491The Journal of Continuing Education in Nursing · Vol 50, No 11, 2019

leadership and development

In a recent conversation with a col-
league who interviewed individu-
als for a leadership position, she

noted that each candidate described
their leadership style as transforma-
tional. When asked to give an example
of a transformation they had led—
and its impact at the organizational
level—few could cite a substantive
transformational change at an organi-
zational level. My colleague lamented
that many see themselves as transfor-
mative leaders, but few actually are. Is
the ability to actually move an orga-
nization in the direction of a desired
change—given its culture, people
with diverse backgrounds and educa-
tional levels, and other complexities—

far more rare than commonplace?
Yet, health care organizations need
to respond to change more than ever,
making implementation science—the
science of change—a requisite compe-
tency.

Dr. Dean Fixsen (2019), articu-
lated three developmental levels on
the journey to implementation sci-
ence. The first level, letting it happen
(change) aligns with the diffusion the-
ory of change popularized by Everett
Rogers who studied how innovations
(change) spread through an organi-
zation, simplified here by describing
change as a domino effect. Fixsen
described the second level as helping
it (change) happen, equated with dis-
semination science. Professional de-
velopment educators know the power
of education in advancing change,
such that when groups are armed with
education on a topic, an added stimu-
lus to change occurs. Yet, education—
as essential as it is as a stimulus for
change—does not always equate to
behavioral modification, individually
or collectively. This leads to the third
level of change mastery and imple-
mentation science. Implementation
science is necessary because it is the
science of making nonoptional things
happen. Leaders must guide organi-
zational change, ensuring compliance
and uniformity of actions, safeguard-

ing the quality and safety of patients,
and managing resources.

IMPLEMENTATION
SCIENCE DEFINED

Bauer, Damschroder, Hagendorn,
Smith, and Kilbourne (2015) offered
a useful and concise definition of im-
plementation science. They defined
implementation science as “the sci-
entific study of methods to promote
the systematic uptake of research find-
ings and other EBPs [evidence-based
practices] into routine practice, and,
hence, it improves the quality and ef-
fectiveness of health services” (p. 1). In
the definition are salient key points—
namely, that leaders should use evi-
dence and research when available to
drive change. A second point is that
the leader/change agent should make
the client group (those affected by
the expected change) keenly aware of
what is at stake with regard to quality
and effectiveness. The third point is
that there is a science to implementa-
tion. The science comprises methods
to drive the systematic uptake of re-
search and evidence-based practices in
practice settings, one of the outcomes
now associated with the Doctor of
Nursing Practice degree and an expec-
tation of leaders in all clinical settings.

Implementation science drives
nonoptional change, standardizes
high-risk and high-stakes clinical in-
terventions, and advances innovations
within an organization. The science
itself addresses the knowledge gap
that exists between interventions that
research has shown to be effective and
its translation into practice in varying
clinical settings. Increasingly, inter-

abstract
Leaders must distinguish be-

tween diffusion as a change strat-
egy, education as a stimulus for
change, and implementation strat-
egies associated with implementa-
tion science. This article provides an
operational definition for implemen-
tation science, the distinguishing
characteristics in leading transfor-
mational change, and the degrees
of implementation. [J Contin Educ
Nurs. 2019;50(11):491-492.]

Dr. Bleich is Senior Professor and Director, Virginia Commonwealth University School of Nursing,
Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer,
NursDynamics, Ballwin, Missouri.

The author has disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN, Senior Professor

and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation
in Quality and Safety, and President and Chief Executive Officer, NursDynamics, 221 Jasmin Park
Court, Ballwin, MO 63021; e-mail: [email protected].

doi:10.3928/00220124-20191015-03

Implementation Science as a Leadership and
Doctor of Nursing Practice Competency

Associate Editors: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN
Jan Jones-Schenk, DHSc, RN, NE-BC, FAAN

Author: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN

492 Copyright © SLACK Incorporated

vention researchers must build into
their studies a science-based imple-
mentation strategy, as well as philan-
thropic organizations, to ensure that
their efforts reach the point of intend-
ed impact (Easterling & Metz, 2016).

DEGREES OF IMPLEMENTATION
A highly recommended resource

for professional development educa-
tors is the work of Fixsen, Naoom,
Blase, Friedman, and Wallace (2005),
which provided a useful synthesis of
implementation science research.
Their summary reflects that imple-
mentation takes place with differ-
ing levels of engagement, similarly
to the letting it change, helping it
change, and making it happen levels
mentioned earlier. Paper implementa-
tion—often required by regulators—
refers to changes that result from the
adoption of policies and procedures,
where a needed paper trail documents
change. Organizational leaders should
be competent in preparing policies,
procedures, algorithms, and protocols
to give direction and insight into prac-
tice.

Process implementation advances
paper implementation. Educators
play a pivotal role as leaders who pro-
vide training as the backdrop for spec-
ifying the rationale for change, the
expectations linked to innovations,
and simulation or competency expec-
tations to ensure that the client system
affected by the change is able to per-
form, without the guarantee that they
will perform or change their practice.
Process implementation eliminates
the variable relating to knowing what
to do, as it has been measured and
evaluated.

The third level of implementa-
tion is where the change is actually
implemented and takes hold in the
organization, known as performance
implementation. This is where the
consolidated framework for imple-
mentation research model developed
by Damschroder et al. (2009) is a use-
ful reference for educators and leaders.
This model depicts the variables at play
during the implementation of innova-
tions with supportive evidence being
generated by implementation scien-
tists. Implementation is influenced by
(a) intervention characteristics, which
vary in factors such as adaptability, ad-
vantage, and complexity; (b) the outer
settings, with factors such as patient ex-
perience and expectations, incentives,
and pressure from peer organizations;
(c) the inner setting, with its unique
structural characteristics and networks;
(d) the characteristics of the individuals
involved, such as their knowledge and
identification with the organization;
and (e) the process of implementation,
such as how it was planned, executed,
and other factors. When taken com-
pletely, it immediately becomes clear
that multiple and often confound-
ing variables are required for effective
change management, offering a par-
tial explanation for the often dismally
slow uptake of innovations in health
care settings. As the Doctor of Nurs-
ing Practice enters the workforce in
expanding roles, it should be with the
ability to discern and lead innovations
and change, from paper to practice.

SUMMARY
The professional development

educator, whether in the practice
or academic setting, who is teach-

ing implementation science content
should move beyond the comfort
zone of the process implementation
described above. Yes, education at the
process level is key to the implementa-
tion of innovations—it can incentiv-
ize and motivate learners to take heed
of answering the “what” and “why” of
change needed. However, widespread
change that takes hold organization-
wide is the skill and competency set
needed by leaders. Novice leaders may
not possess awareness of all the vari-
ables to consider in driving change
that must happen. Offering leaders
training in the models and resources
presented in this article is a starting
point for advancing their competence
in implementation science.

REFERENCES
Bauer, M.S., Damschroder, L., Hagendorn, H.,

Smith, J., & Kilbourne, A.M. (2015). An
introduction to implementation science for
the non-specialist. Retrieved from https://
bmcpsychology.biomedcentral.com/track/
pdf/10.1186/s40359-015-0089-9

Damschroder, L.J., Aron, D.C., Keith, R.E.,
Kirsh, S.R., Alexander, J.A., & Lowery,
J.C. (2009). Fostering implementation of
health services research findings into prac-
tice: A consolidated framework for advanc-
ing implementation science. Implementation
Science, 4(50).

Easterling, D., & Metz, A. (2016). Getting real
with strategy: Insights from implementation
science. The Foundation Review, 8, 97-115.

Fixsen, D. (2019, February 4). The science of im-
plementation—Dr. Dean Fixsen—episode 11
[Video file]. Retrieved from https://www.
youtube.com/watch?v=t4k8pk9Bgps

Fixsen, D.L., Naoom, S.F., Blase, K.A., Fried-
man, R.M., & Wallace, F. (2005). Imple-
mentation research: A synthesis of the litera-
ture. Retrieved from https://nirn.fpg.unc.
edu/sites/nirn.fpg.unc.edu/files/resources/
NIRN-MonographFull-01-2005.pdf

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