Journal of Nursing Management, 2016

Routines for change: how managers can use absorptive capacity

to adopt and implement evidence-based practice
1 2
JENNIFER INNIS MA NP and WHITNEY BERTA PhD

1
PhD Candidate and 2Associate Professor, Institute of Health Policy, Management and Evaluation, University of
Toronto, 425 – 155 College Street, Toronto, Ontario M5T 3M6, Canada

Correspondence INNIS J. & BERTA W. (2016) Journal of Nursing Management

Jennifer Innis Routines for change: how managers can use absorptive capacity to adopt
Institute of Health Policy and implement evidence-based practice
Management and Evaluation
University of Toronto Aims This paper uses the construct of absorptive capacity to understand how
425 – 155 College Street nurse managers can facilitate the adoption and use of evidence-based practice
Toronto within health-care organisations.
Ontario M5T 3M6 Background How health-care organisations adopt and implement innovations
Canada
such as new evidence-based practices will depend on their absorptive, or learning,
E-mail: jennifer.innis@mail.
capacity. Absorptive capacity manifests as routines, which are the practices,
utoronto.ca
procedures and customs that organisational members use to carry out work and
to make work-related decisions.
Methods Using the construct of absorptive capacity as well as a recent literature
review of how health-care organisations take on best practices, we illustrate how
the uptake and use of new knowledge, such as evidence-based practices, can be
facilitated through the use of routines.
Implications for nursing management This paper highlights routines that nurse
managers can use to foster environments where evidence-based practices can be
readily identified, and strategies for facilitating their adoption and implementation.
Conclusions The construct of absorptive capacity and the use of routines can be
used to examine the ways in which nurse managers can adopt, implement and
evaluate the use of evidence-based practices.
Keywords: evidence-based practice, innovation, nursing management, organisational
learning

Accepted for publication: 18 January 2016

ers in the adoption and implementation of evidence-

Aims
Evidence based practices are activities or procedures
shown through research to be effective in improving
patient outcomes (Tucker et al. 2007). Despite the
promise of evidence-based practices for health-care
improvement, the literature shows that all too often
patient care is not based on the current best scientific
evidence and that it can take over a decade for
research findings to be adopted and used by health-
care organisations (Grol & Grimshaw 2003, Okafor
& Thomas 2008, Smith et al. 2013). Nurses are lead-
based practice within health-care organisations, and it
is nurse managers who are often responsible for imple-
menting new practices within their organisations in a
variety of health-care settings (Stetler et al. 2014, Ble-
ich & Kist 2015, Fleiszer et al. 2015, Kueny et al.
2015). The construct of absorptive capacity routines
has been used to understand how health-care organi-
sations implement new practices (Berta & Baker
2004, Berta et al. 2013). This paper uses the construct
of absorptive capacity routines to understand how
nurse managers can work within health-care organisa-

DOI: 10.1111/jonm.12368
ª 2016 John Wiley & Sons Ltd 1
J. Innis and W. Berta
tions to facilitate the adoption and use of evidence
based practices.
Background
Organisations, including health-care organisations,
incorporate new knowledge into their practices and
procedures all the time. New knowledge presents an
innovation, and it can take many forms – new proto-
cols, new technologies, or new knowledge about how
to structure work.
How, and how effectively, health-care organisations
take on new practices will depend upon their learning
or ‘absorptive’ capacity, that is, their ability to recog-
nise the value of new knowledge and information,
assimilate it, and then apply it to make decisions
(Cohen & Levinthal 1990). The concept of absorptive
capacity (AC) has been associated in the health ser-
vices literature with an organisation’s ability to assimi-
late innovations such as best practices (Barnsley et al.
1998, Berta et al. 2010) and it has been linked to
organisational performance (Alegre & Chiva 2008,
Lewin et al. 2011).
Absorptive capacity can manifest as routines – that
is, practices, procedures and customs that organisa-
tional members use to carry out work and to make
work-related decisions. Routines are a form of knowl-
edge and they may be locally generated or may come
from outside the organisation (Cohen & Levinthal
1990, March 1991). Routines are used to facilitate the
use of knowledge within health-care organisations.
Berta and Baker (2004) explored how absorptive
capacity routines can be used to promote knowledge
transfer across hospital units in order to foster the
uptake of patient safety initiatives. The absorptive
capacity routines used to implement evidence-based
practices were also examined in a 2013 study of long-
term care homes (Berta et al. 2013).
There are different levels of routines. Straightfor-
ward, lower level routines are the everyday practices
carried out in the work of the organisation. They are
particular to the organisation, and they represent pro-
cesses that can actually be observed. Metaroutines are
higher order, overarching routines that influence the
ability to perform lower level routines as well as to
effect changes in organisational practices and the use
of new knowledge (Lewin et al. 2011). Lewin et al.
(2011) describe metaroutines as the basis or underpin-
ning of AC. Absorptive capacity metaroutines may be
external or internal.
External absorptive capacity routines are used by
organisations to explore or scan the external environ-
2 Journal of Nursing Management
ment to discover new knowledge that might benefit it
generally, or to solve an existing performance problem.
Internal absorptive capacity routines are those that are
invoked once new knowledge is imported into an
organisation. These are routines that are used to exam-
ine and select new practices to implement, to share
ideas across an organisation, and to reflect on, and
revise, traditional practices (Lewin et al. 2011, Peeters
et al. 2014). Over time, both external and internal rou-
tines may be adapted in response to new problems, new
experiences and organisational learning, or they may be
discarded for new routines that better address prob-
lems. As routines change and grow, new organisational
capabilities can develop (Lewin et al. 2011).
Methods
A scoping literature review (Arksey & O’Malley
2005) was undertaken to examine the factors, context
and processes that influence the uptake, implementa-
tion and sustainability of evidence based practice in
health-care organisations. Thirty studies met the eligi-
bility criteria for this literature review, which focused
on studies published between January 1991 and
March 2014 and used four electronic databases:
MEDLINE, PsycINFO, CINAHL and Business Source
Premier. A qualitative analysis of the studies led to the
development of a number of themes.
Key themes identified by this literature review were:
organisational processes used to select evidence-based
practices for adoption, the use of resources, internal
social networks and external relationships. These
themes are used in this paper to drive a new conceptu-
alisation of how the construct of absorptive capacity,
and the use of routines, can facilitate the uptake and
use of evidence-based practice within health-care
organisations. A full report on the results of this scop-
ing review is available (Innis et al. 2015).
Results
The scoping review afforded insights into the
metaroutines that managers need to consider in order
to facilitate the adoption and use of evidence-based
practice. These metaroutines are: scanning; using par-
ticipative internal selection regimes; allocating
resources; fostering internal social networks; building
and nurturing external relationships; as well as reflect-
ing and updating new and established practices. Each
metaroutine is discussed below with the use of speci-
fic, observable routines from the literature review, and
is articulated as a proposition. The propositions are
ª 2016 John Wiley & Sons Ltd

illustrated in Figure 1. The metaroutines and routines
are summarised in Table 1.
Scanning
Scanning refers to routines that organisations use to
scan the external environment for innovations that
may be of use to solving problems or enhancing per-
formance (Lewin et al. 2011). A 2010 Canadian study
examined the introduction of evidence-based clinical
practice guidelines in long-term care homes in
Ontario. It was found that prior to the adoption of
the guidelines, there was a phase in which key mem-
bers of the organisation, whether asked by manage-
ment or self-directed, scanned sources of information
in the environment to find out about current protocols
and recommendations that were associated with resi-
dent care issues (Berta et al. 2010).
Similarly, an earlier American study examined how
public sector mental health service organisations made
decisions to adopt practice changes. Here, organisa-
tions that made an effort to expose organisational
members to new practices by encouraging them to
scan the environment and to examine activities in
other organisations were more likely to adopt new
practices (Panzano & Roth 2006).
Proposition 1: Health-care organisations with
external absorptive capacity routines for scanning will
facilitate the uptake of evidence-based practices
Internal selection regimes
When looking for practice changes, there are multiple
innovations that an organisation may consider at any
one time. Whether an organisation decides to select an
Using parcipave
internal selecon
regimes
3 Building &
Allocang
resources
Figure 1
Metaroutines for change.
ª 2016 John Wiley & Sons Ltd
Journal of Nursing Management
Routines and evidence-based practice
innovation will depend on the processes in place to
select innovations (Argote 2012). Lewin et al. (2011)
refer to these particular routines as internal selection
regimes. Often, within health-care organisations, selec-
tion decisions may be made by committees at the level
of senior management. However, several Canadian
and American studies identified that the involvement
of front-line staff and managers in the selection of
innovations was highly important to creating support
for the change, and to the successful adoption and use
of the new practice (Leape et al. 2006, Ruffolo et al.
2009, Kimber et al. 2012, Berta et al. 2013). In addi-
tion, an American study of a behavioural health-care
organisation found that involving patients and family
members, while time consuming, was integral to the
success of a new initiative (Ruffolo et al. 2009).
Proposition 2: Health-care organisations with
internal absorptive capacity routines for using partici-
pative internal selection regimes will facilitate the
uptake of evidence-based practices
Resourcing for implementation
The resources of training, time and information tech-
nology (IT) have been found to be particularly impor-
tant factors in the implementation of new practices. It
is not surprising that the implementation of a new
practice will be facilitated by training and educating
staff (Greenhalgh et al. 2004, Berta et al. 2013, Ellen
et al. 2013). In addition, several studies have identified
the importance of time as a resource. This means pro-
viding time for staff to attend in-services as well as
time to implement the new practice. This time needs
to be protected, so that staff are not required to fulfil
clinical responsibilities at the same time as they are
Scanning External AC metarounes
Internal AC metarounes
1
2 Reflecng, updang
6 & replicang
Uptake of
Evidence Based 5
Pracce
nurturing external
relaonships
Fostering internal
social networks
3
J. Innis and W. Berta

Table 1
Metaroutines and routines for nurse managers

Metaroutine Routines

External absorptive capacity metaroutines

Scanning
Building and nurturing relationships with
external organisations
Internal absorptive capacity metaroutines
Using participative internal selection
regimes
Allocating resources
Fostering internal social networks
Scan external sources to find out about current best practices and/or can appoint other organisational
members to do this (Berta et al. 2013)
Expose key organisational members to new practices being carried out in other health-care
organisations (Panzano & Roth 2006)
Establish formal and informal relationships with other health-care organisations, professional
associations and universities (Horbar et al. 2003, Leape et al. 2006, Ploeg et al. 2007, Everett &
Sitterding 2011, Berta et al. 2013, Parsons et al. 2013, Plath 2013)
Ensure that front-line staff and managers are included in groups that select evidence-based practices for
adoption by the organisation (Leape et al. 2006, Ruffolo et al. 2009, Kimber et al. 2012, Berta et al.
2013)
Include customers (i.e. patients and families) in groups that select evidence-based practices for adoption
by the organisation (Ruffolo et al. 2009)
Training
Ensure training and educational opportunities related to the new practice are available for staff
(Greenhalgh et al. 2004, Berta et al. 2013, Ellen et al. 2013)
Time
Ensure that staff have protected time to participate in education sessions, and to implement the new
practice (Fineout-Overholt et al. 2004, Sharp et al. 2004, Ploeg et al. 2007, Kimber et al. 2012, Berta
et al. 2013)
Information technology (IT)
Ensure that staff have access to IT resources, including IT support and computer training (Fineout-
Overholt et al. 2004, Lukas et al. 2007, Ellen et al. 2013)
Ensure that staff do not have restricted access to online research databases and journals (Cadmus
et al. 2008, Ellen et al. 2013)
Encourage multidisciplinary engagement on committees and work groups (Jackson et al. 203, Day 2009,
Kimber et al. 2012)
Provide formal routes for collaboration, such as journal clubs and committee work (Berta et al. 2013,
Ellen et al. 2013)

participating in an education session (Fineout-Over-
holt et al. 2004, Sharp et al. 2004, Ploeg et al. 2007,
Kimber et al. 2012, Berta et al. 2013).
The presence of IT resources in the form of comput-
ers, IT support and the availability of computer train-
ing, have been facilitators to the uptake of evidence-
based practice in several studies (Fineout-Overholt
et al. 2004, Lukas et al. 2007, Ellen et al. 2013).
While health-care organisations may place restrictions
on the use of internet resources by staff members, two
American studies have found that providing frontline
workers with online access to research databases and
journals facilitated their use of evidence (Cadmus
et al. 2008, Ellen et al. 2013).
Proposition 3: Health-care organisations with
internal absorptive capacity routines to allocate
resources for training, time and information technol-
ogy will facilitate the uptake of evidence-based prac-
tices
Internal social networks
Communication processes amongst organisational
members, including routines around the development
and use of social networks in organisations, are
4 Journal of Nursing Management
important to the creation and sharing of new knowl-
edge relating to (new) evidence-based practices (Lewin
et al. 2011, Berta et al. 2013). Internal social net-
works are the formal and informal ways that organi-
sational members may use to exchange information
and communicate about innovations (Lewin et al.
2011). Active encouragement on the part of the organ-
isation for members to form networks is known to be
a facilitator of innovation adoption. For example, the
benefits of internal collaboration and multidisciplinary
engagement were demonstrated in the case studies of
a hand hygiene strategy in a California teaching hospi-
tal (Day 2009), the introduction of a new ventilation
therapy mode into a neonatal intensive care unit
(Jackson et al. 2003) and in the uptake of multiple
practice changes over a 4 year period in a Canadian
paediatric hospital (Kimber et al. 2012). This collabo-
ration has been found to be fostered by ensuring that
staff, managers and administrators have opportunities
to share information and experiences (Berta et al.
2013, Ellen et al. 2013). This can be done informally,
or in formal contexts such as journal clubs or regular
staff meetings focused on quality improvement (Ellen
et al. 2013).
ª 2016 John Wiley & Sons Ltd

Proposition 4: Health-care organisations with
internal absorptive capacity routines to foster internal
social networks will facilitate the uptake of evidence-
based practices
External relationships
Cosmopolitanism is a term used to describe the degree
of relationships an organisation has with other organi-
sations, such as the extent to which it encourages its
staff to foster external relationships (Greenhalgh et al.
2004, Damschroder et al. 2009). Health-care organi-
sations learn from relationships with educational insti-
tutions, professional associations and customers, that
is, patients and families. Collectively these relation-
ships, in addition to internal social networks, form the
organisation’s social capital. Organisations that pro-
mote external relationships are more likely to transfer
new knowledge rapidly (Damschroder et al. 2009).
Several studies have found that a relationship with a
university (Olade 2004, Everett & Sitterding 2011,
Plath 2013) or with a professional association (Ploeg
et al. 2007, Berta et al. 2013, Parsons et al. 2013)
served as a facilitator to the use of best practices within
long term care (Ploeg et al. 2007, Berta et al. 2013),
acute care (Ploeg et al. 2007, Everett & Sitterding
2011, Parsons et al. 2013), primary care (Ploeg et al.
2007) and disability service (Plath 2013) organisations.
A key factor in an organisation’s implementation of
an innovation is the ability to observe the innovation
being implemented successfully, sometimes in other
organisations (Rogers 2003). Two American studies
found a positive relationship between the formation of
collaboratives between hospitals and the reciprocal
uptake of evidence-based practice (Horbar et al. 2003,
Leape et al. 2006).
Proposition 5: Health-care organisations with
external absorptive capacity routines for building and
nurturing external relationships with other universi-
ties, professional associations and other health-care
organisations will facilitate the uptake of evidence-
based practices
Reflecting, updating and replicating
The internal absorptive capacity metaroutines of
reflecting, updating and replicating allow an organisa-
tion to evaluate the utility of an innovation (Lewin
et al. 2011). Reflecting and updating are necessary
precursors to replication, since they allow an organisa-
tion to study the relationship between the application
of knowledge and its influence on performance. In
their study of the implementation of clinical practice
ª 2016 John Wiley & Sons Ltd
Journal of Nursing Management
Routines and evidence-based practice
guidelines in Ontario nursing homes, Berta et al.
(2013) found that ensuring that staff clearly under-
stood the connection between practice changes and
outcomes was important to the success of the guide-
line’s implementation.
In addition, reflecting and updating needs to include
collecting and using feedback from organisational
members. The evaluation of practice changes in a dis-
ability services organisation in Australia demonstrates
the importance of involving front-line staff in the eval-
uation process. Their feedback was essential to dis-
cerning the contextual factors that influenced the
implementation of the changes. In addition, Plath
(2013) highlights the need to demonstrate to staff that
changes are adapted in response to their feedback.
These routines of evaluating and obtaining feedback
from front-line staff not only help to adapt the use of
evidence-based practices, they also help to ensure the
use and growth of new knowledge (Lewin et al. 2011).
Replicating refers to the processes that serve to spread
the innovation across the organisation (Lewin et al.
2011). For example, within a hospital, this could refer
to the spread of an evidence-based discharge process
that meets the health literacy needs of patients and
families. Such a process is illustrated by Project RED
(Re-Engineered Discharge) that has been significantly
associated with decreased hospital readmission (Jack
et al. 2009). An example of replicating could be the
spread of such a process from one hospital department
to another, such as from a medical to a surgical unit.
Proposition 6: Health-care organisations with
internal absorptive capacity routines for reflecting,
updating and replicating will be able to adapt the evi-
dence-based practice to fit the organisation and will
be able to measure the impact of the innovation on
organisational performance
Implications for nursing management
This framework highlights important absorptive
capacity metaroutines and routines that nurse man-
agers might put in place to support the identification,
adoption, implementation, adaptation and replication
of evidence-based practices. As leaders within health-
care organisations, nurse managers are ideally situated
to use these routines to foster the adoption and use of
new practices (Stetler 2004, Fleiszer et al. 2015,
Kueny et al. 2015). Nurse managers can ensure that
there are organisational members who are committed
to scanning the environment for new ideas to improve
patient care, as this has been shown to increase the
5
J. Innis and W. Berta
uptake of evidence-based practice (Panzano & Roth
2006, Berta et al. 2010). This may mean ensuring that
there are unit based nursing councils that are commit-
ted to examining innovations, and that staff nurses are
encouraged to gain further education, such as through
attending conferences or taking courses. In addition,
nurse managers can ensure that front-line staff are
involved in choosing which evidence-based practices
will be used. A participative approach that includes
staff nurses, as well as other direct care providers, has
clear advantages. When front-line staff have a stake in
how new practices are chosen, it has been demon-
strated that they are more committed to their success-
ful implementation (Leape et al. 2006, Ruffolo et al.
2009, Berta et al. 2013).
While the importance of dedicated resources to
uptake is unsurprising, nurse managers are behooved
to be mindful that how these resources are allocated
will impact the success of an innovation’s implementa-
tion. Resources for providing staff education, and for
ensuring that staff have access to and the ability to
use IT resources have been found to facilitate the
adoption of evidence-based practice (Berta et al. 2013,
Ellen et al. 2013).
Fostering internal social networks within the organi-
sation facilitates the sharing of ideas and information
across health disciplines. Nurse managers need to be
aware of relationships not only among nursing staff,
but between nurses and other clinicians and staff
members who are implicated by the practice change,
to ensure that there are clear pathways to collabora-
tion.
Furthermore, nurse managers can facilitate learning
by ensuring that there are relationships with other
health-care organisations, universities and professional
associations. Relationships with these external bodies
have been repeatedly found to increase the use of evi-
dence-based practices across health-care sectors (Ever-
ett & Sitterding 2011, Berta et al. 2013, Parsons et al.
2013, Plath 2013).
Once an evidence-based practice has been adopted,
there is a need to measure outcomes in order to
demonstrate its efficacy, and to find out if it requires
adaptation. Obtaining and responding to feedback
from nurses and front-line staff have been shown to
be key to the successful implementation of new
knowledge.
Conclusions
This paper is not inclusive of all the routines that play
a role in taking on new practices in health care organ-
6 Journal of Nursing Management
isations. Rather, it provides a way of conceptualising
how managers can facilitate the uptake and use of
new practices. Examining the use of routines can be
used to gauge whether health-care organisations have
the capacity in place to take on evidence-based prac-
tices. In addition, examining how different health-care
organisations use routines could be used to understand
the bases for the different experiences among health
services organisations with evidence-based practice
implementation – including impacts, outcomes and
sustainment of practice changes. Finally, examining
the use of routines could be used as a basis for forma-
tive evaluation research to learn how evidence-based
practices are adopted and used in health-care organi-
sations (Damschroder et al. 2009).
Ethical approval
Ethical approval was not required for this paper.
Source of funding
Jennifer Innis is funded by a Canadian Institutes of
Health Research Doctoral Research Award.
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