1. Diffusion of Innovations and Evidence-Based Practice in Geriatric Nursing Deborah Lekan, RNC, MSN Gerontological Clinical Nurse Specialist Clinical Associate Duke University School of Nursing

2. Duke University School of Nursing, 2009 Objectives Explain the elements of the diffusion of innovations model. Explain the elements of the diffusion of innovations model. Describe the use of the diffusion of innovations model in geriatric nursing. Describe the use of the diffusion of innovations model in geriatric nursing. Describe the diffusion model for implementing change in geriatric care. Describe the diffusion model for implementing change in geriatric care.

3. Duke University School of Nursing, 2009 “Good ideas do not sell themselves.” do not sell themselves.” (Rogers, E, 1995) Putting evidence-based nursing interventions into practice can be more complicated and difficult than the original research process that generated the interventions.

4. Duke University School of Nursing, 2009 Change is inevitable, but most people avoid change because...  Change creates uncertainty and anxiety.  It is human nature to attempt to reduce uncertainty by resisting change.

5. Duke University School of Nursing, 2009 Challenges Implementation of best practices hindered by vaguely defined procedures for implementation in diverse settings Implementation of best practices hindered by vaguely defined procedures for implementation in diverse settings CPG implementation imposed by governing bodies, federal or state regulations, organizational policies CPG implementation imposed by governing bodies, federal or state regulations, organizational policies Clear guidance is often lacking Clear guidance is often lacking Therefore, implementation is often Therefore, implementation is often Left to trial & error, Left to trial & error, Is painfully slow, and is marked by Is painfully slow, and is marked by Resistance, incomplete implementation, failure. Resistance, incomplete implementation, failure.

6. Duke University School of Nursing, 2009 Accelerating the Uptake of Evidence- Based Nursing Practices: Diffusion of Innovations Model Offers a model for guiding implementation of evidence-based practices Offers a model for guiding implementation of evidence-based practices Helps us understand the process of change Helps us understand the process of change Takes some of the guesswork out of determining what may or may not work Takes some of the guesswork out of determining what may or may not work Increases chances for successful adoption & sustainability Increases chances for successful adoption & sustainability

7. Duke University School of Nursing, 2009 Diffusion of Innovations: Definition The process by which The process by which (1) an innovation... (2) is communicated through certain channels... (3) over time... (4) among members of a social system. Rogers, E., Diffusion of Innovations, 5 th ed, 2003.

8. Duke University School of Nursing, 2009 Examples of Innovations Products/technology Products/technology Phone technology: digital pager, cell phone, camera phone, Blackberry (phone w/internet), iPod (phone/internet/video/ camera/games/texting) Phone technology: digital pager, cell phone, camera phone, Blackberry (phone w/internet), iPod (phone/internet/video/ camera/games/texting) Ear thermometer, Pulse oximetry, Bladderscan Ear thermometer, Pulse oximetry, Bladderscan Practices Practices Restraint free environment  behavior management techniques, low beds, monitoring devices, chair/bed alarms Restraint free environment  behavior management techniques, low beds, monitoring devices, chair/bed alarms Ideas Ideas Disease, disability, and frailty not a normal part of aging Disease, disability, and frailty not a normal part of aging Pain as the 5 th vital sign Pain as the 5 th vital sign Moist wound healing environment for pressure ulcers Moist wound healing environment for pressure ulcers

9. Duke University School of Nursing, 2009 An innovation is all about Perception If it is new to the user, then it is an innovation.

10. Duke University School of Nursing, 2009 Name a new idea, technology or practice you worked on to get adopted in your clinical setting.

11. Duke University School of Nursing, 2009 What are your sources for new ideas in your nursing practice? Other nurses, nurse specialists Physicians, other health professionals Professional organizations Conferences, workshops Journals, newsletters Product vendors The internet Government regulations or guidelines Family, friends Clinical practice-trial & error Other? How do you evaluate the accuracy and quality of the information?

12. Duke University School of Nursing, 2009 The Adoption Process: 5 Stages Knowledge —Awareness and understanding of the innovation-what it is and how it works Knowledge —Awareness and understanding of the innovation-what it is and how it works Persuasion —Form favorable opinion, determine relative advantage, what outcomes will be achieved Persuasion —Form favorable opinion, determine relative advantage, what outcomes will be achieved Decision —Decide to try it out-does it work Decision —Decide to try it out-does it work Implementation —Put it into use, solve operational problems, develop procedures Implementation —Put it into use, solve operational problems, develop procedures Confirmation Confirmation ADOPTION ADOPTION REINVENTION-modify & then adopt REINVENTION-modify & then adopt REJECTION & discontinue REJECTION & discontinue

13. Duke University School of Nursing, 2009 Confirmation and Adoption, Re- invention, or Rejection Contact Awareness Understanding Knowledge Implementation Persuasion Trial Use Institutionalization Full Scale Use Number of adopters Decision The Innovation-Adoption Process S-curve: Rate of adoption among a % of members in the system Time

14. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Type of decision Type of decision Innovation attributes Innovation attributes Communication channels Communication channels Social system characteristics Social system characteristics Consequences Consequences Change agents, opinion leaders Change agents, opinion leaders

15. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Innovation Attributes Innovation Attributes Relative Advantage– is the innovation better than the status quo, what is in current practice? Relative Advantage– is the innovation better than the status quo, what is in current practice? Compatability -consistent w/values, beliefs? Compatability -consistent w/values, beliefs? Complexity -hard to understand, use, or do? Complexity -hard to understand, use, or do? Triability -can it be tried out on a small scale? Triability -can it be tried out on a small scale? Observability –is the innovation or its results visible? Observability –is the innovation or its results visible?

16. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Type of Decision Type of Decision Optional Optional Collective/consensus Collective/consensus Authority Authority Contingent-sequential combination of two or more of the above Contingent-sequential combination of two or more of the above

17. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Communication Channels Communication Channels Formal/informal, Verbal/written Formal/informal, Verbal/written Shadow system, Rumor mill Shadow system, Rumor mill Mass media, interpersonal routes Mass media, interpersonal routes

18. Duke University School of Nursing, 2009 Interpersonal Communication Channels

19. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Social System characteristics Social System characteristics A set of inter-related units A set of inter-related units Individuals, groups, subgroups Individuals, groups, subgroups How social structures affect diffusion of the innovation How social structures affect diffusion of the innovation Relationships: Hierarchical/ horizontal, formal/ informal Relationships: Hierarchical/ horizontal, formal/ informal System effects: large/small & other characteristics System effects: large/small & other characteristics Norms Norms Established & accepted behavior patterns Established & accepted behavior patterns Values, beliefs, cultural & religious factors influential Values, beliefs, cultural & religious factors influential

20. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Consequences Consequences Desirable/undesirable Desirable/undesirable Direct/indirect Direct/indirect Anticipated/unanticipated Anticipated/unanticipated

21. Duke University School of Nursing, 2009 Factors Affecting the Rate of Diffusion of Innovations Change Agent & Opinion Leader Change Agent & Opinion Leader Create a need Create a need Provide information Provide information Highlight advantages & expected outcomes Highlight advantages & expected outcomes Endorse and persuade Endorse and persuade Model behaviors associated with innovation Model behaviors associated with innovation

22. Duke University School of Nursing, 2009 Adopter Categories

23. Duke University School of Nursing, 2009 Using the Diffusion of Innovations (DOI) Model to Promote Evidence- based Geriatric Nursing Practice Using the Diffusion of Innovations (DOI) Model to Promote Evidence- based Geriatric Nursing Practice

24. Duke University School of Nursing, 2009 Visual Summary of the Diffusion Model

25. Duke University School of Nursing, 2009 Oral Hygiene in LTC Exemplar Oral care of residents with cognitive impairment or who are resistant or combative Oral care of residents with cognitive impairment or who are resistant or combative Direct care CNA staff Direct care CNA staff Recognize oral care as a care priority Recognize oral care as a care priority Inconsistent provision of care Inconsistent provision of care Wanted to provide better care Wanted to provide better care Director of Nursing & leadership supportive Director of Nursing & leadership supportive

26. Duke University School of Nursing, 2009 Oral Hygiene in LTC Exemplar Resident issues Resident issues Bleeding gums deter oral care Bleeding gums deter oral care Many residents have serious dental problems Many residents have serious dental problems Disruptive behaviors Disruptive behaviors Some residents can do own care but are not assisted Some residents can do own care but are not assisted

27. Duke University School of Nursing, 2009 Oral Hygiene in LTC Exemplar Nurse provider issues Nurse provider issues Fear of injury - self & resident Fear of injury - self & resident Fear of accusations of abuse, resident rights Fear of accusations of abuse, resident rights Little knowledge/skill in managing disruptive behaviors Little knowledge/skill in managing disruptive behaviors Some staff are more vigilant than others Some staff are more vigilant than others No standardized or consistent oral health assessment No standardized or consistent oral health assessment Some staff also have poor oral hygiene Some staff also have poor oral hygiene Logistical issues Logistical issues Lack of time-competing responsibilities Lack of time-competing responsibilities Sporadic provision of oral care, no continuity Sporadic provision of oral care, no continuity Oral care supplies not always available Oral care supplies not always available

28. Duke University School of Nursing, 2009 Small Group: Analyze the “Try This” Oral Health Assessment tool for adoption by RNs on your clinical unit or agency Innovation Attributes Innovation Attributes Relative Advantage Relative Advantage Compatability Compatability Complexity Complexity Trialability Trialability Observability Observability

29. Duke University School of Nursing, 2009 Oral Health Assessment Tool Relative Advantage 1.Better than status quo 2.Evidence-based 3.Hydration, nutrition Compatability 1.Oral care valued 2.RN scope of practice 3.Best practice Observability 1.Oral care rounds 2.Documentation 3.Outcomes list Complexity 1.Ease of use 2.Visually “busy” 3.No dental jargon Trialability 1.Try out on one unit 2.Select pts w/problems Innovation Attributes

30. Duke University School of Nursing, 2009 Summary of DOI Diffusion of innovations offers a comprehensive model for planned change. Diffusion of innovations offers a comprehensive model for planned change. Model is multi-dimensional but practical. Model is multi-dimensional but practical. Guides identification and description of organizational, individual, & innovation characterizations. Guides identification and description of organizational, individual, & innovation characterizations. Offers a rational framework for using targeted strategies to facilitate and accelerate adoption of an innovation. Offers a rational framework for using targeted strategies to facilitate and accelerate adoption of an innovation.

31. Duke University School of Nursing, 2009 References Overview of Diffusion of Innovations ( University of S. Florida) Overview of Diffusion of Innovations ( University of S. Florida) ( http://hsc.usf.edu/~kmbrown/Diffusion_of_Innovations_Overview.htm ( http://hsc.usf.edu/~kmbrown/Diffusion_of_Innovations_Overview.htm http://hsc.usf.edu/~kmbrown/Diffusion_of_Innovations_Overview.htm Diffusion of Innovations, 5th Ed. 2003, Everett M. Rogers Diffusion of Innovations, 5th Ed. 2003, Everett M. Rogers http://www.amazon.com/exec/obidos/tg/detail/- /0743222091/104-0730562-2628704?v=glance http://www.amazon.com/exec/obidos/tg/detail/- /0743222091/104-0730562-2628704?v=glance http://www.amazon.com/exec/obidos/tg/detail/- /0743222091/104-0730562-2628704?v=glance http://www.amazon.com/exec/obidos/tg/detail/- /0743222091/104-0730562-2628704?v=glance Summary of Roger’s book (Iowa State University) Summary of Roger’s book (Iowa State University) Part I: http://www.soc.iastate.edu/Sapp/Diffusion1.html Part I: http://www.soc.iastate.edu/Sapp/Diffusion1.htmlhttp://www.soc.iastate.edu/Sapp/Diffusion1.html Part II: http://www.soc.iastate.edu/Sapp/Diffusion2.html Part II: http://www.soc.iastate.edu/Sapp/Diffusion2.htmlhttp://www.soc.iastate.edu/Sapp/Diffusion2.html Shirey MR. (2006). Evidence-based practice: how nurse leaders can facilitate innovation. Nurse Administration, 30(3), 252-265. Shirey MR. (2006). Evidence-based practice: how nurse leaders can facilitate innovation. Nurse Administration, 30(3), 252-265. McConnell ES, Lekan D, Hebert C, Leatherwood L. (2007). Academic-practice partnerships to promote evidence-based practice in long term care: oral hygiene care practices as an exemplar. Nursing Outlook, 55, 95-105. McConnell ES, Lekan D, Hebert C, Leatherwood L. (2007). Academic-practice partnerships to promote evidence-based practice in long term care: oral hygiene care practices as an exemplar. Nursing Outlook, 55, 95-105.