with co-contributor Jacqueline Fawcett

The purpose of this blog is to highlight the importance of nursology theories in the field of implementation science- a science that focuses on generating knowledge about the “research-theory-practice-application” gap between evidence-based interventions (i.e. effective interventions) and how these interventions work or are applied (i.e. implementation strategies) in the “real-world” usual/routine settings (i.e. hospital, home, community, etc.) The topic was inspired by recent calls about implementation science in nursing (i.e., Boehm et al., 2020; Tucker, et al., 2021).

Although the “new” science overlaps with principles of quality improvement, knowledge translation, knowledge application, and research utilization, the focus of implementation science is on what is done by nursologists to assist individuals, teams, organizations, as well as health care and/or policy decision making systems to do/adapt things that are known to be effective in “real world” settings. Interventions that may be of interest to nursology implementation scientists, practitioners, and clinicians may include programs (e.g., pressure ulcers prevention programs), practice (e.g., nursing assessment of pressure ulcers risks), products (e.g., use of hydrocolloid dressings), medications (e.g., pain management options in pressure ulcer care), and policies (e.g., handoff policies for pressure ulcer prevention) (Brown et al., 2017). Achieving external validity is the focus of hypothesis testing and study designs in implementation science studies (Brown et al., 2017). Moreover, implementation outcomes of interest include acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability at various level of analysis, such as individual, interpersonal, organization, community and policy (Proctor, et al., 2011).

Case Reflection with Registered Nurses’ Roles in Mind

Nursology implementation scientists and practitioners are interested in the study of strategies or core components/drivers of implementing the activities and processes of evidence-based nursing interventions and outcomes associated with nursology practice such as those listed in the Nursing Interventions Classification (NIC) and Nursing Outcomes Classifications (NOC).

For example, let us reflect on the NIC example of Hypertension Management and nursology related activities outlined here:  https://nursing.uiowa.edu/sites/nursing.uiowa.edu/files/2021-05/Hypertension_Management.pdf). In this example, what do you think would be the implementation strategies that guide nursologists to adopt and sustain the listed “activities” for managing hypertension in their usual/routine practice settings? Think about the following nursology activity “Instruct the patient on possible causes of hypertension” related to hypertension management. Will the nursologists use a single strategy or multiple strategies? For this activity, the implementation strategy may include providing nursologists with regular competency/training and prompt reminders as part of relevant evidence-based implementation strategies, etc.

Now think about the following questions related to nursology in hypertension management: How does the evidence from bench and clinical trial studies influence nursology specific and team implementation strategies in routine care? How are nursology intradisciplinary and interdisciplinary teams organized and implemented in hypertension management? How do hypertension management implementation strategies differ among populations? The answers to these questions most likely are complex, as managing hypertension is multifaceted. The answers need a biopsychosocial approach which is a strength of all or almost all nursology inquiry and practice activities. However, for the majority of the nursologists, the process of theorizing nursology specific interventions and related implementation strategies to hypertension management maybe a challenge. This is at least partly due to lack of or underutilization of nursology implementation frameworks/models/theories (Drevenhorn, 2018).   The paucity of explicit theory underpinning implementation strategies puts nursology at risk for what Tucker et al. (2021) calls a “secondary gap” in intervention adoption of nursology interventions across real world settings.  Thus, there is an urgent need to evaluate and further develop explicit nursology theoretical approaches to better understand our implementation processes.  

Theoretical Approaches in Dissemination and Implementation Science

Nilsen (2015) identified three major theoretical approaches in implementation science : 1)theories that describe and/or guide the process of translating research into practice – process models (i.e., actions/planned models), 2) theories that provide understanding and/or explaining what influences implementation outcomes and evaluation frameworks – determinants frameworks, classic theories and implementation theories, and  3) theories that guide evaluation of implementation – evaluation frameworks.

Process Models

Examples of work by pioneering nursologist scientists and practitioners focused on advancement of action models for dissemination science (Tabak et al., 2012), with a special focus on quality improvement projects, include:  the Promoting Action on Research Implementation framework (Kitson et al., 1998); the Stetler Model (Stertler, 1994; 2001, 2010); the ACE Star Model of Knowledge Transformation, the Knowledge-to-Action Framework (Graham, et al., 2006), and the Iowa and the Ottawa Models (Logan & Graham, 1998; Graham & Logan, 2004). The Advancing Research & Clinical Practice through Close Collaboration (ARCC) Model (Melynk, 2002; Fine-Overholt et al., 2004) is another example of a nursology process model that was designed for systems-level implementation science.  The ConNECT Framework (Alcaraz, et al., 2017) is yet another example of a process implementation focused framework.

Determinants Frameworks

Examples of determinants frameworks include Neuman’s Systems Model (NSM), and Roy’s Adaptation Model (RAM). These nursology conceptual models include content about multiple stressors (NSM) or stimuli (RAM) that are determinants that function as facilitators of and barriers to effective implementation of evidence-based nursology interventions (primary, secondary and tertiary preventions as intervention in NSM; management of focal and contextual stimuli in RAM) for individuals, groups, and communities.

Other examples of determinants frameworks are classic change theories.  According to Nilsen (2015), these theories are used to study behaviors and analyzing cognitive processes in implementing evidence-based practice.  Existing nursing interactional theories such Peplau’s Theory of Interpersonal Relations and Travelbee’s Human-to-Human Relationship Model can be used to study behavior and decision-making process in nursology implementation science. Likewise, classic process change theories such as the “Peace and Power” Theory can be used to guide nursology intradisciplinary and interdisciplinary team practice in implementation science (i.e. development and relational processes for building healthy teams/communities in evidence-based practice).

Evaluation Frameworks

Most of the nursology process models and determinants frameworks include guidelines for evaluation of implementation of interventions and implementation strategies. These models incorporate an evaluation component with specific constructs and guides for measurement of outcomes. For example, the content of NSM includes a specific evaluation tool that is applicable for diverse populations across various clinical settings (Neuman & Fawcett, 2002).

Owning Our Past/Current Challenges and Moving Forward in Implementation Science

Although our disciplinary knowledge base includes conceptual models and theories that can guide implementation science, many nursologists – students and graduates alike – state that they do not know about or do not need nursology knowledge to practice effectively. For example, some senior undergraduate or graduate students, when asked if they know or have used a nursology model or theory to guide implementation of interventions, mention that they are not aware of this knowledge; others say they “only’ remember Maslow’s Hierarchy of Needs; and others say they do not need nursology theories because nursology is just common sense. These comments reflect how nursologist educators prepare or have prepared the new generation of nursology implementation scientists, practitioners and clinicians. Therefore, it is crucial that nursologist educators realize that it is impossible to think atheoretically (see https://nursology.net/2019/01/22/the-impossibility-of-thinking-atheoretically/) and assist students to learn the relevant models and theories so that everyone explicitly thinks theoretically.  As we move forward, we have to utilize and further refine nursology theories to specific nursology situations of interest, especially when considering the contributions of nursology in improving population health outcomes in real-world healthcare settings; this means that we need to devote more attention to development of situation-specific theories (see https://airtable.com/shrH3knZOc0FSFzyY/tbldApx4b6t8K54Ty).  Thus, we need to address and identify our nursology focus areas of interest in healthcare inquiries, translations and applications. Likewise, we need to assess the available evidence on key opportunities and barriers to nursology implementation strategies and outcomes. If we want to fully engage in multi-disciplinary implementation science, we need to have a clear understanding of nursology discipline-specific knowledge of implementation strategies for nursology interventions.

These questions are offered as a way to catalyze conversations about nursologists’ contributions to implementation science in health care: 

1. What nursology implementation strategies are of special interest to nursologists? (Implementation Strategies). Who sets up these implementation strategies?
2. What are the commonly studied implementation outcomes in nursology implementation research?  How are they described and measured? (Implementation outcomes and measures).
3. What nursology implementation strategies have been directed at the individual, team, and organizational levels? (Implementation intervention and strategies at various socio-ecological levels).
4. How do nursology implementation strategies contribute to the healthcare teams’ or facility/organization’s practice strategies? (Implementation unit of analyses).
5. Which designs have been used in nursology implementation studies?  (Implementation study design including multilevel study designs).
6. Since no single model perfectly fits most implementation projects, which nursology frameworks, theories, and models have contributed to effective implementation of nursology interventions and under what contextual conditions? (Implementation models, frameworks and theories in nursology). What criteria should nursologist use to effectively select and combine models/frameworks for nursology implementation projects?  Do the theories offer guidance on how to meet the current implementation health care demands placed on the nursologist? How can they guide the development of effective implementation strategies that maximize utilization of the full scope of nursology practice at various levels in real world settings?
7. To what extent are nursologists scientists, practitioners and clinicians competent in implementation science and methods? (Implementation science competencies).
8. How can we foster nursologists scientists, practitioners and clinicians’ collaboration to advance nursology implementation science and research? (Nursology implementation science teams). As key implementers of health care interventions, how are nursologists involved in identifying and making intradisciplinary and interdisciplinary team decisions ? 

Please share your thoughts about any of the questions posed in this blog by posting in the comment section of this blog.  

References

Alcaraz, K. I., Sly, J., Ashing, K., Fleisher, L., Gil-Rivas, V., Ford, S., … & Gwede, C. K. (2017). The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity. Journal of behavioral medicine, 40(1), 23-38.

Boehm, L. M., Stolldorf, D. P., Jeffery, A. D. (2020). Implementation Science Training and Resources for Nurses and Nurse Scientists. J Nurs Scholarsh. 52(1), 47-54. doi:10.1111/jnu.12510,

Brown, C. H., Curran, G., Palinkas, L. A., Aarons, G. A., Wells, K. B., Jones, L., Collins, L. M., Duan, N., Mittman, B. S., Wallace, A., Tabak, R. G., Ducharme, L., Chambers, D. A., Neta, G., Wiley, T., Landsverk, J., Cheung, K., & Cruden, G. (2017). An Overview of Research and Evaluation Designs for Dissemination and Implementation. Annual review of public health, 38, 1–22. https://doi.org/10.1146/annurev-publhealth-031816-044215

Brown, C. G. (2014). The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing. Clinical Journal of Oncology Nursing, 18(2), 157-159.

Drevenhorn, E. (2018). A Proposed Middle-Range Theory of Nursing in Hypertension Care. International Journal of hypertension, e2858253. 1-12. doi:10.1155/2018/2858253

Fineout-Overholt, E., Levin, R. F., & Melnyk, B. M. (2004). Strategies for advancing evidence-based practice in clinical settings. JNY State Nurses Assoc, 35(2), 28-32.

Graham, K., & Logan, J. (2004). Using the Ottawa model of research use to implement a skin care program. Journal of nursing care quality, 19(1), 18-26.

Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: time for a map?. Journal of continuing education in the health professions, 26(1), 13-24.

Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence-based practice: a conceptual framework. BMJ Quality & Safety, 7(3), 149-158.

Logan, J. O., & Graham, I. D. (1998). Toward a comprehensive interdisciplinary model of health care research use. Science communication, 20(2), 227-246.

Melnyk, B. M. (2002). Strategies for overcoming barriers in implementing evidence-based practice. Pediatric Nursing, 28(2), 159-161.

Neuman, B., & Fawcett, J. (Eds.). (2002). The Neuman systems model (4th ed.). Upper Saddle River, NJ: Prentice Hall.

Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implement Sci, 10, 53-65. https://doi.org/10.1186/s13012-015-0242-0

Proctor, E., Silmere, H., Raghavan, R. et al. (2011). Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health, 38, 65-76. https://doi.org/10.1007/s10488-010-0319-7

Stevens, K.R. (2004). ACE Star Model of Knowledge Transformation. Academic Center for Evidence-Based Practice, University of Texas Health Science Center at San Antonio. Retrieved from www.acestar.uthscsa.edu

Stetler, C. (1994). Refinement of the Stetler/Marram model for application of research findings to practice. Nursing Outlook, 42, 15-25.

Stetler, C. B. (2001). Updating the Stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49(6), 272-279. DOI: 10.1067/mno.2001.120517

Stetler, C. (2010). Stetler Model. In J. Rycroft-Malone and T. Bucknall (Eds.) Models and frameworks for implementing Evidence-Based Practice: Linking evidence to action. (pp. 51-77). Oxford: Wiley-Blackwell.

Tabak, R. G., Khoong, E. C., Chambers, D. A., & Brownson, R. C. (2012). Bridging research and practice: models for dissemination and implementation research. American journal of preventive medicine, 43(3), 337-350.

Tucker, S., McNett, M., Mazurek Melnyk, B., Hanrahan, K., Hunter, S. C., Kim, B., … & Kitson, A. (2021). Implementation Science: Application of Evidence‐Based Practice Models to Improve Healthcare Quality. Worldviews on Evidence‐Based Nursing, 18(2), 76-84.