Strategy to Address the Problem in Amish Peer Reviewed Article

Figure:

Lynn Gallagher-Ford (left) and Sharon Tucker critique student attempts to develop PICO-T questions in an bear witness-based do (EBP) immersion program at the Lucile Packard Children's Hospital in Palo Alto, California. Photo courtesy of the Fuld Institute for EBP.

Evidence-based practise (EBP) has become a standard for the delivery of safe, quality care and the achievement of optimal patient outcomes. Patients, families, payers, and regulatory agencies expect that care delivery will be based on the virtually current and best available evidence. Numerous models and frameworks exist to guide practitioners in delivering EBP. Nurse and health care staff participation in intensive EBP immersion programs is growing rapidly, and undergraduate and graduate nursing programs are embedding EBP in their curricula.

Despite this important progress, bringing evidence to routine clinical intendance remains an elusive, challenging, and often underresourced goal.¹ To accost this well-recognized gap, research and quality comeback (QI) efforts take focused on implementation and translation models and strategies that tin promote the successful uptake and sustainability of EBP. This article introduces a new serial focused on the implementation stride of EBP. Using the enquiry literature on implementation science, models, and strategies, we will present example studies that are designed to inform readers and practitioners virtually how to minimize barriers and leverage facilitators (such as unit champions or mentors) to achieve success in implementing and sustaining EBP changes.

This new series builds on the previous EBP series published in AJN from 2009 to 2011. That series describes the vii steps of EBP, giving nurses the knowledge and skills needed to implement EBP at their institutions. It also contains some of the nearly pop and downloaded AJN manufactures, reflecting a sense of urgency among nurses, other health care practitioners, and organizations to employ the best evidence to provide safe and high-quality care.

EBP: Step Past Pace

The seven steps of EBP are well established in nursing and other disciplines and present a standardized approach to EBP. As described in the previous AJN series, they are:

• Stride Nothing: Cultivate a spirit of inquiry and an EBP civilization
• Step ane: Ask clinical questions in PICO-T (population, intervention, comparing, upshot, and, if advisable, time) format
• Step 2: Search for the best evidence
• Stride iii: Critically assess the testify and recommend a practise alter
• Step four: Integrate the show with clinical expertise and patient/family unit preferences and values
• Step 5: Evaluate the outcomes of the do decisions or changes based on the testify
• Step 6: Disseminate the results of the EBP change

The widespread endorsement of these EBP steps, along with numerous models and resources, has led to the institution of EBP competencies for health intendance providers.^{2, 3} These competencies reflect a minimum set of attributes, such as cognition, skills, attitudes, abilities, and judgment, that enable a clinician to see practice standards. Examples of EBP competencies include understanding how to formulate a clinical question in PICO-T format, critically appraising the evidence, and incorporating patient preferences into the implementation of a practice change.

IMPLEMENTATION—THE Nigh CHALLENGING STEP

Great progress has been made in recent years in standardizing EBP. However, Stride 4, the implementation step, in which show is integrated with clinician expertise and patient/family preferences and values, remains perchance the most challenging. The reasons for this are multifactorial and interrelated: the involvement of numerous and diverse stakeholders, resources intensity (such equally pulling staff away from patient intendance to lead the practice modify, or the necessity of sure equipment and supplies for the exercise change), a fast-paced and constantly changing infirmary environs, evolving regulatory and payer demands, resistance to change, and lack of time and effort defended to "hard-wiring" evidence-based modify over time (making the change sustainable and embedded in the system and civilization).

Implementation of EBP is thus a complex and resource-intensive step, and the time and endeavour needed are often underestimated and underresourced. Recognition of the research-to-practice gap was described in 2000 by Balas and colleagues, who published a landmark paper in which they noted it takes an average of 17 years to translate a scientific discovery (such as an testify-based recommendation) into real-world clinical practise and settings.⁴ Since this gap was made transparent, an entire scientific field—implementation or translation science—has emerged, providing models, insight, and strategies to inform and expedite the uptake of EBPs.⁵ Nilsen published a summary of implementation models and theoretical approaches, categorizing them as follows: models that direct or guide the procedure of research into exercise, frameworks for understanding and/or exploring influences on implementation, classic theories largely related to change processes, specific implementation models, and evaluation approaches.⁶ In this EBP series, we'll use the concepts and features of several of these models, suggesting a simplified approach to implementation to guide nurses and other health care practitioners.

SUCCESSFUL STRATEGIES

We will guide readers to think of implementation of an initiative as occurring in phases of change, using select strategies best aligned with each phase. Strategies will address organizational civilisation, leadership structure and support, EBP resources, patient populations and settings, technical and information needs, educational needs, reminders and reinforcement, mentors and champions, QI tools, and data trending, amidst other topics. Early phases of change might address potential obstacles such as staff support for the status quo, beliefs that the current do is working fine, and a full general lack of recognition or openness to exploring a practise change. Afterward phases of change might reverberate a readiness for a do alter, widespread rollout, and efforts to constitute sustainable change over time.

For each stage of the implementation step, we will introduce strategies to keep the initiative moving toward a successful practice change. These strategies volition be based on the work of several researchers, including Grol and Grimshaw,⁷ Grimshaw and colleagues,⁸ Powell and colleagues,^ix and Cullen and colleagues.^{10, 11} The two papers coauthored past Jeremy Grimshaw propose that EBP changes need to be supported by an assessment of the barriers and facilitators to applying the evidence in a specific context or setting; the best evidence should and so be used to select the implementation strategies.^{seven, eight} These strategies include, among others, the use of educational materials, reminders, computerized decision support, performance feedback, stance leaders, multiprofessional collaboration, and mass media campaigns.⁷

The paper past Powell and colleagues is based on a compilation of 73 implementation strategies identified by an expert console.⁹ The panel believed these strategies to be useful edifice blocks for the multifaceted, multilevel strategies used in the implementation of EBP changes in mental health service settings (transferrable to other specialties) and for comparative effectiveness inquiry.

Finally, to guide our discussion of implementation strategies, nosotros'll plough to the work of Cullen and Adams, who recommend strategies aligned with the phases of implementation and target two singled-out groups: clinicians, organizational leaders, and key stakeholders, and the organizational system of support.^ten They also highlight the importance of change agent roles, such as those of change champions, EBP mentors, and opinion leaders.^ten This work led to the production and publication of a useful resource guide—Evidence-Based Practice in Activity: Comprehensive Strategies, Tools, and Tips from the Academy of Iowa Hospitals and Clinics—which includes 63 implementation strategies, each presented with a definition, benefits, process, case example, and supporting references.^xi

SUSTAINABLE CHANGE

Implementation is a major step in the EBP process, merely because its challenges are frequently underappreciated, implementation efforts are often underresourced. It's therefore non surprising that the translation of evidence into practice is often a wearisome process that may never fully occur or cannot exist sustained. In this series, we will focus on the evolution of competency among nurses, nursing leaders, and other health care providers in implementing EBP. We volition employ published models and strategies to help readers better understand how to successfully tackle the implementation of EBP. Moreover, we'll illustrate how others have applied these implementation strategies—with various outcomes, whether successful, partially successful, or stalled and delayed—by inviting EBP experts to tell their stories. These examples will be presented along with our commentary, in which nosotros'll detail the principles and strategies used, highlighting those that can all-time lead to sustainable change.

REFERENCES

1. Li SA, et al. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review Syst Rev 2018 seven 1 72

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2. Albarqouni 50, et al. Core competencies in bear witness-based practise for health professionals: consensus statement based on a systematic review and Delphi survey JAMA Netw Open 2018 one 2 e180281

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3. Melnyk BM, et al. The first U.S. report on nurses' bear witness-based practice competencies indicates major deficits that threaten healthcare quality, condom, and patient outcomes Worldviews Evid Based Nurs 2018 xv 1 16 25

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4. Balas EA, Boren SA Managing clinical cognition for wellness intendance improvement Yearb Med Inform 2000 1 65 seventy

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5. Dearing JW, Kee KF Brownson RC Historical roots of broadcasting and implementation in scientific discipline Dissemination and implementation research in health: translating science to practice 2012 New York, NY Oxford Academy Press 55 71

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6. Nilsen P Making sense of implementation theories, models and frameworks Implement Sci 2015 10 53

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7. Grol R, Grimshaw J From best bear witness to best practice: effective implementation of change in patients' care Lancet 2003 362 9391 1225 30

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eight. Grimshaw JM, et al. Cognition translation of enquiry findings Implement Sci 2012 7 50

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9. Powell BJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project Implement Sci 2015 10 21

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10. Cullen Fifty, Adams SL Planning for implementation of evidence-based do J Nurs Adm 2012 42 four 222 30

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11. Cullen L, et al. Prove-based exercise in activity: comprehensive strategies, tools, and tips from the University of Iowa Hospitals and Clinics. Indianapolis, IN: Sigma Theta Tau International; 2018.

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