JONA Volume 42, Number 4, pp 222-230 Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N
Planning for Implementation of Evidence-Based Practice
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Laura Cullen, MA, RN, FAAN
Susan L. Adams, PhD, RN
Expectations for evidence-based healthcare are growing, yet the most difficult step in the process, implementation, is often left to busy nursing lead- ers who may be unprepared for the challenge. Se- lecting from the long list of implementation strategies and knowing when to apply them are a bit of an ‘‘art,’’ matching clinician needs and organizational context. This article describes an application- oriented resource that nursing leaders can use to plan evidence-based practice implementation in complex healthcare systems.
Nurses in leadership positions have responsibility for provision of evidence-based healthcare that meets the expectations of patients, families, regulators and others.1-3 Research shows that use of evidence is inconsistent. Basic practices from hand hygiene to early ambulation are difficult to implement. Nurs- ing leaders are expanding use of evidence-based care delivery to improve patient and organizational out- comes by developing the infrastructure, defining the processes, strategically planning for implementation, and reporting results.
One of the 1st steps when defining the pro- cess is to select an evidence-based practice (EBP) model.4,5 Several models have been developed to
guide organizational and project leaders through the steps of the EBP process.6-10 Most of these pro- cess models include similar steps such as identifying a problem, critiquing the evidence, implementing evidence-based recommendations, evaluating the change, and disseminating results. Despite exten- sive use of EBP process models, it is understood that additional guidance may be needed at each step. Re- cent attention is now focusing on the indistinct step of implementation.11-14
Failure to provide guidance for use of effective implementation strategies promotes the use of in- effective strategies, or worse, no strategy at all. This results in ‘‘reduced patient care quality and raises costs for all, the worst of both worlds.’’15(p380) It has been demonstrated that change happens over time; the literature provides little direction for nurses re- garding when to use specific strategies. Insights from implementation science and successful EBP work in- dicate that application of implementation strategies varies over the course of the EBP process. Assisting nurses at the point of care in leading EBP projects16
has led to creation of a 4-phase approach for plan- ning implementation.16
This article provides clinicians and nursing lead- ers with an application-oriented approach to orga- nize, plan, and select strategies for implementation of EBP changes. This guide is meant to supplement EBP process models, not replace them. It is designed to be simple and intuitive.
Implementation Strategies for Evidence-Based Practice
The Implementation Strategies for Evidence-Based Practice guide (Figure 1) is organized to assist nurses responsible for EBP in selecting implementation strategies to help practitioners and clinical teams
222 JONA � Vol. 42, No. 4 � April 2012
Author Affiliations: Evidence Based Practice Coordinator (Ms Cullen), Department of Nursing Services and Patient Care, University of Iowa Hospital and Clinics; Investigator (Dr Adams), Comprehensive Access and Delivery Research and Evaluation Center, Iowa City VA Medical Center.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the De- partment of Veterans Affairs.
The authors declare no conflict of interest. Correspondence: Ms Cullen, Department of Nursing Services
and Patient Care, 200 Hawkins Dr, RM T100 GH, Iowa City, IA 52242-1009 (Lauraemail@example.com).
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
move clinical practice recommendations into routine workflow in practice. Strategies are selected and po- sitioned to enhance the movement through 4 phases of implementation: creating awareness and interest, building knowledge and commitment, promoting
action and adoption, and pursuing integration and sustainability to promote application by nursing and team leaders.
The implementation phases are displayed as col- umns progressing from awareness to integration.
Figure 1. Evidence-Based Practice Implementation guide. *Implementation strategy supported by some empirical evidence.
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Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Each column includes strategies based on the goal for that implementation phase. Implementation strat- egies also target 2 distinct groups and are arranged in rows accordingly. The 1st section specifically targets the practitioners and organizational leaders, includ- ing key stakeholders. The 2nd section builds support for the practice change in the organizational system or context. Project leaders select implementation strat- egies that are appropriate for their particular unit and organization as the EBP initiative progresses across phases. Although the guide is diagrammed in a linear format for ease of use, the process is not directly linear and is fluid across implementation phases. In a clinical team, practitioners may be in different phases or move forward or back across phases in a nonlinear manner. Multiple strategies added cumulatively from each phase will need to be carried over for use throughout the process to keep implementation progressing.
A large list of strategies is included (Figure 1), and with varying amount of evidence to support them. The implementation strategies with empirical evidence in healthcare are marked with asterisks. Few strategies have empirical evidence using rig- orous study designs with additional support from reported application in practice or exclusively ad- dressing nursing; therefore, other practical but less well-tested strategies to support application are in- cluded as well. Because research evaluation of strat- egies across a variety of healthcare settings and with various healthcare workers is lacking, a simplified system of identification is used instead of an exten- sive grading schema.
Creating Awareness and Interest
Implementation begins by focusing on strategies to create awareness and interest among clinicians and stakeholders (column 1, Figure 1). These suggested strategies should be started early in the EBP pro- cess and will likely be needed to some degree during the implementation and sustainment phases. Interest wanes over time because of competing demands and staff turnover. Multifaceted, ongoing strategies are needed to keep the practice change in the forefront.
Highlighting the positive characteristics of an EBP change such as the anticipated advantage of the change and the compatibility with group values can promote awareness and interest among clini- cians.17-19 Staff attendance at continuing educa- tional programs20 increases awareness and interest in practice updates in general. Nurse leaders can continue garnering resources to support these pro- fessional development activities with application for practice. Integrating a journal club into the im- plementation process by choosing multiple, high-
quality, project-related articles can serve a dual purpose: expanding nurses’ interest and knowledge regarding the desired practice change while ad- vancing article critiquing skills.21 Journal club re- view of articles on a single clinical topic can be used to guide policy updates, staff education, and auditing of important indicators to improve care.
Although empirical evidence is limited, creating slogans and logos can be a successful and fun way to grab the attention of busy clinicians.22,23 Creating a contest to generate ideas for project slogans can get staff involved, increasing their awareness and com- mitment to practice changes. Strategically placing project logos and slogans on project-related materials throughout implementation (eg, resource manual or materials, reminders, and data feedback) helps busy clinicians quickly refocus on the EBP and their role in promoting adoption of the practice change.24
Posting announcements may generate awareness of a particular practice update, but require additional reinforcement, for example, supplementing with dis- cussions during unit in-services or staff meetings.
Involve senior executives early in the EBP process. Senior leaders want to be supportive of clinician- driven EBP and need sufficient information about the purpose, resource needs, and anticipated return on investment. Leadership from senior executives has a demonstrated impact on uptake and sustained use of EBP recommendations.1,25-27 Announcements from senior leaders create an urgency about an issue, articulate an organizational commitment, and dem- onstrate the availability of resources and support that an impact is expected matching organizational priorities.
Building Knowledge and Commitment
Interventions that increase practitioner’s knowl- edge of and commitment to try a clinical practice recommendation are designed to build on the aware- ness and interest raised in phase 1. For example, comparing organizational outcomes to those de- scribed in the literature through a gap assessment and discussed during unit meetings or journal clubs from phase 1 increases clinician’s knowledge and commitment by highlighting the gap in desired performance. Like raising awareness and interest, increasing knowledge and commitment requires mul- tifaceted ongoing attention.
Educational sessions are a necessary step in raising knowledge and commitment but must be combined with other strategies to be effective.28
Educational sessions can use a variety of methods from unit in-services, readings, or online learning modules to simulation training. One method of in- teractive education that leverages nurses’ preference
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to learn from their colleagues29-31 is to engage and train change agents. There are many different change agent roles32 described in the literature, including internal and external facilitators, change champions, core groups, knowledge brokers, thought leaders, and opinion leaders (Table 1).32,34-37 In general, the change agent role involves sharing information and supporting practice changes with colleagues and may vary based on the size of the unit. Our experience indicates that the roles are not well understood by clinicians. Identifying change agents early, obtaining their support, providing education regarding the practice change, and clarifying their roles facilitate effective use of team members’ strengths and con- nections in the organization.
Identifying change agents from each discipline relevant to the clinical topic at hand can build com- mitment to change. For example, if the goal is to increase hand hygiene, including change agents from infection prevention specialists or epidemiology, mi- crobiology personnel, nurses, nursing assistants, phy- sicians, and someone from inventory supply would be helpful. Including facility services, the unit sec- retary, and housekeeping may be important so that the correct equipment (ie, a full dispenser) is always readily available and positioned in accordance with safety standards. Core group members can serve as
change agents.37 Having a core group of trained change agents available to cover all shifts meets clinicians’ needs and builds expertise as clinicians seek answers through interactions with colleagues.
Unlike strict research protocols, clinical prac- tice guidelines are designed to be locally adapted to individual settings. Teams can modify them for use to create a local practice protocol.38-40 Focusing on key steps that are critical promotes adoption by sim- plifying the change.18,41 Articulating how the EBP was simplified to assist clinician users can promote commitment to practice changes.
Building knowledge and commitment provides an essential foundation for promoting action and adoption of the EBP change. Planning for implemen- tation should be based on a timeline allowing for a focused effort, building practitioners’ knowledge and commitment before proceeding to the next phase of implementation. If the clinical practice recommen- dations are to be piloted in a setting that involves a small number of practitioners (eg, a rural clinic), it may be possible to move more quickly through this phase. If the practice change involves a large number of practitioners from multiple disciplines, covering many shifts, plan for 2 to 3 weeks to help clinicians gain sufficient knowledge and to garner their commitment to the practice change. This phase
Table 1. Change Agent Roles
Name Perspective Educational Role Impact
Change champion Focus is local and is from inside the organization
Review evidence, design practice change (eg, policy), assist with creating resources for implementation, train peers
Assists project leader and links evidence with reality of clinical practice
Core group Focus is local and is from setting adopting the EBP
Review key evidence, train, role model, reinforce, and trouble shoot with colleagues
EBP facilitator/mentor Broad program focus may be from inside or outside the organization
Provide leadership throughout EBP process
Mentoring of or functioning as project director
Knowledge broker Broad program focus from outside the organization
Assess facilitators and barriers, locate best evidence, train, network, mentor, and report results
Leading and connecting with project director(s)
Opinion leader Focus is on the program and across the continuum of care from inside the organization
Review evidence and judge fit, peer education, influence practice of others
Thought leader Focus is local and may be from inside or outside the organization
Provide educational sessions Program preparation influences practice change of the educator; little impact on audience is anticipated
Emerging concept yet to be tested in healthcare
Dobbins et al,33 Doumit et al,34 Greenhalgh et al,32 Russell et al,35 Stetler et al,36 and Titler.37
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of implementation should be clearly articulated with a designated go-live date approaching in the future.
Promoting Action and Adoption
After raising awareness, promoting positive atti- tudes, and building knowledge about the change, the next imperative is to change behavior and put recommendations into practice. What has been described as the implementation phase of an EBP process is essentially the behavior change point in the multiple phases of implementation. Interven- tions to promote action or adoption need to move from active to interactive and target the clinicians so they develop skills in use of the practice change. Training, role modeling, and mentoring by change agents are essential elements of the implementation plan.16,20,36,42-44 Follow-up from unit leaders and project change agents is needed for troubleshoot- ing, reinforcing the desired behavior, and providing recognition at the point of care for correctly and consistently applying practice recommendations.
Practical strategies such as practice prompts pro- mote behavior change by providing timely remind- ers in the practice setting at the point of care. Practice prompts can be sophisticated clinical information system reminders incorporated in the electronic health record (EHR) or as simple as a pocket guide with a logo containing key talking points.45-47 As EHR technology develops, additional innovations will create ways to hardwire provision of some clin- ical practice recommendations (eg, influenza vacci- nations or medication infusion dosages) by requiring justification of variations in practice (eg, skipping timed pediatric immunizations). Creating patient re- minders, clinical checklists, and standing orders builds support in the system and effectively sets parameters for successful use of EBP.48-52
The action and adoption phase of implemen- tation will require several weeks to complete. Dur- ing this phase, clinicians are testing practice changes, finding ways to integrate new practices into work- flow, adapting the practice for unique patient circum- stances, and doing small-scale evaluation.53 Several weeks are needed for progressive uptake of the EBP when change agents are actively promoting adoption, and practitioners are trying the change. Continued use of implementation strategies must occur through- out this phase as early and late adopters progress at varying rates. Participation can be encouraged by having early adopters provide timely feedback on positive results. Active implementation strategies may be used more sporadically after early adopters create sufficient momentum promoting the practice change. Audits with actionable and timely data
feedback of results are essential and highly effective for both adoption and integration of practice change by building support in the organizational system.54,55
Timing should allow for trying and using the EBP change before full evaluation of process and outcome indicators.
Some clinicians lag in action and adoption. Highly interactive and individualized feedback will be needed for clinicians working through adoption while the group is moving toward integration and sustainability of practice changes. Late adopters will be watching the early adopters’ progress and slowly become active adopters. Clear expectations and administrative follow-up through the perfor- mance evaluation process will facilitate action. If a small group of clinicians are slower to adopt prac- tice recommendations, we have found that involv- ing a group leader from the late adopters in planning and troubleshooting implementation early may be helpful. Late adopters may provide important in- sights into issues and propose possible solutions when designing and localizing clinical practice rec- ommendations. In the end, noncompliance becomes the responsibility of administrators.
Pursuing Integration and Sustainability
In order to achieve a return on investment from working through the EBP process, it is essential to realize integration and sustained use of the EBP change.26,56,57 Celebrating successes through senior leadership recognition in public forums supports shif- ting expectations and group norms or standard operating procedures. Creating peer-to-peer discus- sions articulating expectations (ie, peer influence) and using comparative data are likely to be ef- fective. Reinfusion will be needed through the early months of integration to sustain the gains already achieved. Updating postings and practice reminders keep the message fresh and in the forefront. Posters left for extended periods tend to become invisible, so content and strategies must be updated to attract the attention of busy clinicians (eg, update pictures and key points, add names of successful staff). Early and active planning for reinfusion and sustain- ability is highly recommended to prevent slippage, loss of early progress, or loss of momentum for chang- ing practice.
Integration of clinical practice recommendations into daily care requires additional strategies by the clinical team and senior leaders, including strategies built in the social system matching the organizational culture. Reporting results of project implementa- tion and revisions based on evaluative data and practitioner feedback can facilitate additional com- mitment to sustained use of new practices. Graphic
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displays of key indicators may be helpful.58 Reporting and feedback of trended data support progressive integration and positive reinforcement for practi- tioners59,60 and assist with quick identification of the need to reinfuse the EBP.
After trying and implementing the practice change, final revisions in policies, procedures, or protocols are needed.25,61 Project leader reporting of activity and results should target committees in the infrastructure responsible for policy approval, documentation, staff education, quality improve- ment, EBP, and product inventory.27,62,63 Reports to senior leaders should include the project pur- pose; use of the EBP process; impact or return on the investment; link between the project results,
organizational priorities, and infrastructure sup- porting the EBP change. Communicating with senior leaders is strategic for garnering reinforcement, rec- ognition, and future resources.
Building the practice change in the organiza- tional system requires use of additional strategies to promote sustainability. Financial incentives,64,65
awards, recognition,66,67 and support establish the new norms for practice. Incorporating the practice change in the competency review process and ob- taining individual commitments to 1 or 2 actions during staff performance evaluations help to sup- port unit goals and create continuous reinfusion and momentum. Building responsibility for ongoing EBP work in a new or existing unit or organizational
Table 2. Implementation Strategies Used in Different Clinical Area Projects
Strategies Used for Perioperative EBP Strategies Used for Emergency Department EBP
Implementing Preoperative Screening for Sleep Apnea
Thermoregulation for Adult Trauma Patients
Create awareness and interest
& Highlight the advantages and anticipated impact
& Highlight the advantages and anticipated impact
& Staff meetings & Slogan and logo
& Unit in-services & Staff meetings
& Postings & Unit in-services & Postings
Build knowledge and commitment
& Education & Education & Link with quality improvement priorities & Link practice change with stakeholders priorities & Change champion & Change agents & Integrate with other policies & Disseminate credible evidence & Clinician input & Gap assessment & Local adaptation & Clinician input & Case study & Match the practice change with equipment & Teamwork & Resource manual & Trouble shooting implementation & Teamwork & Informed organizational leaders & Troubleshoot use of the protocol & Action planning & Inform organizational leaders
& Action planning
Promote action and adoption
& Educational outreach & Educational outreach & Clinical reminders & Reminders or practice prompts & Demonstrating workflow & Decision algorithm & Feedback evaluation results & Skill competency & Trying the change & Incentives & Multidisciplinary teamwork and discussions & Trying the practice change & Report progress and updates & Reporting progress & Change agents & Change agents & Troubleshooting by change champions at the
point of care & Role modeling practice change
& Documentation changes & Change agents provide trouble shooting and
recognition at point of care & Rounding by unit leaders & Audit and feedback of evaluative data & Report into quality improvement program & Rounding by unit leaders & Report to senior leadership & Report into the quality improvement program
Pursue integration and sustained use
& Recognition for change & Personalize the messages & Update reminders & Peer influence & Report within quality improvement program & Update practice reminders & Trend results & Report to senior leaders & Presenting at educational programs & Project responsibility within unit quality
improvement committee & Present in educational programs
Used with permission from Block et al22 and Dolezal et al.68
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committee will keep responsibility for the work clear and a priority supported in the infrastructure. Mul- tiple strategies are needed to move from awareness to integration and should target clinicians, organi- zational leaders, and the social system.
How to Select Implementation Strategies
When planning for EBP implementation, a nursing leader should ask several questions:
� What EBP changes have been successfully im- plemented previously? How were those prac- tice changes implemented?
� Who are stakeholders or others who might be interested in this EBP? What is the po- tential impact or advantage for them? What are their priorities, and how can those be ad- dressed? How can the process be simplified and built into the system to make adoption easier for them?
� What are barriers and facilitators to adoption of EBP? What creative solutions can address the barriers and/or optimize the facilitators?
� What information or data are the clinicians and stakeholders accustomed to seeing? What information or data are typically shared with EBP changes?
� How can we make this fun? � How can we design messages for clinicians
and leaders describing the EBP that includes credible evidence, why the change is impor- tant, what the EBP change will look like, and what are the expected outcomes?
Answers to these questions provide direction for choosing from among the implementation strat- egies listed. Choose and use implementation strat- egies cumulatively from the early phases through the implementation process. Highlighting the poten- tial advantage, key evidence, project logo, and results of a gap analysis throughout the implementation
process helps busy clinicians stay focused. These ques- tions can be revisited while adding strategies across each phase of the implementation process. EBP projects in various clinical areas may use different implemen- tation strategies; flexibility is key (Table 2).22,68
Implementation is fluid, complex, highly inter- active, and impacted by contextual variations. Pre- scriptive and rigid timing of strategies may never be appropriate.69 Critical thinking skills of nurses in evaluating and adapting strategies to the chang- ing conditions in the clinical setting will continue to be required. Team leaders will almost certainly need to adjust or add implementation strategies as the work progresses. Wensing et al69 describe se- lection of implementation strategies as an ‘‘art,’’ stat- ing that ‘‘research-based evidence can provide some guidance but cannot show decisively which inter- vention is most appropriate,’’ yet a structured ap- proach to selecting implementation strategies may be helpful.69(pE85)
Implementation science is an emerging field with few randomized controlled trials across healthcare settings where nurses work. However, there is a growing body of important research showing the impact of a variety of implementation strategies on nurse-sensitive outcomes.28,51,57,69,70 Implementing EBP change is difficult; consequently, nursing leaders must use effective implementation strategies to en- gage clinicians and promote adoption of evidence- based care delivery to improve patient outcomes. Using the Evidence-Based Practice Implementation guide to select implementation strategies adds clarity to a critical and often undeveloped step in the EBP process. While gaps remain in our knowledge, this guide offers a valuable addition to practice by pro- viding an application-oriented approach for planning implementation using evidence-based implementa- tion strategies.
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230 JONA � Vol. 42, No. 4 � April 2012