mechanisms of effective TRIP interventions.35, 49, 79, 87 Partnership models, which encourage ongoing interaction between researchers and practitioners, may be the way forward to carry out such studies.56 Challenges, issues, methods, and instruments used in translation research are described elsewhere.11, 19, 49, 78, 88–97

Research Evidence

What Is Known About Implementing Evidence-Based Practices?

Multifaceted implementation strategies are needed to promote use of research evidence in clinical and administrative health care decisionmaking.15, 22, 37, 45, 64, 72, 77, 79, 98, 99 Although Grimshaw and colleagues65 suggest that multifaceted interventions are no more effective than single interventions, context (site of care delivery) was not incorporated in the synthesis methodology. As noted by others, the same TRIP intervention may meet with varying degrees of effectiveness when applied in different contexts.35, 49, 79, 80, 87, 100, 101 Implementation strategies also need to address both the individual practitioner and organizational perspective.15, 22, 37, 64, 72, 77, 79, 98 When practitioners decide individually what evidence to use in practice, considerable variability in practice patterns result,71 potentially resulting in adverse patient outcomes.

For example, an “individual” perspective of EBP would leave the decision about use of evidence-based endotracheal suctioning techniques to each nurse and respiratory therapist. Some individuals may be familiar with the research findings for endotracheal suctioning while others may not. This is likely to result in different and conflicting practices being used as people change shifts every 8 to 12 hours. From an organizational perspective, endotracheal suctioning policies and procedures based on research are written, the evidence-based information is integrated into the clinical information systems, and adoption of these practices by nurses and other practitioners is systematically promoted in the organization. This includes assuring that practitioners have the

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necessary knowledge, skills, and equipment to carry out the evidence-based endotracheal suctioning practice. The organizational governance supports use of these practices through various councils and committees such as the Practice Committee, Staff Education Committee, and interdisciplinary EBP work groups.

The Translation Research Model,35 built on Rogers’s seminal work on diffusion of innovations,39 provides a guiding framework for testing and selecting strategies to promote adoption of EBPs. According to the Translation Research Model, adoption of innovations such as EBPs are influenced by the nature of the innovation (e.g., the type and strength of evidence, the clinical topic) and the manner in which it is communicated (disseminated) to members (nurses) of a social system (organization, nursing profession).35 Strategies for promoting adoption of EBPs must address these four areas (nature of the EBP topic; users of the evidence; communication; social system) within a context of participative change (see Figure 2). This model provided the framework for a multisite study that tested the effectiveness of a multifaceted TRIP intervention designed to promote adoption of evidence-based acute pain management practices for hospitalized older adults. The intervention improved the quality of acute pain management practices and reduced costs.81 The model is currently being used to test the effectiveness of a multifaceted TRIP intervention to promote evidence-based cancer pain management of older adults in home hospice settings.* This guiding framework is used herein to overview what is known about implementation interventions to promote use of EBPs in health care systems (see Evidence Table).

Nature of the Innovation or Evidence-Based Practice

Characteristics of an innovation or EBP topic that affect adoption include the relative advantage of the EBP (e.g., effectiveness, relevance to the task, social prestige); the compatibility with values, norms, work, and perceived needs of users; and complexity of the EBP topic.39 For example, EBP topics that are perceived by users as relatively simple (e.g., influenza vaccines for older adults) are more easily adopted in less time than those that are more complex (acute pain management for hospitalized older adults). Strategies to promote adoption of EBPs related to characteristics of the topic include practitioner review and “reinvention” of the EBP guideline to fit the local context, use of quick reference guides and decision aids, and use of clinical reminders.53, 59, 60, 65, 74, 82, 102–107 An important principle to remember when planning implementation of an EBP is that the attributes of the EBP topic as perceived by users and stakeholders (e.g., ease of use, valued part of practice) are neither stable features nor sure determinants of their adoption. Rather it is the interaction among the characteristics of the EBP topic, the intended users, and a particular context of practice that determines the rate and extent of adoption.22, 35, 39

Studies suggest that clinical systems, computerized decision support, and prompts that support practice (e.g., decisionmaking algorithms, paper reminders) have a positive effect on aligning practices with the evidence base.15, 51, 65, 74, 80, 82, 102, 104, 107–110 Computerized knowledge management has consistently demonstrated significant improvements in provider performance and patient outcomes.82 Feldman and colleagues, using a just-in-time e-mail reminder in home health care, have demonstrated (1) improvements in evidence-based care and outcomes for patients with heart failure,64, 77 and (2) reduced pain intensity for cancer patients.75 Clinical information systems should deploy the evidence base to the point of care and incorporate * Principal Investigator: Keela Herr (R01 grant no. CA115363-01; National Cancer Institute (NCI))

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computer decision-support software that integrates evidence for use in clinical decisionmaking about individual patients.40, 104, 111–114 There is still much to learn about the “best” manner of deploying evidence-based information through electronic clinical information systems to support evidence-based care.115

Methods of Communication

Interpersonal communication channels, methods of communication, and influence among social networks of users affect adoption of EBPs.39 Use of mass media, opinion leaders, change champions, and consultation by experts along with education are among strategies tested to promote use of EBPs. Education is necessary but not sufficient to change practice, and didactic continuing education alone does little to change practice behavior.61, 116 There is little evidence that interprofessional education as compared to discipline-specific education improves EBP.117 Interactive education, used in combination with other practice-reinforcing strategies, has more positive effects on improving EBP than didactic education alone.66, 68, 71, 74, 118, 119 There is evidence that mass media messages (e.g., television, radio, newspapers, leaflets, posters and pamphlets), targeted at the health care consumer population, have some effect on use of health services for the targeted behavior (e.g., colorectal cancer screening). However, little empirical evidence is available to guide framing of messages communicated through planned mass media campaigns to achieve the intended change.120

Several studies have demonstrated that opinion leaders are effective in changing behaviors of health care practitioners,22, 68, 79, 100, 116, 121–123 especially in combination with educational outreach or performance feedback. Opinion leaders are from the local peer group, viewed as a respected source of influence, considered by associates as technically competent, and trusted to judge the fit between the innovation and the local situation.39, 116, 121, 124–127 With their wide sphere of influence across several microsystems/units, opinion leaders’ use of the innovation influences peers and alters group norms.39,128 The key characteristic of an opinion leader is that he or she is trusted to evaluate new information in the context of group norms. Opinion leadership is multifaceted and complex, with role functions varying by the circumstances, but few successful projects to implement innovations in organizations have managed without the input of identifiable opinion leaders.22, 35, 39, 81, 96 Social interactions such as “hallway chats,” one-on-one discussions, and addressing questions are important, yet often overlooked components of translation.39, 59 Thus, having local opinion leaders discuss the EBPs with members of their peer group is necessary to translate research into practice. If the EBP that is being implemented is interdisciplinary in nature, discipline-specific opinion leaders should be used to promote the change in practice.39

Change champions are also helpful for implementing innovations.39, 49, 81, 129–131 They are practitioners within the local group setting (e.g., clinic, patient care unit) who are expert clinicians, passionate about the innovation, committed to improving quality of care, and have a positive working relationship with other health care professionals.39, 125, 131, 132 They circulate information, encourage peers to adopt the innovation, arrange demonstrations, and orient staff to the innovation.49, 130 The change champion believes in an idea; will not take “no” for an answer; is undaunted by insults and rebuffs; and, above all, persists.133 Because nurses prefer interpersonal contact and communication with colleagues rather than Internet or traditional sources of practice knowledge,134–137 it is imperative that one or two change champions be identified for each patient care unit or clinic where the change is being made for EBPs to be enacted by direct care providers.81, 138 Conferencing with opinion leaders and change champions

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periodically during implementation is helpful to address questions and provide guidance as needed.35, 66, 81, 106

Because nurses’ preferred information source is through peers and social interactions,134– 137, 139, 140 using a core group in conjunction with change champions is also helpful for implementing the practice change.16, 110, 141 A core group is a select group of practitioners with the mutual goal of disseminating information regarding a practice change and facilitating the change by other staff in their unit/microsystem.142 Core group members represent various shifts and days of the week and become knowledgeable about the scientific basis for the practice; the change champion educates and assists them in using practices that are aligned with the evidence. Each member of the core group, in turn, takes the responsibility for imparting evidence-based information and effecting practice change with two or three of their peers. Members assist the change champion and opinion leader with disseminating the EBP information to other staff, reinforce the practice change on a daily basis, and provide positive feedback to those who align their practice with the evidence base.15 Using a core-group approach in conjunction with a change champion results in a critical mass of practitioners promoting adoption of the EBP.39

Educational outreach, also known as academic detailing, promotes positive changes in practice behaviors of nurses and physicians.22, 64, 66, 71, 74, 75, 77, 81, 119, 143 Academic detailing is done by a topic expert, knowledgeable of the research base (e.g., cancer pain management), who may be external to the practice setting; he or she meets one-on-one with practitioners in their setting to provide information about the EBP topic. These individuals are able to explain the research base for the EBPs to others and are able to respond convincingly to challenges and debates.22 This strategy may include providing feedback on provider or team performance with respect to selected EBP indicators (e.g., frequency of pain assessment).66, 81, 119

Users of the Innovation or Evidence-Based Practice

Members of a social system (e.g., nurses, physicians, clerical staff) influence how quickly and widely EBPs are adopted.39 Audit and feedback, performance gap assessment (PGA), and trying the EBP are strategies that have been tested.15, 22, 65, 66, 70–72, 81, 98, 124, 144 PGA and audit and feedback have consistently shown a positive effect on changing practice behavior of providers.65, 66, 70, 72, 81, 98, 124, 144, 145 PGA (baseline practice performance) informs members, at the beginning of change, about a practice performance and opportunities for improvement. Specific practice indicators selected for PGA are related to the practices that are the focus of evidence- based practice change, such as every-4-hour pain assessment for acute pain management.15, 66, 81

Auditing and feedback are ongoing processes of using and assessing performance indicators (e.g., every-4-hour pain assessment), aggregating data into reports, and discussing the findings with practitioners during the practice change.22, 49, 66, 70, 72, 81, 98, 145 This strategy helps staff know and see how their efforts to improve care and patient outcomes are progressing throughout the implementation process. Although there is no clear empirical evidence for how to provide audit and feedback,70, 146 effects may be larger when clinicians are active participants in implementing change and discuss the data rather than being passive recipients of feedback reports.67, 70 Qualitative studies provide some insight into use of audit and feedback.60, 67 One study on use of data feedback for improving treatment of acute myocardial infarction found that (1) feedback data must be perceived by physicians as important and valid, (2) the data source and timeliness of data feedback are critical to perceived validity, (3) time is required to establish credibility of data within a hospital, (4) benchmarking improves the validity of the data feedback, and (5) physician leaders can enhance the effectiveness of data feedback. Data feedback that profiles an

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individual physician’s practices can be effective but may be perceived as punitive; data feedback must persist to sustain improved performance; and effectiveness of data feedback is intertwined with the organizational context, including physician leadership and organizational culture.60 Hysong and colleagues67 found that high-performing institutions provided timely, individualized, nonpunitive feedback to providers, whereas low performers were more variable in their timeliness and nonpunitiveness and relied more on standardized, facility-level reports. The concept of useful feedback emerged as the core concept around which timeliness, individualization, nonpunitiveness, and customizability are important.

Users of an innovation usually try it for a period of time before adopting it in their practice.22, 39, 147 When “trying an EBP” (piloting the change) is incorporated as part of the implementation process, users have an opportunity to use it for a period of time, provide feedback to those in charge of implementation, and modify the practice if necessary.148 Piloting the EBP as part of implementation has a positive influence on the extent of adoption of the new practice.22, 39, 148

Characteristics of users such as educational preparation, practice specialty, and views on innovativeness may influence adoption of an EBP, although findings are equivocal.27, 39, 130, 149– 153 Nurses’ disposition to critical thinking is, however, positively correlated with research use,154 and those in clinical educator roles are more likely to use research than staff nurses or nurse managers.155

Social System

Clearly, the social system or context of care delivery matters when implementing EBPs.2, 30, 33, 39, 60, 84, 85, 91, 92, 101, 156–163 For example, investigators demonstrated the effectiveness of a prompted voiding intervention for urinary incontinence in nursing homes, but sustaining the intervention in day-to-day practice was limited when the responsibility of carrying out the intervention was shifted to nursing home staff (rather than the investigative team) and required staffing levels in excess of a majority of nursing home settings.164 This illustrates the importance of embedding interventions into ongoing processes of care.

Several organizational factors affect adoption of EBPs.22, 39, 79, 134, 165–167 Vaughn and colleagues101 demonstrated that organizational resources, physician full-time employees (FTEs) per 1,000 patient visits, organizational size, and whether the facility was located in or near a city affected use of evidence in the health care system of the Department of Veterans Affairs (VA). Large, mature, functionally differentiated organizations (e.g., divided into semiautonomous departments and units) that are specialized, with a focus of professional knowledge, slack resources to channel into new projects, decentralized decisionmaking, and low levels of formalization will more readily adopt innovations such as new practices based on evidence. Larger organizations are generally more innovative because size increases the likelihood that other predictors of innovation adoption—such as slack financial and human resources and differentiation—will be present. However, these organizational determinants account for only about 15 percent of the variation in innovation adoption between comparable organizations.22 Adler and colleagues168 hypothesize that while more structurally complex organizations may be more innovative and hence adopt EBPs relatively early, less structurally complex organizations may be able to diffuse EBPs more effectively. Establishing semiautonomous teams is associated with successful implementation of EBPs, and thus should be considered in managing organizational units.168–170

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As part of the work of implementing EBPs, it is important that the social system—unit, service line, or clinic—ensures that policies, procedures, standards, clinical pathways, and documentation systems support the use of the EBPs.49, 68, 72, 73, 103, 140, 171 Documentation forms or clinical information systems may need revision to support changes in practice; documentation systems that fail to readily support the new practice thwart change.82

Absorptive capacity for new knowledge is another social system factor that affects adoption of EBPs. Absorptive capacity is the knowledge and skills to enact the EBPs; the strength of evidence alone will not promote adoption. An organization that is able to systematically identify, capture, interpret, share, reframe, and recodify new knowledge, and put it to appropriate use, will be better able to assimilate EBPs.82, 103, 172, 173 A learning organizational culture and proactive leadership that promotes knowledge sharing are important components of building absorptive capacity for new knowledge.66, 139, 142, 174 Components of a receptive context for EBP include strong leadership, clear strategic vision, good managerial relations, visionary staff in key positions, a climate conducive to experimentation and risk taking, and effective data capture systems. Leadership is critical in encouraging organizational members to break out of the convergent thinking and routines that are the norm in large, well-established organizations.4, 22, 39, 122, 148, 163, 175

An organization may be generally amenable to innovations but not ready or willing to assimilate a particular EBP. Elements of system readiness include tension for change, EBP- system fit, assessment of implications, support and advocacy for the EBP, dedicated time and resources, and capacity to evaluate the impact of the EBP during and following implementation. If there is tension around specific work or clinical issues and staff perceive that the situation is intolerable, a potential EBP is likely to be assimilated if it can successfully address the issues, and thereby reduce the tension.22, 175

Assessing and structuring workflow to fit with a potential EBP is an important component of fostering adoption. If implications of the EBP are fully assessed, anticipated, and planned for, the practice is more likely to be adopted.148, 162, 176 If supporters for a specific EBP outnumber and are more strategically placed within the organizational power base than opponents, the EBP is more likely to be adopted by the organization.60, 175 Organizations that have the capacity to evaluate the impact of the EBP change are more likely to assimilate it. Effective implementation needs both a receptive climate and a good fit between the EBP and intended adopters’ needs and values.22, 60, 140, 175, 177

Leadership support is critical for promoting use of EBPs.33, 59, 72, 85, 98, 122, 178–181 This support, which is expressed verbally, provides necessary resources, materials, and time to fulfill assigned responsibilities.148, 171, 182, 183 Senior leaders need to create an organizational mission, vision, and strategic plan that incorporate EBP; implement performance expectations for staff that include EBP work; integrate the work of EBP into the governance structure of the health care system; demonstrate the value of EBPs through administrative behaviors; and establish explicit expectations that nurse leaders will create microsystems that value and support clinical inquiry.122, 183, 184

A recent review of organizational interventions to implement EBPs for improving patient care examined five major aspects of patient care. The review suggests that revision of professional roles (changing responsibilities and work of health professionals such as expanding roles of nurses and pharmacists) improved processes of care, but it was less clear about the effect on improvement of patient outcomes. Multidisciplinary teams (collaborative practice teams of physicians, nurses, and allied health professionals) treating mostly patients with prevalent

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chronic diseases resulted in improved patient outcomes. Integrated care services (e.g., disease management and case management) resulted in improved patient outcomes and cost savings. Interventions aimed at knowledge management (principally via use of technology to support patient care) resulted in improved adherence to EBPs and patient outcomes. The last aspect, quality management, had the fewest reviews available, with the results uncertain. A number of organizational interventions were not included in this review (e.g., leadership, process redesign, organizational learning), and the authors note that the lack of a widely accepted taxonomy of organizational interventions is a problem in examining effectiveness across studies.82

An organizational intervention that is receiving increasing attention is tailored interventions to overcome barriers to change.162, 175, 185 This type of intervention focuses on first assessing needs in terms of what is causing the gap between current practice and EBP for a specified topic, what behaviors and/or mechanism need to change, what organizational units and persons should be involved, and identification of ways to facilitate the changes. This information is then used in tailoring an intervention for the setting that will promote use of the specified EBP. Based on a recent systematic review, effectiveness of tailored implementation interventions remains uncertain.185

In summary, making an evidence-based change in practice involves a series of action steps and a complex, nonlinear process. Implementing the change will take several weeks to months, depending on the nature of the practice change. Increasing staff knowledge about a specific EBP and passive dissemination strategies are not likely to work, particularly in complex health care settings. Strategies that seem to have a positive effect on promoting use of EBPs include audit and feedback, use of clinical reminders and practice prompts, opinion leaders, change champions, interactive education, mass media, educational outreach/academic detailing, and characteristics of the context of care delivery (e.g., leadership, learning, questioning). It is important that senior leadership and those leading EBP improvements are aware of change as a process and continue to encourage and teach peers about the change in practice. The new practice must be continually reinforced and sustained or the practice change will be intermittent and soon fade, allowing more traditional methods of care to return.15

Practice Implications From Translation Science

Principles of Evidence-Based Practice for Patient Safety

Several translation science principles are informative for implementing patient safety initiatives:

• First, consider the context and engage health care personnel who are at the point of care in selecting and prioritizing patient safety initiatives, clearly communicating the evidence base (strength and type) for the patient safety practice topic(s) and the conditions or setting to which it applies. These communication messages need to be carefully designed and targeted to each stakeholder user group.

• Second, illustrate, through qualitative or quantitative data (e.g., near misses, sentinel events, adverse events, injuries from adverse events), the reason the organization and individuals within the organization should commit to an evidence-based safety practice topic. Clinicians tend to be more engaged in adopting patient safety initiatives when they understand the evidence base of the practice, in contrast to administrators saying, “We must do this because it is an external regulatory requirement.” For example, it is critical

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to converse with busy clinicians about the evidence-based rationale for doing fall-risk assessment, and to help them understand that fall-risk assessment is an external regulatory agency expectation because the strength of the evidence supports this patient safety practice.

• Third, didactic education alone is never enough to change practice; one-time education on a specific safety initiative is not enough. Simply improving knowledge does not necessarily improve practice. Rather, organizations must invest in the tools and skills needed to create a culture of evidence-based patient safety practices where questions are encouraged and systems are created to make it easy to do the right thing.

• Fourth, the context of EBP improvements in patient safety need to be addressed at each step of the implementation process; piloting the change in practice is essential to determine the fit between the EBP patient safety information/innovation and the setting of care delivery. There is no one way to implement, and what works in one agency may need modification to fit the organizational culture of another context.

• Finally, it is important to evaluate the processes and outcomes of implementation. Users and stakeholders need to know that the efforts to improve patient safety have a positive impact on quality of care. For example, if a new barcoding system is being used to administer blood products, it is imperative to know that the steps in the process are being followed (process indicators) and that the change in practice is resulting in fewer blood product transfusion errors (outcome indicators).

Research Implications

Translation science is young, and although there is a growing body of knowledge in this area, we have, to date, many unanswered questions. These include the type of audit and feedback (e.g., frequency, content, format) strategies that are most effective, the characteristics of opinion leaders that are critical for success, the role of specific context variables, and the combination of strategies that are most effective. We also know very little about use of tailored implementation interventions, or the key context attributes to assess and use in developing and testing tailored interventions. The types of clinical reminders that are most effective for making EBP knowledge available at the point of care require further empirical explanation. We also know very little about the intensity and intervention dose of single and multifaceted strategies that are effective for promoting and sustaining use of EBPs or how the effectiveness differs by type of topic (e.g., simple versus complex). Only recently has the context of care delivery been acknowledged as affecting use of evidence, and further empirical work is needed in this area to understand how complex adaptive systems of practice incorporate knowledge acquisition and use. Lastly, we do not know what strategies or combination of strategies work for whom, in what context, why they work in some settings or cases and not others, and what is the mechanism by which these strategies or combination of strategies work.

This is an exciting area of investigation that has a direct impact on implementing patient safety practices. In planning investigations, researchers must use a conceptual model to guide the research and add to the empirical and theoretical understanding of this field of inquiry. Additionally, funding is needed for implementation studies that focus on evidence-based patient safety practices as the topic of concern. To generalize empirical findings from patient safety implementation studies, we must have a better understanding of what implementation strategies work, with whom, and in what types of settings, and we must investigate the underlying

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mechanisms of these strategies. This is likely to require mixed methods, a better understanding of complexity science, and greater appreciation for nontraditional methods and realistic inquiry.87

Conclusion Although the science of translating research into practice is fairly new, there is some guiding

evidence of what implementation interventions to use in promoting patient safety practices. However, there is no magic bullet for translating what is known from research into practice. To move evidence-based interventions into practice, several strategies may be needed. Additionally, what works in one context of care may or may not work in another setting, thereby suggesting that context variables matter in implementation.80

Author Affiliation University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care.

Address correspondence to: Marita G. Titler, Ph.D., R.N., F.A.A.N., University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care, 200 Hawkins Drive RM T10 GH, Iowa City, IA 52242-1009. E-mail: Marita-titler@uiowa.edu.

Search Strategy Several electronic databases were searched (MEDLINE®, CINAHL®, PubMed®) using terms

of evidence-based practice research, implementation research, and patient safety. (The terms “quality improvement” or “quality improvement intervention research” were not used.) The Cochrane Collaboration–Cochrane Reviews was also searched to look for systematic reviews of specific implementation strategies, and the Journal of Implementation Science was also reviewed. I also requested the final reports of the TRIP I and TRIP II studies funded by AHRQ. Classic articles known to the author were also included in this chapter (e.g., Locock et al.123 ).

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