Implementing Evidence in

Clinical Settings
Chapter 9
LEARNING OBJECTIVES:
AT THE END OF THE SESSION, THE LEARNERS
WILL BE ABLE TO:
1. Identify the essential components for
successful EBP implementation;
2. List the key factors for a successful EBP
change implementation;
3. Discuss activities to promote engagement in
evidence-based practice (EBP)
 INTRODUCTION
An Evidence Based Practice (EBP) environment promotes
excellence in clinical care resulting in improvement of patient
outcomes.
Transforming a healthcare institution into a setting where an EBP
culture exists requires persistence, patience, and perseverance .
Persistence—to maintain steadiness on a course of action—
allows time to realize how EBP can improve clinical outcomes and
is a partner with wisdom when change may create significant
stress for staff.
Patience—showing the capacity for endurance—provides the
strength to wait for change to occur.
Perseverance—adhering to a purpose—allows the team to
survive the change process by resolve and dedication during a
time when it is essential to stay the course and believe that EBP
can transform a clinical environment .
 Essential components for successful EBP
implementation in clinical settings

1. Creating a vision(a shared mental

framework)
2. Developing specific goals
3. Identifying a dedicated EBP team, involving
EBP experts
4. Promoting engagement by eliminating
barriers, prioritizing clinical issues, and
evaluating the infrastructure.
 Essential components for successful EBP
implementation in clinical settings

1. Creating a vision(a shared mental framework)

EBP vision (shared mental framework)- is a
compelling and motivating image of desired
changes that is shared across providers,
resulting in excellence in clinical practice
throughout the healthcare organization.
A clear vision gives substance to the actions
needed to transform a healthcare setting into
an EBP environment.
• Reasons for transforming a clinical culture into an EBP
environment:
1. the vision for EBP is based on regulatory initiatives and
insurance-mandated outcomes.
2. calls clinical institutions into action to develop and share
methods for data collection, measurement, and reporting that
support measurement and improvement efforts of both public
and private sector stakeholders at the national and community
level
3. provides specific expectations for transforming a nursing
culture into an environment that promotes superior
performance through EBP
 Essential components for successful EBP
implementation in clinical settings

2. Developing specific goals

Keys to accomplishing a successful vision
include preparation and planning.
Effective programs capture the momentum by
acting quickly to disseminate the vision and by
emphasizing small goals that are easily
attainable.
Small goals with measurable outcomes
provide concrete examples of motivating the
vision for change.
 An example of EBP goals:
• The National Quality Strategy has three aims:
Better Care: Improve the overall quality of care by
making healthcare more patient-centered, reliable,
accessible, and safe.
Healthy People/Healthy Communities: Improve the
health of the U.S. population by supporting proven
interventions to address behavioral, social, and
environmental determinants of health in addition to
delivering higher quality care.
Affordable Care: Reduce the cost of quality healthcare
for individuals, families, employers, and government.
 Essential components for successful EBP
implementation in clinical settings

3. Identifying a dedicated EBP team, involving EBP experts

An effective method to obtain clinical support is to
include experts or mentors at the beginning of an EBP
project, preferably when the vision for change is first
established. Administrative support for the vision is
obtained as soon as those involved have organized their
shared vision or mental framework.
EBP mentor: an advanced practice clinician with in-
depth knowledge and skills in EBP as well as in individual
behavior and organizational change; organizational work
focused.
 Essential components for successful EBP
implementation in clinical settings

4. Promoting engagement by eliminating

barriers, prioritizing clinical issues, and
evaluating the infrastructure
Promoting engagement - stress the importance
of healthcare systems’ commitment to carrying
out activities that promote quality clinical care.
This requires that staff at all levels must be
engaged in high-priority clinical issues to
develop a successful, supportive environment
 Activities to Promote Engagement

1. Assess and Eliminate Barriers

Barrier assessment is an integral component throughout the
engagement and integration phases of EBP implementation.
Change, even when welcome, is stressful to everyone.
• Common barriers to EBP implementation include:
a.) inadequate knowledge and skills,
b.) weak beliefs about the value of EBP,
c.) lack of EBP mentors,
d.) social and organizational influences,
e.) economic restrictions
Overcoming Barriers to EBP Implementation
a.) Lack of knowledge and skills can create barriers to daily
evidence-based care owing to inadequate
understanding of EBP principles, unawareness of how
evidence will improve patient outcomes, and
unfamiliarity with how to implement change. The best
evidence-based policies are of no value to the patients
when the staff lack knowledge of how to implement
them in practice.
> The right information must be in the right place at the
right time and presented in a meaningful way.
b. ) Weak beliefs about the value of EBP and attitudinal barriers can
be more difficult to overcome than knowledge barriers. Negative
attitudes about research and EBP can make it difficult for staff to
engage in EBP.
> Focus group discussions and anonymous electronic surveys can
be valuable in identifying beliefs and attitudes about current and
proposed practice changes.
> Traditional educational techniques (e.g., lectures and web-based
training), when used alone, are usually ineffective in changing
attitudes.
> Interactive discussions with influential colleagues, seeing the
positive impact of change, and removal of perceived barriers can
be powerful in overcoming resistance.
c.) Lack of EBP mentors in the environment can
also be a barrier to implementing EBP by
point-of-care staff.
> Mentors who have in-depth knowledge and
skills in both EBP and individual and
organizational change strategies are also a key
strategy for sustaining change once it is
realized.
d.) Social and organizational barriers to change include lack
of support by leaders, disagreement among clinicians, and
limited resources to support change.
> Effective barrier assessment includes discerning
knowledge, attitudes, and beliefs of mid-level and upper-
level administrators surrounding practice change and their
perceived roles in communicating support for this change.
> Peer group discussions can be very influential, and
informal leaders may weigh in even stronger than formal
leaders on whether practice change will actually occur.
e.) Anticipated economic and workload
implications/restrictions
> Exploring the economic and workload impact of a practice
change early in a project and securing administrative support
when there may be potential increase in cost or workload
can prevent these barriers from impeding progress.
> Economic considerations must include the fact that an
increase in one type of cost may be readily offset with
savings in time (i.e., workload), satisfaction, or the additional
expense of patient complications when best practices are not
implemented.
 Activities to Promote Engagement
2. Prioritize Clinical Issues
In order to spark EBP, it is best to start with a clinical issue of direct
interest to clinicians, because changing one’s own practice can be
much easier than changing the practice of another discipline or
specialty. Initial efforts should focus on maximizing the likelihood of
success. EBP changes are most likely to be successful when they are
based on solid external as well as internal evidence, provide clear
steps for change, and fit within the parameters of the clinician’s
routine practice and patient population. When an organization’s
readiness for change is assessed, regardless of whether the change
will have a large or small impact, an easy win is more likely to occur. A
practice issue that aligns with the organization/administrators’ key
priorities or is a focus of quality initiatives mandated by regulatory
agencies, such as the Joint Commission or the Institute for Healthcare
Improvement, is likely to gain administrative support more readily
than an isolated initiative.
 Activities to Promote Engagement
3. Evaluate the Infrastructure
Organizational leaders must dedicate resources, including
time, to provide support for staff and their EBP mentors to
ask clinical questions; search for and critically appraise
evidence; analyze internal evidence; develop practice
recommendations; plan changes; and develop,
implement, and evaluate the EBP project.
Administrators should seek guidance from expert
clinicians, EBP mentors, and researchers within the
organization while providing authoritative as well as
financial support for the EBP initiative.
 Staff and Stakeholders to Engage at All Levels

• Staff clinicians
• Leadership team members (e.g., executives,
administrators)
• Advanced practice registered nurses
• Stakeholders of all disciplines directly affected
• Physicians
• Family advisory board
• Allied health professionals
• Doctorally prepared nurse researchers
• Evidence-based practice mentors
 Key factors for a successful EBP change
implementation
1. Establish a formal implementation team: Integrate staff
nurses and masters/doctoral prepared nurses.
2. Build excitement: Engage staff, raise awareness of the
need for change, foster enthusiasm, encourage ownership
of EBP initiative.
3. Disseminate evidence: Communicate the process and
rationale for the change and share experiences to increase
motivation to change.
4. Develop clinical tools: Written guidelines, preprinted
orders, or algorithms will encourage adoption of new
practices; alerts and reminders can help influence change.
 Key factors for a successful EBP change
implementation
5. Pilot the evidence-based change: Evaluating changes on a small
scale before moving to widespread implementation can promote
positive attitudes to engage in new practices, but early evaluation
results should be shared with staff promptly along with time to
address questions and concerns.
6. Preserve energy sources: Implementing smaller, more manageable
projects in phases may reduce fatigue and build confidence;
integrating new “champions for change” for each phase can bring
new energy and enthusiasm.
7. Develop a timeline for success: Competing priorities or
environmental issues should be considered with project timelines
for EBP change.
8. Celebrate success: Acknowledge project team members, early
adopters, and positive outcomes of the change.
MCQ:
1. Engage staff, raise awareness of the need for change, foster enthusiasm,
encourage ownership of EBP initiative. This is characteristic key factor
for a successful EBP change implementation that is?
a. Disseminate evidence
b. Build excitement
c. Establish a formal implementation team
d. Pilot the evidence-based change
2. Compelling and motivating image of desired changes that is shared
across providers, resulting in excellence in clinical practice throughout
the healthcare organization. This is an essential component for
successful EBP implementation which is?
a. Developing specific goals
b. Promoting engagement
c. Creating a vision(a shared mental framework)
d. Identifying a dedicated EBP team, involving EBP experts