Week 10 Flashcards
(12 cards)
Why is implementing EBP challenging in real-world healthcare settings
- Often means changing established routines and behaviours which can be hard
- Despite broad agreement that EBP improves care quality, uptake of EBP in routine practice remains low
- Integrating research findings into daily clinical work is not easy, practitioners face lots of barriers
- May have limited time to read research, lack access to training, or work in systems that don’t support change
Evidence might be available but getting a whole team to consistently apply is hard
The role of context, leadership and stakeholder engagement
- Context matters
- The settings culture, resources, and policies influence how easily a new practice can be adopted
- Supportive leadership is critical
- When managers and leaders champion EBP they can inspire urgency and provide resources for change
- Engaging stakeholders at all levels (clinicians, managers, patients)
- Frontline staff are more likely to embrace new practice if they understand why and how its implemented
- Involving team decision-making, addressing their concerns and showing respect for their expertise fosters a sense of ownership of the change
Common barriers to EBP adoption and strategies to overcome them
- Lack of knowledge or skills in EBP: Some staff may feel unsure about how to appraise research or apply it. Strategy: Provide training sessions and ongoing professional development. Workshops on literature searching or critical appraisal, for example, can boost confidence. Designating EBP champions or mentors in the team can also help coach others.
- Resistance to change: People may prefer “the way we’ve always done it” or be skeptical of new methods. Strategy: Acknowledge concerns and involve resistant individuals in the change process. Open forums for discussion, clear communication about the evidence and its benefits, and small pilot trials can help win skeptics over. Highlighting quick wins (early positive results) can demonstrate the value of the new practice, easing fear of the unknown.
- Resource limitations: In some settings, there may be limited access to research articles, insufficient equipment, or lack of funding to support a change. Strategy: Use freely available evidence sources (like open-access journals or clinical guidelines) and seek support from administration for necessary resources. Sometimes, creative solutions like sharing resources across departments or applying for small grants can overcome this barrier.
Organisational culture and policies: If the culture doesn’t value inquiry or if policies are very rigid, implementing EBP is harder. Strategy: Engage leadership to endorse the change and align it with organisational goals or accreditation standards. Showing how the EBP aligns with improving patient outcomes or safety can create organisational buy-in. Policy adjustments (even minor ones) might be needed to accommodate new practices – working with management on these changes is key.
Kotters 8 step implementing change in clinical settings 1-4 (CBFC)
Create a sense of urgency: Begin by helping others see why the change is needed now. In a clinical context, this could mean presenting data about current problems or suboptimal outcomes to highlight the risk of not changing. For example, a clinic manager might share patient outcome statistics or new research evidence showing better results with a proposed intervention. The goal is to instill an understanding that “we can’t keep doing this the old way” – for instance, underscoring the gap between current practice and best evidence to spark motivation for change. (If people don’t feel urgency, it’s hard to get anyone to move forward.)
- Build a guiding coalition: Assemble a small team of motivated people who will lead and drive the change. In healthcare, this could include clinicians, a team leader, a senior specialist, and maybe a patient representative or admin staff – anyone with influence and insight. The coalition’s job is to champion the EBP initiative, coordinate efforts, and support colleagues. Why a team? Having a diverse group of champions creates wider support – for example, a physiotherapy clinic implementing a new treatment might form a team with the practice owner, two experienced physios, and a receptionist (to give an operational perspective). This team works together to plan and advocate for the change.
- Form (develop) a strategic vision and initiatives: Clarify what you are trying to achieve and how you’ll get there. This involves formulating a clear vision of the improved practice (what will patient care look like after the EBP is adopted?) and outlining a basic strategy or set of initiatives to implement it. In our context, the vision could be something like “All stroke patients will receive evidence-based swallowing assessments that improve safety and outcomes.” The corresponding initiative might include steps like staff training sessions, new assessment checklists, and audit of assessment quality. A clear vision helps align everyone’s efforts – it answers, “What are we changing to, and why?” – and the strategy provides the roadmap to follow.
Communicate the vision (and change plan): Now that you have a vision and plan, share it widely and frequently. Use every suitable channel: team meetings, emails, posters in the staff room, one-on-one conversations. Explain the EBP change in simple, relatable terms, and keep discussing it. In a hospital ward, for example, the guiding coalition might present the plan at a multidisciplinary meeting, send out a summary email, and have informal chats with colleagues during breaks. Importantly, invite feedback and listen to concerns – communication is a two-way street. By continually talking about the vision and addressing questions, you build understanding and reduce misinformation. The aim is for everyone to know what the change is, why it’s important, and how it will happen.
Kotters 8 step process for implementing change in clinical settings 5-8 (ECSA)
- Enable action by removing barriers: Anticipate and eliminate obstacles that might impede the change. Barriers in healthcare could be practical (e.g. not having the right equipment or forms), procedural (outdated policies), or people-related (resistance, as discussed). For example, if implementing a new therapy requires scheduling longer appointment slots, a rigid scheduling template is a barrier – adjusting it would be removing that barrier. Another example: if some staff lack confidence in using a new assessment tool, a barrier is knowledge – providing additional training or mentorship removes that barrier. Kotter emphasises empowering people to act by clearing obstacles and providing support. In practice, this could mean securing funding for necessary supplies, simplifying documentation requirements, or addressing individuals who are obstructing the process (perhaps by understanding their issues or reassigning roles). Removing barriers paves the way for staff to actually do the new practice rather than be blocked by old constraints.
- Create short-term wins: Change can be exhausting, so it’s crucial to plan for some quick wins – early successes that you can celebrate. Identify some short-term goals that are achievable within weeks or months, rather than a year. In an allied health example, if you’re implementing an evidence-based exercise program, a short-term win might be seeing a measurable improvement in patient pain scores after 1 month of the new program, or getting positive feedback from the first few patients. When a short-term win is achieved, publicise it! Acknowledge and reward the team’s effort, even if just with praise at a staff meeting or a small reward. These wins provide proof that the change is working and boost morale. They convert skeptics and turn neutral folks into supporters because people love success. Essentially, short-term wins create momentum – “look, we did this and it helped” – which propels the project forward for the longer haul.
- Sustain acceleration (build on the change): After initial wins, don’t declare victory too soon. It’s a common mistake to relax after a couple of early successes, but Kotter warns that real change takes time. This step is about pressing on with the plan, using the credibility from wins to tackle bigger pieces of the change. In a clinical setting, after a successful pilot of a new practice on one ward, sustaining acceleration could mean rolling it out to more wards or extending the practice to more complex cases. Keep setting new goals and keep the urgency up. Also, examine the process so far – what worked? what didn’t? – and use those insights to adapt and continue. Essentially, consolidate gains and keep moving: turn those small wins into broader change. For example, if the new protocol is working for stroke patients, can we extend it to patients with other neurological conditions? And ensure any backsliding is addressed – if people start to slip into old habits, gently remind and refocus them.
- Anchor new approaches in the culture: Finally, to make the change stick, it must become “the way we do things here.” This means embedding the EBP into the fabric of the organisation. Policies, procedures, job descriptions, and informal norms should all incorporate the new practice. For instance, if an occupational therapy clinic successfully implements an evidence-based cognitive rehabilitation technique, they might update their clinical guidelines to reflect this, include it in orientation for new staff, and regularly audit its use. Leadership plays a role here too – continue to support and talk about the new practice so it doesn’t fade away. Over time, as people see improved patient outcomes and the new way proves its value, it becomes part of the organisational identity. Anchoring in culture could also involve recognising and reminding how the change has led to success: e.g., “Since we adopted this falls prevention program, our clinic’s fall rate has dropped 30% – this is now a proud part of our standard care.” In summary, step 8 is about making the EBP integration permanent – ensuring the changes are institutionalised so that old habits don’t creep back.
PARiHs Framework
(Promoting Action on Research Implementation in Health Services): This framework posits that successful implementation of evidence into practice is a function of three factors: Evidence, Context, and Facilitation. In other words, EBP uptake will be effective when: (1) the evidence is high quality and relevant (including research, clinical experience, and patient preferences), (2) the context (setting) is receptive (e.g. a culture that values learning, good leadership, and resources), and (3) there is effective facilitation – someone or some process that helps the change along (like an EBP facilitator or implementation team). Each element ranges from weak to strong (for example, evidence can be low quality or high quality; context can be unsupportive or very supportive). The insight here is that even the best evidence won’t implement itself if the context is poor or no one is actively facilitating the change. Conversely, a great context and enthusiastic facilitation can’t overcome completely lackluster evidence. An easy way to remember: Evidence + Context + Facilitation = Successful Implementation (when all are strong). How does this help you? PARiHS encourages you to assess these three domains for any project. If you have strong evidence but a weak context (say, a resistant work culture), you know you need to work on improving context or emphasizing facilitation (maybe bring in an external facilitator or get leadership on board) to succeed. It’s a diagnostic and planning tool – check your E, C, and F.
Knowledge to action framework
The KTA framework, developed by Graham and colleagues (2006), provides a structured, cyclical process to systematically implement knowledge (evidence) in practice. It consists of two parts: Knowledge Creation and an Action Cycle. The action cycle has seven stages which can be tackled in a loop, not strictly linear. The KTA cycle is often drawn as a circle to emphasize that implementing evidence is an ongoing process that may require going back and forth between steps. For instance, you might evaluate outcomes and find not enough improvement, leading you to go back and assess barriers again or tweak the intervention.
Identifying and addressing resistance from staff and stakeholders
- Listen and understand: Have one-on-one conversations with those who resist. Often, people have specific concerns (e.g., “I’m worried this new method will take too long” or “I don’t see how this is better for patients”). By understanding their perspective, you can target your response.
- Involve them in the process: A powerful way to reduce resistance is to actively involve skeptics in the implementation. For instance, invite them to be part of the planning or to lead a trial of the new practice. This inclusion can convert opposition into ownership – they feel heard and valued, and they get a chance to see the change from the inside.
- Provide support and education: Resistance sometimes comes from lack of confidence or knowledge. Ensure adequate training is provided (hands-on workshops, refreshers, Q&A sessions). If people feel competent in the new practice, their fear often lessens. Pair resisters with a supportive mentor or colleague who is enthusiastic about the change, so they have someone to go to with questions or for encouragement.
- Communicate benefits and evidence: Continuously share success stories, data, and positive feedback regarding the EBP. For example, if some nurses resist a new wound care protocol, share a story of a patient who healed faster because of it, or show the before-and-after infection rates. Seeing tangible benefits can sway opinions.
- Address misconceptions and adjust if needed: Sometimes resistance highlights real issues. Maybe the new procedure does take longer initially, or it has a flaw in the process. Acknowledge valid points and be willing to tweak the implementation plan. This shows that feedback is valued and that the change isn’t rigid or blindly imposed.
Maintain a positive, respectful tone: Avoid punishing or shaming staff who are slow to adopt. Instead, recognize that change is hard and provide positive reinforcement for those making the effort. Create a safe environment for people to express concerns without fear. Over time, peer influence can also help – as more people get on board and speak positively about the change, remaining resistance tends to diminish.
Fostering an EBP culture through training and PD
- Regular EBP training: Incorporate EBP topics into routine professional development. This could be annual workshops on how to search for evidence, appraise a study, or apply guidelines. Even brief in-service sessions or “EBP spotlights” in staff meetings (where someone presents a quick summary of new research) keep the momentum.
- Journal clubs and case study meetings: Establish a monthly journal club where team members discuss a relevant research article, or a case meeting where a challenging case is reviewed with an evidence lens (“What does the literature say we should do for this scenario?”). These activities normalize the use of evidence and improve skills in a collaborative way.
- Mentorship and champions: Identify or assign EBP champions – staff who are passionate and knowledgeable about EBP – to mentor others. For example, a senior occupational therapist who’s research-savvy can mentor junior staff in conducting small evidence-based projects. Champions can also lead by example in their daily practice, demonstrating how they integrate evidence with patient care.
- Embed EBP in orientation and expectations: For new hires, include an introduction to the organisation’s commitment to EBP. Make it clear that using best evidence is part of everyone’s job. Encouraging questions like “What’s the evidence for this?” should be welcome. Some hospitals add EBP goals to performance appraisals (e.g., “Participated in an EBP project or literature review this year”) to reinforce that it’s valued.
- Provide resources: Ensure staff have easy access to evidence sources – subscriptions to key journals, online databases, or summaries of evidence (like clinical guidelines or evidence-based protocols). If possible, have a library service or online repository where clinicians can quickly find the latest evidence on a topic. If you remove the friction of accessing information, people are more likely to use it.
- Celebrate and share: When someone in the team successfully implements an evidence-based change or completes an EBP project, acknowledge it publicly. For example, if a physiotherapist updates the exercise protocol based on new evidence, share this achievement in a newsletter or staff email: “Kudos to Priya for integrating the latest stroke rehab research into our clinic – patient mobility scores are already improving!” This kind of recognition motivates others and builds pride around EBP.
Technology and digital tools to support EBP implementation
- GRADEpro: GRADEpro is free software that helps teams develop evidence-based guidelines and recommendations. It allows you to create summary of findings tables and track the quality of evidence using the GRADE system. While more commonly used by guideline developers, clinicians can use it in-house to summarise evidence for a project or to develop local protocols based on evidence. It’s a handy way to collate research findings and visualise the strength of evidence supporting a practice change.
- RE-AIM framework and tools: RE-AIM stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance. It is a framework often accompanied by worksheets or checklists to plan and evaluate implementation efforts. For example, a RE-AIM planning worksheet might prompt you to consider: Who are we reaching with this change (percentage of target patients/clinicians)? Is it effective (what outcomes to measure)? Are enough people adopting it (usage rates)? Are we implementing it with fidelity (consistency, any adaptations)? And how will we maintain it long-term? The RE-AIM websiteLinks to an external site. provides free tools and checklists to use this framework. This can help you systematically think through an implementation and later evaluate its impact in a structured way.
- Implementation Science Toolkit: This is a more general term – various organisations offer toolkits. For instance, the NIH or other health agencies have online Implementation Toolkits that compile resources like project planning templates, stakeholder analysis tools, evaluation templates, and case studies. One example is an Implementation Science Toolkit for Clinicians (developed by some universities) which might include step-by-step guidance on conducting an EBP project, questions to guide each phase, and tips for common challenges. These toolkits are often free and can be found through healthcare organisations or universities. They essentially condense the wisdom of implementation science into practical worksheets and tip sheets. Using a toolkit can ensure you don’t miss important steps (like considering sustainability from the start or planning how to measure success).
Other Digital Aids: Even simple tools like online survey platforms (to collect feedback from staff about a new practice) or audit tools on a tablet (to quickly audit compliance with the new practice) can support implementation. Mobile apps specific to certain interventions (for example, an app that reminds patients to do their exercises and reports back to clinicians) can also facilitate EBP in practice by improving adherence and data collection
Kotters cycle (IAASMES)
. These stages are: (1) Identify a problem and identify the relevant knowledge (what evidence or guideline could solve this problem?),
(2) Adapt the knowledge to the local context (tailor the recommendation to fit your setting’s needs and constraints),
(3) Assess barriers and facilitators to knowledge use (sounds familiar to Module 1’s barriers – essentially diagnose what might help or hinder in your specific context),
(4) Select and implement interventions to promote the knowledge use (plan the implementation strategies – e.g., training, reminders, policy changes),
(5) Monitor knowledge use (are people actually using the new practice? e.g., audit how often it’s done),
(6) Evaluate outcomes (is it improving patient care or other targets? collect data), and
(7) Sustain knowledge use (ensure the practice continues, similar to Kotter’s anchoring – plan for long-term maintenance)
Difference between Kotter and KTA
How is KTA different from Kotter? Kotter is a general change model from business, whereas KTA is specific to health knowledge implementation and focuses on continuous improvement and evaluation. KTA reminds us to not just implement, but also evaluate and sustain, and that context adaptation is crucial. It’s a bit more detailed on the nitty-gritty of applying evidence in practice, while Kotter is more about leadership and change momentum. In practice, you could easily use Kotter’s steps to manage the human/process side of change while also using KTA as a project roadmap to ensure you cover all bases (from identifying the problem to sustaining the change).
