The Experience of Implementing Evidence-Based Practice Change: A Qualitative Analysis

Strategies to implement evidence-informed decision making at the organizational level: a rapid systematic review

BACKGROUND

Achievement of evidence-informed decision making (EIDM) requires the integration of evidence into all practice decisions by identifying and synthesizing evidence, then developing and executing plans to implement and evaluate changes to practice. This rapid systematic review synthesizes evidence for strategies for the implementation of EIDM across organizations, mapping facilitators and barriers to the COM-B (capability, opportunity, motivation, behaviour) model for behaviour change. The review was conducted to support leadership at organizations delivering public health services (health promotion, communicable disease prevention) to drive change toward evidence-informed public health.

METHODS

A systematic search was conducted in multiple databases and by reviewing publications of key authors. Articles that describe interventions to drive EIDM within teams, departments, or organizations were eligible for inclusion. For each included article, quality was assessed, and details of the intervention, setting, outcomes, facilitators and barriers were extracted. A convergent integrated approach was undertaken to analyze both quantitative and qualitative findings.

RESULTS

Thirty-seven articles are included. Studies were conducted in primary care, public health, social services, and occupational health settings. Strategies to implement EIDM included the establishment of Knowledge Broker-type roles, building the EIDM capacity of staff, and research or academic partnerships. Facilitators and barriers align with the COM-B model for behaviour change. Facilitators for capability include the development of staff knowledge and skill, establishing specialized roles, and knowledge sharing across the organization, though staff turnover and subsequent knowledge loss was a barrier to capability. For opportunity, facilitators include the development of processes or mechanisms to support new practices, forums for learning and skill development, and protected time, and barriers include competing priorities. Facilitators identified for motivation include supportive organizational culture, expectations for new practices to occur, recognition and positive reinforcement, and strong leadership support. Barriers include negative attitudes toward new practices, and lack of understanding and support from management.

CONCLUSION

This review provides a comprehensive analysis of facilitators and barriers for the implementation of EIDM in organizations for public health, mapped to the COM-B model for behaviour change. The existing literature for strategies to support EIDM in public health illustrates several facilitators and barriers linked to realizing EIDM. Knowledge of these factors will help senior leadership develop and implement EIDM strategies tailored to their organization, leading to increased likelihood of implementation success.

REVIEW REGISTRATION

PROSPERO CRD42022318994.

Nurse Practitioners' Implementation of Evidence-Based Practice Into Routine Care: A Scoping Review

BACKGROUND

Implementation of evidence-based practice (EBP) is essential for ensuring high-quality health care at minimum cost. Although all nurses have a responsibility to implement EBP at an individual patient level, nurse practitioners (NPs) as clinical leaders have additional responsibilities in leading and collaborating with transdisciplinary teams to implement EBP across patient groups and embed practice change into routine care.

AIM

To explore the factors affecting the implementation of EBP into routine care by NPs. Specifically, to examine NP beliefs, levels of EBP implementation, and barriers and enablers to EBP implementation into routine care.

METHODS

A scoping review was conducted using the Arksey and O'Malley (International Journal of Social Research Methodology, 8, 2005, 19) framework. The electronic databases CINAHL, Medline, and PsycINFO were searched for studies published between 2009 and 2018 along with gray literature and reference lists of included articles. Abstracts and studies were screened using predefined eligibility criteria. Data extraction was undertaken using a standardized framework and data synthesis completed.

RESULTS

Seven studies were included in the review. Findings indicated NPs valued EBP and believed it to be important in standardizing patient care. NPs' implementation of EBP was found to be relatively low overall. It was not possible to fully determine the extent to which NPs implemented EBP into routine care. NPs experienced similar barriers to EBP implementation as do nurse generalists such as lack of time, lack of EBP competence, lack of support from colleagues and managers, and inadequate resources. In particular, NPs identified collaborative practice issues as factors affecting EBP implementation. Identified barriers included physician-driven practice and the need to maintain professional and political boundaries. Supportive collaborative relationships and having professional confidence were identified facilitators.

LINKING EVIDENCE TO ACTION

An exploration of NPs' experience of interprofessional collaboration when implementing EBP into routine care is needed to identify requirements for support in this area.

Implementation of a multidisciplinary rehabilitation program for patients with chronic low back pain-experiences and perspectives of rehabilitation team members

STUDY RATIONALE

Low back pain is a common condition and one of the leading reasons for years of chronic disability. Rehabilitation has been shown to be effective on low back pain, because it is based on the complex and multifactorial mechanisms that low back pain entails.

AIM

The aim of this study was to describe and interpret rehabilitation team members' experiences and perspectives regarding an integrated rehabilitation program for patients with chronic low back pain.

METHODS AND MATERIALS

This qualitative study used the Interpretive Description methodology. Data consisted of participant observation of 28 rehabilitation team members and four semi-structured focus group interviews with 20 of the 28 participants. The COREQ checklist was used to consolidate the findings in the study.

RESULTS

The results represented an insight into rehabilitation team members' experiences and perspectives regarding the implementation of an integrated rehabilitation program for patients with chronic low back pain. The significance of the rehabilitation team members' expectations was underlined as they initially had positive expectations but along the implementing of the program found their expectations challenged. The challenges they experienced were related to their professional competence, the incongruity of the two programs being compared, and to their utilization of quick fixes.

CONCLUSION

This Interpretive Description study provides insight into the complexity and challenges related to implementation practice. It identifies important elements when implementing a new rehabilitation intervention in clinical practice and emphasizes the importance of expectations among rehabilitation team members in the implementation process. There should be a specific focus on the importance of involving rehabilitation team members when new interventions are to be implemented, as participation contributes to increased positivity in relation to new initiatives.

The realities of practice change: Nurses' perceptions

AIMS AND OBJECTIVES

To explore registered nurses' perceptions of practice change and describe factors that influence the adoption of practice changes.

BACKGROUND

Nurses play a critical role in optimising patient outcomes. Healthcare organisations and nurses must do their part to achieve the Quadruple Aim, which requires nurses to change their practice. Nurses are ideally positioned to improve patient outcomes by changing their practice to align it with research evidence and organisational initiatives; however, this experience of practice change by nurses is grossly under-studied.

DESIGN

A qualitative design, inductive content analysis, was used to understand nurses' perceptions of practice change.

METHODS

Eleven registered nurses, who worked in one hospital system, participated in one-on-one semi-structured interviews. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) were followed.

FINDINGS

The 11 participants described 63 distinct experiences with practice changes. Their experiences with and perceptions of practice change are categorised as (1) There is A History; (2) It's A Lot of Work; (3) It Happens to Nurses; and (4) Doing Right for the Patient.

CONCLUSION

Nurses experience practice change as a central part of the work they do; it occurs frequently and multiple practice changes may co-occur. Nurses identify strategies, such as thoughtful planning, engaging nurses, and communicating the rationale for and the outcomes of the practice change, to facilitate changing practice.

RELEVANCE TO CLINICAL PRACTICE

Involving nurses in practice changes could alleviate some inhibiting factors for adopting new practices. Local hospital and national policies should explore creative and practical ways to balance the competing needs of nurses providing direct care at the bedside and dedicated time to be engaged in practice change initiatives. With the ongoing focus on improving patient care and optimising patient safety, nurses should be viewed as highly valued members of the team when designing and implementing practice changes.

Midwifery leaders' views on the factors considered crucial to implementing evidence-based practice in clinical areas

PROBLEM

The evidence-to-practice gap continues to persist in healthcare and midwives report limited knowledge and use of effective intervention strategies to support the implementation of new evidence-based practices in clinical settings.

BACKGROUND

Despite ongoing development and dissemination of high quality research findings, the translation of latest research evidence by midwives into new evidence-based practices remains sub-optimal. This inefficiency places consumers at risk of obsolete or potentially dangerous healthcare interventions.

AIM

To explore midwifery leaders' views on what information and support midwives require to lead practice change initiatives in clinical areas.

METHODS

The study formed part of a broader Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practice change in clinical settings. The study employed a qualitative design and was guided by the methodological underpinnings of Action Research (AR).

FINDINGS

One core finding emerged to fulfil the aim and objectives of the study. To lead implementation of evidence-based practices, midwives need practical solutions and a map of the process, packaged into a centralised web-based resource.

DISCUSSION

The findings reported in this study provide valuable insight into the specific needs of midwives wanting to improve the uptake and longevity of new evidence based practices in clinical areas. This includes information specific to evidence implementation, support networks and knowledge of Implementation Science.

CONCLUSION

To lead practice change initiatives, midwives require a web-based resource that standardises the process of evidence implementation, while providing midwives with clear direction and the support needed to confidently champion for evidence base change in clinical areas.

The Effect of an Evidence-Based Practice Education and Mentoring Program on Increasing Knowledge, Practice, and Attitudes Toward Evidence-Based Practice in a Rural Critical Access Hospital

OBJECTIVE

The aim of this study was to determine the effect of an evidence-based practice (EBP) education and mentoring program on the knowledge, practice, and attitudes toward EBP among staff nurses and clinicians in a rural critical access hospital.

BACKGROUND

While rural nurses value EBP, they often have more limited resources to engage in EBP activities compared with urban-based nurses.

METHODS

Direct care nurses and clinicians participated in a 5-month EBP education and mentoring program following the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care. The Evidence-Based Practice Questionnaire was used to assess pretest-posttest knowledge, practice, and attitudes toward EBP.

RESULTS

Knowledge and practice of EBP increased significantly (P = .008 and P = .015, respectively) after the EBP education and mentoring intervention. Attitudes toward EBP also increased, although the increase was not statistically significant (P = .106).

CONCLUSIONS

Education and mentoring of healthcare clinicians in rural settings are crucial to the translation of evidence-based research into practice to improve patient outcomes.

Context as a Facilitator of the Implementation of Evidence-based Nursing: A Meta-synthesis

Nurses have numerous difficulties in implementing science due to obstacles related to the work context. The aim is to explore the work-context-related facilitators of the application of evidence in clinical practice by nursing professionals. Qualitative meta-synthesis of primary studies on nurses' experiences of work-context-related facilitators, as defined by the Promoting Action on Research Implementation in Health Services model. Using the Qualitative Appraisal and Review Instrument of the Joanna Briggs Institute. Of the total 57 primary research articles included, an explanatory model of the facilitating factors related to the work context was generated on the basis of four general categories: institutional support (leadership), multidisciplinary support (teamwork and communication), culture of improving quality of care (nursing professionals' attitudes towards change) and use of research (valuing research). Action can be taken on the facilitating factors of the evidence-based practice application in nursing clinical environments, providing resources and motivation from the organization.

Central Line Care: Reducing Central Line-Associated Bloodstream Infections on a Hematologic Malignancy and Stem Cell Transplant Unit

BACKGROUND

Patients with hematologic malignancies and stem cell transplant recipients are at increased risk for infections because of their prolonged periods of profound neutropenia. Central line-associated bloodstream infections (CLABSIs) can result in lengthy hospitalizations, increased healthcare costs, and increased morbidity and mortality.

OBJECTIVES

The aim of this comprehensive educational training program was to reduce CLABSI rates by focusing on the standardized practices associated with use, care, and maintenance of all types of central lines.

METHODS

A pretest was administered to nursing staff. Based on the responses, an education program was then created. The program consisted of a comprehensive two-hour class using different modalities of teaching, including standardized practices associated with central line care.

FINDINGS

The comprehensive education program was effective in standardizing education and improving knowledge gaps, resulting in the reduction of CLABSI rates. Overall, staff knowledge surrounding central line care and maintenance increased by 16%. In addition, no CLABSI events have been reported on the unit from the time of program initiation.

Clinical Research and Practice Collaborative: An Evidence-Based Nursing Clinical Inquiry Expansion

Introduction: Implementation and sustainment of evidence-based practices (EBPs) are common challenges faced by healthcare organizations. The Clinical Research and Practice Collaborative, an evidence-based initiative implemented at a large Military Treatment Facility, addresses EBP implementation and sustainment by expanding the culture of nursing clinical inquiry and broadening nursing research efforts to include EBP. The evidence-based intervention of scheduled, intentional, intraprofessional collaboration between PhD nurse scientists and advanced practice registered nurses as compared to previous methods of spontaneous, consultative collaboration, focuses on developing support for nursing research and EBP initiatives. Materials and Methods: A 2-year pre- and 2-year post-implementation timeframe compared outcomes (proposals, publications, posters) from individual and collaborative nursing research and EBP initiatives. Results: Although nursing research initiatives remained stable, research publications and posters were reduced by 63%, EBP initiatives grew 450%, EBP publications and collaborative nursing initiatives for both research and EBP increased. Additionally, EBP Council membership rose 300%, and an intraprofessional cadre was formed during the implementation. Conclusions: Intentionally scheduled collaboration between PhD nurse scientists and advanced practice registered nurses is a promising model to promote an expanded culture of nursing clinical inquiry and should be considered for medical facilities seeking to enhance EBP and nursing research efforts.

Cancer Center Clinic and Research Team Perceptions of Identity and Interactions

PURPOSE

Conduct of cancer clinical trials requires coordination and cooperation among research and clinic teams. Diffusion of and confusion about responsibility may occur if team members' perceptions of roles and objectives do not align. These factors are critical to the success of cancer centers but are poorly studied.

METHODS

We developed a survey adapting components of the Adapted Team Climate Inventory, Measure of Team Identification, and Measure of In-Group Bias. Surveys were administered to research and clinic staff at a National Cancer Institute-designated comprehensive cancer center. Data were analyzed using descriptive statistics, t tests, and analyses of variance.

RESULTS

Responses were received from 105 staff (clinic, n = 55; research, n = 50; 61% response rate). Compared with clinic staff, research staff identified more strongly with their own group ( P < .01) but less strongly with the overall cancer center ( P = .02). Both clinic staff and research staff viewed their own group's goals as clearer than those of the other group ( P < .01) and felt that members of their groups interacted and shared information within ( P < .01) and across ( P < .01) groups more than the other group did. Research staff perceived daily outcomes as more important than did clinic staff ( P = .05), specifically research-related outcomes ( P = .07).

CONCLUSION

Although there are many similarities between clinic and research teams, we also identified key differences, including perceptions of goal clarity and sharing, understanding and alignment with cancer center goals, and importance of outcomes. Future studies should examine how variation in perceptions and group dynamics between clinic and research teams may impact function and processes of cancer care.

Implementation in nursing and midwifery. A scoping review / Implementationsprojekte in der Pflege und Hebammenarbeit. Scoping review

Background

Evidence-based expertise in nursing and midwifery is growing but is not automatically turned into practice. The importance of implementation research is therefore increasing. International research results on factors facilitating implementation have not yet been sufficiently presented.

Objective

This scoping review will explore the findings on successful preparation, realisation and maintenance of interventions in nursing and midwifery.

Method

Based on an existing systematic approach, relevant data bases were accessed to identify original studies relating to implementation research in nursing and midwifery. The process of study selection and the characteristics of the included studies were charted.

Findings

In the four reviews and 38 studies which met the inclusion criteria, various factors leading to successful implementation are identified. Based on the included studies, four facilitating factors can be pinpointed: (1) workplace culture (16 entries), (2) leadership culture (28 entries), (3) resources (4 entries), and (4) training (22 entries). Depending on the specific phase of the implementation process (preparation, realisation, or maintenance), these factors will vary in importance.

Conclusion

This scoping review provides an orientation for the field of implementation research and it maps the design, themes and results of the studies included. It should be noted that few studies take into consideration the relevant theories, as well as the influence that the researchers and the target group may have on the implementation process, or provide an exact description of the setting in which the implementation takes place.

A Sustainable Smoking Cessation Program for Patients With Lung Cancer

BACKGROUND

Lung cancer is the most preventable leading cause of cancer death in the United States. Smoking while receiving treatment for lung cancer can decrease the effectiveness of the treatment and may reduce quality of life. Although many smoking cessation proposals have focused on how to deliver various interventions, they have neglected the issue of how to sustain the interventions and integrate them into practice.

OBJECTIVES

The purpose of this article is to provide an effective way of educating healthcare professionals (HCPs) on smoking cessation interventions that meet the U.S. Department of Health and Human Services' 2008 evidence-based clinical practice guidelines.

METHODS

This article reviews strategies to integrate evidence from research on smoking cessation into practice in sustainable ways that target patients with lung cancer who smoke.

FINDINGS

HCPs need evidence-based smoking cessation guidelines, along with interventions that will be effective with their specific smoking population. In addition, HCPs need to incorporate clinical practice guidelines for smoking cessation into their care of patients in ways that can be sustained and evaluated.

Registered nurses' experiences of organizational change in acute care settings: a systematic review protocol

REVIEW OBJECTIVE

The objective of this review is to explore how registered nurses working in acute care settings experience organizational change.

Resolving Rivalries and Realigning Goals: Challenges of Clinical and Research Multiteam Systems

This article describes the care processes for a 64-year-old man with newly diagnosed advanced non-small-cell lung cancer who was enrolled in a first-line clinical trial of a new immunotherapy regimen. The case highlights the concept of multiteam systems in cancer clinical research and clinical care. Because clinical research represents a highly dynamic entity-with studies frequently opening, closing, and undergoing modifications-concerted efforts of multiple teams are needed to respond to these changes while continuing to provide consistent, high-level care and timely, accurate clinical data. The case illustrates typical challenges of multiteam care processes. Compared with clinical tasks that are routinely performed by single teams, multiple-team care greatly increases the demands for communication, collaboration, cohesion, and coordination among team members. As the case illustrates, the described research team and clinical team are separated, resulting in suboptimal function. Individual team members interact predominantly with members of their own team. A considerable number of team members lack regular interaction with anyone outside their team. Accompanying this separation, the teams enact rivalries that impede collaboration. The teams have misaligned goals and competing priorities that create competition. Collective identity and cohesion across the two teams are low. Research team and clinical team members have limited knowledge of the roles and work of individuals outside their team. Recommendations to increase trust and collaboration are provided. Clinical providers and researchers may incorporate these themes into development and evaluation of multiteam systems, multidisciplinary teams, and cross-functional teams within their own institutions.