Practice Matters

Implementation science: A framework for integrating evidence-based practice

Implementation science is the study of methods that promote integration of research findings and evidence into healthcare policy and practice. It addresses the challenge of moving health research innovations to practice more quickly, helping to bridge the service- to-science gap. Increasingly, implementation science is being used as a framework because of its potential to change clinical practice and thus affect healthcare outcomes.

As you probably know, evidence-based practice (EBP) refers to integration of the best evidence with clinical expertise to ensure the best possible patient outcomes. For a practice or an intervention to be evidence based, it must be supported by sufficient evaluative evidence.

Outcome data should be measured only after an EBP has been implemented fully with fidelity to both the implementation design and the intervention. Fidelity refers to the extent to which strategies are delivered as the developer intended. Two types of fidelity exist:

• The degree to which an EBP achieves expected outcomes depends on implementation fidelity, which requires ongoing feedback and support loops to ensure practice as intended.

Intervention fidelity refers to verification that an intervention was delivered as designed.

Implementation fidelity requires that systems and processes be in place to ensure successful EBP. Implementation of current EBP with fidelity commonly requires changes in multilevel systems and infrastructure development before outcomes can be realized. This article describes key components of an implementationscience framework that predicts fidelity to EBP.

Key components of implementation science

Implementation science encompasses these core components:

• dissemination of effectiveness research

• successful integration of treatments and interventions at multiple levels.

These core components, or implementation drivers, extend not only to the individual but also to the staff and organization delivering the intervention, along with training and support to translate the intervention with fidelity at each level.

Implementation fidelity relies on staff selection, training, coaching, performance assessment, intervention systems, decision support tools, and facilitative administrative supports for all of those delivering the intervention. Attention to these core concepts is important in evaluating successes and failures of an EBP program.

Take, for example, staff selection. Multiple system variables influence whether staff members chosen to implement an EBP are appropriate to ensure fidelity. Variables that influence outcomes include academic qualifications, willingness, ethics, experience, and judgment. Each of these goes beyond knowledge of the intervention procedures to extend EBP success to variables that improve implementation fidelity. Such variables as coaching and training improve staff selfefficacy or attitudes.

Understanding variable outcomes

Variables related to core components may explain why outcomes are variable despite the evidence. Using an implementation-science framework might suggest that such variables as adequate training, continued coaching during initial implementation, and systems designed to support the intervention to full operation and sustainability are all necessary to achieve outcomes. Lack of attention to these implementation drivers may contribute to an early end to adoption of a particular practice.

Flexibility in implementation fidelity

Finally, attention to core components may permit flexibility in implementation fidelity in terms of supporting strategies and processes that, while not strictly adhering to the innovation, continue to advance practice and achieve positive outcomes. This flexibility fosters translation of research to different populations, practice settings, or disciplines.

Sharing our cumulative knowledge

Once staff members decide to adopt EBP, the implementation science framework describes stages for successful implementation. (See Stages of the implementation process.)

Adoption of implementation science is still in its infancy, although advances have been made in its quantity, quality, and scope of dissemination. In a March 2016 search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database using the keywords “implementation science” and “nursing,” the author found 17 citations of nursing research studies framed by implementation science. Broadening the search by eliminating “nursing” as a keyword revealed well over 150 citations in health-related literature.

With a better understanding of implementation science, nurses can increase their capacity for and sharing of their cumulative knowledge, as well as barriers and challenges to achieving outcomes using EBP.

Pamela P. DiNapoli is an associate professor in the College of Health and Human Services at the University of New Hampshire in Durham.

Selected references

Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research: a synthesis of the literature. University of South Florida; 2005.

Kroelinger CD, Rankin KM, Chambers DA, et al. Using the principles of complex systems thinking and implementation science to enhance maternal and child health program planning and delivery. Matern Child Health J. 2014;18(7):1560-4.

Ogden T, Fixsen DL. Implementation science: a brief overview and a look ahead. Z Psychol. 2014;222(1):4-11.

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