8 American Nurse Today Volume 14, Number 3 AmericanNurseToday.com

YOU’RE UNLIKELY to find a practic-ing nurse who hasn’t heard of evi-dence-based practice (EBP). Nursesare keenly aware of the expectationthat they promote patient safety andquality care with the best availableevidence. Aligned with these expec-tations, nursing education programsprepare new graduates with a foun-dation in EBP as a decision-makingapproach to patient care. Moreover,consumers and third-party payorsexpect evidence-based care alongwith value-based purchasing thatreimburses for quality outcomesrather than number of procedures.

Despite these expectations, re-ports continue of challenges andbarriers to initiating and sustainingan EBP change. Nearly 20 years ago,Balas and colleagues determinedthat the average time for scientificevidence to be translated into prac-tice is 17 years. What’s even morestriking is that this delay was for the14% of evidence-based interventionsthat ever get translated. These obser-vations have led to the developmentof translation and implementationscience, which aims to reduce de-lays and understand what factors fa-cilitate the successful adoption andimplementation of new knowledgeinto practice.

Many evidence-based modelshave emerged to guide implementa-tion through the stages of change.This article will review EBP imple-mentation models, summarize keyresources for selecting implementa-tion strategies, and present a casestudy using an implementation mod-el that promotes successful uptakeof evidence into practice.

EBP implementation modelsNilsen published a summary of im-plementation models, frameworks,and theories that have been devel-oped in implementation science toadvance EBP and expedite uptakeof evidence into real-world settings.He categorized the approaches asmodels that guide the process andsteps of moving research into prac-tice, frameworks for understandingand exploring factors that influenceimplementation, classic theories thatexplain change processes, specificimplementation models, and evalu-ation frameworks.

Process modelsProcess models are action or appli-cation oriented and take a how-toapproach. They’re common in nurs-ing because nurses value practicalapproaches to improving practice.

Examples: The Iowa EBP Modelwas developed and originally im-plemented at the University of Iowa

Hospitals and Clinics to serve as aguide to help nurses and otherhealth care providers use researchfindings to improve patient care.The Advancing Research and Clini-cal Practice through Close Collabo-ration Model developed by Melnykand colleagues begins with an orga-nizational assessment of EBP readi -ness, emphasizes EBP mentors, andpromotes changing beliefs and skillsabout EBP.

Determinants and evaluationframeworks Determinants frameworks empha-size specific factors or characteris-tics that will improve the uptake ofevidence into practice. They aim toimprove adherence to guidelines orEBPs by leveraging enabling factorsand minimizing barriers. They spec-ify barrier and facilitator characteris-tics that influence implementationoutcomes, with some frameworksspecifying relationships betweenchar acteristics and determinants. Eval -uation frameworks provide structurefor evaluating the translation of anevidence-based practice change andaddressing processes and outcomesof the change.

Examples: The Promoting Actionon Research Implementation inHealth Services framework empha-sizes the characteristics of the evi-dence, the context for the adop-tion of the evidence (includingleadership and culture), and facili-tation (person and processes) thatpromotes the EBP initiative andimplementation strategies.

The Consolidated Framework forImplementation Research addresses

Implementation: The linchpin of evidence-based

practice changesTake a strategic approach to translating research into practice.

By Sharon Tucker, PhD, RN, FAAN

LEARNING OBJECTIVES

1. Describe three models, frameworks,and theories used to implement evi-dence-based practice (EBP).

2. Discuss strategies for successful im-plementation of EBP.

The author and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to this activ-ity. See the last page of the article to learn how toearn CNE credit.

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AmericanNurseToday.com March 2019 American Nurse Today 9

the gap between what research tri-als have shown to work and whatactually occurs in real practice set-tings. It includes an overarching tax-onomy and includes five major do-mains: intervention characteristics,outer setting, inner setting, individ-ual characteristics, and processes.Addressing these domains helps fa-cilitate the successful uptake of evi-dence into practice.

The Reach, Effectiveness, Adop-tion, Implementation, and Mainte-nance evaluation framework origi-nally aimed to provide a consistentreporting mechanism for interven-tion studies. It has more recentlybeen used to translate research intopractice and to help plan programsand improve their chances of work-ing in real-world settings. Questionsrelated to this model are: What pop -ulation will be/was reached? Whatis/was the impact of the interven-tion, including positive and nega-tive outcomes? What adoptions willbe/were implemented for real-worldpopulation uptake? What implemen-tation strategies will be/were used?How will/was the practice changemaintained?

Implementation and classictheoriesImplementation theories were devel-oped to advance knowledge aboutbest strategies and processes forpromoting evidence uptake. Theybuild on classic (social cognitive the-ory, theory of diffusion of innova-tion) and change theories from otherfields. Everett Rogers developed thetheory of diffusion of innovation,which is widely used to promote thespread and adoption of new ideas.It recognizes that relative advantage,compatibility, complexity, trialability,and observability are key character-istics to expedite change adoptionand that ideas undergo stages ofadoption: build knowledge aboutthe innovation, build persuasion andinterest in the innovation, make adecision about adopting the innova-tion or practice change, implement

the innovation/practice change, andconfirm whether to continue. Rogersalso emphasized that types of adopt -ers (innovators, early adopters, earlymajority, late majority, and laggards)influence rate and success of newidea adoption.

Examples: The TranstheoreticalModel (TTM), also known as Stagesof Change Model, proposes that peo-ple move through a series of stageswhen modifying behavior. Differentprinciples and processes of changework best at each stage to reduce re-sistance, facilitate pro gress, and pre-vent drift back to old behavior. (SeeTranstheoretical Model.)

EBP uptake strategiesA by-product of developing imple-mentation models is identifyingstrategies for a successful EBP ini-tiative. These strategies generallyfall into seven categories: leader-ship, coaching, communication, re-inforcement, recognition, measure-ment, and reporting.

The following references wereselected to highlight key implemen-tation strategies that nurses can usein their EBP initiatives. Keep in mindthat a toolbox of strategies will im-prove success. A different strategymay be needed at each phase ofthe initiative, for use with barriersand facilitators, and in specific set-tings. These strategies can be usedwith each of the models describedabove.

Grol and Grimshaw: Over 15years ago, Grol and Grimshaw sum-marized 54 reviews about how tosuccessfully change practice. Theyfocused on three areas: attributes ofthe practice, including its complexi-ty and difference from usual prac-tice; barriers and facilitators withinthe practice change setting and peo-ple involved; and the effectivenessof the most frequently used strate-gies for promoting change.

Grol and Grimshaw found thateducation strategies, audit and feed-back, and reminders and computersare important for successful change.

They also recommended interactivesmall group meetings, mass mediacampaigns, and combined strate-gies. The authors concluded thatchange generally requires compre-hensive approaches at different lev-els and for different interventions,and that a one-size-fits-all approachis unlikely to be successful.

Grimshaw and colleagues: Grim -shaw and colleagues suggested thatsuccessfully translating research in-to practice requires asking five keyquestions: • What research evidence should

be translated? • Who should the evidence be

trans ferred to? • Who should translate or deliver

the evidence? • How should the evidence be

translated? • What effects can be expected

from the translation?The authors stressed that a crit-

ical first step is assessing organi-zational barriers and facilitatorsspecific to the proposed practicechange. This assessment can guideimplementation strategy selection.They also reviewed the latest evi-dence on various implementationstrategies and highlighted the mosteffective: Holding educational meet-ings and providing learning mate-rials, leveraging the influence oflocal opinion leaders, auditing cli-nician documentation and provid-ing specific feedback, and build-ing computerized reminders. Inaddition, they noted patient strate-gies—such as patient decisionaids, interactive health communi-cation apps, and communicationbefore consultations to introducerecommended health behavior—that can help facilitate health be-havior change.

University of Iowa Hospitals andClinics (UIHC) Resources: For dec -ades, UIHC nurses have been EBPleaders. The Iowa EBP Model is akey product of this group’s work.Using this model, UIHC teams iden-tified the complexity of EBP imple-

10 American Nurse Today Volume 14, Number 3 AmericanNurseToday.com

mentation. From their observations,UIHC colleagues Cullen and Adamsbuilt on Rogers’ theory of innova-tion and developed a four-phase(create awareness and interest, buildknowledge and commitment, pro-mote action and adoption, and pur-sue integration and sustained use)implementation guide for select-ing the best strategies for a specificpractice.

Cullen and colleagues used thistool along with the Iowa EBP Mod-el as the foundation for an applica-tion-oriented book, Evidence-basedPractice in Action: ComprehensiveStrategies, Tools, and Tips from theUniversity of Iowa Hospitals andClinics. For each of 63 implementa-tion strategies, the authors providea definition, benefits, procedure,case example, and support refer-ences.

Powell and colleagues: Similarto the work led by the UIHC nurs-ing team, Powell and colleaguesused an expert panel to compile alist of 73 implementation strategies(for example, accessing funding,audit and feedback, centralizingtechnical assistance, developing animplementation glossary, distribut-ing education materials, facilitat-ing, and using advisory boardsand data experts) for the mentalhealth sector. The panel was se-lected based on expertise in im-plementation science and clinicalpractice, and members participatedin three rounds of a survey usinga Delphi process research design.The first two rounds involved aweb-based survey; the third roundused a web-based live polling andconsensus process. Although thesestrategies are specific to mentalhealth, they cross disciplines, spe-cialties, and settings.

Li and colleagues: A systematicreview by Li and colleagues fo-cused on organizational contextualfeatures that influence EBP imple-mentation across healthcare set-tings. They reviewed and rated thequality of 36 studies published be-

tween January 2005 and June 2017.Using a standardized rating tool,they scored five studies as highquality, 22 as moderately high qual-ity, and eight as moderate quality.Factors identified as important toimplementation included organiza-tional culture, networks and com-munication, leadership, resources(financial, staffing and workload,time, and education and training),evaluation, monitoring and feed-back, and champions. The authorsnoted that leadership influences allother factors and should be a prior-ity in implementation initiatives andthat combined factors are more in-

fluential than a single factor, point-ing to the importance of a multi-strategy toolkit.

Take a collective approachThese combined resources providenurses with multiple strategies toconsider when embarking on EBPchanges. Tucker and colleaguesfrom the Ohio State University de-veloped a scale that includes a listof implementation strategies clini-cians can rate their confidence inusing. (Visit americannursetoday.com/?p=55438 to view the EBP Imple-mentation Strategies Self-EfficacyScale.)

Case study This case study uses TTM (stagesof change) to illustrate the valueof EBP implementation modelsto guide strategy selection. Likeindividuals making behaviorchange, groups and organiza-tions also experience differentlevels of readiness to change.The TTM stages can guide theselection of implementationstrategies.

Case descriptionAn organization with an opioiduse reduction program decidesto integrate evidence-based non-pharmacologic interventions forpain control in patients withchronic pain (such as back pain)admitted to a hospital unit foracute pain (such as fracturedwrist needing surgery).

Precontemplation stage (not ready)At this stage, many staff mem-bers and leaders may feel thatthe current practice is workingfine, and they aren’t open to ex-ploring change. Maybe the tim-ing isn’t right, the initiative isn’taligned with organizationalstrategic priorities, resourcesaren’t available, or leadership

isn’t on board. Nursing staff andleaders operating in this stagemay view offering nonpharma-cologic interventions for short-term patients admitted to thehospital as unnecessary givenother patient care demands, ormaybe they think the interven-tion is more appropriate for theoutpatient practice.

Implementation strategies: En -gage leadership in discussionsabout pain management andopioid concerns and aligning thechange with strategic priorities.Staff should explore attitudesand goals about nonpharma -cologic pain management to understand resistance they en-counter and offer evidenceabout opioids and nonpharma-cologic interventions. Facts canbe reviewed in a workshop,newsletter, or a journal club fa-cilitated by opinion leaders orchampions.

Contemplation stage (getting ready)Staff are aware that integratingnonpharmacologic pain manage-ment strategies is aligned withthe organization’s opioid use re-duction program. Organizationalleaders are responding to regula-

AmericanNurseToday.com March 2019 American Nurse Today 11

tions and national mandates, andthey’re aware of opioid-relatedmortality rates within their prac-tices and geographic region.They may appoint a task force toexamine the issue and currentpractices, or an interprofessionalteam may convene on its own todiscuss their opioid use practicesand the integration of nonphar-macologic strategies to augmentpain management.

Implementation strategies: Be-gin by exploring expectationsabout using nonpharmacologicinterventions with staff and thensummarizing their pros and cons.Engage leaders and staff in dis-cussions about national opioiduse concerns, their own currentopioid practices, and desired out-comes. Provide education andshare best evidence to build staffconfidence in delivering nonphar-

macologic interventions. Continueto engage local champions.

Preparation stage (ready)Staff and leaders are ready totake action within a specifiedtime period, a literature review isconducted, and an action plan isdeveloped. In the case example,leaders would request an EBPinitiative, and an interprofes-sional team would form and cre-ate an EBP question. (See Fram-ing the question.)

Implementation strategies:Multiple implementation strate-gies can be used in this stage toensure successful adoption of thepractice by all staff. Create an in-terprofessional team with a com-mitted leader who attends plan-ning discussions and supportsneeded resources and time. Be-fore launching, identify and man-

age barriers to practice change,such as resources, lack of knowl-edge, negative attitudes amongselect and influential staff, andlack of leader modeling and en-gagement. The leader will workwith the team to create an actionplan with a timeline and key ac-countable people. Collect base-line data for evaluating the prac-tice change and communicate(through formal announcementsand informal discussions) withall stakeholders, including pa-tients, families, and staff. Imple-ment a toolkit with several non-pharmacologic options andcreate quick references cardsabout opioid assessment andnonpharmacologic pain man-agement approaches. Plan train-ing and education sessions andcreate a patient and family edu-cation pamphlet. Rally earlyadopters.

Action stage (moving forward)At this point, the practice changeshould be in process with multi-ple implementation strategies toincrease evidence uptake. Lead-ers designate resources, such asinformation technology, to con-duct and evaluate the change.The goal is to keep the changemoving forward. In the casestudy, administrative support isobserved with resource alloca-tion. One nursing unit may pilotthe practice change to routinelyoffer nonpharmacologic inter-ventions to patients experiencingpain to augment pharmacologicstrategies.

Implementation strategies:Multiple implementation strate-gies are purposefully selected tomaintain the practice changemomentum. Frequently measureoutcomes such as pain ratings,opioid use, and nonpharmaco-logic interventions. Flexible self-learning modules and pocketreference cards can help staffgain confidence with the new

Transtheoretical Model

The Transtheoretical (Stages ofChange) Model is based on thetheory that individuals follow a

circular rather than linear path asthey flow through a series of

stages to modify behavior.

Precontemplation (not ready)

Contemplation(getting ready)

Preparation withplan (ready)

Action (moving forward)

Maintenance(managing and

preventing drift)

Termination (when appropriate)

12 American Nurse Today Volume 14, Number 3 AmericanNurseToday.com

A sure path to success Implementation is a major step inthe EBP process, but it’s often under-appreciated and lacks resources.Consequently, the translation of evi-dence into practice is slow, can’t besustained, or doesn’t even occur.

Many implementation models pro-mote EBP, and a toolbox of strate-gies is your surest path to success.

Sharon Tucker is the Grayce Sills endowed professorin psychiatric–mental health nursing in the collegeof nursing, the translational/implementation re-

search core director, and the Helene Fuld HealthTrust National Institute for Evidence-based Practicein Nursing and Healthcare nurse scientist at theWexner Medical Center at The Ohio State Universityin Columbus.

Visit americannursetoday.com/?p=55438 for alist of selected references.

practice. Electronic health recordprompts, other types of remind -ers, and reports to leadership re-inforce the new practice. In ad-dition, patient education andsupport help ensure success.

Maintenance stage (manag-ing and preventing drift)This stage demands ongoing ef-fort and resources to ensure thepractice becomes hardwired andreplaces the old practice. Thismay take weeks, months, andeven years. In the case study,staff work to maintain their com-mitment to offering patients non-pharmacologic pain strategies.Leaders must offer ongoing sup-port and encouragement, con-tinue auditing/monitoring, andprovide feedback. Booster train-ing may be needed for existingstaff and a structured processcreated for onboarding new staff.

Implementation strategies:Several implementation strate-gies can help maintain the prac-tice change. Monitor data trends,report data to senior leaders,and encourage leadershiprounds to ask about nonpharma-cologic interventions. Projectteam members and unit leadersshould continue to celebrate andrecognize success and supportchampions with incentives andrewards. Address resistance assoon as it’s identified.

Other strategies include rollingout the practice to other units,recognizing that drift back to theold practice can occur at any time,changing the reminder mech a ni -sms, continuing to review litera-ture and new evidence at regularintervals, setting new goals andobjectives as needed, updatingaction plans, reporting to qualityimprovement teams, presenting

project details and data throughinformal and formal presenta-tions, and including project re-ports in annual reports.

Termination stage (when appropriate)If the practice is truly hard-wired, no additional efforts areneeded to sustain the change,and the implementation processcan be terminated. This stagemay not be reached for a longtime and may not be appropri-ate for many practice changes.Or maybe the practice isn’t fea-sible or effective and it shouldbe abandoned.

Implementation strategies:Specific implementation strate-gies at this stage begin with de-termining if terminating the teamefforts is appropriate. In the casestudy, if termination can occur,team members will want to iden-tify what indicators suggest thatthe nonpharmacologic interven-tions are consistently used andwhich focused implementationstrategies are no longer needed.Leadership will be responsiblefor ongoing monitoring of datatrends and adherence to thepractice change. If evidence ofpractice drift back is identified,the implementation project mayneed to be resumed or a newproject created.

Thank and celebrate all staffmembers, as a group and indi-vidually, and consider thank-yougifts for project team members.Termination interviews or focusgroups can help the organizationlearn which implementationstrategies were most effective.

A common tool to help frame an evidence-based practice (EBP) question is prob -lem/patient/population, intervention/indicator, comparison, and outcome (PICO).Here’s how the tool was applied in the case study

Component Case study

Problem/patient/population Hospitalized patients being simultaneously treated for chronic and acute pain

Intervention/indicator Nonpharmacologic interventions

Comparison Pharmacologic interventions

Outcome Limited opioid use for pain management

The team combined the elements into this EBP question: In hospitalized patientsbeing simultaneously treated for chronic and acute pain, what nonpharmacolog-ic interventions can augment pharmacologic interventions and limit opioid useas compared to opioid use only for pain management?

Framing the question

AmericanNurseToday.com March 2019 American Nurse Today 13

Please mark the correct answer online.

1. An example of a process model for imple-menting evidence-based practice (EBP) is the

a. Consolidated EBP Model.b. Promoting Action Model.c. Iowa EBP Model.d. Effectiveness and Adoption Model.

2. An example of a determinants frameworkfor implementing EBP is the

a. Advancing EBP through Close Collabora-tion Framework.

b. Reach and Implementation Framework. c. Effectiveness and Adoption Framework.d. Consolidated Framework for Implementa-

tion Research.

3. An example of an implementation theorythat can promote uptake of evidence is the

a. Transtheoretical Model.b. University of Indiana Theory.c. Effectiveness and Adoption Framework.d. Transfer Cognition Theory.

4. The implementation model or frameworkthat emphasizes EBP mentors is the

a. Advancing Research and Clinical Practicethrough Close Collaboration Model.

b. Promoting Action on Research Imple-mentation in Health Services framework.

c. Reach, Effectiveness, Adoption, Imple-mentation, and Maintenance evaluationframework.

d. Transtheoretical Model (Stages ofChange).

5. Which type of model or framework speci-fies barrier and facilitator characteristics thatinfluence implementation outcomes?

a. EBP evaluation modelb. Implementation modelc. Process framework d. Determinants framework

6. All of the following are domains in theConsolidated Framework for ImplementationResearch except

a. individual characteristics.b. intervention characteristics.c. inner setting.d. individual tasks.

7. Everett Rogers developed the a. Promoting Research Action Framework.b. theory of dissemination of information.c. Close Collaboration Model.d. theory of diffusion of innovation.

8. Grol and Grimshaw stressed that the firststep in changing practice is

a. holding large town-hall types of meetingsto discuss the practice.

b. assessing organizational barriers and facil-itators related to the proposed change.

c. assessing nurse-related barriers and facili-tators related to the proposed change.

d. determining which strategy would bemost effective to communicate.

9. Cullen and Adams developed a four-phase implementation guide that follows thisorder:

a. create awareness and interest, buildknowledge and commitment, promoteaction and adoption, and pursue integra-tion and sustained use.

b. build knowledge and commitment, cre-ate awareness and interest, promote ac-tion and adoption, and pursue integra-tion and sustained use.

c. promote action and adoption, createawareness and interest, build knowledgeand commitment, and pursue integrationand sustained use.

d. create awareness and interest, promoteaction and adoption, pursue integrationand sustained use, and build knowledgeand commitment.

10. According to a systematic review by Liand colleagues, which of the following influ-ences all other factors and should be a priori-ty in implementation initiatives?

a. Participation b. Leadership c. Communicationd. Evaluation

11. Staff members who are pleased with cur-rent reports of patient satisfaction are inwhich stage of change?

a. Contemplationb. Precontemplationc. Preparation with pland. Action

12. Which stage of change demands ongoingeffort and resources to ensure the practicebecomes hardwired?

a. Contemplationb. Preparation with planc. Maintenance d. Termination

13. A step that should occur during thepreparation stage of change is

a. rally early adopters.b. address resistors.c. appoint a task force. d. hold a town hall meeting.

14. Which statement about implementingEBP is correct?

a. Using multiple strategies, rather thanchoosing only one, is more effective.

b. Using a single strategy, rather than multi-ple ones, is more effective.

c. Patient decision aids do not help facilitatehealth behavior change.

d. Chart audits to review clinical documen-tation by staff should be avoided.

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