Background Implementation of evidence-based clinical interventions in real-world settings becomes a futile effort when effective strategies to foster adoption are not used. A toolkit, or a collection of adaptable documents to inform and facilitate implementation, can increase the use of evidence-based interventions. Most available toolkits provide resources about the intervention but lack guidance for adaptation to different contexts or strategies to support implementation. This paper describes the development and use of a toolkit to guide the implementation of an evidence-based intervention to identify and intervene for people with risky substance use. Methods A descriptive case study describes the development and use of a toolkit throughout a two-year study. Investigators and site coordinators from 14 acute care hospitals developed tools and engaged external stakeholders as they prepared for implementation, integrated the clinical intervention into practice, and reflected on implementation. Results The final toolkit included 54 different tools selected or created to define the intervention, engage and communicate with stakeholders, assess for readiness and plan for implementation, train clinical nurses and other stakeholders, evaluate training and implementation effectiveness, create policies and procedures for different contexts, and identify opportunities for reimbursement. Each tool corresponds to one or more implementation strategies. Conclusion The approach used to develop this implementation toolkit may be used to create resources for the implementation of other evidence-based interventions.

Pressure injury development results in significant morbidity and costs. Despite well-defined guidelines, nurses are frequently faced with subtle and overt patient resistance when implementing prevention strategies. Case law and hospital policies guide decision making when confronted with refusal of medical care; however, there are limited recommendations that guide competent patient refusal of nursing care. This article presents findings of an integrative literature review and idea-generating forum about competent patient refusal of nursing care. Emerging topics from the literature review were mirrored in responses generated during the innovation forum; responses from the forum confirmed the clinical relevance of the issue and the lack of resources to guide care in this area for approach.

BackgroundAlarming rates of unhealthy alcohol, non-prescription drug, and tobacco use highlight the preventable health risks of substance abuse and the urgent need to activate clinicians to recognize and treat risky use. Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and effective processes to identify, reduce and prevent risky use of substances. This paper describes a study protocol testing implementation of a toolkit to enhance use of SBIRT in acute care settings to recognize and address patient risky alcohol, drug, and tobacco use.MethodsThis study uses a phased cluster randomized mixed method design to test nurse-led implementation of an SBIRT toolkit on one medical-surgical unit at 14 acute care hospitals (critical access, community and academic health centers). Medical surgical units will be randomly assigned to implement the SBIRT toolkit (engagement and communication, assessment, planning, training, and evaluation tools) or a wait-list usual care control group that begins implementation 6 months later. Primary endpoints are documentation of SBIRT delivery in randomly selected electronic medical records at baseline, 6 months and 12 months after group 1 implementation (61 records per unit per time period, N = 2562). Two surveys will be administered to unit nurses: smoking cessation activities will be assessed at baseline and SBIRT use will be assessed on randomly-selected days after implementation. In addition, site coordinators will complete a baseline capacity assessment, an implementation fidelity survey post-implementation, and a structured interview at the end of the study. Multilevel mixed-effects effects logistic and linear models will be used to analyze use of SBIRT and cost outcomes.DiscussionThis study will guide subsequent SBIRT implementation, dissemination, and spread across rural, community and urban healthcare systems throughout the state and beyond. The long-term objective is to activate clinicians to recognize, intervene and refer people with risky substance use to improve health and decrease substance use disorders.Trial registration ClinicalTrials.gov NCT03560076