The tools and resources focus on guiding successful adoption while understanding how to navigate within the complexity and reality of healthcare. The healthcare economic environment remains—and will likely continue to be—uncertain for the foreseeable future. Nurses can no longer assume funds will be available to meet nursing priorities. Nurses must be familiar with the best evidence, implement evidence-based care improvements, and measure their impact through evaluation.
These are the most challenging steps in EBP. Evidence-Based Practice in Action provides simple-to-read directions and adaptable tools for use with any evidence-based practice. This book is unique in that tools are available for every step—from the beginning of questioning practice through its dissemination. The book provides specific direction for steps that are particularly challenging, including synthesis, implementation, and evaluation of best evidence. Other books provide tools for generating questions and tools for critiquing research and other best evidence.
This book offers tools that go beyond the early step of research critique. It takes the user through the entire process, including implementation and evaluation of evidence-based change.
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Evidence-Based Practice in Action has innovative and first-of-a-kind resources for implementation. The text provides a unique and extensive set of strategies, tools, and tips for applying implementation science in complex healthcare settings. Definitions, procedures, and examples are provided for more than 60 implementation strategies. The book also provides direction and tools for a scholarly evaluation process—including measuring knowledge, attitudes, and behaviors of clinicians and patients—that impacts implementation and outcomes. A scholarly approach to evaluation establishes when results are clinically significant and is thus important for patients and families.
What are major enhancements of the modified Iowa Model? This model was the result of shared work by nursing scholars from UI Hospitals and Clinics and UI College of Nursing see full titles and authors below. In , another revision of the Iowa Model—the Iowa Model Revised—was completed, prompted by a rapidly evolving healthcare environment, emerging evidence in implementation science, and questions from users.
Because the Iowa Model Revised reflects the work of many people, including previous authors and users, authorship of the Iowa Model Revised is attributed to the Iowa Model Collaborative. Advancements of the Iowa Model Revised over previous versions include explicit inclusion of a problem statement, more detail on designing and piloting the practice change targeting implementation strategies , and addition of new steps for integrating and sustaining the practice change.
The revised model is more linear but provides important feedback loops for cycling back when barriers present. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent.
Nursing and EBP: From asking questions to evaluating results
These competencies focus on utilizing knowledge in clinical decision making and producing research evidence on interventions that promote uptake and use by individual providers and groups of providers. This discussion highlights some of the responses and initiatives that those in the profession of nursing have taken to maximize the valuable contributions that nurses have made, can make, and will make, to deliver on the promise of EBP. EBP is aimed at hardwiring current knowledge into common care decisions to improve care processes and patient outcomes.
Evidence-based practice holds great promise for Following the alarming report that major deficits in healthcare caused significant preventable harm IOM, a blueprint for healthcare redesign was advanced in the first Quality Chasm report IOM, The chasm between what we know to be effective healthcare and what was practiced was to be crossed by using evidence to inform best practices.
Evidence-based practice holds great promise for moving care to a high level of likelihood for producing the intended health outcome. The definition of healthcare quality Box 1 is foundational to evidence-based practice. Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge IOM ; , para 3. The phrases in this definition bring into focus three aspects of quality : services interventions , targeted health outcomes, and consistency with current knowledge research evidence.
It expresses an underlying belief that research produces the most reliable knowledge about the likelihood that a given strategy will change a patient's current health status into desired outcomes. Alignment of services with current professional knowledge evidence is a key goal in quality.
Background and aim
The definition also calls into play the aim of reducing illogical variation in care by standardizing all care to scientific best evidence. The EBP movement began with the characterization of the problem—the unacceptable gap between what we know and what we do in the care of patients IOM, Development of evidence-based practice is fueled by the increasing public and professional demand for accountability in safety and quality improvement in health care. The intended effect of EBP is to standardize healthcare practices to science and best evidence and to reduce illogical variation in care, which is known to produce unpredictable health outcomes.
Therefore, EBP unifies research evidence with clinical expertise and encourages individualization of care through inclusion of patient preferences. While this early definition of EBP has been paraphrased and sometimes distorted, the original version remains most useful and is easily applied in nursing, successfully aligning nursing with the broader field of EBP.
The elements in the definition emphasize knowledge produced through rigorous and systematic inquiry; the experience of the clinician; and the values of the patient, providing an enduring and encompassing definition of EBP.
The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas
The entry of EBP onto the healthcare improvement scene constituted a major paradigm shift. The EBP process has been highly applied, going beyond any applied research efforts previously made in healthcare and nursing. This shift was apparent in the way nurses began to think about research results, the way nurses framed the context for improvement, and the way nurses employed change to transform healthcare. In this wide-ranging effort, another significant player was added…the policymaker.
For EBP to be successfully adopted and sustained, nurses and other healthcare professionals recognized that it must be adopted by individual care providers, microsystem and system leaders, as well as policy makers. Federal, state, local, and other regulatory and recognition actions are necessary for EBP adoption.
A recent survey of the state of EBP in nurses indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in employing it in practice. In spite of many significant advances, nurses still have more to do to achieve EBP across the board. One example of implementation of EBP points to the challenges of change. Yet, because of the change necessary to fully implement and sustain the program across the system supported by organizational culture, a sophisticated implementation plan is required before the evidence-based intervention is adopted across an institution.
Forty-seven prominent EBP models can be identified in the literature.
These frameworks guide the design and implementation of approaches intended to strengthen evidence-based decision making. The ACE Star Model of Knowledge Transformation Stevens, was developed to offer a simple yet comprehensive approach to translate evidence into practice.
As explained in the ACE Star Model, one approach to understanding the use of EBP in nursing is to consider the nature of knowledge and knowledge transformation necessary for utility and relevance in clinical decision making. Rather than having clinicians submersed in the volume of research reports, a more efficient approach is for the clinician to access a summary of all that is known on the topic.
Likewise, rather than requiring frontline providers to master the technical expertise needed in scientific critique, their point-of-care decisions would be better supported by evidence-based recommendations in the form of clinical practice guidelines. The model explains how various stages of knowledge transformation reduce the volume of scientific literature and provide forms of knowledge that can be directly incorporated in care and decision making.
The ACE Star Model emphasizes crucial steps to convert one form of knowledge to the next and incorporate best research evidence with clinical expertise and patient preferences thereby achieving EBP. Depicted in Figure 1 , the model is a five-point star, defining the following forms of knowledge: Point 1 Discovery, representing primary research studies; Point 2 Evidence Summary, which is the synthesis of all available knowledge compiled into a single harmonious statement, such as a systematic review; Point 3 Translation into action, often referred to as evidence-based clinical practice guidelines, combining the evidential base and expertise to extend recommendations; Point 4 Integration into practice is evidence-in-action, in which practice is aligned to reflect best evidence; and Point 5 Evaluation, which is 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.
Quality improvement of healthcare processes and outcomes is the goal of knowledge transformation.
Important new knowledge resources have been developed and advanced owing to the EBP movement. Likewise, the function of clinical practice guidelines is to guide practice IOM, While resources were available for Point 1, only recently have resources been developed for the knowledge forms on Point 2, 3, 4, and 5 of the Model. These resources are outlined in Table 1. Table 1. Resources for Forms of Knowledge in the Star Model. Cochrane Collaboration Database of Systematic Reviews-provides reports of rigorous systematic reviews on clinical topics.
See www. National Guidelines Clearinghouse-sponsored by AHRQ, provides online access to evidence-based clinical practice guidelines. AHRQ Health Care Innovations Exchange-sponsored by AHRQ, provides profiles of innovations, and tools for improving care processes, including adoption guidelines and information to contact the innovator. Following the influential Crossing the Quality Chasm report IOM, , experts emphasized that the preparation of health professionals was crucial to bridging the chasm IOM, The Health Professions Education report IOM, declared that current educational programs do not adequately prepare nurses, physicians, pharmacists or other health professionals to provide the highest quality and safest health care possible.
This overhaul would require changing way that health professionals are educated, in both academic and practice settings. Programs for basic preparation of health professionals were to undergo curriculum revision in order to focus on evidence-based quality improvement processes.
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Also, professional development programs would need to become widely available to update skills of those professionals who were already in practice. Table 4 presents details of each competency. From this core set, IOM urged each profession to develop details and strategies for integrating these new competencies into education. With a focus on employing evidence-based practice, nurses established national consensus on competencies for EBP in nursing in and extended these in Stevens, Through multiple iterations, an expert panel generated, validated, and endorsed competency statements to guide education programs at the basic associate and undergraduate , intermediate masters , and doctoral advanced levels in nursing.
Between 10 and 32 specific competencies are enumerated for each of four levels of nursing education which were published in Essential Competencies for EBP in Nursing Stevens, These competencies address fundamental skills of knowledge management, accountability for scientific basis of nursing practice; organizational and policy change; and development of scientific underpinnings for EBP Stevens, These resources have also been incorporated into educational settings as programs are revised to include EBP skills.
Curricular efforts were also underway. To stimulate curricular reform and faculty development, the IOM suggested that oversight processes such as accreditation be used to encourage adoption of the five core competencies. Initiatives that followed included the new program standards established by the American Association of Colleges of Nursing, crossing undergraduate, masters, and doctoral levels of education AACN, The AACN standards underscored the necessity for nurses to focus on the systems of care as well on the evidence for clinical decisions.
This systems thinking is crucial to effect the changes that are part of employing EBP. Through multiple phases, this project developed a website that serves as a central repository of information on core QSEN competencies, knowledge, skill, attitudes, teaching strategies, and faculty development resources designed to prepare nurses to engage in quality and safety. While the materials presented were in existence in other professional literature, the book added great value by synthesizing what was known into one publication.
This resource was accessible to every faculty member offering teaching strategies and learning resources for incorporating the IOM competencies into curricula across the nation. This close alignment reflects the appreciation that nursing must be part of this solution to effect the desired changes; and remaining in the mainstream with other health professions rather than splintering providers into discipline-centric paradigms. Nascent fields are emerging to understand how to increase effectiveness, efficiency, safety, and timeliness of healthcare; how to improve health service delivery systems; and how to spur performance improvement.
Nursing research has been impacted by recent far-reaching changes in the healthcare research enterprise. These emerging fields include translational and improvement science, implementation research, and health delivery systems science. Investigation into uptake of evidence-based practice is one of the fields that has deeply affected the paradigm shift and is woven into each of the other fields.