Successful implementation and diffusion of any practice change requires careful strategic planning. Considerations are involving appropriate persons throughout the effort, planning for diffusion after a small test of change (if appropriate), preparing staff throughout the change, and monitoring the diffusion efforts. Despite the apparent simplicity of such recommendations, many practice change efforts have been thwarted by inattention to these important strategies.
Below are key points to consider in sustaining an evidence-based practice change.
- How strong is the evidence behind the change? When evidence is strong, it enhances the likelihood of success. When evidence is compelling, it is easier for those making the practice change to understand the need to change their practice. Is the evidence driving the change coming from within or outside of the organization?
- What is the context in which the change will be made? A context or location of the change can be more or less friendly to accepting change. Important contextual factors include type of leadership, history of practice change efforts, staff awareness of outcomes, working relations among staff, interdisciplinary relations, and competing initiatives.
- How will the change be facilitated? Are their adequate resources (staff and other) for implementation and evaluation? Are their appropriate persons – either from within or outside the organization – to facilitate the adoption of the change? How much education of staff and others is needed? Are their potential cues to the new practice that will facilitate its adoption? What sort of feedback is necessary to those making the change to assure that they understand when outcomes have been optimized? Is the organization ready to stick with a facilitation effort long enough to assure success?
Consider an example.
Sustaining EBP in action
At St. Joseph Hospital in Orange, California, an evidence-based practice implemented was a new ambulation policy that required nurse-ordered ambulation of hospitalized patients meeting specific clinical parameters. The evidence that initially triggered this practice change was variability in documentation across medical/surgical units, and anecdotal reports from physical therapists (PT) that nursing staff were not consistently following through with mobility assistance in patients who had received physical therapy.
A literature review found no documented studies about specific ambulation policies for hospitals. The research evidence reviewed mainly came from studies of the effects of immobility, or lack of ambulation. In general, patients in hospitals – especially elders – become rapidly deconditioned when their normal activities were curtailed, and especially, when they were bedridden. Research findings about ambulation pointed to the underlying premise that the more ambulation –- the better (that is, the better patient outcomes would be). Other evidence indicated that problems such as pressure ulcers (PUs) and deep venous thromboses (DVTs) are associated with lack of mobility, and can lead to patient mortality and morbidity. Thus, the evidence was compelling to nurses and PTs on the team that a practice change was needed.
A policy was developed and approved quite easily through regular channels (as with many practice changes, this was the easy part). The ambulation “dose” for patients was determined as one walk at least 30 feet 4 times per day with or without assistance. All hospital units were mapped and marked so that nurses and patients could easily measure distance walked; documentation forms were altered to cue staff to record ambulation frequency, distance, and patient tolerance (using the Borg scale, which came from PT literature). During staff and physician education about the policy, two interesting contextual issues were uncovered: (a) physicians were thrilled to have nurses take back ambulation for specific patients (those with no identified risk factors), some even requesting notice if a patient failed to ambulate; and (b) this policy was a true culture change for staff. Both nurses and nursing assistants saw multiple barriers to this; most of these were time and resource-related.
Following whole hospital education efforts, it was apparent that implementation (as shown by documentation of the three indicators – frequency, distance, tolerance) varied by unit. Unit leadership definitely played into this. The unit whose nurse manager headed up the effort had excellent compliance compared with less compliance on other units. To address the staff-related barriers identified, the team in charge of this effort developed a volunteer program for “ambulation assistants,” who are trained nursing or pre-nursing students who wish to help the hospital by ambulating appropriately screened patients. This program is being implemented with mixed success. Barriers are a culture where nursing staff members were used to ambulation requiring physician orders, not being nurse driven. Educational efforts are ongoing to enhance use of these eager new assistants.
A contextual issue that decidedly affected progress on implementing this policy was the hospital expansion into its new tower just after staff education had begun. This competing initiative – the major logistics of such a move – took away focus for several weeks, and required a regrouping in terms of moving ahead with the change.
The process indicators chosen for the ambulation effort were linked to positive patient outcomes in the evidence base (frequency, distance, tolerance). More difficult to determine were what patient outcomes are specifically affected by ambulation; some considered were prevalence of DVT, PUs, or patient length of stay. Changes in any one of these can be linked to alterations in patient ambulation. While these outcomes also are affected by multiple other factors and care processes, they still are important to consider when evaluating the practice change of an ambulation policy. Currently, the project is monitoring the process indicators and watching the mentioned patient outcomes. Making this easier (a facilitator) is the fact that the chart audits done routinely on the units now include the ambulation process indicators. The patient outcomes are monitored through regular performance improvement efforts, such as a quarterly PU prevalence check.
Facilitation of this ambulation project required capable leadership for the team who initially began discussing ambulation. Unfortunately, the initial leader required a personal leave just as implementation began. A co-leader took over, but was lost. A factor that enabled continued interest has been the strong engagement from physical therapy team members to help nursing staff implement this policy. Monthly meetings assist team members in evaluating progress, discussing strategies that are working or not, and maintaining visibility of this effort. What has become apparent to those involved is that this change, while based on compelling evidence, has not been easy to make, and will continue to require facilitation until the staff culture accepts ambulation as a nurse-driven care practice, requiring systematic attention. Feedback on unit compliance with the process indicators is now being given to unit managers, in hopes that they will be able to address issues that are unique to their units. Hospital-wide initiatives to decrease DVTs and PUs also are being included with the information shared with staff.
Making the change
This ambulation project shares many characteristics of other evidence-based practice efforts in terms of non-linear implementation and evaluation. The difficulties inherent in making and sustaining change have been apparent in nursing for years. Think about the following practice changes and remember how difficult they were to make:
- switching from heparin to saline for intermittent vascular access devices
- invoking developmental care principles for neonates
- eliminating stringent protective isolation practices for all oncology patients
- supporting bowel function in patients receiving opioids
- promoting appropriate sedation management in ventilated patients
- not using air in the stomach to evaluate nasogastric tube placement
- using a 0 to 10 pain intensity scale
In every setting where these evidence-based changes were made, there was interplay among the strength of the evidence, the environment in which the change was made (context), and the facilitation efforts. Some evidence-based practices may never achieve 100% compliance among nursing staff. These include hand hygiene measures, documenting re-assessment of pain once a pain management strategy has been carried out, and carrying out individualized and targeted interventions to prevent falls and PUs in patients at risk. However, efforts must be maintained to ensure patient safety and sustaining each effort requires consideration of the type and strength of evidence behind nursing practices, contexts in which practices are implemented, and facilitation strategies that may assist in meeting goals of optimal patient care.
Dana N. Rutledge is a professor of nursing at California State University in Fullerton and the nursing research facilitator at St. Joseph Hospital in Orange California.
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