NursingStudyHub

Appendix: Evidence-Based Practice Models

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by

Liu
in

Nurses and other healthcare professionals have developed several evidence-based practice (EBP) models that aid in the implementation of EBP. These models serve as organizing guides that integrate the most current research to create best patient care practices. In addition to helping nurses integrate credible evidence into practice, EBP models help assure complete implementation of EBP projects and optimize the use of nurses’ time and healthcare resources. No single EBP model can meet the needs of every organization and every patient situation. Therefore, we are providing model definitions, essential steps, salient points, and information resources for the models to help readers identify the EBP model that best fits their current, specific EBP needs.

Model Definition Essential Steps Salient Points to Consider
Iowa Model of EBP (Titler et al., 2001). The Iowa Model focuses on the entire healthcare system (e.g., patient, practitioner, infrastructure) to implement and guide practice decisions based on best available research and evidence.

  1. Identify either a “problem-focused trigger” or “knowledge-focused trigger” that will generate the need for a practice change.
  2. Determine whether the “trigger” is a healthcare organization priority.
  3. Reflect a team’s topic of interest and include interested stakeholders. The team will search, appraise, and synthesize literature related to the topic.
  4. Evaluate the availability and merit (e.g., level of evidence, quality of evidence) of evidence. If evidence availability and merit are lacking, conduct research.
  5. If credible and reliable evidence is available, pilot the practice change.
  6. Appraise pilot for level of success. If pilot is successful, disseminate findings within the organization and implement recommended change into practice.

  • Recommended for use at organizational systems level
  • Uses pragmatic problem-solving approach to EBP implementation
  • Detailed flowchart (see Chapter 11) guides decision-making process
  • Clearly identified decision points and feedback loops throughout the model
  • Emphasizes necessity of pilot project before initiating system-wide project
  • Designed for interprofessional collaboration
  • Has sustained test of time
Stetler Model (Ciliska et al., 2011; Stetler, 2001). The Stetler Model enables practitioners to assess how research findings and other pertinent evidence are implemented in clinical practice. The model examines how to use evidence to create change that fosters patient-centered care. Steps in this model are referred to as phases.

Phase I. Preparation: Identify a priority need. Identify the purpose of the EBP project, context in which the project will occur, and relevant sources of evidence.

Phase II. Validation: Assess sources of evidence for level and overall quality. Determine whether source has merit and goodness of fit and whether to accept or reject the evidence in relation to project purpose.

Phase III. Comparative Evaluation/Decision Making: Evidence findings are logically summarized and similarities and differences among sources of evidence are evaluated. Determine whether it is acceptable and feasible to apply summation of findings to practice.

Phase IV. Translation/Application: Develop the “how to’s” for implementation of summarized findings. Identify practice implications that justify application of findings for change.

Phase V. Evaluation: Identify expected outcomes of the project and determine whether the goals of EBP were successfully achieved.

  • Designed to encourage critical thinking about the integration of research findings
  • Promotes use of best evidence as an ongoing practice
  • Helps lessen errors in critical decision-making activity
  • Allows for categorization of evidence as external (e.g., research) or internal (e.g., organization outcome data)
  • Emphasizes use by single practitioner but may include groups of practitioners or other stakeholders
Ottawa Model of Research Use (Graham & Logan, 2004 Graham et al., 2006). The Ottawa Model is an interactive model that depicts research as a dynamic process of interconnected decisions made and actions taken by stakeholders. The model is composed of three phases: (a) Assess barriers and supports. (b) Monitor intervention and extent of use. (c) Evaluate outcomes. Subsumed under the three phases are six designated primary elements that must be considered when integrating research into practice:

  1. Assess barriers and supports:

    1. Evidence-based innovation: Clearly identify what the innovation is and what the implementation will involve.
    2. Potential adopters: Identify potential adopters with characteristics that could influence the adoption of the innovation (see Rogers’ Change Theory in Chapter 7).
    3. The practice environment: Identify leaders, formal and informal, who can inspire change. Assess environment for needed resources.

     

  2. Monitor intervention and extent of use:

    1. Implementation of intervention strategies: Select appropriate strategies to increase awareness of implementation and provide necessary education and training for conducting the implementation.
    2. Adoption of innovation: Determine the extent of adoption of implementation.

     

  3. Evaluate outcomes:

    1. Evaluate the impact of innovation on patients, practitioners, stakeholders, and healthcare organization.

     

  • Patients are central to the model’s process and their health outcomes are the primary focus.
  • The model focuses on the unit-level environment instead of the entire healthcare organization.
  • The prescriptive aim of the model is to assess, monitor, and evaluate.
Promoting Action on Research Implementation in Health Services (PARiHS) Framework (Rycroft-Malone, 2004). The PARiHS Framework provides a method to implement research into practice by exploring the interactions among three key elements: (a) evidence, (b) context, and (c) facilitation.

  1. Evidence: Search for and identify the best available evidence from research, clinician experience, patient values, organization data, and information.
  2. Context: This is the local environment where the practice change will occur. Adoption of practice change is dependent on contextual features such as organizational culture and level of acceptance, leadership investment, and evaluation of desired outcomes.
  3. Facilitation: Organizational participants use their knowledge and skills to foster implementation of practice change.

  • Explicitly uses facilitation as a factor impacting integration of research findings into practice
  • Does not address generation of new knowledge
  • Focus is on unit settings more than system-wide environment
  • Codified (e.g., research data) and noncodified (e.g., practitioner experience) sources of evidence used
ACE (Academic Center for Evidence-Based Practice) Star Model of Knowledge Transformation© (Kring, 2008; Stevens, 2004). As a framework, the ACE Star Model aids in systematically integrating best evidence into practice. The model has five major stages that depict forms of knowledge in relative sequence. Research moves through the cycles to combine with other forms of knowledge before integration into practice occurs. Five Stages:

  1. Discovery: This stage involves searching for new knowledge found in traditional quantitative and qualitative methodologies.
  2. Evidence Summary: The primary task is to synthesize the body of research knowledge into a meaningful statement of evidence for a given topic. This is a knowledge-generating stage, which occurs simultaneously with new findings that may arise from the synthesis.
  3. Translation: The aim of translation is to provide clinicians with a practice document (e.g., clinical practice guideline) derived from the synthesis and summation of research findings.
  4. Integration: Practitioner and healthcare organization practices are changed through formal and informal channels.
  5. Evaluation: An array of EBP outcomes are evaluated on impact, quality, and satisfaction.

  • Focus on promoting use of EBP for direct care nurses
  • Includes use of qualitative evidence
  • Primary goal of model is knowledge transformation
  • Does not incorporate nonresearch evidence (patient values, practitioner’s experience)
  • Identifies factors that impact adoption of innovation
Advancing Research and Clinical Practice Through Close Collaboration (ARCC) (Melnyk & Fineout-Overholt, 2015).

  1. Assess the healthcare organization for readiness for change and implantation of EBP project.
  2. Identify potential and actual barriers to and facilitators of EBP project.
  3. Identify EBP champions to work with direct care nurses or specific clinical units.
  4. Implement evidence into practice.
  5. Evaluate EBP outcomes.

  • Promotes use of EBP among advanced practice nurses and direct care nurses
  • Identifies a network of stakeholders who are supportive of the EBP project
  • Cognitive behavioral theory underpinnings
  • Emphasis on healthcare organizational readiness and identification of facilities and barriers
  • Encompasses research, patient values, and clinical expertise as evidence.
Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse, Dearholt, Poe, Pugh, & White, 2007). The JHNEBP Model applies a problem-solving approach to clinical decision making. The model is designed to meet the EBP needs of direct care nurses using an uncomplicated three-step process referred to as PET: (a) Practice Question, (b) Evidence, and (c) Translation.

  1. Practice Question: Using a team approach, the EBP question is identified.
  2. Evidence: The team searches, appraises, rates the strength of evidence, describes quality of evidence, and makes a practice recommendation on the strength of evidence.
  3. Translation: In this stage, feasibility is determined, an action plan is created, and change is implemented and evaluated. Findings are presented to the healthcare organization and broader nursing community.

  • Emphasizes individual use
  • Well-developed tool kit that provides nurses with guide for question development, evidence-rating scale, and appraisal guide for various forms of evidence
Knowledge-to-Action (KTA) Process Framework (Graham et al., 2006). The KTA is a model of knowledge creation and knowledge integration. Phases:

  1. Identify problems that need to be addressed and begin searching for evidence and research about the identified problem.
  2. Adapt the knowledge use to a local context.
  3. Identify barriers to use of knowledge.
  4. Select, adapt, and implement interventions.
  5. Monitor the use of implanted knowledge.
  6. Evaluate outcomes related to knowledge use.
  7. Sustain appropriate knowledge use.

  • Adapts well for use with individuals, teams, and healthcare organizations
  • Is grounded in planned action theory, which makes the model adaptable to a variety of settings
  • Breaks knowledge-to-action process into manageable sections.
REFERENCES

  1. Ciliska D., DiCenso, A., Melynk, B. M., Fineout-Overholt, E., Stettler, C. B., Cullent, L., … Dang, D. (2011) Models to guide implementation of evidence-based practice. In B. M. Melnyk & E. Finout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed., pp. 241–275). Philadelphia, PA: Wolters-Kluwer.
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  2. Graham, I. D., & Logan, J. (2004). Innovations in knowledge transfer and continuity of care. Canadian Journal of Nursing Research, 36(2), 89–103.
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  3. Graham, I. D., Logan, J., Harrison, M., Straus, S., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13–24. doi:10.1002/chp.47