Moving into action: We know what practices we want to change, now what? An implementation guide for health care practitioners - Appendices

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Appendix A: Reference List

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Latimer, M.A., Johnston, C.C., Ritchie, J.A., Clarke, S.P. & Gillin, D. (2009). Factors affecting delivery of evidence-based procedural pain care in hospitalized neonates. Journal of Obstetric, Gynecologic and Neonatal Nursing, 38, 182-194. doi: 10.1111/j.1552-6909.2009.01007.x

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Appendix B: Glossary

Adapting the evidence: Existing evidence is evaluated and customized to fit the local context through a systematic process.

ADAPTE process: "…a systematic approach to adapting guidelines produced in one setting for use in a different cultural and organization context. The process has been designed to ensure that the adapted guideline not only addresses specific health questions relevant to the context of use but also is suited to the needs, priorities, legislation and resources in the target setting."

Barrier: A factor that may inhibit implementation.

Business case: "A proposal that can assist […] in presenting the reasoning for beginning a change project or group of tasks. […]The business case includes the reason for the project, the expected business results and benefits, and the costs and the risks. […] The case serves as a way to capture knowledge, functions as a basis for receiving funding and approval, helps prioritize the project against other competing initiatives that might also require funding, and secures a consistent message to all key stakeholders in the process."

Champion: "…champions can take many different roles such as bringing awareness of best practices to their organization, influencing groups and committees to consider these best practices, mobilizing, coordinating, and facilitating the training and development of professional staff in best practice guideline implementation etc."

Clinical practice guideline: Systematically developed statements of the recommended best practice in a specific clinical area, designed to provide direction to the practitioners in their practice.

Delphi Method: "Method for structuring a group communication process…to deal with a complex problem." This may involve creating a questionnaire that is then sent to a larger group. The results are then summarized and a new questionnaire is formed for the respondents to evaluate the original answers. This can occur until a consensus is formed.

Evidence: "credible verifiable data, facts, or information that have been systematically obtained." Evidence can be based on research findings, local data, consensus of recognized experts/national or international standards, patient preferences, or clinical expertise. For the purposes of this document a preference is made for research based knowledge.

Facilitator: A factor that may enhance implementation.

Focus Groups: Discussion and group interviews to elicit information about a specific topic.

Goal: "The aim or object towards which an endeavour is directed. " It is a concrete, observable and measureable target that you are trying to achieve, usually within a specific time frame.

Implementation: The process by which knowledge is applied to a setting.

Innovation: An idea, practice or object that is perceived as new by an individual or other unit of adoption.

Knowledge to Action Framework: "…based on a concept analysis of 31 planned action theories, was developed to help make sense of […] 'knowledge translation' or 'implementation' by offering a holistic view of the phenomenon by integrating the concepts of knowledge creation and action."

Opinion Leaders: "…informal leaders from the local healthcare setting who are viewed as important and respected sources of influence among their peer group."

Outcomes: The effects of your intervention and practice change on specific outcomes. These should include patient outcomes (e.g.: Lower infection rates). They may also include process outcomes such as specific rates of targeted behaviours; provider outcomes such as reduced turnover, or organizational outcomes such as hospital accreditation.

PARIHS framework: The framework comprises three elements: evidence, context and facilitation where successful implementation is function of these and their interrelationships. This framework can be used as a practical tool by clinicians in the local setting or in research.

Plan, Do, Study, Act (PDSA) Cycle: "…shorthand for testing a change, by planning it, trying it, observing the results, and acting on what is learned."

Stakeholders (taskforce or other organized group): A special committee with an expressed purpose, made up of individuals or groups that have an interest in, or are directly or indirectly affected by the implementation process.

Sustainability: "the degree to which an innovation continues to be used, after initial efforts to secure adoption is completed" (Rogers 2005, pg. 429).

Systematic Review: "seeks to systematically search for, appraise and synthesise research evidence [primary studies], often adhering to the guidelines."

Appendix C: EIDM Process Algorithm (adapted from a draft algorithm developed in the Transition Office at McGill University Health Centre)

This algorithm provides an example of a graphic depiction of the Evidence Informed Decision Making Process that outlines decision points in five inter-dependent phases for implementation and gives the planner an opportunity to consider the Local Resources, including the Tools and Supports, that might be required or available to assist in implementation. The algorithm refers to five phases: Identifying the practice, searching and appraising the evidence, adapting to the local context, implementing the change, and evaluating.

Identifying the practice: first identify the clinical issue and them identify a team to review clinical practice. The team should include a project lead, team members and stakeholders

Searching and appraising the evidence: first formulate a question to guide the review of the evidence, search the literature, assemble relevant research and literature, appraise and synthesise research for use in practice. Ask if there is sufficient knowledge to guide practice.

If the answer is no, then consult other types of evidence, conduct research, or consider other methods to determine what the practice should be.

If the answer is yes, then proceed to the next phase.

Adapting to local context: Consider the acceptability and applicability of the proposed practice, write an evidence-informed practice document and recommendations (eg adapted clinical practice guidelines), assess barriers and faciltators of implementation in this setting.

Implementing the change: Plan implementation strategies and test on a small scale. Ask if the practice change is appropriate for full deployment.

If the answer is no, then modify the implementation plan as needed

If the answer is yes, then implement the practice change.

Evaluating: Monitor and evaluate the outcomes, disseminate the results, sustain the change.

Appendix D: Factors influencing health care behaviours and intentions: A theoretical Model

Reproduced with permission from Implementation Science 2008, 3, 36-48.

This figure, reproduced here with permission from Implementation Science, volume 3 was published in 2008 by Godin and colleagues. The diagram identifies possible factors that could influence the intention and behaviour of health professionals. These factors were identified through a systematic review of studies that used social cognitive theories to explain healthcare behaviour.

The determinants of professionals' intention to adopt a particular behaviour are their beliefs about consequences, social influences, moral norm, role and identity, and the characteristics of the health profressionals. The intention to adopt the behaviour is influenced by the professionals' beliefs about their capabilities and their habits and past behaviours. Together, these three influence the actual behaviour.

Appendix E: Barriers, facilitators and implementation strategies spreadsheet tool

Goals and Outcomes:

Factor Barrier/Facilitation Relevance Implementation Strategy
Characteristics of the innovation
Individual care providers
Practice setting

Appendix F: Examples of barriers and facilitators


Lack of Awareness

Lack of Familiarity



Lack of agreement due to:

  • The scientific value of the evidence
  • The rigidity of the guideline
  • The threat to professional autonomy
  • The perceived bias of the author
  • The lack of clarification and impracticality of the guideline

Lack of applicability due to:

  • The characteristics of the patient
  • The clinical situation
  • The perception that knowledge implementation is not cost-beneficial
  • The lack of confidence in the individuals who are responsible for developing or presenting knowledge implementation

Lack of expectancy due to:

  • The perception that implementation will not lead to improved outcomes for either the patient or the health care process
  • The negative feelings that may be provoked by the new behavior resulted from knowledge implementation, and/or not having taken into account existing feelings around the process of implementation
  • The lack of self-efficacy
  • The lack of motivation to use knowledge or to change one's habits.
External Barriers

Factors associated with the patient:

  • the inability to reconcile patient preferences with the use of knowledge

Factors associated with knowledge use as an innovation:

  • The perception that the innovation cannot be experimented with on a limited basis
  • The perception that the innovation is not consistent with one's own approach
  • The perception that the innovation is difficult to understand and to put into use
  • The lack of visible results in using the innovation
  • The perception that the innovation cannot be created and shared with one another in order to reach a mutual understanding
  • The perception that the use of the innovation will increase uncertainty (for example, the lack of predictability, of structure, of information)
  • The perception that the innovation lacks flexibility to the extent that it is not changeable or modifiable by a user in the process of its adoption and implementation

Factors associated with environmental factors:

  • insufficient time to put knowledge into practice
  • insufficient materials or staff to put knowledge into practice
  • insufficient support from the organization
  • inadequate access to actual or alternative health care services to put knowledge into practice
  • insufficient reimbursement for putting knowledge into practice
  • perceived increase in malpractice liability if new knowledge is put into practice.

Adapted from KT Clearinghouse, CIHR and Implementation Science 2006, 1, 16-28.

Appendix G: Questions to assess barriers and facilitators

These can be used to assess barriers and facilitators with individual practitioners or formal leaders through:

  • Informal discussions or conversations with individuals
  • Semi-structured individual interviews
  • Focus groups
  • Following a presentation to introduce the innovation and group discussion
  • A paper based survey

The answers will help you consider which implementation strategies might be most appropriate.

Adapt the questions so that they are specific to your innovation and health practitioner (adapted from Brett, 1989):

  1. Have you heard or read about the innovation?
  2. Have you observed this innovation in use?
  3. What do you know about the innovation?
  4. Do you already use this innovation?
  5. Do you believe this innovation to be appropriate for this setting? Why or why not?
  6. Do you think this innovation fits with your role (as a nurse, physician, physical therapist etc…)?
  7. Do you think the innovation will lead to improved patient outcomes?
  8. Do you feel you have the skills/training needed to carry out the innovation?
  9. Do you think that there are enough resources (time, financial, space, personnel) to carry out the innovation?
  10. Is this innovation important to you? To your colleagues? To the leadership group? To your organization? To the patients and families?

Appendix H: Implementation checklist tool


  • A question or concern came up in my practice or practice setting.
    • Stakeholders were assembled to address the question and to review the evidence.
  • Evidence for an innovation or practice change was found or created and reviewed.
    • The strength of the evidence was appraised.
    • The best evidence (one or more sources) was found.
  • The gaps between the evidence and actual practice were identified through measurement.
    • Baseline data was collected in my practice setting about the actual state of practice at present.
    • A decision was made whether this concern is relevant enough to warrant moving to implement a change, based on the findings.
    • Goals for the practice change are written and are measurable.
    • The target for the behaviour change was determined. (Who? Where? When? What? How long?)
  • The evidence was adapted to my local setting.
    • The source of evidence was identified.
    • The recommendations were evaluated against evidence.
    • The stakeholders were involved.
    • The recommendations were developed into a user friendly format for my setting.
  • Barriers and facilitators were identified in my setting.
    • A spreadsheet was created.
    • Preparations and considerations were made prior to an assessment of barriers and facilitators.
    • A strategy or strategies to asses barriers and facilitators were chosen.
    • Barriers and facilitators were assessed.
    • The most relevant and influential barriers and facilitators as targets for implementation were determined.
  • Implementation strategies were used to target goals, barriers and to enable facilitators of change.
    • The most relevant and influential barriers and facilitators in my setting were reviewed.
    • Implementation strategies were considered for use in my setting.
    • Implementation strategies were organized in a spreadsheet.
    • The plan was discussed with the stakeholders and adjustments were made.
    • An implementation plan was made.
    • Methods of monitoring and ongoing support during the trial period were created. Adjustments were made as needed.
    • Successes were built on by expanding the implementation (to the objective initially set out.)
  • Outcomes were monitored.
  • The outcomes for implementation were evaluated.
  • Practice change was sustained over time.
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