EBP, IS, AND QI

491The Journal of Continuing Education in Nursing · Vol 50, No 11, 2019

leadership and development

In a recent conversation with a col- league who interviewed individu- als for a leadership position, she

noted that each candidate described their leadership style as transforma- tional. When asked to give an example of a transformation they had led— and its impact at the organizational level—few could cite a substantive transformational change at an organi- zational level. My colleague lamented that many see themselves as transfor- mative leaders, but few actually are. Is the ability to actually move an orga- nization in the direction of a desired change—given its culture, people with diverse backgrounds and educa- tional levels, and other complexities—

far more rare than commonplace? Yet, health care organizations need to respond to change more than ever, making implementation science—the science of change—a requisite compe- tency.

Dr. Dean Fixsen (2019), articu- lated three developmental levels on the journey to implementation sci- ence. The first level, letting it happen (change) aligns with the diffusion the- ory of change popularized by Everett Rogers who studied how innovations (change) spread through an organi- zation, simplified here by describing change as a domino effect. Fixsen described the second level as helping it (change) happen, equated with dis- semination science. Professional de- velopment educators know the power of education in advancing change, such that when groups are armed with education on a topic, an added stimu- lus to change occurs. Yet, education— as essential as it is as a stimulus for change—does not always equate to behavioral modification, individually or collectively. This leads to the third level of change mastery and imple- mentation science. Implementation science is necessary because it is the science of making nonoptional things happen. Leaders must guide organi- zational change, ensuring compliance and uniformity of actions, safeguard-

ing the quality and safety of patients, and managing resources.

IMPLEMENTATION SCIENCE DEFINED

Bauer, Damschroder, Hagendorn, Smith, and Kilbourne (2015) offered a useful and concise definition of im- plementation science. They defined implementation science as “the sci- entific study of methods to promote the systematic uptake of research find- ings and other EBPs [evidence-based practices] into routine practice, and, hence, it improves the quality and ef- fectiveness of health services” (p. 1). In the definition are salient key points— namely, that leaders should use evi- dence and research when available to drive change. A second point is that the leader/change agent should make the client group (those affected by the expected change) keenly aware of what is at stake with regard to quality and effectiveness. The third point is that there is a science to implementa- tion. The science comprises methods to drive the systematic uptake of re- search and evidence-based practices in practice settings, one of the outcomes now associated with the Doctor of Nursing Practice degree and an expec- tation of leaders in all clinical settings.

Implementation science drives nonoptional change, standardizes high-risk and high-stakes clinical in- terventions, and advances innovations within an organization. The science itself addresses the knowledge gap that exists between interventions that research has shown to be effective and its translation into practice in varying clinical settings. Increasingly, inter-

abstract Leaders must distinguish be-

tween diffusion as a change strat- egy, education as a stimulus for change, and implementation strat- egies associated with implementa- tion science. This article provides an operational definition for implemen- tation science, the distinguishing characteristics in leading transfor- mational change, and the degrees of implementation. [J Contin Educ Nurs. 2019;50(11):491-492.]

Dr. Bleich is Senior Professor and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, Ballwin, Missouri.

The author has disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN, Senior Professor

and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, 221 Jasmin Park Court, Ballwin, MO 63021; e-mail: [email protected].

doi:10.3928/00220124-20191015-03

Implementation Science as a Leadership and Doctor of Nursing Practice Competency

Associate Editors: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN Jan Jones-Schenk, DHSc, RN, NE-BC, FAAN

Author: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN

492 Copyright © SLACK Incorporated

vention researchers must build into their studies a science-based imple- mentation strategy, as well as philan- thropic organizations, to ensure that their efforts reach the point of intend- ed impact (Easterling & Metz, 2016).

DEGREES OF IMPLEMENTATION A highly recommended resource

for professional development educa- tors is the work of Fixsen, Naoom, Blase, Friedman, and Wallace (2005), which provided a useful synthesis of implementation science research. Their summary reflects that imple- mentation takes place with differ- ing levels of engagement, similarly to the letting it change, helping it change, and making it happen levels mentioned earlier. Paper implementa- tion—often required by regulators— refers to changes that result from the adoption of policies and procedures, where a needed paper trail documents change. Organizational leaders should be competent in preparing policies, procedures, algorithms, and protocols to give direction and insight into prac- tice.

Process implementation advances paper implementation. Educators play a pivotal role as leaders who pro- vide training as the backdrop for spec- ifying the rationale for change, the expectations linked to innovations, and simulation or competency expec- tations to ensure that the client system affected by the change is able to per- form, without the guarantee that they will perform or change their practice. Process implementation eliminates the variable relating to knowing what to do, as it has been measured and evaluated.

The third level of implementa- tion is where the change is actually implemented and takes hold in the organization, known as performance implementation. This is where the consolidated framework for imple- mentation research model developed by Damschroder et al. (2009) is a use- ful reference for educators and leaders. This model depicts the variables at play during the implementation of innova- tions with supportive evidence being generated by implementation scien- tists. Implementation is influenced by (a) intervention characteristics, which vary in factors such as adaptability, ad- vantage, and complexity; (b) the outer settings, with factors such as patient ex- perience and expectations, incentives, and pressure from peer organizations; (c) the inner setting, with its unique structural characteristics and networks; (d) the characteristics of the individuals involved, such as their knowledge and identification with the organization; and (e) the process of implementation, such as how it was planned, executed, and other factors. When taken com- pletely, it immediately becomes clear that multiple and often confound- ing variables are required for effective change management, offering a par- tial explanation for the often dismally slow uptake of innovations in health care settings. As the Doctor of Nurs- ing Practice enters the workforce in expanding roles, it should be with the ability to discern and lead innovations and change, from paper to practice.

SUMMARY The professional development

educator, whether in the practice or academic setting, who is teach-

ing implementation science content should move beyond the comfort zone of the process implementation described above. Yes, education at the process level is key to the implementa- tion of innovations—it can incentiv- ize and motivate learners to take heed of answering the “what” and “why” of change needed. However, widespread change that takes hold organization- wide is the skill and competency set needed by leaders. Novice leaders may not possess awareness of all the vari- ables to consider in driving change that must happen. Offering leaders training in the models and resources presented in this article is a starting point for advancing their competence in implementation science.

REFERENCES Bauer, M.S., Damschroder, L., Hagendorn, H.,

Smith, J., & Kilbourne, A.M. (2015). An introduction to implementation science for the non-specialist. Retrieved from https:// bmcpsychology.biomedcentral.com/track/ pdf/10.1186/s40359-015-0089-9

Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into prac- tice: A consolidated framework for advanc- ing implementation science. Implementation Science, 4(50).

Easterling, D., & Metz, A. (2016). Getting real with strategy: Insights from implementation science. The Foundation Review, 8, 97-115.

Fixsen, D. (2019, February 4). The science of im- plementation—Dr. Dean Fixsen—episode 11 [Video file]. Retrieved from https://www. youtube.com/watch?v=t4k8pk9Bgps

Fixsen, D.L., Naoom, S.F., Blase, K.A., Fried- man, R.M., & Wallace, F. (2005). Imple- mentation research: A synthesis of the litera- ture. Retrieved from https://nirn.fpg.unc. edu/sites/nirn.fpg.unc.edu/files/resources/ NIRN-MonographFull-01-2005.pdf

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.

491The Journal of Continuing Education in Nursing · Vol 50, No 11, 2019

leadership and development

In a recent conversation with a col- league who interviewed individu- als for a leadership position, she

noted that each candidate described their leadership style as transforma- tional. When asked to give an example of a transformation they had led— and its impact at the organizational level—few could cite a substantive transformational change at an organi- zational level. My colleague lamented that many see themselves as transfor- mative leaders, but few actually are. Is the ability to actually move an orga- nization in the direction of a desired change—given its culture, people with diverse backgrounds and educa- tional levels, and other complexities—

far more rare than commonplace? Yet, health care organizations need to respond to change more than ever, making implementation science—the science of change—a requisite compe- tency.

Dr. Dean Fixsen (2019), articu- lated three developmental levels on the journey to implementation sci- ence. The first level, letting it happen (change) aligns with the diffusion the- ory of change popularized by Everett Rogers who studied how innovations (change) spread through an organi- zation, simplified here by describing change as a domino effect. Fixsen described the second level as helping it (change) happen, equated with dis- semination science. Professional de- velopment educators know the power of education in advancing change, such that when groups are armed with education on a topic, an added stimu- lus to change occurs. Yet, education— as essential as it is as a stimulus for change—does not always equate to behavioral modification, individually or collectively. This leads to the third level of change mastery and imple- mentation science. Implementation science is necessary because it is the science of making nonoptional things happen. Leaders must guide organi- zational change, ensuring compliance and uniformity of actions, safeguard-

ing the quality and safety of patients, and managing resources.

IMPLEMENTATION SCIENCE DEFINED

Bauer, Damschroder, Hagendorn, Smith, and Kilbourne (2015) offered a useful and concise definition of im- plementation science. They defined implementation science as “the sci- entific study of methods to promote the systematic uptake of research find- ings and other EBPs [evidence-based practices] into routine practice, and, hence, it improves the quality and ef- fectiveness of health services” (p. 1). In the definition are salient key points— namely, that leaders should use evi- dence and research when available to drive change. A second point is that the leader/change agent should make the client group (those affected by the expected change) keenly aware of what is at stake with regard to quality and effectiveness. The third point is that there is a science to implementa- tion. The science comprises methods to drive the systematic uptake of re- search and evidence-based practices in practice settings, one of the outcomes now associated with the Doctor of Nursing Practice degree and an expec- tation of leaders in all clinical settings.

Implementation science drives nonoptional change, standardizes high-risk and high-stakes clinical in- terventions, and advances innovations within an organization. The science itself addresses the knowledge gap that exists between interventions that research has shown to be effective and its translation into practice in varying clinical settings. Increasingly, inter-

abstract Leaders must distinguish be-

tween diffusion as a change strat- egy, education as a stimulus for change, and implementation strat- egies associated with implementa- tion science. This article provides an operational definition for implemen- tation science, the distinguishing characteristics in leading transfor- mational change, and the degrees of implementation. [J Contin Educ Nurs. 2019;50(11):491-492.]

Dr. Bleich is Senior Professor and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, Ballwin, Missouri.

The author has disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN, Senior Professor

and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, 221 Jasmin Park Court, Ballwin, MO 63021; e-mail: [email protected].

doi:10.3928/00220124-20191015-03

Implementation Science as a Leadership and Doctor of Nursing Practice Competency

Associate Editors: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN Jan Jones-Schenk, DHSc, RN, NE-BC, FAAN

Author: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN

492 Copyright © SLACK Incorporated

vention researchers must build into their studies a science-based imple- mentation strategy, as well as philan- thropic organizations, to ensure that their efforts reach the point of intend- ed impact (Easterling & Metz, 2016).

DEGREES OF IMPLEMENTATION A highly recommended resource

for professional development educa- tors is the work of Fixsen, Naoom, Blase, Friedman, and Wallace (2005), which provided a useful synthesis of implementation science research. Their summary reflects that imple- mentation takes place with differ- ing levels of engagement, similarly to the letting it change, helping it change, and making it happen levels mentioned earlier. Paper implementa- tion—often required by regulators— refers to changes that result from the adoption of policies and procedures, where a needed paper trail documents change. Organizational leaders should be competent in preparing policies, procedures, algorithms, and protocols to give direction and insight into prac- tice.

Process implementation advances paper implementation. Educators play a pivotal role as leaders who pro- vide training as the backdrop for spec- ifying the rationale for change, the expectations linked to innovations, and simulation or competency expec- tations to ensure that the client system affected by the change is able to per- form, without the guarantee that they will perform or change their practice. Process implementation eliminates the variable relating to knowing what to do, as it has been measured and evaluated.

The third level of implementa- tion is where the change is actually implemented and takes hold in the organization, known as performance implementation. This is where the consolidated framework for imple- mentation research model developed by Damschroder et al. (2009) is a use- ful reference for educators and leaders. This model depicts the variables at play during the implementation of innova- tions with supportive evidence being generated by implementation scien- tists. Implementation is influenced by (a) intervention characteristics, which vary in factors such as adaptability, ad- vantage, and complexity; (b) the outer settings, with factors such as patient ex- perience and expectations, incentives, and pressure from peer organizations; (c) the inner setting, with its unique structural characteristics and networks; (d) the characteristics of the individuals involved, such as their knowledge and identification with the organization; and (e) the process of implementation, such as how it was planned, executed, and other factors. When taken com- pletely, it immediately becomes clear that multiple and often confound- ing variables are required for effective change management, offering a par- tial explanation for the often dismally slow uptake of innovations in health care settings. As the Doctor of Nurs- ing Practice enters the workforce in expanding roles, it should be with the ability to discern and lead innovations and change, from paper to practice.

SUMMARY The professional development

educator, whether in the practice or academic setting, who is teach-

ing implementation science content should move beyond the comfort zone of the process implementation described above. Yes, education at the process level is key to the implementa- tion of innovations—it can incentiv- ize and motivate learners to take heed of answering the “what” and “why” of change needed. However, widespread change that takes hold organization- wide is the skill and competency set needed by leaders. Novice leaders may not possess awareness of all the vari- ables to consider in driving change that must happen. Offering leaders training in the models and resources presented in this article is a starting point for advancing their competence in implementation science.

REFERENCES Bauer, M.S., Damschroder, L., Hagendorn, H.,

Smith, J., & Kilbourne, A.M. (2015). An introduction to implementation science for the non-specialist. Retrieved from https:// bmcpsychology.biomedcentral.com/track/ pdf/10.1186/s40359-015-0089-9

Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into prac- tice: A consolidated framework for advanc- ing implementation science. Implementation Science, 4(50).

Easterling, D., & Metz, A. (2016). Getting real with strategy: Insights from implementation science. The Foundation Review, 8, 97-115.

Fixsen, D. (2019, February 4). The science of im- plementation—Dr. Dean Fixsen—episode 11 [Video file]. Retrieved from https://www. youtube.com/watch?v=t4k8pk9Bgps

Fixsen, D.L., Naoom, S.F., Blase, K.A., Fried- man, R.M., & Wallace, F. (2005). Imple- mentation research: A synthesis of the litera- ture. Retrieved from https://nirn.fpg.unc. edu/sites/nirn.fpg.unc.edu/files/resources/ NIRN-MonographFull-01-2005.pdf

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.