INTRODUCTION:

Evidence-based health care practices are available for a number of conditions such as asthma, heart failure, and diabetes. However, these practices are not always implemented in care delivery, and variation in practices abound. Traditionally, patient safety research has focused on data analyses to identify patient safety issues and to demonstrate that a new practice will lead to improved quality and patient safety. Much less research attention has been paid to how to implement practices. Yet, only by putting into practice what is learned from research will care be made safer. Implementing evidence-based safety practices are difficult and need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and—ultimately—changing health care cultures to be evidence-based safety practice environments [1].

Nursing has a rich history of using research in practice, pioneered by Florence Nightingale. Although during the early and mid-1900s, few nurses contributed to this foundation initiated by Nightingale, the nursing profession has more recently provided major leadership for improving care through application of research findings in practice.

Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decision making is derived principally from non-research evidence sources such as expert opinion and scientific principles. As more research is done in a specific area, the research evidence must be incorporated into the EBP [2].

The EBP models can support an organized approach to implementation of EBP, prevent incomplete implementation, improve use of resources, and facilitate evaluation of outcomes. However, clinicians find there is not one model that meets the needs of all the settings where nurses provide care. The purpose of this discussion is to present a succinct overview of selected EBP models that can be applied to nursing practice and to evaluate their usefulness in clinical and educational settings. It is beyond the scope of this paper to present an in-depth analysis of each EBP model for nursing practice. Rather, this review provides a concise description and evaluation of selected models that occur most frequently in the literature and are used in practice [3].

EVIDENCE-BASED PRACTICE MODELS:

a) Academic Center for Evidence-Based Practice (ACE Star Model):

The Academic Center for Evidence-Based Practice (ACE) developed the ACE Star Model as an interdisciplinary strategy for transferring knowledge into nursing and healthcare practice to meet the goal of quality improvement. This model addresses both translation and implementation aspects of the EBP process. The five model steps are [4]:

(1) Discovery of new knowledge;

(2) Summary of the evidence following a rigorous review process;

(3) Translation of the evidence for clinical practice;

(4) Integration of the recommended change into practice; and

(5) Evaluation of the impact of the practice change for its contribution to quality improvement in health care.

The model emphasizes applying evidence to bedside nursing practice and considers factors that determine likelihood of adoption of evidence into practice.

The Ace Star Model has been used in both educational and clinical practice. In an educational example, the University of Wisconsin-Eau Claire used the ACE Star Model to design an evidence-based approach to promote student success on the NCLEX-RN exam. Authors reviewed trends in exam pass rates, conducted a review of the literature on student success strategies, made recommendations to improve student performance, implemented the strategies, and achieved a statistically significant increase in student pass rate. Other educational projects that have applied the ACE Star Model include identification of EBP competencies for clinical nurse specialists and use of the ACE Star Model as an organizing framework for teaching EBP concepts to undergraduates. Clinically, practitioners have used the model to guide development of a clinical practice guideline for ventilator-associated pneumonia and apply knowledge on social support and positive health practices to working with adolescents in community and school settings.

The ACE Star Model can be used by both individual practitioners and organizations to guide practice change in a variety of settings. The model has been used as a guide to incorporate EBP into nursing curriculum and is also easily understood by staff nurses, in part due to similarity to the nursing process. The emphasis on knowledge transformation contributes to validating the contribution of nursing interventions to quality improvement. Additionally, the translation stage includes clinician expertise and has potential to discuss patient expertise, but is not addressed in the model. Strategies for successful implementation of a practice change are less well defined, such as the organizational culture and context that influence adoption of a practice change [5].

b) Advancing Research and Clinical Practice through Close Collaboration (ARCC model):

The ARCC model focuses on EBP implementation and promotes sustainability at a system wide level. The model has five steps:

(1) Assessment of organizational culture and readiness for implementation in the healthcare system;

(2) Identification of strengths and barriers of the EBP process in the organization;

(3) Identification of EBP mentors;

(4) Implementation of the evidence into organizational practice;

(5) Evaluation of the outcomes resulting from the practice change

The key feature is the use of an EBP mentor to facilitate nurses’ development of skills and knowledge to implement EBP projects effectively. In addition, scales have been developed based on the model for assessment of the organizational culture and measurement of effectiveness of EBP in practice.

Levin et al. piloted the implementation of the ARCC model with nurses working in a community health home care setting. The researchers randomized a convenience sample of 46 nurses to experimental and control groups. The experimental group received didactic content on EBP, an EBP toolkit, posters on EBP, and an available EBP mentor, while nurses in the control group were given didactic content on physical assessment. The EBP mentored group had a significant improvement in EBP beliefs, demonstrated increased implementation of EBP, and had nearly a 50% reduction in the group turnover rate during the study time period.

The ARCC model has been used in hospital and community practice settings and has been tested as a strategy for improving practice outcomes. The emphasis on identifying organizational strengths and barriers to EBP and identifying mentors to work with direct care staff contributes to an organizational culture that supports EBP. As the ARCC model emphasizes organizational environment and factors that support EBP, there is less emphasis in the model on evaluating evidence. The model’s authors caution that while the model emphasizes organizational processes to advance EBP in care delivery, it is important to note that decision-making at the point of care includes clinician expertise and patient preference [6].

c) IOWA model:

The IOWA Model, originally developed as a research utilization model at the University of IOWA Hospitals and Clinics, has been revised to focus on implementation of EBP at the organizational level. The model is represented as an algorithm with defined decision points and feedback loops. The first decision is whether the problem or knowledge-focused trigger is a priority for the organization.

An affirmative decision leads to formation of a team which searches, critiques, and synthesizes the literature. The second decision point considers the adequacy of evidence to change practice. Inadequate evidence leads the practitioner to a choice between conduction of research or utilization of alternative types of evidence (i.e. case reports and expert opinion). When adequate evidence is found, a pilot of the change is conducted. Evaluation of the pilot leads to the third decision point – whether to adopt the change in practice. Ongoing evaluation of the change and dissemination of results are further components of the IOWA Model.

There are numerous examples of application of the Iowa Model to organizational practice change. A New York hospital applied the IOWA Model to the implementation of a critical care pain observation tool for pain assessment of non-verbal patients in an intensive care unit.

Nurses identified the problem trigger as a lack of an accurate pain assessment tool to rate pain levels in non-verbal patients. The unit governance committee from the surgical intensive care unit collaborated with a clinical nurse specialist to develop the question focus and search for evidence. After a thorough review of the literature, a decision was made to pilot a specific pain assessment tool. The group concluded that use of the measure resulted in improved patient outcomes and the use of the pain assessment tool was approved. A search of the literature demonstrated a wide variety of applications for the IOWA Model.

Multiple reports by researchers have demonstrated successful use of the IOWA Model in a variety of settings to guide decisions and implementation for practice change. Practitioners, regardless of prior EBP experience, find the Iowa Model algorithm helpful. The model considers input from the entire organizational system, including the patient, providers, and organizational infrastructure, and involves nurses in each of the steps. An additional strength is the inclusion of a trial of the practice change before making the decision about implementation. Although implied, the model does not specifically address the process of making staff aware of the practice change [7].

d) Stetler model:

The Stetler Model, which in its original development focused on research utilization, has been updated and refined to fit in the EBP paradigm. The model emphasizes the critical thinking process and although practitioner-oriented, is also used by groups for implementing formal organizational change. An important assumption for the model revision is that internal factors such as the characteristics of individual EBP users and organizational practices influence implementation of evidence along with external factors that include formal research and organizational standards and protocols. The Stetler Model consists of five phases.

Phase I, preparation, includes definition of the purpose, contextual assessment and search for sources of evidence.

Phase II is validation of the evidence found.

Phase III is comparative evaluation/decision-making, where the evidence found is critiqued, synthesized, and a decision for use is made with consideration of external and internal factors.

PhaseIV refinements provide implementation/translation guidance for change in practice.

Phase V is evaluation, which includes outcomes met and the degree to which the practice change was implemented.

Romp and Kiehl (2009) used the Stetler Model to guide the redesign of a preceptor program with the goal of improving satisfaction levels of new nurses and reducing the turnover rate. They described how each of the five steps or phases of the Stetler Model led to program redesign.

After reviewing literature on preceptor education, decision makers disseminated recommendations to administrators, managers, and preceptors through committee meetings, individual meetings, or direct mailings. New nurse satisfaction with their preceptors showed a significant improvement and the turnover rate decreased by 3_9%. Additional application examples of the Stetler Model include analysis of evidence for using humour with cancer patients, evaluation of evidence on a screening tool for anxiety in patients with Parkinson’s disease, and development of a screening tool for postpartum depression.

The Stetler Model, although oriented to the individual practitioner, can also be used by a team that is making a practice change decision. The model takes into account characteristics of the individual EBP user. The Stetler Model uses critical thinking and a logical process that emphasizes evaluation of the evidence. In the model, evidence includes quality improvement data, operational and evaluation data, and consensus of experts. Authors caution that experiential information from individual professionals should receive critical reflection before use as evidence.

An updated diagram of the model is used to convey the key points and relationships of the model. However, readers may be confused by the details and complexity. The comprehensive approach of the Stetler Model makes it best suited for practitioners with skills in EBP [8].

CONCLUSION:

This discussion, which has provided an overview of EBP models in practical use, will facilitate the reader in identifying the model that best fits the clinician, organization, and the desired goal. Consideration of how the model facilitates EBP projects, provides guidelines for evidence critique, guides the process for implementing practice change, and can be used across practice areas will assist clinicians in selecting a model that is understood, used, and leads to improved practice.

REFERENCES:

1. Carr CA, Schott A. Differences in evidence-based care in midwifery practice and education. J Nurs Scholarsh 2002; 34(2):153-8.

2. Melnyk B.M. and Fineout-Overholt E. (2011) Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Wolters Kluwer, Philadelphia, PA.

3. Missal B., Schafer B.K., Halm M.A. & Schaffer M.A. (2010) A university and healthcare organization partnership to prepare nurses for evidence-based practice. Journal of Nursing Education 49(8), 456–461.

4. Stetler C.B. (2010) Stetler model. In Models and Frameworks for Implementing Evidence-Based Practice: Linking Evidence to Action (Rycroft-Malone J. and Bucknall T., eds), Wiley-Blackwell, West Sussex, UK, pp. 51–88.

5. Newhouse R.P. and Johnson K. (2009) A case study in evaluating infrastructure for EBP and selecting a model. Journal of Nursing Administration 39(10), 409–411.

6. Newhouse R.P., Dearholt S.L., Poe S.S., Pugh L.C. and White K.M. (2007) Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines. Sigma Theta, Indianapolis, IN.

7. Titler M.G., Kleiber C., Steelman V., Goode C., Rakel B., Budreau G., Everett L.Q., Buckwalter K.C., Tripp-Reimer T. and Goode C.J. (2001) The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America 13(4), 497–509.

8. Romp C.R. and Kiehl E. (2009) Applying the Stetler model of research utilization in staff development: revitalizing a preceptor program. Journal for Nurses in Staff Development 25(6), 278–284.

Received on 04.04.2018 Modified on 12.06.2018

Asian J. Nursing Education and Research. 2018; 8(4):549-552.

DOI: 10.5958/2349-2996.2018.00115.5