Care improvement guided by external evidence and local circumstances has been a longstanding focus with issues that arise at the point-of-care (Harrison et al. 1993
). One underlying premise of this focus is that health care based on “best available evidence” occurs with the adoption and implementation of practice guidelines. Indeed, when delivered appropriately, guidelines have the potential to aid in consistent, high-quality care delivery resulting in superior health outcomes (Grimshaw & Russell 1993
; Grimshaw et al. 2003
Since the mid-1990s, the proliferation of guidelines from credible bodies such as the Royal College of Nursing, Agency Health Care Policy and Research, Scottish Intercollegiate Guidelines Network and others, has provided impetus for care settings to focus on care delivery supported by best available evidence and the use of guidelines. As knowledge tools, practice guidelines represent a major advance in transferring research evidence from a multitude of studies for use at the point of care. Best available evidence is now more accessible and packaged in a more useable form. Guidelines also serve as a vehicle to improve consistency in the structure and process of care both within and across settings thus providing organizations with a “script” as they undertake efforts to deliver evidence-driven care.
On the surface, this seems straightforward: by translating available evidence into practice recommendations, then integrating practice recommendations into service delivery, the result will be improved quality of care and health outcomes. The underlying assumption to this sequence of events is that, when good evidence is embedded in a quality guideline, it will be fairly straightforward to move it into practice.
In reality, however, translating evidence into clinical practice at the point of care is a complex, often overwhelming challenge. In one such effort, our large teaching hospital made a strong commitment to implement guideline recommendations to improve pressure ulcer care. Nonetheless, it took many years of concerted effort to achieve modest gains (Fisher et al. 1996
; Harrison et al. 1996
; Harrison et al. 1998
; Harrison et al. 2006
Further to field efforts, such as ours, focused on guideline uptake, numerous models, and frameworks for evidence-based practice emerged to guide implementation. Ciliska and colleagues examined eight models to guide implementation. Overall they noted a commonality of steps and a recognition of “the need for a systematic approach to practice change” (Mazurek Melnyk & Fineout-Overholt 2010
, p. 272). In another synthesis of selected models, Rycroft-Malone and Bucknell (2010
) critically examined key dimensions postulated to be related to robustness and application. Their analysis provides a means to assess and select a model/framework for specific practice projects. Less clear from these scholarly compilations is how these models/frameworks involve research activity (if at all) and how that might facilitate implementation.
Guideline proponents have recognized that practice recommendations serve only as the first step of a much larger effort (Toman & Harrison 2001
). Rycroft-Malone et al. (2004
) describe evidence as being comprised of research, clinical experience, patient and caregiver experience, and local context information. This broad understanding of evidence provides insight into the crux of the issue, that is, the important local work required first to capture all the “evidence,” not simply the use of the external research housed in guidelines or other knowledge tools. This dynamic evidence changes at the bedside is poorly understood. This paper is focused on the engaged research in acquiring this broad evidence as an active, and proactive, element of implementation. Having worked through implementation processes with different groups, we recognize two important aspects: the iterative nature and linkage between local implementation activities, and the possibility to generate local evidence through “planned action” research. Both can be greatly assisted by a research–practice partnership.
Based on our experiences, we offer a roadmap for researchers to engage in a collaborative research–practice approach to implementation. The approach is illustrated using community wound care as an exemplar (see ) and describes the types of research undertaken to support implementation. We hope this roadmap will provide guidance on how to plan, execute, and evaluate implementation both for researcher-practice partners and for practice settings without researcher–partners.