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544 October 2013 • Volume 17, Number 5 • Clinical Journal of Oncology Nursing

Margaret M. Irwin, PhD, RN, MN, Rosalie M. Bergman, DNP, RN, OCN®, and Rebecca Richards, DNP, RN, NP-B, AOCN®

The Oncology Nursing Society (ONS) and ONS Foundation worked together to develop the Institute for Evidence-Based Practice Change (IEBPC) program to facilitate the implementation of evidence-based practice (EBP) change in nursing. This analysis describes the experience of 19 teams of nurses from various healthcare settings who participated in the IEBPC program. Qualitative analysis of verbatim narratives of activities and observations during the process of implementing an EBP project was used to identify key themes in the experience. EBP implemen- tation enabled participants to learn about their own practice and to experience empowerment through the evidence, and it ignited the spirit of inquiry, team work, and multidisciplinary col- laboration. Experiences and lessons learned from nurses implementing EBP can be useful to

others in planning EBP implementation.

Margaret M. Irwin, PhD, RN, MN, is a research associate at the Oncology Nursing Society in Pittsburgh, PA; Rosalie M. Bergman, DNP, RN, OCN®, is an associate scientific director and medical science liaison at Novartis Pharmaceuticals in Allison Park, PA; and Rebecca Richards, DNP, RN, NP-B, AOCN®, is an oncology clinical coordinator at Genentech BioOncology in Edgar, WI. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Oncology Nursing Society. Irwin can be reached at [email protected], with copy to editor at [email protected]. (Submitted February 2013. Revision submitted March 2013. Accepted for publication April 14, 2013.)

Digital Object Identifier:10.1188/13.CJON.544-549

The Experience of Implementing Evidence-Based Practice Change: A Qualitative Analysis

E vidence-based practice (EBP) is regarded by profes- sionals as the basis for nursing practice ( Jutel, 2008; Newhouse, Dearholt, Poe, Pugh, & White, 2007). However, gaps and delays in translating evidence into clinical practice are well recognized (Dudley-

Brown, 2012; White, 2012), and understanding that those gaps are more about factors that influence the process of EBP implementation than about individual skills for evidence ap- praisal is important (Fineout-Overholt, Melnyk, & Schultz, 2005; Gale & Schaffer, 2009). Development of effective strate- gies to implement evidence in nursing practice is a dedicated area of exploration (Doorenbos et al., 2008). A need exists to describe and understand the experience of implementing EBP in nursing and to determine more effective facilitation strate- gies (Friedman et al., 2009).

The Institute for Evidence-Based Practice Change (IEBPC) was developed by the Oncology Nursing Society (ONS) and ONS Foundation to facilitate implementation of EBP in nursing. Teams of nurses were educated in EBP implementation and, as part of program activities and evaluation, IEBPC participants recorded reflective narratives of their experiences. The purpose of this article is to describe the experience of implementing an EBP change through analysis of verbatim narratives. Learning from the experience of others can help other nurses implement EBP.

Methods The sample consisted of verbatim reflection log entries from 19

teams who participated in the IEBPC in 2009 and 2010. The IEBPC program included a 2.5-day conference involving lectures and group work that provided content for the EBP process, litera- ture searching, and development of an implementation plan, project management, and outcomes measurement. Participant teams consisted of a champion (an advanced practice nurse to lead and advocate for the project), a sponsor (an individual with administrative authority), and a target (staff nurse whose prac- tice was the target of change). Breakout sessions were used to

n Article

FIGURE 1. Questions for Reflection

• How will you use what you have learned to continue to improve and move things forward (if relevant)?

• What have you and your project team learned this month? • What major actions in your project did your team take this month? • What responses did you see to these actions? • As you reflect upon this past month, what things strike you,

surprised you, frustrated you, or delighted you?

or otherwise reuse any or all content from this article, e-mail [email protected]. To purchase high-quality reprints, e-mail [email protected].

Clinical Journal of Oncology Nursing • Volume 17, Number 5 • Implementing Evidence-Based Practice Change 545

develop initial implementation plans, facilitate group discussion on change strategies, and identify appropriate outcome mea- sures for each team. The IEBPC mentor group assigned a mentor to participating teams. Mentors were advanced practice nurses who had successfully implemented EBP in nursing practice set- tings, and they provided individualized, unstructured mentoring for 12 months following the conference via e-mail communica- tion and phone conferences.

As part of the program’s activities for reflective learning and program evaluation, the champion from each team was asked to consider and respond to a series of questions about the ex- periences of the team (see Figure 1). Reflections were posted on a secure virtual office Web site, creating a written verbatim record for analysis. Participants were informed that log entries were voluntary; that information would be used by ONS for analysis, program evaluation, and planning; and that individu- als and organizations involved would not be identified in any publication of resulting information.

Verbatim postings were downloaded from the site and de- identified to maintain confidentiality. All entries were inde- pendently reviewed by two authors using content analysis to identify themes and concepts. An audit trail was maintained by documenting all analysis on verbatim documents. After inde- pendent review, the authors compared, organized, and merged themes and concepts until consensus was reached.

Results Sample Characteristics

The sample consisted of 140 verbatim log entries from 19 IEBPC teams. Eight teams practiced in a comprehensive cancer center, eight in a community hospital, two in an outpatient setting, and one in industry nursing. The number of log entries for each team ranged from 2–13, with a mean of 7.6 per team during a 12-month period. Three entries total were completed by a target nurse; all others were done by team champions. One of the 19 teams withdrew from the program after two months. Participants worked in a variety of practice settings and worked on different aspects of clinical practice. Areas of practice addressed by teams in the EBP projects are shown in Figure 2.

Themes

Analysis demonstrated the following major themes: key implementation actions, critical success factors, difficulties and frustrations, and the process of discovery.

Key implementation actions: Key actions identified by teams in- cluded education, marketing, use of recognition and incentives, development of tools for implementation, and obtaining institu- tional review board (IRB) approval. Corresponding exemplars are shown in Figure 3.

Educational activities included staff education about the project and related evidence, and how to administer assessment tools. Teams also were involved in educating other disciplines or nursing units about the project and presenting to nursing

FIGURE 2. Areas of Nursing Practice Change

• Cancer-related fatigue interventions • Chemotherapy administration guidelines implementation • Depression screening and referral • Interventions for falls prevention • Management of chemotherapy-induced nausea and vomiting • Multidisciplinary walking discharge planning rounds • Oral care protocol for prevention of oral mucositis • Patient adherence to oral chemotherapy • Patient mobility improvement in the inpatient setting • Patient self-care for management of chemotherapy side effects • Patient sexual health • Prevention of central line-associated bloodstream infection • Skin care management during radiation therapy • Ventilator -associated pneumonia care bundle

Educational Activities

“We will also have to educate the staff, MDs, and techs and RNs about the project to ensure compliance.”

“[We] developed an education poster.” “We are educating others about EBP at every opportunity.” “We posted our first educational blog in our online publication for

nurses/clinical staff.”

Marketing

“[We are] showcasing the project to administrative leadership.” “We are translating the concept of EBP to other nurses as well as

nonnursing personnel (i.e., pharmacy and the medical staff) so there is common understanding and sharing goals/mission/vision.”

Recognition and Incentives

“[We are] finding special ways to thank EBP team members for their contributions.”

“We actually came up with an incentive program today to assist us in getting surveys completed.”

“This month, we have celebrated some success.”

Development of Tools for Implementation

“[We] developed . . . call scripts incorporating EBP related to side- effect management as available.”

“[We] developed sample documentation templates.” “[We] developed EBP call flow chart schema.” “Development of all-inclusive line care stamp” “The placement of a visual clue of the HOB [head of bed] at 30

degrees on all the ICU [intensive care unit] walls”

Obtaining Institutional Review Board (IRB) Approval

“We keep our fingers crossed, as the Scientific Review Committee and the IRB are the next hurdles.”

“Institution support seems to be there in the form of an RN who is also a PhD and sits on the IRB—great for us.”

“We hadn’t anticipated . . . that we would need to write a protocol and get IRB approval. This is going to be a major task and our biggest hurdle. It’s frustrating, as we would like to begin, and it seems we get bogged down in red tape.”

FIGURE 3. Key Evidence-Based Practice (EBP) Project Implementation Strategies

546 October 2013 • Volume 17, Number 5 • Clinical Journal of Oncology Nursing

practice councils and medical staff committees. Marketing ef- forts were used to gain support and to facilitate involvement and collaboration with others.

Several teams incorporated recognition and the use of incen- tives into project implementation. These strategies aimed to get staff attention and encourage participation in project activities and related changes to patient care.

Teams developed a variety of tools to implement practice change (i.e., assessment forms, decision-making algorithms, documentation templates, communication scripts, signage, care checklists). Almost all of the teams used visual tools, which in- cluded a mark on the wall that enabled the nurse to see quickly if the head of the bed was sufficiently elevated, as part of a project

to address ventilator-associated pneumonia. One team working to increase patient ambulation obtained a variety of posters from international cities to place on the walls in the hallway so they could encourage patients to “walk to Paris.” One team noted, “The visual cues have helped with our compliance.”

Five teams were required to obtain IRB approval from their organizations before they could begin work on EBP projects. Two of those involved full review, and the others met expedited or exempt review criteria. Some teams expressed frustration with delays associated with getting IRB approval and viewed the pro- cess as a barrier, and others identified the process as part of imple- mentation. Teams that did not express frustration in obtaining IRB approval had assistance from nurse researchers. One team noted, “Institutional support seems to be there in the form of an RN who is also a PhD and sits on the IRB—great for us.” Teams that required IRB approval described delays that ranged from 3–6 months.

Critical success factors: Critical success factors were seen to facil- itate implementation of the practice change when present and, if absent, were considered barriers to change. Critical success factors expressed in reflective narratives included time, organi- zational support, engagement and teamwork, communication, planning, and maintaining focus (see Figure 4).

Time was the critical success factor expressed most fre- quently. Some teams received an appropriate amount of time to work on the EBP project, whereas others experienced a lack of time, which they saw as a barrier.

Support or lack of support was expressed by all teams. Most experienced support from others such as managers, nursing staff, and physicians, but some teams experienced areas where sup- port was lacking. One team initially was unable to get assistance from the organization’s librarian to obtain evidence, and the team was told that the service was not available to nurses. That problem was resolved by the nurse executive. Lack of support was associated with competing priorities within an organization, which prevented providing attention to EBP implementation.

Team reflections also identified the importance of support from mentors in the program. Teams frequently expressed the importance of teamwork and stakeholder engagement. Team- work and engagement of physicians, nursing staff, and other dis- ciplines were associated with progress in EBP implementation. Conversely, lack of engagement of key groups inhibited progress.

Inadequate communication inhibited progress, and teams noted that good communication was a critical success factor. However, time constraints and competing priorities made com- munication challenging. As one team noted, “We learned that when our schedule gets busy, our communication among our team members suffers.”

Teams expressed the importance of planning and identified helpful plan characteristics. Taking small steps, clarity and sim- plicity of actions, and setting deadlines were important compo- nents of planning (see Figure 5). Several teams talked about the difficulty of maintaining focus on their projects and the frequent efforts to refocus. Maintaining focus in the work setting was seen as difficult, and loss of focus was associated with lack of progress.

Difficulties and frustrations: Several difficulties and frustrations were expressed, including competing priorities, challenges in data collection and measurement of results, and the impact of staff turnover (see Figure 6). Competing priorities had an effect on the amount of time and attention devoted to the EBP project

Time

“We are given the time and resources . . . and spend the time needed.”

“We continue to feel frustrated with the lack of available time to meet and work on our project.”

Support

“Nursing administration and our EBP committee have been very supportive and willing to help in our endeavors.”

“Mentoring support really helped move us forward with confidence and needed direction.”

“The support from our oncologists has been amazing.”

Teamwork and Engagement

“It is great to rely on each other and know we have a unified mission/vision.”

“Engaging the staff has brought forth great suggestions and prac- tice changes.”

“We are behind on our timeline. This is mainly occurring because staff participation has slacked.”

Communication

“Poor communication within the team is contributing to ineffec- tiveness.”

“Ongoing communication and sharing project progress is key.”

Planning

“You cannot overplan.” “Careful planning and involvement of all players is key to a suc-

cessful launch.”

Maintaining Focus

“[We] remind each other to focus. We will conquer the world next year.”

“My challenge is always trying to keep focused and not get over- whelmed.”

“The other team members have lost focus with distractions in their roles. . . . We have had to regroup.”

“The challenge is to keep the focus on our project.” “When you focus on an issue, you tend to see results!”

FIGURE 4. Critical Success Factors in Evidence-Based Practice (EBP) Implementation

Clinical Journal of Oncology Nursing • Volume 17, Number 5 • Implementing Evidence-Based Practice Change 547

by team members, and conflicts arose from other organizational initiatives that fought for staff attention. Variation in patient care needs also required that work on the EBP project be postponed.

The program requested teams to be involved in data col- lection and measurement of results to monitor progress. The majority of participants expressed difficulty because of a lack of knowledge, barriers in obtaining data, and a lack of time to collect and analyze data.

Several teams noted the value of data collection and measure- ment in statements such as, “It is exciting to see the results,” and, “We are able to see clear improvement in CLABSI [central line-associated bloodstream infection] rates.” One team noted that once some results could be observed, those results contrib- uted to a positive experience. They said, “We are delighted that we have an end result of our work. We are also excited to begin the next phase of data collection.”

Team progress was affected by turnover of team members as well as changes in staffing and management in the organization. One team expressed the effects of their chief nurse executive resignation by stating, “I am surprised, when there is an underly- ing culture of anxiety and of the unknown, how immobilizing it can be. The uncertainty of survival literally pushes patient care initiatives and things that are important to the background! . . . It has been a bit of a black hole as far as support for our project.”

Discovery: Areas of discovery expressed in narratives included learning about their practices, learning about each other, ignit- ing the spirit of inquiry, experiencing empowerment through evidence, and learning about the challenge of sustaining im- provement. Exemplars in these subthemes are shown in Figure 7. Participants expressed experiences that were instructive, affirm- ing, and inspiring in the process of implementing EBP change.

Discussion This analysis provides a description of the experience of

nurses implementing different EBP change projects in a variety

of settings. Description comes from verbatim narratives of nurses directly involved in the effort. Implementation activities reflected common strategies for EBP change (e.g., education, communica- tion, use of reminders, engagement of stakeholders). Education was identified as a common activity for knowledge translation, and use of reminders was identified as a successful strategy in EBP implementation (Shojania & Grimshaw, 2005; Sudsawad, 2007; Titler, 2008). Nurses who participated in the IEBPC pro- gram demonstrated creativity in the development and use of visual tools in implementing new procedures. Many of these visual tools also functioned as reminders.

Requirements for IRB approval were not consistent across or- ganizations. Projects of two teams involved direct sampling and assignment of patients to test interventions. These projects clearly met recognized definitions of research requiring IRB approval (Cepero, 2011). Other submissions only involved the application of known available evidence to change nursing procedures or policies. IRB processes substantially contributed to delays. Qual- ity care demands that nurses use EBP, but organizations demand approval to do so. Most EBP can be viewed as part of normal clini- cal activity and could be appropriately reviewed by usual clinical management processes, the same way as policies and procedures (Melnyk & Fineout-Overholt, 2011). This area causes some contro- versy, and broad discussion and clarification would be beneficial.

Many of the critical success factors in this article have been identified by others (e.g., time, support, communication, plan- ning). Time constraints have been described as significant bar- riers to EBP in nursing and to sustaining practice improvements (Chin et al., 2008; Cooke et al., 2004; Edvardsson et al., 2011; Smith & Donze, 2010; Wolfson et al., 2009). In the current analy- sis, some participants were given time dedicated only to EBP

Small Steps

“We have learned that all of these small steps bring us closer to our goal. . . . It feels less overwhelming as we complete each step.”

“By working on this bit by bit, we are getting there.” “Our motto is, ‘Slow and steady wins the race.’” “Trying to find ways to break it down and move our project for-

ward (even at a snail’s pace) is the biggest challenge.”

Clear and Simple Actions

“Keep it simple.” “Our team has identified the need to be a little more proactive regard-

ing establishing the action steps needed to complete the project.” “We recognize that we need to have a formal rollout plan.”

Establishing Deadlines

“Deadlines are good. . . . Deadlines are good.” “Deadlines are good. I work better that way.” “Nurses need to be given specific expectations and deadlines.”

FIGURE 5. Useful Plan Characteristics

Competing Priorities

“The number of ‘have to’ projects continues to grow. . . . I am most frustrated with getting everything done.”

“The hospital initiated several projects that took resources from our group.”

“We are competing with many other educational projects at the moment, so we are hanging back.”

Data Collection and Measurement

“It has proved to be a very slow process as we struggle to under- stand statistical information.”

“They just don’t teach the finer points of data collection to regular nurses.”

“It has been a struggle to get the discharge information.” “We have identified gaps in data available.” “Data collection is taking more time than we originally

anticipated.”

Staff Turnover

“Our champion has left. . . . We have been floundering, trying to adjust, so nothing really [was] done this month.”

“The momentum we had gained was lost with . . . the loss of key staff.”

FIGURE 6. Difficulties and Frustrations Encountered

548 October 2013 • Volume 17, Number 5 • Clinical Journal of Oncology Nursing

projects, but others were not. The issue of time as a necessary resource for EBP implementation needs to be addressed if nurses are to achieve the goal of providing evidence-based patient care.

Helpful characteristics for creating a plan (e.g., setting dead- lines, taking small steps) have not been regularly identified in studies of EBP, but they are common to quality improvement (QI) methods and are part of general project management con- cepts (Terhaar, 2012). Collaboration among QI practitioners, managers, and clinicians can provide approaches to facilitate EBP by combining the expertise of these groups.

Findings regarding the value of support and good commu- nication are in concert with findings of others who have de- scribed successful strategies for EBP and guideline implementa-

tion (Terhaar, 2012). The nature of critical supports (e.g., time) points to the role of managers and administrators in facilitating EBP in nursing. Participant narratives in the current analysis support the value of mentoring described by others (Fineout- Overholt & Melnyk, 2011; Mick, 2011).

The need to actively maintain focus and refocus efforts in EBP implementation has not been previously described. Not surprisingly, maintaining attention to a specific new initiative in a setting of competing priorities can be difficult. Purposeful incorporation of strategies and methods to maintain focus may facilitate EBP implementation.

The importance of teamwork and collaboration in implement- ing change and maintaining high-performing organizations has been described in previous studies (Nelson, Batalden, & God- frey, 2007; Wolfson et al., 2009). Findings in the current analysis suggest that the process of implementing an EBP change also can be a vehicle for team building and collaboration. Participant comments demonstrated staff and interdisciplinary engagement in the project, and the process provided opportunities for new interactions within teams and among stakeholders.

In contrast to challenges, frustrations, and barriers to EBP typically identified in the process of implementing EBP, experi- ences here also were uplifting and empowered the nurses. These findings suggest that EBP focus in the nursing profession not only improves patient care, but also can inspire and energize nurses.

Limitations

Limitations stem from the characteristics of the sample and the nature of qualitative methods. The reflections were from participants in the IEBPC program. The program provided education and attention to specific aspects of EBP implementa- tion (e.g., planning, measuring results). This likely influenced participant attention to those areas in the reflections, although not the specific experience described. It also can be assumed that participants in the program already had interest and some personal and organizational commitment to EBP. This limita- tion is mitigated by the fact that many concepts and themes described here are mentioned in other studies.

Qualitative analysis, used in the current analysis, requires clas- sification of the raw data by the reviewers. Different individuals using the same data may arrive at different classification of themes and concepts. Analysis also involved the distillation of a wealth of written data to a relatively small set of themes and observations that cannot describe the full complexity of EBP implementation.

The fact that findings are derived from a variety of different settings and from EBP projects involving diverse aspects of pa- tient care is a strength of this analysis. Because the themes are derived from various situations, they may be relevant in a range of situations. Data also were obtained at the time individuals were involved in their EBP implementation projects, providing reflection on the experience as it occurred. To the authors’ knowledge, the current analysis is the first to record the experi- ence of EBP implementation as it happened.

Conclusions Nurses routinely do not implement evidence in practice, and

translating evidence into clinical practice is a challenging process

Discovery About Practice

“We were actually surprised that the nursing staff did not get 100% on the fatigue knowledge assessment.”

“We thought these were things that all nurses knew. We were wrong.”

Discovery About Each Other

“Our team interactions are providing previously untapped chances to see each other in a variety of scripted and unscripted roles not al- ways reflective of the assigned titles we have in our regular work.”

“The multidisciplinary team has been wonderful and helped us think beyond our own ‘boxes’ of expertise.”

Igniting the Spirit of Inquiry

“Data collection is done. . . . Reading that makes me want to dig deeper.”

“Exposure to a new knowledge area and way of thinking opens up countless opportunities.”

“Successful project experience never ends. . . . It leads to other op- portunities.”

“We were afraid at first that the staff nurses would just complain, ‘What more for me to do?’ But that is not the response we are get- ting at all. They want to have the information at their fingertips.”

Empowerment Through Evidence

“The most exciting and surprising event was to experience our stress level decrease once we got into the meat of the evi- dence and did the grading. We all knew we were experiencing evidence-based practice at a different level.”

“We are seeing each other grow and gain confidence in a new area with evidence-based support.”

“We had to be very well versed in our literature knowledge, and we were able to command this discussion and disallow any ten- dency to disregard evidence.”

Challenge of Sustaining Change

“How do you sustain a change and make it practice?” “We are trying to keep the momentum going and find ways to

sustain the change we have made.” “One of the things we have learned in the past six months is that

sustainability is hard but definitely rewarding, both for the pa- tients and the organization at large.”

FIGURE 7. Subthemes in the Theme of Discovery

Clinical Journal of Oncology Nursing • Volume 17, Number 5 • Implementing Evidence-Based Practice Change 549

(Fineout-Overholt et al., 2005; Wallin, Profetto-McGrath, & Levers, 2005). Findings from this work point to several areas that may be helpful to nurses in planning EBP implementation. Implementation strategies and critical success factors can help prepare others and be included in planning. Findings suggest that a strategy to maintain focus during implementation is important. As professionals, nurses need to develop solutions for time constraints commonly reported as barriers. If organi- zations are motivated, support for dedicated time can facilitate EBP (Mensik, 2011).

Challenges in EBP implementation cannot be minimized. How- ever, as shown in this article, EBP implementation also can be a rewarding and inspirational experience for nurses that fosters teamwork and collaboration to improve patient care.

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Implications for Practice

u Incorporate knowledge of critical success factors identified in this article to plan effective evidence-based practice (EBP) implementation.

u Implement an EBP project for purposeful team building and interdisciplinary collaboration.

u Create a plan that includes small steps, clear actions, and deadlines.

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