Class 1 DQ 1 Spring 2022

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Introducing evidence into nursing practice: using the IOWA model

Ms Catriona M Doody is Registered Intellectual Disability Nurse, Daughters of Charity Service, Ireland and Mr Owen Doody is Lecturer, Department of Nursing and Midwifery, University of Limerick, Ireland

Accepted for publication: May 2011

E vidence-based practice has gained increasing popularity since its introduction in the latter part of the twentieth century, aspiring to

be a dominant theme of practice, policy, management and education within health services across the world (Rycroft-Malone et al, 2004; Ryan et al, 2006). Nurses are urged to use up-to-date research evidence to deliver the best possible care (Haynes et al, 1996; Barnsteiner and Prevost, 2002; LoBiondo- Wood and Haber, 2006). Research-based practice has better patient outcomes than routine, procedural nursing care (Heater et al, 1988; Thomas, 1999) and informs nursing decisions, actions and interactions with patients. Nurses in practice are increasingly challenged by patients and healthcare organizations to provide clearly measurable care of the highest quality (Holleman et al, 2006).

Decision making in health care has changed dramatically, with nurses expected to make choices based on the best available evidence and continually review them as new evidence comes to light (Pearson et al, 2007). Evidence-based practice involves the use of reliable, explicit and judicious evidence to make decisions about the care of individual patients (Sackett et al, 1996), combining the results of well-designed research, clinical expertise, patient concerns and patient preferences (Sackett et al, 1996; Flemming et al, 1997;Grol and Grimshaw, 1999; Holleman et al, 2006). A major criticism of evidence-based practice is the lack of available evidence or inconclusive research. While a lack of evidence can be perceived as a barrier, it should be recognized that the need to base practice on evidence has only become a concern for health professionals relatively recently (Pearson et al, 2007). Although the dtive for evidence-based practice has gained momentum, it is still dependent on the nurse’s ability to gather and appraise the evidence on which they base their care.

The results of well-designed research provide an obvious source of evidence but these are by no means the only data used in everyday practice (Pearson et al, 2007). The limitations of research conducted became

use of research, along with other types of evidence (Titler et al, 2001). Since its origin in 1994, it has been continually referenced in nursing journal articles and extensively used in clinical research programmes (LoBiondo- Wood and Haber, 2006). This model allows us to focus on knowledge and problem-focused triggers, leading staff to question current nursing practices and whether care can be improved through the use of current research findings (Titler, 2006). In using the Iowa model, there are seven steps to follow. These are outlined in Figure 1.

Step 1: Selection of a topic In selecting a topic for evidence-based practice, several factors need to be considered. These include the priority and magnitude of the problem, its application to all areas of practice, its contribution to improving care, the availability of data and evidence in the problem area, the multidisciplinary nature of the problem, and the commitment of staff.

Catriona M Doody, Owen Doody

Abstract Evidence-based practice has gained increasing popularity in all healthcare settings. Nurses are urged to use up-to-date research evidence to ensure better patient outcomes and inform decisions, actions and interactions with patients, to deliver the best possible care. Within the practice setting, there is an increasing challenge to provide clearly measurable care of the highest quality, which is evidence-based. In order for nurses to operate from an evidence-based perspective, they need to be aware of how to introduce, develop and evaluate evidence-based practice. This article presents how evidence may be introduced into practice using the Iowa model, offering practical advice and explanation of the issues concerning nurses in practice.

Key Words: Evidence based practice n Nursing n IOWA model

obvious when the nursing profession began to adopt an evidence-based model. Biomedical knowledge alone is inadequate for the practice of nursing. A holistic approach is necessitated, which acknowledges all aspects of people while also understanding their experiences (Pearson et al, 2007).

All knowledge and information used to make decisions can be referred to as evidence; however, the validity of this evidence may be variable. There is no necessary relationship between quantity and quality, nor between either of these and evidence usage (Newell and Burnard, 2006). Therefore, nurses must take into account the quality of evidence, assessing the degree to which it meets the four principles of feasibility, appropriateness, meaningfulness and effectiveness (National Institute for Health and Clinical Excellence, 2003; Gagan and Hewitt-Taylor, 2004; Pearson et al, 2007). In order for nurses to operate in an evidence-based manner, they need to be aware of how to introduce, develop and evaluate evidence-based practice. This article presents how evidence may be introduced into practice using the Iowa model, offering practical advice and explanation of the issues concerning nurses in practice.

Process of introducing Evidence- based practice The Iowa model focuses on organization and collaboration incorporating conduct and

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Professional focus

Step 2: Forming a team The team is responsible for development, implementation, and evaluation (LoBiondo- Wood and Haber, 2006). The composition of the team should be directed by the chosen topic and include all interested stakeholders. The process of changing a specific area of practice will be assisted by specialist staff team members, who can provide input and support, and discuss the practicality of guideline implementation (Frost et al, 2003; Gagan and Hewitt-Taylor, 2004). A bottom-up approach to implementing evidence-based practice is essential as change is more successful when initiated by frontline practitioners, rather than imposed by management (Gough, 2001). Staff support is also important. Junior staff require support from senior staff to effect change, as senior members or institutions often impede junior members from implementing evidence-based practice (Bhandari et al, 2003). Without the necessary resources and managerial involvement, the team will not feel they have the authority to change care or the support from their organization to implement the change in practice (Feasey and Fox, 2001).

To develop evidence-based practice at unit level, the team should draw up written policies, procedures and guidelines that are evidence based (LoBiondo-Wood and Haber, 2006). Interaction should take place between the organization’s direct care providers and

management such as nurse managers, to support these changes (Retsas, 2000; Nagy et al, 2001; Berwick, 2003; LoBiondo-Wood and Haber, 2006). As social and organizational factors interfere with the application of research findings, they need to be identified and addressed prior to the development of evidence based practice or application of an evidence based practice initiative to other practice areas within the organisation. The factors identified within the literature include workload, support of management and colleagues, level of education, experience of research, lack of exposure to research, lack of training in research use, preference for practice wisdom rather than research evidence, time availability, accessibility to research, champion to assist efforts, organisation support to use and conduct research (Gerrish and Clayton, 2004; Brown et al, 2009). Nurses or management may perceive task performance as a more justifiable use of time than seeking evidence for action or designing guidelines for existing practice (Gagan and Hewitt-Taylor, 2004; Pearson et al, 2007).

Step 3: Evidence retrieval From the team formation and topic selection, a brainstorming session should be held to identify available sources and key terms to guide the search for evidence. Evidence should be retrieved through electronic databases such as Cinahl, Medline, Cochrane, Web of

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Science and Blackwell Synergy, utilizing key terms. Other sources of evidence such as the National Institute of Health and Clinical Excellence (NICE) and Quality Improvement and Innovation Partnership (QIIP) should be consulted with regards to relevant care standards and guidelines.

Step 4: Grading the evidence To grade the evidence, the team will address quality areas of the individual research and the strength of the body of evidence overall. There is a tendency to classify research as quantitative or qualitative. Qualitative data is collected in order to derive understanding of phenomena from a subjective perspective. The focus is on description, understanding, and empowerment. The theory is developed based on inductive reasoning, and is grounded in reality as it is perceived and experienced by the participants involved. Conversely, quantitative data is based on the process of deduction, hypothesis testing and objective methods in order to control phenomena with its focus on theory testing and prediction.

The relative merits of both of these forms of data are the subject of much heated debate. On one hand, qualitative methods are seen to most certainly increase understanding but they are often criticized as being biased, subjected to the question, ‘Well, now that we understand, so what?’ (Pearson et al, 2007). On the other hand, quantitative methods are seen to give an apparently unbiased, objective picture of a situation or phenomenon, but they are often criticized as being ‘only half the story’ or of being overly concerned with numbers and statistics (Pearson et al, 2007). Central to the debate however, must be the paradigmatic stance from which the researcher works, and the stance from which the consumer of research reads. As long as the method is consistent with, or true to, the paradigm that underpins the research, and is the appropriate method to address the research question, in theory the debate becomes redundant. However, the debate still continues to rage largely because of deeply entrenched allegiances to a particular paradigm.

The research question influences the research methodology, which influences the way in which data is collected and analysed, as the methods are also dependent on the methodology adopted. Table 1 identifies a range of methodological approaches, which are consistent with the philosophical view of knowledge embodied in each paradigm and may guide staff in the appraisal of evidence.

1. Selection of a Topic

2. Forming a Team

3. Evidence retrieval

4. Grading the Evidence

6. Implement the EBP

7. Evaluation

5. Developing an EBP

Standard

Figure 1. Seven steps of the IOWA model

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Review protocols are vital to ensuring practices are based on the most current research evidence. Criteria should be set for retrieval of the evidence so each team member identifies areas for grading and grading criteria sheets should be given to each staff member to complete on relevant studies. Addressing areas of effectiveness, appropriateness and feasibility, Table 2 highlights the areas and criteria involved. A three-tier grading system can be used: A. Strong support that merits application, B. Moderate support that merits application, C. Not supported (Joanna Briggs Institute, 2008).

Step 5: Developing an Evidence- Based Practice (EBP) standard After a critique of the literature, team members come together to set recommendations for practice. The type and strength of evidence used in practice needs to be clear (LoBiondo- Wood and Haber, 2006) and based in the consistency of replicated studies. The design of the studies and recommendations made should be based on identifiable benefits and risks to the patients. This sets the standard of practice guidelines, assessments, actions, and treatment as required. These will be based on the group decision, considering the relevance for practice, its feasibility, appropriateness, meaningfulness, and effectiveness for practice (Pearson et al, 2007). To support evidence-based practice, guidelines should be devised for the patient group, health screening issues addressed, and policy and procedural guidelines devised highlighting frequency and areas of screening. Evidence-based practice is ideally a patient- centred approach, which when implemented is highly individualized. However, poor implementation has the potential to give rise to ‘cookbook care’ where clinical guidelines are used simply as a recipe for healthcare delivery without due consideration for the individual patient (Pearson et al, 2007). Any practice failing to consider the preferences of the individual patient is not evidence-based, so a partnership approach is needed which takes into account patient autonomy, choice and preference to be expressed (van Hooren et al, 2002).

Step 6: Implementing EPB For implementation to occur, aspects such as written policy, procedures and guidelines that are evidence based need to be considered (LoBiondo-Wood and Haber, 2006). There needs to be a direct interaction between the direct care providers, the organization, and its leadership roles (eg. nurse managers) to

support these changes (Retsas, 2000; Nagy et al. 2001; Berwick 2003; LoBiondo-Wood and Haber, 2006). The evidence also needs to be diffused and should focus on its strengths and perceived benefits (Berwick, 2003; Rogers, 2003), including the manner in which it is communicated (Rogers, 1995; Titler and Everelt, 2001). This can be achieved through in-service education, audit and feedback provided by team members (Jamtvedt et al,

2004; Titler, 2004). Social and organizational factors can affect implementation and there needs to be support and value placed on the integration of evidence into practice and the application of research findings (Gagan and Hewitt-Taylor, 2004; Pearson et al, 2007).

Step 7: Evaluation Evaluation is essential to seeing the value and contribution of the evidence into practice. A

Table 1. Paradigms, methodologies and methods for research studies (Pearson et al, 2007)

Positivist paradigm Randomized controlled trials Methods that measure outcomes such as temperature, blood pressure, and attitudes Cohort studies Methods that measure outcomes (as above) Case series studies Methods that measure outcomes (as above) Time series studies Methods that measure outcomes (as above)

Interpretive paradigm Phenomenology Interviews Historiography Textual analysis; interviews Participant observation; interviews of key informants Ethnography Textual analysis; interviews Participant observation; interviews of key informants Grounded theory Participant observation; interviews

Critical paradigm Action research Participative group interaction; observation; interviews Feminist research Participative group interaction; observation; interviews

Paradigm Methodology Method

Table 2. Grading criteria

Effectiveness Relates to whether the intervention • Does the intervention work? achieves the intended outcomes. • What are the benefits and harm? • Who will benefit from its use?

Appropriateness Concerned more with the psychosocial • What is the experience of the aspects of care than with the consumer? physiological. • What health issues are important to the consumer? • Does the consumer view the outcomes as beneficial?

Feasibility Addresses the broader environment • What resources are required for in which the intervention is situated the intervention to be successfully and involves determining whether implemented? the intervention can and should be • Will it be accepted and used by implemented. healthcare workers? This focus acknowledges that the • How should it be implemented? process of intentional change in large • What are the economic organizations is very complex. implications of using the intervention?

Area Concern Criteria

Professional focus

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baseline of the data before implementation would benefit, as it would show how the evidence has contributed to patient care. Audit and feedback through the process of implementation should be conducted (Thomson O Brien et al, 2003; Jamtvedt et al, 2004) and success will not be achieved without support from frontline leaders and the organization (Baggs and Mick, 2000; Carr and Schott, 2002; Stetler, 2003). Evaluation will highlight the programme’s impact but its consistency can only be assessed against an actual change occurring and having the desired effect (Pearson et al, 2007). For any change to take place, barriers that could hinder its progress need to be identified. Information and skill deficit are common barriers to evidence-based practice. A lack of knowledge regarding the indications and contraindications, current recommendations, and guidelines or results of research, has the potential to cause nurses to feel they do not have sufficient training, skill or expertise to implement the change (Pearson et al, 2007). Lack of awareness of evidence will inhibit its translation into practice (Scullion, 2002). A useful method for identifying perceived barriers is the use of a force field analysis conducted by the team leader. Impact evaluation, which relates to the immediate effect of the intervention, should be carried out (Naidoo and Wills, 2002). However, some benefits may only become apparent after a considerable period of time. This is known as the sleep effect. On the contrary, the back-sliding effect could also occur where the intervention has a more or less immediate effect, which decreases over time. If we evaluate too late, we will miss measuring the immediate impact. Even if we do observe the early effect, we cannot assume it will last (Green, 1977; Nutbeam, 1998). Therefore, evaluation should be carried out at different periods during and following the intervention.

Conclusion The effectiveness of clinical care and treatment is central to the quality of health care (Thompson, 2000) and providing a high quality care based on best practice is the responsibility of nurses. In many clinical settings, nurses are

under increased time pressure and evidence- based practice may fail, having a low priority among competing duties (Lawrie et al, 2000; Bhandari et al, 2003; Frost et al, 2003; Thomas et al, 2003). Quality improvement is often seen as an additional task to an already busy workload (Long, 2003). However, it may be that nurses perceive activity to be a more worthy use of time than seeking evidence upon which to act (Gagan and Hewitt- Taylor, 2004). For evidence-based practice to be implemented, this value system and the norms that lead to it need to be addressed as a priority, and this is the responsibility of each practitioner in any given situation (Gagan and Hewitt-Taylor, 2004). As the largest group providing care to patients and having the most contact with them, nurses have the opportunity to influence the course of their illness and recovery. If care is not evidence- based, the potential of harm increases (Newell and Burnard, 2006). Therefore, nurses must actively engage in reading, critiquing and grading the evidence to continually challenge the practice.

Baggs JG, Mick DJ (2000) Collaboration: a tool addressing ethical issues for elderly patients near the end of life in intensive care units. J Gerontol Nurs 26(9): 41–7

Barnsteiner J, Prevost S (2002) How to implement evidence- based practice. Reflect Nurs Leadersh 28(2): 18–21

Berwick DM (2003) Disseminating innovations in health care. JAMA 289(15): 1969–75

Bhandari M, Montori V, Devereaux PJ, Dosanjh S, Sprague S, Guyatt GH (2003) Challenges to the practice of evidence-based medicine during residents surgical training: a qualitative study using grounded theory.Acad Med 78(11): 1183–90

Brown CE, Wickline MA, Ecoff L, Glaser D (2009) Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. J Adv Nurs 65(2): 371–381 Epub

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

Feasey S, Fox C (2001) Benchmarking evidence-based care. Paediatr Nurs 13(5): 22–5

Flemming K, Thompson C, Cullum N (1997) Doing the right thing. Nurs Stand 12(7): 28–31

Frost S, Crowford P, Mera S, Chappell B (2003) Implementing good practice in epilepsy care. Seizure 12(2): 77–84

Gagan M, Hewitt-Taylor J (2004) The issues of nurses involved in implementing evidence in practice. Br J Nurs 13(20): 1216–20

Gerrish K, Clayton J (2004) Promoting evidence-based practice: an organizational approach. J Nurs Manag 12(2): 114–123

Gough J (2001) Public relations. Nurs Stand 15(26): 63 Green LW (1977) Evaluation and measurement: some

dilemmas for health education. Am J Public Health 67(2):155-61

Grol R, Grimshaw J (1999) Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv 25(10): 503–13

Haynes RB, Sackett DL, Gray JM, Cook DJ, Guyatt GH (1996) Transferring evidence from research into practice: 1. The role of clinical care research evidence in clinical decisions. ACP J Club 125(3): A14–6

Heater BS, Becker AM, Olson RK (1988) Nursing interventions and patient outcomes: a meta-analysis of studies. Nurs Res 37(5): 303–7

Holleman G, Eliens A, van Vliet M, van Achterberg T (2006) Promotion of evidence-based practice by professional

Nursing associations: literature review. J Adv Nurs 53(6): 702–9

Jamtvedt G, Young JM, Kristoffersen DT, Thomson O Brien MA, Oxman AD (2004) Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev (3):CD000259

Lawrie SM, Scott AI, Sharpe MC (2000) Evidence-based psychiatry: do psychiatrists want it and can they do it? Health Bull 58(1): 25–33

Lo Biondo-Wood G, Haber J (2006) Nursing research: methods and critical appraisal for evidence-based practice 6th edn. Elsevier- Mosby, Philadelphia

Long LE (2003) Imbedding quality improvement into all aspects of nursing practice. Int J Nurs Pract 9(5): 280–4

Naidoo J, Wills J (2002) Health promotion: foundations for practice 2nd edn. Bailliere Tindall, Edinburgh

Nagy S. Lumby J, McKinley S, Macfarlane C (2001) Nurses beliefs about the conditions that hinder or support evidence-based nursing. Int J Nurs Pract 7(5): 314–21

National Institute for Health Clinical Excellence (2003) Factsheet: general information about clinical guidelines. NICE, London

Newell R, Burnard P (2006) Research for evidence-based practice. Blackwell Publishing Ltd, Oxford

Nutbeam D (1998) Evaluating health promotion: progress, problems and solutions. Health Promot Int 13(1): 27–44

Pearson A, Field J, Jordan Z (2007) Evidence-based clinical practice in nursing and health care: assimilating research, experience and expertise. Blackwell Publishing, Oxford

Retsas A (2000) Barriers to using research evidence in nursing practice. J Adv Nurs 31(3): 599–606

Rogers EM (1995) Diffusion of Innovations 4th edn. The Free Press, New York

Rogers EM (2003) Diffusion of innovations 5th edn. The Free Press, New York

Ryan D, Mannix McNamara P, Deasy C (2006) Health promotion Ireland: principles, practice and research. Gill & Macmillan, Dublin

Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A (2004) An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs 13(8):913–24

Sackett D, Rosenberg W, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312(7023): 71–2

Scullion PA (2002) Effective disemination strategies. Nurse Res 10(1): 65–77

Settler CB (2003) Role of the organization in translating research into evidence-based practice. Outcomes Manag 7(3): 97–105

The Joanna Briggs Institute (2008) The JBI approach to evidence-based practice. http://tinyurl.com/447wy24 (accessed 27 May 2011)

Thomas DE, Kukuruzovic R, Martino B, Chauhan SS, Elliott EJ (2003) Knowledge and use of evidence-based nutrition: a survey of paediatric dietitians. J Hum Nutr Diet 16(5): 315–22

Thomas L (1999) Clinical practice guidelines. Evidence-Based Nursing 2(2): 38–9

Thompson P (2000) Implementing evidence-based health care: the nurse teachers’ role in supporting the dissemination and implementation of SIGN clinical guidelines. Nurse Educ Today 20(3): 207–17

Thomson OBrien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL (2003) Audit and feedback versus alternative strategies: effects on professional practice and health care outcomes, (Cochrane Review), The Cochrane Library (Issue 1) John Wiley and Sons Ltd, Chichester

Titler MG (2004) Methods in translation science. Worldviews Evid Based Nurs 1(1): 38–48

Titler MG (2006) Developing an evidence-based practice, In: LoBiondo-Wood G, Haber J (eds.), Nursing research: methods and critical appraisal of evidence-based practice 6th edn. Elsevier/ Mosby, Philadelphia

Titler MG, Everett LQ (2001) Translating research into practice: considerations for critical care investigators.Crit Care Nurs Clin North Am 13(4): 587–604

Titler MG, Kleiber C, Steelman VJ et al (2001) The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am 13(4): 497–509

van Hooren RH, Widdershoven GA, Borne HW, Curfs LM (2002) Autonomy and intellectual disability: the case of prevention of obesity in Prader-Willi syndrome. J Intellect Disabil Res 46(Pt 7): 560–8

KEy POInTs

n Nurses need to continuously update their knowledge and act from an evidence-based approach rather than working solely from practice wisdom

n There is a constant challenge for nurses in the practice setting to provide measurable care and outcomes of the highest standard in an evidence-based manner

n Evaluation of evidence and development of evidence-based practice will empower nurses

n Collective work and the use of tools such as the IOWA model can assist nurses with EBP

BJN

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not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

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