For this Assignment , read the book chapter by Titler (2008) presented in this week’s resources that describes evidence-based practice and translational science, as well as the kind of research needed for both. Then, reflect on how the knowledge you gained about research will support your effort as a nursing professional to improve patient quality and safety.
Describe how you will use evidence-based practice to improve patient quality and safety in your health care setting. Be specific and provide examples. Then, explain how the knowledge gained about research in this course will support your role in practice as a nursing professional. Then, describe how you will use evidence-based practice to improve patient quality and safety.
Complete a five-paragraph (at least 550 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames.
Chapter 7. The Evidence for Evidence-Based Practice
Implementation
Marita G. Titler
Overview of Evidence-Based Practice
Evidence-based health care practices are available for a number of conditions such as asthma,
heart failure, and diabetes. However, these practices are not always implemented in care
delivery, and variation in practices abound.1–
4
Traditionally, patient safety research has focused
on data analyses to identify patient safety issues and to demonstrate that a new practice will lead
to improved quality and patient safety.
5
Much less research attention has been paid to how to
implement practices. Yet, only by putting into practice what is learned from research will care be
made safer.5 Implementing evidence-based safety practices are difficult and need strategies that
address the complexity of systems of care, individual practitioners, senior leadership, and—
ultimately—changing health care cultures to be evidence-based safety practice environments.5
Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6–
9
Although during the early and mid-
19
00s, few nurses contributed to this foundation initiated
by Nightingale,
10
the nursing profession has more recently provided major leadership for
improving care through application of research findings in practice.1
1
Evidence-based practice (EBP) is the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care
decisions.12–
15
Best evidence includes empirical evidence from randomized controlled trials;
evidence from other scientific methods such as descriptive and qualitative research; as well as
use of information from case reports, scientific principles, and expert opinion. When enough
research evidence is available, the practice should be guided by research evidence in conjunction
with clinical expertise and patient values. In some cases, however, a sufficient research base may
not be available, and health care decisionmaking is derived principally from nonresearch
evidence sources such as expert opinion and scientific principles.1
6
As more research is done in a
specific area, the research evidence must be incorporated into the EBP.15
Models of Evidence-Based Practice
Multiple models of EBP are available and have been used in a variety of clinical settings.
16
–36
Although review of these models is beyond the scope of this chapter, common elements of these
models are selecting a practice topic (e.g., discharge instructions for individuals with heart
failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient
care and provider performance, and consideration of the context/setting in which the practice is
implemented.15, 1
7
The learning that occurs during the process of translating research into
practice is valuable information to capture and feed back into the process, so that others can
adapt the evidence-based guideline and/or the implementation strategies.
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Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
A recent conceptual framework for maximizing and accelerating the transfer of research
results from the Agency for Healthcare Research and Quality (AHRQ) patient safety research
portfolio to health care delivery was developed by the dissemination subcommittee of the AHRQ
Patient Safety Research Coordinating Committee.37 This model is a synthesis of concepts from
scientific information on knowledge transfer, social marketing, social and organizational
innovation, and behavior change (see Figure 1).37 Although the framework is portrayed as a
series of stages, the authors of this framework do not believe that the knowledge transfer process
is linear; rather, activities occur simultaneously or in different sequences, with implementation of
EBPs being a multifaceted process with many actors and systems.
Steps of Evidence-Based Practice
Steps of promoting adoption of EBPs can be viewed from the perspective of those who
conduct research or generate knowledge,23, 37 those who use the evidence-based information in
practice,16, 31 and those who serve as boundary spanners to link knowledge generators with
knowledge users.19
Steps of knowledge transfer in the AHRQ model37 represent three major stages: (1)
knowledge creation and distillation, (2) diffusion and dissemination, and (3) organizational
adoption and implementation. These stages of knowledge transfer are viewed through the lens of
researchers/creators of new knowledge and begin with determining what findings from the
patient safety portfolio or individual research projects ought to be disseminated.
Knowledge creation and distillation is conducting research (with expected variation in
readiness for use in health care delivery systems) and then packaging relevant research findings
into products that can be put into action—such as specific practice recommendations—thereby
increasing the likelihood that research evidence will find its way into practice.37 It is essential
that the knowledge distillation process be informed and guided by end users for research findings
to be implemented in care delivery. The criteria used in knowledge distillation should include
perspectives of the end users (e.g., transportability to the real-world health care setting,
feasibility, volume of evidence needed by health care organizations and clinicians), as well as
traditional knowledge generation considerations (e.g., strength of the evidence, generalizability).
Diffusion and dissemination involves partnering with professional opinion leaders and health
care organizations to disseminate knowledge that can form the basis of action (e.g., essential
elements for discharge teaching for hospitalized patient with heart failure) to potential users.
Dissemination partnerships link researchers with intermediaries that can function as knowledge
brokers and connectors to the practitioners and health care delivery organizations. Intermediaries
can be professional organizations such as the National Patient Safety Foundation or
multidisciplinary knowledge transfer teams such as those that are effective in disseminating
research-based cancer prevention programs. In this model, dissemination partnerships provide an
authoritative seal of approval for new knowledge and help identify influential groups and
communities that can create a demand for application of the evidence in practice. Both mass
communication and targeted dissemination are used to reach audiences with the anticipation that
early users will influence the latter adopters of the new usable, evidence-based research findings.
Targeted dissemination efforts must use multifaceted dissemination strategies, with an emphasis
on channels and media that are most effective for particular user segments (e.g., nurses,
physicians, pharmacists).
End user adoption, implementation, and institutionalization is the final stage of the
knowledge transfer process.37 This stage focuses on getting organizations, teams, and individuals
2
Evidence-Based Practice Implementation
to adopt and consistently use evidence-based research findings and innovations in everyday
practice. Implementing and sustaining EBPs in health care settings involves complex
interrelationships among the EBP topic (e.g., reduction of medication errors), the organizational
social system characteristics (such as operational structures and values, the external health care
environment), and the individual clinicians.35, 37–39 A variety of strategies for implementation
include using a change champion in the organization who can address potential implementation
challenges, piloting/trying the change in a particular patient care area of the organization, and
using multidisciplinary implementation teams to assist in the practical aspects of embedding
innovations into ongoing organizational processes.35, 37 Changing practice takes considerable
effort at both the individual and organizational level to apply evidence-based information and
products in a particular context.22 When improvements in care are demonstrated in the pilot
studies and communicated to other relevant units in the organization, key personnel may then
agree to fully adopt and sustain the change in practice. Once the EBP change is incorporated into
the structure of the organization, the change is no longer considered an innovation but a standard
of care.22, 37
In comparison, other models of EBP (e.g., Iowa Model of Evidence-based Practice to
Promote Quality of Care16) view the steps of the EBP process from the perspective of clinicians
and/or organizational/clinical contexts of care delivery. When viewing steps of the EBP process
through the lens of an end user, the process begins with selecting an area for improving care
based on evidence (rather than asking what findings ought to be disseminated); determining the
priority of the potential topic for the organization; formulating an EBP team composed of key
stakeholders; finding, critiquing, and synthesizing the evidence; setting forth EBP
recommendations, with the type and strength of evidence used to support each clearly
documented; determining if the evidence findings are appropriate for use in practice; writing an
EBP standard specific to the organization; piloting the change in practice; implementing changes
in practice in other relevant practice areas (depending on the outcome of the pilot); evaluating
the EBP changes; and transitioning ongoing quality improvement (QI) monitoring, staff
education, and competency review of the EBP topic to appropriate organizational groups as
defined by the organizational structure.15, 40 The work of EBP implementation from the
perspective of the end user is greatly facilitated by efforts of AHRQ, professional nursing
organizations (e.g., Oncology Nursing Society), and others that distill and package research
findings into useful products and tools for use at the point of care delivery.
When the clinical questions of end users can be addressed through use of existing evidence
that is packaged with end users in mind, steps of the EBP process take less time and more effort
can be directed toward the implementation, evaluation, and sustainability components of the
process. For example, finding, critiquing, and synthesizing the evidence; setting forth EBP
recommendations with documentation of the type and strength of evidence for each
recommendation; and determining appropriateness of the evidence for use in practice are
accelerated when the knowledge-based information is readily available. Some distilled research
findings also include quick reference guides that can be used at the point of care and/or
integrated into health care information systems, which also helps with implementation.41, 42
Translation Science: An Overview
Translation science is the investigation of methods, interventions, and variables that
influence adoption by individuals and organizations of EBPs to improve clinical and operational
decisionmaking in health care.35, 43–46 This includes testing the effect of interventions on
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promoting and sustaining adoption of EBPs. Examples of translation studies include describing
facilitators and barriers to knowledge uptake and use, organizational predictors of adherence to
EBP guidelines, attitudes toward EBPs, and defining the structure of the scientific field.11, 47–49
Translation science must be guided by a conceptual model that organizes the strategies being
tested, elucidates the extraneous variables (e.g., behaviors and facilitators) that may influence
adoption of EBPs (e.g., organizational size, characteristics of users), and builds a scientific
knowledge base for this field of inquiry.15, 50 Conceptual models used in the translating-research-
into-practice studies funded by AHRQ were adult learning, health education, social influence,
marketing, and organizational and behavior theories.51 Investigators have used Rogers’s
Diffusion of Innovation model,35, 39, 52–55 the Promoting Action on Research Implementation in
Health Services (PARIHS) model,29 the push/pull framework,23, 56, 57 the decisionmaking
framework,5
8
and the Institute for Healthcare Improvement (IHI) model59 in translation science.
Study findings regarding evidence-based practices in a diversity of health care settings are
building an empirical foundation of translation science.19, 43, 51, 60–83 These investigations and
others
18
, 84–86 provide initial scientific knowledge to guide us in how to best promote use of
evidence in practice. To advance knowledge about promoting and sustaining adoption of EBPs in
health care, translation science needs more studies that test translating research into practice
(TRIP) interventions: studies that investigate what TRIP interventions work, for whom, in what
circumstances, in what types of settings; and studies that explain the underlying mechanisms of
effective TRIP interventions.35, 49, 79, 87 Partnership models, which encourage ongoing interaction
between researchers and practitioners, may be the way forward to carry out such studies.56
Challenges, issues, methods, and instruments used in translation research are described
elsewhere.11, 19, 49, 78, 88–97
What Is Known About Implementing Evidence-Based Practices?
Multifaceted implementation strategies are needed to promote use of research evidence in
clinical and administrative health care decisionmaking.15, 22, 37, 45, 64, 72, 77, 79, 98, 99 Although
Grimshaw and colleagues65 suggest that multifaceted interventions are no more effective than
single interventions, context (site of care delivery) was not incorporated in the synthesis
methodology. As noted by others, the same TRIP intervention may meet with varying degrees of
effectiveness when applied in different contexts.35, 49, 79, 80, 87, 100, 101 Implementation strategies
also need to address both the individual practitioner and organizational
perspective.15, 22, 37, 64, 72, 77, 79, 98 When practitioners decide individually what evidence to use in
practice, considerable variability in practice patterns result,71 potentially resulting in adverse
patient outcomes.
For example, an “individual” perspective of EBP would leave the decision about use of
evidence-based endotracheal suctioning techniques to each nurse and respiratory therapist. Some
individuals may be familiar with the research findings for endotracheal suctioning while others
may not. This is likely to result in different and conflicting practices being used as people change
shifts every 8 to
12
hours. From an organizational perspective, endotracheal suctioning policies
and procedures based on research are written, the evidence-based information is integrated into
the clinical information systems, and adoption of these practices by nurses and other practitioners
is systematically promoted in the organization. This includes assuring that practitioners have the
4
Evidence-Based Practice Implementation
necessary knowledge, skills, and equipment to carry out the evidence-based endotracheal
suctioning practice. The organizational governance supports use of these practices through
various councils and committees such as the Practice Committee, Staff Education Committee,
and interdisciplinary EBP work groups.
The Translation Research Model,35 built on Rogers’s seminal work on diffusion of
innovations,39 provides a guiding framework for testing and selecting strategies to promote
adoption of EBPs. According to the Translation Research Model, adoption of innovations such
as EBPs are influenced by the nature of the innovation (e.g., the type and strength of evidence,
the clinical topic) and the manner in which it is communicated (disseminated) to members
(nurses) of a social system (organization, nursing profession).35 Strategies for promoting
adoption of EBPs must address these four areas (nature of the EBP topic; users of the evidence;
communication; social system) within a context of participative change (see Figure 2). This
model provided the framework for a multisite study that tested the effectiveness of a multifaceted
TRIP intervention designed to promote adoption of evidence-based acute pain management
practices for hospitalized older adults. The intervention improved the quality of acute pain
management practices and reduced costs.81 The model is currently being used to test the
effectiveness of a multifaceted TRIP intervention to promote evidence-based cancer pain
management of older adults in home hospice settings.* This guiding framework is used herein to
overview what is known about implementation interventions to promote use of EBPs in health
care systems (see Evidence Table).
Nature of the Innovation or Evidence-Based Practice
Characteristics of an innovation or EBP topic that affect adoption include the relative
advantage of the EBP (e.g., effectiveness, relevance to the task, social prestige); the
compatibility with values, norms, work, and perceived needs of users; and complexity of the
EBP topic.39 For example, EBP topics that are perceived by users as relatively simple (e.g.,
influenza vaccines for older adults) are more easily adopted in less time than those that are more
complex (acute pain management for hospitalized older adults). Strategies to promote adoption
of EBPs related to characteristics of the topic include practitioner review and “reinvention” of
the EBP guideline to fit the local context, use of quick reference guides and decision aids, and
use of clinical reminders.53, 59, 60, 65, 74, 82, 102–107 An important principle to remember when
planning implementation of an EBP is that the attributes of the EBP topic as perceived by users
and stakeholders (e.g., ease of use, valued part of practice) are neither stable features nor sure
determinants of their adoption. Rather it is the interaction among the characteristics of the EBP
topic, the intended users, and a particular context of practice that determines the rate and extent
of adoption.22, 35, 39
Studies suggest that clinical systems, computerized decision support, and prompts that
support practice (e.g., decisionmaking algorithms, paper reminders) have a positive effect on
aligning practices with the evidence base.15, 51, 65, 74, 80, 82, 102, 104, 107–110 Computerized knowledge
management has consistently demonstrated significant improvements in provider performance
and patient outcomes.82 Feldman and colleagues, using a just-in-time e-mail reminder in home
health care, have demonstrated (1) improvements in evidence-based care and outcomes for
patients with heart failure,64, 77 and (2) reduced pain intensity for cancer patients.75 Clinical
information systems should deploy the evidence base to the point of care and incorporate
* Principal Investigator: Keela Herr (R01 grant no. CA115363-01; National Cancer Institute (NCI))
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computer decision-support software that integrates evidence for use in clinical decisionmaking
about individual patients.40, 104, 111–1
14
There is still much to learn about the “best” manner of
deploying evidence-based information through electronic clinical information systems to support
evidence-based care.115
Methods of Communication
Interpersonal communication channels, methods of communication, and influence among
social networks of users affect adoption of EBPs.39 Use of mass media, opinion leaders, change
champions, and consultation by experts along with education are among strategies tested to
promote use of EBPs. Education is necessary but not sufficient to change practice, and didactic
continuing education alone does little to change practice behavior.61, 116 There is little evidence
that interprofessional education as compared to discipline-specific education improves EBP.1
17
Interactive education, used in combination with other practice-reinforcing strategies, has more
positive effects on improving EBP than didactic education alone.66, 68, 71, 74, 118, 119 There is
evidence that mass media messages (e.g., television, radio, newspapers, leaflets, posters and
pamphlets), targeted at the health care consumer population, have some effect on use of health
services for the targeted behavior (e.g., colorectal cancer screening). However, little empirical
evidence is available to guide framing of messages communicated through planned mass media
campaigns to achieve the intended change.120
Several studies have demonstrated that opinion leaders are effective in changing behaviors of
health care practitioners,22, 68, 79, 100, 116, 121–123 especially in combination with educational
outreach or performance feedback. Opinion leaders are from the local peer group, viewed as a
respected source of influence, considered by associates as technically competent, and trusted to
judge the fit between the innovation and the local situation.39, 116, 121, 124–127 With their wide
sphere of influence across several microsystems/units, opinion leaders’ use of the innovation
influences peers and alters group norms.39,128 The key characteristic of an opinion leader is that
he or she is trusted to evaluate new information in the context of group norms. Opinion
leadership is multifaceted and complex, with role functions varying by the circumstances, but
few successful projects to implement innovations in organizations have managed without the
input of identifiable opinion leaders.22, 35, 39, 81, 96 Social interactions such as “hallway chats,”
one-on-one discussions, and addressing questions are important, yet often overlooked
components of translation.39, 59 Thus, having local opinion leaders discuss the EBPs with
members of their peer group is necessary to translate research into practice. If the EBP that is
being implemented is interdisciplinary in nature, discipline-specific opinion leaders should be
used to promote the change in practice.39
Change champions are also helpful for implementing innovations.39, 49, 81, 129–
13
1 They are
practitioners within the local group setting (e.g., clinic, patient care unit) who are expert
clinicians, passionate about the innovation, committed to improving quality of care, and have a
positive working relationship with other health care professionals.39, 125, 131, 132 They circulate
information, encourage peers to adopt the innovation, arrange demonstrations, and orient staff to
the innovation.49, 130 The change champion believes in an idea; will not take “no” for an answer;
is undaunted by insults and rebuffs; and, above all, persists.133 Because nurses prefer
interpersonal contact and communication with colleagues rather than Internet or traditional
sources of practice knowledge,134–137 it is imperative that one or two change champions be
identified for each patient care unit or clinic where the change is being made for EBPs to be
enacted by direct care providers.81, 138 Conferencing with opinion leaders and change champions
6
Evidence-Based Practice Implementation
periodically during implementation is helpful to address questions and provide guidance as
needed.35, 66, 81, 106
Because nurses’ preferred information source is through peers and social interactions,134–
137, 139, 140 using a core group in conjunction with change champions is also helpful for
implementing the practice change.16, 110, 141 A core group is a select group of practitioners with
the mutual goal of disseminating information regarding a practice change and facilitating the
change by other staff in their unit/microsystem.142 Core group members represent various shifts
and days of the week and become knowledgeable about the scientific basis for the practice; the
change champion educates and assists them in using practices that are aligned with the evidence.
Each member of the core group, in turn, takes the responsibility for imparting evidence-based
information and effecting practice change with two or three of their peers. Members assist the
change champion and opinion leader with disseminating the EBP information to other staff,
reinforce the practice change on a daily basis, and provide positive feedback to those who align
their practice with the evidence base.15 Using a core-group approach in conjunction with a
change champion results in a critical mass of practitioners promoting adoption of the EBP.39
Educational outreach, also known as academic detailing, promotes positive changes in
practice behaviors of nurses and physicians.22, 64, 66, 71, 74, 75, 77, 81, 119, 143 Academic detailing is
done by a topic expert, knowledgeable of the research base (e.g., cancer pain management), who
may be external to the practice setting; he or she meets one-on-one with practitioners in their
setting to provide information about the EBP topic. These individuals are able to explain the
research base for the EBPs to others and are able to respond convincingly to challenges and
debates.22 This strategy may include providing feedback on provider or team performance with
respect to selected EBP indicators (e.g., frequency of pain assessment).66, 81, 119
Users of the Innovation or Evidence-Based Practice
Members of a social system (e.g., nurses, physicians, clerical staff) influence how quickly
and widely EBPs are adopted.39 Audit and feedback, performance gap assessment (PGA), and
trying the EBP are strategies that have been tested.15, 22, 65, 66, 70–72, 81, 98, 124, 144 PGA and audit and
feedback have consistently shown a positive effect on changing practice behavior of
providers.65, 66, 70, 72, 81, 98, 124, 144, 145 PGA (baseline practice performance) informs members, at the
beginning of change, about a practice performance and opportunities for improvement. Specific
practice indicators selected for PGA are related to the practices that are the focus of evidence-
based practice change, such as every-4-hour pain assessment for acute pain management.15, 66, 81
Auditing and feedback are ongoing processes of using and assessing performance indicators
(e.g., every-4-hour pain assessment), aggregating data into reports, and discussing the findings
with practitioners during the practice change.22, 49, 66, 70, 72, 81, 98, 145 This strategy helps staff know
and see how their efforts to improve care and patient outcomes are progressing throughout the
implementation process. Although there is no clear empirical evidence for how to provide audit
and feedback,70, 146 effects may be larger when clinicians are active participants in implementing
change and discuss the data rather than being passive recipients of feedback reports.67, 70
Qualitative studies provide some insight into use of audit and feedback.60, 67 One study on use of
data feedback for improving treatment of acute myocardial infarction found that (1) feedback
data must be perceived by physicians as important and valid, (2) the data source and timeliness
of data feedback are critical to perceived validity, (3) time is required to establish credibility of
data within a hospital, (4) benchmarking improves the validity of the data feedback, and (5)
physician leaders can enhance the effectiveness of data feedback. Data feedback that profiles an
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individual physician’s practices can be effective but may be perceived as punitive; data feedback
must persist to sustain improved performance; and effectiveness of data feedback is intertwined
with the organizational context, including physician leadership and organizational culture.60
Hysong and colleagues67 found that high-performing institutions provided timely,
individualized, nonpunitive feedback to providers, whereas low performers were more variable
in their timeliness and nonpunitiveness and relied more on standardized, facility-level reports.
The concept of useful feedback emerged as the core concept around which timeliness,
individualization, nonpunitiveness, and customizability are important.
Users of an innovation usually try it for a period of time before adopting it in their
practice.22, 39, 147 When “trying an EBP” (piloting the change) is incorporated as part of the
implementation process, users have an opportunity to use it for a period of time, provide
feedback to those in charge of implementation, and modify the practice if necessary.148 Piloting
the EBP as part of implementation has a positive influence on the extent of adoption of the new
practice.22, 39, 148
Characteristics of users such as educational preparation, practice specialty, and views on
innovativeness may influence adoption of an EBP, although findings are equivocal.27, 39, 130, 149–
153 Nurses’ disposition to critical thinking is, however, positively correlated with research use,154
and those in clinical educator roles are more likely to use research than staff nurses or nurse
managers.155
Social System
Clearly, the social system or context of care delivery matters when implementing
EBPs.2, 30, 33, 39, 60, 84, 85, 91, 92, 101, 156–163 For example, investigators demonstrated the effectiveness
of a prompted voiding intervention for urinary incontinence in nursing homes, but sustaining the
intervention in day-to-day practice was limited when the responsibility of carrying out the
intervention was shifted to nursing home staff (rather than the investigative team) and required
staffing levels in excess of a majority of nursing home settings.164 This illustrates the importance
of embedding interventions into ongoing processes of care.
Several organizational factors affect adoption of EBPs.22, 39, 79, 134, 165–167 Vaughn and
colleagues101 demonstrated that organizational resources, physician full-time employees (FTEs)
per 1,000 patient visits, organizational size, and whether the facility was located in or near a city
affected use of evidence in the health care system of the Department of Veterans Affairs (VA).
Large, mature, functionally differentiated organizations (e.g., divided into semiautonomous
departments and units) that are specialized, with a focus of professional knowledge, slack
resources to channel into new projects, decentralized decisionmaking, and low levels of
formalization will more readily adopt innovations such as new practices based on evidence.
Larger organizations are generally more innovative because size increases the likelihood that
other predictors of innovation adoption—such as slack financial and human resources and
differentiation—will be present. However, these organizational determinants account for only
about 15 percent of the variation in innovation adoption between comparable organizations.22
Adler and colleagues168 hypothesize that while more structurally complex organizations may be
more innovative and hence adopt EBPs relatively early, less structurally complex organizations
may be able to diffuse EBPs more effectively. Establishing semiautonomous teams is associated
with successful implementation of EBPs, and thus should be considered in managing
organizational units.168–170
8
Evidence-Based Practice Implementation
As part of the work of implementing EBPs, it is important that the social system—unit,
service line, or clinic—ensures that policies, procedures, standards, clinical pathways, and
documentation systems support the use of the EBPs.49, 68, 72, 73, 103, 140, 171 Documentation forms or
clinical information systems may need revision to support changes in practice; documentation
systems that fail to readily support the new practice thwart change.82
Absorptive capacity for new knowledge is another social system factor that affects adoption
of EBPs. Absorptive capacity is the knowledge and skills to enact the EBPs; the strength of
evidence alone will not promote adoption. An organization that is able to systematically identify,
capture, interpret, share, reframe, and recodify new knowledge, and put it to appropriate use, will
be better able to assimilate EBPs.82, 103, 172, 173 A learning organizational culture and proactive
leadership that promotes knowledge sharing are important components of building absorptive
capacity for new knowledge.66, 139, 142, 174 Components of a receptive context for EBP include
strong leadership, clear strategic vision, good managerial relations, visionary staff in key
positions, a climate conducive to experimentation and risk taking, and effective data capture
systems. Leadership is critical in encouraging organizational members to break out of the
convergent thinking and routines that are the norm in large, well-established
organizations.4, 22, 39, 122, 148, 163, 175
An organization may be generally amenable to innovations but not ready or willing to
assimilate a particular EBP. Elements of system readiness include tension for change, EBP-
system fit, assessment of implications, support and advocacy for the EBP, dedicated time and
resources, and capacity to evaluate the impact of the EBP during and following implementation.
If there is tension around specific work or clinical issues and staff perceive that the situation is
intolerable, a potential EBP is likely to be assimilated if it can successfully address the issues,
and thereby reduce the tension.22, 175
Assessing and structuring workflow to fit with a potential EBP is an important component of
fostering adoption. If implications of the EBP are fully assessed, anticipated, and planned for, the
practice is more likely to be adopted.148, 162, 176 If supporters for a specific EBP outnumber and
are more strategically placed within the organizational power base than opponents, the EBP is
more likely to be adopted by the organization.60, 175 Organizations that have the capacity to
evaluate the impact of the EBP change are more likely to assimilate it. Effective implementation
needs both a receptive climate and a good fit between the EBP and intended adopters’ needs and
values.22, 60, 140, 175, 177
Leadership support is critical for promoting use of EBPs.33, 59, 72, 85, 98, 122, 178–181 This support,
which is expressed verbally, provides necessary resources, materials, and time to fulfill assigned
responsibilities.148, 171, 182, 183 Senior leaders need to create an organizational mission, vision, and
strategic plan that incorporate EBP; implement performance expectations for staff that include
EBP work; integrate the work of EBP into the governance structure of the health care system;
demonstrate the value of EBPs through administrative behaviors; and establish explicit
expectations that nurse leaders will create microsystems that value and support clinical
inquiry.122, 183, 184
A recent review of organizational interventions to implement EBPs for improving patient
care examined five major aspects of patient care. The review suggests that revision of
professional roles (changing responsibilities and work of health professionals such as expanding
roles of nurses and pharmacists) improved processes of care, but it was less clear about the effect
on improvement of patient outcomes. Multidisciplinary teams (collaborative practice teams of
physicians, nurses, and allied health professionals) treating mostly patients with prevalent
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Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
chronic diseases resulted in improved patient outcomes. Integrated care services (e.g., disease
management and case management) resulted in improved patient outcomes and cost savings.
Interventions aimed at knowledge management (principally via use of technology to support
patient care) resulted in improved adherence to EBPs and patient outcomes. The last aspect,
quality management, had the fewest reviews available, with the results uncertain. A number of
organizational interventions were not included in this review (e.g., leadership, process redesign,
organizational learning), and the authors note that the lack of a widely accepted taxonomy of
organizational interventions is a problem in examining effectiveness across studies.82
An organizational intervention that is receiving increasing attention is tailored interventions
to overcome barriers to change.162, 175, 185 This type of intervention focuses on first assessing
needs in terms of what is causing the gap between current practice and EBP for a specified topic,
what behaviors and/or mechanism need to change, what organizational units and persons should
be involved, and identification of ways to facilitate the changes. This information is then used in
tailoring an intervention for the setting that will promote use of the specified EBP. Based on a
recent systematic review, effectiveness of tailored implementation interventions remains
uncertain.185
In summary, making an evidence-based change in practice involves a series of action steps
and a complex, nonlinear process. Implementing the change will take several weeks to months,
depending on the nature of the practice change. Increasing staff knowledge about a specific EBP
and passive dissemination strategies are not likely to work, particularly in complex health care
settings. Strategies that seem to have a positive effect on promoting use of EBPs include audit
and feedback, use of clinical reminders and practice prompts, opinion leaders, change
champions, interactive education, mass media, educational outreach/academic detailing, and
characteristics of the context of care delivery (e.g., leadership, learning, questioning). It is
important that senior leadership and those leading EBP improvements are aware of change as a
process and continue to encourage and teach peers about the change in practice. The new
practice must be continually reinforced and sustained or the practice change will be intermittent
and soon fade, allowing more traditional methods of care to return.15
Principles of Evidence-Based Practice for Patient Safety
Several translation science principles are informative for implementing patient safety
initiatives:
• First, consider the context and engage health care personnel who are at the point of care
in selecting and prioritizing patient safety initiatives, clearly communicating the evidence
base (strength and type) for the patient safety practice topic(s) and the conditions or
setting to which it applies. These communication messages need to be carefully designed
and targeted to each stakeholder user group.
• Second, illustrate, through qualitative or quantitative data (e.g., near misses, sentinel
events, adverse events, injuries from adverse events), the reason the organization and
individuals within the organization should commit to an evidence-based safety practice
topic. Clinicians tend to be more engaged in adopting patient safety initiatives when they
understand the evidence base of the practice, in contrast to administrators saying, “We
must do this because it is an external regulatory requirement.” For example, it is critical
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Evidence-Based Practice Implementation
to converse with busy clinicians about the evidence-based rationale for doing fall-risk
assessment, and to help them understand that fall-risk assessment is an external
regulatory agency expectation because the strength of the evidence supports this patient
safety practice.
• Third, didactic education alone is never enough to change practice; one-time education
on a specific safety initiative is not enough. Simply improving knowledge does not
necessarily improve practice. Rather, organizations must invest in the tools and skills
needed to create a culture of evidence-based patient safety practices where questions are
encouraged and systems are created to make it easy to do the right thing.
• Fourth, the context of EBP improvements in patient safety need to be addressed at each
step of the implementation process; piloting the change in practice is essential to
determine the fit between the EBP patient safety information/innovation and the setting
of care delivery. There is no one way to implement, and what works in one agency may
need modification to fit the organizational culture of another context.
• Finally, it is important to evaluate the processes and outcomes of implementation. Users
and stakeholders need to know that the efforts to improve patient safety have a positive
impact on quality of care. For example, if a new barcoding system is being used to
administer blood products, it is imperative to know that the steps in the process are being
followed (process indicators) and that the change in practice is resulting in fewer blood
product transfusion errors (outcome indicators).
Research Implications
Translation science is young, and although there is a growing body of knowledge in this area,
we have, to date, many unanswered questions. These include the type of audit and feedback (e.g.,
frequency, content, format) strategies that are most effective, the characteristics of opinion
leaders that are critical for success, the role of specific context variables, and the combination of
strategies that are most effective. We also know very little about use of tailored implementation
interventions, or the key context attributes to assess and use in developing and testing tailored
interventions. The types of clinical reminders that are most effective for making EBP knowledge
available at the point of care require further empirical explanation. We also know very little
about the intensity and intervention dose of single and multifaceted strategies that are effective
for promoting and sustaining use of EBPs or how the effectiveness differs by type of topic (e.g.,
simple versus complex). Only recently has the context of care delivery been acknowledged as
affecting use of evidence, and further empirical work is needed in this area to understand how
complex adaptive systems of practice incorporate knowledge acquisition and use. Lastly, we do
not know what strategies or combination of strategies work for whom, in what context, why they
work in some settings or cases and not others, and what is the mechanism by which these
strategies or combination of strategies work.
This is an exciting area of investigation that has a direct impact on implementing patient
safety practices. In planning investigations, researchers must use a conceptual model to guide the
research and add to the empirical and theoretical understanding of this field of inquiry.
Additionally, funding is needed for implementation studies that focus on evidence-based patient
safety practices as the topic of concern. To generalize empirical findings from patient safety
implementation studies, we must have a better understanding of what implementation strategies
work, with whom, and in what types of settings, and we must investigate the underlying
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mechanisms of these strategies. This is likely to require mixed methods, a better understanding
of complexity science, and greater appreciation for nontraditional methods and realistic
inquiry.87
Although the science of translating research into practice is fairly new, there is some guiding
evidence of what implementation interventions to use in promoting patient safety practices.
However, there is no magic bullet for translating what is known from research into practice. To
move evidence-based interventions into practice, several strategies may be needed. Additionally,
what works in one context of care may or may not work in another setting, thereby suggesting
that context variables matter in implementation.80
University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care.
Address correspondence to: Marita G. Titler, Ph.D., R.N., F.A.A.N., University of Iowa
Hospitals and Clinics, Department of Nursing Services and Patient Care, 200 Hawkins Drive RM
T10 GH, Iowa City, IA 52242-1009. E-mail: Marita-titler@uiowa.edu.
Several electronic databases were searched (MEDLINE®, CINAHL®, PubMed®) using terms
of evidence-based practice research, implementation research, and patient safety. (The terms
“quality improvement” or “quality improvement intervention research” were not used.) The
Cochrane Collaboration–Cochrane Reviews was also searched to look for systematic reviews of
specific implementation strategies, and the Journal of Implementation Science was also
reviewed. I also requested the final reports of the TRIP I and TRIP II studies funded by AHRQ.
Classic articles known to the author were also included in this chapter (e.g., Locock et al.123 ).
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problem: professional and the intraorganizational
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the case of hospitals. Working paper 3-15. Los
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Southern California. Available at
http://www.marshall.usc.edu/web/MOR.cfm?doc_id
= 5561 2003. June 2006.
169. Grumbach K, Bodenheimer T. Can healthcare teams
improve primary care practice? JAMA
2004;291(10):1246-51.
170. Shortell SM, Weist EM, Keita Sow M-S, et al.
Implementing the Institute of Medicine’s
recommended curriculum content in schools of
public health: a baseline assessment. Am J Public
Health 2004;94(10):1671-4.
171. Rutledge DN, Donaldson NE. Building
organizational capacity to engage in research
utilization. J Nurs Admin 1995;25(10):12-6.
172. Barnsley J, Lemieux-Charles L, McKinney MM.
Integrating learning into integrated delivery systems.
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173. Ferlie E, Gabbay J, Fitzgerald L, et al. Evidence-
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174. Lozano P, Finkelstein JA, Carey VJ, et al. A multisite
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Arch Pediatr Adolesc Med 2004;158:875-83.
175. Hagedorn H, Hogan M, Smith JL, et al. Lessons
learned about implementing research evidence into
clinical practice: experiences from VA QUERI. J
Gen Intern Med 2006;21:S21-4.
176. Buonocore D. Leadership and action: creating a
change in practice. AACN Clin Issues
2004;15(2):170-81.
177. Bradley EH, Holmboe ES, Mattera JA, et al. Data
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learned from U.S. hospitals. Qual Saf Health Care
2004;13:26-31.
178. Antrobus S, Kitson A. Nursing leadership:
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practice. J Adv Nurs 1999;29(3):746-53.
179. Baggs JG, Mick DJ. Collaboration: a tool addressing
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in intensive care units. J Gerontol Nurs
2000;26(9):41-7.
180. Carr CA, Schott A. Differences in evidence-based
care in midwifery practice and education. J Nurs
Scholarsh 2002;34(2):153-8.
181. Nagy S, Lumby J, McKinley S, et al. Nurses’ beliefs
about the conditions that hinder or support evidence-
based nursing. Int J Nurs Pract 2001;7(5):314-21.
182. Omery A, Williams RP. An appraisal of research
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1999;29(12):50-6.
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Clinics; 2002.
185. Shaw B, Cheater F, Gillies C, et al. Tailored
interventions to overcome identified barriers to
change: effects on professional practice and health
care outcomes. The Cochrane Database of Systematic
Reviews 2005(3):CD005470. DOI:
10.1002/14651858.
186. Chin MH, Cook S, Drum ML, et al. Improving
diabetes care in Midwest community health centers
with the health disparities collaborative. Diabetes
Care 2004;27:2-8.
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Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
20
187. Davey P, Brown E, Fenelon L, et al. Interventions to
improve antibiotic prescribing practices for hospital
inpatients. The Cochrane Database of Systematic
Reviews 2005(4): CD003543. DOI:
10.1002/14651858.
188. Foxcroft DR, Cole N. Organisational infrastructures
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2000(3):CD002212. DOI: 10.1002/14651858.
189. Ozer EM, Adams SH, Lustig JL, et al. Increasing the
screening and counseling of adolescents for risky
health behaviors: a primary care intervention.
Pediatrics 2005;115(4):960-8.
Figure 1. AHRQ Model of Knowledge Transfer
21
E
vidence-B
ased P
ractice Im
Adapted from Nieva, V., Murphy, R., Ridley, N., et al.37 Used with permission. http://www.ahrq.gov/qual/advances/
plem
entation
http://www.ahrq.gov/qual/advances/
http://www.ahrq.gov/qual/advances/
Figure 2.* Implementation Model Patient S
afety and Q
uality: V
ol. 1
Redrawn from Rogers EM. Diffusion of innovations. 5th ed. New York: The Free Press; 2003; Titler MG, Everett LQ. Translating research into
practice: considerations for critical care investigators. Crit Care Nurs Clin North Am 2001a;13(4):587-604. (Copyright of this model retained by
Marita Titler.)
22
Communication
Process
Rate and Extent
of Adoption
Characteristics of
the EBP
Social
Users of the
EBP
C
om
m
un
ic
at
io
n
Sourc
e
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Berner 2003121 Local opinion
leaders.
Group
randomized
controlled trial
(RCT). Evidence
level 2.
RCT 3 study arms: no
intervention, traditional
health care QI; opinion
leader (OL) plus QI (level
2). Outcomes = 6
evidence-based quality
indicators for 1994
unstable angina
guidelines (level 2).
Hospitals in
Alabama. Patients
admitted to an
Alabama hospital
during 1997–98
(baseline) and
1999–2000
(followup) with
ICD-9 CM codes
of unstable
angina, angina
pectoris, coronary
artery disease,
and chest pain
unspecified. Mean
age of patients
was >70 years of
age.
Peer nominated opinion
leader added to a
Centers for Medicare and
Medicaid Services (CMS)
QI intervention.
OL treatment
effects (over QI
group) found for
antiplatelet
medication within
24 hours and
heparin use (2 of 5
indicators).
23
E
vidence-B
ased P
ractice Im
plem
entation
24
P
atient S
afety and Q
uality: A
n E
vidence-B
ased H
andbook for N
urses: V
ol. 1
Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Bootsmiller
2004103
Assess the
implementation
methods for 4
clinical practice
guidelines
(CPGs) in the
VA health care
system.
Retrospective
cohort study.
Evidence level 5.
Survey methods with
questionnaire sent to
416 quality managers,
primary care
administrators, or others
involved with guideline
implementation in
primary care at 143 VA
medical centers with
primary care clinics
(level 9). Modified
Dillman method was
used.
Outcomes: methods
used to implement
guidelines (level 4).
Primary care
clinics of VA
medical centers.
Study population
is individual
responsible for
guideline
implementation.
242 surveys
returned from 130
hospitals. CPGs
were chronic
obstructive
pulmonary disease
(COPD), diabetes,
heart failure, and
major depressive
disorder.
Total number of
interventions used were
counted and type of
interventions used to
implement CPGs were
categorized as
consistently effective,
variably effective, and
minimally effective,
based on Bero’s
categories:
Consistently effective:
– Forms created/revised
– Computer interactive
education
– Internet discussion
groups
– Responsibilities of
nonphysicians changed
academic detailing
Variably effective:
– CPG workgroup
– Clinical meetings to
discuss CPG
Minimally effective:
– Providers receive brief
summary
– Providers receive CPG
– Providers receive
pocket guide
– Storyboards
– Instructional tape of
CPG
– Grand rounds
Commonly used
approaches were
clinical meetings to
discuss guidelines
(variably
effective/Bero’s
classification),
provider receipt of
brief summary
(minimally effective
classification),
forms created or
revised
(consistently
effective
classification),
responsibilities of
nonphysicians
revised
(consistently
effective
classification). Most
facilities used 4–7
approaches.
Consistently and
minimally effective
approaches were
used most
frequently.
Strategies used
together almost
always included
one consistently
effective approach.
25
E
vidence-B
ased P
ractice Im
plem
entation
Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Bradley 200460
Describe the
implementation
process for the
Hospital Elder
Life Program
(HELP)—an
evidence-based
program for
improving care
of older
patients.
Descriptive
prospective
study.
Qualitative analyses of
implementation process
at the beginning of
implementation and
every 6 months for up to
18 months.
8 hospitals
implementing
HELP. In-depth,
open-ended
interviews were
conducted by
telephone with
physicians,
nurses,
volunteers, and
administrative staff
involved in the
HELP
implementation.
Major themes in
implementing the
HELP program
were (1) gain
internal support for
the program,
recognizing diverse
requirements and
goals; (2) ensure
effective clinical
leadership in
multiple roles; (3)
integrate with
existing geriatric
programs to foster
coordination rather
than competition;
(4) balance
program fidelity
with hospital-
specific
circumstances; (5)
document and
publicize positive
outcomes; (6)
maintain
momentum while
changing practice
and shifting
organizational
culture.
26
P
atient S
afety and Q
uality: A
n E
vidence-B
ased H
andbook for N
urses: V
ol. 1
Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Bradley 2004177
Identify key
themes about
effective
approaches for
data feedback
as well as
pitfalls to avoid
in using data
feedback to
support
performance
improvement
efforts.
Retrospective
cohort study.
Evidence level 5.
Qualitative study with
open-ended interviews
of clinical and
administrative staff at 8
hospitals representing a
range of sizes,
geographical regions,
and beta-blocker use
rate after AMI (level 9).
Outcomes = key themes
in use of data feedback.
8 hospitals.
Interviewed
physicians (n =
14), nurses (n =
15), quality
management (n =
11), and
administrative (n =
5) staff who were
identified as key in
improving care of
patients with AMI.
Data feedback for
improving performance of
beta-blocker use after
AMI.
7 major themes:
Data must be
perceived by
physicians as valid
to motivate change.
It takes time to
develop credibility
of data within a
hospital. The
source and
timeliness of the
data are critical to
perceived validity.
Benchmarking
improves the
validity of the data
feedback.
Physician leaders
can enhance the
effectiveness of
data feedback.
Data feedback that
profiles an
individual
physician’s
practices can be
effective but may
be perceived as
punitive. Data
feedback must
persist to sustain
improved
performance.
Effectiveness of
data feedback
might be
intertwined with the
organizational
context, including
physician
leadership and
organizational
culture.
27
E
vidence-B
ased P
ractice Im
plem
entation
Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Carter 200561
Evaluation of
the relationship
between
physicians’
knowledge of
hypertension
guidelines and
blood pressure
(BP) control in
their patients.
Cross-sectional
study
Cross-sectional study of
physicians’ knowledge
about Joint National
Committee (JNC) 7
hypertension guidelines
(level 4).
Outcomes were BP
values of patients each
physician treated.
Study setting was
two academic
primary care
clinics located in
the same
academic medical
center. The
sample was 32
primary care
physicians and
613 patients they
treated. Mean age
of physicians was
41 years
(Standard
Deviation [SD]. =
10.9), majority
were men (66%).
Association between
physician knowledge and
BP control. Covariates of
presence of diabetes,
patient age.
There was a strong
inverse relationship
between BP control
rates and correct
responses by
physicians on the
knowledge test (r =
-0.524; p = .002).
Strong correlation
was also found
between correct
responses on the
knowledge survey
and a higher mean
systolic BP (r =
0.453; p = .009).
When the
covariates of
patient age and
diabetes were
added to the
model, there was
no longer a
significant
association
between physician
knowledge and BP
control. However,
the correlation (in
the multivariate
model) was still in
the same direction;
for every 5 points
better on the
knowledge test,
there was a 16%
decrease in the
rate of BP control
(p = .13), and for
every 10 years
increase in patient
age, there was a
16% decrease in
BP control (p =
.04).
28
P
atient S
afety and Q
uality: A
n E
vidence-B
ased H
andbook for N
urses: V
ol. 1
Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Chin 200462, 186 To determine
the additive
effect of
additional
support for
organizational
change
techniques and
chronic care
management as
they are added
to the Health
Disparities
Collaborative
initiatives to
improve
diabetes care in
community
health centers.
RCT 34 centers were
randomized to a
standardized intensity
arm (Health Disparities
Collaborative initiatives)
or high intensity arm.
(level 2).
Outcomes included
process of care
measures; laboratory
values based on
American Diabetes
Association (ADA)
recommendations; and
patient surveys of
satisfaction with
provider’s
communication style and
overall care, attitudes
about interacting with
providers, knowledge of
ADA recommendations,
and provider
performance of key
processes of care (levels
1 and 2).
34 community
health centers
from the Midwest
or West Central
clusters that
participated in the
1998–99 or 1999–
2000 Diabetes
Collaborative of
the Bureau of
Primary Health
Care in Improving
Diabetes Care
Collaboratively in
the Community.
These centers
care for the
medically
underserved. In
the standard arm,
there were 843
patients at
baseline and 665
in the followup
standard intensity
group. 993
patients were in
the high intensity
arm at baseline
and 818
postinterventions
high intensity
group. Mean age
of subjects ranged
from 56 to 58, a
majority were
female, and white.
All 34 centers were
community health
centers that are overseen
by the Bureau of Primary
Health Care and had
participated in the Health
Disparities Collaborative
to improve diabetes care.
Interventions included
forming a QI team,
adoption of the Plan-Do-
Study-Act (PDSA) cycle
for QI, learning sessions,
data feedback, monthly
teleconferences, and
regional meetings over a
year. The centers
randomized to the
standard intensity arm
continued to receive
quarterly data-feedback
reports, conference calls
with other centers, and a
yearly in-person meeting
with other health centers.
The high intensity sites
received the standard
intensity interventions
plus additional support in
organizational change
strategies, chronic care
management, and
strategies to engage
patients in behavioral
change designed to get
them to be more active in
their care.
Centers in the high
intensity arm
showed higher
rates of Hgb A1c
and urine
microalbumin
assessment, eye
exam, foot exam,
dental referral, and
increased
prescription of
home glucose
monitoring
postintervention as
compared to the
standard intensity
arm. No significant
differences by
treatment arm were
noted for patient
survey data.
29
E
vidence-B
ased P
ractice Im
plem
entation
Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Davey 2005187
To estimate the
effectiveness of
persuasive
interventions,
restrictive
interventions,
and structural
interventions
(alone or in
combination) in
promoting
prudent
antibiotic
prescribing to
hospital
inpatients.
Systematic
literature review.
Evidence level 1.
(Table 3.1)
RCTs, quasi-randomized
controlled trials,
controlled before and
after studies, and
interrupted time series
studies (levels 2 and 3).
Outcomes were
appropriate antibiotic
prescribing and patient
outcomes, including
length of stay, inpatient
mortality, and 28-day
mortality (levels 1 and 2).
66 studies (43
interrupted time
series studies, 13
RCTs, 6 controlled
before/after
studies, 2
controlled clinical
trials, 1 cluster
clinical trial, 1
cluster
randomized trial.
The majority of
studies (42) were
from the United
States. Study
participants were
health care
professionals who
prescribe
antibiotics to
hospitalized
inpatients
receiving acute
care.
Interventions were
categorized as
persuasive interventions
(distribution of
educational materials;
local consensus process;
educational outreach
visits; local opinion
leaders; reminders
provided verbally, on
paper, or via the
computer; audit and
feedback), restrictive
interventions (formulary
restrictions, prior
authorization
requirements, therapeutic
substations, automatic
stop orders and antibiotic
policy changes), and
structural (changing from
paper to computerized
records, introduction of
quality monitoring
mechanisms).
A wide variety of
interventions has
been shown to be
effective in
changing antibiotic
prescribing for
hospitalized
patients. Restrictive
interventions have
a greater
immediate impact
than persuasive
interventions,
although their
impact on clinical
outcomes and long-
term effects are
uncertain.
30
P
atient S
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uality: A
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vidence-B
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Source
Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Estabrooks
200420
To map
research
utilization as a
field of study in
nursing and
identify the
structure of this
scientific
community,
including the
current network
of researchers.
Systematic
literature review.
Bibliometric analysis to
map the development
and structure of the field.
Outcomes were journal
patterns of publication,
country patterns of
publication, author
patterns of publication,
references per article,
co-occurrence of words,
citation patterns,
interdisciplinary flow of
information, within field
diffusion of information.
630 articles (350
opinion articles, 65
conceptual
articles, 112
research utilization
studies, 103
research articles)
published in 194
different journals.
Article location and data
abstraction up to
2001/2002.
On the basis of co-
citation, scholars at
the core of the field
are Horsley,
Stetler, Fun, Titler,
and Goode. The
field has attained a
critical mass of
nurse scholars and
scholarly works as
demonstrated by
more than 60% of
the references in
articles are to
research by nurses.
Emergence of
interdisciplinary
collaborative
groups in this field
is yet evolving.
Feldman
200564
Murtaugh
200577
Tested a basic
and an
augmented e-
mail reminder to
improve
evidence-based
care of
individuals with
heart failure
(HF) in home
health care
settings.
RCT.
Evidence level 2
(Table 3.1)
Prospective randomized
trail with 3 groups
(control, basic e-mail
reminder, augmented e-
mail reminder). Outcome
measures were nursing
practices and patient
outcomes.
Level 1 outcomes.
Older adults with
heart failure (n =
628; x age = 72)
and nurses (n =
354; x age =
43.6; 93% female)
caring for those
patients.
Home health care
agency in a large
urban setting.
Basic e-mail reminder
upon patient admission
to the nurses’ care that
highlighted 6 HF-specific
clinical practices for
improving patient
outcomes. Augmented
intervention included
basic e-mail reminder
plus package of material
for care of HF patient
(medication
management, prompter
card for improving
communication with
physicians, self-care
guide for patients) and
followup outreach by a
clinical nurse specialist
(CNS) who served as an
expert peer.
Basic and
augmented
intervention
significantly
improved delivery
of evidence-based
care over control
group; augmented
intervention
improved care
more than basic
intervention.
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Foxcroft and
Cole 2000188
Organizational
infrastructures
to promote
evidence-based
nursing practice.
Systematic
literature review.
RCT, controlled clinical
trial, and interrupted time
series (levels 2, 3, 7).
Unit of intervention was
organizational,
comprising nurses or
groups of professionals
including nurses.
Outcomes = objective
measures of evidence-
based practice (levels 1
and 2).
121 papers were
identified as
potentially
relevant, but no
studies met the
inclusion criteria.
After relaxing the
criteria, 7 studies
were included and
all used a
retrospective case
study design (15).
Entire or identified
component of an
organizational
infrastructure to promote
effective nursing
interventions.
No high-quality
studies that
reported the
effectiveness of
organizational
infrastructure
interventions to
promote evidence-
based nursing
practice were
identified.
Conceptual models
that were assessed
positively against
criteria are briefly
included in this
review.
Greenhalgh
200522
Diffusion,
spread, and
sustainability of
innovations in
the organization
and delivery of
health services.
Systematic
literature review.
Evidence level 1
(Table 3.1).
Metanarrative review. Comprehensive
report of factors
and strategies to
promote use of
innovations in
health care
services.
7 key topic areas
addressed:
characteristics of the
innovation, adoption by
individuals, assimilation
by organizations,
diffusion and
dissemination, the inner
context, the outer
context, implementation
and routinization.
Complex process
requiring multiple
strategies.
Excellent resource
of scholarly work in
knowledge transfer
and innovation
adoption.
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Grilli 2002120
Assess the
effect of mass
media on use of
health services.
Systematic
literature review.
Evidence level 1
(Table 3.1).
RCTs, controlled clinical
trials, controlled before-
and-after studies, and
interrupted time series
analysis (levels 2, 3, 4).
Outcomes were
objective measures of
health services (drugs,
medical or surgical
procedures, diagnostic
tests) by professionals,
patients, or the public.
26 papers
reporting 20 time
series and on
controlled before-
and-after study
met the inclusion
criteria.
All studies relied on a
variety of media,
including radio, TV,
newspapers, posters,
and leaflets. To meet
inclusion criteria, studies
had to use mass media,
be targeted at the
population level, and
aimed to
promote/discourage use
of evidence-based health
care interventions or
change public lifestyle.
Mass media
campaigns have a
positive influence
upon the manner in
which health
services are used.
Mass media have
an important role in
influencing use of
health care
interventions. Mass
media campaign is
one of the tools that
may encourage use
of effective services
and discourage
those of unproven
effectiveness.
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Grimshaw
2004144
Grimshaw
200665
Assessment of
the
effectiveness of
guideline
dissemination
and
implementation
strategies.
Systematic
literature review.
Evidence level 1
(Table 3.1).
RCTs, controlled clinical
trials, controlled before-
and-after studies,
interrupted time series
from 1966 to 1998
(levels 2, 3, 4).
Outcomes were
objective measures of
provider behavior and/or
patient outcomes (levels
1, 2).
Studies of
guidelines aimed at
medically qualified
professionals.
(Studies on
guidelines aimed at
multiple
professionals were
included only if
results for medical
professionals were
reported separately
or if medical
professionals
represented more
than 50% of the
targeted
population.) The
review included 110
clustered RCTs, 29
patient RCTs, 7
clustered controlled
clinical trials, 10
patient controlled
clinical trials, 40
controlled before-
and-after studies,
and 39 interrupted
time series designs.
The most common
setting was primary
care (39%) followed
by inpatient settings
(19%) and
generalist
ambulatory settings
(19%). Other
studies addressed
settings across
sites of care or
were in a variety of
other types of
settings (e.g.,
nursing homes).
Interventions were
educational materials,
educational meetings,
educational outreach,
consensus, opinion
leaders, patient-directed
interventions, audit and
feedback, reminders, other
professional (marketing,
mass media), financial
interventions,
organizational
interventions, structural
interventions, and
regulatory interventions.
Studies compared single
interventions to no
intervention, multifaceted
interventions to no
intervention, or a control
receiving one or more
single intervention. This
systematic review
compared findings from
studies with a single
intervention against a “no-
intervention” control group;
single interventions
against an “intervention”
control group; multifaceted
interventions against “no-
intervention” control group
(7 different types of
comparisons); multifaceted
interventions against
intervention controls (4
different types of
comparisons). A total of
309 comparisons were
done. This systematic
review also includes
economic evaluations and
cost analysis.
This is a
comprehensive review
of implementation
strategies. The reader
is referred to the
technology report, as a
comprehensive
summary of findings is
beyond the scope of
this chapter. Overall
findings include: the
overall quality of
studies were poor; the
majority of comparisons
(86.6%) observed
improvements in care;
reminders are a
potentially effective
intervention and are
likely to result in
moderate
improvements in care
processes; educational
outreach may result in
modest improvements
in processes of care;
educational materials
and audit and feedback
appeared to result in
modest improvements
in care; multifaceted
interventions did not
appear to be more
effective than single
interventions;
multifaceted
interventions did not
appear to increase with
the number of
component
interventions. The lack
of a coherent
theoretical basis for
understanding
professional and
organizational behavior
change limits the
understanding of the
findings from studies.
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Grimshaw
2006124
Examine the
feasibility of
identifying
opinion leaders
using a
sociometric
instrument
(frequency of
nomination of
an individual as
an OL by the
responder) and
a self-
designating
instrument
(tendency for
others to regard
them as
influential).
Cross-sectional
study. Evidence
level 5 (Table
3.1).
Survey. Mailed
questionnaires of
different professional
groups.
Outcomes = general and
condition-specific
opinion leader types
classified as sociometric
OLs and self-designated
OLs (level 2 outcomes).
All general
practitioners,
practice nurses,
and practice
managers in two
regions of
Scotland. All
physicians and
surgeons and
medical and
surgical nursing
staff in two district
general hospitals
and one teaching
hospital in
Scotland as well
as Scottish
obstetric and
gynecology, and
oncology
consultants.
None The self-
designating
instrument
identified more
OLs. OLs appear to
be condition
specific.
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Horbar 200466
To evaluate a
coordinated,
multifaceted
implementation
intervention
designed to
promote
evidence-based
surfactant
therapy.
Clustered
randomized trial.
Cluster randomized trial
with randomization at the
hospital level (level 2).
Outcomes were
proportion of infants
receiving their first dose
of surfactant in the
delivery room, proportion
of infants treated with
surfactant who received
their fist dose more than
2 hours after birth, and
time after birth at which
the first dose of
surfactant was
administered; proportion
of all infants who
developed a
pneumothorax, and
proportion of all infants
who died prior to
discharge (levels 1 and
2).
114 hospitals with
membership in the
Vermont Oxford
Network, not
participating in a
formal quality
improvement
collaborative, with
the majority of
infants born in the
hospital rather
than transferred in
and born in 1998
and 1999;
received the first
dose of surfactant
within 15 minutes
after birth.
Subjects were
high-risk preterm
infants 23 to 29
weeks gestational
age. The
intervention group
had 3,313
neonates and
2,726 in the
comparison group.
The multifaceted 18-
month intervention
included quarterly audit
and feedback of data,
evidence reviews, an
interactive 3-day training
workshop, and ongoing
support to participants
via conference calls and
e-mail discussion.
The proportion of
infants 23 to 29
weeks gestational
age receiving
surfactant in the
delivery room was
significantly higher
in the intervention
than the control
group for all infants
(OR = 5.38). Those
who received
surfactant more
than 2 hours after
birth was
significantly lower
in the intervention
than control group
(OR = 0.35). There
were no significant
differences in rates
of mortality or
pneumothorax
between groups.
Infants in the
intervention group
received their first
dose of surfactant
significantly sooner
after birth with a
median time of 21
minutes as
compared to 78
minutes in the
control group (p <
.001).
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Hysong 200667
Exploratory
study of how
high-performing
facilities and
low-performing
facilities differ in
the way they
use clinical data
for feedback
purposes.
Cross-sectional
study.
Descriptive, qualitative,
cross-sectional study.
Subjects were
interviewed using a
semistructured interview
format (level 4).
Outcomes were
participant responses to
questions asking how
CPGs were currently
implemented at their
facility, including
strategies, barriers, and
facilitators.
Study setting was
6 VA medical
settings (from a
pool of 15) ranked
as high performing
(n = 3) and low
performing (n = 3)
organizations with
respect to 20
indicators for 6
chronic conditions
treated in
outpatient settings.
102 employees
across 6 facilities
were the subjects.
Within each
facility, facility
leadership (n =
25), middle
management (n =
34), and outpatient
clinic personnel (n
= 33) were
interviewed.
No study intervention, but
transcripts were analyzed
using grounded theory,
and passages that
specifically addressed
feedback of data were
included in the analyses.
High-performing
institutions
provided timely,
individualized,
nonpunitive
feedback to
providers, whereas
low performers
were more variable
in their timeliness
and
nonpunitiveness
and relied more on
standardized,
facility-level
reports. The
concept of
actionable
feedback emerged
as the core concept
around which
timeliness,
individualization,
nonpunitiveness,
and customizability
are important.
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Irwin & Ozer
200468
Ozer 2005189
To determine if
a systems
intervention for
primary care
providers
resulted in
increased
preventive
screening and
counseling of
adolescent
patients
compared to
usual care.
Controlled trial. 2 intervention outpatient
pediatric clinics and 2
comparison outpatient
pediatric clinics in the
same health system
were used to test the
intervention. Level 3.
Outcomes were
adolescent reports of
whether their provider
screened and counseled
them for risky behavior
(tobacco, alcohol, drugs,
sexual behavior, and
safety—helmet and
seatbelt use). Level 2.
4 outpatient
pediatric clinics
within Kaiser
Permanente,
Northern
California. 76
clinicians were in
the study (37 in
each treatment
arm). Adolescent
reports of provider
behavior—across
all phases of the
study, the
intervention
sample size was
1,717, and the
comparison
sample size was
911. Mean age of
adolescents was
14.8 years (SD =
1.34). Data were
collected from
adolescents at
baseline, following
training, and
following forms
implementation.
The intervention was 2
phases. First phase was
an 8-hour clinician
training in adolescent
preventative services
based on social cognitive
theory, including didactic
education, discussions,
demonstration role plays,
and interactive role-plays
at each intervention site
(4 months). Second
phase was
implementation of
screening and chart
forms customized for this
study (4 months). All
clinicians participated in
the training and the tools
were implemented on a
clinic-wide basis. Local
opinion leaders were
integrally involved in the
intervention.
Average baseline
screening rates in the
intervention group
ranged from 42% for
helmet use to 71% for
tobacco use. Following
training, screening
rates increased
significantly across all 6
target areas, ranging
from 70% for helmet
use to 85% for tobacco
use, and remained
constant during the
posttools
implementation phase.
Counseling rates
followed a similar
pattern. By comparison,
screening and
counseling rates in the
comparison group
tended to remain stable
across all 3 data
collection points.
Screening and
counseling rates were
significantly higher in
the intervention group
than the comparison
group after the full
implementation of the
intervention; screening
and counseling rates
were significantly
higher in the
intervention than the
comparison group after
the training component
of the intervention;
screening and
counseling rates did not
increase significantly in
the intervention group
compared to the
comparison group after
the addition of the tools
component.
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Jacobson
200569
Assessment of
the
effectiveness of
patient reminder
and patient
recall systems
in improving
immunization
rates.
Systematic
literature review.
Evidence level 1
(Table 3.1).
RCTs, controlled before-
and-after studies, and
interrupted time series
(levels 2 and 3).
Outcomes were
immunization rates or
the proportion of the
target population up to
date on recommended
immunizations.
43 studies.
Approximately
three-fourths of
the studies were
conducted in the
United States. The
majority of the
studies were
RCTs. Studies
included children
and adults and a
variety of settings.
Reminder methods and
recall systems included
letters to patients,
postcards, person-to-
person telephone calls,
autodialer, postcard and
phone combination, and
tracking and outreach.
Patients receiving
patient reminder
and recall
interventions were
more likely to have
been immunized or
up to date on
immunizations (OR
= 1.70). All types of
reminders and
recall were found to
be effective, with
increases in
immunization rates
on the order of 5%–
20%. Person-to-
person telephone
reminders were the
most effective
single approach
(OR = 1.92). Letter
reminders were
similar to phone
reminders in
effectiveness (OR =
1.89). Reminder
and recall
interventions were
effective for
children and adults
in all types of
settings.
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Jamtvedt
200670
Use of audit and
feedback to
improve
professional
practice.
Systematic
literature review.
Metaregression
along with visual
and qualitative
analyses.
Evidence level 1
(Table 3.1).
Randomized trails (level
2). Outcome measures =
noncompliance with
guideline
recommendations (level
2).
85 studies. 53
trials in North
America, 16 in
Europe, 8 in
Australia, 2 in
Thailand, 1 in
Uganda. In most
trials, the
professionals were
physicians; in 2
studies the
providers were
nurses, and 5
involved mixed
providers.
Audit and feedback
defined as any summary
of clinical performance of
health care over a
specified period of time,
delivered in written,
electronic, or verbal
format.
Audit and feedback
can be effective in
improving
professional
practice with effects
generally
moderate. Absolute
effects of audit and
feedback are more
likely to be larger
when baseline
adherence to
recommended
practice is low.
Audit and feedback
should be targeted
where it is likely to
effect change.
Jones 200471 Improvement of
pain practices in
nursing homes.
Clustered
RCT.
Evidence level 2
(Table 3.1).
An intervention study to
improve pain practices
(RCT). The intervention
was implemented in 6
nursing homes (level 2).
Outcomes = pain
knowledge and attitudes
of staff; pain assessment
and treatment decisions
based on 2 short case
studies; barriers to
effective pain
management. Outcomes
measured from
questionnaires
distributed to nurses and
nursing assistants (level
3).
12 long-term care
sites in
Colorado—6 in
urban sites and 6
in rural sites.
Nursing homes
ranged in size
from 65 to 150
beds.
Education for staff;
resident educational
video; designation of a 3-
member internal pain
team; pain vital sign; site
visits with discussion of
feedback reports; pain
rounds and
consultations.
Implementation phase
lasted 9 months.
No significant
treatment effect for
staff knowledge or
staff attitudes; staff
in the treatment
group were 2.5
times more likely to
chose an
aggressive pain
management
strategy than those
in the control group
(p = .002); no
significant
treatment effect for
decreasing barriers
to pain
management.
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Katz 200472,98 Testing an
intervention to
improve use of
EBP smoking
cessation
guidelines.
RCT with
randomization at
the clinic level.
Evidence level 2
(Table 3.1).
Prospective randomized
trial of 8 primary care
clinics in southern
Wisconsin (level 2).
Outcomes included staff
performance and patient
quit rates (levels 1 and
2).
8 community-
based clinics (6
family practice, 2
internal medicine).
Multimodality intervention
(5 components—didactic
and interactive education
of staff, modified vital
signs stamp imprinted on
each encounter form,
offering nicotine patches
and telephone
counseling, group and
confidential individual
feedback to providers on
whether clinicians had
assessed smoking status
and provided cessation
counseling as needed) to
implement AHRQ
smoking cessation
guideline.
Quit rates higher in
experimental (E)
sites at 2 and 6
months.
Percentage of
patients advised to
quit smoking higher
at E sites than
control (C) sites.
Levine 200473
Test a nurse-
administered,
protocol-driven
model for
comprehensive
preventive
services in a
low-income
outpatient
setting. Focus
was on
preventive
services as
recommended
by the U.S.
Preventive
Services Task
Force
(USPSTF).
Controlled trial. Controlled comparison
using a convenience
sample of patients within
a single practice (n =
987) and a usual care
group (n = 666) obtained
from a random sample of
households from the
postal zip codes served
by the same practice
(level 3).
Outcomes were
percentage of preventive
services initiated in the
treatment arm versus the
comparison arm (level
1).
Primary care
single practice
with internal
medicine, family
medicine, and
pediatric clinics.
Patients receiving
care in this clinic
between January
and September
2001. Children =
514 (about 170 in
each of 3 age
groups: 0–2, 3–7,
8–17; 63% African
American). Adults
= 473 (about 170
in each age group
18–49 and 50–64;
130 in 65 or older;
76% African
American).
Offer all identified
preventive services that
are needed using a
nursing model under the
guidance of a protocol
agreed upon by the
medical staff.
Use of a nursing
protocol for
USPSTF
recommendations
was associated
with a significantly
higher percentage
of preventive
services initiated
(99.6%) in the
experimental arm
as compared to
usual care group
(18.6%) (p < .001).
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Locock 2001123
Role of opinion
leader in
innovation and
change.
Systematic
literature review.
Case studies using
principally qualitative
methods.
Outcomes =
effectiveness of opinion
leaders in promoting
change/adoption of
evidence-based
practices (level 2.)
Variety of acute
care and primary
care settings.
Evaluation of
PACE project100
and Welsh Clinical
National
Demonstration
Project.
Local opinion leaders
defined as those
perceived as having
particular influence on
the beliefs and actions of
their colleagues, either
positive or negative.
Both expert and
peer opinion
leaders have
important and
distinct roles to play
in promoting
adoption of EBPs.
Opinion leadership
is part of a wider
process that cannot
be understood in
isolation of other
contextual
variables with
which it may
interact. The value
of the expert
opinion leader is in
the initial stages of
getting an idea
rolling, endorsing
the evidence, and
translating it into a
form that is
acceptable to
practitioners and
takes account of
their local
experience. Peer
opinion leader
influence seems to
be important in
mainstream
implementation,
providing a role
model for fellow
practitioners and
building their
confidence. The
local context may
modify or magnify
the opinion leader
influence.
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Loeb 200474
To test the
effect of a
multifaceted
implementation
intervention for
safely reducing
antimicrobial
prescriptions for
suspected
urinary tract
infections in
nursing home
residents.
Cluster RCT. The study design was
randomization of 24
nursing homes to an
intervention group or a
usual care group (level
2). Main outcome
measures were
antimicrobials prescribed
for urinary infections,
total antimicrobials,
hospitalizations, and
deaths (level 1).
Free standing,
community-based
nursing homes
with 100 or more
beds in Hamilton,
Ontario, region
and Boise, Idaho,
region were sites
for the study. The
numbers of
residents were
2,156 in the
intervention arm
and 2,061 in the
comparison arm.
Implementation of
algorithms for diagnostic
testing and antibiotic
prescribing developed
from research findings.
Implementation
strategies included
interactive education with
nurses, one-on-one
meeting with physicians
that see more than 80%
of the patients, written
materials, real-time paper
reminders, and quarterly
outreach visits targeted
to nurses and physicians.
The rate of
antimicrobial use
for suspected
urinary infections
was significantly
lower in the
treatment arm (1.17
courses of
antimicrobials per
1,000 resident
days) as compared
to the comparison
arm (1.59 per 1,000
patient days) (P =
.03). The proportion
of antimicrobials
prescribed for
suspected urinary
infections were
lower in the
intervention arm
than the
comparison arm (P
= .02). There was
no significant
difference for total
antimicrobial use,
rate of urine
cultures obtained,
overall
hospitalization, or
mortality.
43
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Study Setting &
Study Population Study Intervention Key Findings
Lozano 2004174 To test the
effectiveness of
2
implementation
interventions in
reducing
asthma
symptom days
as compared to
usual care.
Cluster RCT. RTC.
Outcomes were
annualized asthma
symptom days, asthma-
specific functional health
status, and frequency of
brief oral steroid bursts
(level 1).
42 primary care
practices in 3
locales and
targeted 3–17-
year-old children
with mild to
moderate
persistent asthma
enrolled in
practices affiliated
with man-
aged care
organizations.
Among the 638
patient subjects,
the mean age was
9.4 years (SD =
3.5); the majority
were white (66%)
and boys (60%).
3 treatment arms were
usual care, provider (MD,
PA, NP) oriented strategy
of targeted education
through an on-site peer
leader, and an
organizational approach
that combined the
provider education with a
nurse-run intervention
(planned care arm) to
better organize chronic
asthma care in the
primary care practice.
Children in the
planned care arm
had 13.3 fewer
symptoms annually
(P = .02) and 39%
lower oral steroid
burst rate per year
relative to usual
care (P = .01).
Those in the peer
leader arm showed
a 36% decrease in
annualized steroid
bursts per year as
compared to usual
care (P = .008).
Improvements in
asthma-specific
functional status
were also found for
both the peer
leader and planned
care arm as
compared to usual
care.
McDonald
200575
Testing of 2
computer-based
reminder
interventions
designed to
promote
evidence-based
pain
management
practices among
home care
nurses.
RCT.
Evidence level 2
(Table 3.1).
Nurses were randomly
assigned to one of 3
treatment groups
(control, basic e-mail
reminder, augmented e-
mail reminder).
Outcomes = pain
management practices
of nurses and patient’s
pain (levels 1 and 2).
Home health care.
Nurses were
mostly female (>
90%) with an
average age of
43.3 years.
Basic e-mail reminder
that focused on 6 key
practices (2 treatment
arms) was sent to nurse
every time an eligible
cancer patient with pain
was admitted to his/her
care. Nurses in the
augmented intervention
group also received
provider prompts, patient
education material, and
CNS outreach.
Nursing pain
management
practices did not
differ significantly
among the groups
(P < .05), but pain
levels were lower in
the 2 treatment
groups as
compared to the
control group.
Patients treated by
nurses in the
augmented group
had a 25%
reduction in the
probability of
hospitalization.
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O’Brien 1997119
Assess the
effect of
outreach visits
on improving
professional
practice or
patient
outcomes.
Systematic
literature review.
Evidence level 1
(Table 3.1).
Randomized trials (level
2). Outcomes of provider
performance (level 2).
18 trials. Providers
were mainly
primary care
physicians
practicing in
community
settings. In 13
trials the behaviors
were prescribing
practices. 10 trials
in North America,
4 in Europe, 2 in
Indonesia, and 2
in Australia.
Outreach visits defined
as use of a trained
person who meets with
providers in their practice
settings to provide
information with the
intent of changing
provider’s performance.
The information may
include feedback about
performance.
Positive effects on
practice were
observed in all
studies. Only 1
study measured a
patient outcome.
Educational
outreach visits,
particularly when
combined with
social marketing,
appear to be a
promising approach
to modifying health
professional
behavior, especially
prescribing. Further
research is needed
to identify key
characteristics of
outreach visits
important to
success.
O’Brien 1999116
Assessment of
the use of local
opinion leaders
on the practice
of health
professionals or
patient
outcomes.
Systematic
literature review.
Evidence level 1
(Table 3.1).
RCTs (level 2).
Outcomes were
objectively measured
provider performance in
a health care setting or
health outcomes (levels
1 and 2).
Focus was on
health care
providers
responsible for
patient care.
Use of providers
nominated by their
colleagues as
educationally influential.
8 studies met inclusion
criteria. A variety of
patient problems were
targeted.
In 3 trials that
measured patient
outcomes, 1
achieved an impact
on practice. Only 2
trials provided
strong evidence for
improving
performance of
health care
providers. Local
opinion leaders
may be important
change agents for
some problems.
45
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Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
O’Brien 2001118
Assess the
effects of
educational
meetings on
professional
practice and
health care
outcomes.
Systematic
literature review.
Evidence level 1
(Table 3.1).
Randomized trials and
well-designed quasi-
experimental studies
(levels 2 and 3).
Outcomes were
objectively measured
health professional
practice behaviors or
patient outcomes in a
setting where health
care was provided
(levels 1, 2, 3).
32 studies met
inclusion criteria
with 30 RCTs. 24
studies were in
North America, 2
in the United
Kingdom, and 1
each in Australia,
Brazil, France,
Indonesia, Sri
Lanka, and
Zambia. Most of
the study
participants were
physicians; 4
included nurses,
and 3 other health
professionals.
The intervention was
defined as continuing
education: meetings,
conferences, lectures,
workshops, seminars,
symposia, and courses
that occurred off-site
from the practice setting.
Education was defined
as didactic
(predominately lectures
with Q and A), or
interactive (sessions that
involved some type of
interaction in small,
moderate, or large
groups). 7 studies were
didactic and 25 were
interactive. Duration and
frequency of the
intervention varied
widely.
The few studies
that compared
didactic education
to no intervention
did not show an
effect on
professional
practice. Studies
that used
interactive
education were
more likely to be
effective in
improving practice.
Studies did not
include information
to determine what
makes some
interactive
educational
sessions more
effective than
others. Interactive
workshops can
result in moderately
large changes in
professional
practice. Didactic
education alone is
unlikely to change
professional
practice.
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Study Setting &
Study Population Study Intervention Key Findings
Redfern 200379 Evaluation of
the South
Thames
Evidence-based
Practice (STEP)
project.
Pretest and
posttest.
Each of the 9 projects
followed a
pretest/posttest design
within a clinical audit
framework over a period
of 27 months (level 6).
Outcomes =
intermediate outcomes
of uptake of change by
staff and patient
outcomes (levels 1 and
2).
9 projects that
focused on
improving
evidence-based
nursing practices.
UK sites included
acute care wards,
community nursing
services, and long-
term care. Topics
were leg ulcer
management,
breast-feeding,
pressure ulcer
care, nutrition in
stroke patients (n
= 2), Use of
functional
independence
measure (FIM)
assessment tool,
assessment of
continence,
assessment and
transfer of older
adults on
discharge from
hospital, family
therapy in
schizophrenia.
A 2-week training
program followed by 3
monthly seminars, staff
training program, active
support in the practice
setting.
Intermediate
outcomes improved
in most projects;
leaders’ ratings of
staff adherence
were moderate or
better in the
majority of the
projects; patient
outcomes improved
in most projects.
Organizational
factors were found
to have a major
impact on
achieving
successful change
in practice. Having
enough staff of the
right skill mix,
strong leadership,
supportive
managers and
colleagues, and
organizational
stability are
important to
successful change.
Project leaders and
a credible change
agent who works
with practitioners
face-to-face to
encourage
enthusiastic
involvement are
also important.
47
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vidence-B
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Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Shaw 2005185 Tailored
interventions to
address specific
identified
barriers to
change in
professional
performance.
Systematic
literature review
with
metaregression.
Evidence level 1
(Table 3.1).
RCTs (level 2).
Outcomes = professional
performance, patient
outcomes, or both (levels
1 and 2).
15 RCTs. 7 in
primary care or
community
settings and
health care
professionals
responsible for
patient care. 10 in
North America, 2
in the United
Kingdom, 2 in
Indonesia, and 1
in Norway.
An intervention was
defined as tailored if it
was chosen after
identification of barriers
and to overcome those
barriers.
Results were mixed
with variation in the
direction and size
of effect. The
effectiveness of
tailored
interventions
remains uncertain,
and more rigorous
trials including
process
evaluations are
needed.
Titler 200681 Testing a TRIP
intervention for
promoting
adoption of
evidence-based
acute pain
management
practices for
care of older
adults
hospitalized with
hip fracture.
RCT with
randomization at
the clinic level.
Evidence level 2
(Table 3.1).
Prospective randomized
trial of 12 acute care
hospitals in the Midwest
United States (level 2).
Outcomes included
nurse and physician
performance, patient
pain levels, and cost
effectiveness (levels 1
and 2).
12 large (n = 2),
medium (n = 6),
and small
hospitals (n = 4) in
the Midwest.
Multifaceted intervention
that addressed the
characteristics of the
EBP, the users, the
social context of care,
and communication,
based on Rogers’
diffusion of innovation
framework.
Acute pain
management
strategies improved
more in the
experimental than
comparison group,
and the TRIP
intervention saved
health care dollars.
48
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Study Setting &
Study Population Study Intervention Key Findings
Wensing 200682
Organizational
strategies for
improving
professional
performance,
patient
outcomes, and
costs.
Systematic
literature review.
Evidence level 1.
A review of reviews that
included RCTs,
interrupted time series,
controlled before/after
studies, and prospective
comparative
observational studies
(levels 2, 5, 6, 7).
Outcomes = professional
practice and patient
outcomes (levels 1 and
2).
36 reviews were
included. A
taxonomy of
organizational
strategies to
improve patient
care was
developed to
organize findings.
Revision of professional
roles, multidisciplinary
teams, integrated care
services, knowledge
management, quality
management.
Revision of
professional roles can
improve professional
performance, while
positive effects on
patient outcomes
remain uncertain.
Multidisciplinary
teams can improve
patient outcomes but
have primarily been
tested in highly
prevalent chronic
diseases. Integrated
care systems can
improve patient
outcomes and save
costs; they have been
extensively tested in
highly prevalent
chronic conditions.
Professional
performance and
patient outcomes can
be improved by
implementation of
computers in clinical
practice settings
(knowledge
management). Effects
of quality
management on
professional
performance and
patient outcomes
remain uncertain.
There is growing
evidence of rigorous
evaluations of
organizational
strategies, but the
evidence underlying
some strategies is
limited; for no strategy
can the effects be
predicted with high
certainty.
49
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Issue Related
to EBP Design Type*
Study Design & Study
Outcome Measure(s)
Study Setting &
Study Population Study Intervention Key Findings
Zwarenstein
2000117
Usefulness of
interprofessional
education (IPE)
interventions on
professional
practice and
health care
outcomes.
Systematic
literature review.
Evidence level 1
(Table 3.1).
RCTs, controlled before-
and-after studies, and
interrupted time series
studies (levels 2, 6, 7).
Outcomes included
health care outcomes
(mortality rates,
complication rates,
readmission rates) and
impact on professional
practice (teamwork and
cooperative practice)
(levels 1 and 2).
89 studies were
reviewed for
possible inclusion,
but none met the
inclusion criteria.
An educational
intervention during which
members of more than
one health and/or social
care profession learn
interactively together for
the purpose of improving
collaborative practice
and/or the health of
patients.
Despite finding a
large body of
literature on the
evaluation of IPE,
studies lacked the
methodological
rigor needed to
understand the
impact of IPE.
*Study design type: Use the following numbers for categories to reference the specific type of evidence (“evidence level”):
1. Meta-analysis
2. Randomized controlled trials
3. Non-randomized trials
4. Cross-sectional studies
5. Case control studies
6. Pretest and post-test (before and after) studies
7. Time series studies
8. Noncomparative studies
9. Retrospective cohort studies
10. Prospective cohort studies
11. Systematic literature reviews
12. Literature reviews, nonsystematic/narrative
13. Quality improvement projects/research
14. Changing practice projects/research
15. Case series
16. Consensus reports
17. Published guidelines
18. Unpublished research, reviews, etc.
- Background
- Translation science is the investigation of methods, interventions, and variables that influence adoption by individuals and organizations of EBPs to improve clinical and operational decisionmaking in health care.35, 43–46 This includes testing the effect of interventions on promoting and sustaining adoption of EBPs. Examples of translation studies include describing facilitators and barriers to knowledge uptake and use, organizational predictors of adherence to EBP guidelines, attitudes toward EBPs, and defining the structure of the scientific field.11, 47–49
- Translation science must be guided by a conceptual model that organizes the strategies being tested, elucidates the extraneous variables (e.g., behaviors and facilitators) that may influence adoption of EBPs (e.g., organizational size, characteristics of users), and builds a scientific knowledge base for this field of inquiry.15, 50 Conceptual models used in the translating-research-into-practice studies funded by AHRQ were adult learning, health education, social influence, marketing, and organizational and behavior theories.51 Investigators have used Rogers’s Diffusion of Innovation model,35, 39, 52–55 the Promoting Action on Research Implementation in Health Services (PARIHS) model,29 the push/pull framework,23, 56, 57 the decisionmaking framework,58 and the Institute for Healthcare Improvement (IHI) model59 in translation science.
Overview of Evidence-Based Practice
Models of Evidence-Based Practice
Steps of Evidence-Based Practice
Translation Science: An Overview
Research Evidence
What Is Known About Implementing Evidence-Based Practices?
Nature of the Innovation or Evidence-Based Practice
Methods of Communication
Users of the Innovation or Evidence-Based Practice
Social System
Practice Implications From Translation Science
Principles of Evidence-Based Practice for Patient Safety
Research Implications
Conclusion
Author Affiliation
Search Strategy
References
Evidence Table. Evidence-Based Practice in Nursing