Models and Frameworks for Implementing Evidence-Based Practice E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Evidence Based Nursing
• Sprache: Englisch

Seitenzahl: 402

Veröffentlichungsjahr: 2011

Beschreibung

The Evidence-Based Nursing Series is co-published with Sigma Theta Tau International (STTI). The series focuses on implementing evidence-based practice in nursing and mirrors the remit of Worldviews on Evidence-Based Nursing, encompassing clinical practice, administration, research and public policy.

Models and Frameworks for Implementing Evidence- Based Practice: Linking Evidence to Action looks at ways of implementing evidence gained through research and factors that influence successful implementation. It acknowledges the gap that exists between obtaining evidence and the practicalities of putting it into practice and provides direction to help to close this gap. This, the first book in the series, helps the reader to make decisions about the appropriateness of using various models and frameworks. A selection of models and frameworks are examined in detail including examples of their use in practice. The book concludes with an analysis and synthesis of the included models and frameworks.

The models and frameworks that have been included are based on a number of criteria: that they are internationally recognised, have undergone widespread evaluation and testing, are transferable across different settings, and can be used by different disciplines. Models and frameworks include:

• Stetler Model
• Ottowa Model of Research Use
• IOWA model of evidence-based practice
• Advancing Research and Clinical Practice through Close Collaboration (ARCC) model
• Dobbins’ dissemination and use of research evidence for policy and practice framework
• Joanna Briggs Institute model
• Knowledge to Action framework
• Promoting Action on Research Implementation in Health Services (PARIHS)

Key  Points:

• Includes an overview of implementation issues and the use of theory and frameworks in implementing evidence into practice
• Chapters are written by the developers of the model or framework
• Each chapter provides background on an implementation model or framework, suitable applications, underlying theory and examples of use
• Each chapter examines strengths and weaknesses of each model alongside barriers and facilitators for its  implementation

Leseprobe

Contents

Notes on Contributors

Foreword by Huw Davis

Reference

Preface

Chapter 1 Evidence-based practice

Introduction

What is evidence-based practice?

What does implementation of evidence into practice mean?

Attributes influencing successful implementation

Why this book?

References

Chapter 2 Theory, frameworks, and models

Introduction

Theory informed evidence-based practice

Using theory and frameworks for implementing evidence-based practice

Models and frameworks

Models and frameworks included in this book

Summary

References

Chapter 3 Stetler model

Introduction and purpose of the model

Background and context

Intended audience and actual users of the model

Hypotheses and propositions

Use and related evaluation of the Stetler model

Perceived strengths and weaknesses of the model

Information on barriers and facilitators to implementing the model

The future

Summary

References

Chapter 4 The Ottawa Model of Research Use

Purpose and assumptions

Background and context

Intended audience/users

Hypotheses and research possibilities

Critique (strengths and limitations of OMRU)

Future possibilities

Conclusion

Summary: How the model can be used/applied

References

Chapter 5 Promoting Action on Research Implementation in Health Services (PARIHS)

Background

Purpose and assumptions

Background to PARIHS’ development

Intended users

Hypotheses and propositions

Others’ use of PARIHS

Critique (strengths and weaknesses) of PARIHS

Future plans

Conclusion

Summary: How PARIHS could be used

References

Chapter 6 Iowa model of evidence-based practice

Overview and purpose

Development of the model

Intended users

Hypothesis generation

Critique (strengths and weaknesses) of the Iowa model

Barriers and facilitators to model implementation

Future plans for model revisions

Summary: How the model can be used/applied

References

Chapter 7 Dissemination and use of research evidence for policy and practice

Introduction

Purpose of the framework

Model development

Intended audience

Hypothesis generation

Examples of framework’s use

Perceived strengths and weaknesses

Future plans for framework modifications

Summary: How the model can be used/applied

References

Chapter 8 ARCC (Advancing Research and Clinical practice through close Collaboration)

Purpose of and assumptions in the ARCC model

Background to the ARCC model

Intended users

Hypotheses generated from the ARCC model

Use and implementation of the ARCC model and implications for future research

Critique (strengths and weaknesses) of the ARCC model

Summary: How the model can be used/applied

References

Chapter 9 The Joanna Briggs Institute model of evidence-based health care as a framework for implementing evidence

Purpose and assumptions

Background to the JBI model’s development

Intended users of the model

Hypotheses and propositions

Others’ use of the JBI model for implementing evidence

Critique (strengths and weaknesses) of the JBI model for implementing evidence

Future plans

Summary: How the model can be used/applied

References

Chapter 10 The Knowledge To Action framework

Purpose of the framework

Background and context

Framework description

Intended audiences/users

Hypotheses and research possibilities – Has the framework generated hypotheses or propositions that the developers and others can and/or have been testing?

Evaluation and use of the KTA framework

Strengths and limitations

Future plans for the development of the framework

Summary: How the model can be used/applied

References

Chapter 11 Analysis and synthesis of models and frameworks

Background

Synthesis

Conclusion

References

Chapter 12 Summary and concluding comments

A note about implementation

A note about impact

Applying models and frameworks to guide implementation

Concluding remarks

References

Appendix

Index

Evidence-Based Nursing Series

The Evidence-Based Nursing Series is co-published with Sigma Theta Tau International (STTI). The series focuses on implementing evidence-based practice in nursing and mirrors the remit of Worldviews on Evidence-Based Nursing, encompassing clinical practice, administration, research and public policy.

Other titles in the Evidence-Based Nursing Series:

Clinical Context for Evidence-Based Practice Edited by Bridie Kent and Brendan McCormack ISBN: 978-1-4051-8433-5

Evaluating the Impact of Implementing Evidence-Based Practice Edited by Debra Bick and Ian D. Graham ISBN: 978-1-4051-8384-0

This edition first published 2010© 2010 Sigma Theta Tau InternationalBlackwell Publishing was acquired by John Wiley & Sons in February 2007.Blackwell’s publishing programme has been merged with Wiley’s global Scientific,Technical, and Medical business to form Wiley-Blackwell.

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Library of Congress Cataloging-in-Publication Data

Models and frameworks for implementing evidence-based practice: linking evidence to action / edited by Jo Rycroft-Malone and Tracey Bucknall.p.; cm.Includes bibliographical references and index.ISBN 978-1-4051-7594-4 (pbk.: alk. paper)1. Evidence-based nursing. I. Rycroft-Malone, Jo. II. Bucknall, Tracey.[DNLM: 1. Evidence-Based Nursing—methods. 2. Models, Nursing.WY 100.7 M689 2010]RT84.5.M625 2010610.73—dc222009040321

Notes on Contributors

Tracey Bucknall

Tracey Bucknall RN, ICU Cert, BN, Grad Dip Adv Nurs, PhD is Professor in School of Nursing, Deakin University and Head, Cabrini-Deakin Centre for Nursing Research, Cabrini Health, and Associate Editor of Worldviews on Evidence Based Nursing. Tracey’s primary research interests are clinical decision making and implementation of research into practice. Her research focuses on understanding how individuals make decisions routinely and in uncertainty, the environmental and social influences encountered in changing contexts, and interventions to improve the uptake of research in practice. More recently she has incorporated patient involvement in decision making as a means of influencing clinician uptake of research evidence.

Kara DeCorby

Kara DeCorby MSc is a research coordinator in the Faculty of Health Sciences at McMaster University. Kara has worked on several research projects related to knowledge translation and uptake; specifically promoting evidence-informed practice in public health decision making. She led the process of locating, relevance testing, key wording, and critical appraisal of reviews, in addition to summarizing review evidence and methodology in the development of http://www.health-evidence.ca, a registry of systematic review-level evidence on the effectiveness of public health interventions. Kara holds a clinical faculty appointment and cotutors a School of Nursing course on research methods and critical appraisal for primary studies and systematic literature reviews.

Maureen Dobbins

Maureen Dobbins RN, PhD is an Associate Professor and Career Scientist, Ontario Ministry of Health and Long-Term Care and is also associated with School of Nursing, McMaster University, Ontario, Canada. Her research is focused on understanding knowledge translation and exchange among public health decision makers in Canada. Studies have included: identification of barriers and facilitators to knowledge translation and exchange; understanding the information needs of public health decision makers; evaluating the use of systematic reviews in provincial policies; exploring where research evidence fits into the decision-making process; evaluating the impact of knowledge translation and exchange strategies; and exploring the role of knowledge brokers in facilitating evidence informed public health decision making.

Ellen Fineout-Overholt

Ellen Fineout-Overholt PhD, RN, FNAP, FAAN is Clinical Professor and Director at Arizona State University Center for the Advancement of Evidence-based Practice, AZ, USA. Dr. Fineout-Overholt has 20 years of combined experience as a critical care nurse, advanced practice nurse, researcher, and educator. Her program of research is developing and testing models of evidence-based practice in a variety of settings. Dr. Fineout-Overholt is coeditor of the recurring section, Teaching EBP, in Wiley-Blackwell and Sigma Theta Tau International’s journal Worldviews on Evidence-based Nursing. In addition, she is coeditor of the number one selling book on EBP published by Lippincott Williams & Wilkins entitled, Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. In recognition of her contributions to professional nursing practice, Dr. Fineout-Overholt was inducted as a fellow in the National Academies of Practice in 2006 and the American Academy of Nursing in 2008.

Ian D Graham

Ian D Graham PhD is Vice-President of Knowledge Translation at the Canadian Institutes of Health Research and an Associate Professor in the School of Nursing at the University of Ottawa, Canada. Ian Graham has a PhD in medical sociology from McGill University. His research focuses on knowledge translation science and conducting applied research on the determinants of research use, strategies to increase implementation of research findings and evidence-based practice, and KT theories and models.

Jo Logan

Jo Logan is BScN and a PhD in Education. Jo Logan’s interest in evidence-based practice began while teaching in hospital nursing staff development and extended to her position as Director of Nursing Research. Her efforts toward research utilization include the codevelopment and application of the Ottawa model of research use. The model was refined when Jo joined the University of Ottawa, School of Nursing. Her research interests focused on the foundations of evidence-based nursing. Currently, she holds a position as Adjunct Nursing Professor at the University of Ottawa.

Bernadette Mazurek Melnyk

Bernadette Mazurek Melnyk PhD, RN, CPNP/NPP, FNAP, FAAN is Dean and Distinguished Foundation Professor in Nursing at Arizona State University College of Nursing and Health Innovation and Associate Editor of Worldviews on Evidence-Based Nursing. Dr. Melnyk is a nationally/internationally recognized researcher, educator, clinician, speaker, and expert in evidence-based practice as well as in child and adolescent mental health. Her record of scholarship includes over 120 publications, including two books entitled Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice and the KySS Guide to Child and Adolescent Mental Health Screening, and Early Intervention and Health Promotion. Dr. Melnyk has received numerous national/international awards and is a current member of the United States Preventive Services Task Force.

Alan Pearson

Alan Pearson RN, PhD, FRCNA, FAAG, FRCN is Executive Director at The Joanna Briggs Institute and Professor of Evidence Based Healthcare, The University of Adelaide, Australia. Professor Alan Pearson has extensive experience in nursing practice, nursing research, and academic nursing. He has practiced in the fields of orthopedics, maternal, child and community health and aged care in the United Kingdom, Papua New Guinea, and Australia. Professor Pearson has been an active researcher since 1981, known internationally for his pioneering work on the establishment and evaluation of nursing beds in Oxford, UK from 1981 to 1986 and for his ongoing work emphasizing the centrality of practice and evidence-based practice. He founded the Joanna Briggs Institute in 1996 and developed the JBI Model of Evidence-Based Healthcare with colleagues, in 2005.

Jo Rycroft-Malone

Jo Rycroft-Malone RN, MSc, BSc(Hons), PhD is Professor of Health Services and Implementation Research, Bangor University, UK and Editor of Worldviews on Evidence-Based Nursing. Jo’s particular expertise and interests lie in knowledge translation research and evidence-based practice processes. She has successfully obtained national and international level competitive grants to study the processes and outcomes of evidence into practice interventions in a wide variety of topics. She is also a member of the PARIHS framework group. She sits on a number of national and international strategy development and funding groups including the National Institute for Health and Clinical Excellence (NICE) Implementation Strategy Group and the Canadian Institutes for Health Research Knowledge Exchange and Translation Committee. Jo is the inaugural editor of Worldviews on Evidence-Based Nursing.

Cheryl B Stetler

Cheryl B Stetler PhD, RN, FAAN. For over 25 years, Dr. Stetler worked in the acute care setting in a variety of positions, where she often was involved in implementing, conceptualizing, and evaluating research utilization/evidence-based practice and other change programs. Currently she is an international consultant on evidence-based practice and evaluation, providing consultation to, for example, the Veterans Administration QUERI Program; and is a Research Associate at the Boston University School of Public Health in Boston, MA, USA. Overall, her focus is the conceptualization and implementation of research utilization/evidence-based practice with a particular emphasis upon theory and organizational institutionalization of EBP into routine professional practice.

Marita Titler

Marita Titler PhD, RN, FAAN, is Professor, Associate Dean for Practice and Clinical Scholarship Development and the Rhetaugh Dumas Endowed Chair, University of Michigan School of Nursing, MI, USA. Marita’s program of research focuses on translation science, interventions to improve outcomes of adults with chronic illnesses, and dissemination of evidence-based practice guidelines for the elderly. She has held multimillion dollar grants to study translation practice across a variety of topics including pain management and falls prevention. She is currently a member of the Institute of Medicine Forum on the Science of Health Care Quality Improvement and Implementation, the AHRQ HCTDS study section and the Appalachian Regional Healthcare, Board of Trustees, and is a fellow in the American Academy of Nursing. She has published widely and spoken nationally and internationally on evidence-based practice.

Paula Robeson

Paula Robeson BN, MScN, is Knowledge Broker (KB), health-evidence. ca (H-E) at McMaster University, Canada. As the KB, Paula plays an integral role in the delivery of services and resources to Canadian public health decision makers. In particular, she conducts tailored organizational, divisional, or team assessments of capacity for evidence-informed decision making with practical recommendations for action; provides customized knowledge brokering services to mentor individuals or teams in their efforts to incorporate the best available evidence in their practice, programs, and policy decisions; facilitates standard and tailored workshops and presentations addressing the “how to’s” of evidence-informed practice; responds to practice-based questions and requests for evidence that are posted on the H-E website.

Jacqueline M Tetroe

Jacqueline M Tetroe MA, Knowledge Translation Portfolio, Canadian Institutes of Health Research, Ottawa, Canada. Jacqueline has a Masters Degree in developmental psychology and studied cognitive and educational psychology at the Ontario Institute for Studies in Education. She currently works as a senior advisor in knowledge translation at the Canadian Institutes of Health Research. Her research interests focus on the process of knowledge translation and on strategies to increase the uptake and implementation of evidence-based practice as well as to increase the understanding of the barriers and facilitators that impact on successful implementation. She is a strong advocate of the use of conceptual models to both guide and interpret research.

Foreword

Around the globe, huge expenditure supports a veritable industry of research to underpin evidence in health care. Studies on diagnostics, prognostics, and therapeutics provide ever finer-grained understandings about the nature of ill health, its assessment, potential causal pathways, likely trajectory and scope for amelioration. A more recent elaboration of this industry has been the many and varied attempts to collate, synthesis, and integrate the findings from diverse research into “evidence,” with the hope that such evidence will be “implemented” by health-care practitioners for the betterment of patient care. Of course, both “evidence” and “implementation” are tricky customers that elude neat and consensual definitions (of which more later), but the central concern of this book is that we have an abundance of evidence alongside a relatively impoverished view of implementation. The stubborn and widespread failure of health-care practice to align with best evidence is a testimony to the rightness of this concern.

Dominating thinking on evidence-based practice – often implicitly – is a poorly expressed combination of cybernetics alongside notions of cognitive behavioral change. Too often, the emphasis has been on the proper and rigorous processes for the creation of evidence (systematic reviews, guidelines, clinical pathways, best-practice statements), and the promulgation of these through health systems, organizations and the professions (dissemination strategies of one form or another). Such dissemination may then be accompanied both by attempts to skill-up individual health-care practitioners in evidence use (seeking, appraising, applying, etc.), and by systems of audit and accountability for evidence uptake and impact (measuring and monitoring, and sometimes incentivizing, process measures of change). The problem to which this book addresses itself is that these latter activities (dissemination, implementation, impact assessment) are poorly or even erroneously conceptualized, underresourced, underresearched and, in short, somewhat neglected.

It is a real pleasure to see drawn together some of the better work on implementation that has unfolded over the past two decades and sometimes more. The theories, models, and frameworks presented here, often by some of their progenitors, provide a timely antidote to the narrowness of view that cybernetics and cognitive behavioral change are the sole (or even primary) engines of implementation. While earlier models presented may have their roots in individual-level change, more recent elaborations – or indeed, newer models – often take a broader view of multilevel change, seeing it as operating at individual, team, and organization levels. And while evidence is obviously an important component in each of the models, the social and contextual understandings of this evidence are brought to the fore in many, and evidence-use becomes conceptualized as a complex, socially situated process.

The plethora of theories, models, and frameworks available, and the careful laying out of the relative strengths, challenges, and scope for application, provides for the first time a comprehensive overview of not just ways of thinking about implementation, but also guidance on the practical application of these ways of thinking. Moreover, the editors have been careful to ensure good read-across between chapters (allowing easy comparison of convergence and divergence between models) and have taken the trouble to synthesize some of the key features of the models in a couple of useful concluding chapters. After all this careful laying out of the tools available, there is now no excuse among managers and practitioners for any lack of explicit underpinnings to any implementation effort.

If there is a criticism of the models presented in this book, it is that most take a “research into practice” view, where the task is conceived of as the application of preexisting knowledge in new contexts. Yet, as alluded to in the opening paragraph, “evidence” may not be so static a resource as that, and reducing research “implementation” to a simple matter of “doing the right thing” may undersell its contribution. Indeed, evidence may be created (or cocreated) as much in the process of implementation as it exists outside of that process. While these challenges are taken up in, for example, the knowledge to action framework, many of the models take a rather more unproblematic view of evidence and its use. Of course, such a criticism should be seen in context: much of the evidence base now available in health care is indeed of the instrumentalist kind. Although a critical understanding of how such evidence is received and constructed is important, the practical challenges may well come down to issues of application of that evidence in practice, challenges to which these models are well suited.

Kurt Lewin (1890–1947), recognized as one of the founders of social psychology, noted that “there is nothing so practical as a good theory” (1951: 169). This book provides a rich demonstration of that assertion. It will be invaluable not only to nurses and other health-care practitioners interested in more nuanced and better conceptualized understandings of implementation, but also to all those interested in the role of theories for understanding knowledge-informed change. It is to be hoped that it is used not only to inform new implementation strategies, but also to inform new investigative efforts on the success or otherwise of those strategies. Theories, models, and frameworks retain their vitality only in as much as they are invigorated through the application of fresh data.

Huw DaviesProfessor of Health Care Policy & ManagementUniversity of St Andrews

and

Director, Knowledge Mobilisation & Capacity Building forThe UK’s National Institute for Health Research (NIHR) ServiceDelivery and Organisation (SDO) National Research Programme

Reference

Lewin, K. (1951). Field theory in social science: Selected theoretical papers. D. Cartwright (ed.). New York: Harper & Row.

Preface

This book and book series emerged from many discussions between us about the lack of resources that specifically consider the implementation of evidence into practice. Governments in developed countries across the world have made considerable investments in an infrastructure to support evidence generation (e.g., clinical guideline development, production of systematic reviews) but much less investment in evidence implementation. Arguably the political focus on evidence generation has been at the expense of implementation of that evidence. For example, when a national clinical guideline has been developed – there is often little or no consideration of the implementation implications of the practice recommendations contained within it. Furthermore, there has been a focus on developing the skills and knowledge of individual practitioner’s to appraise research and make rational decisions using this knowledge in practice. We believe that while critical appraisal is an important skill, it is not sufficient for using evidence in day-to-day practice. Using evidence in practice is a complex process (not a one-off event), which requires more than a focus on individual factors. The implementation of evidence-based practice depends on an ability to achieve significant and planned change involving individuals, teams, and organizations.

When we did some research on what resources are available to guide and support implementation, we were surprised by how few there are. While there are many books under the umbrella of “evidence-based practice,” these tend to take readers through the critical appraisal and research process, with extremely limited coverage of implementation issues. This book, one in a series of three to be published in parallel, aims to redress this imbalance.

The objective of this book is to consider the use of theory, models, and frameworks in the implementation of evidence-based practice, provide a collection of models and frameworks written by their developers, and offer a review and synthesis of these. Our intention is to provide a useful resource to help readers make decisions about the appropriateness of the various models’ and frameworks’ use in implementation efforts, and to inform theory use and development in the field more generally.

Jo Rycroft-MaloneTracey Bucknall

Chapter 1

Evidence-based practice

Doing the right thing for patients

Tracey Bucknall and Jo Rycroft-Malone

Introduction

Profound changes in health care have occurred as a result of advances in technology and scientific knowledge. Although these developments have improved our ability to achieve better patient outcomes, the health system has struggled to incorporate new knowledge into practice. This partly occurs because of the huge volume of new knowledge available that the average clinician is unable to keep abreast of the research evidence being published on a daily basis. A commonly held belief is that knowledge of the correct treatment options by clinicians will lead more informed decision making and therefore the correct treatment for an individual. Yet the literature is full of examples of patients receiving treatments and interventions that are known to be less effective or even harmful to patients. Although clinicians genuinely wish to do the right thing for patients, Reilly (2004) suggests that good science is just one of several components to influence health professionals. Faced with political, economic, and sociocultural considerations, in addition to scientific knowledge and patients’ preferences, decision making becomes a question of what care is appropriate for which person under what circumstances. Not surprisingly, to supplement to clinical expertise, critical appraisal has become an important prerequisite for all clinicians (nurses, physicians, and allied health) to evaluate and integrate the evidence into practice.

Although there is the potential to offer the best health care to date, many problems exist that prevent the health care system from delivering up to its potential. Globally, we have seen continuous escalation of health care costs, changes in professional and nonprofessional roles and accountability related to widespread workforce shortages, and limitations placed on the accessibility and availability of resources. A further development has been the increased access to information via multimedia, which has promoted greater involvement of consumers in their treatment and management. This combination has lead to a focus on improving the quality of health care universally and the evolution of evidence-based practice (EBP).

What is evidence-based practice?

Early descriptions simply defined EBP as the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making (Sackett et al., 2000: 1). The nursing society, Sigma Theta Tau International 2005–2007 Research & Scholarship Advisory Committee (2008) further delineated evidence-based nursing as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served” (p.69). However, an early focus on using the best evidence to solve patient health problems oversimplified the complexity of clinical judgment and failed to acknowledge the contextual influences such as the patient’s status or the organizational resources available that change constantly and are different in every situation.

Haynes et al. (2002) expanded the definition and developed a prescriptive model for evidence-based clinical decisions. Their model focused on the individual and health care provider and incorporated the following: the patient’s clinical state, the setting and circumstances; patient preferences and actions; research evidence; and clinical expertise. Di Censo et al. (2005) expanded the model further to contain four central components: the patient’s clinical state, the setting and circumstances; patient preferences and actions; research evidence; and a new component health care resources, with all components overlaid by clinical expertise (Fig. 1.1). This conceptualization has since been incorporated into a new international position statement about EBP (STTI, 2008). This statement broadens out the concept of evidence further to include other sources of robust information such as audit data. It also includes key concepts of knowledge creation and distillation, diffusion and dissemination, and adoption, implementation, and institutionalization.

Figure 1.1 The interrelationship between evidence-based practice and clinical expertise (reprinted from Di Censo et al., 2005, with permission from © 2005 Elsevier)

These changes to definitions and adaptations to models highlight the evolutionary process of EBP, from a description of clinical decision making to a guide that informs decisions. While there is an emphasis on a combination of multiple sources of information to inform clinicians’ decision making in practice, it remains unknown how components are weighted and trade-offs made for specific decisions.

The evolution of evidence-based practice

A British epidemiologist, Archie Cochrane, was an early activist for EBP. In his seminal work, Cochrane (1972) challenged the use of limited public funding for health care that was not based on empirical research evidence. He called for systematic reviews of research so that clinical decisions were based on the strongest available evidence. Cochrane recommended that evidence be based on randomized controlled trials (RCTs) because they were more reliable than other forms of evidence. Research reviews should be systematically and rigorously prepared and updated regularly to include new evidence. These principles resonated with both the public and health care providers.

In 1987, Cochrane noted that clinical trials on the effectiveness of corticosteroid treatments in premature labor in high-risk pregnancies were supportive of treatment but had never been comprehensively analyzed. He referred to a systematic review that indicated corticosteroid therapy could reduce low-birth-weight premature infant mortality rates by 20% (Cochrane Collaboration, 2009). In recognition of his work and leadership, the first Cochrane Centre was opened 4 years after his death; the Cochrane Collaboration was founded a year later in 1993. The aim of the collaboration is to ensure that current research evidence in health care is systematically reviewed and disseminated internationally. Beginning in medicine, the collaboration now has many health professions represented on review groups including consumers.

As Kitson (2004) noted, the rise of evidence-based medicine (EBM) was in itself, a study of innovation diffusion, “offering a strong ideology, influential leaders, policy support and investment with requisite infrastructures and product” (p. 6). Early work by Sackett and team at McMaster University in Canada and Chalmers and team at Oxford in the UK propelled EBM forward, gaining international momentum. Since 1995, the Cochrane Library has published over 5000 systematic reviews, and has over 11,500 people working across 90 different countries (Cochrane Collaboration, 2009).

The application of EBM core principles spread beyond medicine and resulted in a broader concept of EBP. In nursing, research utilization (RU) was the term most commonly used from the early 1970s until the 1990s when EBP came into vogue. Estabrooks (1998) defined RU as “the use of research findings in any and all aspects of one’s work as a registered nurse” (p. 19). More recently, Di Censo et al. (2005) have argued that EBP is a more comprehensive term than RU. It includes identification of the specific problem, critical thinking to locate the sources, and determine the validity of evidence, weighting up different forms of evidence including the patients preferences, identification of the options for management, planning a strategy to implement the evidence, and evaluating the effectiveness of the plan afterwards (Di Censo et al., 2005).

The emergence of EBP has been amazingly effective in a short time because of the simple message that clinicians find hard to disagree with, that is, where possible, practice should be based on up to date, valid, and reliable research evidence (Trinder and Reynolds, 2000). In Box 1.1, four consistent reasons for the strong emergence of EBP across the health disciplines are summarized by Trinder and Reynolds (2000).

Box 1.1 The emergence of evidence-based practice (Trinder and Reynolds, 2000)

Research–practice gapSlow and limited use of research evidence. Dependence on training knowledge, clinical experience, expert opinion, bias and practice fads.Poor quality of much researchMethodologically weak, not based on RCTs, or is inapplicable in clinical settings.Information overloadToo much research, unable to distinguish between valid and reliable research and invalid and unreliable research.Practice not evidence-basedClinicians continue to use harmful and ineffective interventions. Slow or limited uptake of proven effective interventions being available.

It is worth noting, however, that while generally accepted as an idea “whose time has come,” EBP is not without its critics. It is often challenged on the basis that it erodes professional status (as a way of “controlling” the professions), and as a reaction to the traditional hierarchy of evidence (see Rycroft-Malone, 2006 for a detailed discussion of these arguments).

Although significant investment has been provided to produce and synthesize the evidence, a considerably smaller investment has been made toward the implementation side of the process. As a consequence, we have variable levels of uptake across the health disciplines and minimal understanding of the effectiveness of interventions and strategies used to promote utilization of evidence.

What does implementation of evidence into practice mean?

In health care, there have been many terms used to imply the introduction of an innovation or change into practice such as quality improvement, practice development, adoption of innovation, dissemination, diffusion, or change management. The diversity in terminology has often evolved from the varying perspectives of those engaged in the activity such as clinicians, managers, policy makers, or researchers. Box 1.2 differentiates some of the definitions most frequently provided.

Box 1.2 What is meant by implementation?

Source: Definitions adapted from Davis and Taylor-Vaisey (1997).

DiffusionInformation is distributed unaided, occurs naturally (passively) through clinicians adoption of policies, procedures, and practices.DisseminationInformation is communicated (actively) to clinicians to improve their knowledge or skills; a target audience is selected for the dissemination.ImplementationActively and systematically integrating information into place; identifying barriers to change, targeting effective communication strategies to address barriers, using administrative and educational techniques to increase effectiveness.AdoptionClinicians commit to and actually change their practice.

Figure 1.2 Nature of spread

These definitions imply a continuum of implementation from the most passive form of natural diffusion after release of information toward more active dissemination where a target audience is selected and communicated the information to improve their skills and knowledge. Further along the continuum is the systematically planned, programed, and implemented strategy or intervention where barriers are identified and addressed and enablers are used to promote implementation for maximum engagement and sustainability (Fig. 1.2).

Implementation in health care has also been informed by many different research traditions. In a systematic review of the literature on diffusion, dissemination, and sustainability of innovations in health services, Greenhalgh et al. (2004) found 11 different research traditions that were relevant to understanding implementation in health care. These were: Diffusion of innovations; rural sociology; medical sociology; communication; marketing and economics; development studies; health promotion; EBM; organizational studies; narrative organizational studies; complexity and general systems theory. Box 1.3 outlines the research traditions and some key findings derived from the research.

Box 1.3 Examples of research traditions influencing diffusion, dissemination, and sustainable change

Source: Adapted from Greenhalgh et al. (2004).

Research traditionFindingsDiffusion of innovationInnovation originates at a point and diffuses outward (Ryan, 1969).Rural sociologyPeople copy and adopt new ideas from opinion leaders (Ryan and Gross, 1943).Medical sociologyInnovations spread through social networks (Coleman et al., 1966).CommunicationPersuading consumers while informing them (MacDonald, 2002). More effective if source and receiver share values and beliefs (MacGuire, 1978).Marketing and economicsPersuading consumers to purchase a product or service. Mass media creates awareness; interpersonal channels promote adoption (MacGuire, 1978).Development studiesSocial inequities need to be addressed if widespread diffusion is to occur across different socioeconomic groups and lead to greater equity (Bourdenave, 1976).Health promotionCreating an awareness of the problem and offering a solution through social marketing. Messengers and change agents from target group increase success (MacDonald, 2002; Rogers, 1995).Evidence-based medicineNo causal link between the supply of information and its usage. Complexity of intervention and context influence implementation in real world (Greenhalgh et al., 2004).Organizational studiesInnovation as knowledge is characterized by uncertainty, immeasurability, and context dependence (Greenhalgh et al., 2004).Narrative organizational studiesStorytelling captures the complex interplay of actions and contexts; humanizing and sense-making, creating imaginative and memorable organizational folklore (Greenhalgh et al., 2004; Gabriel, 2000).Complexity and general systemsComplex systems are adaptive, self-organizing and responsive to different environments. Innovations spread via the local self-organizing interaction of actors and units (Plsek and Greenhalgh, 2001).

The many different research traditions have used diverse research methods that at times produce contrasting results. For researchers, it offers significant flexibility in research design and depends on the research questions being asked and tested. For clinicians and managers, research theories offer guidance for developing interventions by exposing essential elements to be considered. These elements are often grouped at individual, organizational, and environmental levels, as they require different activities and strategies to address the element. The following section offers a limited review of the different attributes that are known to influence the success of implementation and need to be considered prior to implementing evidence into practice.

Attributes influencing successful implementation

Unlike the rapid spread associated with some forms of technology, which may simply require the intuitive use of a gadget and little persuasion to purchase it, many health care changes are complex interventions requiring significant skills and knowledge to make clinical decisions prior to integration into practice. Not surprisingly then, implementation of evidence into practice is mostly a protracted process, consisting of multiple steps, with varying degrees of complexity depending on the context. Numerous challenges arise out of the process that can be categorized into following five areas (Greenhalgh et al., 2004): the evidence or information to be implemented, the individual clinicians who need to learn about the new evidence, the structure and function of health care organizations, the communication and facilitation of the evidence, and lastly, the circumstances of the patient who will be the receiver of the new evidence. These challenges need to be considered when tailoring interventions and strategies to the requirements of various stakeholders (Bucknall, 2006).

The evidence

There is much literature indicating that the characteristics of the evidence are an important consideration in planning implementation. Different types of evidence are known to spread at different rates. Characteristics of evidence include the type of evidence available to be implemented, the quality of the particular evidence, and the volume of evidence available to the decision maker such as a single RCT or a systematic review of multiple studies. These characteristics will all influence the rate, extent, and adherence of adoption by different individuals. In Rogers (1995) seminal works, he identified six major attributes of evidence that affect its uptake and sustained adoption. These included the relative advantage offered by the evidence to the patient or the clinician. First, clinicians must be able to clearly identify the benefits for patients or their own practice, either for improving patient outcomes, reducing harm, increasing access to resources, or decreasing costs. Second, the adopter’s values and practices must be compatible with the evidence. Third, the more complex the evidence, the more difficult it will be for the clinician to use and to integrate into practice. Fourth, the degree to which the evidence can be tested on a limited basis, known as trialability, is important.

Trialing the evidence allows clinicians to practice and minimize any harmful or unexpected events associated with the implementation. Fifth, the adoption of evidence is also more likely when clinicians can observe others using the evidence; it provides some reassurance about the processes and minimization of harm for patients. Finally, to integrate the evidence into differing contexts, clinicians may need to reinvent, refine, or adapt the evidence to suit their own and their organizational needs (Rogers, 1995).

However, in their systematic review, Greenhalgh et al. (2004) argued that Roger’s list of evidence attributes does not completely explain the adoption and adherence of complex health service innovations. New constructs have evolved from health service studies such as the importance of assessing the evidence in terms of relevance and usefulness for a specific task; the feasibility of implementing the change, the degree of implementation difficulty because numerous disciplines and specialties are involved; the ability to break the process into components to implement sections sequentially; and the prior knowledge and skills needed to use the evidence such as implementing new technology (Agarwal et al., 1997; Greenhalgh et al., 2004, Yetton et al., 1999).

The individual clinician

Much early research paid close attention to characteristics of the individual in attempting to understand the reasons for the research–practice gap (Champion and Leach, 1989; Coyle and Sokop 1990; Estabrooks et al., 2003; Rodgers, 2000). One of the challenges frequently identified is the prior knowledge and skills of the individual clinician. To assimilate the evidence into practice, clinicians need to be able to critically appraise the evidence to determine its validity and reliability. If they lack these basic educational skills then their ability to assess contradictory evidence and decide on the right course of action will be impaired (Bucknall, 2006; Bucknall et al., 2008). Not only must clinicians weight the evidence, the volume may also require significant time to reflect and process the information. Again, this may depend on the ability of the individual as to the time taken to digest the information.

Personality traits such as motivation, learning styles, and the individual’s capability will also determine adoption (Greenhalgh et al., 2004). Wejnert (2002) suggested that depending on the organizational context at the time, the individual may assign greater meaning to the evidence and thus be more receptive to practice changes. The changing concerns and priorities, commonly associated with health care, may motivate different individuals at different stages throughout the process; each individual will have distinct personal makeup, knowledge and clinical experience, and as a consequence, unique concerns (Hall and Hord, 1987).

To a greater or lesser extent (and differently in different contexts), individuals seek innovations out, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, work round them, talk to others about them, develop know-how about them, modify them to fit particular tasks, and attempt to improve or redesign them-often (and most successfully) through dialogue with other users. (Greenhalgh et al., 2004: 163)

The health care organization

More recently, the failure of successful implementation in health care organizations has been attributed to the disregard shown toward organizational attributes or contextual factors. Organizational attributes are described as “those characteristics of health-care organizations, or units within those institutions, and of governance structures outside of those institutions that facilitate the dissemination and uptake of research findings” (Estabrooks, 1999: 61).

It is well recognized that organizations vary enormously within and between each other, hampering generalizability of research findings on implementation from one site or unit to the next. Indeed, the challenge for clinicians and managers is to overcome the structural determinants such as size, duration of establishment, degree of specialization, and decision-making structures known to influence knowledge transfer and uptake (Greenhalgh et al., 2004). Greenhalgh et al.’s (2004) review showed that organizations were more likely to be successful at evidence integration if they have the capability to analyze, reframe, and combine the information with existing knowledge, that is, organizations with greater absorptive capacity. Organizations must also be receptive to change, taking risks, and experimenting with new evidence. The climate of the organization is shown to be fostered by strong leadership at managerial level and also within the clinical units (Bucknall, 2006). In addition, a culture of continuous learning is needed, appraising first and then using new knowledge and knowledge generated from monitoring changes, feeding back the information for refining the process within and across disciplines (Greenhalgh et al., 2004).

Externally, informal interorganizational networks have been shown to be influential in successful practice change. It would appear though that a threshold proportion of organizations may be required to change before influencing others to do so. In contrast, an organizational network can be a negative effect that deters others from trying the change (Burns and Wholey, 1993; Valente, 1996) or stimulate a competitive environment (Castle, 2001). This has been useful in guideline implementation across quality improvement collaboratives when data is compared between organizations (Ovretveit et al., 2002). Policy makers have been shown to have some influence although the success may be determined by the capacity to change (Fitzgerald et al., 2002).

Communication and facilitation

In a classic study, Innvaer et al. (2002) reviewed 24 studies on research use by policy makers and found the primary facilitator and barrier of research use was personal contact (13/24) or lack thereof (11/24), respectively. Therefore, it comes as no surprise that communication with social contacts and networks have proven effective in transferring knowledge and increasing uptake of new evidence.

Four approaches have shown positive outcomes. The social network approach has been successful in different professional groups in health services. A social network is a group of people within a social system that provides friendship, advice, support, and communication (Valente, 1996). West et al. (1999) found that nurses had formal vertical networks whereas doctors had more informal horizontal networks. Vertical networks tend to cascade authoritative decisions more successfully, while horizontal networks wield greater influence during the reframing of evidence for local consumption (West et al., 1999). In addition, there is greater success likely during implementation if the social network has similar educational, professional, and socioeconomic backgrounds (Rogers, 1995).

Change champions are another frequently used approach to endorse adoption of new evidence in organizations. Change champions are individuals who continually promote and support the use of new evidence within the group. Usually they are passionate experts, respected and informal leaders who have positive working relationships with other professionals (Greenhalgh et al., 2004). Change champions can be placed at any level of the organization and provide differing roles.

The third approach for promoting practice change, influencing the actions and beliefs of their peers are opinion leaders (Locock et al., 2001). Similar to change champions, opinion leaders operate at different levels of the organization. They can be internal, external, and peer opinion leaders. In general, opinion leaders are local, respected sources of influence trusted among their peer group to appraise new information and reframe it in the context of the local situation. They are accomplished in role modeling, influencing peers, and altering group norms (Rogers, 1995). Opinion leaders may also have a negative influence on the success of an intervention deterring their peers from using the evidence (Locock et al., 2001).

A fourth approach for communicating evidence is through boundary spanners. Boundary spanners appraise and filter the evidence before disseminating it throughout the organization (Rogers, 1995). Their extensive social ties, both within and across organizations, link organizations experienced in the uptake of evidence to those yet to experience or in early stages of adoption.

The patient

Patient involvement in health care delivery can improve the success of implementation studies (Wensing et al., 2005). From the early days of EBP, Sackett et al. (1996) argued that clinicians must take account of the patient’s condition, baseline risk, values, and circumstances when making decisions about health care treatments. The inclusion of patient preferences into models of EBP demonstrates the growing support for patient involvement in health care decisions. The aim of involving patients in treatment decisions is to allow the patient to make health care decisions that accurately reflect their preferences and values (Bucknall, 2006). Benbassat et al. (1998) argued there is a lack of consistency by clinicians in assembling information on patient’s values and preferences during treatment selection. Providers’ beliefs of importance and what patients actually want may in fact be disparate. Similar to other individuals, patients are influenced by the type and stage of their illness, age, gender, culture, and socioeconomic status (Caress et al., 1998; Pierce and Hicks, 2001). O’Connor et al. (1999) believe that health treatments always have advantages and disadvantages; therefore evidence alone cannot determine the best choice of treatment. Although the trade-offs for many clinical decisions are clear, there are occasions when there is a precarious balance between risks and benefits, and choices will differ across patients (O’Connor et al., 1999).

Given we are all consumers of health care resources at some point in our lives, most of us would prefer the ability to choose the latest and most effective treatments and interventions to improve our situation. When patients have the capacity to understand and analyze information, they prefer a shared decision-making model (Degner et al., 1997; Edwards and Elwyn, 2004).

The increased availability and accessibility to multimedia technology has ensured that patients and clients have increasing access to the same or similar information as clinicians. Searches of the Internet highlight the choices available for patients, potentially increasing their involvement in health management decisions and guiding the treatments administered by clinicians. Yet little is known about the role of the patient in promoting the rate of adoption among clinicians (Bucknall et al., 2004; Wensing et al., 2005). Patient-mediated interventions have been targeted at different stages: the decision to seek medical treatment and care; before and during contact with clinicians; and after care is delivered, for feedback on service (Wensing et al., 2005). Greater responsiveness to patients may improve patient outcomes and the success of implementation.

Table 1.1 identifies the main elements and subelements that need to be considered during implementation of evidence into practice. It offers examples of questions for each subelement when planning an implementation strategy.

Why this book?

The application of knowledge into practice to improve patient care and outcomes is fundamental to health care. Yet our ability to translate knowledge into practice continues to be slow, fraught with challenges, and at times unsuccessful. The objective of this book is to provide a critical analysis of models and approaches for implementing EBP into a range of health care settings. In doing so, it will provide readers with a selection from which to choose the most appropriate model or approach to assist them in a successful implementation strategy for an assortment of evidence, individuals, and contexts.

Table 1.1 Considerations for the successful implementation of evidence into practice

Source: Elements adapted from Rycroft-Malone et al. (2002), Greenhalgh et al. (2004), and Bucknall (2006)

ElementSubelementsQuestions for planning implementationEvidenceType of evidenceIs specific evidence available? Is it accessible? What is its quality?Does a relative advantage exist? Will patients benefit from receiving the EBP? Will anyone else benefit?CompatibilityHow compatible is the evidence with practice?ComplexityHow complex are the interventions? Are different levels of clinicians involved? Are different disciplines involved in the process? What do we need to change?Trialability