1. Johnson, Joyce A. PhD, RN-BC

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"Implementation of evidence is essential for patients to receive the best care possible" (Fineout-Overholt & Johnson, 2006, p. 194). "The existence of a gap between science and practice is universally recognized [horizontal ellipsis]and many interventions never reach those who could benefit. It is estimated that it takes an average of 17 years to translate 14% of original research into benefit for patients and an average of 9 years for interventions recommended as evidence-based practices (EBPs) to be fully adopted" (Tinkle, Kimball, Haozous, Shuster, & Grochowski, 2013, p. 1). "Part of this extensive delay in translation of research into practice is that nurses tend to view research findings as something someone else should be concerned with versus a critical element of their daily practice" (Fineout-Overholt & Johnson, 2006, p. 194).


These past few months, I have worked to integrate evidence into a simple policy for intramuscular injections (IMs). The policy needed approval from the leaders in ambulatory care. The group was willing to go along with the change from the dorsogluteal to the ventrogluteal site for injection but did not accept the evidence that all IMs should be administered Z track. They also could not support the evidence that gloves were not required unless it could be reasonably anticipated that the staff might have hand contact with blood, other potentially infectious material, mucous membranes, and/or nonintact skin. Why was it so difficult for them to accept the evidence? Cost was certainly one issue on the side of Z track technique. The medical assistants had not been using the Z track for injections although it is within the scope of their practice. Although they were trained in school, they would have to be retrained now at a cost. On the other hand, gloves are expensive; however, the group believed that gloves should be worn and changed for every injection. "The patients expect it," they said. But wouldn't the patients expect the best possible procedure (Z track) because it reduces pain, increases absorption of the injectate, and decreases the rate of infection?


When we changed the policy to eliminate aspiration before injection of immunizations, vaccines, and insulin, many people responded that they would continue to aspirate because that was the way they were taught; some had experience with blood return, and some thought it was safer practice. However, the evidence shows that aspiration in these cases is not necessary and just increases the injection time for the patient. If we cannot get leaders to implement evidence into practice, do we have a hope of the nurse at the point of service doing so?


Here are some of the reasons expressed for reluctance to incorporate evidence into practice.


* That's the way I was trained.


* We have always done it that way with no problems.


* It's ritual and tradition.


* It's a "sacred cow"; we can't change that.


* It's how we do things here; it's our group culture.


* Change is uncomfortable.


* It costs too much to change.


* I don't trust the evidence; who did that study and was it done with rigor?


* We can't make all these changes at one time.


* When I am in a hurry I do what I have always done[horizontal ellipsis]. it's just not a habit yet.


* There needs to be more research so we can be sure.


* There is a lack of resources for evidence at the bedside, lack of knowledge, lack of skill, and lack of time.


* I don't feel it will make a difference.


* There are too many competing demands.



Making changes is an age old problem. Consider the case of treatment for scurvy.


* 1593: Sir Richard Hawkins recommended sour oranges and lemons as a treatment.


* 1601: Lancaster showed that lemon juice supplement eliminates scurvy among sailors (nonrandomized controlled trial).


* 1747: Lind shows that citrus juice supplement eliminates scurvy.


* 1795: 94 years after the evidence (level 2) is presented, the British Navy implements citrus juice supplements (Kirsh & Aron, 2009).



Another barrier to implementing evidence is the lack of research on the most successful ways to disseminate evidence and research findings. There is some evidence that passive approaches to dissemination of research such as publication and mass mailings are ineffective (Tinkle et al., 2013). More promising methods of dissemination include hands-on technical assistance, replication guides, and targeted training workshops with hands-on experience (Tinkle et al., 2013). According to Kiefe and Sales (2006), research into the science of implementation is needed.


So, how can we encourage staff to implement new evidence in practice? Here are some thoughts.


* Make the data meaningful. One of my colleagues told me of a time when she was practicing clinical nursing and the physician wanted the nurses to position babies on their backs. However, at that time, they were all taught to place babies on their stomach or side to avoid aspiration if they vomited. No matter how often the physician suggested the change, the nurses went back to their familiar practice until, one day, he made the data meaningful. He gathered the nurses around a basinet and registered pulse oximetry with the baby on her side, then on her stomach, and then on her back. When the nurses saw the difference in the results they agreed that placing the baby on her back was best[horizontal ellipsis]and they changed their practice.


* Select a nurse who is interested in nursing research to serve as an EBP mentor. Having an EBP mentor or champion who works with the staff on the unit in implementing evidence into care legitimizes the practice. Mentors can offer help with point-of-care decisions based on evidence. The mentor might also help the staff conduct library searches and literature reviews and can diagnose gaps in knowledge regarding EBP.


* Implement a journal club where staff read articles on care of patients in their specialty and discuss the findings; this activity focuses the staff on looking at current evidence.


* Ensure that the staff has access to library resources and the time to investigate them and share what they learn with other staff members.


* Facilitate a culture of inquiry and research by encouraging staff to ask questions such as the following: Why do we do this? Why not do it this way? What else might we do?


* Incorporate evidence-based discussions in staff meetings. Use meeting time to review new evidence-based policies and procedures relative to patients, and informally quiz the staff on the information. Encourage staff reflection on care given; what worked and what did not. Include the staff in decision making about how change can best be implemented in the unit/department.


* Provide education for staff on EBP including posters, educational sessions, an "evidence" book with articles that the staff must read, email "blurbs" if staff has access to email, a Web site containing EBP information for the unit, and most importantly, the opportunity for hands-on simulated practice.


* Expose staff to initiatives that are focused on the use of data.


* Involve direct care nurses in the discovery of new knowledge through data collection and participation in local research projects.


* Identify staff who are "early adopters" and will most influence implementation. Who does the staff listen to and view as a resource? Then, get that staff member on board first as you implement changes.


* Report back to leaders on your efforts to implement EBP in the department and the results of that implementation. Take credit for your good work; brag shamelessly. Let staff know that leadership is aware of EBP efforts.


* Demonstrate that you value implementing evidence into practice by providing time for the staff to participate in your chosen method of education and dissemination.



As professional nurses, leaders, and nursing professional development specialists, it is our responsibility to incorporate evidence into our practice to ensure the best possible outcomes for patients.




Fineout-Overholt E., Johnston L. (Eds.). (2006). Teaching EBP: Implementation of evidence: Moving from evidence to action. Worldviews on Evidence-Based Nursing, 3 (4), 194-200. [Context Link]


Kiefe C., Sales A. (2006). A state-of-the-art conference on implementing evidence in health care: Reasons and recommendations. Journal of General Internal Medicine, 21 (Suppl 2), S67-S70. [Context Link]


Kirsh, S., & Aron, D. (2009). Integrating research and practice to bridge the researcher/practitioner divide: Three examples involving diabetes shared medical appointments. Presentation given to the Center for Implementation Practice & Research Support, March 24, 2009. Retrieved from[Context Link]


Tinkle M., Kimball R., Haozous E., Shuster G., Grochowski R. (2013). Dissemination and implementation research funded by the US National Institutes of Health, 2005-2012. Nursing Research and Practice, 2013, 909606.[Context Link]