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. 2024 Nov 17;21(6):644–651. doi: 10.1111/wvn.12755

The use of a nursing implementation framework to enhance the uptake of an evidence‐based intervention

Kesley Karim 1, Sommer Trower 2, Lisa S Segre 1,✉
PMCID: PMC11655700  PMID: 39552104

Abstract

Background

Evidence‐based practices (EBPs) are instrumental in improving patient outcomes and ensuring high‐quality nursing care, yet their implementation often encounters substantial barriers. The Iowa Implementation for Sustainability Framework and the Precision Implementation Approach© offer systematic strategies for overcoming barriers and enhancing EBP implementation and sustainability in health care settings.

Aim

This project aimed to use the Iowa Implementation for Sustainability Framework and the Precision Implementation Approach© to support the use of an evidence‐based maternal depression intervention within Iowa's Title V Maternal Health Program that serves mothers of young children living in poverty.

Methods

This practice‐based implementation was accomplished in three steps: (1) hold intervention‐focused staff meetings, (2) identify barriers to using the intervention, and (3) identify and deliver implementation strategies. Collected data included barriers identified, selected implementation strategies, and evaluation of meeting attendance and impact on confidence.

Results

Four of the monthly virtual staff meetings focused on Listening Visits (LV) use. The 7 strategies comprising our approach to supporting LV use addressed three categories of identified barriers: lack of confidence, logistical issues, and not understanding intervention procedures. In the LV‐focused meetings, representation of the 14 maternal health clinics was high, although attendance by individual staff was inconsistent. Post‐meeting polls indicated that 40% to 65% of attendees felt more confident using intervention skills.

Linking evidence to action

This practical nursing‐implementation framework facilitated EBP adoption, and our well‐structured targeted strategies effectively increased staff confidence. Nursing managers and educators should consider using this framework to enhance their organizations' capacity to implement EBPs sustainably.

Keywords: community care, evidence‐based practice, implementation science, intervention focused staff meetings, listening visits, maternal health, nursing framework, sustainability

INTRODUCTION

Implementing evidence‐based practices (EBPs) improves patient outcomes and ensures quality nursing care (Connor et al., 2023). Yet, EBP adoption often encounters significant barriers in real‐world health care settings, necessitating strategic approaches for enhancing EBP uptake (Berthelsen & Hølge‐Hazelton, 2021; Crawford et al., 2023; Warren et al., 2016). A common misconception persists: that education alone is enough for an EBP to be adopted by nursing staff. Aptly illustrating this misconception is the coat hook analogy: educating about the purpose of a coat hook does not necessarily lead to its effective use (Cullen, Laures, et al., 2022). Similarly, providing education on the use of an EBP is often inadequate if the broader contextual factors that influence its integration into practice are not addressed.

The Iowa Implementation for Sustainability Framework (Cullen, Hanrahan, et al., 2022), a nurse‐developed application‐oriented implementation framework, is based on Rogers' Diffusion of Innovation theory (2003). This framework is designed to sustain EBPs through four distinct phases of implementation: (1) creating awareness and interest, (2) building knowledge and commitment, (3) promoting action and adoption, and (4) pursuing integration and sustained use (Figure 1). The framework's list of strategies moves beyond education by offering a range of implementation strategies that overcome common barriers and promote the integration of EBPs into routine practice. The Precision Implementation Approach© further tailors the selection of strategies to the implementation context by considering unique barriers, facilitators, and characteristics of the target setting (Cullen, Laures, et al., 2022). Together, these elements provide a structured yet tailored pathway for implementing EBPs in clinical settings.

FIGURE 1.

FIGURE 1

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The Iowa Implementation for Sustainability Framework. From: Cullen, Hanrahan, et al. (2022). Reprinted with permission.

In this paper we describe how we used these two elements to integrate Listening Visits (LV), an evidence‐based treatment for maternal depression, into maternal clinics serving at‐risk impoverished mothers in Iowa.

BACKGROUND AND SIGNIFICANCE OF POSTPARTUM DEPRESSION

Postpartum depression (PPD) is a mental health condition affecting up to 14% of new mothers globally (Liu et al., 2022). In the United States, depression disproportionately affects women living in poverty and women of color (Corcoran et al., 2021; Tabb et al., 2020). Approximately 57% of women who experience maternal mental health conditions, like PPD, go untreated (Xue et al., 2020). Lack of treatment is often due to a range of challenges, for example, not perceiving a need for specialist care, stigma, prohibitive cost, lack of time, and unavailability of mental health specialists (Iturralde et al., 2021; Place et al., 2024).

Listening visits are a non‐directive counseling intervention for mild to moderate depression that were developed specifically for British public health nurses (called health visitors) to provide to depressed postpartum women (Holden et al., 1989). A meta‐analysis of randomized clinical trials conducted in the United Kingdom, Sweden, and the United States, found that LV delivered by nurses are an effective intervention that equaled treatments delivered by mental health specialists (McCabe et al., 2021). In Iowa, LV were confirmed to be effective in home‐visiting settings (Brock et al., 2017; Segre et al., 2010, 2015), prompting a funding directive from the administrator of Iowa's Title V Maternal Health Program, which provides preventive health services to impoverished pregnant and postpartum women (Segre et al., 2018). Notably, this statewide implementation of LV relied on education alone in the form of LV workshops. After those first LV educational workshops, LV training has been provided every 2 years to all new maternal‐health clinic staff. Yet, even with this ongoing support of the LV intervention, the administrator of Iowa's Title V Maternal Health Program believed the intervention was underutilized.

As with many other evidence‐based practices (EBPs), the LV intervention is difficult to integrate into regular clinical practice, despite robust supporting evidence. Indeed, studies show that even with robust evidence, establishing EBPs can take 15 years, on average (Khan et al., 2021). Recognizing that training alone does not ensure LV use, the Title V Maternal Health Program administrator invited the third author, an LV expert, to supplement training by creating, implementing, and evaluating the LV‐focused staff meetings. This invitation offered an opportunity to utilize the Iowa Implementation for Sustainability Framework and the Precision Implementation Approach©.

Aim/design

This practice‐based implementation was intended to facilitate staff use of the LV intervention at Iowa's maternal health clinics. The project design focused on developing an implementation strategy that would function in a real‐world clinical setting.

METHODS

Ethics approval

The University's Institutional Review Board reviewed this project and deemed it not human subjects' research.

Setting

Iowa's Title V Maternal Health Program provides free prenatal and postpartum support services to Medicaid‐eligible and other low‐income women, statewide. Following the standards of the American College of OB/GYN for ambulatory obstetric care, the 14 contracted maternal health clinics offer medical and dental assessments, health and nutrition education, psychosocial screening and referral, care coordination, assistance with plans for delivery, and postpartum support. These services are provided in home visits, maternal‐health clinics, or Women Infant and Children's clinics and are delivered by nurses, social workers, and dietitians (who from here are referred to as ‘maternal health clinic staff’). Listening Visits are provided by nurses and social workers as part of postpartum support services.

Procedures

This practice‐based project was put in place to promote the use of LV in maternal health clinics and was implemented in three steps:

  • Step 1: Establish intervention‐focused staff meetings. In April 2023, the LV‐implementation team from the University's College of Nursing (1st and 3rd authors) met with the state‐wide administrator of Iowa's Title V Maternal Health Program (2nd author). In this meeting, the administrator offered to designate four of the virtual monthly staff meetings as LV‐focused meetings.

  • Step 2: Identify barriers to using the intervention. In May 2023, and in alignment with the guidance of the Precision Implementation Approach© to assess local implementation barriers (Cullen, Laures, et al., 2022), maternal health clinic staff completed a Qualtrics survey assessing their perceptions of barriers to LV use. Because only 15 of the 40 staff completed the survey, the implementation team gathered more information about barriers during the first LV‐focused staff meeting (June 2023).

  • Step 3: Identify and deliver implementation strategies. After the meeting in which the project was introduced and barriers to LV use were assessed (June 2023), and in alignment with the Precision Implementation Approach©, the team selected barrier‐breaking strategies listed in the Iowa Implementation for Sustainability Framework (Figure 1). The selected strategies listed in Table 1 became the main topics of LV‐focused staff meetings.

TABLE 1.

Barriers to LV use and selected implementation strategies.

Number/per cent Selected framework strategy/stage a What was done
Confidence barriers
Lacked confidence in LV skills, that is, introducing LV, reflective listening, problem solving

7/15

46.7%

Staff meeting

Stage 1

‐Education

Stage 2

 Provided a refresher training in which the LV skill was briefly reviewed and then practiced
Not confident in delivering LV

2/15

13.3%

Change champions

Case Study

Stage 2

Role model

Stage 3

 Identified two LV champions who shared positive experiences and case studies to model LV‐use and foster confidence
Knowledge barriers
Did not understand Medicaid billing or LV paperwork procedures

7/15

46.7%

Education

Stage 2

 Provided an educational presentation by the Title V Maternal Health Program administrator
Difficult to remember LV procedures in between clients, for example, who is eligible, steps of intervention

15/15

100%

Pocket Guide

Stage 2

Used notes from the engagement sessions to develop a pocket guide to providing LV.

Presented to maternal health clinic's staff at non‐LV engagement staff meetings
Logistic barriers
Difficult to complete LV visit with children present

15/15

100%

Trouble shoot

Stage 2

Formed a “toy kit committee,” which included the maternal health administrator and staff.

Meetings to select toys, obtain funding approval, and purchase of toys and assemble kits.

Toy kits distributed to the maternal health clinics
Workload does not allow time

9/15

60.0%

Incentive

Stage 3

 The Title V Maternal Health Program administrator applied for CEUs for LV training
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a

To ensure a comprehensive and systematic process for embedding EBPs into routine practice the Iowa Implementation for Sustainability Framework categorizes its 81 strategies into four stages: Stage 1: Create Awareness & Interest; Stage 2: Build Knowledge and Commitment; Stage 3: Promote Action & Adoption, and Stage 4: Pursue Integration and Sustained Use.

Data collection and evaluation

During the meeting development phase in steps 2 and 3, collected data included the results of the barriers survey as well as the strategies selected to mitigate those barriers. In the implementation phase in step 3, data collection also included the representation of each maternal‐health clinic at the LV‐focused staff meetings, individual staff attendance, and post‐meeting poll ratings of confidence in using the targeted skill. Descriptive statistics were used to characterize attendance and the results of the post‐LV session engagement polls.

Measures

Barriers to use of LV

A 20‐item survey developed for this project used a four‐point Likert scale (strongly agree, somewhat agree, somewhat disagree, or strongly agree) to assess potential barriers to LV use, including staff knowledge of LV procedures (e.g., I am knowledgeable about how to complete the paperwork required to bill for LV), confidence in providing LV (e.g., I am confident in my training to provide LV), and any logistical barrier that made it difficult to use LV (e.g., I feel my workload would allow me time to do a Listening Visit.)

Post‐meeting confidence polls

A post‐meeting poll (with yes or no response options) assessed whether attendees felt confident about using the LV skill discussed during that LV‐focused staff meeting.

RESULTS

Establishing staff meetings focused on the EBP

A primary outcome of this project was that it enabled the administrator of the state's Title V Maternal Health Program to newly integrate LV‐focused staff meetings into the established monthly virtual staff meetings. Specifically, the June meeting was used to introduce the project and supplement the Qualtrics survey assessment of barriers to LV use. The July, September, and November meetings were used to implement the strategies selected to address identified barriers preventing the use of LV.

Barriers identified and strategies selected

Barriers to LV use fell into three categories (Table 1). First, confidence barriers included a hesitancy to introduce and deliver the intervention, and uncertainty with respect to using two intervention elements: active/reflective listening and problem solving. Second, knowledge barriers included not understanding how to use the intervention paperwork or Medicaid billing procedures, and difficulty remembering intervention procedures because opportunities to use the intervention were infrequent. Finally, logistic barriers included difficulty completing the intervention sessions with children present and lacking enough time in their work schedule to provide the intervention.

Seven implementation strategies (Table 1) were selected to address these context‐specific barriers. These strategies, which determined the content of each LV‐focused staff meeting, were drawn from the Iowa Implementation for Sustainability Framework's first three phases: creating awareness and interest (Phase 1), building knowledge and commitment (Phase 2), and promoting action and adoption (Phase 3).

Meeting attendance and impact

Among the 40 members of the maternal‐health clinic staff, attendance to the LV‐focused staff meetings was somewhat uneven (July N = 16; September N = 26; November N = 20). Nevertheless, among the 14 maternal health clinics, representation at each LV‐focused staff meeting was consistently high (July N = 13; September N = 11; November N = 12). The post meeting poll assessing confidence in using the skill discussed in each meeting indicated a generally positive impact. After each meeting, and as indicated in Figure 2, between 40% and 65% of attendees indicated they felt confident in implementing the skill on which the meeting had focused.

FIGURE 2.

FIGURE 2

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Confidence ratings of maternal health staff after each LV‐focused staff meeting.

DISCUSSION

Our initiative aimed to shift expectations for EBP implementation away from the idea that once trained to provide an intervention, clinic staff will regularly do so. In the real world, the integration of evidence‐based treatments, like LV, into clinical practice hinges on the use of implementation frameworks that ensure sustainability and effectiveness. Our project leveraged an application‐oriented, nursing implementation framework to engraft an evidence‐based treatment for maternal depression. This aim aligns with the imperative to move evidence garnered from programs of clinical research into clinical care (Melnyk, 2014). Our approach springs from published work suggesting the use of evidence‐backed frameworks to guide implementation efforts (McNett et al., 2021) and the need for evidence‐based implementation practices (Tucker et al., 2021). Both aspects of this project, including the actions we took to promote LV use and the outcomes assessed, are discussed.

Actions for promoting uptake of an EBP

Having the administrator of the Title V Maternal Health Program designate four of the 12 staff meetings to LV discussion was the most powerful outcome of this project. Apart from the introductory LV‐focused meeting, the remaining three meetings not only raised awareness and interest in LV (stage 1 of the Iowa Implementation for Sustainability framework), but also signaled administrative endorsement and provided a means for staff to discuss their experiences in using LV. Local leadership was transformative in implementing EBPs, echoing the need for administrators and managers to support EBPs as acknowledged in the literature (Warren et al., 2016).

The content for our LV‐focused staff meetings was developed using the Precision Implementation Approach Solution©, which entailed assessing barriers to LV use, following the framework's strategies for targeting those barriers with solutions, and implementing those solutions in the real world (Cullen, Laures, et al., 2022). Our example of matching strategies to barriers (Table 1) demonstrates how these two elements combine to provide a structured and accessible approach to implementation barriers.

Outcomes

Two aspects of the LV‐focused staff meetings were evaluated: attendance and staff confidence. Although attendance by individual maternal health clinic staff varied across the three meetings, representation of the 14 maternal health clinics was consistently high. This consistent representation of clinics by their personnel likely reflected organizational support for the implementation effort, perhaps highlighting the importance placed on the LV‐focused staff meetings by clinic leadership. In terms of impact, after an LV‐focused staff meeting, attendees' confidence in LV implementation was high. As noted in the Advancing Research and Clinical Practice Model (ARCC©) for evidence‐based implementation framework, confidence is a crucial factor for success (Melnyk et al., 2021).

Limitations

Implementation limitations

One limitation was the relatively low attendance among individual clinical staff. Although our team collaborated with the administrator to establish the schedule and the venue of the LV‐focused staff meetings, the meetings themselves were developed and led by the first author as part of her DNP capstone project. Including key stakeholders and leadership in meeting development (McNett et al., 2021), the use of an EBP project mentor (Magers, 2014), and use of a project champion (Brunkert et al., 2021) are proven strategies for engaging staff in EPB use. In terms of strategies selected from the framework, another limitation is that we did not use any Phase 4 strategies (Figure 1), which focus on integration and sustainability. Ongoing use of the LV‐focused staff meetings will incorporate some of these elements as well.

Evaluation limitations

This practice‐based implementation project was not a research study (i.e., evaluation was limited to attendance and self‐reported confidence) and did not assess the actual use of LV. Moreover, because several of the strategies were not available until the end of the project (e.g., the pocket guide, toy kits, and CEU credits for attending LV training listed in Table 1), it was not possible to assess their impact. For a more robust evaluation, future implementation efforts should evaluate both the process and outcome measures.

LINKING EVIDENCE TO ACTION

  • Implementing EBPs in the real world requires addressing both individual and systemic barriers. Rather than relying solely on educational workshops, health care settings should employ a comprehensive approach that includes continuous support, practical tools, and administrative backing to ensure that EBPs are integrated into daily practice.

  • Support strategies should be tailored to needs and focus on overcoming barriers for health care providers (which significantly enhances EBP adoption). This can include creating easy‐to‐use resources, on‐the‐job training and fostering a supportive community that encourages staff to share experiences and propose solutions.

  • Administrative and managerial support is crucial in promoting the use of EBPs. Leaders should actively endorse EBPs, allocate resources for their implementation, and cultivate a workplace culture that values and rewards evidence‐based practice. This cultural shift can create an environment where EBPs are not only adopted but sustained.

CONCLUSION

This project demonstrates the potential of using structured nursing implementation frameworks to integrate EBPs into clinical settings by addressing barriers head on. In our particular case, barriers to implementing a maternal depression intervention (LVs) were overcome systematically via the Iowa Implementation for Sustainability Framework and the Precision Implementation Approach©. Use of these two elements yielded promising results, including increased staff confidence, and also highlighted areas for improvement, particularly in stakeholder engagement and the inclusion of strategies for long‐term integration and sustainability.

CONFLICT OF INTEREST STATEMENT

The authors report no conflicts of interests.

ACKNOWLEDGMENTS

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors. The authors acknowledge the contribution of all Iowa's Title V maternal‐health clinic staff, with a special note of thanks to those who facilitated or actively participated: Lydia Amissah‐Harris, MPH, Jana Larsen, BA, Sylvia Navin, MPH, Nafla Poff‐Dainty, MPH, Paula Spies, LBSW, and LaBridgette Tensley, MSW. DNP capstone project mentors included Amalia Gedney Lose, DNP, ARNP, NP‐C and Ann Weltin DNP, FNP, CMM. Guest presenters in the LV‐focused staff meetings include Stephanie, Trusty RN, BSN (Iowa Department of Health and Human Services), Rebecca Chuffo Davila, DNP, ARNP (Stead Family Children's Hospital, University of Iowa Hospitals and Clinics), and Lisa Kelly, PhD (University of Iowa). Madison Botos, an undergraduate in the College of Nursing, University of Iowa, assisted in materials development and collection of data. We also acknowledge the helpful comments of Alberto Segre PhD (University of Iowa) on an earlier draft and the College of Nursing editor, Diana Colgan, PhD.

Karim, K. , Trower, S. , & Segre, L. S. (2024). The use of a nursing implementation framework to enhance the uptake of an evidence‐based intervention. Worldviews on Evidence‐Based Nursing, 21, 644–651. 10.1111/wvn.12755

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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