Copyright © 2011 Wolters Kluwer Health Lippincott Williams.docx

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams
& Wilkins
Chapter 13
Models to Guide Implementation and Sustainability of
Evidence-Based Practice
*
Copyright © 2015 Wolters Kluwer • All Rights Reserved
Components That Need to Be Considered in the Clinical
Decision-Making Model of EBPPatient
preferences and behaviorsClinical state, setting, and
circumstances Availability of healthcare resources High-
quality research evidence
*
Factors That Are Impacted by the
Practitioner’s Clinical ExpertiseQuality of the initial assessment
of the client’s clinical state and circumstancesProblem

formulationDecision about whether the best evidence and
availability of healthcare resources support a new
approachExploration of patient preferencesDelivery of the
clinical interventionEvaluation of the outcome for that
particular patient
*
Commonalities Found in Models Used for
Implementation of EBPIdentifying a problem that needs
addressingIdentifying stakeholders or change agents who will
help make the change happen in practice Identifying a practice
change shown to be effective through high-quality research that
is designed to address the problemIdentifying and, if possible,
addressing the potential barriers to the practice change
*
Commonalities Found in Models Used for Implementation
of EBP—(cont.)Using effective strategies to disseminate
information about the practice change to those implementing
itImplementing the practice changeEvaluating the impact of the
practice change on structure, process, and outcome
measuresIdentifying activities that will help sustain the change
in practice
*

Commonly Used Models That Facilitate Integration of
Evidence Into PracticeThe Stetler Model of Evidence-Based
PracticeThe Iowa Model of Evidence-Based Practice to promote
quality careThe Model for Evidence-Based Practice ChangeThe
Advancing Research and Clinical practice through close
Collaboration (ARCC) model for implementation and
sustainability of EBP
*
Commonly Used Models That Facilitate Integration of
Evidence Into Practice—
(cont.)The Promoting Action on Research Implementation
in Health Services (PARIHS) frameworkThe Clinical Scholar
modelThe Johns Hopkins Nursing Evidence-Based Practice
modelThe ACE Star Model of Knowledge Transformation
*
Fives Phases of the Stetler Model of EBPPreparation:
Identifying the purpose, context, and sources of evidence
Validation: Assessing the credibility of the evidence and its
statistical and clinical significanceComparative
evaluation/decision making: Synthesizing evidence and making

decisions/recommendations for useTranslation/application:
Developing plan for implementation and measurement of
processes/outcomesEvaluation: Evaluation of processes and
outcomes
*
The Iowa Model of EBPIdentifying problem- and
knowledge-focused triggersDetermining whether the issue is an
organizational priorityForming a teamSelecting, reviewing,
critiquing, and synthesizing available research evidencePiloting
the practice changeEvaluating the pilot and dissemination of
resultsDepending on pilot results, rollout and integration of the
practice are facilitated with periodic evaluation
*
Steps in the Model for Evidence-Based Practice Change
(Larrabee, 2009; Rosswurm & Larrabee, 1999)Assess
the need for change in practice: Stakeholders collect internal
data and compare with external evidence/benchmarks to identify
problems and link them with interventions and outcomesLocate
the best evidence: Determine the types and sources of evidence;
plan and conduct the searchCritically analyze the evidence:
Appraise, weigh, and synthesize evidence; assess feasibility,
benefits, and risksDesign practice change: Define proposed
change and resources needed; design pilot implementation and

its evaluation
*
Steps in the Model for Evidence-Based Practice Change
(Larrabee, 2009; Rosswurm & Larrabee, 1999)—
(cont.)Implement and evaluate change in practice: Implement
pilot; evaluate processes, costs, and outcomes; develop
conclusions and recommendationsIntegrate and maintain change
in practice: Communicate pilot results to stakeholders and make
recommendations; integrate change into practice; routinely
monitor process and outcomes; disseminate monitoring results
and celebrate successes
*
The Advancing Research and Clinical Practice Through Close
Collaboration Model (ARCC©
Model)Provides healthcare institutions and clinical settings with
an organized conceptual framework that can guide system-wide
implementation and sustainability of EBP to achieve quality
outcomesModel is a product of nurse input about barriers and
facilitators of EBP, control theory (Carver & Scheier, 1982,
1998), and cognitive behavioral theory (Beck, Rush, Shaw, &
Emery, 1979)Use of mentors is a central mechanism for
implementing and sustaining EBP
*

Control Theory as a Conceptual
Guide for the ARCC Model
*
The ARCC Model
*
Promoting Action on Research Implementation in
Health Services Framework (PARIHS) Framework
Framework is based on the formula:
SI = f(E,C,F)
where SI represents successful implementation; f, function of;
E, evidence; C, context; and F, facilitation The three elements
(i.e., evidence, context, and facilitation) are each
conceptualized on a high-to-low continuum; the focus is to
move the elements in the formula toward “high” in order to
optimize the chances of success
*

The PARIHS Framework—(cont.)
The three PARIHS elements and their subelements:Evidence:
Propositional and nonpropositional knowledge from the
subelements of research, clinical experience, patient experience,
and local data/informationContext: The environment in which
the proposed change is to be implemented. Subelements include
culture, leadership, and evaluation.Facilitation: The process of
enabling or making easier the implementation of evidence into
practice. Subelements include role, skills, and attributes.
*
The Clinical Scholar (CS) ModelDeveloped to promote
the spirit of inquiry, educate direct care providers, and guide a
mentorship program for EBP and the conduct of research at the
point of careClinical scholars are described as individuals with
a high degree of curiosity that possess advanced critical
thinking skills and continuously seek new knowledge through
learning opportunitiesClinical scholar mentors play a central
role in the modelThe Clinical Scholar Program was developed
to actualize the Clinical Scholar Model
*
The Clinical Scholar (CS) Model—(cont.)

Four central goals of the model include that the CS should be
able to:Challenge current direct care practicesSpeak and
understand research language, making day-to-day dialog about
new research findings a common occurrence Critique and
synthesize current research as the core of evidenceServe as
mentors to other staff and to teams who question their clinical
practices and seek to improve clinical outcomes
*
The Johns Hopkins Nursing Evidence- Based Practice
(JHNEBP) ModelFacilitates bedside nurses in translating
evidence to clinical, administrative, and educational nursing
practiceSets a goal of building a culture of nursing practice
based on evidenceAims to demystify the EBP process for
bedside nurses and embed EBP into the fabric of nursing
practiceDesired outcomes include enhancing nurse autonomy,
leadership, and engagement with interdisciplinary colleagues
*
The JHNEBP Conceptual Model

(From Dearholt, S. L., & Dang, D. (2012). Johns Hopkins
nursing evidence-based practice model and guidelines (2nd ed.).
Indianapolis, IN: Sigma Theta Tau International. Used with
permission.)
*
The JHNEBP Process for EBP:
The PET ProcessPractice question: Identify an
EBP question and define its scope; leadership responsibility
assigned and interdisciplinary stakeholders recruited for team;
team meetings scheduledEvidence: Internal and external
evidence search conducted; evidence critiqued, summarized, and
rated; recommendations developed depending on the evidence
strength and need for change Translation: Determine
appropriateness of recommendation in specific settings; develop
action and evaluation plan; implement plan; evaluate and report
outcomes; secure support for widespread change; identify next
steps
*

The ACE Star ModelDevelopment of the ACE
Star Model was prompted through the work of the Academic
Center for Evidence-Based Practice (ACE) at the University of
Texas Health Science Center San Antonio during the early
phases of the EBP movement in the United States The ACE Star
Model explains how to overcome the challenges of the volume
of research evidence; the misfit between form and use of
knowledge; and integration of expertise and patient preference
into best practiceThe ACE Star Model is a model of knowledge
transformation, to which quality improvement of healthcare
processes and outcomes is the goal
*
The ACE Star Model—(cont.)
(© Stevens, 2004. Reprinted with expressed permission.)
*

The ACE Star Model—(cont.)Star Point 1: Discovery—
represents conduction of primary research studiesStar Point 2:
Evidence summary—represents the synthesis of all available
knowledge compiled into a single harmonious
statement/document, such as a systematic reviewStar Point 3:
Translation into action—combining the existing evidential base
with expertise to extend recommendations into evidence-based
clinical practice guidelines
*
The ACE Star Model—(cont.)Star Point 4: Integration
into practice—practice is aligned to reflect the best
evidenceStar Point 5: Evaluation—an inclusive view of the
impact that the evidence-based practice has on patient health
outcomes, satisfaction, efficacy and efficiency of care, and
health policy
*
Question
The use of EBP mentors is a major component of which model
for evidence-based practice change?The Model for Evidence-
Based Practice Change The ARCC© modelThe Stetler modelThe
Iowa model

*
Answer
b. The ARCC© model
Rationale: The ARCC model is the only model of those listed
that considers the lack of EBP mentors to be a major barrier to
the implementation of EBP and uses training of a cadre of EBP
mentors as a step in implementing the model.
*
Question
Is the following statement true or false?
Both the Model for Evidence-Based Practice Change and the
Iowa model include the use of a small-scale pilot study during
the process of introducing an evidence-based change in practice.
*
Answer
True

Rationale: Pilot studies are explicit components of both the
Model for Evidence-Based Practice Change and the Iowa model.
*
Question
Feedback loops are a central component of which of the
following models for evidence-based practice change?The
Model for Evidence-Based Practice Change The Clinical
Scholar modelThe ARCC modelThe Iowa model
*
Answer
d. The Iowa model
Rationale: The Iowa model includes multiple feedback loops
that refer the user back to earlier points in the process. This is
not a central feature of the Model for Evidence-Based Practice
Change, the Clinical Scholar model, or the ARCC model.
*
*
*

*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*

*
*
*
*
*
*
*
*
*
*
*
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams
& Wilkins
Chapter 14
Creating a Vision and Motivating a Change to Evidence-Based
Practice in Individuals, Teams, and Organizations

*
Implementing EBP
Among the most important elements that need to be present for
change to be accomplished successfully are:
1. Vision: Developing a clear and exciting vision of what is to
be accomplished can unify stakeholders
2. Belief: Belief that the change to EBP is beneficial can lead to
behavior change and foster the ability to successfully make the
change
*
Implementing EBP—(cont.)
3. Strategic planning: Goals are established with deadline
dates; a well-defined strategic plan is written. Use of a SCOT
(Strengths, Challenges, Opportunities, and Threats) analysis
will assist in the planning process: Assess and identify system
Strengths that will facilitate the success of a new projectAssess
and identify Challenges that may hinder the initiativeOutline
the Opportunities for successDelineate the Threats to project
completion, with strategies to overcome them
*

Implementing EBP—(cont.)
4. Action: Putting the strategic plan with its actionable
objectives into motion
5. Persistence: Continuing to move forward despite of
unforeseen barriers; being nimble and open to revising
approaches to allow continued progress
6. Patience: Allows for continued progress even when results of
actions are not yet seen
*
Organizational Change Models: Basic Assumptions of the
Change Curve Model Changing an organization is a highly
emotional processGroup change requires individual changeNo
fundamental change takes place without strong leadershipThe
leader must be willing to change before others are expected to
changeThe larger and more drastic the change, the more
difficult the changeThe greater the number of individuals
involved, the tougher the change will be to make (Duck,
2002)
*
Organizational Change Models: Stages of the
Change Curve Model Stage I: Stagnation: Characteristics
include lack of effective leadership, failed initiatives, and too

few resources; depression occurs and/or hyperactivity exists;
individuals may feel stressed and exhausted Stage II:
Preparation: Emotional climate is anxiety mixed with
hopefulness; possibly reduced productivity; buy-in is essential;
opportunity exists of getting people excited, but may fail if
preparation is too long or too short
*
Organizational Change Models: Stages of the Change Curve
Model—(cont.) Stage III: Implementation: Individuals must see
“what is in it for me?”; it is essential to assess readiness for
change and increase confidence in making the change Stage IV:
Determination: The highest chance of failure is in this stage; if
results are not as expected, change fatigue may set in if
determination to see the change through is not firm;
highlighting small successes is crucial Stage V: Fruition:
Positive outcomes are seen; reward and celebration for effort is
important; danger in this stage is that organization reverts back
to complacency and begins stagnation
*
Organizational Change Models: Kotter and Cohen’s
Model of ChangeStep 1: Create a sense of urgency: Create the
emotional feeling that “we need to move NOW,” which is
especially important when individuals are complacentStep 2:
Form a team: Select members who possess the needed

knowledge and skills, the respect and trust of others, and
enthusiasm and commitment; opinion leaders are particularly
importantStep 3: Vision and strategy: Create a clear vision and
workable strategy with reasonable timeline
*
Organizational Change Models: Kotter and Cohen’s Model of
Change—(cont.)Step 4: Communicating the vision:
Communicate the vision and strategies with “heartfelt
messages” that appeal to the emotions, which will motivate
change; repeating the message will make the strategies
clearerStep 5: Empowerment: Remove barriers that inhibit
successful changeStep 6: Interim successes: Establish short-
term successes to celebrate
*
Organizational Change Models: Kotter and Cohen’s Model of
Change—(cont.)Step 7: Ongoing persistence: Cultivate ongoing
persistence; giving up too early will doom the projectStep 8:
Nourishment: Encourage and feed the new culture to make the
change permanent through celebration and planting meaningful
infrastructures
*

Organizational Change Models: Roger’s Theory of Diffusion of
Innovations
*
Organizational Change Models: The Transtheoretical
Model of Health Behavior Change
Originally conceptualized to explain the process of changes in
health behaviors, but also is applicable to organizational change
Stages:Precontemplation: The individual is not intending to take
action in the next 6 months (40% of an
organization)Contemplation: The individual is intending to take
action within the next 6 months (40% of an
organization)Preparation: The individual plans to take action in
the next 30 days (20% of organization)
*
Organizational Change Models: The Transtheoretical Model
of Health Behavior Change—(cont.)
Stages—(cont.):Action: Overt changes were made less than 6
months agoMaintenance: Overt changes were made more than 6
months ago
By matching intervention strategies to the stage in which
individuals are currently engaged, the model proposes that

resistance, stress, and the time needed to implement the change
will diminish
*
Strategies to Overcome Barriers to
Implementing EBPAllow individuals to express their
skepticism, fears, and anxieties in order to clarify
misconceptionsEducate clinicians about EBP in a way that
appeals to their emotions; this enhances their beliefs about their
ability to implement it Know the personality types of the
individuals involvedProduce a written strategic planDevelop
SMART (i.e., Specific, Measurable, Attainable, Relevant, and
Time bound) goals to be achieved
*
Strategies to Overcome Barriers to
Implementing EBP—(cont.)Communicate the plan clearly
and often; use several media modes (e.g., written,
visual/graphic, and video) if possibleAcknowledge that the
team-building process is dynamic and requires creativity and
flexibilityMatch organizational resources and administrative
support closely to the diffusion of EBPEnlist leaders and
managers early in the change Create a critical mass of EBP
adopters within leadership and individual clinicians to sustain
the change

*
“Knowing and Working with Personality Types”: Rohm’s
Taxonomy (the DISC
Model) Type Characteristics StrategyDriversLike to take
charge and are highly task orientedGive them opportunities to
lead specific tasksInspiredAre socially oriented and like to have
funShow them that the change can be fun and exciting; have
them assist in celebrations of success
*
“Knowing and Working with Personality Types”: Rohm’s
Taxonomy (the DISC Model)—
(cont.) Type Characteristics StrategySupportive and
steadyTypically reserved and like to be ledEmphasize that they
are important to the project, but do not have to
leadContemplatorsVery analytical and detail orientedShow them
all of the details; consider giving them a leadership role in
tracking processes and outcomes
*
Stages of Team FormationStageStage

CharacteristicsFormingAnxiety, excitement, testing,
dependence, exploration, and trustStormingResistance to
different approaches; competitiveness and defensiveness;
tension and disunityNormingTrust and respect develops;
satisfaction increases; feedback is provided to others;
responsibilities are shared; decisions are madePerformingLevel
of interaction is high; performance increases; team members are
comfortable with one another; there is optimism and confidence
*
Question
According to Roger’s theory of diffusion of innovation, the
minimum percentage (critical mass) of people who “adopt” to
the change that would signal that a change has begun to take
hold is:
a. 5%
b. 15%
c. 40%
d. 60%
*
Answer
b. 15%
Rationale: According to the theory, there needs to be a critical
mass of 15% to 20% of a combination of innovators, early

adopters, and early majority before it can be assumed that an
innovative change really begins to take hold.
*
Question
What model of organizational change would be most likely to
give priority to changing nurses’ feelings about EBP over
presenting them with new information?The transtheoretical
model of health behavior changeThe Change Curve
modelDiffusion of innovations modelKotter and Cohen’s model
of change
*
Answer
d. Kotter and Cohen’s model of change
Rationale: Kotter and Cohen propose that the key to
organizational change lies in helping people to feel differently
(i.e., appealing to their emotions). They assert that individuals
change their behavior less when they are given facts or analyses
than when they are shown evidence that influences their
feelings.
*

Question
According to Rohm’s taxonomy (the DISC model), individuals
with which of the following personality styles are most likely to
be comfortable in a leadership role?DriverInspiredSupportive
and steadyContemplator
*
Answer
a. Driver
Individuals with “D” (Driver) personality styles like to take
charge of projects and are highly task oriented, making them
well suited to positions of leadership
*
*
*
*
*
*
*

Copyright © 2011 Wolters Kluwer Health Lippincott Williams.docx

Recommended

Recommended

More Related Content

Similar to Copyright © 2011 Wolters Kluwer Health Lippincott Williams.docx

Similar to Copyright © 2011 Wolters Kluwer Health Lippincott Williams.docx (20)

More from dickonsondorris

More from dickonsondorris (20)

Recently uploaded

Recently uploaded (20)

Copyright © 2011 Wolters Kluwer Health Lippincott Williams.docx