Article

An exploration of the factors that influence the implementation of evidence into practice. Issues in clinical nursing

Ulster University, Aontroim, Northern Ireland, United Kingdom
Journal of Clinical Nursing (Impact Factor: 1.26). 12/2004; 13(8):913-24. DOI: 10.1111/j.1365-2702.2004.01007.x
Source: PubMed

ABSTRACT

The challenges of implementing evidence-based practice are complex and varied. Against this background a framework has been developed to represent the multiple factors that may influence the implementation of evidence into practice. It is proposed that successful implementation is dependent upon the nature of the evidence being used, the quality of context, and, the type of facilitation required to enable the change process. This study sets out to scrutinize the elements of the framework through empirical enquiry.
The aim of the study was to address the following questions: * What factors do practitioners identify as the most important in enabling implementation of evidence into practice? * What are the factors practitioners identify that mediate the implementation of evidence into practice? * Do the concepts of evidence, context and facilitation constitute the key elements of a framework for getting evidence into practice?
The study was conducted in two phases. Phase 1: Exploratory focus groups (n = 2) were conducted to inform the development of an interview guide. This was used with individual key informants in case study sites. Phase 2: Two sites with on-going or recent implementation projects were studied. Within sites semi-structured interviews were conducted (n = 17).
A number of key issues in relation to the implementation of evidence into practice emerged including: the nature and role of evidence, relevance and fit with organizational and practice issues, multi-professional relationships and collaboration, role of the project lead and resources.
The results are discussed with reference to the wider literature and in relation to the on-going development of the framework. Crucially the growing body of evidence reveals that a focus on individual approaches to implementing evidence-based practice, such as skilling-up practitioners to appraise research evidence, will be ineffective by themselves.
Key elements that require attention in implementing evidence into practice are presented and may provide a useful checklist for future implementation and evaluation projects.

    • "PARIHS refers to the context as the environment or setting where the evidence-based knowledge is planned and implemented. Three broad sub-elements of 'culture, leadership and evaluation' (op cit: 112) are proposed to interact in a dynamic and multifaceted way, which influences whether or not successful implementation will occur (Rycroft-Malone et al. 2004; McCormack et al. 2002). The context sub-element of staff culture is broadly defined to consist of factors such as values and beliefs, teamwork, power and authority, rewards and recognition (Rycroft-Malone 2010). "
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    ABSTRACT: Knowledge utilization is politically “hot” because it informs decisions on improving the quality of care in nursing homes (NHs). The difficulties encountered in implementing evidence-based knowledge into practice may be explained by contextual factors. Contextual factors are crucial to understanding the process of knowledge utilization; how the evidence’ is implemented and received locally by identifying facilitators, as well as barriers to change. This article is based on an evidence-based education intervention executed by four teams of two facilitators with care staff, which aimed to prevent the use of restraint in nursing home (NH) residents with dementia in 24 NHs in Norway. The study used a mixed method design combining cluster randomized controlled trial (C-RCT), participatory action research (PAR) and ethnography, where the aim was to document and examine the success or failure of the education intervention. The empirical material for this paper is primarily based on a post –intervention ethnographic investigation in three NHs in the sample, to investigate the relationship between an education intervention and staff culture. The ethnographic investigation gave a setting and context-specific plausible explanation of why the educational intervention failed or succeeded. This study has shown that the social process of knowledge utilization is influenced by contextual factors such as staff culture, patient mix and milieu as well as structural conditions. The NH conditions are not stable, but rather moving and constantly changing as a response to variation in the staff culture, the patient mix, the resources available and the nursing homes current situation. Therefore, the evidence in connection with staff culture could be understood as “a ball of clay” molding itself differently when coming in touch with staff culture and their collective and individual experiences. Potential for a successful process of knowledge utilization has to do with timing and organizational readiness, which is difficult to foresee when planning an education intervention.
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    • "Research shows that improving the quality of resident care is a complex, difficult, and demanding process and does not follow prescribed and linear paths [30]. Therefore, more static structural quality indicators at the institutional level, such as having protocols might be less influential in changing practice outcomes than structural quality indicators at the ward level, which probably are more closely linked to actual care process and more concretely in line with daily practice. "
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    ABSTRACT: Objective The aim of this study is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in the Netherlands, Germany and Austria. Furthermore differences in malnutrition prevalence and structural quality indicators for nutritional care nursing homes in the three countries are examined. Research methods and procedures A cross-sectional, multi-centre study using a standardised questionnaire at patient, ward and institution level. Malnutrition was assessed by low Body Mass Index, undesired weight loss and reduced intake. Structural quality indicators of nutritional care were measured at ward and institutional level. Results The prevalence of malnutrition differed significantly between the three countries (Netherlands 18.0%, Germany 20.0%, Austria 22.7%). Structural quality indicators related to nutritional care as having a guideline of prevention and treatment of malnutrition were related to malnutrition and explain malnutrition prevalence variance between the Netherlands and Germany. Differences between the Netherlands and Austria in malnutrition prevalence still existed after controlling for these quality structural indicators. Conclusion(s) Structural quality indicators of nutritional care are important in explaining malnutrition variance between the Netherlands and Germany. However they did not explain the difference in malnutrition prevalence between the Netherlands and Austria. Investigating the role of process indicators may provide insight in the role of structural quality indicators of nutritional care in explaining the malnutrition prevalence differences between the Netherlands and Austria.
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    • "While earlier studies suggest that learning, in this case implementation of new knowledge, is a process related primarily to the individual [22], more recent studies suggest that context plays an important role [23]. As previously suggested in the PARIHS framework, implementation of evidence must function as a process combining the evidence, the context, and how implementation is facilitated [24]. Our findings suggest that when considering if and how stroke care data from an NQR facilitates EBP, again, the context in which the evidence is introduced, and the way the process is facilitated is fundamental. "
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    ABSTRACT: Background National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. Methods A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR’s criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. Results An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. Conclusion While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.
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