Importance of Using Best Available Evidence to Guide Nursing Practice

It is clear from this sampling of studies that EBP is continuing to evolve, but not to the extent that is necessary. Nurses must understand the importance of EBP, and healthcare organizations must invest in resources necessary for nurses to have access to evidence at the point of care. However, a systematic approach to using that evidence is necessary: A formal process is needed that uses specific criteria to appraise evidence to enhance efficiency and effectiveness of practice and uses methods for incorporating that evidence into practice. There are many good EBP models that have been developed to organize and assist nurses to ask clinical questions, evaluate new evidence, and to make changes in the clinical setting. Each of these models has advantages and disadvantages, and they vary in usefulness by setting and context. Gawlinski and Rutledge (2008) suggested that a deliberate process should be followed by an organization to select a model for EBP. They suggested that first a group should be developed to champion the EBP process and that this group should review models by using specific criteria and then summarize the strengths and weaknesses of the models by asking specific questions such as:

They also suggested that once a model is chosen, the EBP champion group should educate the staff. Dearholt, White, Newhouse, Pugh, and Poe (2008) have gone further, suggesting that once the organization decides that an evidence-based foundation for nursing is needed, a model should be chosen that is easy for the staff nurse to use; the administration should also create a strategic initiative around the implementation of EBP for the nursing department, supporting the initiative with resources in terms of time, money, and people.

Stetler’s Model of Research Utilization

Cheryl Stetler’s Model of Research Utilization (Figure 1.1) was one of the original models developed as an EBP for nursing that began to receive attention. She originally developed the model in 1994 and revised it in 2001. The purpose of the model is to formulate a series of critical-thinking and decision-making steps that are designed to facilitate the effective use of research findings (Stetler, 2001; Stetler & Marram, 1976). The model is an individual practitioner-oriented model rather than an organizational-focused model. The revised model promotes the use of both internal data (such as quality improvement, operational, evaluation, and practitioner experience data) and external evidence (such as primary research and consensus of national experts). The model describes five phases of research utilization. In phase I, preparation, the nurse searches for and selects research to be evaluated for practice implementation. This step is driven by critical thinking about potential internal and external influencing factors. During phase II, validation, the nurse appraises the findings of the study using specific methodology and utilization considerations. In phase III, the comparative evaluation or decision-making phase, a decision about whether a practice change can be made is determined using four applicability criteria: (a) the substantiating evidence, (b) the fit for implementing the research findings in the setting, (c) the feasibility of implementation, and (d) the evaluation of current practice. Phase IV is when the translation or application of the research findings is implemented and the “how tos” of implementation are considered. Phase V, evaluation, requires that processes include different types and levels of evaluation.

FIGURE 1.1

The Stetler model.

r, r, r, risk factors, resources, and readiness of others to be involved.

Source: From Stetler, C. (2010). Stetler model. In J. Rycroft-Malone & T. Bucknall (Eds.), Evidence-based practice series. Oxford, UK: Wiley-Blackwell.

Dobbins’s Framework for Dissemination and Utilization of Research

In 2001, Dobbins, Cockerill, and Barnsley studied the factors affecting the utilization of systematic reviews. The purpose of their study was to determine the extent to which public health decision makers in Ontario used five systematic reviews to make policy decisions and to determine the characteristics that predict their use. The findings of the study were used to assist health services researchers in disseminating research. Informed by their own research and using Everett Rogers’s Diffusion of Innovations theory, the Dobbins’s framework for dissemination and utilization of research (Figure 1.2) was developed to inform policy and practice. The model illustrates that the process of adoption of research evidence is influenced by characteristics related to the individual, organization, environment, and innovation. The model includes five stages of innovation: knowledge, persuasion, decision, implementation, and confirmation. Identified under each of the five stages are the considerations for transferring research to practice in healthcare (Dobbins, Ciliska, Cockerill, Barnsley, & DiCenso, 2002).

FIGURE 1.2

Framework for research dissemination and utilization.

CME, continuing medical education.

Source: Adapted with permission from Dobbins, M., Ciliska, D., Cockerill, R., & Barnsley, J. (2001). Factors affecting the utilization of systematic reviews: A study of public health decision makers. International Journal of Technology Assessment in Health Care, 17(2), 203–214. doi:10.1017/S0266462300105069

Funk’s Model for Improving the Dissemination of Nursing Research

In 1987, the research team of Funk, Champagne, Tornquist, and Wiese, after concluding that there was a huge gap between the conduct of nursing research and the use of research findings to improve practice, developed the BARRIERS scale to assess the perceptions of barriers of clinicians, administrators, and academicians to the utilization of research findings in practice. Items were derived from the literature, from research data, and from the Conduct and Utilization of Research in Nursing (CURN) project’s research utilization questionnaire (Crane, Pelz, & Horsley, 1977). The BARRIERS scale consisted of 28 items in four categories: characteristics of the adopter, the organization, the innovation, and the communication. The tool was tested with a sample of 1,948 RNs in clinical practice (n = 924). Standard psychometric analyses of the tool were performed and replicated. Using the results of this analysis, the team developed a model for improving research utilization. The Funk model for improving dissemination of nursing research (Figure 1.3) includes three components: the qualities of the research, characteristics of communication, and facilitation of utilization (Funk, Tornquist, & Champagne, 1989). The model delineates three mechanisms to achieve the dissemination of research: (a) hold topic-focused, practice-oriented research conferences; (b) write monographs that are based on the research conference presentations; and (c) develop an information center that provides ongoing dialogue, support, and consultation for the dissemination (Funk et al., 1989). The goal of the approach is to reach the practicing nurse with research results and to provide support and consultation to those doing the research.

Clinical Practice Guideline Implementation Model

The Registered Nurses Association of Ontario (RNAO; 2002) took the lead in Canada in developing best practice guidelines for nurses. The Nursing Best Practice Guidelines (NBPG) project was funded by the Ontario Ministry of Health and Long-Term Care and involved the development, implementation, evaluation, and dissemination of a series of clinical practice guidelines (CPGs). Early on in the project it became evident that healthcare organizations were struggling to identify ways to implement the guidelines, and little attention was being paid to implementation strategies. The RNAO established a panel of nurses and researchers, chaired by Alba DiCenso, to develop a planned, systematic approach to the implementation of the CPGs (DiCenso et al., 2002). The likelihood of success in implementing CPGs increases when:

The panel developed an implementation model (Figure 1.4) with an accompanying tool kit for implementing CPGs (rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition).

FIGURE 1.3

The Funk research dissemination model.

Source: Reprinted with permission from Funk, S. G., Tornquist, E. M., & Champagne, M. T. (1989). A model for the dissemination of nursing research. Western Journal of Nursing Research, 11(3), 361–372. doi:10.1177/019394598901100311. Copyright by Sage Publications, Inc.

FIGURE 1.4

CPG implementation model.

CPG, clinical practice guideline.

Source: From Registered Nurses Association of Ontario. (2002). Toolkit: Implementation of clinical practice guidelines. Retrieved from http://rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition.

The Johns Hopkins Nursing EBP Model and Guidelines

The Johns Hopkins Nursing EBP (JHNEBP) Model (Figure 1.5) was developed by a collaborative team of nurse leaders from the Johns Hopkins Hospital (JHH) and the Johns Hopkins University School of Nursing (JHUSON) asked to evaluate current practice, policies and procedures to ensure they were evidence-based. The team developed this practical model with accompanying guidelines and tools so that staff nurses would be able to evaluate current evidence and translate research findings into patient care. The goals of EBP at both the JHH and JHUSON are to:

FIGURE 1.5

Johns Hopkins Nursing evidence-based practice conceptual model.

Source: From Dang, D., & Dearholt, S. (2017). The Johns Hopkins nursing evidence-based practice model and guidelines. Indianapolis, IN: Sigma Theta Tau International.

The JHNEBP conceptual model was updated in 2017 to reflect more contemporary practice and terminology.

The JHNEBP model is defined as a problem-solving approach to clinical decision-making within a healthcare organization, which integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence, considers internal and external influences on practice, and encourages critical thinking in the judicious application of such evidence to the care of the individual patient, patient population, or system (Newhouse, Dearholt, Poe, Pugh, & White, 2005). The model also includes the three domains of professional nursing: nursing practice, education, and research.

The guidelines that accompany the model describe the three phases in getting to an EBP (Figure 1.6). These three phases are described as the “PET” process, an acronym that stands for the practice question, evidence, and translation.

The first phase, or “P” in PET, is the practice question and involves six steps:

The second phase, or “E” in PET, is evidence and involves another five steps:

The third phase, or “T” in PET, is translation, which includes the following nine steps:

This model includes a set of tools for use during each of the phases discussed previously and a very important project management tool that delineates the 19 steps in the PET process for the user. These tools are a critical added dimension to the model and make its use very practical for the staff nurse. The eight tools are:

The Iowa Model of Research-Based Practice to Promote Quality Care

The Iowa Model of Research-Based Practice was developed as a decision-making algorithm to guide nurses in using research findings to improve the quality of care (Figure 1.7). It was originally published in 1994, revised in 2001, and revised again in 2015 by the Iowa Model Collaborative. The revision was based on changes in the healthcare system, emerging evidence in implementation science, and questions from users (Cullen, Hanrahan and Kleiber, 2018). The Iowa model uses the concept of “triggers” for EBP, either clinical problem-focused or new knowledge-focused triggers often coming from outside the organization. These triggers set an EBP inquiry into motion and at each point in the algorithm, the nurse must consider the organizational context and the strength and quantity of evidence, while answering several questions:

This model emphasizes the use of pilot testing versus the implementation of a practice change.

Rosswurm and Larrabee’s Model for EBP Change

Rosswurm and Larrabee (1999), at the University of West Virginia, developed a six-step model to facilitate a shift from traditional and intuition-driven practice to implement evidence-based changes into practice (Figure 1.8). The model has been tested in the acute care clinical setting, but the authors think it is adaptable to primary care settings. The following are the six steps in the model (Larrabee, 2009):

FIGURE 1.7

The 2017 Iowa Model—Revised: Evidence-based practice to promote excellence in healthcare.

Note: Used/reprinted with permission from the University of Iowa Hospitals and Clinics, Copyright 2015. For permission to use or reproduce the model, please contact the University of Iowa Hospitals and Clinics at 319-384-9098 or [email protected].

Source: From Iowa Model Collaborative. (2017). Iowa Model of evidence-based practice: Revisions and validation. Worldviews on Ev i dence-Based Nursing, 14(3), 175–182. doi:10.1111/wvn.12223

FIGURE 1.8

A model for change to evidence-based practice.

Source: Reprinted with permission from Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4), 317–322. doi:10.1111/j.1547-5069.1999.tb00510.x. Copyright by Blackwell Publishing.

The ACE Star Model of Knowledge Transformation

The Academic Center for Evidence-Based Practice (ACE; n.d.) Star Model of Knowledge Transformation (Figure 1.9) was developed by Kathleen Stevens and staff at the University of Texas Health Science Center in San Antonio to provide a framework for understanding the cycles, nature, and characteristics of knowledge that are used in EBP processes (http://nursing.uthscsa.edu/onrs/starmodel/institute/su08/starmodel.html; Stevens, 2013). The goal of the process is knowledge transformation that is defined as “the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of [evidence-based] care” (Stevens, 2004). The model promotes EBP by stressing the identification of knowledge types (from research to integrative reviews to translation). This model does not discuss the use of nonresearch evidence. The ACE Star Model is depicted using a five-pointed star for the five stages of knowledge transformation:

FIGURE 1.9

The ACE Star Model of Knowledge Transformation.

Source: Adapted from Stevens, K. R. (2004). ACE Star model of EBP: Knowledge transformation. San Antonio, TX: Academic Center for Evidence-Based Practice, The University of Texas Health Science Center at San Antonio. Retrieved from http://nursing.uthscsa.edu/onrs/starmodel/institute/su08/starmodel.html. © Stevens, 2015. Used with expressed permission.

Advancing Research Through Close Clinical Collaboration

The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model (Figure 1.10) was originally developed by Fineout-Overholt, Melnyk, and Schultz (2005) at the University of Rochester Medical Center.

The goals of the ARCC Model are as follows:

This model was originally developed to create a link between a college of nursing and a medical center. It is referred to as a clinical scholar model and relies on mentors with in-depth knowledge of EBP and expert clinical and group facilitation skills. The following are the five steps in the model:

Melnyk and Fineout-Overholt (2005) conducted a pilot study to test the ARCC Model at two acute care sites. The pilot study examined what must be present for a successful implementation of EBP in the acute care setting. These essentials include identifying EBP champions, redefining nurses’ roles to include EBP activities, allocating time and money to the EBP process, and creating an organizational culture that fosters EBP. In addition, practical strategies for implementing EBP are presented to encourage implementation of EBP (Melnyk & Fineout-Overholt, 2005).

The Clinical Scholar Model

The Clinical Scholar Model is attributed to work facilitated by Alyce Schultz and a team of nurses at the Maine Medical Center in Portland, Maine (see Figure 1.11). The model is based on the assumption that “knowledge users produce better patient outcomes,” and is a grassroots approach to developing a core group of point-of-care nurses who become clinical scholars and are committed to improving patient care through research, evidence-based practice, and quality improvement (Strout, Lancaster, & Schultz, 2009). The model uses an inductive approach to promote interdisciplinary EBP teamwork at the point of care by developing bedside nurses who mentor their colleagues to critique, integrate, implement, and evaluate evidence and build a cadre of innovators necessary to develop and sustain an EBP culture. The model proposes five major steps to the use of evidence in practice: observation, analysis, synthesis, application/evaluation, and dissemination.

FIGURE 1.11

The Clinical Scholar Model.

IRB, institutional review board.

Source: Courtesy of Alyce A. Schultz RN, PhD, FAAN, Chandler, Arizona.

Honess, Gallant, and Keane (2009) reported on three EBP projects that started at the point of care by staff nurses who questioned traditional practices; used the model to guide the identification, implementation, and evaluation of their current clinical practice; and used internal and external evidence to develop sound EBP changes.

Veterans Administration’s Quality Enhancement Research Initiative Model

The Quality Enhancement Research Initiative (QUERI) Model (Figure 1.12) was developed by the Department of Veterans Affairs in 1998 to improve the quality of healthcare throughout the veterans system through the use of research-based best practices (Stetler, Mittman, & Francis, 2008). The program had a quality-improvement focus and included a redesign of organizational structures and policies and implementation of new information technology and a performance accountability system (Perrin & Stevens, 2004). The QUERI process model includes six steps (Stetler et al., 2008):

FIGURE 1.12

Quality Enhancement Research Initiative Model.

HSR, health services research; QI, quality improvement.

Source: From Feussner, J. R., Kizer, K. W., & Demakis, J. G. (2000). The Quality Enhancement Research Initiative (QUERI): From evidence to action. Medical Care, 38(6, Suppl. 1), I1–I6. doi:10.1097/00005650-200006001-00001

The program has been implemented in a four-phase pipeline framework that begins with pilot projects for improvement and feasibility, then advances to small clinical trials, and moves to regional rollouts, and, finally, the improvement based on research becomes a national effort (Department of Veterans Affairs, 2011a, 2011b). The QUERI Model is highlighted graphically showing an intersection between research and practice, and showing that the translation of research is accomplished through clinical and quality-improvement (QI) activities and enhanced by feedback in the system.