Education

Implementation science is the study of strategies that facilitate the uptake of evidence-based practice and research into bedside practice, but what should nurses know about it?

Introduction to Implementation Science for Nurses

One of the challenges nurses face at the bedside is infusing research evidence in their daily practice. Evidence-based practice (EBP) interventions can be procedures, policies, or products that have been demonstrated to improve health outcomes through research. For example, interventions such as handwashing or catheter-associated urinary tract infection bundles are known to reduce the spread of infections but not everyone adheres to them all the time. In addition, everyday research articles are published with new evidence for various interventions but not all of them make it into our clinical practice.

In fact, studies show that it takes on average 17 years1 to carry out successful interventions from research setting and into routine care. What is more dire in this research-to-practice gap is that half of the evidence-based interventions never even reach widespread clinical usage2.

So, how can nurses facilitate the translation of research findings at bedside?

There are many ways that nurses can implement EBP. Implementation strategies are the actions taken to adopt, implement, scale, and sustain EBP in clinical practice across the health system. These strategies vary in complexity, from single components, such as training sessions or reminders, to multifaceted implementation strategies (e.g. interdisciplinary rounds led by practice champions). They can effect change on various levels, targeting bedside nurses and other clinicians, nurse managers, organizational policies, financing, or any combination thereof.

Nursing implementations have often focused on individual nurses employing education and skills training (e.g. in-service), as a commonly used implementation strategy. However, there are many other options. The table below provides some examples of strategies that can be used in implementing EBP in the clinical setting.

 

Implementation strategy Examples
Use evaluative and iterative strategies Assess for readiness and identify barriers and facilitators

Audit and provide feedback

Develop and implement tools for quality monitoring

Provide interactive assistance Provide local technical assistance

Provide clinical supervision

Adapt and tailor to context Tailor strategies

Use data experts

Develop stakeholder interrelationships Identify and prepare champions

Organize clinician implementation team meetings

Obtain formal commitments

Visit other sites

Train and educate stakeholders Conduct ongoing training

Develop educational materials

Make training dynamic

Support clinicians Remind clinicians

Revise professional roles

Create new clinical teams

Engage consumers Involve patients/consumers and family members

Prepare patients to be active participants

Increase demand

Utilize financial strategies Fund and contract for the clinical innovation

Alter incentives

Develop disincentives

Change infrastructure Mandate change

Change records systems

Change physical structure and environment

Adapted from Waltz, et al. (2015) “Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert Recommendations for Implementing Change (ERIC) study.” Implementation Science. 10, 109 https://digitalcommons.wustl.edu/open_access_pubs/4149

 

But which strategies work best in what situations and for what EBP?

To answer this question, we may look to implementation science3-4, a study of translating, applying, and disseminating research to clinical practice. It seeks to close the gap between what we know and what we do, drawing on knowledge and methods from various disciplines, including health services research, economics, sociology, and organizational science.

Implementation research seeks to understand and work in “real world” or usual practice setting. This contrasts with randomized clinical trial designs where researchers tightly control the conditions, trying to isolate the effects of the intervention from the influence of daily practice. Instead, it pays attention to the audience that will use the research (e.g. nurses, managers, policy makers), the context in which implementation occurs (e.g. clinic environment) , and the facilitators and barriers (e.g. time, resources, specific policies) that affect implementation, usability, scalability and sustainability of EBP.

To advance science, implementation research uses conceptual models to understand the relationships between these various factors and how they can be changed. An example is provided below. The model shows the general flow of how an EBP (or EBI) translates to health outcomes, depending on a set of implementation strategies and outcomes.

Adapted from Proctor, et al. (2009). Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health, 36(1), 24–34. https://doi.org/10.1007/s10488-008-0197-4

How is implementation science different from quality improvement?

Both implementation science and quality improvement (QI) efforts have the shared goal of improving quality of healthcare. However, there are some major differences. QI typically begins with identifying a problem in a specific setting, such as a single unit or clinic and tends not to seek to contribute generalizable knowledge. Implementation science, on the other hand, focuses on the solution, or the EBP to disseminate and contributes to knowledge by identifying generalizable technics that can be scaled across various settings. However, both use some overlapping methods and QI can be informed by implementation science in the selection of implementation strategies.

Conclusion

Nurses are uniquely positioned to implement EBP in clinical setting and can draw on implementation science findings to disseminate and scale these practices.

If you want to learn more:

Watch a video from Duke Clinical Research Institute on “Implementation Science: Bridging the Gap from Clinical Research to Population Health” https://www.youtube.com/watch?v=jOKdaRantZI

References

  1. Alberts B, Kirschner MW, Tilghman S, Varmus H. Rescuing US biomedical research from its systemic flaws. Proc Natl Acad Sci U S A. 2014;111(16):5773–7. doi: 10.1073/pnas.1404402111.
  2. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J Roy Soc Med. 2011;104:510–20. doi: 10.1258/jrsm.2011.110180.
  3. Bauer, M. S., Damschroder, L., Hagedorn, H., Smith, J., & Kilbourne, A. M. (2015). An introduction to implementation science for the non-specialist. BMC Psychology, 3(1), 32. https://doi.org/10.1186/s40359-015-0089-9
  4. Peters, D. H., Adam, T., Alonge, O., Agyepong, I. A., & Tran, N. (2013). Implementation research: What it is and how to do it. BMJ (Online), 347(November), 1–7. https://doi.org/10.1136/bmj.f6753

Article By: Maria Yefimova, PhD, RN

Book an appointment or get a consultation.