DEFINING EVIDENCE, IMPLEMENTATION, being learned and technology offers momentum.

ANDTRANSLATIONAL SCIENCES Struggling with what it takes to apply evidence

in ways that promo lasting, safe, cost-
EBP adds action to the use effective, and high quality care is gradually
of evidence. leading to measurable outcome improvements.
EBP provides processes for TOOLS USED FOR SUPPORTING TRANSLATION
using evidence to generate OF DATA TO INFORMATION TO KNOWLEDGE
knowledge. It is a widely TO WISDOM
used term that is easier to
define than to Nursing is an information-based discipline (Graves&
operationalize. Corcoran, 1989). Nursing informatics unites nursing
sScience, computer science, and information science
in ways that transform what this means.
The evolution of nursing as an information-based
EBP is a "problem solving approach to clinical decision- discipline changes how data, information, and
making that involves the Conscientious use of the best knowledge are managed in nursing practice (Staggers
available evidence (including a systematic search for & Thompson, 2002)
and critical appraisal of the most relevant evidence) to
answer a clinical question with one's own clinical What is learned through research, evaluation, quality
expertise along with patient values and preferences to improvenmenty and safety activities contributes to
improve outcomes for individuals, groups, communities wisdom.
and systems" (2011).
Once wisdom achieved, feedback contributes to
- Melnyk & Fineout-Overholt ongoing improve and to generate new hypotheses

Implementation science- is the study of methods to

promote the integration of research findings and .EVOLUTION OF EVIDENCE
evidence into healthcare policy and practice (National How Evidence ls Generated
Institutes of Health Fogarty International Center,
2013). Research results can be used to address important
clinical questions after being accepted as part of the
evidence base for a clinical question.
Implementation science is relevant to nurses and
others who work directly with patients because it
Research results become part of the evidence base for
focuses on what is needed to improve outcomes.
a disease or condition only after going through rigorous
and explicit processes designed to find, Compare, and
EBP is also central to what Titler and Everett (2001)
combine data. Reviews of research findings involve
define as "translational research” which tests the
critical appraisal using explicit and objective inclusion
effect of interventions to facilitate the rate and extent
and exclusion criteria.
to which evidence-based practices are adopted (2001).
 Such criteria identifies studies to be considered
Although defined in different ways, Ttranslation
when trying to answer a clinical question, such
emphasizes processes such as dissemination and
as which nursing interventions for reducing
implementation of empirical, patient-centered findings
pain are the most effective and scientifically
that have been rigorously tested in broad populations
grounded. An organized approach is used to
and sub-groups before deemed ready for
identify valid and reliable peer reviewed
implementation in clinical practice. Feedback and
publications to be considered further.
evaluation often follow implementation.
 Rigorous methods determine the efficacy of
specific interventions and their effectiveness
As evidence moves through dissemination,
when used with real patients outside of tightly
implementation, evaluation, and other stages,
controlled conditions.
evidence-driven care is fostered through
 Advanced statistical analysis, using Bayesian or
iterative and interactive processes (Harrison &
other methods, helps understand how best to
Graham, 2012). Although there is growing
combine findings.
awareness of the importance of evidence
uptake, we are in the early stages of knowing
how to systematically operationalize translation Through these techniques, systematic reviews pull
and sustain improvements after satety and together what is known about the benefits and harms
quality related interventions end. But much is of the interventions surrounding a clinical question.
It also helps reveal the trade-offs associated with key
treatment, diagnostic, or prevention interventions.
The Origins of Evidence-Based Practice
The term EBP became popular after 1992 when first
used by Gordon Guyatt and a group he led at
McMaster University (Guyatt,2002).
David L. Sackett described EBP as the best use of
current best evidence in making decision about the care
of individual patients.
EBP came to describe a systematic approach to
organizing, collecting and using research findings in
ways that contribute to the best possible outcomes.
INFORMATICS TOOLS THAT PROMOTE AND
FACILITATE KNOWLEDGE GENERATION OF
EVIDENCE
Nurses help themselves, their students, patients,
professional nursing groups, and their clinical team
understand whether the information commonly
downloaded about a specific condition or disease is
accurate (valid and reliable) while pointing out potential
benefits and harms.
Caution may be needed if information is being used
without critical review.
A nurse can generate (and regularly update) lists of
credible online evidence-based resources to suggest to
patients, families, and other providers.
Because evidence becomes outdated, nurses can
monitor to be sure that their teams and patients have
current information, including understanding any legal
and ethical concerns or privacy issues.
Criteria to evaluate health-related information found
online has been developed and disseminated by several
organizations including HON Code, American Medical
Association, Internet Health Care Coalition, Hi-Ethics,
and Med Certain (Berland, Elliott, & Morales, 2001).
Criterias designed for evaluating health and medical
information, and increasingly the rest of us are using
mobile and portable devices, including tablets, portable
computers, and smart phones to seek the evidence and
engage with actual automated interventions (such as
online counselling).
 Web-based screening, prevention, outreach, and
intervention tools
- help patients access valid and reliable
evidence about fundamental public health issues, such
as obesity, stress management, and tobacco cessation,
while also helping patients track, reinforce, and
manage healthy choices and gain online support.
 E-mail, evidence, and twitter alert systems
- involve voluntary registration based on clinical
interest in order to receive alerts or updates related
to interventions.
- Ideal for receiving information about new
evidence or to send alerts about a safety concern,
such as spreading information that a medication
has been found dangerous.
Alerts - are often linked to resources that allow access
to the scientific literature matched to a specific clinical
interest.
- Alerts also deliver information that has
already been rated.
Technology platform
- Provide assessments and interventions.
- Allow for tracking and feedback about the
patient's use of the tool to a nurse or other
clinician.
- Some of these tools are interactive and Web-
based or may be
run from a DVD,
local computer, or
flash-drive.
Mobile tools - such as
phones and tablets, are
also used.
Nurses help by addressing
what is lost (in terms of non-verbal interactions, cues,
and physical assistance) versus what is gained (through
access and convenience) when a technology-based
intervention works with other non-nursing clinicians.
Nurses can then tailor these tools to the needs of
specific patients.
MODELS AND THEORETICAL FRAMEWORKS
CONNECTING CRITICAL THINKING TO PROCESS
THAT SUPPORT THE USE OF EVIDENCE IN
NURSING PRACTICE
Models and frameworks help link critical thinking step-
wise processes that promote the use of evidence
,including accounting for factors that lead to safe and
lasting outcome and organizational improvements.
Theories help nurses critically examine the contextual
factors, assumptions, and influences surrounding
implementation.
Using models and frameworks helps nurses prepare a
cogent plan for translation within complicated
situations, such as the implementation of an EBP when
change and disruption are anticipated.

Contributed to theories :
Donabedian's (1980) structure, process, and
outcomes framework, which focus on problem
solving.
Rogers Diffusion of Innovations model, the Funk Model,
the PRECEDE Model, the Chronic Care Model, the
PARiHS Model, the Stetler Model, the lowa Model and
Translation Research Model, Russworm's and
Larrabee's Model, the ARCC Model, Kitson's Framework,
Melnyk and Fineout-Overholt's Model of EBP, the Lean
Framework, the PICOT Model, the QUERI model,
Rossworm and Larrabee's Model, and the Institute for
Healthcare Improvement's breakthrough model.
Specific contributions:
Roger's understanding of "attributes" (including
complexity) and Alison Kitson's emphasis on
understanding the environment, including the
importance of a clearly articulated collaborative
Knowledge Translation (KT approach that can be
embedded into the research design (Kitson, Powell,
Hoon, Newbury, Wilson, & Beilby, 2013).
The Promoting Action on Research
Implementation Health Services (PARIHS)
framework helps define and measure key factors
leading to successful implementation and has been
widely used, including by Squires et al (2012) who
designed strategies to implement resear based policies
and procedures.
Dr. Marita Titler
Leadership for AHRQ's TRIP initiatives and
has also studied the context in which EBPs are
translated. Important influences found include:
(1) tne nature of the innovation strength of evidence)
and
(2) the manner it is communicated to nurses and
physician (Herr et al 2012; Titler 2010; Titler 2011).
Dr. Carole Estabrooks describe the importance of
considering the significant needs found in complex care
environments, such as nursing homes (Estabrooks com
et al., 2013).
Dr. Cheryl Stetler
Stetler Model of Evidence-Based
shaped the evolution of EBP and also synthesized
literature on use PARIHS framework, including
development of a companion guide to assist
researchers using PARIHS
The PARIHS framework is widely used
internationally, including Bergström, Peterson,
Namusoko, Waiswa, and Wallinn (2012) who used
PARIHS as a framework for knowledge translation in
Ugenda
Rycroft-Malone et al. (2012) and McCormack
et al. (2013)
Realist review and synthesis -focuses on
understanding the mechanisms by which an
intervention works or does not work.
Hynes, Whittier, and Owens (2013)
QUERI model - demonstrate how HIT
approaches could be characterized as facilitators or
barriers to implementation. Two pathways were found
to contribute to translation:
(1) compliance and collaboration with information
technology policies and procedures;
(2) operating within organizational policies and building
collaborations with end users, clinicians, and
administrators; and obtaining and maintaining research
resources and ovals.
Harrison. Graham, van den Hoek, Dogherty,Carley, and
Angus (2013)
CAN-IMPLEMENT- refer to the importance of
CAN planning support in development of a framework
INFORMATICS TOOLS THAT PROMOTE THE USE
OF EVIDENCE AND APPLY KNOWLEDGE TO
PRACTICE
 Adoption of evidence is now providing access
to a single clinical practice guideline or
Webinar.
 Shifted to understanding the conditions that
foster ongoing and lasting change once the
evidence is found and introduced, often using
multiple implementation strategies.
 Implementation strategies being used to apply
the evidence are also grounded in science.
What will facilitate implementation and what will be the
barriers? Under what conditions is successful
implementation anticipated?
 Collecting data was challenging during this
study because the patients did not want to be
critical. But sustained improvement depended
upon understanding patient perspectives about
the benefits and challenges of care
coordination and home telehealth.
Understanding the influence of patient perceptions
assured that expectations could be met. This facilitated
translation.
The information explosion presents challenges to
healthcare providers who seek new evidence on an
ongoing basis.
 Evidence-based clinical or point-of-care
resources, especially literature reviews, make it
easier to access information.
 Easy access helps nurses avoid making
decisions based on experience alone or on the
advice of a colleague or teacher.
 Evidence-based tools help by organizing
evidence and aiding cognition in evidence
selection, interpretation, implementation, and
evaluation. When coupled with technology,
evidence-based tools become central to
practice.
 Nurses are challenged to create, find, test,
implement, and evaluate the right evidence-
based tools. Such tools include complex
tecnnology new to some nurses, including
innovate support using mobile health-based.
Decision support includes integrating
experience with the evidence.
 Evidence-based tools are not "cookbooks"
when implementing a clinical intervention using
an automated evidence-based tool, clinical
judgment is needed because translation and
decision support overlap, each is inherently
multi-disciplinary.
 Nursing joins public health medicine, and other
health disciplines in seeking better
understanding of the conditions needed to
successfully apply evidence to decisions
support in real situation, then measure the
impact and feed data back after evaluation.
 Computer-literate nurses brings to their teams
knowledge of how to identify and then critically
appraise the best available evidence or use the
evidence-based tool(s) to support decisions.
 Explaining evidence includes understanding the
unintended consequences that accompany
translation and dealing with uncertainty when
evidence is incomplete, misleading, or
contradictory
For some patients or sub-groups, multiple evidence-
based tools may need to be translated at the same time
or specific interventions from different evidence-based
tools tried together.
 Models help nurses create a cogent plan that
pulls these interventions together.
 Decision support now occurs within the context
of change.
 HIT supports EBP by making it easier to access
and use evidence and evidence-based tools,
such as automated reminders.
"Meaningful use” Affordable Care Act (ACA)
promote the use of evidence to
drive improved outcomes, quality,
and safety.
 Carefully planned use of HIT
contributes to new and
restructured systems that
address the over-use,
underuse, and misuse of
healthcare (Doebbling and
Flanagan, 2011).
 Understanding the context in which HIT and
EBP merge means studying what works and
does not work during translation.
The Use of Electronic Health Records (EHRs).
Automated tools are often linked to computerized
health records, such as:
Electronic Health Record (EHR)
- refers to
patient records collected
across settings, ideally
to support care along
the continuum of an
individual's lifespan.
- provides a
vehicle to transmit
evidence by embedding
evidence-based tools
into routine nursing
functions.
- Can be especially powerful if the data are
standardized and copied into data warehouses or
datamarts where data can be easily exchanged for
follow-up purposes.
Because EHR promotes meaningful use of technology
and enhances information exchange, it plays a growing
role in the translation of evidence into practice.
 Later, these data may become part of the body
of evidence used to update the next version of
a clinical practice guideline.
 Poe, Abbott, and Pronovost (2011) used peer
coaches to build and sustain competencies
needed by nurses using EHR in clinical settings.
  Both satisfaction and confidence increased
through the use of an evidence-based coach
intervention.
 Ongoing diligence is needed to assure the
timeliness of updates, the accuracy of input as
well as the usefulness and safety of output
Applying Evidence in Informatics to Improve
Safety and Quality of Care
Nurses seeking to improve the safety and quality of
care can often find literature review, systematic
reviews, meta-analyses, or evidence based tools that
address their specific goals or are relevant to their
areas of practice.
Technology-based tools - used within an organization in processes in patient care.
ways that makes it easier and faster to implement
evidence-based tools while also making it harder to
harm a patient.
Electronic tools – used to promote quality and safety
offer a promising approach. The impacts should need
to be evaluated prior to, during, and after
implementation.
A dynamic high functioning quality and safety culture
required nurses continually examine the conditions
needed to foster ongoing learning.
Performance, quality, and safety do not come through
the technology alone but are influenced by those who
implement, monitor, and use the technology.
Innovation and progress are impeded by fear.
The tools associated with implementing bar-coded
patient wrist bracelets that match automated records to
prevent patients from receiving wrong medication or
surveillance systems designed to detect healthcare-
acquaired infections are only useful when safely
implemented and maintained.
EVIDENCE EMBEDDED INTO CLINICAL
DECISION SUPPORT
TOOLS (CDS)
Evidence is often
embedded in Clinical
Decision Support (CDS)
tools.
CDS – captures the
processes used to enhance
health-related decision and actions with pertinent,
organized clinical knowledge and patient information, to
improve health and healthcare delivery.
It includes automated templates for orders and
referral that link to reminders or other forms evidence.
Computerized pathways, flow charts, algortihms, and
critical paths are CDS tools that facilitate
implementation in ways that reduce errors and
promoter compliance.
Automated reminders are a form of decision support
used in “real time” or at the point of patient contact.
Clinical practice guidelines (CPGs)
"systematically developed statements to assist
practitioners and patient decisions about appropriate
health care for specific circumstances".
Guidelines are designed to support the decision-making
The content of a guideline is based on a systematic
review of clinical evidence - the main source for
evidence-based care.
Purposes of guidelines
 To describe appropriate care based on the best
available scientific evidence and broad
consensus;
 To reduce inappropriate variation in practice;
 To provide a more rational basis for referral;
 To provide a focus for continuing education;
 To promote efficient use of resources;
 To Act as focus for quality control, including
audit;
 To highlight shortcomings of existing literature
and suggest appropriate future research.
Clinical protocols can be seen as more specific than
guidelines, defined in greater detail.
Protocols provide "a comprehensive set of rigid criteria
outlining the management steps for a single clinical
condition or aspects of organization"
Computerized guidelines
Computerized guidelines encode evidence-based
recommendations for and can automatically generate
recommendations about what medical procedures to
perform tailored for an individual patient.
Computerized guidelines offer benefits over and
above those offered by paper-based guidelines:
 They offer a readily accessible reference,
providing selective access to guideline
knowledge.
  They help reveal errors in the content of a
guideline;
 They help improve the clarity of a guideline,
e.g. in decision criteria and clinical
recommendations;
 They help offer better descriptions of patient
states;
 They can automatically propose timely, patient-
specific decision support and reminders.
Guideline Implementation (Translating
guidelines into practice)
1. Wollersheim H, Burgers J, Grol R. Clinical guidelines
to improve patient care. Neth J Med. 2005
Jun;63(6):188-92.
"The aim of clinical guidelines is to improve quality of
care by translating new research findings into practice.
There is evidence that the following characteristics
contribute to their use: inclusion of specific
recommendations, sufficient supporting evidence, a
clear structure and an attractive lay out. In the process
of formulating recommendations, implicit norms of the
target users should be taken into account. Guidelines
should be developed within a structured and
coordinated program by a credible central organization.
To promote their implementation, guidelines could be
used as a template for local protocols, clinical pathways
and interprofessional agreements. "
2. Davis DA, Taylor-Vaisey A. Translating guidelines
into practice. A systematic review of theoretic
concepts, practical experience and research
evidence in the adoption of clinical practice
guidelines. CMAJ. 1997 Aug 15;157(4):408-16.
"OBJECTIVE: To recommend effective strategies for
implementing clinical practice guidelines (CPGs).
DATA SOURCES: The Research and Development
Resource Base in Continuing Medical Education,
maintained by the University of Toronto, was searched,
as was MEDLINE from January 1990 to June 1996,
inclusive, with the use of the MeSH heading "practice
guidelines" and relevant text words.
STUDY SELECTION: Studies of CPG implementation
strategies and reviews of such studies were selected.
Randomized controlled trials and trials that objectively
measured physicians' performance or health care
outcomes were emphasized.
DATA EXTRACTION: Articles were reviewed to
determine the effect of various factors on the adoption
of guidelines.
DATA SYNTHESIS: The articles showed that CPG
dissemination or implementation processes have mixed
results. Variables that affect the adoption of guidelines
include qualities of the guidelines, characteristics of the
health care professional, characteristics of the practice
setting, incentives, regulation and patient factors. The
interventions were shown to be weak (didactic,
traditional continuing medical education and mailings),
moderately effective (audit and feedback, especially
concurrent, targeted to specific providers and delivered
by peers or opinion leaders) and relatively strong
(reminder systems, academic detailing and multiple
interventions).
CONCLUSIONS: The evidence shows serious
deficiencies in the adoption of CPGs in practice. Future
implementation strategies must overcome this failure
through an understanding of the forces and variables
influencing practice and through the use of methods
that are practice- and community-based rather than
didactic "
3. Entwistle M and Shiffman RN. Turning Guidelines
into Practice: Making It Happen With Standards.
Health Care and Informatics Review Online
[HCRO]. March 2005.
"Successful delivery of the knowledge incorporated into
guidelines requires a systemic approach which
integrates knowledge with workflow using existing
clinical information systems. Electronic clinical decision
support (ECDS) systems are the means through which
the knowledge embedded in guidelines can be
managed and delivered effectively.
Barriers to the success of guideline-based ECDS are
multiple and include: guideline-related obstacles, both
extrinsic to the guideline (organizational and provider
specific obstacles) and intrinsic to the guideline (such
as failure to meet adequate standards in guideline
development and format, identification and summary of
evidence, and formulation of recommendations)
electronic decision support issues which include such
factors as: the extreme complexity of integrated
decision support systems; poor alignment of the goals
of different players; complex technical requirements;
complex content requirements. Initiatives with the goal
of "improving the guidelines" include the AGREE[ b ]
instrument for guideline quality appraisal, the GuideLine
Implementability Appraisal (GLIA) instrument which
predicts barriers to implementation and the COGS
(Conference on Guideline Standardization) checklist of
necessary components of practice guidelines.
Numerous projects in "guideline translation" have taken
place worldwide, each using different approaches in
guideline representation architecture and
implementation. These attempts have advanced the
process of transforming clinical knowledge expressed in
a guideline to a computable format but the absence of
commonly agreed standards has created major
difficulties for guideline implementers and decision-
support systems designers. Standards are now seen as
essential to improvements in the process of "guideline
transformation" for ECDS and underpin a further critical
requirement – the need for ECDS, which has typically
been viewed as a software application, to be
considered from a wider systems perspective. ... "
4. Grol R, Grimshaw J. Evidence-based
implementation of evidence-based medicine. Jt
Comm J Qual Improv. 1999 Oct;25(10):503-13.
" BACKGROUND: The slow and haphazard process of
translating research findings into clinical practice
compromises the potential benefits of clinical research.
Most quality improvement (QI) initiatives are based on
the beliefs of decision makers rather than on the
growing theoretical and empirical knowledge about
organizational and provider behavior change. If future
QI activities are to improve the translation of evidence
into practice, they should be based on an
understanding of the different models and strategies
for implementing research evidence and the evidence
base supporting their use. Evidence-based medicine
should be complemented by evidence-based
implementation.
THE EVIDENCE FOR DIFFERENT STRATEGIES OF
IMPLEMENTING CHANGE:
A general framework for changing practice based on
theoretical perspectives and research evidence
considers a variety of theoretical approaches and their
contribution to an understanding of provider behavior
change. The framework summarizes evidence from
systematic reviews of provider behavior change, which
suggest the potential of several dissemination and
implementation strategies that are effective under
certain conditions. Passive dissemination approaches
are largely ineffective; specific strategies to implement
research-based recommendations appear to be
necessary to ensure practice change. Multifaceted
interventions that address specific barriers to change
are more likely to lead to changes in practice.
PRACTICAL, FIVE-STAGE FRAMEWORK:
It includes development of a concrete proposal for
change; analysis of the target setting and group to
identify obstacles to change; linking interventions to
needs, facilitators, and obstacles to change;
development of an implementation plan; and
monitoring progress with implementation. "
5. Thomson R, Lavender M, Madhok R. How to ensure
that guidelines are effective. BMJ. 1995 Jul
22;311(6999):237-42.
Summary points: "Guidelines are a way to support
effective clinical practice; There is a growing body of
literature on the factors that influence the effectiveness
of guidelines; Reference to these factors will enhance
the likelihood of achieving the objectives of guidelines;
The use of this series of reflective questions rooted in
this literature will support the effective development,
dissemination, implementation, and review of
guidelines. "
Conclusion: "McKeown states: "Medicine must be
prepared to face the tests which are inescapable in
private enterprise and which it is almost unique among
public activities in having evaded hitherto: Is our work
well done? Is it worth doing? and Does it pay its
way"40 The process that leads from selecting a topic to
having an impact on patient care is complex and full of
potential pitfalls. None the less, there is a growing body
of research evidence on appropriate approaches. We
have reviewed this literature and produced a series of
reflective questions to help incorporate this knowledge
into practice. We believe that the potential for
guidelines to influence the quality of patient care is
considerable, particularly when aligned with the process
of audit and quality assurance, in the setting of the
purchaser-provider interaction, and within an overall
culture of continuous quality improvement. "
6. Haynes RB. Using informatics principles and tools
to harness research evidence for patient care:
evidence-based informatics. Medinfo. 1998;9 Pt
1:suppl 33-6.
" Many potentially remediable factors
are responsible for this dilemma in
research transfer, including defective
continuing education for health
professionals and patients;
increasingly complex medical
regimens; diminishing resources for
health care; and inadequate evidence
management. The principles and
procedures of health informatics can
help overcome some of these barriers
to research transfer, particularly such
evidence management tasks as
retrieving, processing, summarizing,
disseminating and applying evidence
for clinical care. Evidence retrieval has
been improved by better indexing and
electronic search engines, by
improved access from clinical and
other settings, and by integration of
evidence into clinical decision support
systems. Evidence processing has
been greatly accelerated by
behaviour by making guidelines
specific. BMJ. 2004 Feb
7;328(7435):343-5.
"The problems of getting people to act
on evidence based guidelines are
widely recognized. An overview of 41
systematic reviews found that the
most promising approach was to use a
variety of interventions including audit
and feedback, reminders, and
educational outreach. The effective
streamlined methods of critical
appraisal of research and by
centralization of these procedures for
the development of current awareness
publications and cumulative "best
evidence" databases. The Cochrane
Collaboration has revolutionized the
summarization (systematic review) of
evidence. The internet has provided
access to patients, practitioners, and
policy makers, alike. Direct-from-
patient automated data collection
promises to move the connection
between evidence and practice to a
higher level. In all of these
innovations, health care practice is
most likely to be enhanced by
intertwining best evidence with best
informatics techniques. "
Michie S, Johnston M. Changing
clinical
interventions often involved
complicated procedures and were
always an addition to the provision of
guidelines. None of the studies used
the simplest intervention—that is,
changing the wording of the
guidelines. We examine the
importance of precise behavioural
recommendations and suggest how
some current guidelines could be
improved. ... "
TRANSLATION OF EVIDENCE
INTO NURSING PRACTICE,

EVIDENCE CLINICAL
PRACTICE GUIDELINES

AND
AUTOMATED
IMPLEMENTATION TOOLS

(IN NURSING INFROMATICS)

Submitted by:

JEVANETTE A. VELACRUZ
JULIE ANN VILLAFLORES MARCIAL N.
MESIAS DE V, RN, MAN

CLINICAL INSTRUCTOR