1. Models to Guide Implementation of Evidence-Based Practice

2. Models to Change Practice in an Organization
Numerous models have been designed to help clinicians implement an evidence-based change in practice
They all differ, but commonalities exist in terms of steps and phases
Healthcare professionals are often motivated to be evidence-based practitioners. There may be individual obstacles such as lack of confidence to implement a change, isolation from colleagues with whom they would discuss research, and the lack of skills for searching and for evaluating research.
Not only do individual barriers impact the implementation of EBP, organizational factors provide barriers. Organizational barriers include but are not limited to: lack of interest, motivation, leadership, vision, strategy, and direction among managers for EBP.
Appendix N in the back of your textbook describes an instrument available to you to evaluate your organizational culture and its readiness for system-wide integration of EBP.
Numerous models have been designed to help clinicians implement an evidence-based change in practice. While they all have different qualities, many commonalities exist. For example many of the models contain similar steps and phases.
The steps and phases include:
- Identifying the program
Identifying the stake holders or change agents who will help make the change
Identify a practice change that is supported by high-quality research
Identify and address the potential barriers to the practice change
Use effective strategies to disseminate information to those implementing the practice change
Implement the practice change
Evaluate the impact of the practice change on the structure, process and outcome measures
Identify activities that will help sustain the change in practice
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3. The Stetler Model of Evidence-Based Practice
Well-known as a practitioner-oriented model
Considers both internal and external evidence
Phases or stages
Preparation
Validation
Evaluation
Translation/application
Comparative evaluation/decision making
The first model we are going to describe is the Stetler Model of Evidence-Based Practice.
The five stages of the model are designed to move the organization forward towards EBP
The Stetler model has known as a practitioner model because of the focus on critical thinking and the use of findings by the individual practitioner.
The model provides a guided problem-solving process that applies to practitioners engaged in Research utilization and Evidence based practice
The model supports a bottom line assumption that research based recommendations applied at the skilled practitioner level to individual patients, staff members or other stakeholders, need to use critical thinking or else the application of research may become a task-oriented, mechanistic routine that can lead to inappropriate, ineffective, and non-evidence-based practice.
Assumptions of the Stetler Model generate the critical thinking and practitioner orientation. The assumptions include:
Research findings can be used both formally and informally. The next assumption is:
The use of the model requires a Research utilization and Evidence based practice competent individual to be on board, such individuals also can informally use the model’s critical-thinking process in their routine practice; also an assumption is
Research findings and related evidence can be used symbolically (for example, strategically) to influence the thinking and behavior of others
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5. Iowa Model of Evidence-Based Practice to Promote Quality Care
Provides guidance for nurses and other clinicians in making decisions about day-to-day practices that affect patient outcomes
A pragmatic multiphase change process with feedback loops
Widely recognized for its applicability and ease of use by multidisciplinary healthcare teams
- Another model is the Iowa Model of Evidence-Based Evidence to promote quality care.
The Iowa model is practical and applicable to multidisciplinary teams.
The Iowa model is known for a practical multiphase change process including feedback loops
Using the Iowa model is intuitive and easy to apply.
Clinicians begin with asking practice questions and or identifying a trigger that begins the process.
Next a team is formed to gather appropriate evidence to being the process, the practice change is piloted, followed by assessing the pilot change results, along with an on-going evaluation and lastly dissemination of the findings.
Using the Iowa Model involves several steps: practitioners begin with a practice questions or “triggers;” next
A team is formed to develop, implement, and evaluate the practice change
A team is selected and begins to review, critique, and synthesize the available research evidence; next
A practice change is piloted in order to determine if an adoption is appropriate beyond the pilot; in other words was the pilot successful?
On-going evaluation is continued followed by dissemination.
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6. The Model for Evidence-Based Practice Change
A revised version of the model by Rosswurm and Larrabee (1999)
Steps:
Assess the Need for Change in Practice
Locate the Best Evidence
Critically Analyze the Evidence
Design Practice Change
Implement and Evaluate Change in Practice
Integrate and Maintain Change in Practice
- Next we will talk about Rosswurm and Larraee’s model.
This model most resembles the steps we will be pursuing throughout this course.
The first step being assessing for the need for change, locate the best evidence, critically appraise the evidence, design a practice change, implement and evaluate the change in practice followed by integration and maintenance of the practice change.
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8. The Advancing Research and Clinical Practice Through Close Collaboration Model (ARCC Model)
Exists to provide healthcare institutions and clinical settings with an organized conceptual framework that can guide system-wide implementation and sustainability of EBP to achieve quality outcomes
Developed out of nurse input as well as Control Theory and Cognitive Behavioral Theory
The Advancing Research and Clinical Practice Through Close Collaboration Model referred to as the ARCC model exists to provide healthcare institutions and clinical settings with an organized conceptual framework that can guide system-wide implementation and sustainability of Evidence based practice to achieve quality outcomes
The ARCC model was developed out of nurse input as well as Control Theory and Cognitive Behavioral Theory
Control Theory is defined simply as a discrepancy between a standard or goal and a current state should motivate behaviors in individuals to reach the goal.
Cognitive Behavioral theory identifies the importance of individual, social, and environmental factors that influence cognition, learning, emotions and behaviors. Cognitive behavioral theory contends individuals behaviors, emotions are determined by the way the individual thinks or believes.
The ARCC model supports when clinicians’ beliefs about the value of Evidence Based Practice and their ability to implement evidence based practice are strengthened, there will be greater implementation of evidence-based care.
Evidence based practice mentors play a central role to success of Evidence based practice.
Workshops and academic offerings are available that can develop these mentors
Barriers and facilitators to Evidence Based Practice, along with clinicians’ beliefs about and actual implementation of Evidence Based Practice, can be readily assessed and identified by organizations using established instruments

9. Promoting Action on Research Implementation in Health Services Framework (PARIHS)
Developed in an attempt to reflect the complexities of bringing evidence to practice
Elements are:
Evidence
Context
Facilitation
The next model is the Promoting Action on Research Implementation in Health Services Framework , the PARIHS framework represents a shift from focusing on individual practitioners and on barriers to a focus on the ability to achieve meaningful and planned behavior change involving individuals, teams, and organizations. The conceptual model reflects complexities, representing the interdependence and interplay of the many factors that appear to play a role in the successful implementation of evidence into practice.
Successful implementation is represented as a function of the nature and type of evidence , the qualities of the context in which the evidence is being introduced, and the way the process is facilitated.
The three elements; evidence, context, and facilitation are each positioned on a high-to-low continuum, where in each implementation effort, the aim is to move toward a “high” in order to optimize the chances of success.
Evidence is described as 4 different types of evidence; research, clinical experience, patients and caregivers’ experience, and local context of information.
Context is described as the setting or environment where the proposed change is to be implemented. The contextual elements function in a multileveled way. The subelements include: culture, leadership, and evaluation.
Facilitation is described as the process of facilitating the implementation of evidence into practice.
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10. The Clinical Scholar Model
Promotes:
The spirit of inquiry
Education of direct care providers
Guides a mentorship program for EBP
The next model is referred to as The clinical scholar model. It was developed to promote the spirit of inquiry, educate direct care providers, and guide a mentorship program for Evidence Based Practice and to conduct of research at the point of care. The model purports the staff nurse has a high degree of insight into linking practice and research.
The Clinical Scholar Program was developed to actualize the Clinical Scholar Model.
Clinical scholars are described as individuals with a high degree of curiosity that possess advanced critical-thinking skills and continuously seek new knowledge through continuous learning opportunities
Clinical scholar mentors play a central role
The program is composed of educating, processing, and mentoring. The program utilizes workshops
The Clinical Scholar Model Promotes a spirit of inquiry by utilizing the steps:
Observe and reflect
Critique and analyze
Synthesize
Apply and evaluate and lastly to
Disseminate
The workshops goals are to challenge the current nursing practices, to speak and understand research language, to critically appraise, critique and to synthesize, implement, evaluate and disseminate evidence and to educate direct care providers to serve as mentors to other direct care providers.
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12. The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP)
Facilitates bedside nurses in translating evidence to clinical, administrative, and educational nursing practice
Sets a goal to build a culture of nursing practice based on evidence
Aims to demystify the EBP process for bedside nurses and embed EBP into the fabric of nursing practice
The final model we will discuss is
The Johns Hopkins Nursing Evidence Based Practice Model (JHNEBP) facilitates bedside nurses in translating evidence to clinical, administrative, and educational nursing practice
The model sets a goal to build a culture of nursing practice based on evidence
The model aims to demystify the Evidence Based Practice process for bedside nurses and embed Evidence Based Practice into the fabric of nursing practice
The JHNEBP contains three major components:
Practice question
Evidence
Translation
Within these 3 components there are 18 prescriptive steps, in addition seven tools to support the 18 critical steps in the process.
A teaching guide is available for faculty. In addition a book is available with tools to guide teams when utilizing the JHNEBP model.
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13. Summary Models Stetler Model Iowa Model
The Model for Evidence-Based Practice Change
ARCC Model – Advancing Research & Clinical Practice Through Close Collaboration Model
PARIHS – Promoting Action on Research Implementation in Health Services Framework
The Clinical Scholar Model
JHNEBP – John Hopkins Nursing Evidence-Based Practice Model
In summary, the seven models described in this lesson are:
Stetler Model which is often referred to as the practitioner’s model.
The Iowa Model
The Model for Evidence-Based Practice Change
ARCC Model – Advancing Research & Clinical Practice Through Close Collaboration Model was Developed out of nurse input as well as Control Theory and Cognitive Behavioral Theory
PARIHS – Promoting Action on Research Implementation in Health Services Framework
The Clinical Scholar Model shifts from individual practitioners and barriers to a focus on the ability to achieve behavior change
JHNEBP – John Hopkins Nursing Evidence-Based Practice Model utilizes an 18 prescriptive step process throughout the model.
The seven models have common steps such as Identifying the stake holders or change agents who will help lead the change, identification of the problem, barriers to change, high-quality research to support the change, strategies to engage stakeholders to assist with the change. Once the change is implemented, evaluation, of the change is necessary and an identification of what should be in place to sustain the change in practice.
This is the end of the lesson.