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jessicaaajessCopyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 13
Models to Guide Implementation and Sustainability of Evidence-Based Practice
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Components That Need to Be Considered in the Clinical Decision-Making Model of EBP
- Patient preferences and behaviors
- Clinical state, setting, and circumstances
- Availability of healthcare resources
- High-quality research evidence
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Factors That Are Impacted by the Practitioner’s Clinical Expertise
- Quality of the initial assessment of the client’s clinical state and circumstances
- Problem formulation
- Decision about whether the best evidence and availability of healthcare resources support a new approach
- Exploration of patient preferences
- Delivery of the clinical intervention
- Evaluation of the outcome for that particular patient
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Commonalities Found in Models Used for Implementation of EBP
- Identifying a problem that needs addressing
- Identifying stakeholders or change agents who will help make the change happen in practice
- Identifying a practice change shown to be effective through high-quality research that is designed to address the problem
- Identifying and, if possible, addressing the potential barriers to the practice change
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Commonalities Found in Models Used for Implementation of EBP—(cont.)
- Using effective strategies to disseminate information about the practice change to those implementing it
- Implementing the practice change
- Evaluating the impact of the practice change on structure, process, and outcome measures
- Identifying activities that will help sustain the change in practice
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Commonly Used Models That Facilitate Integration of Evidence Into Practice
- The Stetler Model of Evidence-Based Practice
- The Iowa Model of Evidence-Based Practice to promote quality care
- The Model for Evidence-Based Practice Change
- The Advancing Research and Clinical practice through close Collaboration (ARCC) model for implementation and sustainability of EBP
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Commonly Used Models That Facilitate Integration of Evidence Into Practice— (cont.)
- The Promoting Action on Research Implementation in Health Services (PARIHS) framework
- The Clinical Scholar model
- The Johns Hopkins Nursing Evidence-Based Practice model
- The ACE Star Model of Knowledge Transformation
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Fives Phases of the Stetler Model of EBP
- Preparation: Identifying the purpose, context, and sources of evidence
- Validation: Assessing the credibility of the evidence and its statistical and clinical significance
- Comparative evaluation/decision making: Synthesizing evidence and making decisions/recommendations for use
- Translation/application: Developing plan for implementation and measurement of processes/outcomes
- Evaluation: Evaluation of processes and outcomes
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The Iowa Model of EBP
- Identifying problem- and knowledge-focused triggers
- Determining whether the issue is an organizational priority
- Forming a team
- Selecting, reviewing, critiquing, and synthesizing available research evidence
- Piloting the practice change
- Evaluating the pilot and dissemination of results
- Depending on pilot results, rollout and integration of the practice are facilitated with periodic evaluation
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Steps in the Model for Evidence-Based Practice Change (Larrabee, 2009; Rosswurm & Larrabee, 1999)
- Assess the need for change in practice: Stakeholders collect internal data and compare with external evidence/benchmarks to identify problems and link them with interventions and outcomes
- Locate the best evidence: Determine the types and sources of evidence; plan and conduct the search
- Critically analyze the evidence: Appraise, weigh, and synthesize evidence; assess feasibility, benefits, and risks
- Design practice change: Define proposed change and resources needed; design pilot implementation and its evaluation
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Steps in the Model for Evidence-Based Practice Change (Larrabee, 2009; Rosswurm & Larrabee, 1999)—(cont.)
- Implement and evaluate change in practice: Implement pilot; evaluate processes, costs, and outcomes; develop conclusions and recommendations
- Integrate and maintain change in practice: Communicate pilot results to stakeholders and make recommendations; integrate change into practice; routinely monitor process and outcomes; disseminate monitoring results and celebrate successes
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The Advancing Research and Clinical Practice Through Close Collaboration Model (ARCC© Model)
- Provides healthcare institutions and clinical settings with an organized conceptual framework that can guide system-wide implementation and sustainability of EBP to achieve quality outcomes
- Model is a product of nurse input about barriers and facilitators of EBP, control theory (Carver & Scheier, 1982, 1998), and cognitive behavioral theory (Beck, Rush, Shaw, & Emery, 1979)
- Use of mentors is a central mechanism for implementing and sustaining EBP
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Control Theory as a Conceptual Guide for the ARCC Model
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The ARCC Model
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Promoting Action on Research Implementation in Health Services Framework (PARIHS) Framework
Framework is based on the formula:
SI = f(E,C,F)
where SI represents successful implementation; f, function of; E, evidence; C, context; and F, facilitation
- The three elements (i.e., evidence, context, and facilitation) are each conceptualized on a high-to-low continuum; the focus is to move the elements in the formula toward “high” in order to optimize the chances of success
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The PARIHS Framework—(cont.)
The three PARIHS elements and their subelements:
- Evidence: Propositional and nonpropositional knowledge from the subelements of research, clinical experience, patient experience, and local data/information
- Context: The environment in which the proposed change is to be implemented. Subelements include culture, leadership, and evaluation.
- Facilitation: The process of enabling or making easier the implementation of evidence into practice. Subelements include role, skills, and attributes.
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The Clinical Scholar (CS) Model
- Developed to promote the spirit of inquiry, educate direct care providers, and guide a mentorship program for EBP and the conduct of research at the point of care
- Clinical scholars are described as individuals with a high degree of curiosity that possess advanced critical thinking skills and continuously seek new knowledge through learning opportunities
- Clinical scholar mentors play a central role in the model
- The Clinical Scholar Program was developed to actualize the Clinical Scholar Model
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The Clinical Scholar (CS) Model—(cont.)
Four central goals of the model include that the CS should be able to:
- Challenge current direct care practices
- Speak and understand research language, making day-to-day dialog about new research findings a common occurrence
- Critique and synthesize current research as the core of evidence
- Serve as mentors to other staff and to teams who question their clinical practices and seek to improve clinical outcomes
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The Johns Hopkins Nursing Evidence- Based Practice (JHNEBP) Model
- Facilitates bedside nurses in translating evidence to clinical, administrative, and educational nursing practice
- Sets a goal of building 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
- Desired outcomes include enhancing nurse autonomy, leadership, and engagement with interdisciplinary colleagues
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The JHNEBP Conceptual Model
(From Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International. Used with permission.)
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The JHNEBP Process for EBP:
The PET Process
- Practice question: Identify an EBP question and define its scope; leadership responsibility assigned and interdisciplinary stakeholders recruited for team; team meetings scheduled
- Evidence: Internal and external evidence search conducted; evidence critiqued, summarized, and rated; recommendations developed depending on the evidence strength and need for change
- Translation: Determine appropriateness of recommendation in specific settings; develop action and evaluation plan; implement plan; evaluate and report outcomes; secure support for widespread change; identify next steps
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The ACE Star Model
- Development of the ACE Star Model was prompted through the work of the Academic Center for Evidence-Based Practice (ACE) at the University of Texas Health Science Center San Antonio during the early phases of the EBP movement in the United States
- The ACE Star Model explains how to overcome the challenges of the volume of research evidence; the misfit between form and use of knowledge; and integration of expertise and patient preference into best practice
- The ACE Star Model is a model of knowledge transformation, to which quality improvement of healthcare processes and outcomes is the goal
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The ACE Star Model—(cont.)
(© Stevens, 2004. Reprinted with expressed permission.)
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The ACE Star Model—(cont.)
- Star Point 1: Discovery—represents conduction of primary research studies
- Star Point 2: Evidence summary—represents the synthesis of all available knowledge compiled into a single harmonious statement/document, such as a systematic review
- Star Point 3: Translation into action—combining the existing evidential base with expertise to extend recommendations into evidence-based clinical practice guidelines
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The ACE Star Model—(cont.)
- Star Point 4: Integration into practice—practice is aligned to reflect the best evidence
- Star Point 5: Evaluation—an inclusive view of the impact that the evidence-based practice has on patient health outcomes, satisfaction, efficacy and efficiency of care, and health policy
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Question
The use of EBP mentors is a major component of which model for evidence-based practice change?
- The Model for Evidence-Based Practice Change
- The ARCC© model
- The Stetler model
- The Iowa model
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Answer
b. The ARCC© model
Rationale: The ARCC model is the only model of those listed that considers the lack of EBP mentors to be a major barrier to the implementation of EBP and uses training of a cadre of EBP mentors as a step in implementing the model.
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Question
Is the following statement true or false?
Both the Model for Evidence-Based Practice Change and the Iowa model include the use of a small-scale pilot study during the process of introducing an evidence-based change in practice.
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Answer
True
Rationale: Pilot studies are explicit components of both the Model for Evidence-Based Practice Change and the Iowa model.
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Question
Feedback loops are a central component of which of the following models for evidence-based practice change?
- The Model for Evidence-Based Practice Change
- The Clinical Scholar model
- The ARCC model
- The Iowa model
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Answer
d. The Iowa model
Rationale: The Iowa model includes multiple feedback loops that refer the user back to earlier points in the process. This is not a central feature of the Model for Evidence-Based Practice Change, the Clinical Scholar model, or the ARCC model.
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