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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.
Duke University School of Nursing, 2009
““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.
Duke University School of Nursing, 2009
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.
Duke University School of Nursing, 2009
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.
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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.
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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.
Duke University School of Nursing, 2009
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.
Duke University School of Nursing, 2009
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?
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations
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?
Duke University School of Nursing, 2009
Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations
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
Duke University School of Nursing, 2009
Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations
Communication ChannelsCommunication Channels Formal/informal, Verbal/writtenFormal/informal, Verbal/written Shadow system, Rumor millShadow system, Rumor mill Mass media, interpersonal routesMass media, interpersonal routes
Duke University School of Nursing, 2009
Interpersonal Communication Interpersonal Communication ChannelsChannels
Duke University School of Nursing, 2009
Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations
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
Duke University School of Nursing, 2009
Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations
ConsequencesConsequences Desirable/undesirableDesirable/undesirable Direct/indirectDirect/indirect Anticipated/unanticipatedAnticipated/unanticipated
Duke University School of Nursing, 2009
Factors Affecting the Rate Factors Affecting the Rate of Diffusion of Innovationsof Diffusion of Innovations
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
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
Oral Hygiene in LTC Oral Hygiene in LTC ExemplarExemplar
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
Duke University School of Nursing, 2009
Oral Hygiene in LTC Oral Hygiene in LTC ExemplarExemplar
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
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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
Duke University School of Nursing, 2009
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.
Duke University School of Nursing, 2009
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.