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The substantial push for enhanced patient safety began with the publication of the National Academy of Medicine’s (NAM) groundbreaking report To Err is Human: Building a Safer Health System. This report revealed that numerous patient deaths occur as the result of preventable medical errors (Kohn, Corrigan, & Donaldson, 2000). The NAM’s second report, Crossing the Quality Chasm, provided solutions to address the risks to patient safety by proposing six dimensions for healthcare improvement (Institute of Medicine Committee on Quality of Health Care in America, 2001). Specifically, healthcare organizations must improve to provide care that is safe, effective, patient

centered, timely, efficient, and equitable. These dimen- sions provide the focus for implementation of evidence- based practice (EBP), reducing preventable harm in healthcare, and continue to drive quality improvement (QI) initiatives.

Considering that half of research evidence relevant to clinical practice never reaches the clinical setting, translating evidence into routine clinical care requires focused interdisciplinary efforts (Balas & Boren, 2000). Implementation science (IS) was established to develop evidence-based strategies to promote the uptake of EBP into clinical care. The purpose of this article is to describe the differences between QI and IS, the

Implementation Science Training and Resources for Nurses and Nurse Scientists Leanne M. Boehm, PhD, RN, ACNS-BC1 , Deonni P. Stolldorf, PhD, RN2, & Alvin D. Jeffery, PhD, RN3

1 Iota, Assistant Professor, Vanderbilt University School of Nursing, Nashville, TN USA 2 Iota, Assistant Professor, Vanderbilt University School of Nursing, Nashville, TN USA 3 Iota & Nu Lambda, Medical Informatics Fellow, U.S. Department of Veterans Affairs, Nashville, TN USA

Key words Evidence-based practice, implementation

science, quality

Correspondence Dr. Leanne M. Boehm, 461 21st Avenue South,

419 Godchaux Hall, Nashville, TN 37129, USA.

E-mail: [email protected]

Accepted June 17, 2019

doi:10.1111/jnu.12510

Abstract

Purpose: The purpose of this article is to describe the differences between quality improvement and implementation science, the urgency for nurses and nurse scientists to engage in implementation science, and international educational opportunities and resources for implementation science. Organizing Construct: There is a push for providing safe, effective, patient- centered, timely, efficient, and equitable health care. Implementation science plays a key role in adoption and integration of evidence-based practices to improve quality of care. Methods: We reviewed implementation science programs, organizations, and literature to analyze the roles of nurses and nurse scientists in trans- lating evidence into routine practice. Findings: Implementation-trained nurses and nurse scientists are needed as part of multidisciplinary teams to advance implementation science be- cause of their unique understanding of contextual barriers within nursing practice. Likewise, nurses are uniquely qualified for recognizing what im- plementation strategies are needed to improve nursing care across practice settings. Conclusions: Many international clinical and training resources exist and are supplied to aid interested readers in learning more about implementa- tion science. Clinical Relevance: Half of research evidence never reaches the clinical setting, and the other half takes 20 years to translate into clinical practice. Implementation science-trained nurses are in a position to be excellent improvers for meaningful change in practice.

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urgency for nurses and nurse scientists to engage in IS, and international educational opportunities and resources for nurses interested in IS.

Quality Improvement vs. Implementation Science

Quality Improvement

QI broadly refers to work that aims to improve the quality, safety, and value of health care. One common QI framework is the Model for Improvement, which guides users in the development of a specific, measur- able, achievable, relevant, and time-bound (SMART) aim (Langley, 2009). This SMART aim comprises quan- titative measures to assess outcomes along with a change strategy for successful improvement. QI is further characterized by visualization of the current system (e.g., process map), commitment to rapid testing of change strategies via Plan-Do-Study-Act (PDSA) cycles, and observing for variation in the data in order to determine statistically significant improvement (Langley, 2009). Testing changes on a small scale, learning from each PDSA cycle, and refining change strategies can then lead to broader change for a microsystem or population.

Implementation Science

Implementation science also aims to improve the quality of health care, but the approach is focused on systematic adoption and integration of evidence- based health interventions within a particular setting (Brownson, Colditz, & Proctor, 2018). While QI is informed largely by the automotive industry (e.g., Toyota lean manufacturing), IS is informed by behav- ioral science because implementation requires chang- ing practice patterns within specific settings. Figuratively, one could think of QI as the practice arm of improvement and IS as the research arm of improvement via informed implementation of EBP. It currently requires almost 20 years to transform original research into practice that benefits patient care (Balas & Boren, 2000). Thus, IS primarily explores outcomes related to the implementation of healthcare interventions such as acceptability, appropriateness, adoption, feasibility, and sustainability, in addition to those outcomes important to QI (e.g., safe, effec- tive, equitable, timely) (Proctor et al., 2011). Implementation science may also include client out- comes like patient satisfaction, function, and quality of life as secondary outcomes (Proctor et al., 2011). Measurement of specific implementation outcomes

and the accompanying development of robust imple- mentation methods can enhance the effectiveness of implementation efforts, lead to more timely adoption of EBP, and improve the quality of health care.

Clinical Example: Addressing Delirium Using QI vs. IS Approaches

Valid and reliable tools are guideline recommended for the assessment of delirium in hospitalized patients. One hospital that implemented a validated delirium screening tool later identified inaccuracies in nursing assessments, which resulted in unidentified delirium and missed opportunities to treat patients with delirium (DiLibero, DeSanto-Madeya, Dottery, Sullivan, & O’Donoghue, 2018; DiLibero et al., 2016). The sub- sequent QI project aim was to achieve >80% delirium assessment accuracy by nurses. The improvement team used a multifaceted educational intervention and conducted real-time tracking of delirium assessment accuracy trends via a run chart. Over 11 months, delirium assessment accuracy improved from 70% to 96%. The resulting success of this QI initiative led to subsequent spread to two other hospital units. The focus of the QI project was to implement specific, evidence-based interventions (i.e., education and moni- toring accuracy trends) to improve patient clinical outcomes.

Using the same example of enhancing delirium assess- ment in hospitalized patients, an implementation sci- entist might focus on (a) assessing current adherence to, and accuracy of, delirium assessment in a practice setting; (b) employing a multidisciplinary team to explore the best strategies for addressing implementation chal- lenges; and (c) selecting appropriate measures to deter- mine the effectiveness of a strategy. Implementation scientists identify implementation strategies (e.g., audit and feedback, dynamic training, disincentives, peer leaders, etc.) in order to better implement an inter- vention within a practice setting. Implementation sci- entists might evaluate how nurses use a particular implementation strategy and whether that strategy resulted in improved implementation (e.g., satisfaction, usefulness, utility, and feasibility). Alternatively, frontline nurses might apply IS methods by developing a unit advisory board, critically evaluating the literature related to delirium assessment, and proposing strategies best suited for their environment and most likely to improve implementation. Implementation scientists evaluate out- comes specific to implementation efforts (e.g., accept- ability and sustainability of the delirium screening tool), while frontline nurses evaluate clinical outcomes (e.g., delirium assessment accuracy).

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Table 1. Resources for Learning and/or Conducting Implementation Science

Institution/location Website Description

Universities

Adult and Child Consortium for Health

Outcomes Research and Delivery Science

(University of Colorado, U.S.A.)

ucden ver.edu/acade mics/colle ges/medic

alsch ool/progr ams/ACCOR DS/Pages/

welco me.aspx. See Cores and Programs.

Offers internal training grants, online resources

(e.g., checklists, textbooks, worksheets), and

learning opportunities

Online

Center for Clinical Quality & Implementation

Research (Vanderbilt University Medical

Center, U.S.A.)

vumc.org/imple menta tion/ Interdepartmental, multidisciplinary center that

offers internal training grants, learning

opportunities (e.g., seminars, symposia,

workshops), and consultation

Center for Health Innovation &

Implementation Science (Indiana

University, U.S.A.)

hii.iu.edu/ Offers boot camp workshop, implementation short

course, webinars, distance-education graduate

certificate program

Online

Centre for Implementation Science (King’s

College, U.K.)

kcl.ac.uk/ioppn/ depts/ hspr/research/cis/

train ing-events.aspx

Provides consultations for local organizations, hosts

seminars, 2-day implementation master class,

and international conference

Gillings School of Public Health

(University of North Carolina, U.S.A.)

sph.unc.edu/resea rch/explo re/imple menta

tion-scien ce/

Offers in-person seminars and >10 implementation

science-focused graduate courses

Online

Implementation Research Institute

(Washington University, U.S.A.)

iristl.org/ Supports career development for early- and

mid-career investigators; applicants can receive

distance training and mentorship

Online

IMPSCIX (University of North Carolina,

U.S.A.)

impsci.tracs.unc.edu/ Multiple resources and tutorials for theories,

frameworks, grant writing, and publishing

implementation science

Online, free

Institute for Clinical & Translational

Research (University of Wisconsin-

Madison, U.S.A.)

ictr.wisc.edu/ Offers short courses, conferences, certificates,

workshops, and consultation

Online, free

Specialist Certificate in Implementation

Science (University of Melbourne,

Australia)

https ://study.unime lb.edu.au/find/cours es/

gradu ate/speci alist-certi ficate-in-imple

menta tion-scien ce/

6-month certificate in implementation science;

domestic and international students welcome

Online

Fellowships and career development awards

F32, K01, K08, T32, & R36 Grant

Mechanisms (Agency for Healthcare

Research & Quality)

ahrq.gov/fundi ng/train ing-grant s/index.html Provides funding to individuals and organizations

for predoctoral, postdoctoral, and early-career

health services and implementation science

researchers

K12 Grant Mechanism (U.S. National Heart,

Lung, & Blood Institute)

nhlbi.nih.gov/ Provides funding to organizations to offer

intramural career development awards to

research faculty

Quality Scholars Fellowship (U.S.

Department of Veterans Affairs)

vaqs.org/ 2-year interdisciplinary fellowship focused on both

quality improvement and implementation science

Grants

Dissemination & Implementation Research

in Health R-Level Funding (U.S. National

Institutes of Health)

grants.nih.gov/grant s/oer.htm Funding opportunities for R01, R03, and R21

mechanisms solicit investigator-initiated

proposals for pilot through large-scale research

studies in dissemination and implementation

Fogarty International Center (U.S. National

Institutes of Health)

fic.nih.gov/Pages/ Defau lt.aspx The “Implementation Science Information and

Resources” page provides news, resources, and

funding mechanisms

Health Services Research R18

Demonstration and Dissemination Grants

(Agency for Healthcare Research &

Quality)

grants.nih.gov/grant s/guide/ pa-files/

PA-18-793.html

Funding opportunity for organizations or

institutions working toward a concretely scoped

health services research project

(Continues)

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Institution/location Website Description

Professional organizations (*1 or more relevant conferences hosted by organization)

Academy Health* acade myhea lth.org/ Professional home for health services researchers

that focuses on implementation research as a

foundational science to most healthcare delivery

improvement activities; co-hosts “Annual

Conference on the Science of Dissemination &

Implementation in Health” with U.S. National

Cancer Institute

Canadian Coalition for Global Health

Research

ccghr.ca/resou rces/knowl edge-trans latio n/ Contains free, online curriculum of three modules

focused on knowledge translation within

healthcare settings

Online, free

Consortium for Implementation Science (RTI

International)

conso rtium foris.org/ Actively conducts implementation science projects

and shares details via website, which contains

many examples for well-scoped implementation

research studies

European Implementation Collaborative

(EIC)*

implementation.eu Organization that aims to improve lives through

implementation of evidence-informed human

services across Europe. Connects visitors to

international implementation resources,

networks, and events.

Institute for Healthcare Improvement* ihi.org/educa tion/Pages/ defau lt.aspx Leading organization in healthcare quality

improvement; website contains access to a

number of online and in-person training

opportunities emphasizing quality improvement

Online, free

Kings College London

Center for Implementation Science

clahr c-south london.nihr.ac.uk/centr e-imple

menta tion-science

Center is part of the National Institute of Health

Research with an array of experts in implementa-

tion and improvement science. Aims to

understand the implementation of evidence-

based practice and clinical research in healthcare

settings.

Knowledge Translation Canada* ktcan ada.org/ Offers Knowledge Translation Conference with

focus on implementation and serves as a

resource to facilitate the uptake of research

evidence in practice; offers seminar series and

summer implementation institute

Scottish Improvement Science Collaborating

Centre

siscc.dundee.ac.uk/ National organization focused on identifying and

creating methods for large-scale healthcare

improvement activities

Society for Implementation Research

Collaboration*

socie tyfor imple menta tionr esear chcol labor

ation.org/

Facilitates networking, has information on many

in-person training workshops and conferences,

and provides dozens of introductory resources/

videos for those new to implementation science

Training Institute for Dissemination &

Implementation Research in Health

[TIDIRH] (U.S. National Institutes of

Health)

obssr.od.nih.gov/train ing/ Training program that includes a 4-month online

course and 2-day in-person training covering the

entire continuum from theoretical foundations to

practical considerations

Online

Training Institute for Dissemination &

Implementation Research in Cancer

[TIDIRC] (U.S. National Cancer Institute)

cance rcont rol.cancer.gov/IS/train ing-educa

tion/tidir c/index.html

Training program that includes a 4-month online

course and 2-day in-person training covering the

entire continuum from theoretical foundations to

practical considerations across the cancer

control continuum.

Online

Table 1. (Continued)

(Continues)

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Need for Implementation-Trained Nurses: Why Nurses and Why IS?

It is critical for IS-focused clinicians to be present in health care. Implementation teams are inherently mul- tidisciplinary because many interventions span across disciplines, and success is more likely when all disciplines involved in the intervention are represented in imple- mentation processes (Stolldorf, 2017; Stolldorf, Mion, & Jones, 2016). As the clinicians embedded in almost every sector of health care and typically on the front lines of patient care, implementation-trained nurses are posi- tioned to be excellent “meta-improvers” for meaningful change. Nurses are often at the forefront of QI initia- tives to implement EBP healthcare interventions. Therefore, healthcare systems increasingly need well- trained nurses and leaders who are knowledgeable of ideal implementation strategies for use across diverse settings, populations, and interventions.

The National Institutes of Health is working to build capacity in IS by funding formal training programs and generating program announcements soliciting investigator-initiated proposals for translating research into practice (Glasgow et al., 2012). Nurses and nurse scientists are needed to lead and contribute to mul- tidisciplinary research teams advancing the science of implementation. Given nurses’ unique clinical role and affinity for interprofessional collaboration, coupled with their ongoing involvement with implementing EBP in

clinical settings, nurses have a vested interest in learn- ing and applying IS. Specifically, nurses need advanced knowledge of the factors affecting adoption, imple- mentation, and sustainment of EBP and further develop IS methods to accelerate the implementation of EBP.

Organizational change can be difficult to achieve due to a variety of contextual factors (e.g., capacity, leadership support, lack of interprofessional collabora- tion) known to impede implementation efforts (Arroyave, Penaranda, & Lewis, 2011; Lau et al., 2015; Shoemaker, 2015). To achieve implementation success, change is often needed at different organizational levels (i.e., individuals, units, and/or organizations) (Chaudoir, Dugan, & Barr, 2013). When nurses develop imple- mentation plans that include the careful selection of processes that will facilitate change at the desired organizational level, successful implementation is more likely. Implementation plans must also account for existing organizational barriers like nursing culture and leadership, hospital size, staffing, finance, workload, administrative responsiveness, and resistance to change, which can significantly influence implementation of an evidence-based intervention (Powell et al., 2017; van Achterberg, Schoonhoven, & Grol, 2008).

Sound knowledge in IS will enable nurses to suc- cessfully tailor implementation efforts to meet the needs of their organizations. Nurse scientists understand these contextual barriers within which nurses’ practice and can facilitate the necessary buy-in from colleagues and

Institution/location Website Description

U.S. Department of Veterans Affairs’ Quality

Enhancement Research Initiative

queri.resea rch.va.gov/ Primary focus is quality improvement, but

organization stores free webinars focused on

implementation science using real-world

scenarios

Online, free

Other resources and materials

Advanced Topics in Implementation Science

Webinars (U.S. National Cancer Institute)

cance rcont rol.cancer.gov/IS/train ing-educa

tion/Webin ars.aspx

Provides free video webinars via YouTube for

implementation methods related to cancer care

Online, free

Dissemination and Implementation Models

in Health Research and Practice

dissemination-implementation.org/ Helps with selecting dissemination and implemen-

tation models and find measurement instruments

for model constructs

Online, free

Dissemination and Implementation Research

in Health: Translating Science to Practice,

2nd edition

ISBN-13: 978-0190683214

ISBN-10: 019068321X

Serves as a practical guide to implementation

science and includes relevant resources at the

end of each chapter

Implementation Science journal imple menta tions cience.biome dcent ral.com/ Premier peer-reviewed journal for healthcare-

focused implementation science methods

Implementation Research Toolkit (World

Health Organization)

who.int/tdr/publi catio ns/topic s/ir-toolk it/

en/

Online, module-based curriculum for learning about

implementation research

Online, free

Note: free = free training available; online = online training available.

Table 1. (Continued)

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serve as opinion leaders to enhance implementation. These skills, in addition to nurses’ implicit ability to problem solve and think critically, make them well- equipped to understand what implementation strategies are best for enhancing the incorporation of EBP into nursing and healthcare. There are nurse scientists already beginning to make a difference (Costa et al., 2017; Dolansky, Schexnayder, Patrician, & Sales, 2017; Leeman et al., 2018; Sales et al., 2016; Stetler, Ritchie, Rycroft-Malone, Schultz, & Charns, 2009), and more implementation-trained nurses are needed to continue this important work.

Clinical and Training Resources Training is required to prepare the next generation

of IS nurse scientists to ensure consistent application of IS concepts. Concepts critical to training include theories, models, frameworks, designs, measurement, strategies, and outcomes specific to implementation. We have identified a variety of resources to share with the community to assist interested readers in learning more about IS. We have curated university- based programs, fellowship and career development grants, independent research grants, professional organi- zations, conferences/meetings, and other miscellaneous readings and tutorials. The data presented in Table 1 can guide individualized training plans and serve as a resource for incorporating IS competencies into nurs- ing curricula (Chambers, Proctor, Brownson, & Straus, 2017; Ginossar et al., 2018).

Conclusions It can be challenging to find opportunities for

learning new skill sets, but many international resources do exist for becoming more knowledgeable and experienced with implementation and IS. We encourage interested readers to take advantage of the opportunities we have outlined here and con- tribute to this important and growing field. Our patients and communities cannot wait another 20 years to receive the best possible care; we need well- equipped nurses and nurse scientists now who can successfully facilitate implementation efforts to improve health and health care.

Acknowledgments Deonni P. Stolldorf is currently receiving a grant

(#K01HS025486) from the Agency for Healthcare Research & Quality. Leanne M. Boehm is currently receiving grant funding from the National Heart, Lung,

and Blood Institute (#K12HL137943-01), American Association of Critical-Care Nurses, and National Center for Advancing Translational Sciences (#UL1TR002243).

Clinical Resources • Implementation Science. https ://imple menta

tions cience.biome dcent ral.com/ • TDR. Implementation research toolkit. https ://

www.who.int/tdr/publi catio ns/topic s/ir-toolk it/ en/

• University of North Carolina at Chapel Hill. Implementation Science Exchange. https :// impsci.tracs.unc.edu/

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