Effective implementation of evidence-based practice

How to implement Evidence-Based Practice

Updated March 2020

Evidence-Based Practice implementation

Effective implementation of evidence-based practice presents a series of real challenges to many organisations. Whilst evidence-based practice is the gold standard for decision making and practice or operations in any organisation, it, as a systematic practice, is far from a simple prospect to implement in an organisation and, as a consequence, a growing amount of research is being conducted around best practice for implementing evidence-based practice.

This page is dedicated to EBP implementation issues and what the research says about Evidence-Based Practice implementation and is a spur page from the The Essential Guide to Evidence-Based Practice page.


Problems faced with implementing evidence-based practice

A number of studies (1) show that whilst many specialists look upon the idea of EBP in a favourable way, there are barriers in understanding how to translate evidence and apply it to practice. Many different fields, from business to sport, need good research to be properly disseminated and implemented in the organisation if it is going to lead to real, practical improvements. However a series of problems do cause barriers to implementing evidence-based practice. The four major barriers to successful implementation have been found to be:

  1. Access to resources has been cited as a primary problem for many individuals and organisations. Access to professional resources required to develop EBP is often quite difficult and time consuming. In some cases this just means the use of textbooks and Web sites. However, some areas of practice may require access to electronic online journals or databases with specialist research and this is often limited. In some cases, the specialist knowledge required for the organisation may require an investment into resource access and the skills to translate the sources into useful material. Nonetheless, improving knowledge of how to use freely available online resources may be sufficient to allow for the rapid development of EBP. (2)
  2. Time constraints are regularly cited in every profession as being a key barrier to the application of EBP. For instance, in education, research indicates that teachers and instructors suggest that they are generally pushed to the limit and that the time needed to do research and introduce best practice is difficult to find. This is often because, in an ever-demanding workplace, specialists in most fields find that they often have to “wear multiple hats”, leading to legitimate concerns about time availability. (3) A number of studies have found that time constraints to source, obtain and translate research studies into something that is practical is the number one barrier to implementing and maintaining evidence-based practice across all professions.
  3. Lack of expertise, experience and knowledge of implementation.  A number of studies have shown that organisations with little experience and expertise the following areas all significantly reduce the chances of successful implementation:
    1. Evidence-based practice
    2. Implementation 
    3. Management of evidence-based practice and of practitioners
    4. Evidence-based practice leadership 
  4. Lack of an implementation model / strategy. Failing to have a strategy for the implementation of evidence-based practice in organisations has been found to severely limit the longevity, embededness and integration of the practice in to people's working lives (4).
  5. Another key issue is a lack of support at organisational and managerial levels to give people the time to engage with the research needed to implement EBP properly. This can be overcome through the introduction of reliable administrative support in the organisation and a careful consideration of priorities when the application of EBP is likely to bring substantial transformative benefits or by using specialist research translators and providers like The Oxford Review.

At the bottom of all of the barriers to implementation of evidence-based practice is usually a simple lack of knowledge and understanding. Individuals and organisations are often completely unaware of the new developments in their field, or the scientific evidence available to them that could completely revolutionise their organisation, outcomes and thinking. In addition, many specialists lack the basic skills required to assess the value and applicability of research, as well as its trustworthiness. Educational workshops and training within an organisation can be vital to help understand and integrate new practices in to everyday operations. Employees may benefit from training sessions led by external experts. The building of knowledge and understanding of how to use EBP can give specialists the confidence to go beyond a sole reliance on poor-quality subjective approaches. (6)

A 2019 study  (7) found that new practitioners tend not to transfer their learning of evidence-based practice  into the workplace for a number of specific reasons:

There tends to be an essential disconnection in practitioners minds between evidence and research. This backs up another 2017 study which found that practitioners often only have a shallow understanding of evidence and fail to understand the importance of systematic and valid research evidence to inform practitioner experience and the immediate evidence of the situation.

Additionally the study found that:

  1. Practitioners know that they should be using research evidence as part of the evidence-based mix but recognise they aren’t.
  2. This is appears, is because they move form a culture of research centrality (at university) into a culture of practice, immediacy and reduced time.
  3. From a student’s and practitioner’s point of view, research is someone else’s job.
  4. Practitioners and particularly new practitioners who usually work within a hierarchy and usually at the bottom levels of the hierarchy feel that their voice, opinion and knowledge of the research doesn’t carry much weight.
  5. In the intensity of daily work and practical concerns, knowledge production and study tend to get seen as situated in the college or university and not the work environment. 

However, the study found that the culture of the workplace appeared to be a prime indicator of whether or not new practitioners engage with evidence-based practice.

One of the biggest issues and barriers is how evidence-based practice is promoted and people are introduced to it.



4 Stages of implementation

A number of studies have developed stages of implementation as a way of working out the order evidence-based practice implementation should occur in. This is in essence a proto-strategy or first level strategy. A normal stage model of EBP implementation involves the following stages of implementation (5):

  1. Exploration
  2. Preparation / adoption
  3. Implementation
  4. Sustainment



The EPIS framework

The EPIS frame work is based on the four stages of implementation (Exploration, Preparation, Implementation and Sustainment) and separates or highlights two types of implementation activity:

The EPIS Framework

The 2 types of  implementation activity

  1. Strategic processes and 
  2. Operational processes or activities

Based on research published in 2008 (8) the EPIS framework is an wholistic approach to the implementation of evidence-based practice and takes into consideration four sets of factors that need to be taken into account when involved in getting EBP integrated into an organisations working and decision-making practices. 

The 4 implementation factors

  1. Outer or external context factors
  2. Bridging factors
  3. Innovation factors 
  4. The inner organisational context
Outer / external context factors

Each of the following series of factors has been found in previous studies to have an impact on the implementation and functioning of evidence-based practice schemes and their impact on the implementation of evidence-based practice need to be understood and taken into consideration, particularly in understanding which factors will cause problems and which factors can be leveraged or used to assist with the implementation:

  • The market environment
  • Funding
  • Inter organisational environment networks
  • Client or customer characteristics
  • Client or customer advocacy
  • Social perspectives
  • Stakeholder understanding

Bridging factors

The following bridging factors have been found to have a significant impact on evidence-based practice implementation and functioning:

  1. Partnership with academic institutions
  2. Purveyors and intermediaries

In particular having a partnership with academic institutions like universities and other organisations that are evidence-based have been found to be key success factors for the implementation of evidence-based practice.

Innovation factors

The following innovation factors have been found to have a significant impact on the success of the implementation of evidence-based practice:

  • The innovation/evidence-based practice fit
  • Innovation generation systems within the organisation
  • Client/customer interaction
  • The understanding of innovation practitioners and evidence-based practice developers
  • The characteristics of the evidence-based process and the innovation processes within the organisation
Inner context

The following inner context factors or internal organisational issues have all been found to have a significant impact on the implementation of evidence-based practice:

  1. Organisational leadership and management understanding
  2. A range of organisational characteristics
  3. The level of quality monitoring and support
  4. Organisational staffing processes
  5. Characteristics of individuals engaging with, or in, evidence-based practice

Why the EPIS framework doesn't work

Whilst the EPIS framework itself is evidence-based, many organisations still struggle to implement evidence-based practice. A recent systematic review (9) found that the majority of the problems were caused by:

  1. Overly focussing on implementation (which is stage 3 of the process) and missing out stages 1 and 2 in particular ( Exploration and Preparation). 
  2. Indeed most organisations (about 73%) were found to only pay a moderate amount of attention to EPIS as a strategic tool.  
  3. Organisation were frequently found to stop their efforts at the of implementation stage and not resource or work on sustainment. 

The systematic review discovered that there is a strong correlation between success of evidence-based practice schemes and having a considered practical approach to sustainment, which is derived in the exploration preparation phases.

An example of the type of problem that failing to engage with exploration, preparation and sustainment can cause is when a scheme fails to explore and examine service providers’ and internal managers’ attitudes and perceptions of knowledge and evidence-based practice. This failure to explore people's attitudes and perceptions of knowledge and evidence-based practice has been shown in a number of studies to be a primary cause of failure or significant difficulty in implementing evidence-based practice.

Part of the purpose behind the expiration and preparation phases for implementing evidence-based practice is to work out the relationships and interconnections between the elements that are likely to support or detract from the implementation of evidence-based practice before starting to implement.

Whilst EPIS has been applied inconsistently across implementation and research projects, the researchers were able to discern that the projects that were more systematic and comprehensive in using the EPIS framework tended to have greater levels of success.


EPIS strategic decision points

Implementation recommendations

  1. Implementation of evidence-based practice should start with exploration and preparation, including having the question of how evidence-based practice is going to be sustained within the organisation beyond the implementation phase.
  2. That the exploration phase which starts the EPIS framework is both about gaining knowledge around the subject of evidence-based practice and, critically, around how the organisation, people and external stakeholders are likely to perceive and orient themselves towards knowledge and evidence-based practice. Having this understanding means that the preparation phase is significantly more informed.
  3. That the preparation phase is significantly more than drawing up a set of plans for implementation. It is, in fact, the phase in which the organisation is prepared both cognitively, operationally and emotionally for the change that is about to occur when evidence-based practice starts being implemented.
  4. That implementation is seen as a series of experiments and knowledge creation events about how evidence-based practice will work best within this particular organisation. EPIS is actually an invitation to engage in evidence-based practice for implementing and sustaining evidence-based practice in the unique and individual organisation. This means that there needs to be a series of properly informed, rigorous and thoughtful trials conducted within the organisation and that the data is collected and analysed as part of the implementation process.
  5. That sustainment of evidence-based practice within any organisation is a dynamic ongoing process of knowledge creation within itself.


References


  1. W. McCarty, C., Hankemeier, D. A., Walter, J. M., Newton, E. J., & Van Lunen, B. L. (2013). Use of evidence-based practice among athletic training educators, clinicians, and students, part 2: attitudes, beliefs, accessibility, and barriers.Journal of athletic training,48(3), 405-415.
  2. Manspeaker, S., & Van Lunen, B. (2011). Overcoming barriers to implementation of evidence-based practice concepts in athletic training education: perceptions of select educators.
  3. Coomarasamy, Arri, and Khalid S. Khan. "What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review." Bmj329.7473 (2004): 1017.
  4. Muller, A., McCauley, K., Harrington, P., Jablonski, J., & Strauss, R. (2011). Evidence-based practice implementation strategy: the central role of the clinical nurse specialist. Nursing administration quarterly35(2), 140-151.
  5. Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research38(1), 4-23.
  6. Coomarasamy, Arri, and Khalid S. Khan. "What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review." Bmj329.7473 (2004): 1017.
  7. Moore, F., & Tierney, S. (2019). What and how… but where does the why fit in? The disconnection between practice and research evidence from the perspective of UK nurses involved in a qualitative study. Nurse education in practice34, 90-96
  8. Bell, K. M., & Naugle, A. E. (2008). Intimate partner violence theoretical considerations: Moving towards a contextual framework. Clinical psychology review28(7), 1096-1107.
  9. Moullin, J. C., Dickson, K. S., Stadnick, N. A., Rabin, B., & Aarons, G. A. (2019). Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implementation Science14(1), 1.


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