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Volume 19, Number 3, pp.291–300
© 2008, AACN
Selecting a Model for Evidence-Based
Practice Changes
A Practical Approach
Anna Gawlinski, DNSc, RN, FAAN
Dana Rutledge, PhD, RN
ABSTRACT
Evidence-based practice models have been
developed to help nurses move evidence into
practice. Use of these models leads to an organized approach to evidence-based practice, prevents incomplete implementation, and can
maximize use of nursing time and resources.
No one model of evidence-based practice is
present that meets the needs of all nursing environments. This article outlines a systematic
process that can be used by organizations to
select an evidence-based practice model that
best meets the needs of their institution.
Keywords: evidence-based practice models,
evidence-based practice, models
actors related to patient safety, quality, and tions and discussions can occur about various
F
evidence-based practice (EBP) are driving EBP models, their advantages and disadvanchanges in healthcare. Nurses are interested in tages, and their applicability to organizational
how to move good evidence into practice to
optimize patients’ outcomes; thus, nurses may
benefit from understanding more about EBP
models. These models have been developed to
help nurses conceptualize moving evidence into
practice. They can assist nurses in focusing
efforts derived either from clinical problems or
from “good ideas” toward actual implementation in a specific practice setting. Use of EBP
models leads to systematic approaches to EBP,
prevents incomplete implementation, promotes
timely evaluation, and maximizes use of time
and resources.
This article describes a systematic process
for organizations to use as a template for
choosing an EBP nursing model. Strategies
for involving staff nurses and clinical and
administrative leaders are discussed. Finally,
a summary of key EBP nursing models is
presented.
Creating Structures or
Forums for Discussions
The first step in selecting a model is to establish a structure or a forum in which presenta-
needs. Several possible strategies include:
• use of an existing nursing research committee in which selection of an EBP model is
added to annual goals and activities;
• formation of an EBP council, with an initial
task of selecting an EBP model;
• appointment of a task force charged with
selecting an EBP model;
• use of an educational event to increase
knowledge about EBP models while facilitating the selection of a model appropriate
for the organization; and
• use of a focus group process to select an EBP
model consistent with the philosophy,
vision, and mission of the organization.1
Anna Gawlinski is Director, Evidence-Based Practice, and
Adjunct Professor, Ronald Reagan University of California, Los
Angeles Medical Center & University of California, Los Angeles
School of Nursing, 757 Westwood Plaza, Los Angeles, CA
90095 ([email protected]).
Dana Rutledge is Professor, Department of Nursing, California
State University Fullerton; and Nursing Research Facilitator,
Saint Joseph Hospital, Irvine, California.
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Any of these strategies could help “set the
stage” for an organization to choose an EBP
model. For example, the authors used an
existing nursing research committee/council
to begin the process of selecting an EBP model
in 2 different settings. In a third hospital, a
multidisciplinary EBP council took on the
task of selecting an EBP model. Regardless of
the structure or the forum used, a thoughtful
and systematic process is helpful.
Composition of the Committee
or the Group
The second step to identifying an EBP model is
to carefully consider appropriate members of
the committee or the group. Administrative
and clinical leaders such as nurse managers,
clinical nurse specialists, and nurse educators
should be represented, as should interested
staff nurses. Staff nurses who are clinical
resources in their units, share an interest in
improving patient care, or are curious about
research are likely members. The educational
level of the committee members should reflect
that of nurses within the department or the
institution and will most commonly include
nurses with associate, bachelor’s, and master’s
degrees. In addition, members should represent the various clinical units/departments or
specialties within the institution.
Involvement of persons with special expertise in research or EBP, such as a nurse researcher
or faculty member from a local unit, hospital,
or school of nursing, may be especially helpful.
These persons may be internal or external to the
organization and have valuable expertise in
EBP nursing models. They can function as
active members or as consultants. A librarian
member may also be useful in retrieving needed
publications to evaluate selected models.
The evaluation process and the number of
EBP models that are considered can influence
the desirable number of committee members.
For example, at one institution (a university
academic hospital), the nursing research
council selected 7 EBP nursing models for
review and evaluation. Table 1 lists the models and shows the criteria used to evaluate
them. These 7 models were chosen for evaluation either because they were commonly mentioned in publications about EBP nursing
models or because they were identified by
committee members. At another institution (a
community hospital), the nursing research
council selected 4 EBP nursing models to eval-
uate on the basis of council members’ knowledge of the models’ utility and potential fit
with the organization.
Involvement of all committee members in
the evaluation process is vital. Using a process
where 2 or 3 persons volunteer to review and
present 1 to 2 EBP nursing models can get all
members involved. Staff nurses can be paired
with administrative or clinical leaders in teams
of 2 to 3 persons. All committee members can
then participate in the process of evaluating
models by attending presentations about each
model and actively participating in discussions. By having small groups present each
model, the workload is divided among group
members. The more people involved in the
process, the greater the need for coordination
and oversight by the chairperson.
Organizing the First Meeting
Once the group has been selected, the next
step is to organize the first meeting so that
clear communication about the roles and
responsibilities of team members can occur.
The chairperson or the leader can survey the
group members to determine the optimal date,
time, and comfortable location for this meeting. Because of the nature of the work
involved in selecting a model, 2 hours is an
optimal duration for meetings. An agenda
should accompany the meeting invitations and
initially will include items such as discussions
of the purpose and goals of the committee and
the roles and responsibilities of committee
members (Table 2). Providing a brief reading
assignment that gives an overview of EBP
models and should be completed before the
first meeting is advisable. The chairperson can
request committee members who are already
knowledgeable about EBP models to highlight
parts of the reading assignment at the first
meeting to promote discussion. The chairperson should also collaborate with unit leaders
to ensure that staff nurses have appropriate
release time for meetings.
Roles and Responsibilities of
Committee or Members
At the first meeting, roles and responsibilities
of the members for reviewing, presenting, and
evaluating each EBP model should be
addressed. Assignments and due dates are
determined to ensure steady progress. For
example, a member can elect to work in a
small group to review the literature on an EBP
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Table 1: Evaluation Criteria and Scoring for 7 Models of Evidence-Based Practice
Changesa
Evaluation Criteria for EBP Model
Purpose of Project: Evaluation and selection of an EBP model for the Nursing Department of Ronald
Reagan University of California, Los Angeles Medical Center.
1. Search, retrieve, and synthesize the current literature describing EBP models to help staff nurses use
EBP concepts and apply them in clinical practice.
2. Recommend the adoption of a specific EBP model for use by UCLA nurses.
Scoring system:
0 not present; 1 present/yes; 2 highly present/yes
Criteria
Models
1. Concepts and organization of model are
clear and concise
2. Diagrammatic representation of the
model allows quick assimilation of
concepts and organizes the steps in the
process of EBP changes
3. The model is comprehensive from
beginning stages through implementation
and evaluation of outcomes
4. The model is easy to use when
concepts are applied to direct EBP
changes and practice issues in clinical
settings
5. The model is general and can be applied
to various populations of patients,
EBP projects, and department initiatives
and programs
6. The model can be easily applied to
typical practice issues as evidenced
with practice scenario or in published
literature
Total
Comments
EBP Model:
Strengths:
Weaknesses:
EBP Model:
Strengths:
Weaknesses:
EBP Model:
Strengths:
Weaknesses:
EBP Model:
Strengths:
Weaknesses:
EBP Model:
Strengths:
Weaknesses:
a
Used with permission from the Evidence-Based Practice Program, Nursing Department at Ronald Reagan University of California, Los
Angeles Medical Center, Los Angeles, California.
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Table 2: Example of Agenda Items for the
First Evidence-Based Practice
Committee or Group Meeting
Welcome and introduce members
Review agenda
Discuss the goals of the committee
Discuss roles and responsibilities of committee
members
Select models for evaluation
Discuss the process for presenting and evaluating
evidence-based practice models
Make assignments and schedule
Identify resources and forms
Identify strategies to communicate ongoing
committee work to the department
Open discussion of other items
Plan for next meeting
model. Work teams should be assigned a presentation date to present details of the reviewed
EBP model to committee members. Presentations of each EBP model may take 30 to 45
minutes and might include information on the
history and development of the EBP model
(who, what, when, where, and how), revision
of the model over time, overall concepts in the
EBP model, the process and flow of the EBP
model, and publications describing how the
model guided EBP changes in other facilities.
Each presentation of an EBP model can be
followed by 10 or 15 minutes for group members to raise questions and discuss specific
aspects of the EBP model. After the presentation and discussion, group members could
review an example of how the EBP model might
be applied in a realistic practice scenario that
requires consideration of a practice change
(Table 3). Group members could then use the
EBP model under discussion to address the
practice issue. Depending on the group’s size,
this work can be done in small groups, with
each small group slated to report back to the
larger group its opinion about how the model
“worked.” It is recommended that groups
break into smaller groups of 2 or 3 persons to
“rate” the models’ applicability on the basis of
predetermined criteria (Table 4). Criteria for
evaluating the applicability of the EBP model
should include clarity of the EBP model concepts and diagrammatic representation, applicability of the EBP model to clinical practice
issues for diverse patient care situations in the
institution, ease and user-friendliness of the EBP
model, and the ability of the EBP model to provide direction for all phases of the EBP process.
Table 1 shows an example of an evaluation
tool that can be used by committee members
when reviewing each EBP model. After the
evaluation instrument is administered and
scored, committee members can compare and
contrast the ratings, strengths, and weaknesses
for addressing the practice scenarios, and
potential adoption by the institution for each
model is reviewed.
The use of a structured process provides
members with little or no background in evaluating an EBP model to learn about EBP models
and have greater participation and support in
the evaluation process. The link of the EBP
model to practice is clear when the practice scenario is used. Members increase their knowledge and skills in using EBP models for practice
changes and become champions for the adoption of a model within the organization.
Finally, the ongoing work of the committee
should be communicated through forums such
as mass e-mails, newsletters, posters, nursing
grand rounds, and other continuing education
programs. Such communication helps disseminate the process used in selecting a model for
the organization, while inviting others to participate via comments and feedback.
Summary of Selected
EBP Nursing Models
A number of EBP models have been developed; many appear very different from each
other. Some of these models are more useful in
some contexts than others, and each has
advantages and disadvantages. The following
steps or phases are common to most models:
• Identification of a clinical problem or potential problem
• Gathering of best evidence
• Critical appraisal and evaluation of evidence; when appropriate, determination of a
potential change in practice
• Implementation of the practice change
• Evaluation of practice change outcomes,
both in terms of adherence to processes
and planned outcomes (eg, clinical, fiscal,
administrative)
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Table 3: Sample Practice Scenario for Evaluating Applicability of Models for EvidenceBased Practice Changesa
Scenario for Application of Evidence-Based Practice Nursing Models
Note: The following scenario includes selected literature on the subject for the purpose of providing a
clinical practice issue for use when applying EBP models. The following does not include an extensive or
integrated review of the literature on the subject.
Clinical Issue
Suctioning patients who have endotracheal and tracheal tubes is a frequent and important nursing intervention.
These tubes interrupt the normal mucociliary system and can result in a patient’s inability to mobilize and
expectorate secretions).13 Suctioning is an intervention that has beneficial effects such as removal of secretions,
maintenance of airway patency, and promotion of optimal ventilation and oxygenation.13
It is common practice for nurses and other healthcare providers to instill 3 to 10 mL of sodium chloride
in the endotracheal or tracheal tubes before suctioning.14 The action of sodium chloride is believed to
loosen and thin secretions, stimulate a cough, and lubricate the suction catheter.13,15,16
Research and Evidence-Based Literature
Results of research on the benefits of sodium chloride instillation have been inconclusive.13,17–23 In fact,
studies indicate that this practice may result in the following adverse outcomes:
• Interferes with the alveolar-capillary oxygen exchange, causing a decrease in oxygen saturation,
• Increases rate of respiration,
• Increases the risk of infection by dislodging significantly more bacterial colonies, and
• Increases intracranial pressure.13,19,21,22
Furthermore, patients can panic or feel as though they are drowning during routine instillation of
sodium chloride via endotracheal or tracheal tubes.24
Research results indicate that mucus and sodium chloride solution are immiscible.13,17 Therefore, it is
unlikely that instillation of sodium chloride loosens secretions and aids in the expectoration of airway
secretions.13 The application of heat and humidification to the airway and the use of sodium chloride
nebulizers are effective in thinning secretions and promoting airway clearance.13,23
Nursing Staff and EBP Process
The nurses in your unit have recently heard a lecture presenting the lack of evidence supporting the
routine use of instillation of sodium chloride before suctioning patients with endotracheal and tracheal
tubes and the potential deleterious effects. They are questioning this practice and come to you as the unit
manager or the clinical nurse specialist to help them with considering a change in this practice.
Reflect on this EBP model to guide you through the steps to help your staff with this EBP change project.
a
Used with permission from the Evidence-Based Practice Program, Nursing Department, Ronald Reagan University of California, Los Angeles
Medical Center, Los Angeles, California.
Table 4: Criteria for Evaluation of Evidence-Based Practice Models to Meet
Institutional Needs
Concepts and organization of the model are clear and concise
Diagrammatic representation of the model allows quick assimilation of concepts and organizes the steps
in the process of EBP changes
Model is comprehensive from beginning stages to implementation and evaluation of outcomes
Model is easy to use when concepts are applied to direct EBP changes and practice issues in clinical settings
Model is general and can be applied to various populations of patients, EBP projects, and department
initiatives and programs
Model can be easily applied to typical practice issues as evidenced with practice scenario or in the
published literature
Abbreviation: EBP, evidence-based practice.
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Table 5: Selected Evidence-Based Practice Nursing Models and Key Components
Iowa Model3
Stetler’s Model2
Emphasis
Organizational
process
At individual nurse
or organizational
level
Stages/
phases
1 Trigger: Problem 1 Preparation
or new knowledge
2 Validation
2 Organizational
3 Comparative
priority?
evaluation
3 Team formation
4 Decision making
4 Evidence gathered
5 Translation/
application
5 Research base
critiqued and
6 Evaluation
synthesized
6 Sufficient?
7 Pilot change
8 Decision?
9 Widespread
implementation
with continual
monitoring of
outcomes
Johns Hopkins
Nursing Model5
ACE Star Model of
Knowledge
Transformation6
Organizational process Organizational
process
Knowledge
transformation
Rosswurm and
Larrabee’s Model4
1 Assess need for
change in practice
1 Practice question
identified
1 Knowledge
discovery
2 Link problem
interventions and
outcomes
2 Evidence gathered
2 Evidence
summary
3 Synthesize best
evidence
3 Translation:
Plan, implement,
evaluate, and
communicate
3 Translation into
practice
recommendations
4 Design practice
change
4 Integration into
practice
5 Implement and
evaluate change
in practice
5 Evaluation
6 Integrate and
maintain
10 Dissemination
of results
The following paragraphs describe several
EBP models that are often considered for use
in hospitals (Tables 5 and 6). These models
were selected on the basis of the following
criteria: (1) they commonly appear in nursing publications about EBP models; (2) published reports support their use to guide EBP
changes in the clinical setting; (3) institutions
(hospitals or schools of nursing) use the
model; and (4) the models are intended to be
used by nurses as they set out to find and use
evidence to enhance patients’ or organizations’ outcomes. Table 5 describes selected
EBP models that have specific steps or phases
to guide the EBP process. Table 6 identifies
key components of EBP models that do not
have specific steps or phases but help describe
and conceptualize the many variables and
interactions that occur when making EBP
practice changes.
One of the oldest models that has recently
been revised to include EBP outcomes is Stetler’s
EBP model.2 This model is one of the few that
does not focus entirely on formal changes led by
nurses in organizational settings, suggesting use
by individual nurses as well. Developed as a
model for nurses within an East Coast hospital,
Stetler’s model promotes use of both internal
(eg, data from quality improvement, operational, or evaluation projects) and external
(primary research evidence and consensus of
national experts) evidence. Stetler’s model consists of 5 phases, ranging from searching for evidence about a clinical problem to formal and/or
informal evaluations. Decision making about
whether a practice change should be made
includes consideration of substantiating evidence, setting fit, feasibility, and current
practice.
Developed as a model to promote quality
care, the Iowa model of EBP has been used in
multiple academic and clinical settings.3 This
model melds quality improvement with
research utilization in an algorithm that nurses
find intuitively understandable. Unique to the
Iowa model is the concept of “triggers” of EBP.
Evidence-based practice may be spurred by a
clinical problem or by knowledge coming from
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Table 6: Select Evidence-Based Practice Frameworks
ARCC Model7–9
PARIHS Framework10,11
Key focus
Organization of department or unit
Understanding key components of EBP
Key concepts
EBP mentor—an individual who has
expert knowledge and skills in
EBP and the passion to help
others practice daily from an
evidence base
Evidence
Major proposition
The development of APNs and other
nurses as EBP mentors facilitates
an organizational culture change
toward evidence-based care
Practice changes are most likely when
they are based upon robust evidence,
conducted in a context “friendly” to
change, and facilitated well
Utility—practical
implications
Need to…
Need to…
• assess and organize culture and
readiness for EBP
• critically appraise evidence
• identify strengths and major
barriers to EBP implementation
• implement ARCC strategies
• develop and use EBP mentors
• interactive EBP skill-building
workshop
Context
Facilitation
• thoroughly understand the
practice arena before implementing
a change
• make a strategic plan for
facilitation of any practice change—
from development to
implementation and evaluation
• make EBP rounds and form
journal clubs
• implement EBP
• improve patient, nurse, and
system outcomes
Abbreviations: ARCC, Advancing Research and Clinical Practice through Close Collaboration; EBP, evidence-based practice; PARIHS,
Promoting Action on Research Implementation in Health Services.
outside an organization. Either of these triggers
can set an EBP project into motion. Thereafter,
the model delineates 3 key decision points
during the process of making a practice change:
(1) Is there an institutional reason to focus on
this problem or use this knowledge? (2) Is there
a sufficient research base? (3) Is the change
appropriate for adoption in practice? At 2 of
these points, users must focus on the realities
within an organizational context; the third
point infers the possibility that evidence is not
sufficient and thus that a research study may be
needed or other evidence sought.
Rosswurm and Larrabee4 developed a
6-step model for change in EBP that aims for
integration of EBP into a care delivery system. The initial need for change is determined by comparing internal data such as
quality indicators with data from outside the
organization. When possible, this problem is
linked to standard interventions and outcomes. Research and contextual evidence are
sought to solve the problem and combined
with clinical judgment. With sufficient evidence, a practice protocol is developed and a
pilot test done to determine effects on outcomes. With widespread implementation,
both processes (eg, staff adherence to the
change) and clinical outcomes are evaluated.
The practice change is maintained by using
theoretically derived diffusion strategies.
The Johns Hopkins Nursing EBP model
was developed in collaboration with the Johns
Hopkins Hospital and the Johns Hopkins University School of Nursing.5 To ensure that current research findings were incorporated into
patient care, nursing administrative leaders
from Johns Hopkins Hospital developed a
model for the department of nursing. The
resulting model addressed the following 3
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domains of professional nursing: nursing practice, education, and research. The model
incorporates use of available evidence as a
core component for decision making within
these domains. Guidelines for the model
reflect the “PET” process, an acronym that
stands for practice question, evidence, and
translation. First, a team identifies an important practice question. The team gathers
evidence by reviewing literature, rates the evidence, and makes recommendations for
changes in processes of care or systems. The
last phase is the translation in which a plan of
action is developed and implemented and outcomes are evaluated and communicated.5
The ACE Star Model of Knowledge Transformation aims to promote EBP by depicting
knowledge types (from research to integrative
reviews to translation) as necessary precursors
to practice integration.6 This model does not
discuss use of nonresearch evidence. The 5
major stages of knowledge transformation are
(1) knowledge discovery, (2) evidence summary, (3) translation into practice recommendations, (4) integration into practice, and (5)
evaluation. The goal of the process is knowledge transformation, defined as “the conversion of research findings from primary
research results, through a series of stages and
forms, to impact on health outcomes by way
of [evidence-based] care.”6
Another EBP model that is considered a
“mentorship” model is the Advancing
Research and Clinical Practice through Close
Collaboration model. This EBP model resembles an organizational plan for a department
of EBP. The model focuses on establishing
relationships across systems to bring experienced researchers together with clinicians to
integrate research and clinical practice more
fully.7 Originally an organizational model for
linkages between a college of nursing and a
medical center, the model relies heavily on
EBP mentors, ideally advanced practice
nurses, with in-depth knowledge of EBP and
expert clinical and group facilitation skills.7–9
This model may be most useful in academic
settings with formal linkages between nursing
education and practice in which APNs are
abundant.
Out of the British system comes the Promoting Action on Research Implementation
in Health Services framework,10,11 which is
“useful as a heuristic device to help make
sense of the many variables and interactions
that take place in practice.”12(pS1) This intuitive model aids in understanding the key
components of EBP: evidence, context, and
facilitation. The model aims to represent the
complexity of making practice changes on
the basis of evidence. The key proposition in
the model is that “the nature of the evidence,
the quality of the context, and the type of
facilitation all impact simultaneously on
whether implementation is successful.”11(p178)
Further understanding of the relationships
among evidence, context, and facilitation is
needed to maximize EBP. This model, though
very useful as a theoretical explanation, has
not been documented as useful in driving
projects within organizations.
Selection of EBP Model
for the Institution
After evaluation of each of the EBP models, committee members should be able to narrow the
selection of these models to 1 or 2 models. This
can be done by selecting the top 2 models with
the highest scores on the evaluation tool and by
discussions that facilitate group consensus.
If 2 models score similarly on the evaluation tool, having members discuss general
advantages and disadvantages of each of the
models can help delineate the model that
“fits” the needs of the organization best. For
example, the group members might discuss
advantages and disadvantages of the models
reviewed and make the final selection on the
basis of (1) how easy the EBP model was to
understand and whether it would guide users
in the EBP process; (2) appropriate direction
by the model for the conduct of research when
evidence is insufficient to support a practice
change; (3) the flow of steps in the model is
similar to the flow of practice algorithms for
staff; and (4) decision points in the EBP model
would provide users with opportunities for
thoughtful reflection and decision making.
To maximize leadership buy-in, nurse managers, administrators, and clinical leaders who are
not part of the selection committee should also be
included in the evaluation and selection process.
This can be accomplished by having members of
the nursing research committee attend leadership
meetings to present either the final model or the
final 2 models determined by the selection committee. Leadership members can then participate
in the exercise of evaluating and scoring the final
model(s) by using the practice scenario. The management group can then discuss the results,
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advantages, and disadvantages, and make final
recommendation for adoption. Including broader
nursing leadership representation in the selection
of an EBP model would build consensus and promote support of the adopted model. If the initial
committee is having trouble making a decision,
leadership input can help break a tie or may result
in new insights as to why one model might fit
better than another.
Dissemination and Integration
of the Selected Model
Once the model is chosen, the committee can
brainstorm strategies to promote its dissemination and use. Educational sessions that are
planned should use active participation of
learners to enable participants to increase their
knowledge and skills in using the model to
answer clinically important questions that
require evidence-based solutions. Several strategies can be used for dissemination and integration of the selected model:
• Incorporating a class about EBP and the
selected model into the new graduate orientation or residency program. This ensures
that each new employee has basic knowledge about the use of the selected model.
• Add content about use of the EBP model in
preceptor development programs. Preceptors are often clinical leaders in their respective units. Enhancing their knowledge and
skills about EBP models can increase the
likelihood that preceptors will serve as
agents of change and champions of EBP
within their clinical areas.
• Incorporate education and skill building on
use of the selected EBP model into the
annual skills laboratories or competency
forums. This strategy ensures wider
dissemination of the selected model and aids
in establishing baseline knowledge and skills
for all nurses throughout the organization.
• Conduct nursing grand rounds on the
selected model, with examples of use of the
model in clinical practice. Grand rounds can
provide a forum for more in-depth knowledge and skill building with respect to use of
the model. Examples of how the model can
be used to answer important clinical practice questions can also be presented and discussed. Feedback can be obtained from the
grand rounds participants about the clarity
and feasibility of using the model for the
EBP process. Ideas can be elicited from the
participants about strategies to overcome
challenges to using the model.
• Provide EBP programs for the nursing leadership group. The program should introduce
this group to more extensive concepts of the
model, involve them in several examples of
how to use the model for both administrative
and clinical changes, and discuss their role in
increasing use of the model in their respective
areas. The infrastructures available to
facilitate use of the model should also be
discussed.
• Implement special “train-the-trainer” EBP
development programs. Content about
various innovative methods to teach others
about the model should be included, along
with a general discussion of the structure,
concepts, and processes of the model.
• Include content in institution-sponsored
research and EBP conferences by selecting
programs that increase participants’ knowledge and skill building relative to the use of
the model for EBP practice changes.
• Integrate the selected EBP model into the curriculum of any existing EBP immersion programs, such as an EBP internship or
fellowship programs.
• Encourage members of the nursing research
committee/council to brainstorm addit