EBP 2.

0:
IMPLEMENTING AND SUSTAINING CHANGE

EBP 2.0: From Strategy to Implementation

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A new series showcases exemplars of evidence-based practice change.

This is the first article in a new series about evidence-based practice (EBP) that builds on AJN’s award-winning
previous series—Evidence-Based Practice, Step by Step—published between 2009 and 2011 (to access the
series, go to http://links.lww.com/AJN/A133). This follow-up series will feature case studies illustrating the
various strategies that can be used to implement EBP changes—one of the most challenging steps in the
EBP process.

E
vidence-based practice (EBP) has become a
standard for the delivery of safe, quality care
and the achievement of optimal patient out-
comes. Patients, families, payers, and regulatory
agencies expect that care delivery will be based on
the most current and best available evidence. Nu-
merous models and frameworks exist to guide prac-
titioners in delivering EBP. Nurse and health care
staff participation in intensive EBP immersion pro-
grams is growing rapidly, and undergraduate and
graduate nursing programs are embedding EBP in
their curricula.
Despite this important progress, bringing evi-
dence to routine clinical care remains an elusive,
challenging, and often underresourced goal.1 To
­address this well-recognized gap, research and qual-
ity improvement (QI) efforts have focused on im-
plementation and translation models and strategies
that can promote the successful uptake and sustain-
ability of EBP. This article introduces a new series
focused on the implementation step of EBP. Using
the research literature on implementation science,
models, and strategies, we will present case studies
that are designed to inform readers and practitio-
ners about how to minimize barriers and leverage
facilitators (such as unit champions or mentors) to
achieve success in implementing and sustaining EBP
changes.
This new series builds on the previous EBP series
published in AJN from 2009 to 2011. That series
describes the seven steps of EBP, giving nurses the
knowledge and skills needed to implement EBP at
their institutions. It also contains some of the most
popular and downloaded AJN articles, reflecting a
sense of urgency among nurses, other health care
practitioners, and organizations to use the best evi-
dence to provide safe and high-quality care.
EBP: STEP BY STEP
The seven steps of EBP are well established in nurs-
ing and other disciplines and present a standardized
approach to EBP. As described in the previous AJN
series, they are:
• Step Zero: Cultivate a spirit of inquiry and an
EBP culture
• Step 1: Ask clinical questions in PICO-T (popu-
lation, intervention, comparison, outcome, and,
if appropriate, time) format
• Step 2: Search for the best evidence
• Step 3: Critically appraise the evidence and recom-
mend a practice change
• Step 4: Integrate the evidence with clinical exper-
tise and patient/family preferences and values
• Step 5: Evaluate the outcomes of the practice de-
cisions or changes based on the evidence
• Step 6: Disseminate the results of the EBP change
The widespread endorsement of these EBP steps,
along with numerous models and resources, has led
to the establishment of EBP competencies for health
care providers.2, 3 These competencies reflect a mini-
mum set of attributes, such as knowledge, skills, atti-
tudes, abilities, and judgment, that enable a clinician
to meet practice standards. Examples of EBP com-
petencies include understanding how to formulate a
clinical question in PICO-T format, critically apprais-
ing the evidence, and incorporating patient prefer-
ences into the implementation of a practice change.
IMPLEMENTATION—THE MOST CHALLENGING STEP
Great progress has been made in recent years in
standardizing EBP. However, Step 4, the implemen-
tation step, in which evidence is integrated with cli-
nician expertise and patient/family preferences and
values, remains perhaps the most challenging. The
reasons for this are multifactorial and interrelated:

50 AJN ▼ April 2019 ▼ Vol. 119, No. 4 ajnonline.com


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Lynn Gallagher-Ford (left) and Sharon Tucker critique student attempts to develop PICO-T questions in an evidence-based practice
(EBP) immersion program at the Lucile Packard Children’s Hospital in Palo Alto, California. Photo courtesy of the Fuld Institute for EBP.
the involvement of numerous and diverse stakehold-
ers, resource intensity (such as pulling staff away
from patient care to lead the practice change, or the
necessity of certain equipment and supplies for the
practice change), a fast-paced and constantly chang-
ing hospital environment, evolving regulatory and
payer demands, resistance to change, and lack of
time and effort dedicated to “hard-wiring” evidence-
based change over time (making the change sustain-
able and embedded in the system and culture).
Implementation of EBP is thus a complex and
­resource-intensive step, and the time and effort
needed are often underestimated and underre-
sourced. Recognition of the research-to-practice
gap was described in 2000 by Balas and colleagues,
who published a landmark paper in which they
noted it takes an average of 17 years to translate a
scientific discovery (such as an evidence-based rec-
ommendation) into real-world clinical practice and
settings.4 Since this gap was made transparent, an
­entire scientific field—implementation or translation
science—has emerged, providing models, insight, and
strategies to inform and expedite the uptake of EBPs.5
Nilsen published a summary of implementation mod-
els and theoretical approaches, categorizing them as
ajn@wolterskluwer.com
By Sharon J. Tucker, PhD, RN, FAAN, and
Lynn Gallagher-Ford, PhD, RN, NE-BC, DPFNAP, FAAN
follows: models that direct or guide the process of re-
search into practice, frameworks for understanding
and/or exploring influences on implementation, clas-
sic theories largely related to change processes, specific
implementation models, and evaluation approaches.6
In this EBP series, we’ll use the concepts and features
of several of these models, suggesting a simplified ap-
proach to implementation to guide nurses and other
health care practitioners.
SUCCESSFUL STRATEGIES
We will guide readers to think of implementation
of an initiative as occurring in phases of change,
­using select strategies best aligned with each phase.
Strategies will address organizational culture, lead­
ership structure and support, EBP resources, pa-
tient populations and settings, technical and data
needs, educational needs, reminders and reinforce-
ment, mentors and champions, QI tools, and data
trending, among other topics. Early phases of change
might address potential obstacles such as staff sup-
port for the status quo, beliefs that the current prac-
tice is working fine, and a general lack of recognition
or openness to exploring a practice change. Later
phases of change might reflect a readiness for a
AJN ▼ April 2019 ▼ Vol. 119, No. 4 51
 EBP 2.0:
IMPLEMENTING AND SUSTAINING CHANGE
practice change, widespread rollout, and efforts to
institute sustainable change over time.
For each phase of the implementation step, we will
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introduce strategies to keep the initiative moving to-
ward a successful practice change. These strategies will
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be based on the work of several researchers, including
Grol and Grimshaw,7 Grimshaw and colleagues,8 Pow-
ell and colleagues,9 and Cullen and colleagues.10, 11 The
two papers coauthored by Jeremy Grimshaw propose
that EBP changes need to be supported by an assess-
ment of the barriers and facilitators to applying the ev-
idence in a specific context or setting; the best evidence
should then be used to select the implementation strat-
egies.7, 8 These strategies include, among others, the use
of educational materials, reminders, computerized de-
cision support, performance feedback, opinion leaders,
multiprofessional collaboration, and mass media cam-
paigns.7
Implementation of EBP occurs in
phases of change.
The paper by Powell and colleagues is based on
a compilation of 73 implementation strategies iden-
tified by an expert panel.9 The panel believed these
strategies to be useful building blocks for the multi-
faceted, multilevel strategies used in the implementa-
tion of EBP changes in mental health service settings
(transferrable to other specialties) and for compara-
tive effectiveness research.
Finally, to guide our discussion of implementation
strategies, we’ll turn to the work of Cullen and Ad-
ams, who recommend strategies aligned with the
phases of implementation and target two distinct
groups: clinicians, organizational leaders, and key
stakeholders, and the organizational system of sup-
port.10 They also highlight the importance of change
agent roles, such as those of change champions,
EBP mentors, and opinion leaders.10 This work led
to the production and publication of a useful re-
source guide—Evidence-Based Practice in Action:
Comprehensive Strategies, Tools, and Tips from the
University of Iowa Hospitals and Clinics—which in-
cludes 63 implementation strategies, each presented
with a definition, benefits, procedure, case example,
and supporting references.11
SUSTAINABLE CHANGE
Implementation is a major step in the EBP process,
but because its challenges are often underappreciated,
52 AJN ▼ April 2019 ▼ Vol. 119, No. 4 ajnonline.com
implementation efforts are often underresourced. It’s
therefore not surprising that the translation of evi-
dence into practice is often a slow process that may
never fully occur or cannot be sustained. In this se-
ries, we will focus on the development of competency
among nurses, nursing leaders, and other health care
providers in implementing EBP. We will use published
models and strategies to help readers better under-
stand how to successfully tackle the implementation
of EBP. Moreover, we’ll illustrate how others have ap-
plied these implementation strategies—with various
outcomes, whether successful, partially successful, or
stalled and delayed—by inviting EBP experts to tell
their stories. These examples will be presented along
with our commentary, in which we’ll detail the prin-
ciples and strategies used, highlighting those that can
best lead to sustainable change. ▼
Sharon J. Tucker is the Grayce Sills Endowed Professor of
Psychiatric-Mental Health Nursing and director, Translational/
Implementation Research Core, and Lynn Gallagher-Ford is se-
nior director, both at the Helene Fuld Health Trust National In-
stitute for Evidence-Based Practice in Nursing and Healthcare
at the Ohio State University College of Nursing in Columbus.
Contact author: Sharon J. Tucker, tucker.701@osu.edu. The au-
thors have disclosed no potential conflicts of interest, financial
or otherwise.
REFERENCES
1. Li SA, et al. Organizational contextual features that influ-
ence the implementation of evidence-based practices across
healthcare settings: a systematic integrative review. Syst Rev
2018;7(1):72.
2. Albarqouni L, et al. Core competencies in evidence-based
practice for health professionals: consensus statement based
on a systematic review and Delphi survey. JAMA Netw Open
2018;1(2):e180281.
3. Melnyk BM, et al. The first U.S. study on nurses’ evidence-
based practice competencies indicates major deficits that
threaten healthcare quality, safety, and patient outcomes.
Worldviews Evid Based Nurs 2018;15(1):16-25.
4. Balas EA, Boren SA. Managing clinical knowledge for health
care improvement. Yearb Med Inform 2000;(1):65-70.
5. Dearing JW, Kee KF. Historical roots of dissemination and
implementation in science. In: Brownson RC, et al., editors.
Dissemination and implementation research in health: trans-
lating science to practice. New York, NY: Oxford University
Press; 2012. p. 55-71.
6. Nilsen P. Making sense of implementation theories, models
and frameworks. Implement Sci 2015;10:53.
7. Grol R, Grimshaw J. From best evidence to best practice: ef-
fective implementation of change in patients’ care. Lancet
2003;362(9391):1225-30.
8. Grimshaw JM, et al. Knowledge translation of research find-
ings. Implement Sci 2012;7:50.
9. Powell BJ, et al. A refined compilation of implementation strat-
egies: results from the Expert Recommendations for Imple-
menting Change (ERIC) project. Implement Sci 2015;10:21.
10. Cullen L, Adams SL. Planning for implementation of evidence-
based practice. J Nurs Adm 2012;42(4):222-30.
11. Cullen L, et al. Evidence-based practice in action: compre-
hensive strategies, tools, and tips from the University of Iowa
Hospitals and Clinics. Indianapolis, IN: Sigma Theta Tau In-
ternational; 2018.