Chapter 7. The Evidence for Evidence-Based Practice 

Implementation 

Marita G. Titler 

Background 

Overview of Evidence-Based Practice 

Evidence-based health care practices are available for a number of conditions such as asthma, 

heart failure, and diabetes. However, these practices are not always implemented in care 

delivery, and variation in practices abound.1–4 Traditionally, patient safety research has focused 

on data analyses to identify patient safety issues and to demonstrate that a new practice will lead 

to improved quality and patient safety.5 Much less research attention has been paid to how to 

implement practices. Yet, only by putting into practice what is learned from research will care be 

made safer.5 Implementing evidence-based safety practices are difficult and need strategies that 

address the complexity of systems of care, individual practitioners, senior leadership, and—

ultimately—changing health care cultures to be evidence-based safety practice environments.5 

Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6–

9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated 

by Nightingale,10 the nursing profession has more recently provided major leadership for 

improving care through application of research findings in practice.11 

Evidence-based practice (EBP) is the conscientious and judicious use of current best 

evidence in conjunction with clinical expertise and patient values to guide health care 

decisions.12–15 Best evidence includes empirical evidence from randomized controlled trials; 

evidence from other scientific methods such as descriptive and qualitative research; as well as 

use of information from case reports, scientific principles, and expert opinion. When enough 

research evidence is available, the practice should be guided by research evidence in conjunction 

with clinical expertise and patient values. In some cases, however, a sufficient research base may 

not be available, and health care decisionmaking is derived principally from nonresearch 

evidence sources such as expert opinion and scientific principles.16 As more research is done in a 

specific area, the research evidence must be incorporated into the EBP.15

Models of Evidence-Based Practice

Multiple models of EBP are available and have been used in a variety of clinical settings.16–36

Although review of these models is beyond the scope of this chapter, common elements of these 

models are selecting a practice topic (e.g., discharge instructions for individuals with heart 

failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient 

care and provider performance, and consideration of the context/setting in which the practice is 

implemented.15, 17 The learning that occurs during the process of translating research into 

practice is valuable information to capture and feed back into the process, so that others can 

adapt the evidence-based guideline and/or the implementation strategies.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

A recent conceptual framework for maximizing and accelerating the transfer of research 

results from the Agency for Healthcare Research and Quality (AHRQ) patient safety research 

portfolio to health care delivery was developed by the dissemination subcommittee of the AHRQ 

Patient Safety Research Coordinating Committee.37 This model is a synthesis of concepts from 

scientific information on knowledge transfer, social marketing, social and organizational 

innovation, and behavior change (see Figure 1).37 Although the framework is portrayed as a 

series of stages, the authors of this framework do not believe that the knowledge transfer process 

is linear; rather, activities occur simultaneously or in different sequences, with implementation of 

EBPs being a multifaceted process with many actors and systems.

Steps of Evidence-Based Practice 

Steps of promoting adoption of EBPs can be viewed from the perspective of those who 

conduct research or generate knowledge,23, 37 those who use the evidence-based information in 

practice,16, 31 and those who serve as boundary spanners to link knowledge generators with 

knowledge users.19 

Steps of knowledge transfer in the AHRQ model37 represent three major stages: (1) 

knowledge creation and distillation, (2) diffusion and dissemination, and (3) organizational 

adoption and implementation. These stages of knowledge transfer are viewed through the lens of 

researchers/creators of new knowledge and begin with determining what findings from the 

patient safety portfolio or individual research projects ought to be disseminated. 

Knowledge creation and distillation is conducting research (with expected variation in 

readiness for use in health care delivery systems) and then packaging relevant research findings 

into products that can be put into action—such as specific practice recommendations—thereby 

increasing the likelihood that research evidence will find its way into practice.37 It is essential 

that the knowledge distillation process be informed and guided by end users for research findings 

to be implemented in care delivery. The criteria used in knowledge distillation should include 

perspectives of the end users (e.g., transportability to the real-world health care setting, 

feasibility, volume of evidence needed by health care organizations and clinicians), as well as 

traditional knowledge generation considerations (e.g., strength of the evidence, generalizability). 

Diffusion and dissemination involves partnering with professional opinion leaders and health 

care organizations to disseminate knowledge that can form the basis of action (e.g., essential 

elements for discharge teaching for hospitalized patient with heart failure) to potential users. 

Dissemination partnerships link researchers with intermediaries that can function as knowledge 

brokers and connectors to the practitioners and health care delivery organizations. Intermediaries 

can be professional organizations such as the National Patient Safety Foundation or 

multidisciplinary knowledge transfer teams such as those that are effective in disseminating 

research-based cancer prevention programs. In this model, dissemination partnerships provide an 

authoritative seal of approval for new knowledge and help identify influential groups and 

communities that can create a demand for application of the evidence in practice. Both mass 

communication and targeted dissemination are used to reach audiences with the anticipation that 

early users will influence the latter adopters of the new usable, evidence-based research findings. 

Targeted dissemination efforts must use multifaceted dissemination strategies, with an emphasis 

on channels and media that are most effective for particular user segments (e.g., nurses, 

physicians, pharmacists). 

End user adoption, implementation, and institutionalization is the final stage of the 

knowledge transfer process.37 This stage focuses on getting organizations, teams, and individuals 

2 
Evidence-Based Practice Implementation

to adopt and consistently use evidence-based research findings and innovations in everyday 

practice. Implementing and sustaining EBPs in health care settings involves complex 

interrelationships among the EBP topic (e.g., reduction of medication errors), the organizational 

social system characteristics (such as operational structures and values, the external health care 

environment), and the individual clinicians.35, 37–39 A variety of strategies for implementation 

include using a change champion in the organization who can address potential implementation 

challenges, piloting/trying the change in a particular patient care area of the organization, and 

using multidisciplinary implementation teams to assist in the practical aspects of embedding 

innovations into ongoing organizational processes.35, 37 Changing practice takes considerable 

effort at both the individual and organizational level to apply evidence-based information and 

products in a particular context.22 When improvements in care are demonstrated in the pilot 

studies and communicated to other relevant units in the organization, key personnel may then 

agree to fully adopt and sustain the change in practice. Once the EBP change is incorporated into 

the structure of the organization, the change is no longer considered an innovation but a standard 

of care.22, 37 

In comparison, other models of EBP (e.g., Iowa Model of Evidence-based Practice to 

Promote Quality of Care16) view the steps of the EBP process from the perspective of clinicians 

and/or organizational/clinical contexts of care delivery. When viewing steps of the EBP process 

through the lens of an end user, the process begins with selecting an area for improving care 

based on evidence (rather than asking what findings ought to be disseminated); determining the 

priority of the potential topic for the organization; formulating an EBP team composed of key 

stakeholders; finding, critiquing, and synthesizing the evidence; setting forth EBP 

recommendations, with the type and strength of evidence used to support each clearly 

documented; determining if the evidence findings are appropriate for use in practice; writing an 

EBP standard specific to the organization; piloting the change in practice; implementing changes 

in practice in other relevant practice areas (depending on the outcome of the pilot); evaluating 

the EBP changes; and transitioning ongoing quality improvement (QI) monitoring, staff 

education, and competency review of the EBP topic to appropriate organizational groups as 

defined by the organizational structure.15, 40 The work of EBP implementation from the 

perspective of the end user is greatly facilitated by efforts of AHRQ, professional nursing 

organizations (e.g., Oncology Nursing Society), and others that distill and package research 

findings into useful products and tools for use at the point of care delivery. 

When the clinical questions of end users can be addressed through use of existing evidence 

that is packaged with end users in mind, steps of the EBP process take less time and more effort 

can be directed toward the implementation, evaluation, and sustainability components of the 

process. For example, finding, critiquing, and synthesizing the evidence; setting forth EBP 

recommendations with documentation of the type and strength of evidence for each 

recommendation; and determining appropriateness of the evidence for use in practice are 

accelerated when the knowledge-based information is readily available. Some distilled research 

findings also include quick reference guides that can be used at the point of care and/or 

integrated into health care information systems, which also helps with implementation.41, 42 

Translation Science: An Overview 

Translation science is the investigation of methods, interventions, and variables that 

influence adoption by individuals and organizations of EBPs to improve clinical and operational 

decisionmaking in health care.35, 43–46 This includes testing the effect of interventions on 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

promoting and sustaining adoption of EBPs. Examples of translation studies include describing 

facilitators and barriers to knowledge uptake and use, organizational predictors of adherence to 

EBP guidelines, attitudes toward EBPs, and defining the structure of the scientific field.11, 47–49 

Translation science must be guided by a conceptual model that organizes the strategies being 

tested, elucidates the extraneous variables (e.g., behaviors and facilitators) that may influence 

adoption of EBPs (e.g., organizational size, characteristics of users), and builds a scientific 

knowledge base for this field of inquiry.15, 50 Conceptual models used in the translating-researchinto-practice studies funded by AHRQ were adult learning, health education, social influence, 

marketing, and organizational and behavior theories.51 Investigators have used Rogers’s 

Diffusion of Innovation model,35, 39, 52–55 the Promoting Action on Research Implementation in 

Health Services (PARIHS) model,29 the push/pull framework,23, 56, 57 the decisionmaking 

framework,58 and the Institute for Healthcare Improvement (IHI) model59 in translation science.

Study findings regarding evidence-based practices in a diversity of health care settings are 

building an empirical foundation of translation science.19, 43, 51, 60–83 These investigations and 

others18, 84–86 provide initial scientific knowledge to guide us in how to best promote use of 

evidence in practice. To advance knowledge about promoting and sustaining adoption of EBPs in 

health care, translation science needs more studies that test translating research into practice 

(TRIP) interventions: studies that investigate what TRIP interventions work, for whom, in what 

circumstances, in what types of settings; and studies that explain the underlying mechanisms of 

effective TRIP interventions.35, 49, 79, 87 Partnership models, which encourage ongoing interaction 

between researchers and practitioners, may be the way forward to carry out such studies.56

Challenges, issues, methods, and instruments used in translation research are described 

elsewhere.11, 19, 49, 78, 88–97

Research Evidence

What Is Known About Implementing Evidence-Based Practices? 

Multifaceted implementation strategies are needed to promote use of research evidence in 

clinical and administrative health care decisionmaking.15, 22, 37, 45, 64, 72, 77, 79, 98, 99 Although 

Grimshaw and colleagues65 suggest that multifaceted interventions are no more effective than 

single interventions, context (site of care delivery) was not incorporated in the synthesis 

methodology. As noted by others, the same TRIP intervention may meet with varying degrees of 

effectiveness when applied in different contexts.35, 49, 79, 80, 87, 100, 101 Implementation strategies 

also need to address both the individual practitioner and organizational 

perspective.15, 22, 37, 64, 72, 77, 79, 98 When practitioners decide individually what evidence to use in 

practice, considerable variability in practice patterns result,71 potentially resulting in adverse 

patient outcomes. 

For example, an “individual” perspective of EBP would leave the decision about use of 

evidence-based endotracheal suctioning techniques to each nurse and respiratory therapist. Some 

individuals may be familiar with the research findings for endotracheal suctioning while others 

may not. This is likely to result in different and conflicting practices being used as people change 

shifts every 8 to 12 hours. From an organizational perspective, endotracheal suctioning policies 

and procedures based on research are written, the evidence-based information is integrated into 

the clinical information systems, and adoption of these practices by nurses and other practitioners 

is systematically promoted in the organization. This includes assuring that practitioners have the 

4 
Evidence-Based Practice Implementation

necessary knowledge, skills, and equipment to carry out the evidence-based endotracheal 

suctioning practice. The organizational governance supports use of these practices through 

various councils and committees such as the Practice Committee, Staff Education Committee, 

and interdisciplinary EBP work groups.

The Translation Research Model,35 built on Rogers’s seminal work on diffusion of 

innovations,39 provides a guiding framework for testing and selecting strategies to promote 

adoption of EBPs. According to the Translation Research Model, adoption of innovations such 

as EBPs are influenced by the nature of the innovation (e.g., the type and strength of evidence, 

the clinical topic) and the manner in which it is communicated (disseminated) to members 

(nurses) of a social system (organization, nursing profession).35 Strategies for promoting 

adoption of EBPs must address these four areas (nature of the EBP topic; users of the evidence; 

communication; social system) within a context of participative change (see Figure 2). This 

model provided the framework for a multisite study that tested the effectiveness of a multifaceted 

TRIP intervention designed to promote adoption of evidence-based acute pain management 

practices for hospitalized older adults. The intervention improved the quality of acute pain 

management practices and reduced costs.81 The model is currently being used to test the 

effectiveness of a multifaceted TRIP intervention to promote evidence-based cancer pain 

management of older adults in home hospice settings.* This guiding framework is used herein to 

overview what is known about implementation interventions to promote use of EBPs in health 

care systems (see Evidence Table).

Nature of the Innovation or Evidence-Based Practice 

Characteristics of an innovation or EBP topic that affect adoption include the relative 

advantage of the EBP (e.g., effectiveness, relevance to the task, social prestige); the 

compatibility with values, norms, work, and perceived needs of users; and complexity of the 

EBP topic.39 For example, EBP topics that are perceived by users as relatively simple (e.g., 

influenza vaccines for older adults) are more easily adopted in less time than those that are more 

complex (acute pain management for hospitalized older adults). Strategies to promote adoption 

of EBPs related to characteristics of the topic include practitioner review and “reinvention” of 

the EBP guideline to fit the local context, use of quick reference guides and decision aids, and 

use of clinical reminders.53, 59, 60, 65, 74, 82, 102–107 An important principle to remember when 

planning implementation of an EBP is that the attributes of the EBP topic as perceived by users 

and stakeholders (e.g., ease of use, valued part of practice) are neither stable features nor sure 

determinants of their adoption. Rather it is the interaction among the characteristics of the EBP 

topic, the intended users, and a particular context of practice that determines the rate and extent 

of adoption.22, 35, 39 

Studies suggest that clinical systems, computerized decision support, and prompts that 

support practice (e.g., decisionmaking algorithms, paper reminders) have a positive effect on 

aligning practices with the evidence base.15, 51, 65, 74, 80, 82, 102, 104, 107–110 Computerized knowledge 

management has consistently demonstrated significant improvements in provider performance 

and patient outcomes.82 Feldman and colleagues, using a just-in-time e-mail reminder in home 

health care, have demonstrated (1) improvements in evidence-based care and outcomes for 

patients with heart failure,64, 77 and (2) reduced pain intensity for cancer patients.75 Clinical 

information systems should deploy the evidence base to the point of care and incorporate 

 

*

 Principal Investigator: Keela Herr (R01 grant no. CA115363-01; National Cancer Institute (NCI)) 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

computer decision-support software that integrates evidence for use in clinical decisionmaking 

about individual patients.40, 104, 111–114 There is still much to learn about the “best” manner of 

deploying evidence-based information through electronic clinical information systems to support 

evidence-based care.115 

Methods of Communication

Interpersonal communication channels, methods of communication, and influence among 

social networks of users affect adoption of EBPs.39 Use of mass media, opinion leaders, change 

champions, and consultation by experts along with education are among strategies tested to 

promote use of EBPs. Education is necessary but not sufficient to change practice, and didactic 

continuing education alone does little to change practice behavior.61, 116 There is little evidence 

that interprofessional education as compared to discipline-specific education improves EBP.117 

Interactive education, used in combination with other practice-reinforcing strategies, has more 

positive effects on improving EBP than didactic education alone.66, 68, 71, 74, 118, 119 There is 

evidence that mass media messages (e.g., television, radio, newspapers, leaflets, posters and 

pamphlets), targeted at the health care consumer population, have some effect on use of health 

services for the targeted behavior (e.g., colorectal cancer screening). However, little empirical 

evidence is available to guide framing of messages communicated through planned mass media 

campaigns to achieve the intended change.120 

Several studies have demonstrated that opinion leaders are effective in changing behaviors of 

health care practitioners,22, 68, 79, 100, 116, 121–123 especially in combination with educational 

outreach or performance feedback. Opinion leaders are from the local peer group, viewed as a 

respected source of influence, considered by associates as technically competent, and trusted to 

judge the fit between the innovation and the local situation.39, 116, 121, 124–127 With their wide 

sphere of influence across several microsystems/units, opinion leaders’ use of the innovation 

influences peers and alters group norms.39,128 The key characteristic of an opinion leader is that 

he or she is trusted to evaluate new information in the context of group norms. Opinion 

leadership is multifaceted and complex, with role functions varying by the circumstances, but 

few successful projects to implement innovations in organizations have managed without the 

input of identifiable opinion leaders.22, 35, 39, 81, 96 Social interactions such as “hallway chats,” 

one-on-one discussions, and addressing questions are important, yet often overlooked 

components of translation.39, 59 Thus, having local opinion leaders discuss the EBPs with 

members of their peer group is necessary to translate research into practice. If the EBP that is 

being implemented is interdisciplinary in nature, discipline-specific opinion leaders should be 

used to promote the change in practice.39 

Change champions are also helpful for implementing innovations.39, 49, 81, 129–131 They are 

practitioners within the local group setting (e.g., clinic, patient care unit) who are expert 

clinicians, passionate about the innovation, committed to improving quality of care, and have a 

positive working relationship with other health care professionals.39, 125, 131, 132 They circulate 

information, encourage peers to adopt the innovation, arrange demonstrations, and orient staff to 

the innovation.49, 130 The change champion believes in an idea; will not take “no” for an answer; 

is undaunted by insults and rebuffs; and, above all, persists.133 Because nurses prefer 

interpersonal contact and communication with colleagues rather than Internet or traditional 

sources of practice knowledge,134–137 it is imperative that one or two change champions be 

identified for each patient care unit or clinic where the change is being made for EBPs to be 

enacted by direct care providers.81, 138 Conferencing with opinion leaders and change champions 

6 
Evidence-Based Practice Implementation

periodically during implementation is helpful to address questions and provide guidance as 

needed.35, 66, 81, 106 

Because nurses’ preferred information source is through peers and social interactions,134–

137, 139, 140 using a core group in conjunction with change champions is also helpful for 

implementing the practice change.16, 110, 141 A core group is a select group of practitioners with 

the mutual goal of disseminating information regarding a practice change and facilitating the 

change by other staff in their unit/microsystem.142 Core group members represent various shifts 

and days of the week and become knowledgeable about the scientific basis for the practice; the 

change champion educates and assists them in using practices that are aligned with the evidence. 

Each member of the core group, in turn, takes the responsibility for imparting evidence-based 

information and effecting practice change with two or three of their peers. Members assist the 

change champion and opinion leader with disseminating the EBP information to other staff, 

reinforce the practice change on a daily basis, and provide positive feedback to those who align 

their practice with the evidence base.15 Using a core-group approach in conjunction with a 

change champion results in a critical mass of practitioners promoting adoption of the EBP.39 

Educational outreach, also known as academic detailing, promotes positive changes in 

practice behaviors of nurses and physicians.22, 64, 66, 71, 74, 75, 77, 81, 119, 143 Academic detailing is 

done by a topic expert, knowledgeable of the research base (e.g., cancer pain management), who 

may be external to the practice setting; he or she meets one-on-one with practitioners in their 

setting to provide information about the EBP topic. These individuals are able to explain the 

research base for the EBPs to others and are able to respond convincingly to challenges and 

debates.22 This strategy may include providing feedback on provider or team performance with 

respect to selected EBP indicators (e.g., frequency of pain assessment).66, 81, 119 

Users of the Innovation or Evidence-Based Practice 

Members of a social system (e.g., nurses, physicians, clerical staff) influence how quickly 

and widely EBPs are adopted.39 Audit and feedback, performance gap assessment (PGA), and 

trying the EBP are strategies that have been tested.15, 22, 65, 66, 70–72, 81, 98, 124, 144 PGA and audit and 

feedback have consistently shown a positive effect on changing practice behavior of 

providers.65, 66, 70, 72, 81, 98, 124, 144, 145 PGA (baseline practice performance) informs members, at the 

beginning of change, about a practice performance and opportunities for improvement. Specific 

practice indicators selected for PGA are related to the practices that are the focus of evidencebased practice change, such as every-4-hour pain assessment for acute pain management.15, 66, 81 

Auditing and feedback are ongoing processes of using and assessing performance indicators 

(e.g., every-4-hour pain assessment), aggregating data into reports, and discussing the findings 

with practitioners during the practice change.22, 49, 66, 70, 72, 81, 98, 145 This strategy helps staff know 

and see how their efforts to improve care and patient outcomes are progressing throughout the 

implementation process. Although there is no clear empirical evidence for how to provide audit 

and feedback,70, 146 effects may be larger when clinicians are active participants in implementing 

change and discuss the data rather than being passive recipients of feedback reports.67, 70 

Qualitative studies provide some insight into use of audit and feedback.60, 67 One study on use of 

data feedback for improving treatment of acute myocardial infarction found that (1) feedback 

data must be perceived by physicians as important and valid, (2) the data source and timeliness 

of data feedback are critical to perceived validity, (3) time is required to establish credibility of 

data within a hospital, (4) benchmarking improves the validity of the data feedback, and (5) 

physician leaders can enhance the effectiveness of data feedback. Data feedback that profiles an 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

individual physician’s practices can be effective but may be perceived as punitive; data feedback 

must persist to sustain improved performance; and effectiveness of data feedback is intertwined 

with the organizational context, including physician leadership and organizational culture.60 

Hysong and colleagues67 found that high-performing institutions provided timely, 

individualized, nonpunitive feedback to providers, whereas low performers were more variable 

in their timeliness and nonpunitiveness and relied more on standardized, facility-level reports. 

The concept of useful feedback emerged as the core concept around which timeliness, 

individualization, nonpunitiveness, and customizability are important.

Users of an innovation usually try it for a period of time before adopting it in their 

practice.22, 39, 147 When “trying an EBP” (piloting the change) is incorporated as part of the 

implementation process, users have an opportunity to use it for a period of time, provide 

feedback to those in charge of implementation, and modify the practice if necessary.148 Piloting 

the EBP as part of implementation has a positive influence on the extent of adoption of the new 

practice.22, 39, 148 

Characteristics of users such as educational preparation, practice specialty, and views on 

innovativeness may influence adoption of an EBP, although findings are equivocal.27, 39, 130, 149–

153 Nurses’ disposition to critical thinking is, however, positively correlated with research use,154 

and those in clinical educator roles are more likely to use research than staff nurses or nurse 

managers.155 

Social System 

Clearly, the social system or context of care delivery matters when implementing 

EBPs.2, 30, 33, 39, 60, 84, 85, 91, 92, 101, 156–163 For example, investigators demonstrated the effectiveness 

of a prompted voiding intervention for urinary incontinence in nursing homes, but sustaining the 

intervention in day-to-day practice was limited when the responsibility of carrying out the 

intervention was shifted to nursing home staff (rather than the investigative team) and required 

staffing levels in excess of a majority of nursing home settings.164 This illustrates the importance 

of embedding interventions into ongoing processes of care.

Several organizational factors affect adoption of EBPs.22, 39, 79, 134, 165–167 Vaughn and 

colleagues101 demonstrated that organizational resources, physician full-time employees (FTEs) 

per 1,000 patient visits, organizational size, and whether the facility was located in or near a city 

affected use of evidence in the health care system of the Department of Veterans Affairs (VA). 

Large, mature, functionally differentiated organizations (e.g., divided into semiautonomous 

departments and units) that are specialized, with a focus of professional knowledge, slack 

resources to channel into new projects, decentralized decisionmaking, and low levels of 

formalization will more readily adopt innovations such as new practices based on evidence. 

Larger organizations are generally more innovative because size increases the likelihood that 

other predictors of innovation adoption—such as slack financial and human resources and 

differentiation—will be present. However, these organizational determinants account for only 

about 15 percent of the variation in innovation adoption between comparable organizations.22 

Adler and colleagues168 hypothesize that while more structurally complex organizations may be 

more innovative and hence adopt EBPs relatively early, less structurally complex organizations 

may be able to diffuse EBPs more effectively. Establishing semiautonomous teams is associated 

with successful implementation of EBPs, and thus should be considered in managing 

organizational units.168–170 

8 
Evidence-Based Practice Implementation

As part of the work of implementing EBPs, it is important that the social system—unit, 

service line, or clinic—ensures that policies, procedures, standards, clinical pathways, and 

documentation systems support the use of the EBPs.49, 68, 72, 73, 103, 140, 171 Documentation forms or 

clinical information systems may need revision to support changes in practice; documentation 

systems that fail to readily support the new practice thwart change.82 

Absorptive capacity for new knowledge is another social system factor that affects adoption 

of EBPs. Absorptive capacity is the knowledge and skills to enact the EBPs; the strength of 

evidence alone will not promote adoption. An organization that is able to systematically identify, 

capture, interpret, share, reframe, and recodify new knowledge, and put it to appropriate use, will 

be better able to assimilate EBPs.82, 103, 172, 173 A learning organizational culture and proactive 

leadership that promotes knowledge sharing are important components of building absorptive 

capacity for new knowledge.66, 139, 142, 174 Components of a receptive context for EBP include 

strong leadership, clear strategic vision, good managerial relations, visionary staff in key 

positions, a climate conducive to experimentation and risk taking, and effective data capture 

systems. Leadership is critical in encouraging organizational members to break out of the 

convergent thinking and routines that are the norm in large, well-established 

organizations.4, 22, 39, 122, 148, 163, 175 

An organization may be generally amenable to innovations but not ready or willing to 

assimilate a particular EBP. Elements of system readiness include tension for change, EBPsystem fit, assessment of implications, support and advocacy for the EBP, dedicated time and 

resources, and capacity to evaluate the impact of the EBP during and following implementation. 

If there is tension around specific work or clinical issues and staff perceive that the situation is 

intolerable, a potential EBP is likely to be assimilated if it can successfully address the issues, 

and thereby reduce the tension.22, 175 

Assessing and structuring workflow to fit with a potential EBP is an important component of 

fostering adoption. If implications of the EBP are fully assessed, anticipated, and planned for, the 

practice is more likely to be adopted.148, 162, 176 If supporters for a specific EBP outnumber and 

are more strategically placed within the organizational power base than opponents, the EBP is 

more likely to be adopted by the organization.60, 175 Organizations that have the capacity to 

evaluate the impact of the EBP change are more likely to assimilate it. Effective implementation 

needs both a receptive climate and a good fit between the EBP and intended adopters’ needs and 

values.22, 60, 140, 175, 177 

Leadership support is critical for promoting use of EBPs.33, 59, 72, 85, 98, 122, 178–181 This support, 

which is expressed verbally, provides necessary resources, materials, and time to fulfill assigned 

responsibilities.148, 171, 182, 183 Senior leaders need to create an organizational mission, vision, and 

strategic plan that incorporate EBP; implement performance expectations for staff that include 

EBP work; integrate the work of EBP into the governance structure of the health care system; 

demonstrate the value of EBPs through administrative behaviors; and establish explicit 

expectations that nurse leaders will create microsystems that value and support clinical 

inquiry.122, 183, 184 

A recent review of organizational interventions to implement EBPs for improving patient 

care examined five major aspects of patient care. The review suggests that revision of 

professional roles (changing responsibilities and work of health professionals such as expanding 

roles of nurses and pharmacists) improved processes of care, but it was less clear about the effect 

on improvement of patient outcomes. Multidisciplinary teams (collaborative practice teams of 

physicians, nurses, and allied health professionals) treating mostly patients with prevalent 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

chronic diseases resulted in improved patient outcomes. Integrated care services (e.g., disease 

management and case management) resulted in improved patient outcomes and cost savings. 

Interventions aimed at knowledge management (principally via use of technology to support 

patient care) resulted in improved adherence to EBPs and patient outcomes. The last aspect, 

quality management, had the fewest reviews available, with the results uncertain. A number of 

organizational interventions were not included in this review (e.g., leadership, process redesign, 

organizational learning), and the authors note that the lack of a widely accepted taxonomy of 

organizational interventions is a problem in examining effectiveness across studies.82 

An organizational intervention that is receiving increasing attention is tailored interventions 

to overcome barriers to change.162, 175, 185 This type of intervention focuses on first assessing 

needs in terms of what is causing the gap between current practice and EBP for a specified topic, 

what behaviors and/or mechanism need to change, what organizational units and persons should 

be involved, and identification of ways to facilitate the changes. This information is then used in 

tailoring an intervention for the setting that will promote use of the specified EBP. Based on a 

recent systematic review, effectiveness of tailored implementation interventions remains 

uncertain.185 

In summary, making an evidence-based change in practice involves a series of action steps 

and a complex, nonlinear process. Implementing the change will take several weeks to months, 

depending on the nature of the practice change. Increasing staff knowledge about a specific EBP 

and passive dissemination strategies are not likely to work, particularly in complex health care 

settings. Strategies that seem to have a positive effect on promoting use of EBPs include audit 

and feedback, use of clinical reminders and practice prompts, opinion leaders, change 

champions, interactive education, mass media, educational outreach/academic detailing, and 

characteristics of the context of care delivery (e.g., leadership, learning, questioning). It is 

important that senior leadership and those leading EBP improvements are aware of change as a 

process and continue to encourage and teach peers about the change in practice. The new 

practice must be continually reinforced and sustained or the practice change will be intermittent 

and soon fade, allowing more traditional methods of care to return.15 

Practice Implications From Translation Science

Principles of Evidence-Based Practice for Patient Safety 

Several translation science principles are informative for implementing patient safety 

initiatives: 

• First, consider the context and engage health care personnel who are at the point of care 

in selecting and prioritizing patient safety initiatives, clearly communicating the evidence 

base (strength and type) for the patient safety practice topic(s) and the conditions or 

setting to which it applies. These communication messages need to be carefully designed 

and targeted to each stakeholder user group. 

• Second, illustrate, through qualitative or quantitative data (e.g., near misses, sentinel 

events, adverse events, injuries from adverse events), the reason the organization and 

individuals within the organization should commit to an evidence-based safety practice 

topic. Clinicians tend to be more engaged in adopting patient safety initiatives when they 

understand the evidence base of the practice, in contrast to administrators saying, “We 

must do this because it is an external regulatory requirement.” For example, it is critical 

10 
Evidence-Based Practice Implementation

to converse with busy clinicians about the evidence-based rationale for doing fall-risk 

assessment, and to help them understand that fall-risk assessment is an external 

regulatory agency expectation because the strength of the evidence supports this patient 

safety practice. 

• Third, didactic education alone is never enough to change practice; one-time education 

on a specific safety initiative is not enough. Simply improving knowledge does not 

necessarily improve practice. Rather, organizations must invest in the tools and skills 

needed to create a culture of evidence-based patient safety practices where questions are 

encouraged and systems are created to make it easy to do the right thing. 

• Fourth, the context of EBP improvements in patient safety need to be addressed at each 

step of the implementation process; piloting the change in practice is essential to 

determine the fit between the EBP patient safety information/innovation and the setting 

of care delivery. There is no one way to implement, and what works in one agency may 

need modification to fit the organizational culture of another context. 

• Finally, it is important to evaluate the processes and outcomes of implementation. Users 

and stakeholders need to know that the efforts to improve patient safety have a positive 

impact on quality of care. For example, if a new barcoding system is being used to 

administer blood products, it is imperative to know that the steps in the process are being 

followed (process indicators) and that the change in practice is resulting in fewer blood 

product transfusion errors (outcome indicators). 

Research Implications

Translation science is young, and although there is a growing body of knowledge in this area, 

we have, to date, many unanswered questions. These include the type of audit and feedback (e.g., 

frequency, content, format) strategies that are most effective, the characteristics of opinion 

leaders that are critical for success, the role of specific context variables, and the combination of 

strategies that are most effective. We also know very little about use of tailored implementation 

interventions, or the key context attributes to assess and use in developing and testing tailored 

interventions. The types of clinical reminders that are most effective for making EBP knowledge 

available at the point of care require further empirical explanation. We also know very little 

about the intensity and intervention dose of single and multifaceted strategies that are effective 

for promoting and sustaining use of EBPs or how the effectiveness differs by type of topic (e.g., 

simple versus complex). Only recently has the context of care delivery been acknowledged as 

affecting use of evidence, and further empirical work is needed in this area to understand how 

complex adaptive systems of practice incorporate knowledge acquisition and use. Lastly, we do 

not know what strategies or combination of strategies work for whom, in what context, why they 

work in some settings or cases and not others, and what is the mechanism by which these 

strategies or combination of strategies work. 

This is an exciting area of investigation that has a direct impact on implementing patient 

safety practices. In planning investigations, researchers must use a conceptual model to guide the 

research and add to the empirical and theoretical understanding of this field of inquiry. 

Additionally, funding is needed for implementation studies that focus on evidence-based patient 

safety practices as the topic of concern. To generalize empirical findings from patient safety 

implementation studies, we must have a better understanding of what implementation strategies 

work, with whom, and in what types of settings, and we must investigate the underlying 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

mechanisms of these strategies. This is likely to require mixed methods, a better understanding 

of complexity science, and greater appreciation for nontraditional methods and realistic 

inquiry.87 

Conclusion 

Although the science of translating research into practice is fairly new, there is some guiding 

evidence of what implementation interventions to use in promoting patient safety practices. 

However, there is no magic bullet for translating what is known from research into practice. To 

move evidence-based interventions into practice, several strategies may be needed. Additionally, 

what works in one context of care may or may not work in another setting, thereby suggesting 

that context variables matter in implementation.80 

Author Affiliation 

University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care. 

Address correspondence to: Marita G. Titler, Ph.D., R.N., F.A.A.N., University of Iowa 

Hospitals and Clinics, Department of Nursing Services and Patient Care, 200 Hawkins Drive RM 

T10 GH, Iowa City, IA 52242-1009; e-mail: Marita-titler@uiowa.edu.

Search Strategy 

Several electronic databases were searched (MEDLINE®, CINAHL®, PubMed®) using terms 

of evidence-based practice research, implementation research, and patient safety. (The terms 

“quality improvement” or “quality improvement intervention research” were not used.) The 

Cochrane Collaboration–Cochrane Reviews was also searched to look for systematic reviews of 

specific implementation strategies, and the Journal of Implementation Science was also 

reviewed. I also requested the final reports of the TRIP I and TRIP II studies funded by AHRQ. 

Classic articles known to the author were also included in this chapter (e.g., Locock et al.123 ). 

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Profiling Canadian nurses’ preferred knowledge 

sources for clinical practice. Can J Nurs Res 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

136. Estabrooks CA, Rutakumwa W, O’Leary KA, et al. 

Sources of practice knowledge among nurses. Qual 

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implications for organizations and administrators. 

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practice: an organizational approach. J Nurs Manag 

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143. Hendryx MS, Fieselmann JF, Bock MJ et al. 

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care. Results of a randomized trial. Am J Respir Crit 

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and implementation strategies. Health Technol 

Assess 2004;8(6):i-xi, 1-72. 

145. Duncan K, Pozehl B. Effects of performance 

feedback on patient pain outcomes. Clin Nurs Res 

2000;9(4):379-97. 

146. Kiefe CI, Allison JJ, Williams OD, et al. Improving 

quality improvement using achievable benchmarks 

for physician feedback: a randomized controlled trial. 

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147. Meyer AD, Goes JB. Organizational assimilation of 

innovations: a multilevel contextual analysis. 

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148. Stetler CB, Legro MW, Wallace CM, et al. The role 

of formative evaluation in implementation research 

and the QUERI experience. J Gen Intern Med 

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systematic review. J Adv Nurs 2003a;43(5):506-20. 

150. Retchin SM. The modification of physician practice 

patterns. Clin Perform Qual Health Care 1997;5:202-

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151. Rutledge DN, Greene P, Mooney K, et al. Use of 

research-based practices by oncology staff nurses. 

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Attitudes about clinical practice guidelines in a mixed 

model HMO: the influence of physician and 

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1997;11(3):111-7. 

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for aligning current and best medical practices: the 

role of information technologies. West J Med 

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154. Profetto-McGrath J, Hesketh KL, Lang S, et al. A 

study of critical thinking and research utilization 

among nurses. West J Nurs Res 2003;25(3):322-37. 

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nurse educators as agents for change: increasing 

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914. 

156. Anderson RA, Issel LM, McDaniel RR. Nursing 

homes as complex adaptive systems: relationship 

between management practice and resident outcomes. 

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power of relationship for high-quality long-term care. 

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158. Anderson RA, Crabtree BF, Steele DJ, et al. Case 

study research: the view from complexity science. 

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Microsystems in health care: Part 9. Developing 

small clinical units to attain peak performance. Joint 

Comm J Qual Saf 2003;29(11):575-85. 

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diffusion patterns for complex health care 

innovations. Health Care Manage Rev 

2002;27(3):60-73. 

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of innovation within health care organizations: 

literature review and Delphi study. Int J Qual Health 

Care 2004;16(2):107-23. 

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Evidence-Based Practice Implementation

162. Kochevar LK, Yano EM. Understanding health care 

organization needs and context: beyond performance 

gaps. J Gen Intern Med 2006;21:S25-29. 

163. Litaker D, Tomolo A, Liberatore V, et al. Using 

complexity theory to build interventions that improve 

health care delivery in primary care. J Gen Intern 

Med 2006;21:S30-4. 

164. Engberg S, Kincade J, Thompson D. Future 

directions for incontinence research with frail elders. 

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evidence-based practice: an organizational and MICU 

exemplar. Crit Care Nurs Clin North Am 

2005;17(2):127-42. 

166. Redman RW. Improving the practice environment for 

evidence-based practice. Res Theory Nurs Pract 

2004;18(2-3):127-9. 

167. Scott-Findlay S, Golden-Biddle K. Understanding 

how organizational culture shapes research use. J 

Nurs Admin 2005;35(7/8):359-65. 

168. Adler PS, Kwon S-W, Singer JMK. The “Six-West" 

problem: professional and the intraorganizational 

diffusion of innovations, with particular reference to 

the case of hospitals. Working paper 3-15. Los 

Angeles, Marshall School of Business, University of 

Southern California. Available at 

http://www.marshall.usc.edu/web/MOR.cfm?doc_id 

= 5561 2003. June 2006. 

169. Grumbach K, Bodenheimer T. Can healthcare teams 

improve primary care practice? JAMA 

2004;291(10):1246-51. 

170. Shortell SM, Weist EM, Keita Sow M-S, et al. 

Implementing the Institute of Medicine’s 

recommended curriculum content in schools of 

public health: a baseline assessment. Am J Public 

Health 2004;94(10):1671-4. 

171. Rutledge DN, Donaldson NE. Building 

organizational capacity to engage in research 

utilization. J Nurs Admin 1995;25(10):12-6. 

172. Barnsley J, Lemieux-Charles L, McKinney MM. 

Integrating learning into integrated delivery systems. 

Health Care Manage Rev 1998;18-28. 

173. Ferlie E, Gabbay J, Fitzgerald L, et al. Evidencebased medicine and organisational change: an 

overview of some recent qualitative research. In: 

Ashburner L, ed. Organisational behavior and 

organisational studies in health care: reflections on 

the future. Basingstoke, UK: Palgrave; 2001. 

174. Lozano P, Finkelstein JA, Carey VJ, et al. A multisite 

randomized trial of the effects of physician education 

and organizational change in chronic-asthma care. 

Arch Pediatr Adolesc Med 2004;158:875-83. 

175. Hagedorn H, Hogan M, Smith JL, et al. Lessons 

learned about implementing research evidence into 

clinical practice: experiences from VA QUERI. J 

Gen Intern Med 2006;21:S21-4. 

176. Buonocore D. Leadership and action: creating a 

change in practice. AACN Clin Issues 

2004;15(2):170-81. 

177. Bradley EH, Holmboe ES, Mattera JA, et al. Data 

feedback efforts in quality improvement: lessons 

learned from U.S. hospitals. Qual Saf Health Care 

2004;13:26-31. 

178. Antrobus S, Kitson A. Nursing leadership: 

influencing and shaping health policy and nursing 

practice. J Adv Nurs 1999;29(3):746-53. 

179. Baggs JG, Mick DJ. Collaboration: a tool addressing 

ethical issues for elderly patients near the end of life 

in intensive care units. J Gerontol Nurs 

2000;26(9):41-7. 

180. Carr CA, Schott A. Differences in evidence-based 

care in midwifery practice and education. J Nurs 

Scholarsh 2002;34(2):153-8. 

181. Nagy S, Lumby J, McKinley S, et al. Nurses’ beliefs 

about the conditions that hinder or support evidencebased nursing. Int J Nurs Pract 2001;7(5):314-21. 

182. Omery A, Williams RP. An appraisal of research 

utilization across the United States. J Nurs Admin 

1999;29(12):50-6. 

183. Titler MG, Cullen L, Ardery G. Evidence-based 

practice: an administrative perspective. Reflect Nurs 

Leadersh 2002b;28(2):26-27, 46. 

184. Titler MG. Toolkit for promoting evidence-based 

practice. Iowa City: Department of Nursing Services 

and Patient Care, University of Iowa Hospitals and 

Clinics; 2002. 

185. Shaw B, Cheater F, Gillies C, et al. Tailored 

interventions to overcome identified barriers to 

change: effects on professional practice and health 

care outcomes. The Cochrane Database of Systematic 

Reviews 2005(3):CD005470. DOI: 

10.1002/14651858. 

186. Chin MH, Cook S, Drum ML, et al. Improving 

diabetes care in Midwest community health centers 

with the health disparities collaborative. Diabetes 

Care 2004;27:2-8. 

19 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

20 

187. Davey P, Brown E, Fenelon L, et al. Interventions to 

improve antibiotic prescribing practices for hospital 

inpatients. The Cochrane Database of Systematic 

Reviews 2005(4): CD003543. DOI: 

10.1002/14651858. 

188. Foxcroft DR, Cole N. Organisational infrastructures 

to promote evidence based nursing practice. 

Cochrane Database of Systematic Reviews 

2000(3):CD002212. DOI: 10.1002/14651858. 

189. Ozer EM, Adams SH, Lustig JL, et al. Increasing the 

screening and counseling of adolescents for risky 

health behaviors: a primary care intervention. 

Pediatrics 2005;115(4):960-8. 
Figure 1. AHRQ Model of Knowledge Transfer

21

Adapted from Nieva, V., Murphy, R., Ridley, N., et al.37 Used with permission. http://www.ahrq.gov/qual/advances/ 
Figure 2.* Implementation Model 

Redrawn from Rogers EM. Diffusion of innovations. 5th ed. New York: The Free Press; 2003; Titler MG, Everett LQ. Tpractice: considerations for critical care investigators. Crit Care Nurs Clin North Am 2001a;13(4):587-604. (Copyright oMarita Titler.)

22

Communication 

Process 

Characteristics of the EBP 

Social System 

Users of the 

EBP 

Communication 
Evidence Table. Evidence-Based Practice in Nursing 

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Berner 2003121 Local opinion 

leaders. 

Group randomized controlled trial (RCT). Evidence level 2. 

RCT 3 study arms: no intervention, traditional health care QI; opinion leader (OL) plus QI (level 2). Outcomes = 6 evidence-based quality indicators for 1994 unstable angina guidelines (level 2). 

Hospitals in Alabama. Patients admitted to an Alabama hospital during 1997–98 (baseline) and 1999–2000 (followup) with ICD-9 CM codes of unstable angina, angina pectoris, coronary artery disease, and chest pain unspecified. Mean age of patients was >70 years of age. 

Peer nominated opinion leader added to a Centers for Medicare and Medicaid Services (CMS) QI intervention. 

23
24

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Bootsmiller 2004103 Assess the implementation methods for 4 clinical practice guidelines (CPGs) in the VA health care system. Retrospective cohort study. Evidence level 5. Survey methods with questionnaire sent to 416 quality managers, primary care administrators, or others involved with guideline implementation in primary care at 143 VA medical centers with primary care clinics (level 9). Modified Dillman method was used. Outcomes: methods used to implement guidelines (level 4). Primary care clinics of VA medical centers. Study population is individual responsible for guideline implementation. 242 surveys returned from 130 hospitals. CPGs were chronic obstructive pulmonary disease (COPD), diabetes, heart failure, and major depressive disorder. Total number of interventions used were counted and type of interventions used to implement CPGs were categorized as consistently effective, variably effective, and minimally effective, based on Bero’s categories: Consistently effective: - Forms created/revised - Computer interactive education - Internet discussion groups - Responsibilities of nonphysicians changed academic detailing Variably effective: - CPG workgroup - Clinical meetings to discuss CPG Minimally effective: - Providers receive brief summary - Providers receive CPG 

- Providers receive pocket guide - Storyboards - Instructional tape of CPG - Grand rounds 
25

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Bradley 200460 Describe the 

implementation process for the Hospital Elder Life Program (HELP)—an evidence-based program for improving care of older patients. 

Descriptive prospective study. 

Qualitative analyses of implementation process at the beginning of implementation and every 6 months for up to 18 months. 

8 hospitals implementing HELP. In-depth, open-ended interviews were conducted by telephone with physicians, nurses, volunteers, and administrative staff involved in the HELP implementation. 
26

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Bradley 2004177 Identify key themes about effective approaches for data feedback as well as pitfalls to avoid in using data feedback to support performance improvement efforts. Retrospective cohort study. Evidence level 5. Qualitative study with open-ended interviews of clinical and administrative staff at 8 hospitals representing a range of sizes, geographical regions, and beta-blocker use rate after AMI (level 9). Outcomes = key themes in use of data feedback. 8 hospitals. Interviewed physicians (n = 14), nurses (n = 15), quality management (n = 11), and administrative (n = 5) staff who were identified as key in improving care of patients with AMI. Data feedback for improving performance of beta-blocker use after AMI. 
27

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

Carter 200561 Evaluation of 

the relationship between physicians’ knowledge of hypertension guidelines and blood pressure (BP) control in their patients. 

Cross-sectional study 

Cross-sectional study of physicians’ knowledge about Joint National Committee (JNC) 7 hypertension guidelines (level 4). Outcomes were BP values of patients each physician treated. 

Study setting was two academic primary care clinics located in the same academic medical center. The sample was 32 primary care physicians and 613 patients they treated. Mean age of physicians was 41 years (Standard Deviation [SD]. = 10.9), majority were men (66%). 

Association between physician knowledge and BP control. Covariates of presence of diabetes, patient age. 
28

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Chin 200462, 186 To determine the additive effect of additional support for organizational change techniques and chronic care management as they are added to the Health Disparities Collaborative initiatives to improve diabetes care in community health centers. RCT 34 centers were randomized to a standardized intensity arm (Health Disparities Collaborative initiatives) or high intensity arm. (level 2). Outcomes included process of care measures; laboratory values based on American Diabetes Association (ADA) recommendations; and patient surveys of satisfaction with provider’s communication style and overall care, attitudes about interacting with providers, knowledge of ADA recommendations, and provider performance of key processes of care (levels 1 and 2). 34 community health centers from the Midwest or West Central clusters that participated in the 1998–99 or 1999– 2000 Diabetes Collaborative of the Bureau of Primary Health Care in Improving Diabetes Care Collaboratively in the Community. These centers care for the medically underserved. In the standard arm, there were 843 patients at baseline and 665 in the followup standard intensity group. 993 patients were in the high intensity 

arm at baseline and 818 postinterventions high intensity group. Mean age of subjects ranged from 56 to 58, a majority were female, and white. 

All 34 centers were community health centers that are overseen by the Bureau of Primary Health Care and had participated in the Health Disparities Collaborative to improve diabetes care. Interventions included forming a QI team, adoption of the Plan-DoStudy-Act (PDSA) cycle for QI, learning sessions, data feedback, monthly teleconferences, and regional meetings over a year. The centers randomized to the standard intensity arm continued to receive quarterly data-feedback reports, conference calls with other centers, and a yearly in-person meeting with other health centers. The high intensity sites received the standard intensity interventions plus additional support in organizational change strategies, chronic care management, and strategies to engage patients in behavioral change designed to get them to be more active in their care. 
29

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

Davey 2005187 To estimate the 

effectiveness of persuasive interventions, restrictive interventions, and structural interventions (alone or in combination) in promoting prudent antibiotic prescribing to hospital inpatients. 

Systematic literature review.

Evidence level 1. (Table 3.1) 

RCTs, quasi-randomized controlled trials, controlled before and after studies, and interrupted time series studies (levels 2 and 3). Outcomes were appropriate antibiotic prescribing and patient outcomes, including length of stay, inpatient mortality, and 28-day mortality (levels 1 and 2). 

66 studies (43 interrupted time series studies, 13 RCTs, 6 controlled before/after studies, 2 controlled clinical trials, 1 cluster clinical trial, 1 cluster randomized trial. The majority of studies (42) were from the United States. Study participants were health care professionals who prescribe antibiotics to hospitalized inpatients receiving acute care. 

Interventions were categorized as persuasive interventions (distribution of educational materials; local consensus process; educational outreach visits; local opinion leaders; reminders provided verbally, on paper, or via the computer; audit and feedback), restrictive interventions (formulary restrictions, prior authorization requirements, therapeutic substations, automatic stop orders and antibiotic policy changes), and structural (changing from paper to computerized records, introduction of quality monitoring mechanisms). 
30

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Estabrooks 200420 To map research utilization as a field of study in nursing and identify the structure of this scientific community, including the current network of researchers. Systematic literature review. Bibliometric analysis to map the development and structure of the field. Outcomes were journal patterns of publication, country patterns of publication, author patterns of publication, references per article, co-occurrence of words, citation patterns, interdisciplinary flow of information, within field diffusion of information. 630 articles (350 opinion articles, 65 conceptual articles, 112 research utilization studies, 103 research articles) published in 194 different journals. Article location and data abstraction up to 2001/2002. Feldman 200564 Murtaugh 200577 Tested a basic and an augmented e- mail reminder to improve evidence-based care of individuals with 

heart failure (HF) in home health care settings. 

RCT. Evidence level 2 (Table 3.1) 

Prospective randomized trail with 3 groups (control, basic e-mail reminder, augmented email reminder). Outcome measures were nursing practices and patient outcomes.

Level 1 outcomes. 

Older adults with heart failure (n = 628; x age = 72) 

and nurses (n = 354; x age = 43.6; 93% female) caring for those patients.Home health care agency in a large urban setting. 

Basic e-mail reminder upon patient admission to the nurses’ care that highlighted 6 HF-specific clinical practices for improving patient outcomes. Augmented intervention included basic e-mail reminder plus package of material for care of HF patient (medication management, prompter card for improving communication with physicians, self-care guide for patients) and followup outreach by a clinical nurse specialist (CNS) who served as an expert peer. 
31

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Foxcroft and Cole 2000188 Organizational infrastructures 

to promote evidence-based nursing practice. 

Systematic literature review. 

RCT, controlled clinical trial, and interrupted time series (levels 2, 3, 7). Unit of intervention was organizational, comprising nurses or groups of professionals including nurses. Outcomes = objective measures of evidencebased practice (levels 1 and 2). 

121 papers were identified as potentially relevant, but no studies met the inclusion criteria. After relaxing the criteria, 7 studies were included and all used a retrospective case study design (15). 

Entire or identified component of an organizational infrastructure to promote effective nursing interventions. 

Greenhalgh 200522 

Diffusion, spread, and sustainability of innovations in the organization and delivery of health services. 

Systematic literature review. Evidence level 1 (Table 3.1). 

Metanarrative review. Comprehensive 

report of factors and strategies to promote use of innovations in health care services. 

7 key topic areas addressed: characteristics of the innovation, adoption by individuals, assimilation by organizations, diffusion and dissemination, the inner context, the outer context, implementation and routinization. 
32

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Grilli 2002120 Assess the effect of mass media on use of health services. Systematic literature review. Evidence level 1 (Table 3.1). RCTs, controlled clinical trials, controlled before- and-after studies, and interrupted time series analysis (levels 2, 3, 4). Outcomes were objective measures of health services (drugs, medical or surgical procedures, diagnostic tests) by professionals, patients, or the public. 26 papers reporting 20 time series and on controlled before- and-after study met the inclusion criteria. All studies relied on a variety of media, including radio, TV, newspapers, posters, and leaflets. To meet inclusion criteria, studies had to use mass media, be targeted at the population level, and aimed to promote/discourage use of evidence-based health care interventions or change public lifestyle. 
33

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

Grimshaw 2004144 

Grimshaw 200665 

Assessment of the effectiveness of guideline dissemination and implementation strategies. 

Systematic literature review. Evidence level 1 (Table 3.1). 

RCTs, controlled clinical trials, controlled beforeand-after studies, interrupted time series from 1966 to 1998 (levels 2, 3, 4). Outcomes were objective measures of provider behavior and/or patient outcomes (levels 1, 2). 

Studies of guidelines aimed at medically qualified professionals. (Studies on guidelines aimed at multiple professionals were included only if results for medical professionals were reported separately or if medical professionals represented more than 50% of the targeted population.) The review included 110 clustered RCTs, 29 patient RCTs, 7 clustered controlled clinical trials, 10 patient controlled clinical trials, 40 controlled before-and-after studies, and 39 interrupted time series designs. The most common setting was primary care (39%) followed by inpatient settings (19%) and generalist ambulatory settings (19%). Other studies addressed settings across sites of care or were in a variety of other types of settings (e.g., nursing homes). 

Interventions were educational materials, educational meetings, educational outreach, consensus, opinion leaders, patient-directed interventions, audit and feedback, reminders, other professional (marketing, mass media), financial interventions, organizational interventions, structural interventions, and regulatory interventions. Studies compared single interventions to no intervention, multifaceted interventions to no intervention, or a control receiving one or more single intervention. This systematic review compared findings from studies with a single intervention against a “no-intervention” control group; single interventions against an “intervention” control group; multifaceted interventions against “nointervention” control group (7 different types of comparisons); multifaceted interventions against intervention controls (4 different types of comparisons). A total of 309 comparisons were done. This systematic review also includes economic evaluations and cost analysis. 
34

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Grimshaw 2006124 Examine the feasibility of identifying opinion leaders using a sociometric instrument (frequency of nomination of an individual as an OL by the responder) and a self- designating instrument (tendency for others to regard them as influential). Cross-sectional study. Evidence level 5 (Table 3.1). Survey. Mailed questionnaires of different professional groups. Outcomes = general and condition-specific opinion leader types classified as sociometric OLs and self-designated OLs (level 2 outcomes). All general practitioners, practice nurses, and practice managers in two regions of Scotland. All physicians and surgeons and medical and surgical nursing staff in two district general hospitals and one teaching hospital in Scotland as well as Scottish obstetric and gynecology, and oncology consultants. None 
35

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

Horbar 200466 To evaluate a 

coordinated, multifaceted implementation intervention designed to promote evidence-based surfactant therapy. 

Clustered randomized trial. 

Cluster randomized trial with randomization at the hospital level (level 2). Outcomes were proportion of infants receiving their first dose of surfactant in the delivery room, proportion of infants treated with surfactant who received their fist dose more than 2 hours after birth, and time after birth at which the first dose of surfactant was administered; proportion of all infants who developed a pneumothorax, and proportion of all infants who died prior to discharge (levels 1 and 2). 

114 hospitals with membership in the Vermont Oxford Network, not participating in a formal quality improvement collaborative, with the majority of infants born in the hospital rather than transferred in and born in 1998 and 1999; received the first dose of surfactant within 15 minutes after birth. Subjects were high-risk preterm infants 23 to 29 weeks gestational age. The intervention group had 3,313 neonates and 2,726 in the comparison group. 

The multifaceted 18-month intervention included quarterly audit and feedback of data, evidence reviews, an interactive 3-day training workshop, and ongoing support to participants via conference calls and e-mail discussion. 
36

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Hysong 200667 Exploratory study of how high-performing facilities and low-performing facilities differ in the way they use clinical data for feedback purposes. Cross-sectional study. Descriptive, qualitative, cross-sectional study. Subjects were interviewed using a semistructured interview format (level 4). Outcomes were participant responses to questions asking how CPGs were currently implemented at their facility, including strategies, barriers, and facilitators. Study setting was 6 VA medical settings (from a pool of 15) ranked as high performing (n = 3) and low performing (n = 3) organizations with respect to 20 indicators for 6 chronic conditions treated in outpatient settings. 102 employees across 6 facilities were the subjects. Within each facility, facility leadership (n = 25), middle management (n = 34), and outpatient clinic personnel (n = 33) were interviewed. No study intervention, but transcripts were analyzed using grounded theory, and passages that specifically addressed feedback of data were included in the analyses. 
37

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

Irwin & Ozer 200468 Ozer 2005189 

To determine if a systems intervention for primary care providers resulted in increased preventive screening and counseling of adolescent patients compared to usual care. 

Controlled trial. 2 intervention outpatient 

pediatric clinics and 2 comparison outpatient pediatric clinics in the same health system were used to test the intervention. Level 3.

Outcomes were adolescent reports of whether their provider screened and counseled them for risky behavior (tobacco, alcohol, drugs, sexual behavior, and safety—helmet and seatbelt use). Level 2. 

4 outpatient pediatric clinics within Kaiser Permanente, Northern California. 76 clinicians were in the study (37 in each treatment arm). Adolescent reports of provider behavior—across all phases of the study, the intervention sample size was 1,717, and the comparison sample size was 911. Mean age of adolescents was 14.8 years (SD = 1.34). Data were collected from adolescents at baseline, following training, and following forms implementation. 

The intervention was 2 phases. First phase was an 8-hour clinician training in adolescent preventative services based on social cognitive theory, including didactic education, discussions, demonstration role plays, and interactive role-plays at each intervention site (4 months). Second phase was implementation of screening and chart forms customized for this study (4 months). All clinicians participated in the training and the tools were implemented on a clinic-wide basis. Local opinion leaders were integrally involved in the intervention. 
38

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Jacobson 200569 Assessment of the effectiveness of patient reminder and patient recall systems in improving immunization rates. Systematic literature review. Evidence level 1 (Table 3.1). RCTs, controlled before- and-after studies, and interrupted time series (levels 2 and 3). Outcomes were immunization rates or the proportion of the target population up to date on recommended immunizations. 43 studies. Approximately three-fourths of the studies were conducted in the United States. The majority of the studies were RCTs. Studies included children and adults and a variety of settings. Reminder methods and recall systems included letters to patients, postcards, person-to- person telephone calls, autodialer, postcard and phone combination, and tracking and outreach. 
39

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Jamtvedt 200670 

Use of audit and feedback to improve professional practice. 

Systematic literature review. Metaregression along with visual and qualitative analyses.

Evidence level 1 (Table 3.1). 

Randomized trails (level 2). Outcome measures = noncompliance with guideline recommendations (level 2). 

85 studies. 53 trials in North America, 16 in Europe, 8 in Australia, 2 in Thailand, 1 in Uganda. In most trials, the professionals were physicians; in 2 studies the providers were nurses, and 5 involved mixed providers. 

Audit and feedback defined as any summary of clinical performance of health care over a specified period of time, delivered in written, electronic, or verbal format. 

Jones 200471 Improvement of 

pain practices in nursing homes. 

Clustered RCT. Evidence level 2 (Table 3.1). 

An intervention study to improve pain practices (RCT). The intervention was implemented in 6 nursing homes (level 2). Outcomes = pain knowledge and attitudes of staff; pain assessment and treatment decisions based on 2 short case studies; barriers to effective pain management. Outcomes measured from questionnaires distributed to nurses and nursing assistants (level 3). 

12 long-term care sites in Colorado—6 in urban sites and 6 in rural sites. Nursing homes ranged in size from 65 to 150 beds. 

Education for staff; resident educational video; designation of a 3-member internal pain team; pain vital sign; site visits with discussion of feedback reports; pain rounds and consultations. Implementation phase lasted 9 months. 
40

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Katz 200472,98 Testing an intervention to improve use of EBP smoking cessation guidelines. RCT with randomization at the clinic level. Evidence level 2 (Table 3.1). Prospective randomized trial of 8 primary care clinics in southern Wisconsin (level 2). Outcomes included staff performance and patient quit rates (levels 1 and 2). 8 community- based clinics (6 family practice, 2 internal medicine). Multimodality intervention (5 components—didactic and interactive education of staff, modified vital signs stamp imprinted on each encounter form, offering nicotine patches and telephone counseling, group and confidential individual feedback to providers on whether clinicians had assessed smoking status and provided cessation counseling as needed) to implement AHRQ smoking cessation guideline. Levine 200473 Test a nurse- administered, protocol-driven model for comprehensive preventive services in a low-income outpatient setting. Focus 

was on preventive services as recommended by the U.S. Preventive Services Task Force (USPSTF). 

Controlled trial. Controlled comparison 

using a convenience sample of patients within a single practice (n = 987) and a usual care group (n = 666) obtained from a random sample of households from the postal zip codes served by the same practice (level 3). Outcomes were percentage of preventive services initiated in the treatment arm versus the comparison arm (level 1). 

Primary care single practice with internal medicine, family medicine, and pediatric clinics. Patients receiving care in this clinic between January and September 2001. Children = 514 (about 170 in each of 3 age groups: 0–2, 3–7, 8–17; 63% African American). Adults = 473 (about 170 in each age group 18–49 and 50–64; 130 in 65 or older; 76% African American). 

Offer all identified preventive services that are needed using a nursing model under the guidance of a protocol agreed upon by the medical staff. 
41

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Locock 2001123 Role of opinion 

leader in innovation and change. 

Systematic literature review. 

Case studies using principally qualitative methods. Outcomes = effectiveness of opinion leaders in promoting change/adoption of evidence-based practices (level 2.) 

Variety of acute care and primary care settings. Evaluation of PACE project100 

and Welsh Clinical National Demonstration Project. 

Local opinion leaders defined as those perceived as having particular influence on the beliefs and actions of their colleagues, either positive or negative. 
42

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Loeb 200474 To test the effect of a multifaceted implementation intervention for safely reducing antimicrobial prescriptions for suspected urinary tract infections in nursing home residents. Cluster RCT. The study design was randomization of 24 nursing homes to an intervention group or a usual care group (level 2). Main outcome measures were antimicrobials prescribed for urinary infections, total antimicrobials, hospitalizations, and deaths (level 1). Free standing, community-based nursing homes with 100 or more beds in Hamilton, Ontario, region and Boise, Idaho, region were sites for the study. The numbers of residents were 2,156 in the intervention arm and 2,061 in the comparison arm. Implementation of algorithms for diagnostic testing and antibiotic prescribing developed from research findings. Implementation strategies included interactive education with nurses, one-on-one meeting with physicians that see more than 80% of the patients, written materials, real-time paper reminders, and quarterly outreach visits targeted to nurses and physicians. 
43

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Lozano 2004174 To test the 

effectiveness of 2 implementation interventions in reducing asthma symptom days as compared to usual care. 

Cluster RCT. RTC. 

Outcomes were annualized asthma symptom days, asthmaspecific functional health status, and frequency of brief oral steroid bursts (level 1). 

42 primary care practices in 3 locales and targeted 3–17-year-old children with mild to moderate persistent asthma enrolled in practices affiliated with managed care organizations. Among the 638 patient subjects, the mean age was 9.4 years (SD = 3.5); the majority were white (66%) and boys (60%). 

3 treatment arms were usual care, provider (MD, PA, NP) oriented strategy of targeted education through an on-site peer leader, and an organizational approach that combined the provider education with a nurse-run intervention (planned care arm) to better organize chronic asthma care in the primary care practice. 

McDonald 200575 Testing of 2 computer-based 

reminder interventions designed to promote evidence-based pain management practices among home care nurses. 

RCT.Evidence level 2 (Table 3.1). 

Nurses were randomly assigned to one of 3 treatment groups (control, basic e-mail reminder, augmented email reminder). Outcomes = pain management practices of nurses and patient’s pain (levels 1 and 2). 

Home health care. Nurses were mostly female (> 90%) with an average age of 43.3 years. 

Basic e-mail reminder that focused on 6 key practices (2 treatment arms) was sent to nurse every time an eligible cancer patient with pain was admitted to his/her care. Nurses in the augmented intervention group also received provider prompts, patient education material, and CNS outreach. 
44

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention O’Brien 1997119 Assess the effect of outreach visits on improving professional practice or patient outcomes. Systematic literature review. Evidence level 1 (Table 3.1). Randomized trials (level 2). Outcomes of provider performance (level 2). 18 trials. Providers were mainly primary care physicians practicing in community settings. In 13 trials the behaviors were prescribing practices. 10 trials in North America, 4 in Europe, 2 in Indonesia, and 2 in Australia. Outreach visits defined as use of a trained person who meets with providers in their practice settings to provide information with the intent of changing provider’s performance. The information may include feedback about performance. O’Brien 1999116 Assessment of the use of local opinion leaders on the practice of health 

professionals or patient outcomes. 

Systematic literature review. Evidence level 1 (Table 3.1). 

RCTs (level 2). Outcomes were objectively measured provider performance in a health care setting or health outcomes (levels 1 and 2). 

Focus was on health care providers responsible for patient care. 

Use of providers nominated by their colleagues as educationally influential. 8 studies met inclusion criteria. A variety of patient problems were targeted. 
45

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

O’Brien 2001118 Assess the 

effects of educational meetings on professional practice and health care outcomes. 

Systematic literature review.

Evidence level 1 (Table 3.1). 

Randomized trials and well-designed quasiexperimental studies (levels 2 and 3). Outcomes were objectively measured health professional practice behaviors or patient outcomes in a setting where health care was provided (levels 1, 2, 3). 

32 studies met inclusion criteria with 30 RCTs. 24 studies were in North America, 2 in the United Kingdom, and 1 each in Australia, Brazil, France, Indonesia, Sri Lanka, and Zambia. Most of the study participants were physicians; 4 included nurses, and 3 other health professionals. 

The intervention was defined as continuing education: meetings, conferences, lectures, workshops, seminars, symposia, and courses that occurred off-site from the practice setting. Education was defined as didactic (predominately lectures with Q and A), or interactive (sessions that involved some type of interaction in small, moderate, or large groups). 7 studies were didactic and 25 were interactive. Duration and frequency of the intervention varied widely. 
46

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Redfern 200379 Evaluation of the South Thames Evidence-based Practice (STEP) project. Pretest and posttest. Each of the 9 projects followed a pretest/posttest design within a clinical audit framework over a period of 27 months (level 6). Outcomes = intermediate outcomes of uptake of change by staff and patient outcomes (levels 1 and 2). 9 projects that focused on improving evidence-based nursing practices. UK sites included acute care wards, community nursing services, and long- term care. Topics were leg ulcer management, breast-feeding, pressure ulcer care, nutrition in stroke patients (n = 2), Use of functional independence measure (FIM) assessment tool, assessment of continence, assessment and transfer of older adults on discharge from hospital, family 

therapy in schizophrenia. 

A 2-week training program followed by 3 monthly seminars, staff training program, active support in the practice setting. 
47

Source 

Issue Related

to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention 

Shaw 2005185 Tailored 

interventions to address specific identified barriers to change in professional performance. 

Systematic literature review with metaregression.

Evidence level 1 (Table 3.1). 

RCTs (level 2). Outcomes = professional performance, patient outcomes, or both (levels 1 and 2). 

15 RCTs. 7 in primary care or community settings and

health care professionals responsible for patient care. 10 in North America, 2 in the United Kingdom, 2 in Indonesia, and 1 in Norway. 

An intervention was defined as tailored if it was chosen after identification of barriers and to overcome those barriers. 

Titler 200681 Testing a TRIP 

intervention for promoting adoption of evidence-based acute pain management practices for care of older adults hospitalized with hip fracture. 

RCT with randomization at the clinic level. Evidence level 2 (Table 3.1). 

Prospective randomized trial of 12 acute care hospitals in the Midwest United States (level 2). Outcomes included nurse and physician performance, patient pain levels, and cost effectiveness (levels 1 and 2). 

12 large (n = 2), medium (n = 6), and small hospitals (n = 4) in the Midwest. 

Multifaceted intervention that addressed the characteristics of the EBP, the users, the social context of care, and communication, based on Rogers’ diffusion of innovation framework. 
48

Source Issue Related to EBP Design Type* Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Wensing 200682 Organizational strategies for improving professional performance, patient outcomes, and costs. Systematic literature review. Evidence level 1. A review of reviews that included RCTs, interrupted time series, controlled before/after studies, and prospective comparative observational studies (levels 2, 5, 6, 7). Outcomes = professional practice and patient outcomes (levels 1 and 2). 36 reviews were included. A taxonomy of organizational strategies to improve patient care was developed to organize findings. Revision of professional roles, multidisciplinary teams, integrated care services, knowledge management, quality management. 
49

Source 

Issue Related

to EBP Design Type

* Study Design & Study 

Outcome Measure(s) 

Study Setting & Study Population Study Intervention 

Zwarenstein 2000117 

Usefulness of interprofessional education (IPE) interventions on professional practice and health care outcomes. 

Systematic literature review. Evidence level 1 (Table 3.1). 

RCTs, controlled beforeand-after studies, and interrupted time series studies (levels 2, 6, 7). Outcomes included health care outcomes (mortality rates, complication rates, readmission rates) and impact on professional practice (teamwork and cooperative practice) (levels 1 and 2). 

89 studies were reviewed for possible inclusion, but none met the inclusion criteria. 

An educational intervention during which members of more than one health and/or social care profession learn interactively together for the purpose of improving collaborative practice and/or the health of patients. 

*Study design type: Use the following numbers for categories to reference the specific type of evidence (“evidence le

1. Meta-analysis 2. Randomized controlled trials 3. Non-randomized trials 4. Cross-sectional studies 5. Case control studies 6. Pretest and post-test (before and after) studies 7. Time series studies 8. Noncomparative studies 9. Retrospective cohort studies 10. Prospective cohort studies 11. Systematic literature reviews 12. Literature reviews, nonsystematic/narrative 13. Quality improvement projects/research 14. Changing practice projects/research 15. Case series 16. Consensus reports 17. Published guidelines 18. Unpublished research, reviews, etc.