Application to Practice

The incorporation of evidence-based practice into an agency, clinical setting, or organization should not come as a surprise. Rather, it should be an intentional, coordinated and deliberate process. Planned change can be used to prepare the organization for change and facilitate the process. Three phases of the change process are unfreezing, moving, and refreezing (Welch, 1979). Three stages of adopting a practice innovation based on the evidence are knowledge, persuasion, and adoption (Rogers, 1995).

• Increase staff awareness about what evidence-based practice is and why it is important
• Disseminate information about how evidence-based practice can improve the quality of care provided
• Solicit ideas from staff as to potential areas for practice changes (Robinson et al. (CJON article 2000, 4[2]), p. 83 "Revisions").

Preliminary Phase

• Identify expected outcomes of the change. A broad outcome may have been set at the beginning of the EBP process, but now definitive outcomes need to be established.
• Outcomes should be measurable and relevant. The more relevant the outcomes are to the organization, the more likely the practice will be accepted (Rosswurm & Larrabee, 1999).
• Outcomes may be clinical, financial, or process-related:
  Examples of clinical outcomes: decreased infection rate, less breakthrough pain.
  Examples of financial outcomes: decreased length of stay, decreased resource utilization, use of less costly medication.
  Examples of process-related outcomes: transdermal fentanyl prescribed more appropriately; fewer routine lab tests ordered as "daily"; referral for nutritional assessment written within the first 24 hours of admission.
• Collect baseline data on current practice within the organization. Examples: quality assurance/quality improvement activities, current knowledge and attitude surveys, chart audits, patient interviews.
• Identify stakeholders.

• Determine costs and resources necessary for implementation and maintenance
  Examples: equipment, personnel, training, facilities, classroom space

Planning Phase

• Identify setting for implementation of practice change.
  Examples: inpatient nursing unit, outpatient clinic, organization-wide
• Identify structure or process components that need to be revised
  Examples: policies, procedures, standards, documentation forms
• Determine the appropriate approval process
• Are administrative approvals needed prior to a pilot project?
• Who (both individuals and committees) must approve a new or revised protocol or procedure? Prior to implementing the guidelines for the use of transdermal fentanyl, the pharmacy-nursing advisory committee, a drug utilization and evaluation committee, and the pharmacy and therapeutics committee reviewed and approved the guideline (Wakefield et al, 1998, p.1508).
• Identify barriers and bridges
• Organizational and administrative support
• Staff involvement - Change is more likely to be accepted when staff participate in making the changes
• Physician support
• Costs and cost savings (Wakefield p.1508)
• Competency of staff to implement practice change.
• Impact on quality of life
• Cultural climate of organization - Barriers to change are greatest in large bureaucratic organizations where changes are made by the top-down method (Rosswurm & Larrabee, 1999).
• Timing of change - consider other activities occurring within the organization during the anticipated time frame for planned change. Horsley, Crane et al (1983) have developed a "Probability of Adoption Assessment Guide" to assist change agents in nursing departments in assessing the characteristics of potential nursing practice innovations that might affect their successful adoption.
• Develop a time frame for educating all involved staff.
• Develop staff education materials, and
• Teaching plans

• When possible, begin a trial implementation or pilot on one or two units. A trial or pilot allows assessment of the feasibility of the practice change in the target setting and allows practitioners to influence adaptation of the change, giving a sense of ownership of the change process and contributing to a smoother integration of the change (Rosswurm & Larrabee, 1999). Choose an area, service, or unit to initiate the implementation that offers the best venue for success.
• Communicate practice changes - Dissemination strategies and techniques can strongly influence the degree to which a practice change is adopted (Bostrum & Suter, 1993).
  Examples: Inservices, posters, grand rounds, staff meetings, newsletters, videotapes, audiotapes, computer prompts, demonstrations
• Provide rationale for the change in practice and the evidence supporting the change

Evaluation provides essential data for decision-making and assists staff in determining whether the intervention should be accepted, rejected or modified for use in the clinical setting (Goode, 1995).