The TRM focuses on characteristics of the innovation and how the innovation is communicated to users in their social context Titler et al. An action oriented model to guide clinicians in the steps of evidence-based practice from selection of a clinical focus through evaluation Titler et al. An issue in translation science is how these theories are applied. Application of these theories is meant to facilitate the identification of determinants of implementation, guide the selection of implementation strategies, and inform all phases of the research, including the constructs to be measured and the relationships among constructs to be tested Birken, Powell, Shea et al.
Several implementation scientists have noted, however, that these theories are not used, are used superficially, or are misused in translation science Birken, Powell, Shea et al. This poses a substantial challenge for generalizing findings across diverse settings.
Implementation is a dynamic, iterative process. According to this model see Figure 1 , adoption of EBPs is influenced by four key areas:. Successful implementation requires strategies to address each of these four areas Titler, ; Titler et al. Table 3 provides examples of implementation strategies organized by the four components of the TRM. Table 3. Characteristics of good QRGs include clarity, accuracy and accessibility. Careful editing is needed to distill the necessary information for clinicians. Visual representation of the EB care processes with decision points and information to guide decision-making.
Empirical support for the effectiveness of CDS tools embedded in electronic health records is mixed. Reminders about an EBP posted at the point of care. Distilling the essence of the EBP to a few key points on signs, posters. Ongoing auditing of performance indicators, aggregating data into reports, and discussing the findings with practitioners on a regular basis during the practice change. Education of clinicians about the EBPs is necessary but not sufficient to change practice and didactic continuing education alone does little to change practice behaviors.
They are visible and communicate with others via their interpersonal networks. Interpersonal communication with colleagues is a preferred source of practice knowledge for staff. Actions of CC include education and mentoring, auditing EBP performance indicators, making changes in organizational documents to incorporate EBP recommendations. Face-to-face interaction with clinicians in their practice setting by an individual usually a clinician with expertise about the EBPs.
Consider who will perform this role and the frequency of outreach during implementation.
The person performing this role should be consistent — a consistent individual with a consistent message. Assessment of internal strengths and challenges for implementation of EBPs. Environmental scans include the structure and function of the organization.
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Delineate how the EBPs contribute to the organizational strategic initiatives. Decide on methods for keeping senior leaders informed throughout implementation. Seek their input to overcome challenges. Documentation systems that fail to readily support the EBPs thwart change.
Standards of practice should reflect the evidence references. Consider nominating individuals or teams for practice excellence awards offered by the health system, or professional organizations. Some form of monetary compensation. Examples: bonus payments, salary increases, provision of educational funds. Consider providing financial support for an individual or team to attend a regional or national conference to present their work.
These issues continue to be debated among investigators and are not uncommon in a young, transdisciplinary area of science. Context matters and is widely acknowledged as an important influence on implementation outcomes. Context matters and is widely acknowledged as an important influence on implementation outcomes Birken et al. Context refers to the characteristics of the setting of implementation and the social dynamic factors in which implementation processes occur May et al.
Setting encompasses the structural factors, such as the physical or operational characteristics of the setting e. Social dynamic factors pertain to the roles, relationships, and dynamics of the individuals and groups within a practice setting Birken, Powell, Presseau et al.
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Context factors that impact implementation include:. Investigators studying implementation should incorporate these dynamic context factors into their research. Implementation studies have traditionally included structural factors that influence adoption of EBPs but few studies have included the social dynamic factors, such as organizational capacity, EBP leadership behaviors, and climate for EBP implementation Shuman, Powers et al. Incorporating measures such as these into implementation studies will provide insights into why some implementation strategies work in some settings and not others, and the mechanisms underlying the effectiveness of these strategies.
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We are unlikely to close the critical gap between research and practice if studies do not examine the interplay between dynamic context factors and the implementation strategies used to promote uptake of EBPs. In addition, context factors that impact implementation should be routinely assessed by healthcare systems to build strong organizational capacity for adoption of EBPs. For example, if scores for hiring staff that value EBP are low, an organization may want to examine hiring practices and interview questions used in selection of staff.
Translation science is a relatively new area of investigation and nurse scientists are setting directions in this field. Nurse scientists have a rich history and are making major contributions to EBP and translation science. An overview of terminology, examples of theories and models of translation science, descriptions of various implementation strategies, and the importance of context in implementation science have been presented. Challenges noted include diversity of terminology associated with translation science, multiple theoretical models with inconsistent or underuse to guide implementation research, lack of agreement of an ontology and taxonomy of implementation strategies, underdeveloped methods for calculating implementation intervention dose, and controversies regarding methods for measurement of implementation effectiveness.
Dynamic context factors are emerging as an important area to address in implementation research. This field of investigation continues to provide multiple opportunities for nurse scientists and practicing clinicians to address application of evidence in practice to improve care delivery, patient outcomes, and population health. Marita G. Titler is a Professor, the Rhetaugh G. Her program of research is in outcomes effectiveness and implementation science and is supported by federal and foundation funding.
She has been PI on five funded translation and outcomes effectiveness studies, and co-investigator on numerous other funded investigations. Aarons, G. Aligning leadership across systems and organizations to develop a strategic climate for evidence-based practice implementation. Annual Review of Public Health, 35 , — Alexander, J. Methods and metrics challenges of delivery-system research. Implementation Science, 7 Armstrong, R. Knowledge transition strategies to improve the use of evidence in public health decision making in local government: Intervention design and implementation plan.
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Implementation Science, 12 2. Criteria for selecting implementation science theories and frameworks: Results from an international survey. Bornbaum, C. Exploring the function and effectiveness of knowledge brokers as facilitators of knowledge translation in health-related settings: A systematic review and thematic analysis. Implementation Science, 10 Brownson, R. Understanding the evidence-based public health policy. American Journal of Public Health, 99 9 , — Knowledge translation. Cane, J. Validation of the theoretical domains framework for use in behavior change and implementation research.