Implementation Science: Translating Research into Practice Pat Bruckenthal, PhD, APRN-BC, FAAN Associate Dean for Research and Innovation Stony Brook University School of Nursing Implementation Science: Translating Research into Practice

Conflict of Interest Pat Bruckenthal has no COI relative to this presentation

Compare and contrast implementation science to other scientific research methods Discuss various implementation science models Apply implementation strategies to real world practice Objectives

“There are not two sciences “There are not two sciences. There is science and the application of science, and these two are linked as the fruit is to the tree” Louis Pasteur

Background for Implementation Science in Nursing Purpose: to promote the systematic uptake of research findings and other EBP’s into routine practice to improve the quality, safety, and effectiveness of health services and care Addresses challenges associated with the use of research to achieve more evidenced based practice Uses robust theoretical underpinnings from psychology, sociology, and organizational theory (behavioral change within organizational systems)

Definitions Basic Research: seeks to increase or advance knowledge through systematic investigation of a subject or phenomenon Translational Research: transforms scientific findings or discoveries from basic laboratory, clinical, or population studies into new clinical tools, processes, or applications Implementation Science: is the scientific study of the use of strategies to adapt and integrate evidence-based health interventions into clinical and community settings to improve patient outcomes and benefit population health Evidence Based Practice: refers to integration of the best evidence with clinical expertise to ensure the best possible patient outcomes Quality Improvement: Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (QSEN, 2003)

Steps of EBP process

Implementation Theories, Models, and Frameworks Go from more abstract to structured. They explain, describe, or structure phenomena Aims in implementation science: Describe or guide the process of translating research into practice Understand or explain what influences implementation outcomes Evaluation of implementation 5 types of theories, models, and frameworks used in implementation science Process models Determinant framework Classic theories Implementation theories Evaluation frameworks Implementation Theories, Models, and Frameworks

Basic Implementation Model

Specify steps in the process of translating research into practice including the implementation and use of research K2A Framework Stetler Model ACE Star Model (Academic Center for Evidenced-Based Practice) IOWA Model Ottawa Model Process Models

Knowledge to Action Cycle (Graham, et al., 2006)

Ottawa Model (Logan and Graham, 1998, 2004)

Determinant Frameworks Specify types of determinants and individual determinants which act as barriers and enablers that influence implementation outcomes PARIHS (Promoting Action on Research Implementation and Health Sciences) Ecological Framework CFIR Framework Determinant Frameworks

CFIR Framework (Damschroder, et al., 2009)

PARHIS Framework

Theories originating form fields external to implementation science which can be applied to provide understanding and/or explanation of aspects of implementation Theory of Diffusion Various organizational theories Classic Theories

Rogers’ Theory for Diffusion of Innovations

Implementation Theories Theories that have been developed from scratch or by combing theories Implementation Climate Organizational Readiness COM-B Implementation Theories

COM-B Model (Mitchie et al., 2011)

Evaluation Frameworks Specify aspects of implementation that could be evaluated to determine implementation success RE-AIM PRECEDE-PROCEED Evaluation Frameworks

RE-AIM Model (Glasgow et al., 1999)

PRECEDE-PROCEED MODEL (Green, et al., 2005)

Strategies to match facilitators and barriers to implementation Facilitator/Barrier Strategy Knowledge Active learning Advanced organizers Attitude Shifting perspective Anticipated regret Self efficacy Modeling Planned coping responses Social norms Role modeling leadership Organization Priority setting at organizational level Financing Financial incentives . Bartholomew, et al. (2006)

Implementation of the Critical Care Pain Observation Tool increases the frequency of pain assessment for noncommunicative ICU patients (Phillips, ML., Kuruvilla, V., Bailey, M. 2018, Australian Critical Care) Problem: the common practice in this ICU was informal observational assessment of noncommunicative patients, which was inconsistent with international guidelines. EBP: The Behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) are both valid in critically ill patients and recommended in expert consensus clinical practice guidelines Purpose: implement the CPOT in our routine ICU practice and evaluate the effects on pain assessment and management. Framework: Powell et al (2013) Plan strategies (Gather information, assess for readiness and barriers), Education strategies (education principles of “develop materials”, “educate”, and “educate through peers”) Outcomes: Improved frequency of assessments and pain management strategies.

Using Diffusion of Innovations Theory to Implement the Confusion Assessment Method for the Intensive Care Unit (Bowen,M., Stanton, M., Manno, M., (2012), Journal of Nursing Care Quality) Problem: the common practice in this ICU was informal observational assessment of noncommunicative patients, which was inconsistent with international guidelines EBP: Review of delirium assessment tools. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) reliable, valid and feasible Purpose: to use the Diffusion of Innovations Theory as a guide for developing strategies to increase the frequency of assessments when implementing the CAM-ICU Planning-Pilot: barriers to the use and successful implementation of the CAM-ICU, 1) low frequency of assessments( less than 10% ) 2) Informal interviews revealed nurses perceptions on the usefulness of delirium assessments, time it took to perform the assessments, and availability of the CAM-ICU worksheets, which were not kept with their daily paperwork 3)results of the CAM-ICU were not ascertained by the physicians or residents or used for the development of the plan of care

Framework: Roger’s Diffusion of Innovation Knowledge: 1-hour in-services, (double the length of the in-service from the original pilot) A short video demonstrating time it took to perform the assessment Poster boards placed them in the nurses’ lounge Meeting with intensivist and key stakeholders to discuss implementing the CAM-ICU Persuasion: Nurse managers identified as “CAM Champs” Decision: poster boards and open access journal articles were used to provide weekly information and influence the nurses’ decision to continue to assess for delirium. Implementation: Assess delirium at the beginning of each shift, 8:00 am and 8:00 pm. CAM-ICU worksheets were placed in the patients’ binders with the nurses’ daily paperwork Placement of laminated CAM-ICU flow sheets in the patients’ binders Continued support from the CAM Champs, nurse manager, and clinical educator Confirmation Continued feedback and support Nurse manager and clinical educator informally discussed the potential for the development of a protocol for the management of delirium and possibility of performing research with the nurses Evaluation Data on the number of mechanically ventilated patients on each unit were collected on a daily basis The frequency of CAM-ICU assessments was measured by determining how many assessments would be expected and how many were actually completed

Research is a “team sport” Multidisciplinary: Coordination of research among scientists of different backgrounds and disciplines Interdisciplinary: Cooperative effort of scientists on issues that fall between disciplinary boundaries Transdisciplinary: Collaborative projects where information exchange, the modification of scientific approaches, and the integration of scientists and approaches from different disciplines advances research toward a common scientific goal

DNP vs PhD

Get Started Identify a problem Assemble your team QI departments, decision support, etc… Partner with DNP. PhD’s (others with experience and interest) Plan the project out with a time line Just do it Celebrate your success

Thank you