MANIBA BHULA NURSING COLLEGE

Subject: Advanced Nursing Practice

Topic: Evidence Based Practice Model

SUBMITTED TO, SUBMITTED BY,

 EVIDENCE BASED PACTICE
 INTRODUCTION :
 During 1980s the term “evidence-based medicine” emerged to describe the approach that
used scientific evidence to determine the best practice. Evidence based practice movement
started in England in the early 1990s
 Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has
been gaining ground following its formal introduction in 1992. It started
in medicine as evidence-based medicine (EBM) and spread to other fields such
as dentistry, nursing, psychology, education, library and information science and other
fields.
 It is an approach to making quality decisions and providing nursing care based upon
personal clinical expertise in combination with the most current, relevant research
available on the topic. It implements the most up to date methods of providing care, which
have been proven through appraisal of high quality studies and statistically significant
research findings.
 Evidence-based practice is the integration of best research evidence with clinical expertise
and patient values to facilitate clinical decision making.
 Evidence-based clinical decision making should incorporate consideration of the patient’s
clinical state, the clinical setting, and clinical circumstances.

 DEFINITION:

Evidence based practice in nursing is a way of providing nursing care that is guided by
the integration of the best available scientific knowledge with nursing expertise. This
approach requires nurses to critically assess relevant scientific data research evidence and
to implement high quality interventions for their nursing practice.
( NLM Pubmed)
 The conscientious, explicit and judicious use of current best evidence in making
decisions about the care of the individual patient.
(Dr. David Sackett)

 EVIDENCED BASED NURSING PRACTICE is the process by which nurses

make clinical decisions using the best available research evidence, their clinical
expertise and patient preferences.

 THE CONCEPT OF EBP

 EBP is a problem-solving approach to clinical decision making
 EBP encourages critical thinking
 EBP uses the latest research evidence to produce high quality health care.

 THE VALUE OF EBP

 EBP ensures efficacy, efficiency and effectiveness.
 EBP weighs risk, benefit, and cost against a backdrop of patient preferences.
 Promote patient satisfaction and higher health-related quality of life.

 AIM OF EBP:

 To do the right thing, at the right time, for the right person, ensure quality care for the
individual client.

 PRINCIPLES OF EBP:

 The evidence is never enough

 There is hierarchy of evidence

 IMPORTANCE:

 Evidence-based practice helps nurses provide high-quality patient care based on research and
knowledge rather than because “this is the way we have always done it,” or based on
traditions, myths, hunches, advice of colleagues, or outdated textbooks.
 It results in better patient outcomes
 It contributes to the science of nursing
 It keeps practice current and relevant
 It increases confidence in decision-making
 Policies and procedures are current and include the latest research,
 Integration of EBP into nursing practice is essential for high-quality patient care and
achievement
 EBP IMPLICATIONS FOR NURSES:
 Nurses serve instrumental roles in ensuring and providing evidence-based practice.
 Nurses are also well positioned to work with other members of the healthcare team to
identify clinical problems and use existing evidence to improve practice. Numerous
opportunities exist for nurses to question current nursing practices and use evidence to make
care more effective.
 For example, a recently published evidence-based project describes the potential benefits of
discontinuing the routine practice of listening to the bowel sounds of patients who have under
gone elective abdominal surgery. The authors reviewed the literature and conducted an
assessment of current practice, and they subsequently developed and evaluated a new
practice guideline.
 The authors found that this evidence-based project resulted in saving nursing time without
having negative patient outcomes (Madsen et al., 2005).

 FOR NURSE EDUCATOR: Evidence-based nursing practice is an approach to nursing care

that is essential to the improvement of patient outcomes.
 Situational issues present within clinical practice settings have made a more evidence-based
approach difficult to attain for many registered nurses.
 Clinical nurse educators have the opportunity to become potential change agents in the
facilitation of evidence-based nursing within the clinical practice setting.

 FOR CLINICAL NURSING EDUCATION: Nurse Educators have the opportunity to

promote improved patient outcomes in the future by facilitating an evidence-based nursing
approach within clinical nursing education. They also suggested that, to provide rationales
for quality nursing actions, nursing faculty could help students recognize the importance of
current research evidence and other sources of knowledge, such as ethical, personal, and
aesthetic.
 The students enhanced their evidence-based knowledge by creating guided research
questions, conducting systematic searches, reading and critiquing the strength of the
evidence, synthesizing the evidence, and preparing evidence-based recommendations.
 Newhouse, Dearholt, Poe, Pugh, and White (2005) proposed a model for evidence-based
practice that is practical and effective for the implementation of evidence-based changes to
nursing practices. The three-phase model includes identifying an evidence-based practice
question, identifying evidence, and translating an evidence-based change. This model could
be used by nursing faculty as a teaching guide for clinical student journal clubs and student
analysis of nursing procedures within their clinical practicum settings.

 STEPS OF EVIDENCE BASED PRACTICE:

Step 1: Cultivate a spirit of inquiry:

 The process of forming an EBP question often begins when one of the following questions
arises:
1. What evidence is the basis for this treatment?
2. Is there a scientific basis for this treatment?
3. What was the rationale for making that decision?
4. What are the clinical implications of this practice?
STEP 2: Ask clinical questions in PICOT format:

 P - Patient, population, or problem.

 I - Intervention or Interest
 C - Comparison /control
 O - Outcome
 T - Time
Patient:
 Age, sex, ethnicity, etc.
 Condition, diseases, general health status
Intervention:
 Education, diagnostics, treatment plan, self-care, etc

Comparison Intervention:
 Placebo, etc.
Outcome:
 Expected and actual effects on patient
Time:

 The time it takes for the intervention to achieve an outcome

The PICOT format provides an efficient framework for searching electronic databases,
one designed to retrieve only those articles relevant to the clinical question. Using the case
scenario on rapid response teams as an example, the way to frame a question about whether use
of such teams would result in positive outcomes would be: "In acute care hospitals (patient
population), how does having a rapid response team (intervention) compared with not having a
response team (comparison) affect the number of cardiac arrests (outcome) during a three-month
period (time)?"

STEP 3: Search for the best evidence.

The search for evidence to inform clinical practice is tremendously streamlined when
questions are asked in PICOT format. If the nurse in the rapid response scenario had simply
typed "What is the impact of having a rapid response team?" into the search field of the database,
the result would have been hundreds of abstracts, most of them irrelevant. Using the PICOT
format helps to identify key words or phrases that, when entered successively and then
combined; expedite the location of relevant articles in massive research databases such as
MEDLINE or CINAHL.

STEP 4: Critically appraise the evidence:

Once articles are selected for review, they must be rapidly appraised to determine
which are most relevant, valid, reliable, and applicable to the clinical question.
STEP 5: Integrate the evidence with clinical expertise and patient preferences and values.
Research evidence alone is not sufficient to justify a change in practice. Clinical expertise,
based on patient assessments, laboratory data, and data from outcomes management programs, as
well as patients' preferences and values are important components of EBP.

For example, say there's a strong body of evidence showing reduced incidence of
depression in burn patients if they receive eight sessions of cognitive-behavioral therapy prior to
hospital discharge. You want your patients to have this therapy and so do they. But budget
constraints at your hospital prevent hiring a therapist to offer the treatment. This resource deficit
hinders implementation of EBP.

STEP 6: Evaluate the outcomes of the practice decisions or changes based on evidence.
After implementing EBP, it's important to monitor and evaluate any changes in outcomes
so that positive effects can be supported and negative ones remedied. Just because an
intervention was effective in a rigorously controlled trial doesn't mean it will work exactly the
same way in the clinical setting. Monitoring the effect of an EBP change on health care quality
and outcomes can help clinicians’ spot flaws in implementation and identify more precisely
which patients are most likely to benefit. When results differ from those reported in the research
literature, monitoring can help determine why.

STEP 7: Disseminate EBP results:

Clinicians can achieve wonderful outcomes for their patients through EBP, but they often
fail to share their experiences with colleagues and their own or other health care organizations.
This leads to needless duplication of effort, and perpetuates clinical approaches that are not
evidence based. Among ways to disseminate successful initiatives are EBP rounds in your
institution, presentations at local, regional, and national conferences, and reports in peer-
reviewed journals, professional newsletters, and publications for general audiences.

 MODELS
 These selected models and frameworks can be used to understand the contextual factors that
could play important roles in the success or failure of the knowledge translation effort should
be taken into consideration in all stages of the knowledge translation ( K T) process.

 EVIDENCE PRACTICE MODEL

1. The Johns Hopkins Nursing Evidence-Based Practice Model
2. The Ace Star Model
3. Iowa model
4. Stetler’s model
5. Rosswurm and larrabee’s model
1. JOHN HOPKIN’S MODEL
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model is a
powerful problem-solving approach to clinical decision-making, and is accompanied by user-
friendly tools to guide individual or group use. It is designed specifically to meet the needs of
the practicing nurse and uses a three-step process called PET: practice question, evidence,
and translation. The goal of the model is to ensure that the latest research findings and best
practices are quickly and appropriately incorporated into patient care.

 John Hopkins nursing EBP Model- Used as a framework to guide the synthesis and
translation of evidence into practice. (Newhouse, Dearholt, Poe, Pugh, & White, 2007).

 There are three phases to the JHNEBP model

1. The identification of an answerable question.
2. A systematic review and synthesis of both research and non-research evidence.
3. Translation includes implementation of the practice change as a pilot study, measurement
of outcomes, and dissemination of findings.
2. THE ACE STAR MODEL


The ACE STAR Model of Knowledge Transformation is a framework for the systematic
integration of evidence into practice.

The STAR Model is composed of five major stages: knowledge discovery, evidence
summary, translation into practice recommendations, integration into practice, and
evaluation. The model is one of the most commonly used frameworks that have shaped
evidence-based nursing.

The model was developed by Dr. Kathleen Stevens at the Academic Center for Evidence-
Based Practice located at the University Of Texas Health Science Center at San Antonio.

1. Discovery

This is a knowledge generating stage. In this stage, new knowledge is discovered through
the traditional research methodologies and scientific inquiry. Research results are generated
through the conduct of a single study. This may be called a primary research study and
 research designs range from descriptive to correlational to causal; and from randomized
control trials to qualitative. This stage builds the corpus of research about clinical actions.

2. Evidence Summary

 Evidence summary is the first unique step in EBP—the task is to synthesize the corpus of
research knowledge into a single, meaningful statement of the state of the knowledge

 This stage is also considered a knowledge generating stage, which occurs simultaneously
with the summarization. Evidence summary produces new knowledge by combining
findings from all studies to identify bias and limit chance effects in the conclusions. The
systematic methodology also increases reliability and reproducibility of results

3. Translation

 The transformation of evidence summaries into actual practice requires two stages:
translation of evidence into practice recommendations and integration into practice.

The aim of translation is to provide a useful and relevant package of summarized

evidence to clinicians and clients in a form that suits the time, cost, and care standard.
Recommendations are generically termed clinical practice guidelines (CPGs) and may be
represented or embedded in care standards, clinical pathways, protocols, and algorithms.
Summarized research evidence is interpreted and combined with other sources of
knowledge (such as clinical expertise and theoretical guides) and then contextualized to
the specific client population and setting. Evidence-based CPGs explicitly articulate the
link between the clinical recommendation and the strength of supporting evidence and/or
strength of recommendation.

4. Integration

Integration is perhaps the most familiar stage in healthcare because of society’s long-
standing expectation that healthcare be based on most current knowledge, thus, requiring
implementation of innovations. This step involves changing both individual and
organizational practices through formal and informal channels. Major factors addressed in
this stage are those that affect individual and organizational rate of adoption of innovation
and integration of the change into sustainable systems.

5. Evaluation

The final stage in knowledge transformation is evaluation. In EBP, a broad array of

endpoints and outcomes are evaluated. These include evaluation of the impact of EBP on
patient health outcomes, provider and patient satisfaction, efficacy, efficiency, economic
 analysis, and health status impact. As new knowledge is transformed through the five
stages, the final outcome is evidence-based quality improvement of health care.

3. IOWA MODEL

 The Iowa model focuses on organization and collaboration incorporating conduct and use
of research, along with other types of evidence. (Titler et al, 2001). It was originated in
1994.

 The Iowa Model of EBP was developed by Marita G. Titler, PhD, RN, FAAN, Director
Nursing Research, Quality and Outcomes Management, Department of Nursing Services
and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa, and her
colleagues to describe knowledge transformation and to guide implementation of research
into clinical practice.

 The Iowa model highlights the importance of considering the entire healthcare system from
the provider, to the patient, to the infrastructure, using research within these contexts to
guide practice decisions. A number of steps have been identified in the Iowa model to
facilitate NP engagement in problem identification and solution development as it relates to
incorporating evidence findings into practice.

 The first step in the Iowa Model of EBP is to identify either a problem-focused trigger or a
knowledge-focused trigger that will initiate the need for change. A problem-focused trigger
could be a clinical problem, or a risk management issue; knowledge triggers might be new
research findings or a new practice guideline.

 In the Iowa model, it is important for the NP to consider if the issue identified is a priority
problem for the organization. Once the problem is identified and its priority determined, the
second step is to review and critique relevant literature. If there is sufficient evidence to
make a change in practice, the third step is to identify research evidence that supports the
change in clinical practice. The final steps are to implement a change in practice and
monitor the outcomes.
4. STETLER’S MODEL:

 This model examines how to use evidence to create formal change within organizations, as
well how individual practitioners can use research on an informal basis as part of critical
thinking and reflective practice.

 The Stetler Model of Research Utilization applies research findings at the individual
practitioner level.

 Critical thinking and decision making are emphasized.

 The Stetler model of evidence-based practice based on the following

 Use may be instrumental, conceptual and/or symbolic/strategic.

 Other types of evidence and/or non-research-related information are likely to be combined

with research findings to facilitate decision making or problem solving.

 Internal or external factors can influence an individual's or group's review and use of
evidence.

 Research and evaluation provide probabilistic information, not absolutes.

 Lack of knowledge and skills pertaining to research use and evidence-informed practice can
inhibit appropriate and effective use.
 The model has Five phases:

(1) Preparation,

(2) Validation,

(3) Comparative evaluation / Decision making,

(4) Translation and application, and

(5) Evaluation.

 This model consists of five phases. Each phase is designed to

 Facilitate critical thinking about the practical application of research findings

 Result in the use of evidence in the context of daily practice

 Mitigate some of the human errors made in decision making.

Five Phases
5. ROSSWURM AND LARRABEE’S MODEL

 The model has been represented in many nursing textbooks, used as part of an intervention to
increase EBP competencies, and used a framework for instruments measuring EBP readiness.
Rosswurm and Larrabee (1999) proposed a model for guiding nurses through a systematic
process for the change to evidence-based practice .This model recognized that translation of
research into practice requires a solid grounding in change theory, principles of research
utilization, and use of standardized nomenclature.

 The model has the following six phases:

1. Assess the Need for Change in Practice.

Is there evidence to support the use of an early warning scoring system and communication
triggers to guide nurses in clinical decision making in the medical setting? The issue came to the
NPS as part of an examination of current practice. Stakeholders were involved intentionally by
asking a staff nurse (who serves as team leader) and a CNS to lead the literature search.

2. Link the problem, Interventions, and Outcomes.

Standardized nursing classification systems and nomenclature were used to identify the problem,
and the desired outcomes of recognition of early warning signs and prevention of clinical
deterioration in medical-surgical patients.

3. Synthesize the Best Evidence.

The director of library services used a systematic, organized strategy to guide the nursing
literature search using the Cumulative Index to Nursing and Allied Health Literature (CINAHL)
database. The team read and critically reviewed the literature, and weighed the evidence in
conjunction with the clinical nurse researcher.

4. Design Practice Change.

A roundtable Discussion was conducted at the EBNP conference, followed by several other
focused discussions about practice changes. Several strategies were identified to explore the
original issue further and to implement it into practice. For instance, programs have been
implemented educating and mentoring nurses in strategies of detecting early warning signs and
communicating these effectively to other members of the health care team.

5. Implement and Evaluate the Change in Practice.

Currently, the evidence does not support changing practice, but rather building and fortifying
systems of knowing the patient, identifying problems early, and communicating and managing
changes in patient status in a timely manner.

6. Integrate and Maintain the Change in Practice.

This step of the model is pending further evaluation and consideration. As a start, the article by
Minick and Harvey (2003) and information from the conference have been included in the
Advanced Preceptor Workshop
 ADVANTAGES OF EBP:

 Provides better information to practitioner

 Enable consistency of care
 Better patient outcome
 Provide client focused care
 Structured process
 Increased confidence in decision making
 Generalize information
 Contribute to science in nursing
 Provide guidelines for further research
 Help nurses to provide high quality patient care

 DISADVANTAGES OF EBP:

 Not enough evidence for EBP

 Time consuming
 Reduced client choice
 Reduced professional judgement/autonomy
 Supress creativity
 Influence legal proceedings
 Publication bias
 BARRIERS IN EBP:

1. Organizational barriers: include difficulty accessing evidence, resource constraints that

keep nurses’ workloads too heavy for them to learn about and implement evidence-based
nursing practice, lack of funds for ongoing skill development, and management priorities that
don’t include evidence based nursing practice.
2. Environmental barriers: include government policy, a culture of change that leaves nurses
too overwhelmed to cope with further changes that might enhance their practice, and a shift
in managerial responsibilities that leaves nurse managers and nurses with different agendas.
3. Lack of competence by nurse managers.
4. Many lack advanced academic skills
5. Limited ability to apply research to practice is another factor.
6. Some nurse managers try to help their nurses cope by making too few demands.
7. People are not trained to use research for practical applications, and a large research-practice
gap exists in the profession.
8. Heavy workloads leave nurses too exhausted to advocate for changes that could strengthen
the quality of care they provide.
9. Lack of value for research in practice
10. Lack of administrative support
11. Insufficient time to conduct research
12. Lack of education about the research process
13. Lack of awareness about research or evidence-based practice
14. Research reports/articles not readily available
15. Difficulty accessing research reports and articles
16. No time on the job to read research
17. Complexity of research reports
18. Lack of knowledge about EBP and critique of articles

 RESPONSIBILTY FOR EVIDENCE-BASED NURSING PRACTICE:

Professional associations, regulatory bodies for nurses, specialty groups for nurses
individual nurses, schools of nursing, organizations employing nurses, accreditation councils,
governments, health information agencies and nurse researchers share the responsibility of
facilitating evidence-based decision-making and evidence-based practice.
These responsibilities extend to identifying the barriers and enhancing the factors within
organizational structures that facilitate and promote evidence-based practice.
1. Individual nurses:
 Position themselves to provide optimal care by acquiring competencies7 for evidence-
based nursing practice;
 Generate researchable questions and communicate them to researchers; and
 Evaluate, use and promote evidence-based nursing practice.

2. Professional, regulatory and nursing specialty associations:

 Use the best available evidence as a basis for standards and guidelines; and
 Lobby governments for funding to support nursing research and health information system
that include nursing data.
3. Researchers:
 Identify knowledge gaps and use them to establish research priorities in conjunction with
practitioners;
 Generate high quality evidence through research;
 Engage in effective knowledge transfer, translation and exchange to communicate relevant
findings of the results of research to those who require the information; and
 Develop and carry out ongoing research to explore the concepts of evidence, evidence
dissemination and utilization in nursing practice.
4. Educators and educational institutions:
 Ensure that those graduating from basic and continuing nursing education programs acquire
competencies to provide evidence-based nursing;
 Use and develop evidence-based curricula; and Promote a spirit of inquiry, critical thinking
and a philosophy of life-long learning.
5. Employers of registered nurses:
 Reduce barriers against and enhancing the factors within organizations to promote evidence-
based practice; and provide continuing education to assist nurses to maintain and increase
their competence with respect to evidence-based practice.
6. Governments:
 Support development of health information systems that support evidence-based nursing
practice;
 Support health information institutions; and
 Provide adequate funding to support nursing research in all its phases.
7. National and provincial health information institutions:
 Collect, store, maintain and retrieve health data in broader health information systems;
 Provide comprehensive, integrated and relational systems that include nursing data and
patient outcomes;
 Collect data using standardized languages to ensure that nursing data can be aggregated and
compared across and between sites.

 EXAMPLES OF NURSING RESEARCH PROJECTS IN EVIDENCE-

BASED PRACTICE:
 Efficacy of examination gloves for simple dressing changes
 Reliability of methods used to determine nasogastric tube placement
 The effects of relaxation and guided imagery on preoperative anxiety
 Quality of life in patients with chronic pain
 Improve patient satisfaction through noise reduction activities
 Assess the effectiveness of using a fall-risk assessment in decreasing the number and severity
of patient falls
 The above example related to falls could also be an evidence-based practice or research
project. If after searching the nursing literature you found another fall-risk assessment tool
and you changed practice in your organization, the information you collected could
contribute to an evidence-based project. You also might find multiple best practices or
nursing interventions related to falls prevention. You can use this information to formulate a
 research question and conduct a nursing research study within your organization to see which
interventions provide the best outcomes in your specific patient population.

 CONCLUSION
Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that
has been gaining ground following its formal introduction in 1992. It started
in medicine as evidence-based medicine (EBM) and spread to other fields such
as dentistry, nursing, psychology, education, library and information science and other fields

 BIBLIOGRAPHY:
1. EMMESS, “ A Concise Textbook of ADVANCED NURSING PRACTICE” 1st edition,
EMMESS Medical Publishers
2. Jacob Anthikad, “ PSYCHOLOGY FOR GRADUATE NURSES”, 4th edition, Jaypee
Brothers Medical Publishers
3. Rawat H.C, “Textbook of ADVANCED NURSING PRACTICE” 1st edition, Jaypee
Brothers Medical Publishers
4. ANN J. ZWEMER, “BASIC PSYCHOLOGY FOR NURSE IN INDIA”, B.I publications
pvt. Ltd.
5. Kozier Barbara “FUNDAMENTAL OF NURSING”;7th
Edition;2004;Published by Pearson Education (p) ltd; New Delhi;
India; Page No- 5-8,26-38.
6. Navdeep kaur Brar, H.C.Rawal,” Textbook of Advanced Nursing Practice” 1st edition,
2015, Jaypee Brother Publication, New Delhi. Page No- 11-15.

7. Potter and Perry “FUNDAMENTAL OF NURSING”; 6th

Edition, 2006;Published by Elsevier India (p)ltd; New Delhi; Page
No- 5-22.
8. Shebber. P. Basheer & S. Yaseen Khan,” A Concise Text Book of Advanced Nursing
Practice”, 1st edition, 2013, EMMESS Medical Publication, Bangalore. Page
No- 06-09.

 Website
1. www.promisingpractices.net/briefs/briefs_evidence_based_practices.asp
2. https://www.nurse.com/evidence-based-practice
3. www.hopkinsmedicine.org/evidence-based-practice/jhn_ebp.html
4. https://en.wikipedia.org/wiki/Evidence-based_practice