diffusion of innovations and evidence-based practice in geriatric nursing deborah lekan, rnc, msn...

Diffusion of Innovations Diffusion of Innovations

and Evidence-Based and Evidence-Based Practice in Geriatric Practice in Geriatric

NursingNursingDeborah Lekan, RNC, MSNDeborah Lekan, RNC, MSN

Gerontological Clinical Nurse Gerontological Clinical Nurse Specialist Specialist

Clinical AssociateClinical AssociateDuke University School of NursingDuke University School of Nursing

Duke University School of Nursing, 2009

ObjectivesObjectives Explain the elements of the Explain the elements of the

diffusion of innovations model.diffusion of innovations model. Describe the use of the diffusion Describe the use of the diffusion

of innovations model in geriatric of innovations model in geriatric nursing.nursing.

Describe the diffusion model for Describe the diffusion model for implementing change in geriatric implementing change in geriatric care. care.


““Good ideas Good ideas

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

Putting evidence-based nursing Putting evidence-based nursing interventions interventions into practiceinto practice can be can be more complicated and difficult than more complicated and difficult than the original research process that the original research process that generated the interventions.generated the interventions.


Change is inevitable, but Change is inevitable, but most people avoid change most people avoid change because...because... Change creates uncertainty and Change creates uncertainty and anxiety.anxiety. It is human nature to attempt to It is human nature to attempt to reduce uncertainty by resisting reduce uncertainty by resisting change.change.


Challenges Challenges Implementation of best practices Implementation of best practices

hindered by vaguely defined hindered by vaguely defined procedures for implementation in procedures for implementation in diverse settingsdiverse settings CPG implementation imposed by CPG implementation imposed by

governing bodies, federal or state governing bodies, federal or state regulations, organizational policies regulations, organizational policies

Clear guidance is often lackingClear guidance is often lacking Therefore, implementation is Therefore, implementation is

oftenoften Left to trial & error,Left to trial & error, Is painfully slow, and is marked byIs painfully slow, and is marked by Resistance, incomplete Resistance, incomplete

implementation, failure.implementation, failure.


Accelerating the Uptake of Accelerating the Uptake of Evidence-Based Nursing Evidence-Based Nursing

Practices: Practices: Diffusion of Innovations Diffusion of Innovations

ModelModel Offers a model for guiding implementation Offers a model for guiding implementation of evidence-based practices of evidence-based practices

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 workdetermining what may or may not work

Increases chances for successful adoption Increases chances for successful adoption & sustainability& sustainability


Diffusion of Innovations: Diffusion of Innovations: DefinitionDefinition

The process by which The process by which (1) an innovation ...(1) an innovation ...

(2) is communicated through certain (2) is communicated through certain channels ...channels ...

(3) over time ...(3) over time ...

(4) among members of a social (4) among members of a social systemsystem..Rogers, E., Diffusion of Innovations, 5th ed, 2003.


Examples of InnovationsExamples of Innovations Products/technologyProducts/technology

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

Ear thermometer, Pulse oximetry, BladderscanEar thermometer, Pulse oximetry, Bladderscan PracticesPractices

Restraint free environmentRestraint free environment behavior management behavior management techniques, low beds, monitoring devices, chair/bed techniques, low beds, monitoring devices, chair/bed alarmsalarms

IdeasIdeas Disease, disability, and frailty not a normal part of Disease, disability, and frailty not a normal part of

aging aging Pain as the 5Pain as the 5thth vital sign vital sign Moist wound healing environment for pressure ulcersMoist wound healing environment for pressure ulcers


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 innovation.an innovation.


Name a new idea, Name a new idea, technology or practice technology or practice you worked on to get you worked on to get

adopted in your clinical adopted in your clinical setting.setting.


What are your sources for What are your sources for new ideas in your nursing new ideas in your nursing

practice?practice?Other nurses, nurse specialistsPhysicians, other health professionalsProfessional organizationsConferences, workshopsJournals, newslettersProduct vendorsThe internetGovernment regulations or guidelinesFamily, friendsClinical practice-trial & errorOther?

How do you evaluate the accuracy and quality of the information?


The Adoption Process: 5 The Adoption Process: 5 StagesStages

KnowledgeKnowledge — —Awareness and understanding Awareness and understanding of the innovation-what it is and how it works of the innovation-what it is and how it works

PersuasionPersuasion — —Form favorable opinion, Form favorable opinion, determine relative advantage, what determine relative advantage, what outcomes will be achievedoutcomes will be achieved

DecisionDecision — —Decide to try it out-does it workDecide to try it out-does it work ImplementationImplementation — —Put it into use, solve Put it into use, solve

operational problems, develop proceduresoperational problems, develop procedures ConfirmationConfirmation

ADOPTION ADOPTION REINVENTION-modify & then adopt REINVENTION-modify & then adopt REJECTION & discontinueREJECTION & discontinue


Confirmation and

Adoption, Re-invention, or Rejection

ContactAwareness

Understanding

Knowledge

Implementation

PersuasionTrial Use

Institutionalization

Full Scale UseNumber

of adopters

Decision

The Innovation-Adoption Process

S-curve:

Rate of adoption among a % of members in the system

Time


Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations

Type of decisionType of decision Innovation attributesInnovation attributes Communication channelsCommunication channels Social system characteristicsSocial system characteristics Consequences Consequences Change agents, opinion leadersChange agents, opinion leaders



Innovation AttributesInnovation Attributes Relative AdvantageRelative Advantage– is the innovation better – is the innovation better

than the status quo, what is in current than the status quo, what is in current practice?practice?

CompatabilityCompatability -consistent w/values, beliefs? -consistent w/values, beliefs? ComplexityComplexity -hard to understand, use, or do? -hard to understand, use, or do? TriabilityTriability -can it be tried out on a small scale? -can it be tried out on a small scale? ObservabilityObservability –is the innovation or its results –is the innovation or its results

visible?visible?



Type of DecisionType of Decision OptionalOptional Collective/consensus Collective/consensus AuthorityAuthority Contingent-sequential combination Contingent-sequential combination

of two or more of the aboveof two or more of the above



Communication ChannelsCommunication Channels Formal/informal, Verbal/writtenFormal/informal, Verbal/written Shadow system, Rumor millShadow system, Rumor mill Mass media, interpersonal routesMass media, interpersonal routes


Interpersonal Communication Interpersonal Communication ChannelsChannels



Social System characteristicsSocial System characteristics A set of inter-related unitsA set of inter-related units

Individuals, groups, subgroupsIndividuals, groups, subgroups How social structures affect diffusion of the How social structures affect diffusion of the

innovationinnovation Relationships: Hierarchical/ horizontal, formal/ Relationships: Hierarchical/ horizontal, formal/

informalinformal System effects: large/small & other System effects: large/small & other

characteristics characteristics NormsNorms

Established & accepted behavior patternsEstablished & accepted behavior patterns Values, beliefs, cultural & religious factors influentialValues, beliefs, cultural & religious factors influential



ConsequencesConsequences Desirable/undesirableDesirable/undesirable Direct/indirectDirect/indirect Anticipated/unanticipatedAnticipated/unanticipated



Change Agent & Opinion Change Agent & Opinion LeaderLeader Create a needCreate a need Provide informationProvide information Highlight advantages & expected Highlight advantages & expected

outcomesoutcomes Endorse and persuadeEndorse and persuade Model behaviors associated with Model behaviors associated with

innovationinnovation


Adopter Categories


Using the Diffusion of Using the Diffusion of Innovations (DOI) Model to Innovations (DOI) Model to Promote Evidence-based Promote Evidence-based Geriatric Nursing Practice Geriatric Nursing Practice


Visual Summary of the Diffusion Model


Oral Hygiene in LTC Oral Hygiene in LTC ExemplarExemplar

Oral care of residents with Oral care of residents with cognitive impairment or who are cognitive impairment or who are resistant or combativeresistant or combative

Direct care CNA staffDirect care CNA staff Recognize oral care as a care priorityRecognize oral care as a care priority Inconsistent provision of careInconsistent provision of care Wanted to provide better careWanted to provide better care

Director of Nursing & leadership Director of Nursing & leadership supportivesupportive



Resident issuesResident issues Bleeding gums deter oral careBleeding gums deter oral care Many residents have serious dental Many residents have serious dental

problemsproblems Disruptive behaviorsDisruptive behaviors Some residents can do own care but are Some residents can do own care but are

not assistednot assisted



Nurse provider issuesNurse provider issues Fear of injury - self & residentFear of injury - self & resident Fear of accusations of abuse, resident rightsFear of accusations of abuse, resident rights Little knowledge/skill in managing disruptive Little knowledge/skill in managing disruptive

behaviors behaviors Some staff are more vigilant than othersSome staff are more vigilant than others No standardized or consistent oral health No standardized or consistent oral health

assessmentassessment Some staff also have poor oral hygieneSome staff also have poor oral hygiene

Logistical issuesLogistical issues Lack of time-competing responsibilitiesLack of time-competing responsibilities Sporadic provision of oral care, no continuitySporadic provision of oral care, no continuity Oral care supplies not always availableOral care supplies not always available


Small Group: Small Group: Analyze the “Try This” Oral Analyze the “Try This” Oral Health Assessment tool for Health Assessment tool for adoption by RNs on your adoption by RNs on your clinical unit or agencyclinical unit or agency

Innovation AttributesInnovation Attributes Relative AdvantageRelative Advantage Compatability Compatability ComplexityComplexity TrialabilityTrialability ObservabilityObservability


Oral Health Assessment

Tool

Relative Advantage

1. Better than status quo2. Evidence-based3. Hydration, nutrition

Compatability

1. Oral care valued2. RN scope of practice3. Best practice

Observability

1. Oral care rounds2. Documentation3. Outcomes list

Complexity

1. Ease of use2. Visually “busy”3. No dental jargon

Trialability

1. Try out on one unit2. Select pts w/problems

Innovation Attributes


Summary of DOISummary of DOI Diffusion of innovations offers a Diffusion of innovations offers a

comprehensive model for planned comprehensive model for planned change.change.

Model is multi-dimensional but Model is multi-dimensional but practical.practical.

Guides identification and description of Guides identification and description of organizational, individual, & innovation organizational, individual, & innovation characterizations.characterizations.

Offers a rational framework for using Offers a rational framework for using targeted strategies to facilitate and targeted strategies to facilitate and accelerate adoption of an innovation.accelerate adoption of an innovation.


ReferencesReferences Overview of Diffusion of Innovations (Overview of Diffusion of Innovations (University of S. University of S.

Florida)Florida) ((

http://hsc.usf.edu/~kmbrown/Diffusion_of_Innovations_Overview.hthttp://hsc.usf.edu/~kmbrown/Diffusion_of_Innovations_Overview.htmm

Diffusion of Innovations, Diffusion of Innovations, 5th Ed5th Ed. 2003, Everett M. . 2003, Everett M. RogersRogers http://www.amazon.com/exec/obidos/tg/detail/-/0743222http://www.amazon.com/exec/obidos/tg/detail/-/0743222

091/104-0730562-2628704?v=glance091/104-0730562-2628704?v=glance

Summary of Roger’s book Summary of Roger’s book (Iowa State University) (Iowa State University) Part I: Part I: http://www.soc.iastate.edu/Sapp/Diffusion1.htmlhttp://www.soc.iastate.edu/Sapp/Diffusion1.html Part II: Part II: http://www.soc.iastate.edu/Sapp/Diffusion2.htmlhttp://www.soc.iastate.edu/Sapp/Diffusion2.html

Shirey MR. (2006). Evidence-based practice: how nurse Shirey MR. (2006). Evidence-based practice: how nurse leaders can facilitate innovation. leaders can facilitate innovation. Nurse AdministrationNurse Administration, , 30(3), 252-265.30(3), 252-265.

McConnell ES, Lekan D, Hebert C, Leatherwood L. (2007). McConnell ES, Lekan D, Hebert C, Leatherwood L. (2007). Academic-practice partnerships to promote evidence-based Academic-practice partnerships to promote evidence-based practice in long term care: oral hygiene care practices as practice in long term care: oral hygiene care practices as an exemplar. an exemplar. Nursing OutlookNursing Outlook, 55, 95-105., 55, 95-105.

diffusion of innovations and evidence-based practice in geriatric nursing deborah lekan, rnc, msn...

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