Special Article

MODELS FOR IMPLEMENTATION AND

INTEGRATION OF EVIDENCE-BASED PRACTICE

Laura Cullen, DNP, RN, FAAN

Evidence-Based Practice Scientist
Nursing Research, Evidence-Based Practice and Quality
Department of Nursing Services and Patient Care
University of Iowa Hospitals and Clinics

Nurses in a variety of roles are responsible for providing and leading evidence-based practice improvements. There are many models
and the list of potential implementation strategies is extensive. Yet few in healthcare are prepared to lead EBP through the most difficult
step in the process, including implementation and integration of the practice change. Selecting a model, choosing implementation
strategies to use and when to apply them, continues to be a bit of an ‘art’. This article describes two models. One model outlines the EBP
process. The Iowa Model is well established and used in 38 countries worldwide. Another model, the EBP Implementation Guide, can
be used for promoting adoption of clinical practice recommendations in complex healthcare systems by providing an organized method
for planning implementation. The EBP Implementation Guide is rapidly spreading and in less than two years, has been adopted for use
in 15 countries. The model presents four phases that facilitate selection and use of effective strategies to promote provision of evidence-
based healthcare. Both models build upon the seminal work of Everett Rogers.1

KEY WORDS：Evidence-based practice, evidence-based
practice model, Iowa Model, evidence-based implementation
model, model, implementation science
Nurses are responsible f or leading evidence-based
practice improvements. An increasing number of national and
international agencies, regulatory standards, and professional
organizations endorse evidence-based healthcare. Third party
payers in the U.S.（e.g., insurance companies and the Centers for
Medicare and Medicaid）are using reimbursement to promote
2
evidence-based care that improves outcomes. In countries with
government supported health care, public policy establishes
evidence-based health care as the standard. Now with quality
comparisons 3 and access to inf ormation on the internet,
consumers expect evidence-based healthcare as well.
Evidence-based practice is defined as “the process of
shared decision-making between practitioner, patient and others
significant to them based on research evidence, the patient’ s
experiences and pre f erences, clinical expertise or know-how, and
4
other available robust sources of inf ormation”. Recommendations
for evidence-based care are abundant. Yet research shows
inconsistent use of evidence globally. 5-13 Basic nursing
interventions from oral care to sleep and activity promotion
are difficult despite evidence showing improved outcomes for
patients.14-17 Even hand hygiene has suboptimal compliance
despite strong evidence, regulatory standards and relevance to
practice.18
Several models guide organizational and project leaders
through the steps of the evidence-based practice（EBP）
process.19-22 Most of these process models include similarity
in over-arching problem-solving steps such as identif ying
a problem; critiquing evidence; implementing appropriate
recommendations; evaluating the change in patient outcomes and
disseminating results. Additional models and frameworks focus
on implementation.23-27
The EBP process model selected for use should assist
frontline clinician to move an EBP change forward into practice.
Selecting a model for an organization requires thoughtful review
by clinician users.28 The model should be relevant to users and
provide guidance given the reality that EBP is a messy, non-linear
process. The Iowa Model22 will be described here, as it is one of
the most commonly used globally with over 3,000 requests from

千葉看会誌 VOL.20 No.２ 2015.１ 51

38 countries.29
Using the Iowa Model of EBP to Promote
Quality Care
The Iowa model begins by encouraging clinicians to
identify practice questions or “triggers”（Figure 1）
. Some triggers
have existing data highlighting an opportunity for improvement.
Others come from new knowledge（e.g., scientific updates）
. Even
difficult to change practice traditions have been addressed using
30
the Iowa Model. The next step, identifying organizational
priorities will facilitate garnering support for EBP. Priority
may be given to topics that address high-volume, high-risk, or
high-cost procedures, those that are closely aligned with the
institution’s vision or strategic plan, or those driven by other
institutional or market forces.
Once there is commitment to address the topic, a team
is formed to develop, implement, and evaluate the practice
change. The team includes stakeholders representing staff
nurses, interdisciplinary colleagues, with unit and organizational
leaders. Unit leaders establish the continued commitment, adjust

Figure 1 Iowa Model of Evidence-Based Practice to Promote Q uality Care（Used with permission, Titler et al., 2001）22

52 千葉看会誌 VOL.20 No.２ 2015.１

scheduling to promote staff nurse participation, and integrate
the practice into clinician’s workflow. EBP experts may be
team members or consultants serving to mentor clinicians,
obtaining funding, and troubleshoot application in practice. Team
members also provided active committee linkages within the
governance structure through their membership. For example,
an oral mucositis EBP included members from nursing quality,
hospital dentistry, dietary, hematology–oncology, radiation
oncology, oral pathology, patient education, staff education, the
products committee, nursing policy committee, and the nursing
31
management council. The team used these linkages to support
communication and coordination.
Initially, the team selects, reviews, critiques, and synthesizes
available research evidence. Collaboration with librarians
can be particularly helpful in optimizing yields from online
32
bibliographic databases and other resources. When the research
is sufficient or lower level evidence are used, a practice change is
piloted. Piloting is an essential step in trialing the EBP change
and is essential for identifying issues before instituting a hospital-
wide rollout. Piloting involves multiple steps. Developing a
practice protocol can take many forms including development
of an evidence-based policy, procedure, care map, algorithm, or
other document outlining the practice and decision points for
clinician users. Implementation during the pilot requires planning
23,33,34
and selection of effective implementation strategies.
comparison of baseline and post-pilot data shows the success of
the pilot, effectiveness and feasibility of the EBP, and need for
modification of either the implementation plan or the practice
protocol.
Following the pilot, a determination is made regarding
appropriateness of sustained adoption in the pilot unit and
beyond. A decision regarding adoption or modification of the
practice is based upon pilot data. If the practice change is not
appropriate for adoption and rollout, quality or performance
improvement monitoring is needed to ensure high-quality care.
If pilot results are positive, rollout and integration of EBP are
facilitated through leadership support, education, and continuous
35,36
monitoring of outcomes. Monitoring and reporting trends
in structure, process, and outcome indicators with actionable
feedback promotes integration.35,37 Dissemination of project
results is a key step in the cycle promoting adoption of EBPs
35
within the system.
The Iowa model provides a practical guide for the EBP
process. The model includes feedback loops highlighting the
messy and nonlinear nature of EBP and support teams moving
forward. The Iowa model was designed to support evidence-
based healthcare delivery by interdisciplinary teams.36,38 The Iowa
Model provides step-by-step direction but some steps require
careful consideration and planning.
Guiding Implementation
As practitioners know, the change process is complex.
Change theories provide a conceptual foundation, yet lack
direction for planning and rarely address the needs of teams.
Teams need step-by-step guidance for implementation at the
point of care. Current approaches are ineffective and lead to
“reduced patient care quality and raises costs for all, the worst of
both worlds”.39（p.380）
The Evidence-Based Practice Implementation Model builds
1
upon Rogers（2003） Diffusion of Innovation Theory and
several others24,25,40. In addition, the implementation model draws
from the field of implementation science, translational research
and EBP, organizing the long list of implementation strategies
that promote adoption of EBP.41 In addition to these sources,
patterns from use of a variety of implementation strategies from
decades of work added insight in its development.23 It is well
established that change happens over time and a large number
of implementation strategies have been tested and reported, yet,
there is little direction regarding when to use specific strategies
A throughout the implementation process. This model is meant to
supplement EBP process models, not replace them. It is designed
to be simple and intuitive.
The Evidence-Based Practice
Implementation Guide
The Evidence-Based Practice Implementation Guide（Figure
2）is organized to provide clinicians and leaders guidance in
planning for and select effective strategies for implementing
EBP changes. Strategies are selected and positioned in the
model to enhance the movement through four phases of
implementation: creating awareness and interest; building
knowledge and commitment; promoting action and adoption;
pursuing integration and sustainability to promote application.
Implementation phases are displayed as columns progressing from
awareness to integration. Implementation strategies are arranged
in two rows, according to target groups. The first group of
strategies, shown in row one, specifically target the practitioners
and organizational leaders, including key stakeholders. The
second group of strategies, shown in row two, builds support
within the organizational system or context, to hard wire the
千葉看会誌 VOL.20 No.２ 2015.１ 53
EBP to improve adherence. Project leaders select implementation
strategies moving across phases that are appropriate for their
particular unit and organization as the EBP initiative progresses.
Although the model is diagrammed in a linear format for ease
of use, the process is not linear and is fluid across implementation
phases. Within a clinical team, practitioners may be in different
phases or move forward or back across phases in a non-linear
manner. Some strategies from an earlier phase will need to be
carried over for use throughout the implementation process.
Selecting Implementation Strategies
No standard set of implementation strategies can be

Figure 2 Evidence-Based Practice Implementation Guide（Used with permission, Cullen & Adams, 2012）23

54 千葉看会誌 VOL.20 No.２ 2015.１

suggested.42 Evidence supporting individual strategies varies and
41
is beyond the scope of this paper. Implementation strategies
with some empirical evidence are marked with asterisks, despite
the varying strength of evidence. Thus, a simplified system is
used so as not to distract from use of the model. Within less
than two years, the EBP Implementation Guide has already
demonstrated usefulness, with over 700 requests from 15
countries.43
Some strategies are highly effective and widely applicable.
For example, audit and data feedback have extensive research
37
evidence, supplemented by reports from practice. Academic
detailing or educational outreach visits are a strategy with
evidence showing impact particularly on physician prescribing
in ambulatory settings and growing evidence in other settings,
44
impacting other healthcare practices and practitioners. Some
implementation strategies included in the model have little
to no research evidence of effectiveness（e.g., education using
unit posters; reporting of local case studies demonstrating an
opportunity for improvement; creating slogans and logos）
. is to have a core group of change agents use academic detailing,
Despite these challenges they are commonly used strategies
and may be appropriate to include in a comprehensive
implementation plan.
In addition to var ying bodies of evidence f or each
implementation strategy, is the added issue of localizing use to
the clinical context. Implementation strategies are expected to
work differently in different settings. What works in one area
may not work in another. Selection of implementation strategies
is based on strength of evidence, adaptability to the setting,
expectations of clinicians and guided by user feedback.
Creating Awareness and Interest
Becoming aware and interested in a practice change is
the first step toward adoption（Column 1 of Figure 2） . These
strategies start early and some may be helpful throughout the
implementation and sustainment phases. Interest wanes over time
due to competing demands and staff turnover. Multifaceted,
on-going strategies are needed to keep the practice change in the
forefront.
Highlighting the positive characteristics of an EBP change
such as the relative advantage and compatibility with group
values can promote awareness and interest among clinicians.1
Although empirical evidence is limited, creating slogans and
45
logos can be a fun way to grab the attention of busy clinicians.
Creating a contest to generate a project slogan can get staff
involved. Strategically placing these logos on project related
materials throughout implementation（e.g., resource manual or
materials, reminders, and data feedback）keeps busy clinicians
focused on promoting adoption.
Involve senior executives early. Senior leaders want to
support clinician driven evidence-based improvements and
need suf ficient inf ormation about the purpose, resource
needs and anticipated return on investment to do so. Senior
executive leadership promotes uptake and sustained use of EBP
recommendations.46-49 Announcements from senior leaders create
a sense of urgency, articulate an organizational commitment,
demonstrate resources are available and an impact is expected
that matches organizational priorities.
Building Knowledge and Commitment
Interventions that increase practitioner’s knowledge of
and commitment to the clinical practice recommendation are
designed to build on the awareness and interest, and likewise
require multifaceted on-going attention. One useful approach
identify practice gaps, localize the EBP to the setting and
use train-the-trainer.50 One method of interactive education
matching nurses’ preference to learn from their colleagues51,52 is to
engage and train change agents. There are many different change
agent roles31,53 described in the literature, including internal and
external facilitators.24,54-55 Identify change agents early from
relevant disciplines, get their support, and provide education
about the practice change and their role functions as background
work.
Comparing organizational outcomes to benchmarks through
a gap assessment increases clinician’s knowledge and commitment
by highlighting the gap in performance. Unlike strict research
protocols, clinical practice guidelines are designed to be
locally adapted to individual settings.31,42,56-58 Focusing on the
few key steps that are critical promotes adoption by simplifying
the change.1 Articulating how the practice change was simplified
to assist clinician-users can stimulate their commitment.
The timeline for adoption should allow for focused effort
building practitioners’ knowledge and commitment before
proceeding, providing an essential foundation for promoting
adoption of EBP through changes in practice. This phase should
be clearly articulated with an approaching “go live” date that
creates motivation to participate.
Promoting Action and Adoption
After raising awareness, promoting positive attitudes, and
千葉看会誌 VOL.20 No.２ 2015.１ 55
building knowledge about the change, the next imperative
is to change clinician’s behaviors and put EBP into practice.
Frequently the ‘implementation phase’ described in the literature
is really the point when adoption is expected, neglecting the
required ground work. Interventions to promote action or
adoption need to move from active to interactive and target
the clinicians so they develop needed skills. Training, role-
59-61
modeling and coaching by the change agents is essential.
Follow-up from unit leaders and change agents is needed for
troubleshooting, reinforcing the desired behavior, and providing
recognition at the point of care for correctly and consistently
applying the practice recommendations.
Practical strategies such as practice prompts promote
behavior change by providing timely reminders at the point of
50
care. Practice prompts can be sophisticated reminders within the
electronic record that require justification for practice variation or
62,63
a simple pocket guide with a logo. Creating patient reminders,
clinical checklists, and standing orders build support within the
64-66
system.
The action and adoption phase of implementation will
require several weeks to complete. During this phase clinicians
are trying out the practice change, finding ways to integrate
the new practice into their workflow, adapting the practice for
unique patient circumstances, and doing small scale evaluation.67
Time is needed for progressive uptake of the EBP when change
agents are actively promoting adoption and practitioners are
trying it out. Continued use of implementation strategies
is essential throughout this phase as early and late adopters
proceed at varying rates. Audit with actionable and timely data
feedback is essential and highly effective for both adoption and
integration of the practice change by building support within
the organizational system.37 Timing should allow for trying the
practice change before full evaluation of process and outcome
indicators.
Some clinicians will lag in action and adoption. Highly
interactive and individualized feedback are needed for clinicians
working through adoption while the group has moved on.
Late adopters will be watching early adopters’ success and
slowly become active adopters. Having clear expectations and
administrative follow-up will facilitate adoption. Involving
a group leader from among late adopters in planning and
troubleshooting early may also be helpful.
Pursuing Integration and Sustainability
In order to achieve a return on the investment from working
56 千葉看会誌 VOL.20 No.２ 2015.１
through the EBP process, it is essential to realize integration and
sustained use of evidence-based health care.68 Senior leadership
recognition in public forums shifts expectations and group norms
toward EBP. Integration of clinical practice recommendation
into daily healthcare practices requires additional strategies by
clinical teams and senior leaders, including strategies built within
the social system matching the organizational culture.48,69,70
Reporting results of implementation and revisions based on both
evaluative data and practitioner feedback can facilitate additional
commitment to sustained use. Periodic feedback of evaluative
data with review and reinfusion of the practice change prevents
slipping back into old practice patterns. Updating postings and
practice reminders keep the message fresh and in the forefront.
Reinfusion is needed through the early months of integration to
sustain the gains already achieved.
Visual displays of key indicators may help integration.
Creating peer to peer discussions articulating the expectations
（i.e., peer influence）and using comparative data is likely to be
effective. Reporting and feedback of trended data supports
progressive integration providing positive reinforcement.71,72
Periodic reporting and trending of results also assists with quick
identification of a need for reinfusion. Early and active planning
for reinfusion and sustainability is highly recommended to
prevent slippage or loss of momentum.
Reporting of project activity and results should target
committees within the infrastructure responsible for policy
approval, documentation, staff education, quality improvement,
EBP and even product inventory.31,70 Building responsibility for
on-going EBP work into a new or existing unit or organizational
committee will keep responsibility clear. Multiple strategies are
needed to move from awareness to integration and should target
the people as well as the social system.
CONCLUSION
The Iowa Model guides clinicians through the EBP process.
The model includes feedback loops, reflecting mid-stream
correction needed throughout the process. These are critical
to adopting evidence to the practice setting and promoting
adoption within the varying healthcare systems and settings
within which nurses’ work. The feedback loops highlight the
messy and nonlinear nature of EBP and support teams moving
forward. The Iowa Model was designed to support evidence-
based healthcare delivery by interdisciplinary teams by following
a basic problem-solving approach using a systematic but simple
process, and being highly application oriented. The large number
of nurses and organizations using the Iowa Model attests to its
usefulness in practice.
Implementation science is a young field, none-the-less
there is a growing body of research showing the impact of a
variety of implementation strategies on nurse-sensitive outcomes.
Practical approaches for implementation of practice include the
EBP Implementation Guide. It is possible that because of the
fluid, complex and interactive nature of implementation and the
impact of contextual variations, prescriptive and rigid timing
of strategies may never be appropriate.42 Critical thinking skills
of nurses in evaluating and adapting strategies to the changing
conditions on the ground will always be required. Wensing
et al.（2010）describe selection of implementations strategies
as an ‘art’, stating that “research-based evidence can provide
some guidance but cannot show decisively which intervention
is most appropriate”, yet a structured approach to selecting
implementation strategies may be helpful（p. E85）
. Implementing
EBP change is difficult, consequently leaders must use effective
implementation strategies to engage clinicians and promote
adoption for evidence-based care delivery to improve patient and
organizational outcomes. Using these models to guide the process
and select implementation strategies adds clarity to steps in the
EBP process.
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