Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality.

BACKGROUND: Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap. AIM: This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes. METHODS: The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice. LINKING EVIDENCE TO ACTION: Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.

Evidence-Based Practice Change Champion Program Improves Quality Care.

Nurses need training and mentoring to lead evidence-based practice (EBP) improvements. An array of roles have been reported to have a positive impact on EBP adoption. A training program was created to assist point-of-care nurses and nurse leader partners in operationalizing the EBP Change Champion role to address priority quality indicators. The program, a case exemplar, and lessons learned are described with implications for leaders responsible for promoting EBP to improve quality care.

Testing of the Nursing Evidence-Based Practice Survey.

BACKGROUND: Clinicians' knowledge and skills for evidence-based practice (EBP) and organizational climate are important for science-based care. There is scant literature regarding aligning organizational culture with EBP implementation and even less for unit and organizational culture. The Nursing EBP Survey examines individual, unit, and organizational factors to better understand registered nurses' (RN) self-reported EBP. AIMS: Establish and confirm factor loading, reliability, and discriminant validity for the untested Nursing EBP Survey. METHODS: The study employed a descriptive cross-sectional survey design and was targeted for RNs. The setting included 14 hospitals and 680 medical offices in Southern California. The 1999 instrument consisted of 22 items; 7 items were added in 2005 for 29 items. The questionnaire used a 5 point, Likert-type scale. The survey website opened in November 2016 and closed after 23 weeks. Psychometric testing and factor determination used parallel analysis, exploratory factor analysis, confirmatory factor analysis (CFA), and ANOVA post hoc comparisons. RESULTS: One thousand one hundred and eighty-one RNs completed the survey. All factor loadings in the CFA model were positive and significant (p < .001). All standardized loadings ranged from .70 to .94. The covariance estimate between Factor 1 and Factor 2 was marginally significant (p = .07). All other covariances and error variances were significant (p < .001). Final factor names were Practice Climate (Factor 1), Data Collection (Factor 2), Evidence Appraisal (Factor 3), Implementation (Factor 4), and Access to Evidence (Factor 5). Four of 5 factors showed significant differences between education levels (p < .05 level). All factors showed significant differences (p < .05) between inpatient and ambulatory staff, with higher scores for inpatient settings. LINKING EVIDENCE TO ACTION: Nurses' knowledge, attitudes, and skills for EBP vary. The 2019 Nursing EBP survey offers RNs direction to plan and support improvement in evidence-based outcomes and tailors future EBP initiatives.

Patient, Nurse, and Organizational Factors That Influence Evidence-Based Fall Prevention for Hospitalized Oncology Patients: An Exploratory Study.

BACKGROUND: Hospital falls remain common despite decades of studies and guidelines to reduce their rate. Research evidence alone is insufficient, and integration of patient values and preferences, clinician expertise and experiences, and organizational culture is needed to ensure sustainable practice changes. Little is known about the best strategies for integrating these constructs to sustain effective fall prevention programs. AIMS: Guided by the Comprehensive Framework for Implementation Research (CFIR), this study aimed to identify patient, nursing staff, and organizational-level factors that influence effective and sustainable fall prevention strategies with the goal of identifying variables amenable to targeted interventions. METHODS: A descriptive research design engaged four oncology units in a Midwestern academic medical center and included patients (N = 39) and nursing staff (N = 70). Questionnaire data were collected from patients with interview assistance, and nursing staff completed a demographic form and two standardized instruments adapted for the study. Data were analyzed using descriptive statistics and narrative summaries. RESULTS: Findings indicated two-thirds of patients did not see themselves at risk for falling, despite nearly half having a fall history. Nursing staff indicated knowledge gaps related to specific known risks and interventions, and confidence in fall prevention management was lowest for team communication about patient risks and engaging patients and families in preventing falls. LINKING EVIDENCE TO ACTION: Engagement of patients in fall risk assessment and management, clear and routine communication among team members, and creating a culture of true engagement with appropriate leadership and resources can potentially improve the sustainability of successful fall prevention programs. The CFIR can guide the planning of fall prevention and other evidence-based practice changes to become hardwired and sustainable over time even with the ongoing introduction of new initiatives.

Usability Evaluation and Implementation of a Health Information Technology Dashboard of Evidence-Based Quality Indicators.

Health information technology dashboards that integrate evidence-based quality indicators can efficiently and accurately display patient risk information to promote early intervention and improve overall quality of patient care. We describe the process of developing, evaluating, and implementing a dashboard designed to promote quality care through display of evidence-based quality indicators within an electronic health record. Clinician feedback was sought throughout the process. Usability evaluations were provided by three nurse pairs and one physician from medical-surgical areas. Task completion times, error rates, and ratings of system usability were collected to compare the use of quality indicators displayed on the dashboard to the indicators displayed in a conventional electronic health record across eight experimental scenarios. Participants rated the dashboard as "highly usable" following System Usability Scale (mean, 87.5 [SD, 9.6]) and Poststudy System Usability Questionnaire (mean, 1.7 [SD, 0.5]) criteria. Use of the dashboard led to reduced task completion times and error rates in comparison to the conventional electronic health record for quality indicator-related tasks. Clinician responses to the dashboard display capabilities were positive, and a multifaceted implementation plan has been used. Results suggest application of the dashboard in the care environment may lead to improved patient care.

Iowa Model of Evidence-Based Practice: Revisions and Validation.

BACKGROUND: The Iowa Model is a widely used framework for the implementation of evidence-based practice (EBP). Changes in health care (e.g., emergence of implementation science, emphasis on patient engagement) prompted the re-evaluation, revision, and validation of the model. METHODS: A systematic multi-step process was used capturing information from the literature and user feedback via an electronic survey and live work groups. The Iowa Model Collaborative critically assessed and synthesized information and recommendations before revising the model. RESULTS: Survey participants (n = 431) had requested access to the Model between years 2001 and 2013. Eighty-eight percent (n = 379) of participants reported using the Iowa Model and identified the most problematic steps as: topic priority, critique, pilot, and institute change. Users provided 587 comments with rich contextual rationale and insightful suggestions. The revised model was then evaluated by participants (n = 299) of the 22nd National EBP Conference in 2015. They validated the model as a practical tool for the EBP process across diverse settings. Specific changes in the model are discussed. CONCLUSION: This user driven revision differs from other frameworks in that it links practice changes within the system. Major model changes are expansion of piloting, implementation, patient engagement, and sustaining change. LINKING EVIDENCE TO ACTION: The Iowa Model-Revised remains an application-oriented guide for the EBP process. Intended users are point of care clinicians who ask questions and seek a systematic, EBP approach to promote excellence in health care.

Sacred cow gone to pasture: a systematic evaluation and integration of evidence-based practice.

BACKGROUND: Sacred cows (SC) are old habits in practice, considered routine and above dispute, regardless of evidence to the contrary. PURPOSE: This is the first known report that aims to conduct a systematic evaluation of practices that have been described in the literature as SC and strategies for planned implementation of evidence-based practices (EBP). METHODS: A large, complex, academic medical center department of nursing compared SC to EBP. Nurses systematically reviewed and rated the degree to which current practices adhered to best-evidence versus SC. This initiative, "Sacred Cow: Gone to Pasture," was developed, structured, and implemented according to the Iowa Model of Evidence-Based Practice to Promote Quality Care, as well as Everett Rogers' Diffusions of Innovations Theory. Implementation of EBP followed a phase plan using the Implementation Strategies for Evidence-Based Practice to help to support adoption and integration. RESULTS: Review of organization-specific policies and procedures and reports of actual practices revealed that SC persist, even in a center internationally recognized as a leader in EBP. The SC initiative caught the attention of busy clinicians, and raised awareness of SC and the importance of adherence to EBP. The SC initiative resulted in policy and practice changes and sparked new EBP and research, resulting in numerous improvements, including a significant decline in catheter-associated urinary tract infections and shifting from basins to commercially prepared cloths for patient bathing. LINKING EVIDENCE TO ACTION: A strategic approach is crucial to eliminating SC and integrating EBP. This report calls nurses globally to action, to identify and abandon ineffective healthcare practices. Further research should compare and test the efficacy of implementation strategies, in particular how to sustain EBP in clinical settings.

Profile of Irish female GPs and factors affecting long-term commitment: a descriptive study.

BACKGROUND: Over the past two decades, many countries have reported an increased percentage of female staff in the general practice workforce. Considering the importance of general practice workforce planning, it is necessary to investigate the current working patterns of female GPs. AIM: To describe the female GP workforce in Ireland and to investigate factors that may affect their long-term commitment to general practice. DESIGN & SETTING: Descriptive, cross-sectional study conducted with female GPs in Ireland. METHOD: A 'membership survey' was emailed to 1985 female GPs in November 2021. In total, 345 female GPs responded, providing a response rate of 17.4%. RESULTS: The study revealed that a majority of the female GP workforce in Ireland worked in the position of the GP principal (62.3%), but also provided out-of-hours services (64.3%), and undertook caring responsibilities (84.1%). In total, 41.2% of the responders disclosed having at least one paid additional role, mainly in the field of academia and teaching. Most female GPs worked fewer than eight clinical sessions a week (80.5%). GPs who held General Medical Services (GMS) contracts (72.8%) were significantly more likely to work more clinical sessions a week and had been longer employed in general practices (>5 years) than GPs who did not have GMS contracts. CONCLUSION: Irish female GPs demonstrated a significant adjustment of their working patterns, including reducing their number of clinical sessions and balancing between additional roles, to ensure their long-term commitment to general practice. Current practices and vision on GP roles must be recognised and supported to allow for adequate workforce planning.

Evidence-based oral care for oral mucositis.

Nurses must intervene to provide evidence-based supportive care and symptom management for cancer patients. Oral mucositis, a distressing side effect of cancer treatment, is both a research and clinical priority. Nurses can lead improvements with evidence-based oral mucositis interventions. This article describes application of evidence-based clinical recommendations for oral mucositis across diverse patient populations.

Planning for implementation of evidence-based practice.

Expectations for evidence-based healthcare are growing, yet the most difficult step in the process, implementation, is often left to busy nursing leaders who may be unprepared for the challenge. Selecting from the long list of implementation strategies and knowing when to apply them are a bit of an "art," matching clinician needs and organizational context. This article describes an application-oriented resource that nursing leaders can use to plan evidence-based practice implementation in complex healthcare systems.

Evidence-based thermoregulation for adult trauma patients.

The purpose of this project was to develop a staff nurse-led initiative to implement and evaluate evidence-based thermoregulation care for adult trauma patients. An evidence-based practice protocol was developed and implemented, addressing varying patient needs across the spectrum of hypothermia seen in practice, serving as a guide for improving thermoregulation care in trauma patients. There were 2 key pieces to the evidence-based practice protocol. The first piece consisted of an interdisciplinary thermoregulation flowchart to provide focused care based on patient temperatures. The flowchart outlined progressive interventions for increasing hypothermia. The second piece outlined the nursing assistant role, preparing the care area before patient arrival and assisting nursing staff during trauma care. Data from staff questionnaires and patient documentation were used in a pre- and postevaluation of the practice change. Improvements were demonstrated in staff feeling better prepared to identify patients with hypothermia, treat hypothermia, and document thermal care of trauma patients. Clinically important improvement in temperature control during emergency treatment in both moderate and severe hypothermic patients were observed. Ongoing monitoring is underway to promote integration of the practice change.