Chapter 12

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 12
Evidence-Based Practice and
Nursing Theory

Overview of Evidence-Based Practice
• Evidence-based practice (EBP) was
introduced in the 1970s by Dr. Archie
Cochrane.
• Dr. Cochrane focused on critical review
of research (emphasis on RCTs) to
improve medical practice.
• Application in nursing has been delayed
but has been growing over the past 10
years.

Overview of Evidence-Based
Practice—(cont.)
• EBP is based on the premise that
health professionals should not base
practice on tradition and belief but on
information grounded in research.
• EBP is not synonymous with research.
– Research focuses on discovery.
– EBP focuses on application.

Overview of Evidence-Based
Practice—(cont.)
• EBP involves:
– Identifying a clinical problem
– Searching the literature and
critically evaluating research
evidence
– Determining appropriate
interventions
• EBP integrates research, theory, and
practice.

Evidence-Based Practice
• EBP is ―the conscientious, explicit, and judicious use of
theory-derived, research-based information in making
decisions about care delivery . . . in consideration of
individual needs and preferences‖
• Key concepts of EBP
– Best evidence
– Expertise
– Patient values
• Careful review of research findings according to
guidelines.
• De-emphasizes ritual, isolated, and unsystematic clinical
experiences, options, and tradition as basis for practice

Question
Which of the following is NOT considered to be a key
concept of EBP?
A. Best evidence
B. Patient values
C. Provider expertise
D. Traditional practices

Answer
D. Traditional practices
Rationale: EBP de-emphasizes ritual, unsupported
practices, and tradition and focuses on research-
supported interventions that considers patients’ desires
and needs and provider expertise.

Evidence-Based Nursing
• Some sources for EBP
information/guidelines
– Cochrane Collaboration/Cochrane
Database of Systematic Reviews—
network that helps health care
providers make informed decisions
about health care
– Agency for Healthcare Research
and Quality (AHRQ)—maintains
database of evidence-based clinical
practice guidelines

Evidence-Based Nursing—(cont.)
• Concerns
– Too much focus on EBP could result in ―cookbook
care‖ and loss of ―art‖ of nursing.
– Lessening of attention to holistic care
– Health care reimbursement might drift exclusively
to interventions substantiated by ―evidence.‖
– Not all health care practices can or should be
based on science per se (What about ―care‖?).
• Consensus agreement that EBP in nursing should
consider all types of evidence (not just RCTs), as well
as clinical experience, patient experiences and
desires, and relevant local/organizational influences.

Practice-Based Evidence
• PBE is a relatively new concept in nursing and health
care.
• Based on the observation that many interventions have
limited formal research support
• PBE recognizes the importance of the environment in
determining practice recommendations.
• Premise of PBE is that large databases should be
reviewed or ―mined‖ to gather data on quality and
effectiveness.

Practice-Based Evidence—(cont.)
• PBE seeks to determine what works best for which patients, under
what circumstances, and at what costs.
• More comprehensive picture than RCTs
• Sources include:
– Benchmarking data
– Clinical expertise
– Cost-effective analyses
– Infection control data
– Medical record data
– National standards of care
– Quality improvement data
– Patient and family preferences

Relationships among practice, theory, research, and the
PBE/ EBP cycle.
(From Walker, L. O., & Avant, K. C. [© 2011]. Strategies for theory
construction in nursing [5th ed., Fig. 2-3; p. 46]. Reprinted by permission of
Pearson Education, Inc., Upper Saddle River, NJ.)

Theory and Evidence-Based Practice
• More awareness of EBP has renewed
appreciation for linkages among
research, theory, and practice.
• Research and clinical data provide
evidence for EBP and/or PBE and can
generate practice guidelines and/or
situation-specific theories.
• Preference for term ―theory-guided,
evidence-based practice‖

Models for Evidence-Based Practice
• For some EBP models, the goal is to
create or establish EBP protocols,
procedures, or guidelines.
• Some EBP models focus on
implementation of EBP in the setting or
institution.

Models for Evidence-Based Practice—
(cont.)
• Most commonly used and described in nursing literature
are:
– Academic Center for Evidence-Based Practice Star
Model (ACE Star Model) (Stevens, 2004)
– Advancing Research and Clinical Practice Through
Close Collaboration (ARCC Model) (Melnyk &
Fineout-Overholt, 2011)
– Iowa Model (Titler et al., 2001)
– Johns Hopkins Nursing Evidence-Based Practice
Model (JHNEBP) (Newhouse et al., 2007)
– Stetler Model of Evidence-Based Practice (Stetler,
2001)

Evidence-Based Practice Models—
ACE Star Model
• Developed by faculty at University of Texas
Health Science Center at San Antonio
• Depicted by five points of sequential knowledge
transformation
– Discovery research
– Evidence summary
– Translation to guidelines
– Practice integration
– Process and outcome evaluation

Diagram of the ACE star model for evidence-based practice.
(Used with permission from Stevens, K. R. [2012]. ACE Star Model: Knowledge
transformation©. Academic Center for Evidence-Based Practice. Available at
http://www.acestar.uthscsa.edu/acestar-model.asp)

ACE Star Model—(cont.)
• Knowledge transformation (KT) consists of
eight premises.
– KT is necessary prior to using research for
clinical decision making.
– KT is derived from multiple sources (e.g.,
research, experience, authority).
– Research process is the most stable
source of knowledge.
– Evidence can be classified by strength of
evidence based on rigor.

ACE Star Model—(cont.)
• Knowledge transformation (KT) consists of eight
premises—(cont.)
– As research is converted through a system of
steps, other knowledge is created.
– The form in which knowledge exists can be
referenced to its use.
– The form of knowledge determines its
usability.
– KT takes place through steps
(summarization, translation, application,
integration, and evaluation).

Evidence-Based Practice Models—ACE Star
Model—(cont.)
• ACE Star Model has been shown useful
in teaching the process of research
evidence.
• For more information, see:
http://www.acestar.uthscsa.edu/index.
asp

ARCC Model
• The Advancing Research and Clinical
Practice Through Close Collaboration
(ARCC) Model was developed to
advance and sustain EBP (Melnyk &
Fineout-Overholt, 2002).
• Basis in control theory and cognitive
behavioral theories
• Appropriate in clinical practice—
particularly acute care

ARCC Model—(cont.)
• Central constructs of the ARCC Model
– Assessment of organizational culture and
readiness for EBP
– Identification of strengths and barriers to
EBP
– Development and use of EBP mentors
– EBP implementation
– Outcome evaluation (providers’ satisfaction,
cohesion, intent to leave, turnover,
improved patient outcomes, hospital costs)

Evidence-Based Models—ARCC
Model—(cont.)
• Several scales have been developed to
measure implementation of EBP using
the ARCC Model.
• Among them are scales to measure
organizational readiness and EBP
beliefs.
• Considerable amount of research
support for the ARCC model

Iowa Model of EBP to Promote
Quality Care
• The Iowa Model of EBP was developed
in the 1990s.
– Intent to promote quality care
through research utilization
– It was developed to provide
guidance for nurses in making
decisions about practice.

Question
Tell whether the following statement is true or false:
The rationale for development of the Iowa Model of EBP
was to manage the costs of health care.

Answer
False
The Iowa Model for EBP was developed to promote quality
nursing care through incorporation of research into
practice.

Evidence-Based Practice Models—Iowa
Model of EBP to Promote Quality Care—
(cont.)
• Organized into starting points, decision points, and feedback loops
– Starting points are problem-focused triggers or knowledge-
focused triggers
– Decision points:
• Is the topic a priority?
• Is there sufficient research base?
• Is change appropriate for adoption in practice?
– There are numerous feedback loops based on the model.
– After implementation of practice change, monitor and analyze
the structure, process, and outcome data; then disseminate
results.

Diagram of the Iowa method
of evidence-based practice.
(Reprinted with permission from
University of Iowa Hospitals and Clinics.
© 1998. For permission to use or
reproduce the model, please contact
University of Iowa Hospitals and Clinics
at 319-384-9098.)

Iowa Model of EBP to Promote
Quality Care—Resources
• For more information, see:
http://www.nnpnetwork.org/ebp-resources/iowa-model
http://www.hinursing.org/pdf/IowaModel.pdf

Johns Hopkins Nursing EBP Model
• The JHNEP Model is a problem-solving
approach to clinical decision making.
• Developed to accelerate research into
nursing practice and promote nursing
autonomy, leadership, and engagement
with colleagues
• Combines the nursing process, the ANA
Standards of Practice, critical thinking,
and research utilization

Johns Hopkins Nursing EBP Model—
(cont.)
• Three core elements (PET)
– Practice question
– Evidence
– Translation
• Several phases composed of 18 steps.
– Each step helps clarify the processes.
– Assist in understanding how to proceed

(cont.)
• Model begins with an EBP question (PICO) consisting
of:
Practice question (patient, population and problem)
Intervention
Comparison as appropriate
Desired Outcome(s)
• Other steps involve defining the scope of the question,
assigning reasonability for leadership, recruiting a team
and scheduling conferences.

Question
When developing a PICO question, the ―C‖ represents
which of the following?
A. Care options
B. Comparison with a baseline or standard
C. Consideration of patient or provider values/wishes
D. Costs of interventions

Answer
B. Comparison with a baseline or standard
Rationale: A PICO question consists of:
Practice question (patient, population, and problem)
Intervention
Comparison as appropriate
Desired Outcome(s)

(cont.)
• Evidence phase includes:
– Literature search
– Team appraisal and recommendations
• Translation phase:
– Team decides whether and how to
implement changes.
– Evaluation of implementation
– Communicate the findings PRN

Resources
• For more information (optional course):
http://www.hinursing.org/pdf/IowaModel.pdf
• Data collection tool:
http://www.nursingworld.org/DocumentVault/Nursi
ngPractice/Research-Toolkit/JHNEBP-Research-
Evidence-Appraisal.pdf

Stetler Model
• Originally implemented in the 1970s as a quality
improvement effort
• Similar to the nursing process thus easily implemented
• Five steps or phases
– Preparation
– Validation
– Comparative evaluation/decision making
– Translation/application
– Evaluation

Stetler Model—(cont.)
• Preparation
– Propose, control, and source research evidence
• Validation
– Determine credibility of findings and potential for qualifiers for
application
• Comparative evaluation/decision making
– Synthesis of information and decisions for recommendations for
criteria and applicability
• Translation/application
– Create operational definitions for use and actions for change
• Evaluation
– Determine alternate types of evaluation

Evidence-Based Practice—Summary
• EBP has become one of the key tenets of
quality nursing care.
• In nursing, it is critical that EBP go beyond
research and be theory based.
• Growing attention to the concept of PBE has
renewed attention to the critical role of
theory in excellent nursing practice.

Chapter 12

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