Diffusion of Innovations: A Framework for Implementing Evidence-Based Practice Deborah Lekan, RNC,...

Diffusion of Diffusion of Innovations:Innovations:

A Framework for A Framework for Implementing Evidence-Implementing Evidence-

Based PracticeBased Practice

Deborah Lekan, RNC, MSNDeborah Lekan, RNC, MSN

Gerontological Nurse Clinical Gerontological Nurse Clinical SpecialistSpecialist

Duke University School of Duke University School of NursingNursing

Duke University School of Nursing, 2007, updated 2009

ObjectivesObjectives Define the key elements of the Define the key elements of the

diffusion of innovations model.diffusion of innovations model. Describe how the diffusion of Describe how the diffusion of

innovations model can be used to innovations model can be used to facilitate evidence-based nursing facilitate evidence-based nursing practice.practice.


““Good ideas Good ideas

do not sell themselves.”do not sell themselves.”(Rogers, E, 1995)(Rogers, E, 1995)

Putting new ideas such as Evidence-Putting new ideas such as Evidence-based Nursing, based Nursing, into practice,into practice, can be can be more complicated & difficult than the more complicated & difficult than the original research process that original research process that generated the scientific generated the scientific recommendations to begin with.recommendations to begin with.


Barriers to Putting Barriers to Putting New Ideas into PracticeNew Ideas into Practice

Implementation of best practices is Implementation of best practices is often--often-- Imposed by others: governing bodies, Imposed by others: governing bodies,

federal or state regulations or corporate federal or state regulations or corporate policies; policies;

Left to trial & error;Left to trial & error; Painfully slow;Painfully slow; Marked by resistance, incomplete Marked by resistance, incomplete

implementation, and failure.implementation, and failure. Planned change is difficult to Planned change is difficult to

accomplishaccomplish


Diffusion of Innovations: Diffusion of Innovations: DefinitionDefinition

The process by which The process by which (1) an (1) an innovationinnovation (2) is (2) is communicatedcommunicated through through certain channelscertain channels (3) over (3) over timetime (4) among (4) among membersmembers of a of a socialsocial systemsystem..

Diffusion is a Diffusion is a social processsocial process..Rogers, E., Diffusion of Innovations, 5th ed, 2003.


Examples of InnovationsExamples of Innovations ProductsProducts

Phone technology: digital pager, cell phone, Phone technology: digital pager, cell phone, camera phone, Blackberry (phone w/internet), camera phone, Blackberry (phone w/internet), iPod/phone/internetiPod/phone/internet

Ear thermometer, Pulse oximetry, BladderScan®Ear thermometer, Pulse oximetry, BladderScan® PracticesPractices

Restraint free environmentRestraint free environment behavior behavior management techniques & environmental management techniques & environmental modificationsmodifications

IdeasIdeas Illness & frailty is not a normal part of aging Illness & frailty is not a normal part of aging Pain as the 5Pain as the 5thth vital sign vital sign


An innovation is An innovation is all about all about PerceptionPerception

If it is If it is newnew to the to the user, then it is user, then it is an innovationan innovation


The Adoption Process: 5 The Adoption Process: 5 StagesStages

KnowledgeKnowledge — —Awareness & Awareness & understanding of the innovation understanding of the innovation

PersuasionPersuasion — —Form favorable opinionForm favorable opinion DecisionDecision — —Try it outTry it out ImplementationImplementation — —Put it to usePut it to use ConfirmationConfirmation —Adoption —Adoption of of

innovationinnovation

oror Rejection Rejection && DiscontinuationDiscontinuation of use of use


Confirmation and

Adoption, Re-invention, or Rejection

ContactAwareness

Understanding

Knowledge

Implementation

PersuasionTrial Use

Institutionalization

Full Scale Use

TIME

RATE or SPEED of ADOPTION

Decision

The Innovation-Adoption Process


Factors Affecting the Factors Affecting the Rate of Diffusion of Rate of Diffusion of

InnovationsInnovations Perceived Innovation Perceived Innovation

AttributesAttributes Type of Innovation- DecisionType of Innovation- Decision Communication ChannelsCommunication Channels Nature of Social SystemNature of Social System Change Agent EffortsChange Agent Efforts


One Area of FocusOne Area of Focus: : Perceived Innovation Perceived Innovation

AttributesAttributes Relative AdvantageRelative Advantage– better than status quo?– better than status quo? CompatabilityCompatability -consistent w/values, beliefs? -consistent w/values, beliefs? ComplexityComplexity -hard to do, use, or understand? -hard to do, use, or understand? TriabilityTriability -can it be tried out on a small scale? -can it be tried out on a small scale? ObservabilityObservability –is innovation or its results –is innovation or its results

visible? Can you see others using it or doing it?visible? Can you see others using it or doing it?


How can the Diffusion of How can the Diffusion of Innovations (DOI) Model help Innovations (DOI) Model help promote Evidence-based promote Evidence-based Nursing Practice?Nursing Practice?


It’s a given: Most people do not It’s a given: Most people do not desire changedesire change Inertia is comfortingInertia is comforting!!

Change creates uncertainty Change creates uncertainty anxietyanxiety

Human nature gravitates to Human nature gravitates to reducing & managing uncertainty reducing & managing uncertainty by resisting changeby resisting change


Diffusion of Innovations Diffusion of Innovations andand

Evidence-based Nursing Evidence-based Nursing PracticePractice Diffusion of innovations-Diffusion of innovations-

Helps us understand the process of Helps us understand the process of changechange

Takes some of the guesswork out of Takes some of the guesswork out of determining what may or may not work determining what may or may not work when attempting changewhen attempting change

A model for guiding implementation A model for guiding implementation of evidence-based practices to of evidence-based practices to enhance success & sustainabilityenhance success & sustainability


First Steps in Applying the DOI First Steps in Applying the DOI ModelModel

Pay attention to the Pay attention to the perception of the perception of the attributesattributes of the innovation among of the innovation among different groupsdifferent groups Relative advantageRelative advantage CompatabilityCompatability ComplexityComplexity Trialability Trialability ObservabilityObservability

Connect with opinion leadersConnect with opinion leaders to elicit to elicit feedback & marshal supportfeedback & marshal support


Heart Failure EBP: Heart Failure EBP: Recognition & Reporting of Recognition & Reporting of

S&SS&S Mrs. Jones appears to be going into Mrs. Jones appears to be going into

acute Heart Failure and you need to acute Heart Failure and you need to do a thorough assessment before do a thorough assessment before calling the MD/NP. calling the MD/NP.

List at least 5 signs & symptoms List at least 5 signs & symptoms of Acute Heart Failure that should of Acute Heart Failure that should be assessed?be assessed?


Acute Heart Failure S&SAcute Heart Failure S&S Shortness of breath, tachypneaShortness of breath, tachypnea Cough- persistent or only at nightCough- persistent or only at night Congestion, frothy sputum, can be blood-tingedCongestion, frothy sputum, can be blood-tinged Pale, cold clammy skinPale, cold clammy skin Edema in LE & sacrum, ascitesEdema in LE & sacrum, ascites Tachycardia, low blood pressure, pulse Tachycardia, low blood pressure, pulse

oximetry ↓oximetry ↓ Change in mental status, agitated, sleepy, Change in mental status, agitated, sleepy,

confusedconfused Decreased urine outputDecreased urine output Fatigue, muscle weakness, loss of appetiteFatigue, muscle weakness, loss of appetite Decline in ADL functionDecline in ADL function AnginaAngina


Heart Failure S&SHeart Failure S&S How can RNs, LPNs & NAs have a How can RNs, LPNs & NAs have a

shared understanding about this shared understanding about this important information? important information?

What information is most critical for What information is most critical for all levels of nursing staff?all levels of nursing staff?

How can this information be How can this information be translated so that staff gain a shared translated so that staff gain a shared knowledge & understanding about knowledge & understanding about the clinically-significant S&S?the clinically-significant S&S?


FACES job aidFACES job aid An acronym developed to simplify heart An acronym developed to simplify heart

failure S&S as a memory aid for all stafffailure S&S as a memory aid for all staff Modified from the Heart Failure Society Modified from the Heart Failure Society

of America of America http://www.hfsa.org/pdf/faces_card.pdfhttp://www.hfsa.org/pdf/faces_card.pdf

FACES used as a job aid, and to structure FACES used as a job aid, and to structure the Nursing Assessment form and the the Nursing Assessment form and the Nurse Aid WorksheetNurse Aid Worksheet

FACES used as a theme in education and FACES used as a theme in education and trainingtraining


FF Fatigue Fatigue Fast pulseFast pulse

AA Activities of Daily LivingActivities of Daily Living Appetite poorAppetite poor

CC CoughCoughCongestionCongestionConfusionConfusionChest PainChest Pain

EE Edema and weight gainEdema and weight gain Elimination-decreased outputElimination-decreased output

SS Shortness of BreathShortness of Breath

FACES: HEART FAILURE

Signs & Symptoms


Putting new Putting new knowledge/innovations knowledge/innovations

into practice can be difficult…into practice can be difficult… Many changes will not “fit” the Many changes will not “fit” the

system & you need to “work out the system & you need to “work out the bugs” or undergo reinvention before bugs” or undergo reinvention before full-scale implementation.full-scale implementation.

Some projects start out too big & fail Some projects start out too big & fail under their own ambitions or from under their own ambitions or from lack of attention to adoption.lack of attention to adoption.

““Change anxiety” can slow or halt a Change anxiety” can slow or halt a project.project.


Collaborative Learning Collaborative Learning Group ExerciseGroup Exercise

Case example:Case example: High rate of hospitalizations & ER transfers of High rate of hospitalizations & ER transfers of

HF patientsHF patients RN Team Leader approach to implementation RN Team Leader approach to implementation

of a heart failure CPG-based protocol with of a heart failure CPG-based protocol with LPNs & CNAs on the clinical unitLPNs & CNAs on the clinical unit

Divide class into small groups of 5Divide class into small groups of 5 Materials: Materials:

Diffusion of Innovations Attributes WorksheetsDiffusion of Innovations Attributes Worksheets Detailed lesson plan for this experience (link)Detailed lesson plan for this experience (link)


Case SummaryCase Summary You are a recent graduate working as a charge nurse in You are a recent graduate working as a charge nurse in

a small community hospital or nursing home. On your a small community hospital or nursing home. On your 24 bed clinical unit, you work with a team of 3 LPNs 24 bed clinical unit, you work with a team of 3 LPNs and 8 NAs.and 8 NAs.

You observe that there is a high rate of ER transfers You observe that there is a high rate of ER transfers and hospitalizations of heart failure patients. Nursing and hospitalizations of heart failure patients. Nursing staff do not routinely assess or monitor patients and staff do not routinely assess or monitor patients and consider HF an intractable problem that only gets consider HF an intractable problem that only gets worse and requires hospitalization for effective worse and requires hospitalization for effective treatment. treatment.

Based on your knowledge of HF CPGs, you decide that a Based on your knowledge of HF CPGs, you decide that a protocol for early detection of HF S&S would improve protocol for early detection of HF S&S would improve nursing staff’s recognition and reporting of early nursing staff’s recognition and reporting of early indicators would facilitate treatment and prevent acute indicators would facilitate treatment and prevent acute events leading to hospitalization and the negative events leading to hospitalization and the negative consequences for the patient.consequences for the patient.

How would you approach the development and How would you approach the development and implementation of a simple way for all staff to implementation of a simple way for all staff to understand the important indictors for HF monitoring? understand the important indictors for HF monitoring?


Implementing a Protocol Implementing a Protocol for Early Recognition of for Early Recognition of

S&S of Acute HF S&S of Acute HF ExacerbationExacerbation

Small group discussion on the Small group discussion on the individual innovation attributes relative individual innovation attributes relative to the use of the FACES job aid & skill to the use of the FACES job aid & skill development among LPNs and CNAsdevelopment among LPNs and CNAs

Large group discussion to share Large group discussion to share strategies to address barriers & strategies to address barriers & facilitatorsfacilitators


Small Group Exercise: Small Group Exercise: DOI & Innovation DOI & Innovation

Attributes Attributes Analyze attributes of Analyze attributes of

the EBP relative to the the EBP relative to the staff involved in staff involved in implementation & implementation & context of carecontext of care

Divide into 5 groupsDivide into 5 groups Use the DOI Use the DOI

worksheets to analyze worksheets to analyze potential barriers & potential barriers & facilitatorsfacilitators

DOI DOI Worksheets:Worksheets:

1-Relative 1-Relative AdvantageAdvantage

2-2-Compatability Compatability

3-Complexity3-Complexity 4-Trialability4-Trialability 5-5-

ObservabilityObservability


Review:Review: DOI Innovation DOI Innovation AttributesAttributes

Relative advantage-Relative advantage--better than what was -better than what was done before, i.e., sporadic recall of some S&Sdone before, i.e., sporadic recall of some S&S

Compatability-Compatability--consistent with expectations -consistent with expectations & previous practice of risk factor assessment& previous practice of risk factor assessment

Complexity-Complexity-- S&S simplified with a - S&S simplified with a pneumonicpneumonic

Trialability-Trialability--piloted tested several versions & -piloted tested several versions & added new clinically-significant symptomsadded new clinically-significant symptoms

Observability—Observability—developed colorful pocket developed colorful pocket cards, posters, formscards, posters, forms


Large Group DiscussionLarge Group Discussion Each group reports on the innovation Each group reports on the innovation

attribute that they analyzed relative to attribute that they analyzed relative to implementation of the HF protocolimplementation of the HF protocol

Discuss key strategies to - Discuss key strategies to - Raise awareness & understanding, Raise awareness & understanding, Foster positive attitude & commitment to the Foster positive attitude & commitment to the

goal of improving detection of early HF, goal of improving detection of early HF, Build skill & self-efficacy, Build skill & self-efficacy, Promote continuity of carePromote continuity of care Embed new practices into daily routines & Embed new practices into daily routines &

documentation systemsdocumentation systems


ReflectionReflection

How does the DOI model and How does the DOI model and innovation attributes facilitate innovation attributes facilitate implementation of new evidence-implementation of new evidence-based practices?based practices?

Identify Identify 2 leadership strategies2 leadership strategies the the RN can use to persuade LPNs & RN can use to persuade LPNs & CNAs about the advantages of the CNAs about the advantages of the HF protocolHF protocol


Diffusion of InnovationsDiffusion of Innovations

The DOI model provides a framework to The DOI model provides a framework to help help identify barriersidentify barriers among individuals, among individuals,

groups, & at the organizational levelgroups, & at the organizational level target strategiestarget strategies to these subgroups that are to these subgroups that are

more likely to overcome or minimize barriersmore likely to overcome or minimize barriers identify strengths or facilitatorsidentify strengths or facilitators that can be that can be

marshaled to accelerate the change processmarshaled to accelerate the change process The goal is to The goal is to accelerateaccelerate the rate of the rate of

adoption and ensure desired outcomes & adoption and ensure desired outcomes & sustainabilitysustainability


““Innovation never happens as planned.”Innovation never happens as planned.” (Gifford Pinchot. Environmentalist)(Gifford Pinchot. Environmentalist)

You can count on Murhpy’s Law! Even the best laid plans You can count on Murhpy’s Law! Even the best laid plans do not lead to an uncomplicated process of smooth do not lead to an uncomplicated process of smooth implementation. If you expect & plan for set backs or implementation. If you expect & plan for set backs or problems, you are better able to manage them rather than problems, you are better able to manage them rather than be at the mercy of being undermined or halted. be at the mercy of being undermined or halted.

““If you want to make enemies, try to If you want to make enemies, try to change something.”change something.” (Woodrow Wilson)(Woodrow Wilson)

It is important to use various tools & strategies for change.It is important to use various tools & strategies for change.

““If you want to truly understand If you want to truly understand something, try to change it.”something, try to change it.” (Kurt Lewin) (Kurt Lewin) All change involves people with different ideas & goals.All change involves people with different ideas & goals.


Suggested ReadingsSuggested Readings

The classic text: Diffusion of The classic text: Diffusion of Innovations, Innovations, 5th Ed5th Ed. 2003, Everett M. . 2003, Everett M. RogersRogers http://www.amazon.com/exec/obidos/tg/http://www.amazon.com/exec/obidos/tg/

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Diffusion of Innovations: A Framework for Implementing Evidence-Based Practice Deborah Lekan, RNC,...

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