Theoretical and Scientific Foundations of Nursing
Evidence-Based Practice and Nursing Theory Evelyn M. Wills and Melanie McEwen
Helen Soderstrom wos stricken with chonges in her vision, disturbances of gait, and occosionol periods of severe fotigue during her senior year of nursing school. She experienced intermittent periods of normality as well as illness, and the periods when she hod no symptoms lasted many months. During a time when her symptoms were unusually active, she sought medical help, and her physician determined that her symptoms were related to stress. Despite the periods of weakness and fatigue, she wos able ta complete the nursing program and graduated with honors.
During Helen's first year of practice, she experienced 1\-vo periods of symptom exacerbation, but each was short-lived. With full insurance, she was able ta see a neurologist who concluded that she was experiencing the beginning stages of a neuromuscular disease. Because there was no "cure," the neurologist worked with Helen lo find interventions that helped her manage the symptoms when they become problem a tic.
After a few years in practice, Helen enrolled in a graduate program to work toward a career as a nurse educator. During her first year of groduote studies, she seldom experienced neurologic symptoms, but during her practice teaching course, they returned.
The recurrence of symptoms, along with a new understanding of evidence-based practice (EBP) from her graduate courses, led Helen to make her personal health ex- perience the topic of her final, capstone paper. To learn more, she sought resources that would help her gain better control of the neuromuscular symptoms as well as assist her in her studies. To that end, she contacted her university hospital's neurosci- ence department and applied ta join a clinical team to learn about the efficacy of treatments and evidence-based interventions currently being used for patients with neuromuscular diseases. As she gained more experience with EBP, she considered what system she would use to develop guidelines on symptom management and selected the Iowa Model of Evidence-Based Practice because of its basis in research applied to clinical problems.
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254 Unit II Nursing Theories
Flon:nn: Nighting,1k, nur~ing\ lirst i1w..:stigator, d..:,·i~ed J. ~tJ.ti~ticJ.l me.im of dr- ..:iphcring her dau from Srnt.1ri during the Crimean war (Cohen, 1984; J\h:Don,1ld, 2014 ). De~pit, her .1..:complishm..:nts as an epidemiologist .rnd n:sean:her, ho\\·n·er, Nighringak failed ro recognize this vital role: for nurs..:s .,s she des..:ribed nursing as an '\1rt" .rnd medicine .1s J "s..:icnce" 1Nightingalc, 1860/19;;7/1969). Focus..:d on th..: "art" of nursing .md the apprentice-styli.: n.uurc of early rmr~ing educ.uion, Nightingale den:loped ,1 sy~tl.'m,nic m..:thod for showing tht' rt'~ulrs of nursing care in her own practice (St't' Chaptt:r 2 )_ In contrast, the idea of "scienc..:-b.1sed mnii- cine" h.1s bc..:n recognized since "mid-nineteenth centur~· Fr.rnce and .:,·..:n c:i.rlier" (Sackett, Ros..:nb..:rg, Gray, Hayne~, & R.ii:h.udson, 1996, p. 71 ). furrh..:rmor.:, th..: ide.11 of ~cienc..:-b.1s..:d medicin..: w.1s intlm:nced by th..: great intlu..:nz,1 ..:pidcmic of 1918 to l 919 when phy~ici,111s k.m,..:d tlut undcrst.rnding factor~ leading to th.lt h..::i.lth crisi~ wer..: necessary to prnnn simil.11· oi:i:ut-rencc~ ( Barr~·. 200:i ).
In th..: 1960s, s..:,·..:ral ph~·sici.m~ led by Dr. Ard1it' Cochr.m..: rnde.l.\ ured to bo:gin r..::i.ching and prai.:ticing mcdii:inc b.1sni on dat,1 prnJrn:..:d by ~ci..:ntiffr and cpid..:- miologic r..:s..:.1rch ( Sur & D.1hm, 2011 ). Cochrane questioned the dlic,Ky of non- res..:arch-ba~cd pr.1i.:tii.:..:s in 111edii.:in..: ( S;Kkctt ct al., l 996; Sh.1h & Chung, 2009 ) .mt! emph.1siz..:d th..: eririi.:.1I review of r..:s..:,1rch, focusing on randomiZL·d i.:ontrnl tri.lls (RCT~ ) to support m..:dical prai.:ticc. His intlucnce l,:d to dc,·dopm..:nt of the Cochrane Colbbor.1tion (now simply "Cochrane" l in 1993, an ..:mkavnr supported by a group of 70 int..:rnatinnal ph~·~ieians (Shah & Chung, 2009 ). Tlut .:ffort, orig- inally tnm..:d "..:,·idcni.:e-bascd 111..:dicinc," ,md 1H ,,, "c,·idcnce-based pr actic..:," ha~ grown expono:ntially. Tod.1~·. th..: Cochran..: initiati,·c, .md its ,ltt..:ml.mt partners, is .rn orgmiz.uion d1.1rg..:d with dcn:loping, 111.1intaining, ,rnd updating systo:m.1tii.: r..:,-i..:ws of he.11th care int..:n cntiom { Cochrane, 2017 ). Th..: intent of ( :oi.:hranc i~ to help tran~form how he.11th dccisiom arc made by gathning .u1d ~ummarizing the best ;w.1ilabk e\"ideni.:c from he,llth-rd,1tcd rc,..:arch to hdp patient!, and h..:alth pro\"idcr~ make informed uc.1tmcnt i:hoii.:es.
rollowing ..:ffons b~· Cochrane tn collect .md su111111arize rc,c:i.rch information, th..: r..:quir..:ment for ~cicntifie re\·i..:w of n:~earch and pr.1i.:tic~· h,1s become widespread in he.11th disciplines. The Jo,mna Brigg~ Institute, for example, was n:i.mcd for .111
Amrr:i.lian nur~c. lmpkmrnted in th..: 1990~, it now ha~ worldwide influ..:nc..: in EB!' (Joanna Brigg:., Institute, 2016; Polit & Beck, 2017). 1ort' recently, Sigm.1 Tht'ta T.rn Int..:rn.1tional, \\·hich h.1, supported m1r~ing rc~..:arch for d..:cad..:s, 1111w ~pon~or~ J
journ.11 foi:us..:d on publishing c\"idcnce-b.1~ed nursing res..:arch ( Polit & Bci.:k, 2017). Although the notion of EBP ,,·a!, ~omewlut del,1~·..:J in b..:ing rci.:ognized .rnd impl..:- m..:ntcd in nursing, m·cr th..: past rwo dc..:ado:!->, EBP h:i.~ now ..:ssentiJlly bei:ome the stand.1rd for research-based, inform..:d d..:cision making for nursing care.
In con tr.1st to "res..:ari.:h," which rdl'r~ to th..: ~ystematic, rigorous, i.:riti.:.11 in- ,·estigation to ans\\·..:r qucstion(s), EBP is an .1pproai.:h to problem soh·ing that i:on- scicnriously colkcts, c,·,1luat..:s, and integrates the most current, or "best," eddcni:t: ba!->nl on met,1-an.1lyses of the l,1test r..:sc;1rch for p.uicnt car..: ( LoBionJo-Wood & Hab..:r, 2018). Nur!->t.:s han; expanded th..: origin,ll FBP n.:l]Uircments (\\"hich l.ugd~· ..:spome experim..:ntal res..:ard1) b~· indudin~ qu,1lirari, eh· deriv..:d findings from phcnom..:nologii.:, cthnogr:i.phi..:, .rnd grounded throry n:se.1ri.:h .md c1s..: ~tudics ( Polit & Beck, 2017 ). "M..:r:i.synthcsis" is tht' term ,1ppli..:d to the proc..:ss of sys- tenutic r..:,·i..:"· of qualitati,·..: studies on ,1 topic ,rnd is a way to sysrcmariz..: such ..:,·id..:ni.:..: for use in nursing situ.uions ( Butler, H.111, & Copndl, 20 l 6; Melnyk & Finrnut-O\'crholt, 2015 ).
Thus, £BP is ,1 pmces!., th.u invoh-..:s idcnti~·ing ,1 dinii.:,1l probl..:111, se,iri.:hing thi: literntun:, symh..:sizing the finding~ to i.:riticJII~· ..:,-.llu.n..: the research c,·idl·11ec, ,md
Box 12-1
Chapter 12 Evidence-Based Practice ond Nursing Theory
American Association of Colleges of Nursing Essentials and Evidence-Based Nursing Practice
Evidence-based practice [EBP) is one of the critical elements identified in the "Essen- tials of Master's Education" !American Association of Colleges of Nursing [AACN),
255
20 l l ), and EBP is mentioned more than 50 times in the document. One statement helps summarize the relationship between EBP, theory, and professional nursing practice: "Master's-prepared nurses, when appropriate, lead the healthcare team in the implementation of evidence-based practice .... Integrate theory, evidence, clinical judgement, research and interprofessionol perspectives using tronslotionol processes lo improve practice and associated health outcomes for patient aggregates" (p. 16).
Similarly, according lo the AACN (20061, doctor of nursing practice (DNP) programs ore designed lo prepare experts in specialized advanced nursing practice. It hos been determined that DNP programs should " ... focus heavily on practice that is innovative and evidence-based, reflecting the application of credible research findings" [p. 31. Indeed, Essential Ill explains the importance of "Analytical Models for Evidence-Based Practice" and includes o number of related competencies and objectives for DNP programs.
then determining appropri.1tc intcncntions. Nursing ~dlllbrs note th.1t EBI' relics un integrating resean.:h, theory, and prai:til.:e and is cqui,-.1knt to thcory-ha~ed pr aetiee .1s the objcctin· of both i~ the highest le,·d of safety and efficacy for patients ( Fawcett & <.,ari~r, 1009 ). Finally, EBP is an "cs~cntial" component of .1d\'.111ced nursing cduc.1- tion .rnd ,·ital for both master', . . 111d doctor.1te-prep.ued nur~o l Box l 2-1 ).
Overview of Evidence-Based Practice The concept of EB!' is widd,· .1ccq1ted as .1 requisite in he.11th c.m:. EBP is ba~cd on the premise tl1.1t he.11th profrssion.1ls should not center practice on tr.1dition .md belief bm 011 ~ound infr>rmation groundl"d in research finding~ .md ,cicntific de,·dopmcnt (i\klnyk & Fineout-On:rholt, 2015; Schmidt & Brown, 2015). Until the earl~- p.ut of thl' 21st ct:ntur~·, the concept of EBP \\'a:, more common in C.rn.1di.111 and British nursing literature than in U.S. nursing literature. Over the Ll~t decade, howeYer, the term l1.1s become ubi4uitou:,. This is .1ttributed in part to the guideline initiati\'cs of the Agency for Healthcare Rnc.1rch .md Quality, the Institute of i\kdicine, .rnd the LT.S. Prcn:nt.lti\'c Scrvil.:es T.l!->k Force, .1111ong other, l Hudson, Duke, H.u~, & \',undl, 2008; i\kln~·k & Fineout-O\'erholt, 2015 ).
1\bny nursing scholars ( DiCcmo, Guyatt, & Cilisb, 2005; H.111, 201-!; Ingersoll, 1000; LoBiondo-\"lood & Haber, 1018; i\lldnyk & Fineout-O\'erholt, 1015; Pugh, 2012; Rycrofr-i\lalone, 200-4- ) h,l\"C pointed out that EBP and rncarch arc not ~ynon- ymous. They arc both schol.uly processes but forns 011 ditfrrent phases of knowledge 1.kvdopment-.1pplication H-r,us disco\'cry. In general. EBP rd~·rs to rill' integration of indi,·idual clinical expertise with the best ,1Yailablc cxtcnl.ll clinical c,·idcncc from sy~tematic n:st:,1rch. It is largely based 011 research studies, p.1rticularly Mudit"s ming clinical triah, meta-analysis, and studies ofdienr outcomes, .md it i~ more likdy to be applied in practice st:ttings that YJ.]uc the usr of new ki10\,·ledgt' and in ~t:ttings that prn,·ide rl'snurccs to .KCC!>S that knowkdgl:. Howe,·er, nur~ing studies that employ 4ualitati,-c methods or mi\ed method rcse.uch .uc con~idered nluJbk- to the disci- pline, as mcntirn1l:d .1bow I H.111, 101-t).
256 Unit II Nursing Theories
Definition and Characteristics of Evidence-Based Practice In mcdicinc, EBP hJ!, bcen ddincd as thc ..:onscicntiow,, n:plicit, .rnd judicious UK
of the currcnt bcst c,·idencc in making dccisions .1bout the care of indi,·iJu.11 pa- tients ( Sackctt, Straus, Riclurdson, Roscnbcrg, & H.1yncs, 2000 ). It i!. :rn .1pproach to health care practice in which the dinician is ,m·,m: of the e,·idenn: th.it n:l.1te~ to clini.:.11 pr,Kticc .md thc strcngth of th.u C\'idencc ( Jennings & Loan, 200 I; Tod, PJlfreynun, & Burke, 200·±).
To d.istingui~h 1rnrsing from mcdicinc in discussing EBP, .1 number of dctinitinns han: becn pre!.entcd in thc litcr.uure. SigmJ Thet.1 T.1u International ( 2005) ddim:d "e\'idence-b,1!.cd nursing' ' JS ".111 integration of the best eYidcncc ,w,1il.1blc, nursing expertise, .111d the , ·.1luc~ and prcti:n:n..:e~ of thc indiYidu.1ls, families, and .:01111111111itic~ who Jrc scm:d" ( p.1ra. 4 ). Simibrh-, DiCem,o Jnd collcagucs I 2005 ) detincd EBP .1s "the intcgrJtion of best research e,·ide1Kc with dinic.11 cxpcrti~e .1nd patient ,·aluc!. to facilitatc clinic.11 decision making" ( p. 4 ). Both of thcsc ddinitiom use similar terms (c.g., bc~t e,·iden..:c, cxpcrtise, patient ,·alucs).
In nur~ing, EBP gcnerally includes c.m:-ful rc,·iew of resc.,rch findingl> .iccording ro guidelines th.n 11ur.,c scholars ha,·c used to mc.1,urc the merit of .1 study or group of srudic5. h·ide1Ke-h.1scd nursing dc-1..·mph.1~ize~ ritu,11, isol.1tcd, Jlld unsystcmaric clinical expericn.:c!,; ungrounded opiniom; .md tr.1dition as a basi~ l<,r pra.:ticc .111,l srrcs5c5 the.: ll5C of rcscarch tinding5. Other 111c.1wrcs or factors, including nursing ex- pertise:, health rc,ou1-ce~, p.1ticnt/famih· pn.:frrcnc1cs, quality improwment efforts, .111d the consensus of rccngnized expats, arc .1bo incorporJtcd .,s appropriate ( ~klnyk & rincout-O\'r.:rholt, 20 IS; Schmidt & Rro\\'n, 2015 ).
In summ.iry. EBP h.1s se,·e1-.1l critical fr,1tun:~. hr5t, it is .1 prohlem-ba~cd ap- pro,ich and comider, thc context of the practitioner's current expcrit:ncc. In .1ddition, EBP brings togcthcr the bc~t J\'ail.iblc nidcnce .111d current practice by combining rc~card1 results "·ith t:Kit kno\\'lcdgc .m,I theory. Third, it incorporates \'Jluc~, bclid;, and desire!. of the p.1ticnts .rnd their families. fin,1lly, EBP fa.:ilitates the applic,Hion of rcsc.m:h tinding;s by incorporating first- .md ,c.:ondlund kno\\'lcdgc into pr.1c- tice. Link co Practi.:e 12- 1 presents inform,1tioll oil databases that nurses ,rnd others l.."an .1c.:c~~ to find specific information Oil currcnt guidclinc5 .111d other collcdiom of "cTidence" rh.n ~·an be ll!,ed to impro,·c he.11th c.1rc.
Concerns Related to Evidence-Based Practice in Nursing Dcspitc growing ,1ecq1t,11Kc of applic:1tion of EBP in nursing, ~omc criticism~ .md con.:erns h.n·c been \'oiccd in the nur~ing. liter,lturc. for exJmplc, thcre is thc .:011-
ccrn that EBP is more fo,·mcd on the ~cicn.:c of nursing than o n thc Jrt of nursing. Some Juthors h,\\'e cxprcsscd concl-rn that ,trict cnncentr.ition on cmpirically bai.ni knowledg1c will lead to thc failurl' w capture thc uniqueness of nursing and the importance of holisti( .:arc in co11tcmpor.uy pr.tcticc ( F,\\,·cctt, \\'arson, Nn1m.111. W.1lkcr, & fitzpatri.:k, 200 I; Hudson ct al., 2008; llpton, 1999).
:\not her (onccrn i~ th.it rclia1Kc on EB P will place n ursc5 in the rolc of medi- c.11 extender o r mcdic.11 technician, where nur\ ing \\'ill hc rcduccd ro ,1 ted111i,·al practice. Th.is ,·0111..:crn \\'.1~ voiced .1s equating EBP with "cookbook care'' and .1 disrcgard t<ir individualized paticnt carc ( finkclman & Kcnncr, 2016; l\klnyk & fincout-O\'crhnlt, 1015). Indeed, .,!tho ugh c,·idence may prm·idc direction fo r development of proce- dures, tcchniqun, .md protocols for nursing, it ha!:> been establishcd th.n the~(.· .1re not
Chapter 12 Evidence-Based Proctice and Nursing Theory 257
Link to Practice l 2- l Key Resources for Evidence-Based Practice Several important databases have been set up over the last 20 years to promote inte- gration of "evidence" in health care. Information on three of the most influential are presented here.
Cochrane Collaboration-http:/ / www.cochrane.org/ The Cochrane Collaboration is an internatianol network that helps health care practi- tioners, policy makers, patients, and their advocates make informed decisions about health care. The Cochrane Library prepares, updates, ond promotes the accessibility of the Cochrane Datobase of Systematic Reviews.
Joanna Briggs Institute-http://www.joonnabriggs.edu.au/ The Joanna Briggs Institute is on international research and development organization from the School of Translational Science ot the University of Adelo,ide, South Australia. The Institute and its collaborating entities promote and support the synthesis, transfer, and utilization of evidence through identifying feasible, appropriate, meaningful, and effective heohh care proctices to assist in the improvement of health core outcomes.
Agency for Healthcare Research and Quality IU.S. Preventative Services Task Force/National Guideline Clearinghouse) - http://www.guideline.gov/ The National Guideline Clearinghouse (NGCJ is a database of evidence-based clinical practice guidelines. It is intended to be used by health professionals, practitioners, patients, and others to obtain objective, detailed information on clinical practice guide- lines and to further their dissemination, implementation, and use.
tht: only knowlt:dgt: th,1t inform~ tht: nursing pranict: and th.1t (omidc:rJcion of indi\'id- uJI nct:ds .md ,-.1lut·s is c:s~rnti.ll (Hudson c:t JI., 2008; ~1icd1dl, 2013).
Third, bl'.,aw,t· rc:~c:an:h in\'oh·ing hum.rns is cmnpl...-x, findings 111.1y bt: opc:n to i1m:rprc:ution .md thc:rc:fort: ~hould not bc: the: ~ok basis for pr.ictiL'c. Rc:M:Jrd1 must ht· c:omidn1:d within tht: cont.:xt of the pra(ti(c prcsaibcd l-iy theory, Jnd it must int.:grntc: th1: v.1luc:~ .rnd bdid; of nursing philosophy ( Chinn & Kramer, 201 :i: ,\kK.:nn.1 & Sli:,·in. 2008: W.1lkt:r & ,-\\-Jnt, 201 I).
:\ fourrh 1:on~·crn rc!Jcc~ to promoting,\ link with c:Yidc:nt:c-ba,ni 111.:dicinc Jnd it~ cmphJsis on pmiti,·ist thinking: .111d th.: dominJn.:c: of dini(,ll tri.tls .1s tht: maior t·,·idc:111:c. Thi, (OIKC:rn i~ rc:l.ltcd to th.: .1b,t:1Kt: of comidc:r.1tion of t:\·i- dc1Kc gatht:r..:d through 4ualitJtin: n::-.t:,m.:h and rhc:ory dc:n·lopm..:nt ( F.m·t:ctr l'.t JI., 200 L knning~ & Loan, 200 L Stl'.\·cm, 2002 ) .
• \ lihh .:rn1,crn n.·latt:, 1n the potential for linking ht:.ilth L',lrt" rcimbur~cmcnt cx- dusi\'dy to intt:n·c:ntions thJt .:Jn bi: ~ub~t.mtiJtt:d b~- ,\ donimt:ntc:d bod~· ofcvidl'!ll"C ( lngc:rwll, 2000 1- Thi~ k.1ds ro .1 numbn of l'thkJI 4ut·~tinns .md i,,uc, thJt ,l10uld be: nmsidc:rt·d. for c:xJmpk, rc,trining "offl.1bd" u,c: of mnfa:Jtions th,lt mJy be:
258 Unit II Nursing Theories
hdpti1I for ..:cn.1in patients or cert.tin diagnoses, .ltrcmpts to .liter fin;111(ial n:imbur!.e- ment to rcdu..:c e1rn:rgcncy anJ spco.:i.1lty care, ,rnd .1djusting pa~·1m:nt to providers for over ( or under) me: of prcscriptinn p.1in medi..:.uit,n~.
Fin,tlly, it is .trguc:d that nor all praaii:e in the h..:.1lth proti:ssiom can or should be ba~cd on !,..:icncc. In nuny ..:,hes, rcscan:has hJ,·e ~·ct ro .1..:cumulatc .1 strfticient body of knowkdge. I 11 other C.l!,CS, .1 ditfrr..:nt fram..: of referc:nce pro,·ides a difter..:nt r.uionak for ,Ktion t McKc:nna & Skvin, 2008 l. In thc!.c instanCt:!I, strict rdi.111ce on EB P may result in numerous \'oid!, when de\'doping a plan of ..:arc.
Con..:nns ~ud1 ,1' the!,C h.1vc been .1ddres~cd by DiC:cnso and colkag.uL•!, ( 2005 ), who a!,!>ert that .1 ti.111d.1111cnr.tl principk of EBP b that n:scJn.:h evidence ,1lonc is not sutfa:ient to pbn c.m:. Other ethic.ti .md pr.1gmatic factors, ~ut:h as benetit~ JnJ risks, asso..:i.1ted t:oSt!,, anJ patie11t'!> wishes, ~hould be o.:onsidcred. furthermore, the,· note that "best research c,-idencc'" Gill t-c quantitative or qualitatin· and does not ·neo.:c~- sarily rely on R.('Ts. Th,:~,: notions .m· .1lso supported by Ryo.:rofi:-~-1.llonl· (2004), \\"ho mai11t.1ins th.tt "·cll-1.:onceiwd .111d wdl-o.:ondut:tc:d 4u.1litari,·c and quantitarivr resc.:,m.:h e,·iden..::t', dinical c:xpc:riencc:, .md patient cxperit:nces, o.:ombinl·d with local or organizational intlucno.:e!>, arc nccnsary to facilitate EBI'.
Evidence-Based Practice and Practice-Based Evidence A new l'.OJKept-"practii:e-bascd e\·idc!Kl'" (PBE)-was introduced into the discm- sion of EHP a fi:w ye;i.r, ago ( Horn & Gassaway, 2007 L The notion of PBE .1ddrcssl'S m.rny of 1hc o.:nnccrn~ noted prc,·iously and is g,roundl·d in tht: recognition th.u fre- quently intcn·l·nrions h,l\'e limited formal re,ean:h ,upport, p,trtit:ul.1rh· in the mun- bcr or qu.tlity of R.CE.
Tiu: pn:misc of l'BE is that hugl· datab.1scs-not just dinical n·searo.:h-.,hould be rl·,·iewt'd or "mined" to gatht:r data to lkmomtr,ltl' qu.1lit~· .rnd cftco.:tiwnl'~s. Thi~ typl' of rc,·icw l·an pm,·idc t:omprL"hensin: inform.ttion about p.nicnt charactl·ristic~, care prot:cssc~. ,md outcomes while controlling for patient difti.·n·nce~ ( \V,1lkn & .-\,·ant, 2011 ). PBE acknowledges the importan..:l' of the crwironmcnt in dt'tnmin- ing practice Tl'Commend.ttions ,md recognizes th.n knowledge l·,111 be genc:r;tted from pra..:tice .1~ well .1~ from 1T~e.ud1 ( Chinn &: Kr.tmt'r, 2015 ).
The intent bdtind PBE is to dt·tennine whJt works best for which paticnts, under what circumstancL"~, and .tt wh.tt costs by pr<J\iding ;1 more comprehensive picture th.tn R.CTs, "·hich typi1:ally examine onl· intL"n·cntion with Iimitl'd popul.ttiom and under strktly i:ontrolled cirrnmsta.nce!> ( Huston, 2017 )_ .-\ddition.11 \OUro.:e~ bt:yond ti.m11.1I research !>tudil's ch.narc appropriate ,1s PBE indud.: benchm.uking dat.1. din- io.:al cxperti~t:, co~t-dfeo.:th·c .malysc-s, intcction t:onrrul data, medic1l ri:cord d,lta, 11.1- tional MandJrd~ of c.ue, quality irnpro\'emcnr dJta, ,llld patient .mJ farnih· preferences ( Huston, 2017).
Hom .111d GassJ\\·ay ( 2007) ..:ondudcd th.H me oft he PBE an,1lyscs c.111 u111.:o,-n bt"tter pr.1t:ticc~ more r.1pidly lc.1ding to imprm·ed patient outcoml's. Figure 12-1 illustr.lll'\ on..: intc:rpretation of thc i1m:rrc!Jtionship~ among EBP, PB E, rt:sc.uo.:h, .111d theory in nursing.
Promotion of Evidence-Based Practice in Nursing ImpkmL"nt..irion of EBI' in nursing is :,till l•,·oh·ing, .1~ often, nursing inccn·enrions an: b.1sed on cxpcricno.:l', tr.1dition, inruition, common ~ensc, .rnd unrestl'd theories.
Figure 12-1
Chapter 12 Evidence-Based Practice ond Nursing Theory
Relationships among practice, theory, research, and the practice-based evidence/ evidence-based practice cycle.
!From Wolker L 0 .. & Avon!. K C. Stro1egies lor Theory Construction in Nursing. 5th ed. © 20 I I Reprinted by permission of Peorson Educot,on. Inc., New York. New York I
259
Although e111ph.1sis on EBP ha~ grown r.1pidly, especially over the I.1st dec.ade, the .1ctu.1l incorporation of nursing research findings in praake 11.ls lagged. ~klnyk ,rnd f ineout-O,·erhult ( 20 I 5 ) han: outlined barriers to impkment.1tion of research and ERP in nursing ( Box 12-2 ).
There is signitic.1nt sllpport for increasing emphasis 011 EBP in nursing, ,rnd man~· organil.1tions, such Js the Institute of ~kdicine, Sigma Theta T.au lnti:rnational, .and the Magnet Recognition Program of the Amerie.rn Nurses Credenti.i.ling Ccrm:r, among others, haYe dcsigned initi.1ti,·ec; to advance EBP ( Finkelman & Kenner, 2016; Huston, 2017; i\klnyk & Fineout-On:rholt, 2015). Indeed, pr.ictitioners, rese.in:h- ers, and scholars should welcomt· it bec.u1st· .1 systemaric process of EBP m.1y assist nmse, in n:ducing the g,1p ben,c.·en theory and pr,Ktice-.
Theory and Evidence-Based Practice The growing interest and appreciation of EBP in nursing, along with its considerable incerconncctedncs~ with research. has scr\'ed in ~ome ways to dc-cmphasizc th,:ory. As nur~es be-come nmn: aware of and attuned to EBP, howc,·cr, they an: rcnl.!\\'ing their appreci.1tio11 of the linkage:. among rcScarch, theory, and pra..:ticc. It h.is bt·cn ohser\'cd that nursing focus on EBP ha~ the potcnri.11 to promote .111d draw ne,,· .1ttt·ntio11 to this ..:onnccrion ( Chinn & Kr.urn:r, 2015 ).
260 Unit II Nursing Theories
Box 12-2 Barriers to Evidence-Based Practice in Nursing
Lack of evidence-based practice (EBP) knowledge and skills Misperceptions or negative attitudes about research and evidence-based core Lack of belief thot EBP will result in more positive outcomes then traditional core Voluminous amounts of information in professional journals Lock of time ond resources to search for and critically appraise evidence Overwhelming patient loads Orgonizotionol constraints, such as lock of administrative support or incentives Demands from patients for o certain type of treatment Peer pressure to continue with practices thot ore steeped in tradition Resistance to change Lock of consequences for not implementing EBP Peer ond leoder/monoger resistance Lock of autonomy over practice ond incentives lnodequote EBP content ond behavioral skills in educational programs Continued teaching of rigorous research methods in bachelor of science in nursing (BSN) and master's of science in nursing (MSN) programs instead of teaching evidence-based approach to core
Source: Mel~yk ond F,neout-Oierholt (20151.
W.,lkn .md .-\\'ant ( 2011) pointed out th.n pra..:ti..:e i~ the ..:entral and ..:ore phe- nom..:non .rnd fonts of nun,ing; argu.,blv, it i~ th..: n:.,son for nursing'~ cxisten..:t. Thus, it is ..:riti..:.,I to remember th.lt theory g;uides prJ..:ti..:c, .rnd it Jl~o gentr.uc, models of testing in rt,c,m:h through both PRE and EBP. furth1..•rmor..:, n:~..::.u..:h and dini..:Jl d.n.1 prm·idc e,·id1:n..:e for EBP or PBF Jnd c.rn grnerate practi..:e guide- line~ ,llld/nr theorii:~ rc.g., situation-spe..:ilic theories). Thi, pnKess i~ int.:r.10.:ti\'e .rnd iter.niw ( W.1lker & A,·anr, 2011 ). for mming, therefore, pral'tiec must not only he c,·idericL··bJscd bur Jbo l-,1..· theory-ba~ed, for when research \·JliJare, a thL·ory, it pro,·idc~ the e,·idcnce required for EBP. Fin,tlly, a ... murc resc,m:h is conduced .1buut .1 .-.pc..:ili..: theory, more ..:videncc: is prO\·idcd to ~upport pra..:ri..:e (Chinn & KrJmer, 201 :,; L~enrgc:, 2011 ).
f.1w..:ett Jnd colleagues ( 200 I J wrote ofa prdcren..:e for rhe term "theory-guided, t'\'idcrKe-based pr,1ctice," noting that theory i.-. the rt.1Mlll for, .md the \',llue of, e,·- idcnce. The "e\'idence," they srJtcd, nrn.-.t cxtcnd beyond .m empha\i~ on empiri..:al te~e.u..:h .md Jl( T~ to includt c,·idenct gi:na.ucJ from theories. Indeed, the e,·idcncc it~elf refer, to e,·idtnce ,1bout rhcorie~. Furth..:rmore, they contcnd that theory de- termine~" h,u count.-..,~ e\'idencc; thus, theory .111d e,·idenct .ire im:xtric.,bly linktd.
Theoretical Models of Evidence-Based Practice Nu1m:rom models of EHP h.we bcen deYdopcd by m,r,n tu cn.:ol11-.1gc tr.111,lation of nursing research into practict·. In many ini.rance~, the go.ii ur intent i ... ro ..:re.1rt· or c~t.,bli,h EBI' protocob, pro..:cdurcs, or guideline~. In ~omc imt.rnce ... , uniwr~irie.., .md hospit,1I gmup\ ha,·e dc:n:lopcd models to .1s.~ist ~tudcnt, or he.llth .:.u-c profrsi.ionals in impkmcnting EBP in their ... erring. In othn instJnces, nur ... ..- re ... earchers .ind schol.lr.-. h.we inteq1rcred the tr.rnster of research e\'idencc.: to nursing cduo.:Jtion Jnd prJctici: through processes that progres..,eJ from theory-based nursing, 9uJ1i~· improvcmc.:nt,
Chapter 12 Evidence-Based Practice ond Nursing Theory 261
n:~c.irch miliz,uion, .md l.itc:I\', c\·idcncc-b.1scd nursing pr,1eticc. This section rc\·iews fiw EBI' models th.tr .1rc Jmong- the mnst frequently dtcd in the m1r~ing liccraturc. Thcsc h.1\'c bccn widdy ~tl1tfa:d .md .1pplic.:d, m.my in multipk scttings .md for .1 ,·a.1iety of p.nicnt issues, situation~. or nur'!>ing carc procc~sc~. Thc~c mo~.kl~ include:
.-k.1dcmic Center for E\'it..knce-Ih~cd Practice St.u 1\lodcl I .-\CE Star ,\lodd I (Stewns, 2005, 2012 l .-\t..hancing Rc~c.uch .md Clinical Practice Through Clmc Coll.1hor.1tion (.-\RCC J\lndd J (i\klnyk & Fincout-O\crholt, 20151 Iowa 1\totkl ( Titkr ct al., 200 I ) lohns Hopkim :-.:u~ing b·idcni.:c -B.1~cd Pr.u:tice ( JH:--:EBP l 1\lodd ( DeJrhult, 2012; Ni.:whlluse, Dcarholt. Poe, Pugh, & White. 20lli l Stetler ,\lodd llf b·idcnce-B.,~cd Pr.1.:rin:- ( Sretkr, 200 I )
Thc~c model~ c,111 proYide guidJ1Kc for prJcticing nur~c~ .md Jt..h·anccd prJcticc nur,c, to promote or cnh.rnn: EBP .md to de\·clop prai:ticc guideline~. protocol!., or intcrn:ntions .1~ ,1ppropriJtt..'. E.1ch modl'I will bc described bridly and re,·iewed for ics mility in m•r~ing practice ,md educ.irion.
Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation
The .-\CE Star ,\lodd w.1~ dc\·cloped by faculty .u the l ' ni,·crsity of Tcx.1s Health Science Center .lt S.111 A.!1ronio (l1THSCSA) (Stc\'cns, 2012). T he Star ~lode! i~ Jepictcd by fi\'e point, of knmdcdgc tr.1nsformarion. The ti\·e form~ of kno\\'lcdg.c tr.m~formJtion occur in "n:l,ni,·e ~c"1ucncc" when rl·,i:.m;h l.',·idcnce progres~c~ through ~cwr.1I cydcs .ind i~ combined with other knowledge ,md then applied in practice.
E.Kh point of the st.lr represents .1 step in J. pmccs,. The sti:pwisc depiction Jllows for c.i.sy i.:omprchension and is therefore usdi.il C\'l'll for nodcc lllll"~l''>. In ordcr, the point~ .1re:
1. Disco\'cn· rcsc.1rch 2. E,·idcnce summ.1r~· 3. Transl.ltion to guiddincs 4. Practice imcgrJtion 5. Prm:ess, outcome e\',lluJrion (Sten:ns, 2012 ) (figure 12-2)
This sct..111e1Kc .1llows the nun,c to nmn: rcsc.uch-bascd knowledge from one point to the next in \cquence to pro\'idc .1 cr.m~lation ofc,·idt.·ncc on which to b.i.~e prJcticc (Sten:ns, 200~, 2012 ). Knowkdge tr,rnsti,rnurion com,ists of eight premises rha.t un- derlie .rnd cxpl.1in the position of the n:se,m:hers who c:rc.neJ the model. These arc prcsl·nted in Box 12-3. The rigor of the proct·s~ the nur~e or committcc use~ b. p,ut of rhc ,·.1luc of the kno\\'ledge tr.1n~fonn.1tion th.n oi.:..:urs when using this model.
The modd i~ used ,lt l'THSCS.-\ hospit.1ls, .md their nursing. pmgr.rn1 n1.1inrJi1h .1 n:ry detailed ,111d informatin- 011linl· t'duc.1rion.1.I site l http:/ /www.ai.:cstar. uthsi.:sa.cdu/ ). The \Wbsite prO\idt..·s .m cxrcnsi,·e 0111im· tutoriJI on the .-\CE Star 1\lodd complete \\ith detailed inform.nion, resource~. in~rru..:th·c ,·id.cos, ,md ~lidt:s . .-\ quiz Jnd ,1 catilil-atc of .1nend.mcc .1rc .wa.il.tbk for tho~c completing in~trunion in the modd (sec Link to Pr.Kticc 12-2 f. The .-\CE Star i\ltKid i~ mdi1l in tcJ.:hing nur-..cs .md nur~ing srudcnrs the proi.:e.~s of rc!>CJ.ri.:h c\·idcnce utilia tion in prai.:ti(t..' I Sch,ltti:r, Sand.1u, & Diedrick, 2013 l. One corK1.T11 or criti.:ism ofrhc .-\ C F. St.1r i\lodd lus been noted by \Vhitc (2016), who pointcJ out tl1.1t it docs nor me C\id~·ncc other rl1.111 n:~earch pa sc:
262 Unit II Nursing Theories
5
c 2012 Stevens
E11idence Summary
2
Figure 12-2 Diagram of the Academic Center for Evidence-Based Practice Star Model for evidence-based practice.
!Used with perrn,ss,on from Slevens K R. [2012] Star model of EBP Knowledge transformation Son Antonio, TX Acodern,c Center for Evidence-Based Pmctice. University al Texas Heahh Science Center Retrieved from http //nursing
Box 12-3 Academic Center for Evidence-Based Practice Star Model: Knowledge Transformation-Underlying Premises
l. Knowledge transformation (KT) is necessory prior to using research results in clinical decision making.
2. KT derives from multiple sources, including research, experience, authority, ITiol and error, ond theoreticol principles.
3. Systematic processes control bias; the research process is the most stable source of knowledge.
4. Evidence con be classified into a hierarchy of strength of evidence depending on the rigor of the science that produced the evidence.
5. Knowledge exists in o variety of forms. As research is converted through o system of steps, other knowledge is erected.
6. The form in which knowledge exists con be referenced lo its use. 7. The form of knowledge determines its usability. 8. Knowledge is transformed through steps, such os summorizotion, lronslotion,
application, integration, and evaluation.
Abstrocted from Stevens, K. ~- j20 l 2) Siu, model of EBP: Knowledge lronsformolion. Son Antonio TX: Academic Center for Evidenc&-Bosed Practice, Universily of Texos Heolth Science Center Retr,.....d from hnp. //nursing. uthscso .edu/ onrs/ stormodel/ star-model.asp
Chapter 12 Evidence-Based Proctice and Nursing Theory 263
Link to Practice l 2-2 Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation Access the website, toke the tutorial, and complete the quiz to obtoin o certificate of completion of the program ot http://nursing.uthscso.edu/onrs/stormodel/star-model.osp. This website may be useful for teaching the elements of evidence-based practice to nursing students.
Advancing Research and Clinical Practice Through Close Collaboration Model Mdnyk and Fineout·On.:rholt (20021 developed tlw :\RCC .\1odcl through th.:ir wmk with many heJlth care institutiom sctking to Jd\'~mce Jnd su.st,tin EBP. This dcvclopmcm \\·as .1 procc,~ rhJt im olwd mJny itcr.ttiom Jnd empirical testing; of key rd.uionship,. The fr.1mc\\'ork of tht: AIU ·c Modd is taken from control theory and eogniti\'c heha\'ior.11 thcoric:s, \\'hich hdp guide nmses' beh:l\"iors .1s rhcy gain .Kumen in EBP ( i\klnyk & fineout ·<>,·erholt, 2015 ). Numerous ~wdies Jnd cumplc~ of how th<: AH.C< · ~1odcl ha~ been implemented in clinieJI pr.1cticc .1rc a,·ail.1bk in the liter· Jture ( ~klnyk, 2002; r-.-kln~·k, 2017; Melnyk, Feinstein, & f,1irbanks, 2002; Melnyk & fincnut-O,·aholt, 20 IL ~klnYk, Fincout·On:rholt. Giggkm.m, & Choy, 2016; Melnyk, R,·crott-M.1lon..:, & Bu..:kn.tll, 2004 ).
The :\/\RC Model rdate.., be~r ro clinicJl practice, .rnd much of the reseJrd1 sup· porting it, de,·elopment .rnd impkmentation WJ~ conducted in Jcute care, pediatric settings. The centr.11 Glll~tntcl!> .ire .1 ... scs~mcnt of org.1niz.1tionJI ,:ulturc .rnd rc.1dinc ...... ti..>r EBP. id..:ntification of strength .... md major barrier~ to EBI\ .rnd de\'clopment and use of F.BP nicmors. These ..:onstrn.:r, .trc done sequc:ntiJlly Jnd fr1llowed by EBP im- pkment.ttion. Outco1m.: ... th.1t ... hould be e,·aluatc:d include health c.uc prm·idcr ~ati..,. faction, cohesion, intent to lc:ave, turm"·er, imprn\'cd patient outcomes, .rnd ho~pitJI C0!>tS ( 1\ldn~'k & Fincout-O,·nholr. 2015 ).
In employing. the :\RCC ~ludcl, the .mthon. de,-clopcd ,e\'crJI ...CJle~ t11 me.1~urc thc .1bili~- to impkmcnt EHP. These .tre the Org;Jniz.1tionJI Culture .md R~·.1dinl.-s~ Sc.1k ti.1r S\'~tem-\\/ide lim·gration ofE,·idence-Based PrJ..:tic<.: (OCR.'-;IEP ) and the EBP Bclict-. 1 EBPB ! ,c.ile ( i\klnyk & fincout-On:rholt, 2015 ). Organization.ti re,1diness is tiN J.5·
scssc:d, .rnd when k.1siblc, mentor~ .ll'e identified .md de,·clopcd. The clini..:al nurses JJ'l'. then mentored through w,e of the AIU ·c system. Melnyk .md fincout-( )\'erholt { 20 I 5 J
, t ,tt.: that 1m:.1sU1ing. the k~y 1.·nmtruct~ ,dong with workshops Jnd Jl..'Jdemi..: otlcrin~ .,s~i~t orgJnizJtions to adopt .1.nd ~u~rain EBP. rinally, 1\klnyk Jnd fineout-On:-rholt (2015) de,·doped a flow ch,ll't to .,~~i~r in u,e of the model. Box 12---1 gi\'es eumples of re<.car..:h tlut lu~ been conducted employing rhc :\RCC i\lodd ofEBP.
The Iowa Model of Evidence-Based Practice to Promote Quality Care The lo\\',\ ,\!odd of EBP was de,·cloped in 199+ to promote qu.ility ,:,m: through re· \eJn:h utilization. It is intended to pro,·ide guidance for m,r~es and othc:r~ in making 1.kcisiom ahout prJcti.:c that .1ffrct~ pJticnt outcrnne~. The Iowa Modd in..:orpomtc::s st.trting point~, which .ue nursing; problems th.1t .1re termed "trigger!,," It continue\
264 Unit II Nursing Theories
Box 12-4 Research Based on the Advaincing Research and Clinical Practice Through Close Collaboration Model of Evidence-Based Practice
Honrohon, K., Wogner, M., Matthews, G., Stewart, S., Dowson, C., Greiner, J., et ol. (2015). Socred cow gone to posture: A systematic evoluotion ond integra- tion of evidence-based practice. Worldviews on Evidence-Based Nursing, 1211). 3-11.
Kim, S. C., Stichler, J., Ecoff, l., Brown, C., Gallo, A.-M., & Davidson, J. (20161. Predic- tors of evidence-based practice implementation, job satisfaction, ond group cohesion omong regional fellowship program porticiponts. Worldviews on Evidence-Based Nursing, I 3(51, 340-348.
Thorsteinsson, H. S. (2013). Icelandic nurses' beliefs, skills, and resources associated with evidence-based practice and related factors: A notional survey. Worldviews on Evidence-Based Nursing, 10(2), 116-126.
Underhill, M., Roper, K., Siefert, M . l., Boucher, J., & Berry, D. (2015]. Evidence-based practice beliefs and implementation before and ofter on initiative to promote evidence-based nursing in on om bulotory oncology setting. Worldviews on Evidence-Based Nursing, 12(2], 70-78.
through multiple d1.·c.:i~ion point~ .md tct'db,Kk loops ro prrn·idc for c,·.1luatiu11 of am changt'!> (Titler ct al., 2001).
The modd lu~ been n:tincd oYcr time to prod u.:c th1.: c.:u1..-ent iter.ttion I T itler, 100-t, 20 I-+ 1. The diagram of the mndd sho\\·s the ~tarting points, 1..kc.:ision poinrs, ,llld tcedba.:k loop~. \\'hen impk1m:ntcd, it \\'ill .l~~i~t in pro\'iding (!Lt.tlity c.:.trc to cli- 1.·ms ot' dini.:s, honw he.11th ,1gcn.:ies, .rnd hmpiral~ ( Titkr ct al., 2001 l ( figure 12-3 l. The lm,·,1 ,\ \odd i~ \'Cry dct.1ilcd and spec.:itic.: .111d lu~ been applicd to ,ldLire~~ ., number of dini.:.u topic.:~. Ir i~ .1lso one of the best rcse.1rc.:hcd EBP modeb. Bux 12-5 ~how~ some of till' rcc.:enr re~e."U"ch studie~ thar h.1,·e used th,.: Imn model.
The Johns Hopkins Nursing Evidence-Based Practice Model Thl" JHNEBP f\lodd \\'.lS dcvclop1.·d to a.:cder.lte the rransti:r ufre~earc.:h to pr.ic.:ri.:e .md to promotc nur": ,llltonomy, leader~hip, .rnd eng,1gcmcm wirh interdi~c.:iplin.uy
Box 12-5 Research Based on the Iowa Model of Evidence-Based Practice to Promote Quality Care
Bonkheod, S., Chong, K., & Kamai, S. (2014). Preventing extubotion failures in a pedi- atric intensive core unit. The Nursing Clinics of North America, 49(2), 321-328.
Brown, C. G. (2014).The Iowa model of evidence-based practice la provide quolity core: An illustrated exomple in oncology nursing. Clinical Journal of Oncology Nursing, I 812), 157-159.
Estus, K. (2014] , Cancer survivorship using IM & EBP to pro mole quality of core. Clinical Nurse Specialist, 28(3), 173-17 4.
Turenne, J. P. , Heon, M., Aita, M., Faessler, J., & Doddridge, C. (2016). Educational intervention far on evidence-based nursing practice of skin to skin contact at birth. The Journal of Perino/of Education, 2512], 116-128. doi: 10.1891/1058-1243 .25.2.116
White, S., & Spruce, L. (2015). Perioperolive nursing leaders implement clinical prac- tice guidelines using the Iowa model of evidence-based practice. AORN Journal, 102(1). 51-56. doi:10.1016/j.oorn.2015.04.001
Chapter 12 Evidence-Bosed Proctice and Nursing Theory
The Iowa Model of Evidence-Based Practice to Promote Quality Care
Problem-FocuNd Trlggen 1. Risk management data 2. Process improvement data 3. Internal/external benchmarking data 4. Ftnanaal data
Knowledp-FocueN Triggers 1 New research or Olller ffterature 2. NallOnal agencies or organizallOnal
standaras and guidehnes 3. Pllllosophies of care
265
5. Identification of cllnlCal problem 4. Questions from 1nsbtubonal S1andards COIT1ll1ltlee
Consider otner
tnggers
No
Assemble relevant research and relaled literature
Cntique and synthesize research for use ,n practice
Yes
PIiot the Change In Practice 1. Select outcomes to be achieved 2 . Colleel baseline data 3. Design evldence-l>aMd
pradlce (EBP) guldeltne(sl 4. Implement EBP on pilot Uruls 5. E1181uate process and OU1oomes 6 Modify ltle practice guldeline
No
8-PrKtlceonOlhel-lypaa olE~: 1. Cue reports 2 Expert opllllOn 3. Scientific principles 4. Theory
Conduct research
Conltnue to evaluate quality of care and new knowledge Institute the change in practice
= a decision point
Monitor and Analyze S1Ncture. iar-. and Outcome Data • Emnronment
~ o_,s_s_e_m_m_a_te_ r_e_su_n_s__,~----...... ,Staff • Cost • Patient and family
Figure 12-3 Diagram af the Iowa model of evidence-based practice. !Repnnred wilh permission from Uni.-ersily of Iowa Hospilals and Clinics. © 1998 For permission 10 use or reproduce 1he model please contacl Un,versiry of Iowa Ho~ilols ond Clime. at 319-384-9098 J
266 Unit II Nursing Theories
.:olleagucs ( De.1rholt & Dang, 2012 ). The JHNEBP i\lndd ,Y,1~ dc~igned .v .. a probkm-sol\'ing J.pproa.:h to dinic.al decision making. It .:ombincs t·lcnu:nt!> of the nursing prrn:..:~s, the .'\.meri.:an :\'urst:~ :\sso.:i.ition's St.rndards of Pr:1.:ti.:e, criti- cal thinking, .md research utiliz.1tion processes ( Dearholt, 2012; Ne\\'house ,et al., 2007). The mudd ha~ numerous lcn:b of ,KtiYity, but it is based on practical teach- ing pro.:es~e~ to promote me by no,·ice nurses .1~ \\'dl as mor<:: o:p.:ric:nccd nurs<::~.
The fHNEBP pro.:css is ba~ni on three .:on: clemcnts: J. pra<::,tic..: qu<:stion, e,·i· dence, and traml.uion LPET) \De.uholt, 2012; Newhouse ct al., 20071. A~ prc~enred in Box 12-6, 18 step~ .1re included in the model. As shown, e.1.:h of the PET phase~ is based on sen:ral steps tlut cbrit\ how the proc..:sscs .1r..: to pro.:ccd.
Thi~ method begins with .m EB!' question, follo\\'ing the PICOT fon11.1t. The fin,t step is to g.encrate an ,1tlS\\'t'l',1bk practice question \l'bich indude~ the P.1tient, population, and the problem. It grn:~ on to define .m lnten·cntion, nukes .1 Com· p.1riso11 "·ith other trc.ltlm:nts if pos~iblc, and finally defines the de~ircd Out..:o me and the Time t,1hk (PICOT) / Dcarholt, 2012; Elias, Polancich, Jones, & C:uh·in, 2015 J. Other st..:p~ in the "practic..: question" phase include defining the scope of the question .md idrnti~·ing. stakeholder~ .. as~ig:ning. responsibility for project leadership, r..:.:ruiting. a te.1m, and ~cheduling .1 meeting.
In the ..:,·idcn.:c phase, the t<::.1111 conducts inten1.1I .md external ~c.1rche.s fr1r c,·. idcncc; thi~ include~ comprchcmiYe literature ~eard1c~ .. --\ppraisal of the le,-cl ~md
Box 12-6 Steps of the Johns Hopkins Nursing Evidence-Based Practice Model
Practice Question 1. Recruit interprofessional team. 2. Develop and refine the evidence-based practice (EBPJ question. (Apply PICO elements.) 3. Define the scope of the EBP question and identify stakeholders. 4. Determine responsibility far project leadership. 5. Schedule teom meetings.
Evidence 6. Conduct internal and external search far evidence. 7. Appraise the level and qualiiy of each piece of evidence. 8. Summarize the individual evidence. 9. Synthesize overall strength and quality of evidence.
10. Develop recommendations far change based on evidence synthesis.
Translation l 1. Determine fit, feasibility, ond appropriateness of recommendation far translotian
pathway. 12. Create action plan. 13. Secure support and resources ta implement octian plan. 14. Implement action plan. 15. Evaluate outcomes. 16. Report outcomes to stakeholders. 17. Identify next steps. 18. Disseminate findings.
Source· Deorholt (2012, pp. 33-53) .
Chapter 12 Evidence-Based Practice ond Nursing Theory 267
quality of the cvidern:e follows, .111d the c,·idem·e is ~ummarized. This ph.,sc:: con- cludes with .1 synthc~is of the overall strength .i.nd qu.1l ity of the e\'idenn: leading to recommendations for ch.rnge ( De.irholt.2012).
In the rhird phase, tr.rn!>lation, the t.c,un decides wheth~·r or not .111d how to im- plement thi: changes. Thi., in\'oh·cs determining tht" fit, ti:.i.sibility, .ind appropriatc::nes!> nfthc rt"commcndatiom,, hefon: creating .111 ,Ktion plan. Support .rnd rl'!>ource~ arc ~e- nm:d, .md the .i.ction plan is implemented .rnd ev.llu.ucd. The m1tcomc~ Jrl." reported to st.1kcholder~ .rnJ "next steps" arc identified, and the finding:, .m;: dis~cmin.1tcd to .i.ppropri.ltl' indi,·idu.11.~ or groups ( De.uholt, 2012 ). The JHNEBP Modd is ckarly npl.lined ;md simple to .1pply. Related writing~ include the guidelines .rnd dcfinitiom of the background, l.'kmcnt~ of the prm:cs~, .rnd th~· step~ of the modd ( Dcarholt & Dang, 2012; Nc\\'hous~· ct al., 2007 ). L.itd~-. Eli.1, ~·t ,\I. ( 2015) haw .1dded ,1 "D'' to the PICOT method to denote "digit.11 d.ua" compo111:nts. Thi!> t.1kl'.':, into .1ccount the factor of the current digit.11 record!> .ind sy,tem~ .:h.1111,te!> in the patil."nt c.1re industn-.
Stetler Model of Evidence-Based Practice The Stetler i\·\odd \\':lS initiated in the 1970s ,\l> .1 4uality imprm·cment ! QI I dlixt employing the rese.irch utiliz.1rion ( RU J ideab then in widespread USl." ( Mdnyk & rineout-Ovcrholt, 20151. Over time .mJ through !>CVer.ll iter.1tions, Stetler up- dated the approach .111d d.1rih~·d tlw ~eric~ of pl1Jsc, of the modd ~uch that it i~ re.1dily impkmcnrcd by practicing nurse~ .rnd useful ,\t the he~bidl'.' ( Stetler, R.it.:hic, Ry.:roti:-Malonc, Sdmltz, & Clum,, 2007 \. Stl."tkr .rnd ~·olk.1gul.'s ( I 998 l .rnd Stetler .md C.1r.1111.1nic.1 (2007) .ugul'.'d that .111 rl."sc,uch ~mdil'.'~ .m:· not ready for use at the bt'dsidc. Furthl'nnorc, they explained th.it altcrn.ni,·e sourc<:s of l'vidcncc .1rc ne.:e~- ~ary to fill thi.: g.ips in nursing re,e.1rch evidence.
The current Stetkr Model of EB P is similar to the nur~ing procc~,; therefore, it i~ e.i~ily J\\itnil.ltcd by pr.Kticing bnhide nun..:~. The pha,c, of the Jpprn.1ch indudc prcpa· r.1tion, validation, comp.irativc cv.1.luation/dccision making, tr,111sl.1tio11/.1pplicatinn, .md c,·alu.uion. It provides pr.ictitioncr~ with ~tcpwise direction, for intcgr.1ting re!>carch into pr.icticc. Sl."e T.1ble 12-1 for dc~cription of the ph.1sc,. The Stetler .\loJd incorvor.1.te, fi,·e ,rep~ to genl."rate .1 process rh.1t t.1kcs into :ll'l'Ollnt the n1.111y other facets of nur.;ing Jnd the clinical situ.1tion prior to using rl."s1.·,1rch findings in the nurse'~ dinic.1I pr.il-tice. \Vhcn impleml."ntcd, the rl."sult~ ~hould bl' s~·~temati.:ally cv;1lu.1tni to tra.-k go.11-oriented our~·oml.", .ind prot1cr both form.ui,e and ,umniati,·l-" l·,·.1lu.1tion ~tr.1.tegie!>. Thi'.' major outcorm·~ ofRl1 or EBP i.hould be improved patient rc,lilt~ a,, \H:11 ,\!> enh.mccJ proks- -.im1.1I practi..:e (Stctla & C.iramanica, 2007).
Theoretical Models: A Summary The fi,·c F.BP modcb dc5cribcd Jbm·c .ire i.:omp.trcd in T.ibk 12-2 ming the ti.lllowing i.:rit~·ria:
Groups of he.ii th .-.m: profcssiniul, .1fti.·acd ( groups affri.:tcd) Ein-ironmcnt.1I fa.-ton, in whid1 the modd i, useful I cm·ironment) Analysis of rhc model ( analysis J Implementation: barriers/facilitators ( i111plemcnt.1tio11 I E\',1luation of dfr..:tiwne~~ identified by the model e\'alu.ttion)
As shown, thcrl'.' .1re .1 number of ~imihritks .1mong. the modeb. Schaffter .rnd colle.igues ( 20 I 3) recently compiled a re,·icw of model~ for organiz.1tional ch.mge bas~·d on F.BP. Simil.1r to wh~H l1.1~ been presented here, their on:r.·icw cx.1111int.'d th..:
268 Unit II Nursing Theories
Table 1 2-l Phases of the Stetler Model Phase Content Actions
Preparation (purpose, control, ond • Define potential issues sources of research evidence) • Seek sources of research evidence • Perceive problems • Focus on high-priority issues • Decide on need for o team • Consider other influential factors • Define desired outcomes • Seek systemolic reviews • Determine need for explicit research evidence • Select research sources with conceptual fit
II Validation (credibility of findings • Credibility of findings and potential for/detailed qualifiers • Critique and synthesize resources of application) • Critique systematic reviews
• Reassess fil of individuol sources • Rote the level ond quolity of evidence • Differentiate stotisticol and clinical significance • Eliminate nancredible sources • End the process ii there is no evidence or clearly insufficient credible reseorch evidence
111 Comparative evaluation/decision • Synthesize the cumulative findings making (synthesis and decisions/ • Evaluate the degree and nature of other criteria recommendations for criteria of • Make o decision whether/what to use applicability) • If decide to "not use," STOP use of the model • If decide to use, determine recommendations for a specific
practice
IV T ronslotion/ application (operotionol • Types definition of use/actions for change) • Methods • Levels • Direct instrumental use • Cognitive use • Symbolic use • Coution: Assess whether translation/product or use goes
beyond octuol findings/evidence • Formal dissemination and change strotegies should be
• planned per relevant research Consider need for appropriate reasoned variation
V Evaluation (alternative types of • Evoluotion con be lormol or informal, individual or insliMionol evaluation) • Consider cost-benefit of evaluation efforts • Use RU os a process to enhance credibility of evoluotion data • For both dynamic and pilot evaluations include two types of
evaluative information
From Steller, C. B. 12001 ). Updating the Stetler model of research utilization to focilitote ev,dence-bosed proc~ce. Nursing Ovtloolc, 49(61, 272-279 From figure JB. Stetler Model Port II: Additional, per phase details.
k,4.•y t~atures of six modds with the vkw to chang:c practice in organizations. ,\ lost of the mndcls incorporate rhc ~tcps of the research procc~~ in M>mc \\'ay, ,md .1U the mod- eb ,1rc focw,cd on bringing the best in safi: .rnJ dkcri\·c mm,ing c.ire to their major focu~: the pJticnt, or recipient of mm,ing c,uc. '.':ur-,c, who .m: actin::ly cng.1ged in promoting EBP arc encouraged to rc\'icw these ,1s \\·di ,ls otha published 11101.kls ,md to select the one th,lt best fit~ their necds and desired outcomes.
Chapter 12 Evidence-Based Practice and Nursing Theory 269
Table 1 2-2 Comparison of Selected Models of Evidence-Based Practice
Models of Evidence-Based Practice
Comparison ACE Stor Johns Hopkins Element Model ARCC Model lowo Model Model Stetler Model
Groups of Instructors, Advanced Instructors, students, Practicing Practicing health core students, practice nurses, practicing nurses nurses nurses or professionals practicing practicing groups of (users) nurses nurses nurses
Environmental Learning Patient core Nursing schools and Learning Clinical factors in environments, organizations patient core agencies environments, situations which the hospitals hospitals model is useful (environment)
Analysis of the Five major Five constructs Six steps of the model: PET (see Five phases: model (analysis) points similar with similarity to Identify knowledge Figure 3-3, (I) Preparation
Implementation: barriers/ facilitators limplementotian)
Evaluation of the effectiveness of the model [evaluation)
to the nursing nursing process or problem-focused p. 42) steps ore (II) Validation process triggers {catalysts to the basis for the 1111) Comparative
critical thinking]. model. evaluation/ Priority: orgonizotionol Team approach decision making Form a teom lo answer (IV} Translation/ responsible for devel- Practice ques- application opment, lions, critique {V) Evaluation lion, and evaluation Evidence, and of EBP Translate it into
usable form
Implementation Implementation Determine sufficiency Team deter- Translation and into practice is is based on al evidence. mines feosibil- application is the fifth stage the mentor's If yes: Pilot recom- ity and creoles the fourth step. and involves determination al mended change. on action pion bringing organizational to implement evidence to readiness. the change. clinical decision making.
Evaluation is Evaluation is the Evaluate pilot success Evaluate Evaluation is the the final stage fifth of the con- and disseminate re- outcomes. lost step !Stetler and focuses structs and hos suits; implement into Report 2001). on verification three levels that practice (Titler et al., outcomes to of the success provide feed- 2001). stakeholders. EBP (Stevens, bock (Melnyk & Identify next 2005). Fineout-Overholt, steps (Deorholt,
2002) 2012, p. 51).
Hdcn, the nur~e from the opening .:.1Sl' ~tudy, ..:ondu.:rcd a system.1tk rc:\'ic\\' of lll'uromw,rnlar illnesse~ .rnd m.111.1g;cml'nr proto..:ols t1\ing the Iow.1 ,\ !Dd..:I of EB P. During thi~ pro..:,:~~ .md ,,·hik working with the 1.:lini..:al tc.un, ~hc ..:.ime m bcm:r undl'l"\tand her illncs~ .ind the tro:.ltllll'nt~ th.it ,niuld mo~t likd~· forc,r.111 dcto:riorJ - tion of her condition. Thc compkxi ty Jnd high k,·d of information ,he ,KcunllllJtcd throug:h ha re,·i,:w of the re~e.1r.:h guided by tl,~·orie~ of EBP brought Heh:n to ,I
kvcl ofpr,1..:ti..:c where ~hc could not only hdp hcr~dfbut .1lso her p.1ticnts ,md dicnt~. follo\\ing gradu.1tion, ~he b.,,l·d hcr dini..:.il practi..:e on the expertise ~he h,1d g,1incd through h.:r extcn~in: ~tudy ofrhc n:~l·ar.:h .rnd prJl."til-e in lll'llromu~cul.u di~l·J,.:s.
270 Unit II Nursing Theor ies
Summary There is lirtk doubt that EBP lu!> hl·come one of the kl'Y tenets of qualitY nursing caa·. A~ dcsrribed, hm,·tTcr, it is critic.ii to rt'ml·mbi.: r th.1t EBP must ~o be\'ond re- si.:.1rd1 per se .rnd t'mph.isis on R( :T but must also be theon· b.1~ed. J\fan~-.wtl~ors hJ, c \\'rittcn .1bout rhe problems and b.11-rias to EBP, .md oth~r~ ban: writ~en on how to strengthen the proce~~ .md m.1ke it n:kYant to practicing nurs1:s.
On:r the I.1st dec.1dc, J number of models h.1n: been constrw:ted ro assist nurses to learn how to proceed in the dcn·lopmem of e,·idencc-bascd guidelines and pro- motion of EB P, .1s illustrated lw the work of Helen in rhe c.1sc ,tudv. T he TI\'C 111udcb de~crib,:d here, along with .1 m;mber of other~ th.a haYc been ment.ioned in the nurs- ing. literature, gin: nurses inforrn,ltion .1bout the ~teps Jnd processes necessary to elicit the e,·idcnce that is needed to proYidc ~ate intcrYentiom that arc dtcctiYc in nursing practi..:c. Nurses " ·ho ~eek to use tested and publi~hed n·idcncc in their dinical .1reas .ire ,ld.\'ised to ~eek t>llt .1 ,,·orking model of EBP .ind follow it through to ctkct rea- sonable:, s.1k, .rnd cffrctiv..: changes for the benetit of their patients or dients.
Key Points Rcse.uch, theory, and pracricc .ire irm:grntcd in nursing; EBP is a key clement .md outcome of that linkage. EBP is an .1ppro.1..:h to problem soh-ing. rh.n u,c, the current best e,·idcncc in the care of patients. In nursing., EBP h.i~ been ddined a~ "'the conscientious, explicit, .111d judkious use of theor~·-deri\'ed, research- based inform.itinn in nuking decisions .,bout care 1.kli,·cry ... in consideration of indi,·idu.11 needs and preference~." Nursing. .1s .1 profession has hccn rclati,·cl~• sin\\' to incorporate EB!'; thi~ has changed in recent ~·cars. S0111..: nurses .11-c concerned that too mud, .1m:ntio11 to ERP will dr.1\1' .Htt:ntion .1way from the ,\rt of nur~ing carc-thJt mrr~ing. \\'ill be..:orn..: lost in the science. l\1odc:ls of EBP h.1,·..: dc,·eloped from early studies of rcse.u-ch utilization and quality impro,·ement . .MJny of these model~ hJ,·e been de,·cloped \\'ith the impe- rus ofhospirals or 1.·ducational institutium' support. The m.i.jor impetLI.~ for integration ,md implementation of rcsean:h e,·idcn..:e- g.uided by EBP-should be rcason.1ble, t:ftt:cti\'.:, Jnd safr c.1rc for p.1tients.
Learnin Activities
l. Similar to the process used by Helen, the nurse in the opening case study, select one model of EBP presented. Using your current clinical setting and a practice problem you hove noticed, determine what you would do to institute EBP into your current practice to address the problem.
2. Compare and contrast two EBP models and write a blog on wh ich would most likely work in your agency or cl inical unit. Explain why one model would work better than the other with your colleagues or your organizational culture.
3. Prepore a proposal for practice chonge in your agency or clinical unit using one of the models given iin this chapter. Use as many of the steps of the model as possible and project the outcom,es for the remaining steps.
Chapter 12 Evidence-Based Practice and Nursing Theory 271
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,\lclm·k, B. M., & fincout -(kcrholt, l-, 1201 l 1. Alak111i; the , ,i>c !i,r c~idcm,:i.::-ha~d pr.lLtkc .md LtilrivJtin~ J ~ririt (11° mquir\'. rn H. ,\\. ,\ld,wk & E. h ncout-0,erhnkl I F.d, 1, Ei·11imc,-/,n;,-,i prnc- t1u m 1wr11u .. 11 \;'"' hrnl tlm1rr: A ~""idf tn b<!I prnctut' i :?n<l ed.~ pp. 3-24 1. r hiladcl11hi.1, !' . .>... I J)1pm,11tt l\'illiam, & l\'ilkin,.
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