Diffusion of Innovations: A Framework for Implementing Evidence-Based Practice Deborah Lekan, RNC,...
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Transcript of Diffusion of Innovations: A Framework for Implementing Evidence-Based Practice Deborah Lekan, RNC,...
Diffusion of Diffusion of Innovations:Innovations:
A Framework for A Framework for Implementing Evidence-Implementing Evidence-
Based PracticeBased Practice
Deborah Lekan, RNC, MSNDeborah Lekan, RNC, MSN
Gerontological Nurse Clinical Gerontological Nurse Clinical SpecialistSpecialist
Duke University School of Duke University School of NursingNursing
Duke University School of Nursing, 2007, updated 2009
ObjectivesObjectives Define the key elements of the Define the key elements of the
diffusion of innovations model.diffusion of innovations model. Describe how the diffusion of Describe how the diffusion of
innovations model can be used to innovations model can be used to facilitate evidence-based nursing facilitate evidence-based nursing practice.practice.
Duke University School of Nursing, 2007, updated 2009
““Good ideas Good ideas
do not sell themselves.”do not sell themselves.”(Rogers, E, 1995)(Rogers, E, 1995)
Putting new ideas such as Evidence-Putting new ideas such as Evidence-based Nursing, based Nursing, into practice,into practice, can be can be more complicated & difficult than the more complicated & difficult than the original research process that original research process that generated the scientific generated the scientific recommendations to begin with.recommendations to begin with.
Duke University School of Nursing, 2007, updated 2009
Barriers to Putting Barriers to Putting New Ideas into PracticeNew Ideas into Practice
Implementation of best practices is Implementation of best practices is often--often-- Imposed by others: governing bodies, Imposed by others: governing bodies,
federal or state regulations or corporate federal or state regulations or corporate policies; policies;
Left to trial & error;Left to trial & error; Painfully slow;Painfully slow; Marked by resistance, incomplete Marked by resistance, incomplete
implementation, and failure.implementation, and failure. Planned change is difficult to Planned change is difficult to
accomplishaccomplish
Duke University School of Nursing, 2007, updated 2009
Diffusion of Innovations: Diffusion of Innovations: DefinitionDefinition
The process by which The process by which (1) an (1) an innovationinnovation (2) is (2) is communicatedcommunicated through through certain channelscertain channels (3) over (3) over timetime (4) among (4) among membersmembers of a of a socialsocial systemsystem..
Diffusion is a Diffusion is a social processsocial process..Rogers, E., Diffusion of Innovations, 5th ed, 2003.
Duke University School of Nursing, 2007, updated 2009
Examples of InnovationsExamples of Innovations ProductsProducts
Phone technology: digital pager, cell phone, Phone technology: digital pager, cell phone, camera phone, Blackberry (phone w/internet), camera phone, Blackberry (phone w/internet), iPod/phone/internetiPod/phone/internet
Ear thermometer, Pulse oximetry, BladderScan®Ear thermometer, Pulse oximetry, BladderScan® PracticesPractices
Restraint free environmentRestraint free environment behavior behavior management techniques & environmental management techniques & environmental modificationsmodifications
IdeasIdeas Illness & frailty is not a normal part of aging Illness & frailty is not a normal part of aging Pain as the 5Pain as the 5thth vital sign vital sign
Duke University School of Nursing, 2007, updated 2009
An innovation is An innovation is all about all about PerceptionPerception
If it is If it is newnew to the to the user, then it is user, then it is an innovationan innovation
Duke University School of Nursing, 2007, updated 2009
The Adoption Process: 5 The Adoption Process: 5 StagesStages
KnowledgeKnowledge — —Awareness & Awareness & understanding of the innovation understanding of the innovation
PersuasionPersuasion — —Form favorable opinionForm favorable opinion DecisionDecision — —Try it outTry it out ImplementationImplementation — —Put it to usePut it to use ConfirmationConfirmation —Adoption —Adoption of of
innovationinnovation
oror Rejection Rejection && DiscontinuationDiscontinuation of use of use
Duke University School of Nursing, 2007, updated 2009
Confirmation and
Adoption, Re-invention, or Rejection
ContactAwareness
Understanding
Knowledge
Implementation
PersuasionTrial Use
Institutionalization
Full Scale Use
TIME
RATE or SPEED of ADOPTION
Decision
The Innovation-Adoption Process
Duke University School of Nursing, 2007, updated 2009
Factors Affecting the Factors Affecting the Rate of Diffusion of Rate of Diffusion of
InnovationsInnovations Perceived Innovation Perceived Innovation
AttributesAttributes Type of Innovation- DecisionType of Innovation- Decision Communication ChannelsCommunication Channels Nature of Social SystemNature of Social System Change Agent EffortsChange Agent Efforts
Duke University School of Nursing, 2007, updated 2009
One Area of FocusOne Area of Focus: : Perceived Innovation Perceived Innovation
AttributesAttributes Relative AdvantageRelative Advantage– better than status quo?– better than status quo? CompatabilityCompatability -consistent w/values, beliefs? -consistent w/values, beliefs? ComplexityComplexity -hard to do, use, or understand? -hard to do, use, or understand? TriabilityTriability -can it be tried out on a small scale? -can it be tried out on a small scale? ObservabilityObservability –is innovation or its results –is innovation or its results
visible? Can you see others using it or doing it?visible? Can you see others using it or doing it?
Duke University School of Nursing, 2007, updated 2009
How can the Diffusion of How can the Diffusion of Innovations (DOI) Model help Innovations (DOI) Model help promote Evidence-based promote Evidence-based Nursing Practice?Nursing Practice?
Duke University School of Nursing, 2007, updated 2009
It’s a given: Most people do not It’s a given: Most people do not desire changedesire change Inertia is comfortingInertia is comforting!!
Change creates uncertainty Change creates uncertainty anxietyanxiety
Human nature gravitates to Human nature gravitates to reducing & managing uncertainty reducing & managing uncertainty by resisting changeby resisting change
Duke University School of Nursing, 2007, updated 2009
Diffusion of Innovations Diffusion of Innovations andand
Evidence-based Nursing Evidence-based Nursing PracticePractice Diffusion of innovations-Diffusion of innovations-
Helps us understand the process of Helps us understand the process of changechange
Takes some of the guesswork out of Takes some of the guesswork out of determining what may or may not work determining what may or may not work when attempting changewhen attempting change
A model for guiding implementation A model for guiding implementation of evidence-based practices to of evidence-based practices to enhance success & sustainabilityenhance success & sustainability
Duke University School of Nursing, 2007, updated 2009
First Steps in Applying the DOI First Steps in Applying the DOI ModelModel
Pay attention to the Pay attention to the perception of the perception of the attributesattributes of the innovation among of the innovation among different groupsdifferent groups Relative advantageRelative advantage CompatabilityCompatability ComplexityComplexity Trialability Trialability ObservabilityObservability
Connect with opinion leadersConnect with opinion leaders to elicit to elicit feedback & marshal supportfeedback & marshal support
Duke University School of Nursing, 2007, updated 2009
Heart Failure EBP: Heart Failure EBP: Recognition & Reporting of Recognition & Reporting of
S&SS&S Mrs. Jones appears to be going into Mrs. Jones appears to be going into
acute Heart Failure and you need to acute Heart Failure and you need to do a thorough assessment before do a thorough assessment before calling the MD/NP. calling the MD/NP.
List at least 5 signs & symptoms List at least 5 signs & symptoms of Acute Heart Failure that should of Acute Heart Failure that should be assessed?be assessed?
Duke University School of Nursing, 2007, updated 2009
Acute Heart Failure S&SAcute Heart Failure S&S Shortness of breath, tachypneaShortness of breath, tachypnea Cough- persistent or only at nightCough- persistent or only at night Congestion, frothy sputum, can be blood-tingedCongestion, frothy sputum, can be blood-tinged Pale, cold clammy skinPale, cold clammy skin Edema in LE & sacrum, ascitesEdema in LE & sacrum, ascites Tachycardia, low blood pressure, pulse Tachycardia, low blood pressure, pulse
oximetry ↓oximetry ↓ Change in mental status, agitated, sleepy, Change in mental status, agitated, sleepy,
confusedconfused Decreased urine outputDecreased urine output Fatigue, muscle weakness, loss of appetiteFatigue, muscle weakness, loss of appetite Decline in ADL functionDecline in ADL function AnginaAngina
Duke University School of Nursing, 2007, updated 2009
Heart Failure S&SHeart Failure S&S How can RNs, LPNs & NAs have a How can RNs, LPNs & NAs have a
shared understanding about this shared understanding about this important information? important information?
What information is most critical for What information is most critical for all levels of nursing staff?all levels of nursing staff?
How can this information be How can this information be translated so that staff gain a shared translated so that staff gain a shared knowledge & understanding about knowledge & understanding about the clinically-significant S&S?the clinically-significant S&S?
Duke University School of Nursing, 2007, updated 2009
FACES job aidFACES job aid An acronym developed to simplify heart An acronym developed to simplify heart
failure S&S as a memory aid for all stafffailure S&S as a memory aid for all staff Modified from the Heart Failure Society Modified from the Heart Failure Society
of America of America http://www.hfsa.org/pdf/faces_card.pdfhttp://www.hfsa.org/pdf/faces_card.pdf
FACES used as a job aid, and to structure FACES used as a job aid, and to structure the Nursing Assessment form and the the Nursing Assessment form and the Nurse Aid WorksheetNurse Aid Worksheet
FACES used as a theme in education and FACES used as a theme in education and trainingtraining
Duke University School of Nursing, 2007, updated 2009
FF Fatigue Fatigue Fast pulseFast pulse
AA Activities of Daily LivingActivities of Daily Living Appetite poorAppetite poor
CC CoughCoughCongestionCongestionConfusionConfusionChest PainChest Pain
EE Edema and weight gainEdema and weight gain Elimination-decreased outputElimination-decreased output
SS Shortness of BreathShortness of Breath
FACES: HEART FAILURE
Signs & Symptoms
Duke University School of Nursing, 2007, updated 2009
Putting new Putting new knowledge/innovations knowledge/innovations
into practice can be difficult…into practice can be difficult… Many changes will not “fit” the Many changes will not “fit” the
system & you need to “work out the system & you need to “work out the bugs” or undergo reinvention before bugs” or undergo reinvention before full-scale implementation.full-scale implementation.
Some projects start out too big & fail Some projects start out too big & fail under their own ambitions or from under their own ambitions or from lack of attention to adoption.lack of attention to adoption.
““Change anxiety” can slow or halt a Change anxiety” can slow or halt a project.project.
Duke University School of Nursing, 2007, updated 2009
Collaborative Learning Collaborative Learning Group ExerciseGroup Exercise
Case example:Case example: High rate of hospitalizations & ER transfers of High rate of hospitalizations & ER transfers of
HF patientsHF patients RN Team Leader approach to implementation RN Team Leader approach to implementation
of a heart failure CPG-based protocol with of a heart failure CPG-based protocol with LPNs & CNAs on the clinical unitLPNs & CNAs on the clinical unit
Divide class into small groups of 5Divide class into small groups of 5 Materials: Materials:
Diffusion of Innovations Attributes WorksheetsDiffusion of Innovations Attributes Worksheets Detailed lesson plan for this experience (link)Detailed lesson plan for this experience (link)
Duke University School of Nursing, 2007, updated 2009
Case SummaryCase Summary You are a recent graduate working as a charge nurse in You are a recent graduate working as a charge nurse in
a small community hospital or nursing home. On your a small community hospital or nursing home. On your 24 bed clinical unit, you work with a team of 3 LPNs 24 bed clinical unit, you work with a team of 3 LPNs and 8 NAs.and 8 NAs.
You observe that there is a high rate of ER transfers You observe that there is a high rate of ER transfers and hospitalizations of heart failure patients. Nursing and hospitalizations of heart failure patients. Nursing staff do not routinely assess or monitor patients and staff do not routinely assess or monitor patients and consider HF an intractable problem that only gets consider HF an intractable problem that only gets worse and requires hospitalization for effective worse and requires hospitalization for effective treatment. treatment.
Based on your knowledge of HF CPGs, you decide that a Based on your knowledge of HF CPGs, you decide that a protocol for early detection of HF S&S would improve protocol for early detection of HF S&S would improve nursing staff’s recognition and reporting of early nursing staff’s recognition and reporting of early indicators would facilitate treatment and prevent acute indicators would facilitate treatment and prevent acute events leading to hospitalization and the negative events leading to hospitalization and the negative consequences for the patient.consequences for the patient.
How would you approach the development and How would you approach the development and implementation of a simple way for all staff to implementation of a simple way for all staff to understand the important indictors for HF monitoring? understand the important indictors for HF monitoring?
Duke University School of Nursing, 2007, updated 2009
Implementing a Protocol Implementing a Protocol for Early Recognition of for Early Recognition of
S&S of Acute HF S&S of Acute HF ExacerbationExacerbation
Small group discussion on the Small group discussion on the individual innovation attributes relative individual innovation attributes relative to the use of the FACES job aid & skill to the use of the FACES job aid & skill development among LPNs and CNAsdevelopment among LPNs and CNAs
Large group discussion to share Large group discussion to share strategies to address barriers & strategies to address barriers & facilitatorsfacilitators
Duke University School of Nursing, 2007, updated 2009
Small Group Exercise: Small Group Exercise: DOI & Innovation DOI & Innovation
Attributes Attributes Analyze attributes of Analyze attributes of
the EBP relative to the the EBP relative to the staff involved in staff involved in implementation & implementation & context of carecontext of care
Divide into 5 groupsDivide into 5 groups Use the DOI Use the DOI
worksheets to analyze worksheets to analyze potential barriers & potential barriers & facilitatorsfacilitators
DOI DOI Worksheets:Worksheets:
1-Relative 1-Relative AdvantageAdvantage
2-2-Compatability Compatability
3-Complexity3-Complexity 4-Trialability4-Trialability 5-5-
ObservabilityObservability
Duke University School of Nursing, 2007, updated 2009
Review:Review: DOI Innovation DOI Innovation AttributesAttributes
Relative advantage-Relative advantage--better than what was -better than what was done before, i.e., sporadic recall of some S&Sdone before, i.e., sporadic recall of some S&S
Compatability-Compatability--consistent with expectations -consistent with expectations & previous practice of risk factor assessment& previous practice of risk factor assessment
Complexity-Complexity-- S&S simplified with a - S&S simplified with a pneumonicpneumonic
Trialability-Trialability--piloted tested several versions & -piloted tested several versions & added new clinically-significant symptomsadded new clinically-significant symptoms
Observability—Observability—developed colorful pocket developed colorful pocket cards, posters, formscards, posters, forms
Duke University School of Nursing, 2007, updated 2009
Large Group DiscussionLarge Group Discussion Each group reports on the innovation Each group reports on the innovation
attribute that they analyzed relative to attribute that they analyzed relative to implementation of the HF protocolimplementation of the HF protocol
Discuss key strategies to - Discuss key strategies to - Raise awareness & understanding, Raise awareness & understanding, Foster positive attitude & commitment to the Foster positive attitude & commitment to the
goal of improving detection of early HF, goal of improving detection of early HF, Build skill & self-efficacy, Build skill & self-efficacy, Promote continuity of carePromote continuity of care Embed new practices into daily routines & Embed new practices into daily routines &
documentation systemsdocumentation systems
Duke University School of Nursing, 2007, updated 2009
ReflectionReflection
How does the DOI model and How does the DOI model and innovation attributes facilitate innovation attributes facilitate implementation of new evidence-implementation of new evidence-based practices?based practices?
Identify Identify 2 leadership strategies2 leadership strategies the the RN can use to persuade LPNs & RN can use to persuade LPNs & CNAs about the advantages of the CNAs about the advantages of the HF protocolHF protocol
Duke University School of Nursing, 2007, updated 2009
Diffusion of InnovationsDiffusion of Innovations
The DOI model provides a framework to The DOI model provides a framework to help help identify barriersidentify barriers among individuals, among individuals,
groups, & at the organizational levelgroups, & at the organizational level target strategiestarget strategies to these subgroups that are to these subgroups that are
more likely to overcome or minimize barriersmore likely to overcome or minimize barriers identify strengths or facilitatorsidentify strengths or facilitators that can be that can be
marshaled to accelerate the change processmarshaled to accelerate the change process The goal is to The goal is to accelerateaccelerate the rate of the rate of
adoption and ensure desired outcomes & adoption and ensure desired outcomes & sustainabilitysustainability
Duke University School of Nursing, 2007, updated 2009
““Innovation never happens as planned.”Innovation never happens as planned.” (Gifford Pinchot. Environmentalist)(Gifford Pinchot. Environmentalist)
You can count on Murhpy’s Law! Even the best laid plans You can count on Murhpy’s Law! Even the best laid plans do not lead to an uncomplicated process of smooth do not lead to an uncomplicated process of smooth implementation. If you expect & plan for set backs or implementation. If you expect & plan for set backs or problems, you are better able to manage them rather than problems, you are better able to manage them rather than be at the mercy of being undermined or halted. be at the mercy of being undermined or halted.
““If you want to make enemies, try to If you want to make enemies, try to change something.”change something.” (Woodrow Wilson)(Woodrow Wilson)
It is important to use various tools & strategies for change.It is important to use various tools & strategies for change.
““If you want to truly understand If you want to truly understand something, try to change it.”something, try to change it.” (Kurt Lewin) (Kurt Lewin) All change involves people with different ideas & goals.All change involves people with different ideas & goals.
Duke University School of Nursing, 2007, updated 2009
Suggested ReadingsSuggested Readings
The classic text: Diffusion of The classic text: Diffusion of Innovations, Innovations, 5th Ed5th Ed. 2003, Everett M. . 2003, Everett M. RogersRogers http://www.amazon.com/exec/obidos/tg/http://www.amazon.com/exec/obidos/tg/
detail/-/0743222091/104-0730562-2628detail/-/0743222091/104-0730562-2628704?v=glance704?v=glance