Implementing A Research Framework Getting from Results to Practice and Policy: Implications for Implementation

Sheila A. Haas, PhD, RN, FAAN Professor Niehoff School of Nursing Loyola University Chicago

Translation Science Definition: “Investigation of methods, interventions and variables that

influence adoption by individuals and organizations of evidence-based practices to improve clinical and operational decision making in health care.” (Titler, 2008, p. 1-115-1-116).

Empirical foundation for translational science is evolving from EBP protocols implemented via translational research in a diversity of settings

Types of Translational Research: T1 research expedites the movement between basic research and

patient-oriented research that leads to new or improved scientific understanding or standards of care.

T2 research facilitates the movement between patient-oriented research and population-based research that leads to better patient outcomes, the implementation of best practices, and improved health status in communities.

T3 research promotes interaction between laboratory-based research and population-based research to stimulate a robust scientific understanding of human health and disease. (Rubio et al., 2010)

Even the best evidence-based guidelines or protocols cannot always: Change practice Enhance care outcomes Be sustained over time

Use of theory in translational research can assist in: Analysis of the context where evidence-based guidelines or

protocols are being implemented Theory is a “road map”

Identification of contextual variables, especially beliefs and attitudes

Development of strategies to assist in controlling contextual variables

Determining dose and timing of interventions Delineating outcomes Development of strategies for sustainability Development of strategies for diffusion of innovation

Lessons from Practice

State of the Science on Theory and Knowledge Translation (Rycroft-Malone, 2007).

Theory use and development = promising approach to better understand the black box of implementation

Within available evidence, issues include: Researchers do not pay enough attention to the theoretical underpinnings

of their work Or, provide sufficient contextual details for an assessment of transferability

(Grimshaw et al., 2004). Some RCTs do not have long enough test time to provide real

understanding of outcomes Currently, no clear directions for translational

researchers, practitioners or administrators to make decisions about: Implementation strategies to use In what context Facilitated by who With what groups or stakeholders What techniques to enhance sustainability

Translation Science Challenges Translation science (TS) is relatively new to U.S. nursing education

and practice

Stakeholders: Health Care Organizations

Need to implement EBP and demonstrate high quality outcomes Need to generate empirical outcomes to meet quality, pay for performance

expectations and attain Magnet status Credentialed Nurses: APNs and Nurses in Specialty Practice

Many masters and BSN prepared were educated more than 10 years ago when evidence-based practice and EBP for specified patient populations was not taught or an expectation of practice

Few APNs prepared at DNP level and high degree of variability among programs producing DNPs

Nurse educators: Now educating re: EBP, yet many unaware of Translation Science Traditional nurse researchers often see TS as “second class” research,

since does not use traditional research methods Limited expectations for TS education; only in DNP essentials of AACN Limited U.S. Translational Science texts, literature and experts

Translation Science Challenges Validity, reliability and volume of data generated through documentation of

processes and outcomes of translational research protocols holds great promise of: Enhancing knowledge of what interventions are most effective With what populations of patients Done by which professionals

Logic Modeling can provide insights and stimulate methods used to enhance data capture of contributions of care providers by discipline and credential

Tracking of EB processes and outcomes is dependent on indicators coded in standardized language and embedded in documentation in the Electronic Health Record (EHR). Yet: Only about 20% of health care organizations in U.S. have fully integrated EHRs Many extant EHRs do not have architecture that will accommodate standardized

language coding of indicators Leadership lacks understanding of need for standardized language coding in

documentation There are shortages of nurse informaticians, so time to production of

documentation screens is protracted

Credentialing and Translational Science Translational science done by credentialed nurses should

accelerate movement between patient-oriented research and population-based research, leading to: Better patient outcomes Implementation and ongoing evaluation of best practices Sustained best practices Improved safety, quality of care and health status in

communities Data generated through translational science when captured in

coded documentation indicators will provide an ongoing robust data base of process and outcome contributions by credentialed nurses

Role of Credentialed Nurses in Translational Research and Science Credentialed nurses are more likely to:

Pursue credible research in their area of expertise Participate as part of an interprofessional team in health care

organizations Understand importance of data, informatics and methods used to

capture documentation data Be a member of a professional organization and be more aware

of quality, safety and health policy issues Be involved in their community initiatives where they share their

expertise Network and take on mentoring with colleagues Understand increasing expectations by HC employers that they

take a lead in identifying and using best evidence in care delivery, administrative decision making, education and fostering policy change to enhance quality, safety and care outcomes

Understand escalating needs to demonstrate “value added” by credentialed professionals

Role of Credentialed Nurses in Translational Research and Science Function as facilitators of Translational Research (TR) teams in

health care organizations: Enhance identification of clinical, administrative, educational and policy

problems amenable to TR Foster development of collaborative interprofessional TP teams Stimulate identification and use of theory to guide TR projects Communicate and effectively collaborate with stakeholders Mentor TR team members in evaluation of evidence and development

of evidence-based protocols Stimulate development of EBP Protocols and modifications based on

implementation trend data Effectively foster development of standardized language coded process

and outcome indicators through interface with informaticians Create and implement plans for sustainability and diffusion of TR

projects Mentor other credentialed nurses to assume a TR facilitator role

If Contributions of Credentialed Nurses were Validated Through Research, Then Health care employers would hire and/or

develop credentialed nurses: Not only for their direct care roles, but leadership in

problem identification and moving evidence into practice and sustaining EBP over time

For their professional commitment to ongoing growth and development both personally and of peers

Also, for their capacity to fully participate in interprofessional teams where quality and safety are paramount

Not only for their focus on patient and family engagement, but commitment to population health management

For advocacy around issues that impact patients, populations, as well as, providers of care

Recommendations: Accelerate pace at which nurse educators learn,

appreciate, teach and facilitate translational research in place of descriptive research

Foster nurse faculty practice as translational research facilitators in health care organizations

Expedite movement to EHR internal architecture that supports use of standardized coding by producers and vendors of EHR software

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Resources for Translational Research (cont.)

Poe, S. & White, K. (2010). Johns Hopkins Nursing Evidence-based Practice: Implementation and Translation. Indianapolis: Sigma Theta Tau

Pronovost, P., Berenholtz, S. & Needham, D. (2008). Translating evidence into practice: A model for large scale knowledge translation. BJJ, 337, 963-965.

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Wagner Model

Reprinted with permission from the American College of Physicians. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998; 1:2-4.