Chapter011

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 11
Models to Guide
Implementation of
Evidence-Based Practice

Implementing EBP
• Individual factors can make it difficult to implement IBP
• However, organizational factors often create the most
significant barriers to evidence-based practice

From Research Utilization (RU) to EBP
• EBP is broader than research utilization because the
clinician is encouraged to consider a number of
dimensions in clinical decision making, one of which is
evidence
− Internal evidence
− Patient preferences, setting, and circumstances
− Clinical expertise
− Available resources

Question
• Tell whether the following statement is true or false.
• Evidence-based clinical decision-making considers the
constraints of a patient’s geographic location while a
research utilization (RU) model does not address this
parameter.

Answer
• True
• Rationale: Evidence-based clinical decision-making takes
into account patient variables such as setting. RU is a
more simplistic paradigm that solely encompasses the
findings of research.

Models to Change Practice in an
Organization
• Numerous models have been designed to help clinicians
implement an evidence-based change in practice
• They all differ, but commonalities exist in terms of steps
and phases

The Stetler Model of Evidence-Based
Practice
• Well-known as a practitioner-oriented model
• Considers both internal and external evidence
• Phases or stages
1. Preparation
2. Validation
3. Evaluation
4. Translation/application
5. Comparative evaluation/decision making
• See Figure 11.2

The Stetler Model of Evidence-Based
Practice (cont’d)
• Use of the model requires an RU/EBP competent
individual
• Such individuals also can informally use the model’s
critical-thinking process in their routine practice
• Research findings and other credible evidence, such as
consensus guidelines, may be used in multiple ways
• Research findings and related evidence can be used
symbolically (i.e., strategically) to influence the thinking
and behavior of others

Question
• When the Stetler Model is used to guide an evidence-
based practice change, which of the following activities
will constitute the final phase of the process?
a. Disseminating the results of the practice change
b. Publishing the findings that result from implementation
c. Evaluating the outcomes of the change in practice
d. Implementing a change in practice based on evidence

Answer
• c. Evaluating the outcomes of the change in practice
• Rationale: The Stetler Model of Evidence-Based Practice
culminates with an evaluation of the change in practice.
Dissemination is not prescribed in the model and
implementation does not form the “end point” of the
implementation process.

Iowa Model of Evidence-Based Practice
to Promote Quality Care
• See Figure 11.3
• Provides guidance for nurses and other clinicians in
making decisions about day-to-day practices that affect
patient outcomes
• A pragmatic multiphase change process with feedback
loops
• Widely recognized for its applicability and ease of use by
multidisciplinary healthcare teams

Using the Iowa Model
• Begins with practice questions or “triggers”
• A team is formed to develop, implement, and evaluate
the practice change
• The team selects, reviews, critiques, and synthesizes
available research evidence
• A practice change is piloted
• A determination is made regarding appropriateness of
adoption beyond the pilot
• On-going evaluation
• Dissemination

The Model for Evidence-Based Practice
Change
• A revised version of the model by Rosswurm and
Larrabee (1999)
• See Figure 11.4
• Steps:
1. Assess the Need for Change in Practice
2. Locate the Best Evidence
3. Critically Analyze the Evidence
4. Design Practice Change
5. Implement and Evaluate Change in Practice
6. Integrate and Maintain Change in Practice

Question
• Tell whether the following statement is 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.

The Advancing Research and Clinical
Practice Through Close Collaboration
Model (ARCC Model)
• Exists to provide healthcare institutions and clinical
settings with an organized conceptual framework that
can guide system-wide implementation and sustainability
of EBP to achieve quality outcomes
• Developed out of nurse input as well as Control Theory
and Cognitive Behavioral Theory

Control Theory as a Conceptual Guide for
the ARCC Model
• See Figure 11.5.

The ARCC Model

The ARCC Model (cont’d)
• Contends that when clinicians’ beliefs about the value of
EBP and their ability to implement it are strengthened,
there will be greater implementation of evidence-based
care
• EBP mentors play a central role
− Workshops and academic offerings are available that
develop these mentors
• Barriers and facilitators to EBP, along with clinicians’
beliefs about and actual implementation of EBP, can be
readily assessed and identified by organizations using
established instruments

Promoting Action on Research
Implementation in Health Services
Framework (PARIHS)
• Developed in an attempt to reflect the complexities of
bringing evidence to practice
• Successful implementation (SI) is represented as a
function (f) of the nature and type of evidence (e), the
qualities of the context (c) in which the evidence is being
introduced, and the way the process is facilitated (f)
• Elements
− Evidence
− Context
− Facilitation

The Clinical Scholar Model
• Developed 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 care
• Clinical scholars are described as individuals with a high
degree of curiosity that possess advanced critical-
thinking skills and continuously seek new knowledge
through continuous learning opportunities
• Clinical scholar mentors play a central role
• The Clinical Scholar Program was developed to actualize
the Clinical Scholar Model

The Clinical Scholar Model

Question
• Feedback loops are a central component of which of the
following models for evidence-based practice change?
a. The Model for Evidence-Based Practice Change
b. The Clinical Scholar Model
c. The ARCC Model
d. The 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 ARCC Model,
the Clinical Scholar Model, or The Model for Evidence-
Based Practice Change.

The Johns Hopkins Nursing Evidence-
Based Practice Model (JHNEBP)
• Facilitates bedside nurses in translating evidence to
clinical, administrative, and educational nursing practice
• Sets a goal to build a culture of nursing practice based on
evidence
• Aims to demystify the EBP process for bedside nurses
and embed EBP into the fabric of nursing practice

JHNEBP Model

The JHNEBP Process: PET
• Practice Question
• Evidence
• Translation

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