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Original Article

Iowa Model of Evidence-Based Practice: Revisions and Validation Authored on behalf of the Iowa Model Collaborative

Keywords

evidence-based practice,

Iowa Model, model,

translation research, implementation,

evaluation, change

ABSTRACT Background: The Iowa Model is a widely used framework for the implementation of evidence- based practice (EBP). Changes in health care (e.g., emergence of implementation science, em- phasis on patient engagement) prompted the re-evaluation, revision, and validation of the model.

Methods: A systematic multi-step process was used capturing information from the literature and user feedback via an electronic survey and live work groups. The Iowa Model Collabora- tive critically assessed and synthesized information and recommendations before revising the model.

Results: Survey participants (n = 431) had requested access to the Model between years 2001 and 2013. Eighty-eight percent (n = 379) of participants reported using the Iowa Model and identified the most problematic steps as: topic priority, critique, pilot, and institute change. Users provided 587 comments with rich contextual rationale and insightful suggestions. The revised model was then evaluated by participants (n = 299) of the 22nd National EBP Conference in 2015. They validated the model as a practical tool for the EBP process across diverse settings. Specific changes in the model are discussed.

Conclusion: This user driven revision differs from other frameworks in that it links practice changes within the system. Major model changes are expansion of piloting, implementation, patient engagement, and sustaining change.

Linking Evidence to Action: The Iowa Model-Revised remains an application-oriented guide for the EBP process. Intended users are point of care clinicians who ask questions and seek a systematic, EBP approach to promote excellence in health care.

INTRODUCTION Using the best evidence to guide clinical practice has been im- portant for decades, but full adoption of evidence-based practice (EBP) remains a challenge. In the early 1990s, a team of nurses from the University of Iowa Hospitals and Clinics (UIHC) and College of Nursing developed a framework called The Iowa Model of Research-Based Practice to Promote Quality Care to guide clinicians in evaluating and infusing research findings into patient care (Titler et al., 1994). The Iowa Model was based on Roger’s (1983) theory, Diffusion of Innovations, and was an outgrowth of the Quality Assurance Model Using Re- search (QAMUR; Watson, Bulechek, & McCloskey, 1987). It is a heuristic model, developed by nurses incorporating success- ful strategies learned when undertaking research utilization projects. Subsequently, research utilization evolved into EBP, incorporating the use of multiple levels of evidence, and the Iowa Model was revised to reflect this expansion as well as provide more detail about infusing change (Titler et al., 2001).

The Iowa Model is widely used and has stood the test of time as a pragmatic guide for the EBP process. Since 2001, over 3,900 requests for permission to use the Iowa Model

have come from clinicians, educators, administrators, and re- searchers from all 50 states and 130 countries. Additionally, the model has been translated into German, Japanese, and Portuguese.

Since the last revision, dramatic changes have evolved in health care, including an explosion of synthesized evidence, national and international initiatives promoting adoption of EBP, enhanced interprofessional collaboration, widespread use of electronic data, emergence of implementation science, pay for performance, and enhanced patient engagement. In 2012, the Iowa Model Collaborative was formed to assess the need for model revision. All prior authors and key stakeholders were invited to participate in the Iowa Model Collaborative.

PURPOSE The purpose of this initiative was to revise and validate the Iowa Model. This paper describes the systematic, multi-phase process used to collect and critically analyze user suggestions. Specific changes in the Iowa Model-Revised are presented.

Iowa Model-Revised

PHASE I: DEVELOPMENT OF THE REVISED MODEL The first step involved generating and assembling potential revisions for the model from multiple sources: (a) literature, including critical analyses of the Iowa Model as well as other EBP models (Rycroft-Malone & Bucknall, 2010); (b) Collabo- rative members’ experiences using the model in clinical and academic settings; and (c) results from a survey of Iowa Model users. The second step involved Collaborative members break- ing into small workgroups to critically assess and synthesize the recommendations, then reaching consensus as a whole.

Procedure Users of the Iowa Model were surveyed to assess its utility, identify challenges, and obtain suggestions for revisions. Par- ticipants were drawn from the UIHC database containing re- quests for the model between 2001 and 2013. The University of Iowa Human Subjects Review Board ruled that this survey did not require IRB approval.

A 41-item electronic REDCapTM (Vanderbilt University) sur- vey was sent to 2,052 individuals with unique e-mail addresses in the database. Each of 13 steps in the model was listed for participants to indicate if that step was problematic (yes or no), identify problem(s), and make suggestions (free text) for revision. A final open-ended question elicited additional sug- gestions for the model overall. A total of 431 useable surveys (21% response rate) were received from respondents who were primarily from the United States (96.3%), had a graduate de- gree (87.9%), worked in a hospital or academic setting (79%), and were either an educator or clinician (52%). Experience us- ing the model varied from novice (9%) to expert (15%), with the vast majority being in-between.

Results Most participants found the model to be very useful (68.4%), stating that it was easy to follow, straightforward, and helped them implement practice changes. A few expressed concern that the model was too complex for novices and needed to be simplified. A total of 94% were interested in a revised model.

Most participants (n = 379, 88%) reported they had used the Iowa Model. Users identified problems in each of the 13 steps of the model. Steps most often identified as problematic were: topic a priority (n = 52, 14%), critique of research (n = 65, 17%), pilot the change (n = 47, 12%), and institute the change (n = 49, 13%). Participants provided 587 comments, both pos- itive and negative, with rich contextual rationale for the prob- lems and made insightful suggestions for each component of the model (see Figure 1 and Supplemental Table S1).

Following collective review of survey results, members of the Collaborative moved revisions forward by forming four workgroups based on decision points in the model. Focusing on specific model components allowed for more in-depth anal- ysis of the data and a review of the literature in that area.

Work groups identified high frequency problems or sug- gestions from survey data and major recurring themes from qualitative data. These themes evolved into specific recommen- dations and rationale for change in respective sections as well as suggestions for overall model improvements. Suggested re- visions were taken back to the whole Collaborative for further discussion and a draft of the Iowa Model-Revised was created.

PHASE II: VALIDATION AND REFINEMENT OF THE IOWA MODEL REVISED The second phase involved validation and refinement of the revised model. The annual National EBP conference at UIHC provided a participant pool with a particular interest in and knowledgeable about EBP processes and issues. Conference attendees were invited to participate in activities designed to validate and further refine the Iowa Model-Revised.

Procedure The “Iowa Model-Revised: Evidence-Based Practice to Promote Excellence in Health Care” was presented as the conference keynote at UIHC’s 22nd National EBP Conference on April 23–24, 2015. The presentation described the process used to revise the model, changes made, and rationale for the revi- sions. Participants (n = 299) individually reflected upon an actual or ideal evidence-based project at their institution and walked through the steps of the revised Iowa Model. They then identified strengths and weaknesses of the model revisions, resources needed for application of the model, and made other suggestions. Participants also met in small groups to work through a specified EBP initiative using the revised model. Questions, issues, and suggestions were reported back and considered during a panel discussion the following day. Panel leaders fielded questions and solicited further feedback for re- finement and clarification of the model.

Results Participants felt the revised model was streamlined and easy to follow. They liked the linear format and added detail under pi- loting the practice change. Specific suggestions were to return “Conduct Research” to a stand-alone step, simplify the arrows, and provide more clarification regarding knowing when evi- dence is sufficient to change practice. Results of all conference activities were tabulated into strengths and issues, and themes identified (available in Supporting Information). These data were used by the Collaborative during a follow-up meeting to further refine the Model.

EXPLANATION OF MODEL REVISIONS The Iowa Model-Revised is presented in Figure 2. The revisions and associated rationale for making changes in each of the Model components are described sequentially from identifying issues through dissemination.

Original Article

Figure 1. Users who identified steps in Iowa Model as problematic. Note. Of 379 users in survey, percent that indicated yes, this step of the Iowa Model is problematic.

Identifying Triggering Issues and Opportunities The model began with parallel boxes listing nine Problem and Knowledge Focused Triggers. This was revised and simplified to five triggering issues and opportunities, which combined triggers from both prior categories.

The reworded bullet “data/new evidence” expanded beyond the original “new research or other literature” to include risk management data, process improvement data, financial data, and internal and external benchmarking data. Two new bullets were added: “Accrediting agency requirements/regulations” and “clinical or patient identified issues.” These topics reflect national quality strategies such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, and initia- tives from accrediting agencies such as the Joint Commission, as well as the growing attention to patient preferences. Re- sponding to patient preferences might involve a palliative care patient requesting pet therapy or massage, or implementation of bedside handoff by nursing staff in response to patient satis- faction surveys. Finally, an existing bullet (i.e., National Agen- cies or Organizational Standards & Guidelines) was modified to “organization, state, or national initiative” which includes initiatives such as the World Health Organization’s surgical checklist (Garcia-Paris, Cohena-Jimenez, Montano-Jimenez, & Cordoba-Fernandez, 2015), and outcome-based quality report- ing and changing reimbursement of potentially avoidable hos- pital acquired conditions (e.g., pressure injury).

State the Question or Purpose A frequent request from users was to add a step for stating the question or purpose of the EBP project, which was included in the revised model. Formally stating the purpose enables a more focused approach to synthesizing the body of evidence and better informs the next decision point, “Is this topic a priority?”, as well as subsequent steps. Users of the model may apply the PICO (Population, Intervention, Comparison, Outcome) or other formats to better frame searchable questions.

Decision Point 1: Is This Topic a Priority? This step remains an important decision point in the revised model, because a low priority project (i.e., one that is not aligned with the organization’s mission and vision or not linked to the organization’s strategic plan) is unlikely to obtain resources necessary to bring it to fruition. However, the words, “for the organization” were eliminated in the revision to extend the model’s applicability to other settings, such as the community, to better incorporate smaller non-organization wide clinical changes and to make the model responsive to projects that are not resource intensive. If the topic is not a priority, the model suggests selecting another question.

(No) Consider Another Issue. This step was unchanged from the last version of the model. Survey participants understood that if a topic could not

Iowa Model-Revised

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care

©University of Iowa Hospitals and Clinics, Revised June 2015 To request permission to use or reproduce, go to

DO NOT REPRODUCE WITHOUT PERMISSION http://www.uihealthcare.org/nursing-research-and-evidence-based-practice/

= a decision point

Identify Triggering Issues / Opportunities • Clinical or patient identified issue • Organization, state, or national initiative • Data / new evidence • Accrediting agency requirements / regulations • Philosophy of care

State the Question or Purpose

Is this topic a priority?

Form a Team

Assemble, Appraise and Synthesize Body of Evidence • Conduct systematic search • Weigh quality, quantity, consistency, and risk

Is there sufficient evidence?

Yes

No Conduct research

Yes

Design and Pilot the Practice Change • Engage patients and verify preferences • Consider resources, constraints, and approval • Develop localized protocol • Create an evaluation plan • Collect baseline data • Develop an implementation plan • Prepare clinicians and materials • Promote adoption • Collect and report post-pilot data

Is change appropriate for

adoption in practice?

Consider alternativesNo

Yes

Integrate and Sustain the Practice Change • Identify and engage key personnel • Hardwire change into system • Monitor key indicators through quality improvement • Reinfuse as needed

Disseminate Results

Consider another Issue / opportunity

Reassemble

Redesign

Original Article generate energy and resources, it would not be prudent to pursue.

(Yes) Form a Team.

Form a Team The next box was described as challenging by some survey re- spondents and conference attendees, who requested guidance on team composition. Because a discussion of teams cannot practically be incorporated into a model, the following discus- sion is offered for guidance. The team may change over time. Selection of team members requires attention to interprofes- sional involvement, as well as the skill sets needed to plan, con- duct, and evaluate the project. Important activities of the team include, reviewing existing literature, obtaining baseline data, and engaging key stakeholders. However, not all stakehold- ers have to be involved in every aspect of the practice change process. For example, while IT personnel might provide insti- tutional data or evidence for review by the team to assist in decision making, they may not participate in the systematic literature search process. Correspondingly, more focused or targeted tasks may be handled by key personnel (e.g., librarian) who may not be a formal member of the team. It may be pru- dent to include naysayers who might be resistant to the change, as well as opinion leaders, as part of the team. Regardless of composition, key stakeholders need to believe the project is worthy.

Assemble, Appraise, and Synthesize Body of Evidence This was outlined as two steps that are now combined in the revised model to reflect the iterative and non-linear nature of this process. Changes were made to emphasize the importance of evaluating the whole body of evidence, not solely research. Other types of evidence are now included as part of the body of evidence. An additional bullet point was added to remind users about four criteria for weighing evidence: quality, quantity, consistency, and risk (Guyatt et al., 2008; Institute of Medicine, 2011; U.S. Preventive Services, 2016).

Some participants suggested moving this step prior to “forming a team,” but after consideration this was rejected. While key project leaders may gather evidence to this point, it is important for the team to conduct a systematic search and be involved in evaluating the evidence to guide subsequent work. The most frequent suggestions for language changes included expanding the term research to include other evidence and replacing critique with appraise.

Some participants wanted to know how to evaluate research, grade, score, and determine the extent of evi- dence. Survey participants identified this step as an area of difficulty, noting that they or their teams lack skills for ap- praising and synthesizing evidence. Readers are advised to seek resources (e.g., http://www.hopkinsmedicine.org/gim/training/ Osler/osler_JAMA_Steps.html; http://www.ahrq.gov/; http:// www.gradeworkinggroup.org/)

Participants also identified barriers to resources (including time, a library, and librarian) and a need for tools, checklists and charts to assist with search strategies, retrieval, and critique of relevant evidence. It is beyond the scope of the model to address many of these difficulties.

Decision Point 2: Is There Sufficient Evidence? Similar to the preceding step, some participants reported that they do not know how to determine if there is sufficient evidence for a practice change. Furthermore, concern was raised that the lack of this skill may lead to premature decisions to implement a practice change without full consideration of risks. Participants asked for clarification of this step including the meaning of sufficient, what questions to ask, when to consider other evidence and factors to consider in weighing evidence. Readers are referred to resources for this step (http://www.uspreventiveservicestaskforce.org/Page/Name/ methods-and-processes; http://www.gradeworkinggroup.org/ publications/JCE_series.htm).

The decision point (i.e., Is there sufficient research base?) was revised. Suggestions included incorporating multiple types of evidence as part of the initial evidence review, evaluating evidence quality, quantity and consistency as well as risk. Thus, the strongest evidence of any type is considered prior to making a decision about changing practice.

(No) Conduct Research. When the body of evidence is not sufficient to guide a practice change, the next step is to conduct research. The Collaborative had considered leaving the research step out because many clinicians are not comfortable with developing research studies. However, users of the model felt strongly that this step remain in. While some participants suggested including the research process in this step, the Collaborative chose to keep the focus and scope of the model on EBP. As an alternative to conduct of research, additional topic development may guide the team toward sufficient evidence to proceed.

Conduct of research leads to the “Reassemble” feedback loop, bringing new findings to bear. The new research findings are assembled with other new evidence from an updated search. This leads to reappraisal of the body of evidence to make a decision about the sufficiency of the evidence.

(Yes) Design and Pilot the Practice Change.

Design and Pilot the Practice Change As expected, there were multiple comments about the “pilot the change in the practice” section of the model. One of the most significant gaps in this section was the lack of engagement of patients and families and incorporation of their values and preferences. This shift from institution centered to patient-centered has been discussed extensively in the research, practice and policy literature, as well as being

Iowa Model-Revised

a long-standing component of the definition of EBP (Sackett, Richardson, Rosenberg, & Haynes, 1997; Sigma Theta Tau International Research and Scholarship Advisory Committee, 2008). Berwick’s (2009) definition of patient-centered care is a shift in power “ . . . out of the hands of those who give care and into the hands of those who receive it” (p. 555). Patient preferences and experiences are key priorities for healthcare providers and organizations (Centers for Medicare and Medicaid Services, 2015). Further, evidence demonstrates that patient engagement can lead to better health outcomes and that cost containment must include patients as a core part of the solution (Carman et al., 2013).

A second important change recommended by users was the need to address necessary resources, constraints, and approvals (e.g., organization or human subject’s committees). Committee review promotes linkages within organizational in- frastructure to avoid wasting resources on unsuccessful change initiatives but also to avoid inconsistency and variation in practice.

A third critique of this section was the paucity of guidance for piloting the practice change. Given the complexity of this multi-step process, many users requested more detail. In the revised model, there is added guidance on localizing the prac- tice protocol to fit the unique unit and setting and that further modifications may be needed when the protocol is applied elsewhere. Localization was first introduced by Rogers (1983) and elaborated by Titler (2008) and others (Harrison et al., 2013) for EBP projects. This strategy also supports the bullet “promote adoption” added to this revision of the Iowa Model. Users requested more detail as to what should be included when adapting for other units as well as what criteria should be in place to move to widespread adoption.

The final bullets added to this section included developing an implementation plan and preparing clinicians and materi- als. This step reflects the phased approach needed for planned change. Because selecting from an extensive list of implemen- tation strategies and knowing when to apply them is chal- lenging for most bedside clinicians, Cullen and Adams (2012) developed a guide to assist clinicians. In this guide, four phases of implementation are presented for clinicians to use when determining the most effective implementation strategies. In the revised Model, a specific step, “develop an implementation plan,” to guide the implementation process was added.

Decision Point 3: Is the Change Appropriate for Adoption? Relatively few comments were made for this step in the process. Suggestions were to provide assistance with this decision point (e.g., create a checklist as a guide). Scholarly evaluation with pilot data will guide this decision by determining if the practice change worked, if the implementation plan was effective and if rollout to other areas would be beneficial. If results are not as anticipated, the team will want to reconsider additional steps prior to scaling up.

(No) Consider Alternatives and Redesign. Results of the pilot will guide the next steps. If findings do not match those anticipated from the evidence, a feed- back loop guides the team to consider alternatives to the practice protocol or revision to the implemen- tation plan. The redesigned practice change is re- evaluated through the piloting process. (Yes) Integrate and Sustain the Practice Change.

Integrate and Sustain the Practice Change Survey respondents found this step one of the most difficult and they offered numerous comments. They wanted more spe- cific instructions on how to make the change sustainable. Again, we used implementation science literature and our own experience to specify key elements for integrating and sustaining change. A major suggestion was to show the link- age with quality improvement methods, as a foundational step for sustaining change (Rocker & Verma, 2014). Although a comprehensive discussion of how to sustain change is be- yond the capabilities of this model, several additions were made. The step “Identify and engage key personnel” was added to the action steps, because integration throughout an organization requires building new teams and identifying new change champions. Adding this component for integra- tion creates linkages within the governance structure (Maher, Gustafson, & Evans, 2010; Milat, Bauman, & Redman, 2015). This promotes essential influence needed from senior leader- ship (Maher et al., 2010; Milat et al., 2015).

The term “Hardwiring change into the system” means that the new practice is embedded into the fabric of the or- ganization. For example, implementing a new fall prevention practice might involve mandatory screening of patients during clinic visits, documentation of fall risk in the electronic health record, and tracking of individual clinicians’ compliance with trending of process and outcome data. Hardwiring occurs when EBP is the default approach, done automatically within the work flow. To address sustaining the change, we added “Re-infuse as needed.” Old habits often resurface, even when they are outdated or dangerous (Maher et al., 2010; Milat et al., 2015). While literature on sustaining change is scant, extant sources and our own experiences with implementing and sustaining EBP indicates that on-going monitoring of key processes and outcomes, providing re-infusion, and actively promoting sustainment beyond the pilot period are key aspects to success, so we revised those steps in the model. Audit and feedback of key indicators remains a necessary component of an integration plan (Maher et al., 2010). Outcomes to monitor in the previous model: environment, staff, cost, and patient and family, were eliminated to maintain brevity. Key indicators to monitor are drawn from the pilot findings and include structure (e.g., staffing, available equipment), process (i.e., knowledge, attitudes, and practices) and outcomes (Bick & Graham, 2010), including balancing measures (Institute for Healthcare Improvement, 2016). Change can only be complete with a combination of implementation strategies. For more

Original Article comprehensive discussions of specific changes strategies we refer readers to other materials (Cullen, Hanrahan, Tucker, Rempel, & Jordan, 2012; Maher et al., 2010; Cullen et al., in press).

DISSEMINATE RESULTS We left this step of the model unchanged, although there were several requests for more information on how to dissem- inate results. Strategic internal dissemination continues to be needed with clinicians and within the governance structure. Sharing lessons learned externally is also valuable. A tip for publishing is to negotiate with journal editors for peer review using EBP and not research criteria.

DISCUSSION AND CONCLUSIONS More than 600 users of the Iowa Model had a voice in this revision, attesting to the validity of this framework in the prac- tice setting. The Iowa Model-Revised, presented in this paper, was disseminated internationally at the 2015 Sigma Theta Tau International convention. It was made available on the UIHC’s web-site on June 24, 2015, and in the first four days was re- quested by over 750 users from 23 countries.

The Iowa Model-Revised remains an application oriented step-by-step guide for the EBP process. It is intended for use by point of care clinicians asking important clinical questions and then seeking to improve quality through the systematic use of evidence. It is adaptable for novice to expert users and its usefulness has been demonstrated in a variety of settings. An important practice implication of the revised model is the explicit inclusion of patient and family values and preferences. The model continues to expand on what is considered evidence and how to determine if practice changes are indicated. Most importantly, revisions address sustainability of EBP changes that improve outcomes.

Evidence to Action Results of the survey conducted for this project have implica- tions for education. Practitioners need knowledge and skills for EBP, particularly regarding appraising evidence and insti- tuting a sustainable practice change using a phased approach. The Iowa Model-Revised can be used to teach students or clini- cians the EBP process. However, additional training is needed to assure clinicians have the skills needed to appraise all types of evidence and lead EBP. Users of this version of the Iowa Model-Revised are encouraged to read previous versions of the Model (Titler et al., 1994; Titler et al., 2001) to understand the supporting rationale for each of the steps. The largest changes in this version of the model are expansion of the sections on piloting and instituting change. The model is designed to be a guide rather than a comprehensive manual for change. In order to keep the model succinct and useful for a broad audience, the Collaborative chose to continue the use of bulleted suggestions rather than step-by-step instructions. The Iowa Model Collab-

orative remains committed to ongoing formative evaluation of the revised model, and welcomes feedback from readers and users. WVN

LINKING EVIDENCE TO ACTION

� The Iowa Model is widely used as a practical pro- cess for promoting EBP.

� Revisions to the Iowa Model capture advances in translation research and patient engagement.

� Use of a systematic approach is essential to deter- mine impact of EBP on patient and health system outcomes.

� Access permission to use Iowa Model-Revised at https://www.uihealthcare.org/otherservices.aspx? id = 1617.

Author information

Iowa Model Collaborative, University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care Office of Nursing Research, Evidence-Based Practice, and Quality and University of Iowa College of Nursing; Kathleen C. Buckwalter, PhD, RN, FAAN, Professor Emeri- tus, University of Iowa College of Nursing, Iowa City, IA, USA; Laura Cullen, DNP, RN, FAAN, Evidence-Based Prac- tice Scientist, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Kirsten Hanrahan, DNP, ARNP, PNP, Associate Research Scientist, Department of Nursing Services and Pa- tient Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Charmaine Kleiber, PhD, RN, CPNP, FAAN, As- sociate Research Scientist, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Ann Marie McCarthy, PhD, RN, PNP, FAAN, University of Iowa College of Nursing, Iowa City, IA, USA; Barbara Rakel, PhD, RN, FAAN, Professor, University of Iowa College of Nursing, Iowa City, IA, USA; Victoria Steel- man, PhD, RN, CNOR, FAAN, Associate Professor, University of Iowa College of Nursing, Iowa City, IA, USA; Toni Tripp- Reimer, PhD, RN, FAAN, Professor, University of Iowa Col- lege of Nursing, Iowa City, IA, USA; Sharon Tucker, PhD, RN, PMHCNS-BC, FAAN, Director, Office of Nursing Research, Evidence-Based Practice and Quality, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Authored on behalf of the Iowa Model Collaborative,

Address correspondence to Dr. Laura Cullen, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, 200 Hawkins Dr. RM T100 GH, Iowa City, IA 52242, USA; [email protected]

Iowa Model-Revised

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doi 10.1111/wvn.12223 WVN 2017;14:175–182

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Table S1. Summary of Participant Feedback From Survey and EBP Conference

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