JONAVolume 42, Number 4, pp 222-230Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Planning for Implementation ofEvidence-Based Practice

Laura Cullen, MA, RN, FAAN

Susan L. Adams, PhD, RN

Expectations for evidence-based healthcare aregrowing, yet the most difficult step in the process,implementation, is often left to busy nursing lead-ers who may be unprepared for the challenge. Se-lecting from the long list of implementation strategiesand knowing when to apply them are a bit of an‘‘art,’’ matching clinician needs and organizationalcontext. This article describes an application-oriented resource that nursing leaders can use toplan evidence-based practice implementation incomplex healthcare systems.

Nurses in leadership positions have responsibility forprovision of evidence-based healthcare that meetsthe expectations of patients, families, regulators andothers.1-3 Research shows that use of evidence isinconsistent. Basic practices from hand hygiene toearly ambulation are difficult to implement. Nurs-ing leaders are expanding use of evidence-based caredelivery to improve patient and organizational out-comes by developing the infrastructure, defining theprocesses, strategically planning for implementation,and reporting results.

One of the 1st steps when defining the pro-cess is to select an evidence-based practice (EBP)model.4,5 Several models have been developed to

guide organizational and project leaders throughthe steps of the EBP process.6-10 Most of these pro-cess models include similar steps such as identifyinga problem, critiquing the evidence, implementingevidence-based recommendations, evaluating thechange, and disseminating results. Despite exten-sive use of EBP process models, it is understood thatadditional guidance may be needed at each step. Re-cent attention is now focusing on the indistinct stepof implementation.11-14

Failure to provide guidance for use of effectiveimplementation strategies promotes the use of in-effective strategies, or worse, no strategy at all. Thisresults in ‘‘reduced patient care quality and raisescosts for all, the worst of both worlds.’’15(p380) It hasbeen demonstrated that change happens over time;the literature provides little direction for nurses re-garding when to use specific strategies. Insights fromimplementation science and successful EBP work in-dicate that application of implementation strategiesvaries over the course of the EBP process. Assistingnurses at the point of care in leading EBP projects16

has led to creation of a 4-phase approach for plan-ning implementation.16

This article provides clinicians and nursing lead-ers with an application-oriented approach to orga-nize, plan, and select strategies for implementation ofEBP changes. This guide is meant to supplement EBPprocess models, not replace them. It is designed to besimple and intuitive.

Implementation Strategies forEvidence-Based Practice

The Implementation Strategies for Evidence-BasedPractice guide (Figure 1) is organized to assist nursesresponsible for EBP in selecting implementationstrategies to help practitioners and clinical teams

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Author Affiliations: Evidence Based Practice Coordinator(Ms Cullen), Department of Nursing Services and Patient Care,University of Iowa Hospital and Clinics; Investigator (Dr Adams),Comprehensive Access and Delivery Research and EvaluationCenter, Iowa City VA Medical Center.

The views expressed in this article are those of the authorsand do not necessarily reflect the position or policy of the De-partment of Veterans Affairs.

The authors declare no conflict of interest.Correspondence: Ms Cullen, Department of Nursing Services

and Patient Care, 200 Hawkins Dr, RM T100 GH, Iowa City, IA52242-1009 (Laura-cullen@uiowa.edu).

DOI: 10.1097/NNA.0b013e31824ccd0a

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

move clinical practice recommendations into routineworkflow in practice. Strategies are selected and po-sitioned to enhance the movement through 4 phasesof implementation: creating awareness and interest,building knowledge and commitment, promoting

action and adoption, and pursuing integration andsustainability to promote application by nursing andteam leaders.

The implementation phases are displayed as col-umns progressing from awareness to integration.

Figure 1. Evidence-Based Practice Implementation guide. *Implementation strategy supported by some empirical evidence.

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Each column includes strategies based on the goal forthat implementation phase. Implementation strat-egies also target 2 distinct groups and are arranged inrows accordingly. The 1st section specifically targetsthe practitioners and organizational leaders, includ-ing key stakeholders. The 2nd section builds supportfor the practice change in the organizational systemor context. Project leaders select implementation strat-egies that are appropriate for their particular unitand organization as the EBP initiative progressesacross phases. Although the guide is diagrammed ina linear format for ease of use, the process is notdirectly linear and is fluid across implementationphases. In a clinical team, practitioners may be indifferent phases or move forward or back acrossphases in a nonlinear manner. Multiple strategiesadded cumulatively from each phase will need to becarried over for use throughout the process to keepimplementation progressing.

A large list of strategies is included (Figure 1),and with varying amount of evidence to supportthem. The implementation strategies with empiricalevidence in healthcare are marked with asterisks.Few strategies have empirical evidence using rig-orous study designs with additional support fromreported application in practice or exclusively ad-dressing nursing; therefore, other practical but lesswell-tested strategies to support application are in-cluded as well. Because research evaluation of strat-egies across a variety of healthcare settings and withvarious healthcare workers is lacking, a simplifiedsystem of identification is used instead of an exten-sive grading schema.

Creating Awareness and Interest

Implementation begins by focusing on strategies tocreate awareness and interest among clinicians andstakeholders (column 1, Figure 1). These suggestedstrategies should be started early in the EBP pro-cess and will likely be needed to some degree duringthe implementation and sustainment phases. Interestwanes over time because of competing demands andstaff turnover. Multifaceted, ongoing strategies areneeded to keep the practice change in the forefront.

Highlighting the positive characteristics of anEBP change such as the anticipated advantage ofthe change and the compatibility with group valuescan promote awareness and interest among clini-cians.17-19 Staff attendance at continuing educa-tional programs20 increases awareness and interestin practice updates in general. Nurse leaders cancontinue garnering resources to support these pro-fessional development activities with applicationfor practice. Integrating a journal club into the im-plementation process by choosing multiple, high-

quality, project-related articles can serve a dualpurpose: expanding nurses’ interest and knowledgeregarding the desired practice change while ad-vancing article critiquing skills.21 Journal club re-view of articles on a single clinical topic can be usedto guide policy updates, staff education, and auditingof important indicators to improve care.

Although empirical evidence is limited, creatingslogans and logos can be a successful and fun way tograb the attention of busy clinicians.22,23 Creating acontest to generate ideas for project slogans can getstaff involved, increasing their awareness and com-mitment to practice changes. Strategically placingproject logos and slogans on project-related materialsthroughout implementation (eg, resource manualor materials, reminders, and data feedback) helpsbusy clinicians quickly refocus on the EBP and theirrole in promoting adoption of the practice change.24

Posting announcements may generate awareness ofa particular practice update, but require additionalreinforcement, for example, supplementing with dis-cussions during unit in-services or staff meetings.

Involve senior executives early in the EBP process.Senior leaders want to be supportive of clinician-driven EBP and need sufficient information aboutthe purpose, resource needs, and anticipated returnon investment. Leadership from senior executiveshas a demonstrated impact on uptake and sustaineduse of EBP recommendations.1,25-27 Announcementsfrom senior leaders create an urgency about an issue,articulate an organizational commitment, and dem-onstrate the availability of resources and supportthat an impact is expected matching organizationalpriorities.

Building Knowledge and Commitment

Interventions that increase practitioner’s knowl-edge of and commitment to try a clinical practicerecommendation are designed to build on the aware-ness and interest raised in phase 1. For example,comparing organizational outcomes to those de-scribed in the literature through a gap assessmentand discussed during unit meetings or journal clubsfrom phase 1 increases clinician’s knowledge andcommitment by highlighting the gap in desiredperformance. Like raising awareness and interest,increasing knowledge and commitment requires mul-tifaceted ongoing attention.

Educational sessions are a necessary step inraising knowledge and commitment but must becombined with other strategies to be effective.28

Educational sessions can use a variety of methodsfrom unit in-services, readings, or online learningmodules to simulation training. One method of in-teractive education that leverages nurses’ preference

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to learn from their colleagues29-31 is to engage andtrain change agents. There are many different changeagent roles32 described in the literature, includinginternal and external facilitators, change champions,core groups, knowledge brokers, thought leaders,and opinion leaders (Table 1).32,34-37 In general, thechange agent role involves sharing information andsupporting practice changes with colleagues and mayvary based on the size of the unit. Our experienceindicates that the roles are not well understood byclinicians. Identifying change agents early, obtainingtheir support, providing education regarding thepractice change, and clarifying their roles facilitateeffective use of team members’ strengths and con-nections in the organization.

Identifying change agents from each disciplinerelevant to the clinical topic at hand can build com-mitment to change. For example, if the goal is toincrease hand hygiene, including change agents frominfection prevention specialists or epidemiology, mi-crobiology personnel, nurses, nursing assistants, phy-sicians, and someone from inventory supply wouldbe helpful. Including facility services, the unit sec-retary, and housekeeping may be important so thatthe correct equipment (ie, a full dispenser) is alwaysreadily available and positioned in accordance withsafety standards. Core group members can serve as

change agents.37 Having a core group of trainedchange agents available to cover all shifts meetsclinicians’ needs and builds expertise as cliniciansseek answers through interactions with colleagues.

Unlike strict research protocols, clinical prac-tice guidelines are designed to be locally adapted toindividual settings. Teams can modify them for useto create a local practice protocol.38-40 Focusing onkey steps that are critical promotes adoption by sim-plifying the change.18,41 Articulating how the EBPwas simplified to assist clinician users can promotecommitment to practice changes.

Building knowledge and commitment providesan essential foundation for promoting action andadoption of the EBP change. Planning for implemen-tation should be based on a timeline allowing for afocused effort, building practitioners’ knowledge andcommitment before proceeding to the next phase ofimplementation. If the clinical practice recommen-dations are to be piloted in a setting that involves asmall number of practitioners (eg, a rural clinic),it may be possible to move more quickly throughthis phase. If the practice change involves a largenumber of practitioners from multiple disciplines,covering many shifts, plan for 2 to 3 weeks to helpclinicians gain sufficient knowledge and to garnertheir commitment to the practice change. This phase

Table 1. Change Agent Roles

Name Perspective Educational Role Impact

Change champion Focus is local and is frominside the organization

Review evidence, design practicechange (eg, policy), assist withcreating resources forimplementation, train peers

Assists project leader and linksevidence with reality ofclinical practice

Core group Focus is local and is fromsetting adopting the EBP

Review key evidence, train,role model, reinforce, andtrouble shoot with colleagues

Point-of-care learning

EBP facilitator/mentor Broad program focus maybe from inside or outsidethe organization

Provide leadership throughoutEBP process

Mentoring of or functioning asproject director

Knowledge broker Broad program focus fromoutside the organization

Assess facilitators and barriers,locate best evidence, train,network, mentor, andreport results

Leading and connecting withproject director(s)

Opinion leader Focus is on the program andacross the continuumof care from insidethe organization

Review evidence and judge fit,peer education, influencepractice of others

Peer influence

Thought leader Focus is local and may befrom inside or outsidethe organization

Provide educational sessions Program preparation influencespractice change of theeducator; little impact onaudience is anticipated

Emerging concept yet to betested in healthcare

Dobbins et al,33 Doumit et al,34 Greenhalgh et al,32 Russell et al,35 Stetler et al,36 and Titler.37

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of implementation should be clearly articulatedwith a designated go-live date approaching in thefuture.

Promoting Action and Adoption

After raising awareness, promoting positive atti-tudes, and building knowledge about the change,the next imperative is to change behavior and putrecommendations into practice. What has beendescribed as the implementation phase of an EBPprocess is essentially the behavior change point inthe multiple phases of implementation. Interven-tions to promote action or adoption need to movefrom active to interactive and target the cliniciansso they develop skills in use of the practice change.Training, role modeling, and mentoring by changeagents are essential elements of the implementationplan.16,20,36,42-44 Follow-up from unit leaders andproject change agents is needed for troubleshoot-ing, reinforcing the desired behavior, and providingrecognition at the point of care for correctly andconsistently applying practice recommendations.

Practical strategies such as practice prompts pro-mote behavior change by providing timely remind-ers in the practice setting at the point of care. Practiceprompts can be sophisticated clinical informationsystem reminders incorporated in the electronichealth record (EHR) or as simple as a pocket guidewith a logo containing key talking points.45-47 AsEHR technology develops, additional innovationswill create ways to hardwire provision of some clin-ical practice recommendations (eg, influenza vacci-nations or medication infusion dosages) by requiringjustification of variations in practice (eg, skippingtimed pediatric immunizations). Creating patient re-minders, clinical checklists, and standing orders buildssupport in the system and effectively sets parametersfor successful use of EBP.48-52

The action and adoption phase of implemen-tation will require several weeks to complete. Dur-ing this phase, clinicians are testing practice changes,finding ways to integrate new practices into work-flow, adapting the practice for unique patient circum-stances, and doing small-scale evaluation.53 Severalweeks are needed for progressive uptake of the EBPwhen change agents are actively promoting adoption,and practitioners are trying the change. Continueduse of implementation strategies must occur through-out this phase as early and late adopters progress atvarying rates. Participation can be encouraged byhaving early adopters provide timely feedback onpositive results. Active implementation strategiesmay be used more sporadically after early adopterscreate sufficient momentum promoting the practicechange. Audits with actionable and timely data

feedback of results are essential and highly effectivefor both adoption and integration of practice changeby building support in the organizational system.54,55

Timing should allow for trying and using the EBPchange before full evaluation of process and outcomeindicators.

Some clinicians lag in action and adoption.Highly interactive and individualized feedback willbe needed for clinicians working through adoptionwhile the group is moving toward integration andsustainability of practice changes. Late adopterswill be watching the early adopters’ progress andslowly become active adopters. Clear expectationsand administrative follow-up through the perfor-mance evaluation process will facilitate action. If asmall group of clinicians are slower to adopt prac-tice recommendations, we have found that involv-ing a group leader from the late adopters in planningand troubleshooting implementation early may behelpful. Late adopters may provide important in-sights into issues and propose possible solutionswhen designing and localizing clinical practice rec-ommendations. In the end, noncompliance becomesthe responsibility of administrators.

Pursuing Integration and Sustainability

In order to achieve a return on investment fromworking through the EBP process, it is essential torealize integration and sustained use of the EBPchange.26,56,57 Celebrating successes through seniorleadership recognition in public forums supports shif-ting expectations and group norms or standardoperating procedures. Creating peer-to-peer discus-sions articulating expectations (ie, peer influence)and using comparative data are likely to be ef-fective. Reinfusion will be needed through the earlymonths of integration to sustain the gains alreadyachieved. Updating postings and practice reminderskeep the message fresh and in the forefront. Postersleft for extended periods tend to become invisible,so content and strategies must be updated to attractthe attention of busy clinicians (eg, update picturesand key points, add names of successful staff).Early and active planning for reinfusion and sustain-ability is highly recommended to prevent slippage,loss of early progress, or loss of momentum for chang-ing practice.

Integration of clinical practice recommendationsinto daily care requires additional strategies by theclinical team and senior leaders, including strategiesbuilt in the social system matching the organizationalculture. Reporting results of project implementa-tion and revisions based on evaluative data andpractitioner feedback can facilitate additional com-mitment to sustained use of new practices. Graphic

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displays of key indicators may be helpful.58 Reportingand feedback of trended data support progressiveintegration and positive reinforcement for practi-tioners59,60 and assist with quick identification ofthe need to reinfuse the EBP.

After trying and implementing the practicechange, final revisions in policies, procedures, orprotocols are needed.25,61 Project leader reportingof activity and results should target committees inthe infrastructure responsible for policy approval,documentation, staff education, quality improve-ment, EBP, and product inventory.27,62,63 Reportsto senior leaders should include the project pur-pose; use of the EBP process; impact or return onthe investment; link between the project results,

organizational priorities, and infrastructure sup-porting the EBP change. Communicating with seniorleaders is strategic for garnering reinforcement, rec-ognition, and future resources.

Building the practice change in the organiza-tional system requires use of additional strategiesto promote sustainability. Financial incentives,64,65

awards, recognition,66,67 and support establish thenew norms for practice. Incorporating the practicechange in the competency review process and ob-taining individual commitments to 1 or 2 actionsduring staff performance evaluations help to sup-port unit goals and create continuous reinfusionand momentum. Building responsibility for ongoingEBP work in a new or existing unit or organizational

Table 2. Implementation Strategies Used in Different Clinical Area Projects

Planning Phase

Strategies Used for Perioperative EBP Strategies Used for Emergency Department EBP

Implementing PreoperativeScreening for Sleep Apnea

Thermoregulation forAdult Trauma Patients

Create awarenessand interest

& Highlight the advantages andanticipated impact

& Highlight the advantages and anticipated impact

& Staff meetings& Slogan and logo

& Unit in-services& Staff meetings

& Postings& Unit in-services& Postings

Build knowledgeand commitment

& Education & Education& Link with quality improvement priorities & Link practice change with stakeholders priorities& Change champion & Change agents& Integrate with other policies & Disseminate credible evidence& Clinician input & Gap assessment& Local adaptation & Clinician input& Case study & Match the practice change with equipment& Teamwork & Resource manual& Trouble shooting implementation & Teamwork& Informed organizational leaders & Troubleshoot use of the protocol& Action planning & Inform organizational leaders

& Action planning

Promote actionand adoption

& Educational outreach & Educational outreach& Clinical reminders & Reminders or practice prompts& Demonstrating workflow & Decision algorithm& Feedback evaluation results & Skill competency& Trying the change & Incentives& Multidisciplinary teamwork and discussions & Trying the practice change& Report progress and updates & Reporting progress& Change agents & Change agents& Troubleshooting by change champions at the

point of care& Role modeling practice change

& Documentation changes& Change agents provide trouble shooting and

recognition at point of care& Rounding by unit leaders & Audit and feedback of evaluative data& Report into quality improvement program & Rounding by unit leaders& Report to senior leadership & Report into the quality improvement program

Pursue integrationand sustained use

& Recognition for change & Personalize the messages& Update reminders & Peer influence& Report within quality improvement program & Update practice reminders& Trend results & Report to senior leaders& Presenting at educational programs & Project responsibility within unit quality

improvement committee& Present in educational programs

Used with permission from Block et al22 and Dolezal et al.68

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committee will keep responsibility for the work clearand a priority supported in the infrastructure. Mul-tiple strategies are needed to move from awarenessto integration and should target clinicians, organi-zational leaders, and the social system.

How to Select Implementation Strategies

When planning for EBP implementation, a nursingleader should ask several questions:

� What EBP changes have been successfully im-plemented previously? How were those prac-tice changes implemented?

� Who are stakeholders or others who mightbe interested in this EBP? What is the po-tential impact or advantage for them? Whatare their priorities, and how can those be ad-dressed? How can the process be simplifiedand built into the system to make adoptioneasier for them?

� What are barriers and facilitators to adoptionof EBP? What creative solutions can addressthe barriers and/or optimize the facilitators?

� What information or data are the cliniciansand stakeholders accustomed to seeing? Whatinformation or data are typically shared withEBP changes?

� How can we make this fun?� How can we design messages for clinicians

and leaders describing the EBP that includescredible evidence, why the change is impor-tant, what the EBP change will look like, andwhat are the expected outcomes?

Answers to these questions provide directionfor choosing from among the implementation strat-egies listed. Choose and use implementation strat-egies cumulatively from the early phases throughthe implementation process. Highlighting the poten-tial advantage, key evidence, project logo, and resultsof a gap analysis throughout the implementation

process helps busy clinicians stay focused. These ques-tions can be revisited while adding strategies acrosseach phase of the implementation process. EBP projectsin various clinical areas may use different implemen-tation strategies; flexibility is key (Table 2).22,68

Implementation is fluid, complex, highly inter-active, and impacted by contextual variations. Pre-scriptive and rigid timing of strategies may never beappropriate.69 Critical thinking skills of nurses inevaluating and adapting strategies to the chang-ing conditions in the clinical setting will continueto be required. Team leaders will almost certainlyneed to adjust or add implementation strategies asthe work progresses. Wensing et al69 describe se-lection of implementation strategies as an ‘‘art,’’ stat-ing that ‘‘research-based evidence can provide someguidance but cannot show decisively which inter-vention is most appropriate,’’ yet a structured ap-proach to selecting implementation strategies maybe helpful.69(pE85)

Conclusion

Implementation science is an emerging field withfew randomized controlled trials across healthcaresettings where nurses work. However, there is agrowing body of important research showing theimpact of a variety of implementation strategies onnurse-sensitive outcomes.28,51,57,69,70 ImplementingEBP change is difficult; consequently, nursing leadersmust use effective implementation strategies to en-gage clinicians and promote adoption of evidence-based care delivery to improve patient outcomes.Using the Evidence-Based Practice Implementationguide to select implementation strategies adds clarityto a critical and often undeveloped step in the EBPprocess. While gaps remain in our knowledge, thisguide offers a valuable addition to practice by pro-viding an application-oriented approach for planningimplementation using evidence-based implementa-tion strategies.

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