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How to use evidence-based practice within a clinical environment

This is an excerpt from Evidence-Based Practice for Rehabilitation Providers by David R. Dolbow,Hope Jervis Rademeyer.

Implementing and Sustaining Evidence-Based Practice Within a Clinical Environment

Even across a national sample of health care providers with additional education and training on EBP implementation after 12 mo, some barriers and facilitators emerged as the most influential to implementing EBP.¹⁵ These barriers were a lack of resources, implementation climate, lack of relative priority, poor leadership engagement, and organizational characteristics. Top facilitators were strong leadership engagement, positive EBP culture, and resource availability. Using a framework can facilitate EBP implementation by addressing barriers, leveraging facilitators, and defining a systematic plan. While you may or may not be involved in designing the implementation plan according to a framework, as a health care provider, you might be involved in different steps. You may be asked to work as a clinical champion to facilitate the adoption and sustainment of the EBP intervention. You could be asked to provide your opinion about barriers and facilitators to the use of the EBP intervention. As part of a clinical research study, you may be asked to use an intervention with patients (e.g., provide certain exercises, use a device, etc.) or provide assessments. Furthermore, you may participate in interviews, focus groups, or surveys to gather evidence about an intervention.

There are three frameworks that you may come across as your team plans to integrate EBP into your clinical practice environment: Promoting Action on Research Implementation in Health Services (PARIHS) framework¹⁶ and the revised implementation-PARIHS (i-PARIHS); Exploration, Preparation, Implementation, Sustainment (EPIS) framework;¹⁷ and Interagency Collaborative Team (ICT) model.^17,18

Promoting Action on Research Implementation in Health Services Framework

The PARIHS framework is composed of three core elements that interact to form the basis of knowledge translation:¹⁶ evidence, context, and facilitation. In other words, successful implementation of EBP is a function of evidence, context, and facilitation (i.e., successful implementation = function of [evidence, context, facilitation]). Each component of the three elements is rated on a continuum from low to high, with high being the preferred choice (e.g., high level of research evidence, high level of culture, high level of role).

The nature and strength of the evidence are assessed in addition to its probable implementation. Under the evidence subheading, the research is evaluated according to quality.¹⁶ Additionally, the health care provider’s clinical experience and patient preferences are considered. The context is the environment or setting in which EBP is implemented. The elements under this heading include understanding the dominant culture, different leadership roles, and the organization’s approach to measurement (i.e., evaluation). The PARIHS framework uses facilitation to describe the type of support needed to help people modify their attitudes, skills, ways of thinking and working, and habits.¹⁹ Facilitation includes personal characteristics (e.g., credibility, openness, etc.), role characteristics (e.g., authority, role clarity, etc.), and facilitation style (e.g., consistent and appropriate presence, range and flexibility of style, etc.).

The PARIHS framework is not only simple and easy to use, but it also has other strengths.²⁰ It acknowledges the nonlinear and holistic nature of implementation.^16,21 It describes the interrelationship among the core elements of evidence, context, and facilitation. This framework is flexible because the user can choose to use only the applicable elements, and it can be incorporated using many different theories.^22,23 Finally, it underscores the importance of patient engagement throughout the implementation process.²⁴

The PARIHS framework has both strengths and limitations. Harvey and Kitson noted that the PARIHS framework requires more rigorous development and testing of evaluative methodologies.²⁵ Also, based on the framework elements, instruments should be designed. Although a facilitator training program is needed to help operationalize the framework, Harvey et al. suggested that there is too much emphasis on the facilitation role rather than the process.²⁶ Furthermore, the elements and sub-elements are poorly defined, and some promising sub-elements were excluded.²⁷ There is limited evidence demonstrating the effectiveness of the original PARIHS framework, and it does not define what successful implementation should look like.²⁶

To improve the PARIHS framework’s design, the implementation-PARIHS (i-PARIHS) framework was created.²⁵ Specific revisions include the description of evidence, integration of the individual and team, and improved content detail.

Exploration, Preparation, Implementation, Sustainment Framework

The EPIS (Exploration, Preparation, Implementation, Sustainment) framework includes four phases that describe the process of implementation.²⁷ During the Exploration phase, the health needs of the target individuals or group (e.g., patients, community) are identified, and different EBPs are explored to address these needs.^17,27 During the Preparation phase, once an EBP is selected, an implementation plan is created to address potential barriers and leverage potential facilitators. Next, in the Implementation phase, use of the EBP begins within the system. Lastly, in the Sustainment phase, the different components of the EPIS framework (i.e., inner context, outer context, bridging factors, innovation factors, and linkages) are maintained and adapted as needed.

Situated within the EPIS phases are the outer context and inner context.²⁷ The outer context is the environment external to the organization, such as services, interorganizational relationships, or the EBP users or targets.¹⁷ The inner context concerns characteristics within the organization, such as leadership, internal policies, staffing, and so on. Bridging and innovation factors span the two contexts and are connected by interconnections, interactions, linkages, or relationships. Innovation factors are related to the overall characteristics of the EBP being implemented. (i.e., EBP fit, EBP developers, EBP characteristics). Bridging factors refer to the relationships between the components of the outer and inner contexts.

A strength of the EPIS framework is that it can apply to a variety of settings. It considers a multilevel conceptualization of implementation processes from individuals to the system.¹⁷ This framework also considers the potential interactions among these processes. The EPIS framework can replace the use of multiple frameworks due to its flexibility in application (e.g., understanding processes, evaluation, determinants, and implementation). Moreover, although EPIS was created in the United States, it has broad applicability across countries.

There are some limitations to using the EPIS framework. It has been suggested that it lacks depth and breadth of application.^17,27 It should include a more precise operationalization of factors. Additionally, it should seek to develop aligned measures and expand its user networks.

Interagency Collaborative Team Model

To achieve EBP implementation across multiple systems, the ICT model uses frontline providers as agents to facilitate adaptation and provide training and quality control.²⁸ It focuses on large geographic areas by leveraging interagency collaboration and sharing of expertise among these agencies.

The ICT implementation processes include (1) initial EBP education, (2) stakeholder development and alignment, (3) practice fit assessment, (4) solidify resource supports, (5) focus on fidelity, (6) skill development, and (7) progress monitoring and feedback.

Furthermore, six steps are involved in each implementation process described by the ICT model, which are as follows: (1) Convene stakeholders, (2) Solicit relevant expertise, (3) Develop commitment and direction among stakeholders, (4) Create an interagency seed team, (5) Form interagency training teams, and (6) Plan a phased reduction in EBP developer involvement.

Hurlburt et al. provide further detail for creating an interagency seed team and forming interagency training teams.¹⁸

Each implementation process within the ICT model can be mapped onto one of the four EPIS framework stages: exploration, preparation, implementation, and sustainment.¹⁸ The six ICT steps are then used in different combinations depending on the specific EPIS stage and the implementation process being targeted.

The ICT model includes some specific strengths. When used together, this model helps clarify and strengthen the EPIS framework. This model also seeks to address some of the EPIS framework’s limitations. For example, the ICT model operationalizes the stages of the EPIS framework. Also, the ICT model provides a staged deployment process, which encourages early successes, thereby leading to increased motivation.¹⁸

Some limitations should be considered when implementing the ICT model. The group members may not share the same organizational values or culture, which may affect their initial commitment. It may be challenging to recruit enough strong leaders for the seed team.¹⁸ Communication structures surrounding implementation may be difficult to establish. Defining roles within the implementation strategy relative to workplace roles (e.g., a physical therapy manager who is involved with the intervention versus an allied health manager who is not part of the intervention) may also be difficult, leading to power imbalances.

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