Critical Evaluation 3165

TheJohnsHopk_JohnsHopkinsNursingEv.pdf

Home >Nursing homework help >Critical Evaluation 3165

Evidence-based practice (EBP) is a core competency for all healthcare professionals (IOM, 2003). Using an evidence-based approach to decision-making in healthcare is not only an expectation in healthcare organizations but also a requirement by professional organizations, regulators, health insurers, and purchasers of healthcare insurance. In 2009, the Institute of Medicine (IOM) set a vision that 90% of clini- cal decisions would be evidence-based by 2020 (IOM, 2009). Because nurses comprise the largest number of healthcare professionals— greater than 3 million—they have the potential to make a major im- pact on the appraisal and translation of evidence into nursing practice (IOM, 2011; Wilson et al., 2015). To do this requires leaders in both academia and service to align their learning and practice environ- ments to promote healthcare based on evidence, to cultivate a spirit of continuous inquiry, and to translate the highest-quality evidence into practice. Using a model for EBP within an organization fosters end- user adoption of evidence, enables users to speak a common language,

3 The Johns Hopkins Nursing

Evidence-Based Practice Model and Process Overview

2 0 1 8 . S i g m a T h e t a T a u I n t e r n a t i o n a l .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE 1625431; Debora Dang, Sandra L. Dearholt; Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines Account:.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition36

standardizes processes, and embeds this practice into the fabric of the organiza- tion. The objectives for this chapter are to

■■ Describe the revised Johns Hopkins Nursing Evidence-Based Practice Model

■■ Introduce frontline nurses and nurse leaders to the PET (Practice question, Evidence, and Translation) process

Johns Hopkins Nursing Evidence-Based Practice Model—Essential Components: Inquiry, Practice, and Learning

The revised Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model (see Figure 3.1) is composed of three interrelated components: inquiry, practice, and learning.

Inquiry Best Practices

Practice Improvements

(Clinical, Learning, Operational)

PRACTICE

LEARNING

Practice Question

Evidence Translation

Figure 3.1 The Johns Hopkins Nursing Evidence-Based Practice Model (2017).

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 37

Inquiry

In the revised JHNEBP Model, inquiry is the initial component that launches the EBP process. The concept of inquiry, a foundation for nursing practice, en- compasses a focused effort to question, examine, and collect information about a problem, an issue, or a concern. The National League for Nursing (2014) de- scribes a spirit of inquiry as “a persistent sense of curiosity that informs both learning and practice. A nurse motivated by a spirit of inquiry will raise ques- tions, challenge traditional and existing practices, and seek creative approaches to problem-solving … A spirit of inquiry in nursing engenders innovative think- ing and extends possibilities for discovering novel solutions in both predictable and unpredictable situations.”

Within the practice setting, such inquisitiveness, characterized by an ongoing cu- riosity about the best evidence to guide clinical decision-making, is what drives EBP (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2009). Questions about practice commonly arise from nurses’ practice settings as they provide everyday care to their patients. These questions may include whether best evidence is be- ing used or whether the care provided is safe, effective, timely, accessible, cost- effective, and high quality. Organizations that foster a culture of inquiry are more likely to have staff that will embrace and actively participate in EBP activities (Melnyk et al., 2009). Nurses have a major impact on building a culture that pro- motes inquiry by committing to generate and apply new knowledge in practice and to achieve quality outcomes.

Practice

Practice, the basic component of all nursing activity, reflects the translation of what nurses know into what they do. It is the who, what, when, where, why, and how that addresses the range of nursing activities that define the care a patient receives (American Nurses Association [ANA], 2010; ANA, 2015).

Nurses are also bound by, and held to, standards established by professional nursing organizations. For example, the ANA (2015) has identified 6 standards of nursing practice (scope) that are based on the nursing process (see Table 3.1) and 11 standards of professional performance (see Table 3.2). In addition to the

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition38

ANA, professional nursing specialty organizations establish standards of care for specific patient populations. Collectively, these standards define nurses’ scope of practice, set expectations for evaluating performance, and guide the care provid- ed to patients and families. Because these standards provide broad expectations for practice, all settings where healthcare is delivered must translate these expec- tations into organization-specific standards such as policies, protocols, and pro- cedures. As part of this process, nurses need to question the basis of their practice and use an evidence-based approach to validate or change current practice based on evidence.

Table 3.1 American Nurses Association Standards of Practice (2015)

Assessment: The collection of comprehensive data pertinent to the healthcare consumer’s health or situation. Data collection should be systematic and ongoing. As applicable, evidence-based assessment tools or instruments should be used (for example, evidence- based fall assessment tools, pain rating scales, or wound assessment tools) to identify patterns and variances.

Diagnosis: The analysis of assessment data to determine actual or potential diagnoses, problems, and issues.

Outcomes identification: The identification of expected outcomes for a plan individualized to the healthcare consumer or the situation. The clinician uses clinical expertise and current evidence-based practice to identify health risks, benefits, costs, or the expected trajectory of the condition.

Planning: The development of a plan that prescribes strategies to attain expected measurable outcomes. Includes the development of a plan that is individualized, holistic, and evidence-based and is created in partnership with the healthcare consumer and interprofessional team.

Implementation: Implementation of the identified plan, which includes partnering with the person, family, significant other, and caregivers as appropriate to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. The clinician utilizes evidence-based interventions and treatments specific to the diagnosis or problem and participates in the translation of evidence into practice. Additionally, the clinician uses evidence-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem or needs of the patient.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 39

Evaluation: Progress toward attainment of outcomes. Includes conducting a systematic, ongoing, and criterion-based evaluation of the goals and outcomes in relation to the structures, processes, and timeline prescribed by the plan.

Traditionally, nurses have based their practice on policies, protocols, and procedures that may be unsubstantiated by evidence (Melnyk et al., 2009). However, the use of an evidence-based approach is now an expectation, a standard for the nursing profession, and often a regulatory requirement. For example, healthcare organizations are responding to national healthcare reform by standardizing practices based on evidence in order to reduce inconsistencies in care, and to improve patient safety and quality while reducing healthcare costs (Warren et al., 2016). Evidence-based practice is a prominent aspect of the New Knowledge, Innovations & Improvement component in the Magnet Model (see Figure 3.2). Organizations aspiring to Magnet recognition must show continued growth and expansion of EBP activities, including critical analysis of outcomes and the demonstration of excellence in care delivery (Ingersoll, Witzel, Berry, & Qualls, 2010).

G lobal Issues in Nursing & Health Care

Empirical Outcomes

Structural Empowerment

Exemplary Professional

Practice

New Knowledge, Innovations, & Improvements

Transformational Leadership

Figure 3.2 American Nurses Credentialing Center Magnet Model components.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition40

Table 3.2 American Nurses Association Standards of Professional Performance (2015)

Ethics: Practicing with compassion and respect for the inherent dignity, worth, and unique attributes of all people. Advocating for the rights, health, and safety of the healthcare of consumers and others. Safeguarding the privacy and confidentiality of healthcare consumers and others and their data and information within ethical, legal, and regulatory parameters.

Culturally congruent practice: Demonstrating respect, equity, and empathy in actions and interactions with all healthcare consumers. Participating in lifelong learning to understand cultural preferences, worldviews, choices, and decision-making processes of diverse consumers.

Communication: Communicating effectively in a variety of formats in all areas of practice.

Collaboration: Collaborating with healthcare consumers, families, and other key stakeholders in the conduct of nursing practice. Partnering with consumers and other key stakeholders to advocate for and effect change, leading to positive outcomes and quality care.

Leadership: Providing leadership in the professional practice setting and the profession. Contributing to the establishment of an environment that supports and maintains respect, trust, and dignity.

Education: Attaining knowledge and competency that reflects current nursing practice and promotes futuristic thinking. Participating in ongoing educational activities. Committing to lifelong learning through self-reflection and inquiry to address learning and personal growth needs.

Evidence-based practice and research: Integrating evidence and research findings into practice by utilizing current evidence-based knowledge, including research findings, to guide practice.

Quality of practice: Contributing to quality nursing practice through quality improvement initiatives, documenting the nursing process in a manner that supports quality and performance improvement, and using creativity and innovation to enhance nursing care.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 41

Professional practice evaluation: Evaluating one’s own and others’ nursing practice. Providing evidence for practice decisions and actions as part of the formal and informal evaluation processes.

Resource utilization: Utilizing appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.

Environmental health: Practicing in an environmentally safe and healthy manner. Promoting a safe and healthy workplace and professional practice environment.

The Magnet Model has five key components: (a) transformational leadership; (b) structural empowerment; (c) exemplary professional practice; (d) new knowl- edge, innovations, and improvements; and (e) empirical outcomes. To provide transformational leadership, nursing leaders need to inspire a shared vision, influ- ence, model the way, challenge the process, enable others to act, encourage the heart, and have clinical knowledge and expertise (Wolf, Triolo, & Ponte, 2008). They need to create the vision and the environment that supports EBP activities, such as continuous questioning of nursing practice, translation of existing evi- dence, and development of new knowledge. Through structural empowerment, nursing leaders promote professional staff involvement and autonomy in identi- fying best practices and using the EBP process to change practice. Magnet organi- zations demonstrate exemplary professional practice such as maintaining strong professional practice models; partnering with patients, families, and interprofes- sional team members; and focusing on systems that promote patient and staff safety. New knowledge, innovations, and improvements challenge Magnet orga- nizations to design new models of care, apply existing and new evidence to prac- tice, and make visible contributions to the science of nursing (American Nurses Credentialing Center [ANCC], 2011). Additionally, organizations are required to have a heightened focus on empirical outcomes to evaluate quality. Advanced practice (nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives) and doctorate of nursing practice (DNP) nurses are vital resources for ensuring a robust EBP process, translating evidence into practice, and evaluating outcomes.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition42

Practice change and improvement will be more readily accepted within the or- ganization and by other disciplines when it is based on evidence that has been evaluated through an interprofessional EBP process. Anecdotal evidence sug- gests that nursing staff who participate in the EBP process feel a greater sense of empowerment and satisfaction as a result of contributing to changes in nursing practice based on evidence. An organization’s ability to create opportunities for nurses as part of an interprofessional team, to develop EBP questions, evaluate evidence, promote critical thinking, make practice changes, and promote profes- sional development is no longer optional.

Learning

According to Braungart, Braungart, and Gramet (2014), “learning is a relatively permanent change in mental processes, emotional functioning, skill, and/or be- havior as a result of experience” (p. 64). It is an ongoing informal process of adopting knowledge by applying it in practice that results in a behavior change (Lancaster, 2016). Ultimately, learning is what the learner hears and understands (Holmen, 2014).

A learning culture is a culture of inquiry that inspires staff to continuously in- crease their knowledge and to develop new skills (Linders, 2014; McCormick, 2016). Learning cultures also improve employee engagement, increase employee satisfaction, promote creativity, and encourage problem solving (Nabong, 2015; McCormick, 2016). Both individual learning and a culture of learning are nec- essary to build practice expertise and maintain staff competency. Education is different from learning in that education imparts knowledge through teaching at a point in time, often in a formal setting. Education makes knowledge avail- able. According to Prabhat (2011), education is largely considered formal and shapes resources from the top down. Formalized education starts with an institu- tion that offers accreditation and then provides resources to meet that expressed goal. In contrast, learning begins with individuals and communities. The desire to learn, a natural desire, is often considered informal learning and is based on the interests of individuals or groups, who access resources in pursuit of that interest.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 43

Ongoing learning is necessary to remain current with new knowledge, technolo- gies, and skills, and to establish clinical competencies. Learning also serves to in- form practice, which leads to changes in care standards that drive improvements in patient outcomes. Because the field of healthcare is becoming increasingly more complex and technical, no single individual can know everything about how best to provide safe and effective care, and no single degree can provide the knowledge needed to span an entire career. It is, therefore, an essential expectation that nurses participate in lifelong learning and continued competency development (IOM, 2011).

Lifelong learning is not only individual learning but also interprofessional, col- laborative, and team-oriented learning. For example, joint learning experiences between nursing and medical students can facilitate a better understanding of roles and responsibilities, make communication more effective, aid in conflict resolution, and foster shared decision-making. Joint learning can also improve collaboration and the ability to work more effectively on interprofessional EBP teams. The use of interprofessional education and learning fosters collaboration in implementing clinical standards, improving services, and preparing teams to solve problems using an EBP approach that exceeds the capacity of any lone pro- fessional (IOM, 2011).

The JHNEBP Model—Description Inquiry is the starting point for using the JHNEBP Model (refer to Figure 3.1 on page 36). An individual or a team, sparked by genuine curiosity, seeks to identify whether current practice reflects the best evidence for a specific problem or a particular patient population. The PET process provides a systematic approach for solving a practice question, finding the best evidence, and translating best evidence into practice. As the individual or team moves through the PET pro- cess, they are continually learning by gaining new knowledge, improving skills in collaboration, and gaining insights. At any point in the learning-and-practice

“Education is what people do to you. Learning is what you do for yourself.”

–Joi Ito

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition44

cycle, insights can trigger a new EBP process. Practice changes can also trigger additional learning as specific practice settings and patient populations are con- sidered. These improvements are often clinical, learning, or operational in nature. As a result, the PET process informs both practice and learning, which prompts behavior changes to improve practice through the use of best evidence. This on- going cycle of inquiry, practice, and learning and identifying best evidence and implementing practice improvements makes the JHNEBP model a dynamic and interactive process for practice changes that are likely to impact system, nurse, and patient outcomes.

Factors Impacting the JHNEBP Model

The JHNEBP Model (2017) is an open system with interrelated components. Because it is an open system, inquiry, learning, and practice are influenced by not only evidence but also factors external and internal to the organization. External factors can include accreditation bodies, legislation, quality measures, regula- tions, and standards. Accreditation bodies (e.g., The Joint Commission, Com- mission on Accreditation of Rehabilitation Facilities) require an organization to achieve and maintain high standards of practice and quality. Legislative and regu- latory bodies (local, state, and federal) enact laws and regulations designed to protect the public and promote access to safe, quality healthcare services. Failure to adhere to these laws and regulations has adverse effects on an organization, most often financial. Examples of regulatory agencies are the Centers for Medi- care & Medicaid Services, Food and Drug Administration, and state boards of nursing. State boards of nursing regulate nursing practice and enforce the Nurse Practice Act, which serves to protect the public. Quality measures (outcome and performance data) and professional standards serve as yardsticks for evaluating current practice and identifying areas for improvement or change. The American Nurses Credentialing Center, through its Magnet Recognition Program, devel- oped criteria to assess the quality of nursing and nursing excellence in organiza- tions. Additionally, many external stakeholders such as healthcare networks, special interest groups/organizations, vendors, patients and their families, the community, and third-party payors exert influence on healthcare organizations.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 45

Internal factors can include organizational culture, values, and beliefs; practice environment (e.g., leadership, resource allocation, patient services, organizational mission and priorities, availability of technology, library support, time to conduct EBP activities); equipment and supplies; staffing; and organizational standards. Enacting EBP within an organization requires

■■ A culture that believes EBP will lead to optimal patient outcomes

■■ Strong leadership support at all levels with the necessary resources (hu- man, technological, and financial) to sustain the process

■■ Clear expectations that incorporate EBP into standards and job descrip- tions

■■ Development of EBP mentors such as unit-based EBP champions, and ad- vanced practice and DNP nurses to serve as teachers and role models and to assist with EBP team leadership

■■ A culture that supports interprofessional collaboration

Partnerships and interprofessional collaboration are crucial for the implemen- tation of EBP initiatives that are in alignment with a healthcare organization’s mission, goals, and strategic priorities (Moch, Quinn-Lee, Gallegos, & Sortedahl, 2015). Knowledge and evaluation of the patient population and the internal and external factors that impact the healthcare institution are essential for successful implementation and sustainability of EBP within an organization.

JHNEBP PET Process: Practice Question, Evidence, and Translation

The 19-step JHNEBP process (see Appendix A) occurs in three phases and can be simply described as PET (see Figure 3.3). The process begins with the identifica- tion of a practice problem, issue, or concern. This step is critically important be- cause how the problem is posed drives the remaining steps in the process. Based on the problem statement, a practice question is developed and refined, and a

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition46

search for evidence is conducted. The evidence is then appraised and synthesized. Based on this synthesis, the team makes a determination of whether the evidence supports a change in practice. If the data supports a change, evidence translation begins and the practice change is planned, implemented, and evaluated. The final step in translation is the dissemination of results to patients and their families, staff, hospital stakeholders, and, if appropriate, the local and national community.

Practice Question Evidence Translation

Figure 3.3 JHNEBP PET process.

Practice Question

The first phase of the process (Steps 1–6) includes forming a team and developing an answerable EBP question. An interprofessional team examines a practice con- cern and develops and refines an EBP question. Refer to the Project Management Guide (see Appendix A) frequently throughout the process to direct the team’s work and gauge progress. The tool identifies the following steps.

Step 1: Recruit interprofessional team

The first step in the EBP process is to form an interprofessional team to examine a specific practice concern. It is important to recruit members for which the question holds relevance. When members are interested and invested in address- ing a specific practice concern, they are generally more effective as a team. Front- line clinicians are key members because they likely have firsthand knowledge of

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 47

the problem, its context, and its impact. Other relevant stakeholders may include team members such as clinical specialists (nursing or pharmacy), members of committees or ancillary departments, physicians, dieticians, pharmacists, patients, and families. These stakeholders provide discipline-specific expertise or insights to create the most comprehensive view of the problem and, thus, the most rel- evant practice question. Keeping the group size to 6–8 members makes it easier to schedule meetings and helps to maximize participation.

Step 2: Define the problem

It is essential that the team take the necessary time to carefully determine the problem accurately. The team needs to identify the gap between the current prac- tice and the desired practice—in other words, between what the team actually sees and experiences and what they want to see and experience. The team should state the question in different ways and get feedback from nonmembers to see whether there is agreement on the problem statement. Teams should spend time on gathering information, both narrative and numerical, to identify why the cur- rent practice is a problem. Team members should also observe the practice and listen to how actual users describe the issues related to the problem. It is helpful for team members to visualize what the current practice looks like in contrast to future practice requirements. The time devoted to probing issues and challenging assumptions about the problem, looking at it from multiple angles and obtaining feedback from as many sources as possible, is always time well spent. Incorrectly identifying the problem results in wasted effort searching and appraising evidence that, in the end, does not provide the insight that allows the team to achieve the desired outcomes.

Step 3: Develop and refine the EBP question

The next step is to develop and refine the clinical, learning, or operational EBP question (see Appendix B). Keeping the EBP question narrowly focused makes the search for evidence specific and manageable. For example, the question “What is the best way to stop the transmission of methicillin-resistant staphylo- coccus aureus (MRSA)?” is extremely broad and could encompass many inter-

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition48

ventions and all practice settings. This type of question, known as a background

question, is often used when the team knows little about the area of concern or is interested in identifying best practices. In contrast, a more focused question is, “What works best in the critical-care setting to prevent the spread of MRSA— hand washing with soap and water or the use of alcohol-based hand sanitizers?” This type of question, known as a foreground question, is generally used by more experienced teams with specialized knowledge to compare interventions or make decisions. In general, foreground questions are narrow and allow the search for evidence to be more precise and focused.

The PET process uses the PICO mnemonic (Sackett, Straus, Richardson, Rosen- berg, & Haynes, 2000) to describe the four elements of a focused question: (a) patient, population, or problem, (b) intervention, (c) comparison with other treatments, and (d) measurable outcomes (see Table 3.3).

Table 3.3 Application of PICO Elements

Patient, population, or problem

Team members determine the specific patient, population, or problem related to the patient/population/issue under examination. Clinical examples include age, ethnicity, disease, and setting. Nonclinical examples include timeliness, effectiveness, efficiency, and patient centeredness.

Intervention

Team members identify the specific intervention process or approach to be examined. Examples include treatments, protocols, education, self-care, and best practices.

Comparison with other interventions, if applicable

Team members identify what they are comparing the intervention to—for example, current practice or intervention.

Outcomes

Team members identify expected outcomes based on the implementation of the practice change. The outcomes (measures) include rate-based and nonrate-based metrics that will determine the effectiveness if a change in practice is implemented.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 49

The Question Development Tool (see Appendix B) guides the team in defining the practice problem, examining current practice, identifying how and why the problem was selected, limiting the scope of the problem, and narrowing the EBP question using the PICO format. The tool also helps the team develop a search strategy by identifying the sources of evidence to be searched and possible search terms. It is important to recognize that the EBP team can go back and further refine the EBP question as more information becomes known as a result of the evidence search and review. Refer to Chapter 4 for more details regarding the de- velopment and refining of an EBP practice question.

Step 4: Identify stakeholders

It is important for the EBP team to identify early the appropriate individuals and stakeholders who should be involved in, and kept informed during, the EBP project. A stakeholder is a person, group, or department in an organiza- tion that has an interest in, or a concern about, the topic or project un- der consideration (Agency for Healthcare Research and Quality, 2011). Stakeholders may include a variety of clinical and nonclinical staff, departmental and organizational leaders, patients and families, regulators, insurers, or policy makers. Keeping key stakeholders informed is instrumental to successful change. The team should consider whether the EBP question is specific to a unit, service, or department or involves multiple departments. If it is the latter, representatives from all areas involved need to be recruited for the EBP team. Key leadership in the affected departments should be kept up-to-date on the team’s progress. If the problem affects multiple disciplines (e.g., nursing, medicine, pharmacy, respira- tory therapy), each discipline should also be included. The Stakeholder Analysis Tool (see Appendix C) can be used to guide stakeholder identification.

Step 5: Determine responsibility for project leadership

Identifying a leader for the EBP project facilitates the process, accountabilities, and responsibilities and keeps the project moving forward. The leader should be knowledgeable about EBP and have experience and a proven track record in leading interprofessional teams. It is also helpful if this individual knows the

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition50

organizational structure and strategies for implementing change within the orga- nization.

Step 6: Schedule team meetings

Setting up the first EBP team meeting includes such activities as

■■ Reserving a room with adequate space conducive to group discussion

■■ Asking team members to bring their calendars so that subsequent meet- ings can be scheduled

■■ Ensuring that a team member is assigned to record discussion points and group decisions

■■ Establishing a timeline for the process

■■ Keeping track of important items (e.g., copies of the EBP tools, literature searches, materials, and resources)

■■ Providing a place to keep project files

Evidence

The second phase (Steps 7–11) of the PET process addresses the search for, ap- praisal of, and synthesis of the best available evidence. Based on these results, the team makes recommendations regarding practice changes.

Step 7: Conduct internal and external search for evidence

Team members determine what type of evidence to search for (see Chapter 5), who is to conduct the search, and who will bring items to the committee for re- view. Enlisting the help of a health information specialist (librarian) is critical. Such assistance saves time and ensures a comprehensive and relevant search. In addition to library resources, other sources of evidence include

■■ Clinical practice guidelines

■■ Community standards

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 51

■■ Opinions of internal and external experts

■■ Organizational financial data

■■ Position statements from professional organizations

■■ Patient and staff surveys and satisfaction data

■■ Quality improvement data

■■ Regulatory, safety, or risk management data

Step 8: Appraise the level and quality of each piece of evidence

In this step, research and nonresearch evidence is appraised for level and quality. The Research Evidence Appraisal Tool (see Appendix E) and the Nonresearch Evidence Appraisal Tool (see Appendix F) assist the team in this activity. Each tool includes a set of questions to determine the type, level, and quality of evi- dence. The PET process uses a 5-level scale to determine the level of the evidence, with Level I evidence as the highest and Level V as the lowest (see Appendix D). Based on the questions provided on the tools, the quality of each piece of evi- dence is rated as high, good, or low-major flaws. The team reviews each piece of evidence and determines both the level and the quality. Evidence with a quality rating of low-major flaws is discarded and is not used in the process. The Indi- vidual Evidence Summary Tool (see Appendix G) tracks the team’s appraisal of each piece of evidence (including the author, date, evidence type, sample, sample size, setting, and study findings), which helps to answer the EBP question and identify the limitations, level, and quality of evidence. Chapters 6 and 7 provide a detailed discussion of evidence appraisal.

Step 9: Summarize the individual evidence

The team numerically sums the evidence documents that answer the practice question for each level of evidence and records the totals on the Synthesis Process and Recommendations Tool (see Appendix H). The relevant findings that answer the EBP question for each level are then written in summary form next to the ap- propriate level.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition52

Step 10: Synthesize overall strength and quality of evidence

Next, the team determines the overall quality for each level of evidence and re- cords it on the Synthesis Process and Recommendations Tool. Through synthesis, the team makes a determination of the overall strength and quality of the collected body of evidence, taking into consideration the (a) level, (b) quantity, (c) consisten- cy of findings across all pieces of evidence, and (d) applicability to the population and setting. The team can use the quality criteria for individual evidence appraisal as a guide for determining overall quality. Making decisions about the overall strength and quality is both an objective and a subjective process. The EBP team should devote the necessary time to thoughtfully evaluate the body of evidence and come to agreement on the overall strength and quality. Refer to Chapters 6 and 7 and Appendix H for more information on evidence synthesis.

Step 11: Develop recommendations for change based on evidence synthesis

Based on the overall appraisal and synthesis of the evidence, the team considers possible pathways to translate evidence into practice. A team has four common pathways to consider when developing a recommendation (Poe & White, 2010):

■■ Evidence may be compelling, with consistent results that support a prac- tice change.

■■ Evidence may be good, with consistent results that support a practice change.

■■ Evidence may be good, but with conflicting results that may or may not support a practice change.

■■ Evidence may be nonexistent or insufficient to support a practice change.

Based on the selected translation pathway, the team then determines whether to make the recommended change or investigate further (see Table 3.4). The team lists its recommendations on the Synthesis Process and Recommendations Tool (see Appendix H). Carefully consider the risks and benefits of making the change. We strongly recommended piloting changes in several representative areas/settings to determine possible unanticipated effects or barriers.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 53

Table 3.4 Translation Pathways for EBP Projects

Evidence

Compelling, consistent

Good, consistent

Good but conflicting

Insufficient/ absent

Make recommended change?

Yes Consider pilot of change

No No

Need for further investigation?

No Yes, particularly for broad application

Yes, consider periodic review for new evidence or development of research study

Risk-benefit analysis

Benefit clearly outweighs risk

Benefit may outweigh risk

Benefit may or may not outweigh risk

Insufficient information to make determination

Reprinted from Poe and White (2010)

Translation

In the third phase (Steps 12–19) of the process, the EBP team determines whether the changes to practice are feasible and appropriate and are a good fit given the target setting. If they are, the team creates an action plan, implements and evalu- ates the change, and communicates the results to appropriate individuals both internal and external to the organization.

Step 12: Determine fit, feasibility, and appropriateness of recommendation(s) for translation pathway

The team communicates and obtains feedback from appropriate organizational leaders, bedside clinicians, and all other stakeholders affected by the practice

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition54

recommendations to determine whether the change is feasible and appropriate and is a good fit for the specific practice setting. Team members examine the risks and benefits of implementing the recommendations. They must also consider the resources available and the organization’s readiness for change (Poe & White, 2010). Even with strong, high-quality evidence, EBP teams may find it difficult to implement practice changes in some cases. For example, an EBP team examined the best strategy for ensuring appropriate enteral tube placement after initial tube insertion. The evidence indicated that x-ray was the only 100% accurate method for identifying tube location. The EBP team recommended that a post-insertion x-ray be added to the enteral tube protocol. Despite their presenting the evidence to clinical leadership and other organizational stakeholders, the team’s recom- mendation was not accepted within the organization. Concerns were raised about the additional costs and adverse effects that may be incurred by patients (appro- priateness). Other concerns related to delays in workflow and the availability of staff to perform the additional x-rays (feasibility). Risk management data showed a lack of documented incidents related to inappropriate enteral tube placement. As a result, after weighing the risks and benefits, the organization decided that making this change was not a good fit at that time. The fit-and-feasibility section of the Synthesis Process and Recommendations Tool (see Appendix H) provides a list of questions to consider when determining both fit and feasibility.

Step 13: Create action plan

If the recommendations are a good fit for the organization, the team develops a plan to implement the practice change(s). The plan may include

■■ Development of (or change to) a standard (policy, protocol, guideline, or procedure), a critical pathway, or a system or process related to the EBP question

■■ Development of a detailed timeline assigning team members to the tasks needed to implement the change (including the evaluation process and reporting of results)

■■ Solicitation of feedback from organizational leaders, bedside clinicians, and other stakeholders.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 55

Essentially, the team must consider the who, what, when, where, how, and why when developing an action plan for the proposed change. The Action Planning Tool (see Appendix I) provides a guide for the EBP team to develop the action plan.

Step 14: Secure support and resources to implement action plan

The team needs to give careful consideration to the human, material, or financial resources needed to implement the action plan. Obtaining support and working closely with departmental and organizational leaders can help to ensure the suc- cessful implementation of the EBP action plan.

Step 15: Implement action plan

When the team implements the action plan, they need to ensure that all affected staff and stakeholders receive verbal and written communication as well as edu- cation about the practice change, implementation plan, and evaluation process. EBP team members should be available to answer any questions and trouble- shoot problems that may arise during implementation.

Step 16: Evaluate outcomes

Using the outcomes identified on the Question Development Tool (see Appendix B), the team evaluates the degree to which the outcomes were met. Although the team desires positive outcomes, unexpected outcomes often provide opportuni- ties for learning, and the team should examine why these occurred. This exami- nation may indicate the need to alter the practice change or the implementation process, followed by reevaluation.

It is also important to note that information from which inferences can be made about the EBP project’s outcomes can fall under one of three categories: struc- ture, process, or outcomes (Donabedian, 1988). Structure refers to the setting in which care is provided and may include, for example, (a) material resources such as facilities, equipment, and money; (b) human resources, such as the num- ber and qualification of personnel; and (c) organizational characteristics such as

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition56

culture, peer review, shared governance, policies, and protocols. Process refers to what is actually being done when providing care (e.g., patient care activities, interaction between patients and providers of care), and outcomes refers to the effects of care on the health status of the patient or the effectiveness of the in- tervention. EBP teams need to recognize the linkage between all three categories when assessing the results of an EBP project. According to Donabedian (1988), if good structures are in place, it increases the likelihood of a good process, which in turn increases the likelihood of good outcomes. As a result, understanding the relationship between all three categories is important to the final analysis of the end results of the EBP project, particularly if the results are less than expected. Upon completion of the evaluation process, if the decision is made to continue the practice change, the organization’s quality improvement process should be undertaken when ongoing measurement, evaluation, and reporting are indicated.

Step 17: Report outcomes to stakeholders

In this step, the team reports the results to appropriate organizational leaders, frontline clinicians, and all other stakeholders. Sharing the results, both favor- able and unfavorable, helps disseminate new knowledge and generates additional practice or research questions. Valuable feedback obtained from stakeholders can overcome barriers to implementation or help develop strategies to improve unfa- vorable results. The Dissemination Tool (see Appendix J) guides the EBP team in identifying the audience(s), key message points, and methods to communicate the team’s findings, recommendations, and practice changes.

Step 18: Identify next steps

EBP team members review the process and findings and consider whether any lessons have emerged that should be shared or whether additional steps need to be taken. These lessons or steps may include a new question that has emerged from the process, the need to do more research on the topic, additional train- ing that may be required, suggestions for new tools, the writing of an article on the process or outcome, or the preparation of an oral or poster presentation at a professional conference. The team may identify other problems that have no

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 57

evidence base and, therefore, require the development of a research protocol. For example, when the recommendation to perform a chest x-ray to validate initial enteral tube placement was not accepted (see the example discussed in Step 12), the EBP team decided to design a research study to look at the use of colorimet- ric carbon dioxide detectors to determine tube location.

Step 19: Disseminate findings

This final step of the process is one that is often overlooked and requires strong organizational support. The results of the EBP project need to be, at minimum, communicated to the organization. Depending on the scope of the EBP question and the outcome, consideration should be given to communicating findings external to the organization in appropriate professional journals or through presentations at professional conferences. Refer to the Dissemination Tool (see Appendix J).

Summary This chapter introduces the revised JHNEBP Model (2017) and the steps of the PET process. Nursing staff with varied experience and educational preparation have successfully used this process with mentorship and organizational support. They have found it rewarding both in understanding the basis for their current nursing interventions and incorporating changes into their practice based on evi- dence (Dearholt & Dang, 2012).

References Agency for Healthcare Research and Quality. (2011). Engaging stakeholders to identify and

prioritize future research needs. Retrieved from http://www.effectivehealthcare.ahrq.gov/ index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=698

American Nurses Association (ANA). (2010). Nursing: Scope and standards of practice. Washington, DC: American Nurses Association.

American Nurses Association (ANA). (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: American Nurses Association.

American Nurses Credentialing Center (ANCC). (2011). Announcing the model for ANCC’s magnet recognition program. Retrieved from http://www.nursecredentialing.org/Magnet/ ProgramOverview/New-Magnet-Model.aspx

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition58

Braungart, M., Braungart, R. G., & Gramet, P. R. (2014). Applying learning theories to healthcare practice. In S. B. Bastable (Ed.), Nurse as Educator, Principles of Teaching and Learning for Nursing Practice (pp. 64–110), Burlington, MA: Jones & Bartlett Learning.

Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743–1748.

Holmen, M. (2014, August 6). Education vs learning—what exactly is the difference [Web log post]. EdTechReview. Retrieved from http://edtechreview.in/trends-insights/insights/1417-education-vs- learning-what-exactly-is-the-difference?utm_content=buffer4e5b8&utm_medium=social&utm_ source=twitter.com&utm_campaign=buffer#.U-NdPce3yG4.twitter

Ingersoll, G. L., Witzel, P. A., Berry, C., & Qualls, B. (2010). Meeting Magnet research and evidence- based expectations through hospital-based research centers. Nursing Economics, 28(4), 226–235.

Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academics Press.

Institute of Medicine (IOM). (2009). Roundtable on evidence-based medicine. Washington, DC: National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK52847

Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academics Press.

Lancaster, J. (2016). Changing health behavior using health education with individuals, families, and groups. In M. Stanhope & J. Lancaster (Eds.), Public Health Nursing (355–376). St. Louis, MO: Elsevier Mosby.

Linders, B. (2014). Nurturing a culture for continuous learning. InfoQ. Retrieved from https:// www.infoq.com/news/2014/07/nurture-culture-learning

McCormick, H. (2016). Seven steps to creating a lasting learning culture. University of North Carolina. Retrieved from http://www.kenan-flagler.unc.edu/~/media/Files/documents/ executive-development/unc-white-paper-7-steps-to-creating-a-lasting-learning-culture

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Igniting a spirit of inquiry: An essential foundation for evidence-based practice. American Journal of Nursing, 109(11), 49–52.

Moch, S. D., Quinn-Lee, L., Gallegos, C., & Sortedahl, C. K. (2015). Navigating evidence-based practice projects: The faculty role. Nursing Education Perspectives, 36(2), 128–130.

Nabong, T. (2015). Creating a learning culture for the improvement of your organization. Training Industry. Retrieved from https://www.trainingindustry.com/workforce-development/articles/ creating-a-learning-culture-for-the-improvement-of-your-organization.aspx

National League for Nursing. (2014). Practical/vocational nursing program outcome: Spirit of inquiry. Retrieved from http://www.nln.org/docs/default-source/default-document-library/ spirit-of-inquiry-final.pdf?sfvrsn=0

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.

3 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 59

Poe, S. S., & White, K. M. (2010). Johns Hopkins Nursing Evidence-Based Practice: Implementation and Translation. Indianapolis, IN: Sigma Theta Tau International.

Prabhat, S. (2011, July 28). Difference between education and learning. Difference Between. Retrieved from http://www.differencebetween.net/miscellaneous/difference-between-education- and-learning

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence- based medicine: How to practice and teach EBM. Edinburgh: Churchill.

Warren, J. I., McLaughlin, M., Bardsley, J., Eich, J., Esche, C. A., Kropkowski, L., & Risch, S. (2016). The strengths and challenges of implementing EBP in healthcare systems. Worldviews on Evidence-Based Nursing, 13(1), 15–24.

Wilson, M., Sleutel, M., Newcomb, P., Behan, D., Walsh, J., Wells, J. N., Baldwin, K. M. (2015). Empowering nurses with evidence-based practice environments: Surveying Magnet, Pathway to Excellence, and non-Magnet facilities in one healthcare system. Worldviews on Evidence-Based Nursing, 12(1), 12–21.

Wolf, G., Triolo, P., & Ponte, P. R. (2008). Magnet recognition program: the next generation. Journal of Nursing Administration, 38(4), 200–204.

EBSCOhost: eBook Collection (EBSCOhost) printed on 1/16/2026 1:51:59 AM UTC via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use.