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Sources and Models for Moving Research Evidence Into Clinical Practice
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CLINICAL ISSUES
Sources and Models for Moving Research Evidence Into Clinical Practice Barbara L. Davies, RN, PhD
High quality research evidence for nursing practice is available from the Cochrane Library and in clinical practice guidelines produced by professional associations. The transfer of research evidence into practice is a complex process, and changing provider behavior is a challenge, even when the relative advantages are strong. An active approach with multifaceted interventions based on the assessment of barriers has been found most effective. An array of interventions for implementing research findings in practice is included, and promising organizational and theoretical perspectives on increasing the use of research evidence for nursing practice are described. JOGNN, 31, 558–562; 2002. DOI: 10.1177/ 088421702237739 Keywords: Clinical practice guidelines—Evidence-based practice—Knowledge utilization— Research transfer Accepted: April 2002 What are the best strategies to use for the transfer of research evidence into clinical nursing practice? This article describes two helpful sources of highquality research evidence. These sources are clinical practice guidelines and the systematic reviews found in the Cochrane Library. To implement or transfer research evidence into clinical practice, multiple strategies or interventions are recommended. What are the possible interventions that you might use? To spark ideas, a simple description of possibilities for interventions is included. Because implementation experts have reported that many contextual variables affect success, this article includes a description of recommended considerations for the practice setting from an organizational 558 JOGNN
perspective. Finally, promising theoretical approaches for future research and practice are provided.
The Evidence Base for Nursing Practice The average practitioner, advanced practice nurse, or manager does not have the time or the skills to find and appraise the large volume of research publications on a given practice question. Furthermore, nurses may be uncertain about which treatment options to use when the research results or the advice of experts is conflicting. Fortunately, over the past 20 years, two tools have emerged to facilitate the application of research evidence to practice. These tools are systematic reviews and clinical practice guidelines.
Systematic Reviews Systematic reviews address a specific clinical question and use well-defined methods to find, appraise, and analyze the results from published and unpublished studies. Some use statistical techniques such as meta-analysis to summarize the results from a number of studies and provide an overall estimate of the effect of an intervention. Cochrane, a British epidemiologist, was concerned about the efficiency and effectiveness of health care and questioned why the public should be expected to pay for forms of care that had not been shown to be effective (Enkin, 1992). Cochrane emphasized the use of evidence from randomized controlled trials because these were likely to provide more reliable information than other sources of evidence. The Cochrane Collaboration maintains a continually updated international electronic database of systematic reviews, including many topics about pregnancy and childbirth. Volume 31, Number 5
In fact, the Cochrane logo seen in the Web site visually depicts the pooled results of studies of the effect of giving corticosteroids to women in premature labor, in which corticosteroids reduced the odds of neonatal death from the complications of prematurity by 30% to 50% (Cochrane Collaboration, 2002). For tips on framing a searchable question and a list of maternal-child titles in the Cochrane database of systematic reviews, you might be interested in the article by Gennaro, Hodnett, and Kearney (2001). In addition, there are many other Cochrane systematic reviews that might be relevant to your practice, about topics such as patient education or decision-making aids (O’Connor et al., 2002).
Clinical Practice Guidelines Clinical practice guidelines or best practice guidelines are a second valuable tool that help professionals stay abreast of the rapidly increasing body of scientific knowledge. Clinical practice guidelines appear to be one of the most promising and effective tools for improving the quality of heath care (Grol, 2001). Clinical practice guidelines are usually constructed by an expert panel and incorporate the results of relevant systematic reviews about a topic, as well as other types of research and the consensus views of expert clinician and researcher panel members. The product is evidence-based guidelines with recommendations for policy and practice. In the United States, the National Guideline Clearinghouse Web site has an extensive collection of evidencebased clinical practice guidelines (see Table 1). In Canada, the largest repository is the Canadian Medical Association Infobase. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN, 2002) has an evidence-based clinical practice guideline series described on their Web site. Topics developed to date by AWHONN include continence for women, nursing management of the second stage of labor, breastfeeding support, and nursing care of the woman receiving regional analgesia/anesthesia in labor. These AWHONN documents include three parts: the practice guideline with recommendations, a background monograph about the importance of the issue, and a quick care reference guide. A strength of the AWHONN guidelines is the inclusion of the level or strength of evidence that each recommendation is based on.
Effectiveness of Implementation Strategies for Physicians Grimshaw et al. (2001) located 41 systematic reviews of the effectiveness of interventions to prompt physicians to translate research findings into practice. They concluded that passive approaches, such as simply mailing information, were not likely to result in a behavior change. The generally effective strategies included educational outSeptember/October 2002
TABLE 1
Selected Web Sources for Research Evidence ♦ AWHONN: Evidence-based clinical practice guidelines series (International) http://www.awhonn.org ♦ Canadian Medical Association Infobase (Canada) http://mdm.ca/cpgsnew/cpgs/index.asp ♦ Cochrane Collaboration (International) http://www./cochrane.org/ ♦ National Guideline Clearinghouse (USA) http://www.guideline.gov/index.asp ♦ Registered Nurses Association of Ontario (Canada) http://www.rnao.org ♦ Toolkit: Implementation of Clinical Practice Guidelines (Canada) http://www.rnao.org/html/BPG/BPG_PDFs/ BPG_Toolkit.pdf
reach and multifaceted interventions based on an assessment of potential barriers. It is not known which components of multifaceted interventions are the most effective. The Effective Practice and Organization of Care group of the Cochrane Collaboration (Bero et al., 2002) has developed a list of interventions that can be used to promote professional implementation of research findings (see Table 2). Other reviewers have also concluded that there is a wide range of interventions to change practice, but there are “no magic bullets,” and multifaceted interventions are recommended (Davis, Thomson, Oxman, & Haynes, 1995; Oxman, Thomson, Davis, & Haynes, 1995). International experts rated organizational capability for change and infrastructure as key factors in supporting physician implementation of medical guidelines (Solberg et al., 2000). These experts echoed the need to attend to many factors and use multiple strategies. In their ranking of the relative effectiveness of a number of implementation strategies, the top five strategies (of 25) were system supports (reminders), focus on physician benefit (change will make work easier), barrier reduction, periodic measurement of improvement, and education (information and training).
Guideline Implementation in Nursing In contrast to the 41 reviews of physicians’ use of research findings in practice, only one systematic review of effects of the introduction of clinical practice guidelines in nursing, midwifery, and other health professions is published in the Cochrane Library (Thomas et al., 2002). This review was also published as a journal article (Thomas, McColl, Cullum, Rousseau, & Soutter, 1999). (An advantage of accessing Cochrane systematic reviews rather than print publications is the inclusion of recent amendments. The reviews are regularly updated, but cli-
JOGNN 559
TABLE 2
Interventions for Implementing Research Findings in Practice Strategy
Description
Educational materials
Distribution of published or printed recommendations for clinical care, such as clinical practice guidelines, audiovisual materials, or electronic publications
Conferences
Participation of health care providers in conferences, lectures, or workshops
Local consensus process
Inclusion of providers in discussions (e.g., about a clinical practice guideline or the definition of adequate care)
Educational outreach visits
Having a trained person meet with providers in their practice settings to provide information, with the intent of changing the providers’ performance. The information may include feedback on the provider’s performance
Local opinion leaders
Use of providers nominated by their colleagues as “educationally influential”
Patient-mediated interventions
Any intervention aimed at changing the performance of health care providers where specific information was sought from or given to patients: for instance, direct mailings to patients, patient counseling, or educational materials given to patients or placed in waiting rooms
Audit and feedback
Summary information (written or verbal) about clinical performance. Information may include the proportion of times a desired clinical action was taken and recommendations for clinical care
Reminders (manual or computerized)
Any intervention that prompts the health care provider to perform a patient- or encounter-specific clinical action
Marketing
Use of personal interviewing, group discussion, or a survey of targeted providers to identify barriers to change and the subsequent design of an intervention that addresses these barriers
Multifaceted interventions
Any intervention that includes two or more of the above
nicians and researchers must check periodically for updates.)
560 JOGNN
The review of the effects of clinical practice guidelines (Thomas et al., 2002) included 18 studies of a total of 467 health professionals. In all but one study, the targeted group was nurses. A variety of guideline topics (e.g., nutrition, labor, infection, headache, vaccinations, falls) were studied. In three of the studies, two or more dissemination strategies were compared. The strategies included opinion leaders, in-service, lectures, provider education, patient education, flow chart records, and patient-specific computerized prompts. The interventions were different in each study, however, and the samples were small. Therefore, it is difficult to make generalizations or conclusions about the best implementation strategies to use in future nursing or allied health research. Improved processes of care after guideline implementation (e.g., better assessments) were found in three of five
G
enerally effective implementation strategies include educational outreach and multifaceted interventions based on an assessment of potential barriers.
studies, and improved patient outcomes were found in six of eight studies. One intervention received an equivocal economic evaluation. The authors concluded that there is some evidence that guideline-driven care is effective, but we must be cautious about generalizing these results owing to the small number of studies and limited followup time. They suggested that implementation should apply strategies effective for physicians and should be informed by theoretical perspectives.
Tools for Organizations Organizational factors and elements in the practice setting can make or break the implementation of research evidence into practice, whether it be the transfer of results from a systematic review or the transfer of recommendations from a clinical practice guideline. There are few resources to assist physicians or nurses in implementing guidelines for practice. Therefore, the Registered Nurses Association of Ontario, with funding from the Ministry of Health, convened an expert panel of active researchers, administrators, and advanced practice nurses and produced an 85-page resource titled Toolkit: Implementation of Clinical Practice Guidelines. This document is available for purchase from the Registered Nurses Association of Ontario or can be downloaded as a .pdf file at no charge from their Web site (see Table 1). The Toolkit is currently under evaluation in a large multisite clinical Volume 31, Number 5
practice guideline implementation project. The document includes valuable state-of-the-art information about implementation strategies, stakeholder engagement, assessing environmental readiness, including evaluation indicators, and developing budgets. Case studies and worksheets are included.
Theoretical Approaches Models describing the process of research utilization in nursing have been available since the 1970s (Stetler, 2001). Classic models, such as the Stetler Model of Research Utilization, have been updated and now include suggestions for research translation and application. However, there are remarkably few intervention studies testing these models or evaluating the relative impact of different interventions on either nursing or patient outcomes. The Ottawa Model of Research Use by Logan and Graham (1998) is a pragmatic framework that specifies a number of elements in the practice setting known to influence the decision to adopt and use research results. Selected elements from this model (structural, social, and patient) are described in Table 3. This framework has been used in evidence-based projects by students in our graduate program. In England, Kitson, Harvey, and McCormack (1998) have been working on enabling the implementation of evidence-based practice for many years. They propose the following model: SU = f(E,C,F), when SU = successful utilization (implementation), E = evidence, C = context, and F = facilitation. In other words, successful utilization is a function of the relationships among the nature of the evi-
T
here is some evidence that guidelinedriven care is effective in changing the process and outcome of care provided.
dence, the context of the proposed change, and the mechanisms by which change will be facilitated. The relationship between the components is not linear, and each dimension is to be considered simultaneously. The odds of successful implementation would be reduced in a context or practice setting that is task-driven, with unclear roles, poor leadership, and few systems for monitoring performance (Kitson et al., 1998). One of the most widely used theoretical approaches to the study of research transfer or dissemination is Rogers’s (1995) Diffusion of Innovations model. As Rogers explained, it is very difficult to get a new idea adopted, even one with obvious advantages. The key to a successSeptember/October 2002
TABLE 3
Practice Environment Influences on Research Use Structural Factors
Social Factors
Decision making Politics Regulations, policies Local champions Physical structure Culture and beliefs Workload Resources and supplies System incentives Medical-legal risks
Patient Factors Problems Beliefs Influence Willingness
Note. From the Ottawa Model of Research Use (Logan and Graham, 1998). Adapted with permission
ful diffusion process is modeling by peers and imitation of the innovative behaviors by potential adopters. Most individuals do not adopt a new idea until learning of their peers’ successful experiences. The diffusion curve is Sshaped. The “innovators” who first adopt a behavior have a low threshold for change, attributed to their “venturesomeness.” Communities and organizations also have thresholds, which are referred to as the “critical mass.” Rogers suggested four strategies for influencing a critical mass of group members. These include (a) targeting top officials for initial adoption, (b) shaping individuals’ perceptions that the innovation is inevitable and desirable, (c) introducing ideas into intact groups, and (d) providing incentives to early adopters. A recent discussion with the operations officer and senior administrator of a large tertiary care institution revealed strong receptivity to the notion of targeting the top official. This administrator concurred with Rogers’s strategies and spontaneously volunteered to assist with the next research transfer study. For example, the administrator was willing to be directly involved and assist with planning information dissemination, particularly in determining “which information is relevant to whom.” In addition, existing quality assurance methods, such as monthly unit reports and patient comment cards, could be adapted to evaluate implementation. Ideas consistent with the proposed change could be directly acknowledged, rewarded, and “nurtured.”
Conclusions In summary, facilitating evidence-based practice is an active area of study, and several promising theoretical models about research use have been published within the last few years. Sources of high-quality research evidence applicable to nursing practice include systematic reviews by the Cochrane Collaboration and clinical practice guidelines from professional associations. Although there have been only a few intervention studies in nursing com-
JOGNN 561
paring two or more methods to transfer research results to practice, the results to date are encouraging and suggest that improvements in processes and outcomes of care occurred in most studies. It is not known which specific strategies are most likely to enhance research-based practice, but it is known that an active approach with multiple methods or strategies is needed. Future work by teams of researchers, administrators, and practitioners is necessary to determine the most efficient and effective strategies to implement the results from research in clinical practice settings, so that optimal patient outcomes can be achieved.
S
trategies for influencing a group include targeting the top officials for initial adoption, emphasizing that adoption is inevitable and desirable, introducing ideas to groups, and providing incentives to early adopters (Rogers, 1995).
REFERENCES Association of Women’s Health, Obstetric and Neonatal Nurses. (2002). Evidence-based clinical practice guidelines series. Retrieved from http://www.awhonn.org. Bero, L., Grilli, R., Grimshaw, J. M., Mowatt, G., Oxman, A. D., & Zwarenstein, M. (Eds.). (2002). Cochrane effective professional and organisation of care group. In The Cochrane Library (Issue 1). Oxford, UK: Update Software. Cochrane Collaboration. (2002). Web site retrieved from htttp://www.cochrane.org/cochrane/general.htm. Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, B. (1995). Changing physician performance. A systematic review of the effect of continuing education strategies. Journal of the American Medical Association, 274, 700706. Enkin, M. (1992). Current overviews of research evidence from controlled trials in midwifery obstetrics. Journal of the Society of Obstetricians and Gynecologists of Canada, 9, 29-33. Gennaro, S., Hodnett, E., & Kearney, M. (2001). Making evidence-based practice a reality in your institution. MCN: American Journal of Maternal Child Nursing, 26, 236-244.
562 JOGNN
Grimshaw, J. M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L., et al. (2001). Changing provider behavior: An overview of systematic reviews of interventions. Medical Care, 39(Suppl. 2), II-2–II-45. Grol, R. (2001). Successes and failures in the implementation of evidence-based guidelines for clinical practice. Medical Care, 39(Suppl. 2), II-46–II-54. Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7, 149-158. Logan, J., & Graham, I. D. (1998). Toward a comprehensive interdisciplinary model of health care research use. Science Communication, 20, 227-246. O’Connor, A. M., Stacey, D., Rovner, D., Holmes-Rovner, M., Tetroe, J., Llewellyn-Thomas, H. et al. (2002). Decision aids for people facing health treatment or screening decisions (Cochrane Review). In: The Cochrane Library (Issue 1). Oxford, UK: Update Software. Oxman, A. D., Thomson, M. A., Davis, D. A., & Haynes, B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153, 1423-1452. Rogers, E. M. (1995) Diffusion of Innovations (4th ed.). New York: The Free Press. Solberg, L. I., Brekke, M. L., Fazio, C. J., Fowles, J., Jacobsen, D. N., Kottke, et al. (2000). Lessons from experienced guideline implementers: Attend to many factors and use multiple strategies. Joint Commission Journal on Quality Improvement, 26, 171-188. Stetler, C. (2001). Updating the Stetler Model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49, 272-279. Thomas, L., Cullum, N., McColl, E., Rousseau, N., Soutter, J., & Steen, N. (2002). Guidelines in professions allied to medicine (Cochrane Review). In: The Cochrane Library (Issue 1). Oxford, UK: Update Software. Thomas, L. H., McColl, E., Cullum, N., Rousseau, N., & Soutter, J. (1999). Clinical guidelines in nursing, midwifery and the therapies: A systematic review. Journal of Advanced Nursing, 30, 40-50.
Barbara L. Davies is an associate professor and career scientist funded by the Ministry of Health (Ontario) at the School of Nursing, University of Ottawa, Ontario, Canada.
Address for correspondence: Barbara L. Davies, RN, PhD, University of Ottawa School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada, K1H 8M5. E-mail [email protected].
Volume 31, Number 5
CLINICAL ISSUES
Sources and Models for Moving Research Evidence Into Clinical Practice Barbara L. Davies, RN, PhD
High quality research evidence for nursing practice is available from the Cochrane Library and in clinical practice guidelines produced by professional associations. The transfer of research evidence into practice is a complex process, and changing provider behavior is a challenge, even when the relative advantages are strong. An active approach with multifaceted interventions based on the assessment of barriers has been found most effective. An array of interventions for implementing research findings in practice is included, and promising organizational and theoretical perspectives on increasing the use of research evidence for nursing practice are described. JOGNN, 31, 558–562; 2002. DOI: 10.1177/ 088421702237739 Keywords: Clinical practice guidelines—Evidence-based practice—Knowledge utilization— Research transfer Accepted: April 2002 What are the best strategies to use for the transfer of research evidence into clinical nursing practice? This article describes two helpful sources of highquality research evidence. These sources are clinical practice guidelines and the systematic reviews found in the Cochrane Library. To implement or transfer research evidence into clinical practice, multiple strategies or interventions are recommended. What are the possible interventions that you might use? To spark ideas, a simple description of possibilities for interventions is included. Because implementation experts have reported that many contextual variables affect success, this article includes a description of recommended considerations for the practice setting from an organizational 558 JOGNN
perspective. Finally, promising theoretical approaches for future research and practice are provided.
The Evidence Base for Nursing Practice The average practitioner, advanced practice nurse, or manager does not have the time or the skills to find and appraise the large volume of research publications on a given practice question. Furthermore, nurses may be uncertain about which treatment options to use when the research results or the advice of experts is conflicting. Fortunately, over the past 20 years, two tools have emerged to facilitate the application of research evidence to practice. These tools are systematic reviews and clinical practice guidelines.
Systematic Reviews Systematic reviews address a specific clinical question and use well-defined methods to find, appraise, and analyze the results from published and unpublished studies. Some use statistical techniques such as meta-analysis to summarize the results from a number of studies and provide an overall estimate of the effect of an intervention. Cochrane, a British epidemiologist, was concerned about the efficiency and effectiveness of health care and questioned why the public should be expected to pay for forms of care that had not been shown to be effective (Enkin, 1992). Cochrane emphasized the use of evidence from randomized controlled trials because these were likely to provide more reliable information than other sources of evidence. The Cochrane Collaboration maintains a continually updated international electronic database of systematic reviews, including many topics about pregnancy and childbirth. Volume 31, Number 5
In fact, the Cochrane logo seen in the Web site visually depicts the pooled results of studies of the effect of giving corticosteroids to women in premature labor, in which corticosteroids reduced the odds of neonatal death from the complications of prematurity by 30% to 50% (Cochrane Collaboration, 2002). For tips on framing a searchable question and a list of maternal-child titles in the Cochrane database of systematic reviews, you might be interested in the article by Gennaro, Hodnett, and Kearney (2001). In addition, there are many other Cochrane systematic reviews that might be relevant to your practice, about topics such as patient education or decision-making aids (O’Connor et al., 2002).
Clinical Practice Guidelines Clinical practice guidelines or best practice guidelines are a second valuable tool that help professionals stay abreast of the rapidly increasing body of scientific knowledge. Clinical practice guidelines appear to be one of the most promising and effective tools for improving the quality of heath care (Grol, 2001). Clinical practice guidelines are usually constructed by an expert panel and incorporate the results of relevant systematic reviews about a topic, as well as other types of research and the consensus views of expert clinician and researcher panel members. The product is evidence-based guidelines with recommendations for policy and practice. In the United States, the National Guideline Clearinghouse Web site has an extensive collection of evidencebased clinical practice guidelines (see Table 1). In Canada, the largest repository is the Canadian Medical Association Infobase. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN, 2002) has an evidence-based clinical practice guideline series described on their Web site. Topics developed to date by AWHONN include continence for women, nursing management of the second stage of labor, breastfeeding support, and nursing care of the woman receiving regional analgesia/anesthesia in labor. These AWHONN documents include three parts: the practice guideline with recommendations, a background monograph about the importance of the issue, and a quick care reference guide. A strength of the AWHONN guidelines is the inclusion of the level or strength of evidence that each recommendation is based on.
Effectiveness of Implementation Strategies for Physicians Grimshaw et al. (2001) located 41 systematic reviews of the effectiveness of interventions to prompt physicians to translate research findings into practice. They concluded that passive approaches, such as simply mailing information, were not likely to result in a behavior change. The generally effective strategies included educational outSeptember/October 2002
TABLE 1
Selected Web Sources for Research Evidence ♦ AWHONN: Evidence-based clinical practice guidelines series (International) http://www.awhonn.org ♦ Canadian Medical Association Infobase (Canada) http://mdm.ca/cpgsnew/cpgs/index.asp ♦ Cochrane Collaboration (International) http://www./cochrane.org/ ♦ National Guideline Clearinghouse (USA) http://www.guideline.gov/index.asp ♦ Registered Nurses Association of Ontario (Canada) http://www.rnao.org ♦ Toolkit: Implementation of Clinical Practice Guidelines (Canada) http://www.rnao.org/html/BPG/BPG_PDFs/ BPG_Toolkit.pdf
reach and multifaceted interventions based on an assessment of potential barriers. It is not known which components of multifaceted interventions are the most effective. The Effective Practice and Organization of Care group of the Cochrane Collaboration (Bero et al., 2002) has developed a list of interventions that can be used to promote professional implementation of research findings (see Table 2). Other reviewers have also concluded that there is a wide range of interventions to change practice, but there are “no magic bullets,” and multifaceted interventions are recommended (Davis, Thomson, Oxman, & Haynes, 1995; Oxman, Thomson, Davis, & Haynes, 1995). International experts rated organizational capability for change and infrastructure as key factors in supporting physician implementation of medical guidelines (Solberg et al., 2000). These experts echoed the need to attend to many factors and use multiple strategies. In their ranking of the relative effectiveness of a number of implementation strategies, the top five strategies (of 25) were system supports (reminders), focus on physician benefit (change will make work easier), barrier reduction, periodic measurement of improvement, and education (information and training).
Guideline Implementation in Nursing In contrast to the 41 reviews of physicians’ use of research findings in practice, only one systematic review of effects of the introduction of clinical practice guidelines in nursing, midwifery, and other health professions is published in the Cochrane Library (Thomas et al., 2002). This review was also published as a journal article (Thomas, McColl, Cullum, Rousseau, & Soutter, 1999). (An advantage of accessing Cochrane systematic reviews rather than print publications is the inclusion of recent amendments. The reviews are regularly updated, but cli-
JOGNN 559
TABLE 2
Interventions for Implementing Research Findings in Practice Strategy
Description
Educational materials
Distribution of published or printed recommendations for clinical care, such as clinical practice guidelines, audiovisual materials, or electronic publications
Conferences
Participation of health care providers in conferences, lectures, or workshops
Local consensus process
Inclusion of providers in discussions (e.g., about a clinical practice guideline or the definition of adequate care)
Educational outreach visits
Having a trained person meet with providers in their practice settings to provide information, with the intent of changing the providers’ performance. The information may include feedback on the provider’s performance
Local opinion leaders
Use of providers nominated by their colleagues as “educationally influential”
Patient-mediated interventions
Any intervention aimed at changing the performance of health care providers where specific information was sought from or given to patients: for instance, direct mailings to patients, patient counseling, or educational materials given to patients or placed in waiting rooms
Audit and feedback
Summary information (written or verbal) about clinical performance. Information may include the proportion of times a desired clinical action was taken and recommendations for clinical care
Reminders (manual or computerized)
Any intervention that prompts the health care provider to perform a patient- or encounter-specific clinical action
Marketing
Use of personal interviewing, group discussion, or a survey of targeted providers to identify barriers to change and the subsequent design of an intervention that addresses these barriers
Multifaceted interventions
Any intervention that includes two or more of the above
nicians and researchers must check periodically for updates.)
560 JOGNN
The review of the effects of clinical practice guidelines (Thomas et al., 2002) included 18 studies of a total of 467 health professionals. In all but one study, the targeted group was nurses. A variety of guideline topics (e.g., nutrition, labor, infection, headache, vaccinations, falls) were studied. In three of the studies, two or more dissemination strategies were compared. The strategies included opinion leaders, in-service, lectures, provider education, patient education, flow chart records, and patient-specific computerized prompts. The interventions were different in each study, however, and the samples were small. Therefore, it is difficult to make generalizations or conclusions about the best implementation strategies to use in future nursing or allied health research. Improved processes of care after guideline implementation (e.g., better assessments) were found in three of five
G
enerally effective implementation strategies include educational outreach and multifaceted interventions based on an assessment of potential barriers.
studies, and improved patient outcomes were found in six of eight studies. One intervention received an equivocal economic evaluation. The authors concluded that there is some evidence that guideline-driven care is effective, but we must be cautious about generalizing these results owing to the small number of studies and limited followup time. They suggested that implementation should apply strategies effective for physicians and should be informed by theoretical perspectives.
Tools for Organizations Organizational factors and elements in the practice setting can make or break the implementation of research evidence into practice, whether it be the transfer of results from a systematic review or the transfer of recommendations from a clinical practice guideline. There are few resources to assist physicians or nurses in implementing guidelines for practice. Therefore, the Registered Nurses Association of Ontario, with funding from the Ministry of Health, convened an expert panel of active researchers, administrators, and advanced practice nurses and produced an 85-page resource titled Toolkit: Implementation of Clinical Practice Guidelines. This document is available for purchase from the Registered Nurses Association of Ontario or can be downloaded as a .pdf file at no charge from their Web site (see Table 1). The Toolkit is currently under evaluation in a large multisite clinical Volume 31, Number 5
practice guideline implementation project. The document includes valuable state-of-the-art information about implementation strategies, stakeholder engagement, assessing environmental readiness, including evaluation indicators, and developing budgets. Case studies and worksheets are included.
Theoretical Approaches Models describing the process of research utilization in nursing have been available since the 1970s (Stetler, 2001). Classic models, such as the Stetler Model of Research Utilization, have been updated and now include suggestions for research translation and application. However, there are remarkably few intervention studies testing these models or evaluating the relative impact of different interventions on either nursing or patient outcomes. The Ottawa Model of Research Use by Logan and Graham (1998) is a pragmatic framework that specifies a number of elements in the practice setting known to influence the decision to adopt and use research results. Selected elements from this model (structural, social, and patient) are described in Table 3. This framework has been used in evidence-based projects by students in our graduate program. In England, Kitson, Harvey, and McCormack (1998) have been working on enabling the implementation of evidence-based practice for many years. They propose the following model: SU = f(E,C,F), when SU = successful utilization (implementation), E = evidence, C = context, and F = facilitation. In other words, successful utilization is a function of the relationships among the nature of the evi-
T
here is some evidence that guidelinedriven care is effective in changing the process and outcome of care provided.
dence, the context of the proposed change, and the mechanisms by which change will be facilitated. The relationship between the components is not linear, and each dimension is to be considered simultaneously. The odds of successful implementation would be reduced in a context or practice setting that is task-driven, with unclear roles, poor leadership, and few systems for monitoring performance (Kitson et al., 1998). One of the most widely used theoretical approaches to the study of research transfer or dissemination is Rogers’s (1995) Diffusion of Innovations model. As Rogers explained, it is very difficult to get a new idea adopted, even one with obvious advantages. The key to a successSeptember/October 2002
TABLE 3
Practice Environment Influences on Research Use Structural Factors
Social Factors
Decision making Politics Regulations, policies Local champions Physical structure Culture and beliefs Workload Resources and supplies System incentives Medical-legal risks
Patient Factors Problems Beliefs Influence Willingness
Note. From the Ottawa Model of Research Use (Logan and Graham, 1998). Adapted with permission
ful diffusion process is modeling by peers and imitation of the innovative behaviors by potential adopters. Most individuals do not adopt a new idea until learning of their peers’ successful experiences. The diffusion curve is Sshaped. The “innovators” who first adopt a behavior have a low threshold for change, attributed to their “venturesomeness.” Communities and organizations also have thresholds, which are referred to as the “critical mass.” Rogers suggested four strategies for influencing a critical mass of group members. These include (a) targeting top officials for initial adoption, (b) shaping individuals’ perceptions that the innovation is inevitable and desirable, (c) introducing ideas into intact groups, and (d) providing incentives to early adopters. A recent discussion with the operations officer and senior administrator of a large tertiary care institution revealed strong receptivity to the notion of targeting the top official. This administrator concurred with Rogers’s strategies and spontaneously volunteered to assist with the next research transfer study. For example, the administrator was willing to be directly involved and assist with planning information dissemination, particularly in determining “which information is relevant to whom.” In addition, existing quality assurance methods, such as monthly unit reports and patient comment cards, could be adapted to evaluate implementation. Ideas consistent with the proposed change could be directly acknowledged, rewarded, and “nurtured.”
Conclusions In summary, facilitating evidence-based practice is an active area of study, and several promising theoretical models about research use have been published within the last few years. Sources of high-quality research evidence applicable to nursing practice include systematic reviews by the Cochrane Collaboration and clinical practice guidelines from professional associations. Although there have been only a few intervention studies in nursing com-
JOGNN 561
paring two or more methods to transfer research results to practice, the results to date are encouraging and suggest that improvements in processes and outcomes of care occurred in most studies. It is not known which specific strategies are most likely to enhance research-based practice, but it is known that an active approach with multiple methods or strategies is needed. Future work by teams of researchers, administrators, and practitioners is necessary to determine the most efficient and effective strategies to implement the results from research in clinical practice settings, so that optimal patient outcomes can be achieved.
S
trategies for influencing a group include targeting the top officials for initial adoption, emphasizing that adoption is inevitable and desirable, introducing ideas to groups, and providing incentives to early adopters (Rogers, 1995).
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Barbara L. Davies is an associate professor and career scientist funded by the Ministry of Health (Ontario) at the School of Nursing, University of Ottawa, Ontario, Canada.
Address for correspondence: Barbara L. Davies, RN, PhD, University of Ottawa School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada, K1H 8M5. E-mail [email protected].
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