ASSIGNMENT

ON
EVIDENCED BASED
PRACTICE
MODEL
Submitted to: submitted by:
MRS Gomathy , P.Manojkumar
Associate professor, Msc nursing 1st year,
Dept of medical surgical nursing, VMCON.
VMCON.

Submitted on: 24-04-2020

 EVIDENCED BASED PRACTICE MODEL
Introduction:
During the 1980s, the term “evidence-based medicine” emerged to describe the approach that used
scientific evidence to determine the best practice. Later, the term shifted to become “evidence-based
practice” as clinicians other than physicians recognized the importance of scientific evidence in clinical
decision-making. Various definitions of evidence-based practice (EBP) have emerged in the literature, but
the most commonly used definition is, “the conscientious, explicit, and judicious use of the current best
evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Hayes, &
Richardson, 1996).
Subsequently, experts began to talk about evidence-based healthcare as a process by which research
evidence is used in making decisions about a specific population or group of patients. Evidence-based
practice and evidence-based healthcare assume that evidence is used in the context of a particular patient’s
preferences and desires, the clinical situation, and the expertise of the clinician. They also expect that
healthcare professionals can read, critique, and synthesize research findings and interpret existing evidence-
based clinical practice guidelines.
The history of medicine and education:
In recent years EBP has been stressed by professional organization such as American psychological
association, American occupational therapy association, American physical therapy association. which have
also recommended their member to carry out investigation to provide evidence supporting or rejecting the
use of specific intervention.
Areas of professional practise such as medicine, psychology, psychiatry, rehabilitation, and so forth have
had period in their past where practise based on loose bodies of knowledge.

Evidenced based practice:

Evidence-based practice (EBP) results from the integration of available research, clinical
expertise, and patient preferences to individualize care and promote effective care decision-making.
The impact of EBP on nursing and patient outcomes is clearly evident. Many organizations have developed
competency-based, nurse-led EBP programs that are redesigning care delivery to increase the effectiveness
and efficiency of interventions while reducing costs and safety risks. For EBP integration to be successful
and sustainable, a culture of EBP readiness must exist through ongoing leadership support, EBP resource
availability, and adoption of an EBP implementation framework.
In recent years, nurse scientists have developed several EBP models to help demystify the process of
translating research into clinical practice. Although the models include varying levels of detail, they share
the following basic phases of the EBP process.
 Ask: Identify a clinical problem.
 Attain: Review relevant literature.
 Appraise: Critically appraise evidence.
 Apply: Evaluate the need for practice change and potential implementation.
 Assess: Evaluate outcomes.
Organizations must adopt the EBP model that best fits their context of care, aligns with improvement
goals, addresses priority clinical problems, and guides a systematic and evaluative approach to collaborative
practice change.

Importance of evidence-based practice:

Evidence-based practice helps nurses provide high-quality patient care based on research and
knowledge rather than because “this is the way we have always done it,”or based on traditions, myths,
hunches, advice of colleagues, or outdated textbooks.
For example, when clinical questions arise, should one look to a nursing textbook for the answers?
Remember that books are not published every year, and new information may not be included in the edition
you have.Also, when using textbooks, consider whether you have the most current edition. There are also
issues to consider when asking colleagues for advice—specifically, be mindful that their responses may be
based on their personal experiences, their observations, what they learned in school, what was reviewed
during nursing orientation, or myths and traditions learned in clinical practice.Evidence-based practice
provides a critical strategy to ensure that care is up to date and that it reflects the latest research evidence.

Importance of EBP to nursing practice:

• It results in better patient outcomes
• It contributes to the science of nursing
• It keeps practice current and relevant
• It increases confidence in decision-making
• Policies and procedures are current and include the latest research, thus supporting JCAHO-readiness
• Integration of EBP into nursing practice is essential for high-quality patient care and achievement of
ANCC Magnet Recognition Program® (MRP) designation
Evidence-based practice can be easier for nurses to use if they refer to already-developed evidence -
based or clinical practice guidelines. Numerous expert groups have already undertaken systematic efforts to
develop guidelines to help both healthcare providers and patients make informed decisions about care
interventions. Guideline developers use a systematic approach to critique the existing research, rate the
strength of the evidence, and establish practice guidelines.The overall goal of these types of efforts focuses
on guiding practice and minimizing the variability in care.
For example in 2002, the Centers for Disease Control and Prevention published Guideline for Hand
Hygiene in Health-Care Settings, which provides healthcare workers with a review of data regarding hand-
washing and hand antisepsis in healthcare environments. Furthermore, it makes recommendations to
improve hand-hygiene practices and reduce transmission of pathogenic microorganisms to both patients and
healthcare personnel.

Barriers of implementing evidence-based practice among nurses:

Nurses often report the following:
• Lack of value for research in practice
• Difficulty in changing practice
• Lack of administrative support
• Lack of knowledgeable mentors
• Insufficient time to conduct research
• Lack of education about the research process
• Lack of awareness about research or evidence-based practice
• Research reports/articles not readily available
• Difficulty accessing research reports and articles
• No time on the job to read research
• Complexity of research reports
• Lack of knowledge about EBP and critique of articles
• Feeling overwhelmed by the process
Despite these barriers, nurses are engaging in EBP and making a difference in patient outcomes.
Furthermore, barriers can be overcome through organizational efforts focused on integrating research in
practice and using strategies such as journal clubs, nursing grand rounds, and having research articles
available for review. Evidence-based practice takes resources, work, time, and effort, but the outcomes make
them worthwhile. Every patient deserves care that is based on the best scientific knowledge and that ensures
high-quality, cost-effective care.

5 step process :
The practise of evidence based practice include five fundamental steps.
Step 1: formulating a well built question
Step 2: identifying articles and other evidence based resources that answer the question.
Step 3: critically appraising the evidence to assess its validity.
Step 4: applying the evidence.
Step5: re evaluating the application of evidence and areas for improvement in the lesson, you will learn
about the five steps in detail.
Step 1 formulating the question:
With clinical cases, there is often a barrage of details to digest. To effectively search EBP resources, you
first need to decide what details are important to the question at hand so you can formulate question.
A well built clinical question includes the following components.
The outcome. The acronym PICO assists in remembering the step P- patient or problem I - intervention c-
comparison o- outcome.
Framing good questions:
1. Describe the subject
2. Define which intervention
3. Define the type of outcome

Step 2 database/resource searching

These resources generally fall into three catogories and are used in sequential order depending on need and
applicability the three catogories are;
a) General information
b) Filtered resources
c) Unfiltered resources
General information:
You may often encounter conditions outside your specialty area or that you don’t see often and need to get a
comprehensive overview. Background resources provide excellent detailed information.
Filtered source:
If you are trying to decide on a cource of action for a patient ( diagnosis, treatment, ) and want to base your
decision on the best available evidence , consult, a filtered source.
Unfiltered source:
If you don’t find an appropriate answer in the filtered resources you will need to search unfiltered resources
to locate studies that answer your question.
Unfiltered resources provide the most recent information but its up to the clinician to evaluate each study
found to determine its validity and applicability to the patient.
Step 3 critical appraisal:
After identifying an article or resources that seems appropriate to your question you must appraise the
information critically. Validity – to check validity for ask questions related to diagnosis, therapy, harm, and
prognosis.
Step 4: applying the evidence:
Once you have determined that a study is internally valid you must decide how the study and information
applies to your question.
Step 5: re evaluating the evidence:
In the process of executing evidence based practise you have developed a clinical question sought out
answer to verify and support your clinical decision and ultimately applied the findings to your patient.
You may ask question such as;
a) Was the diagnosis and treatment successful?
b) Is there new information /data in the literature?
 c) How can I improve and / or update my clinical decisions?

The EBP process :

The most common definition of EBP is taken from dr david a pioneer in evidenced practice. EBP is the
integration of clinical expertise patient values and the best research evidence into the decision making.
Why evidence based practise:
It is one step toward making sure each client gets the best service possible.
Some argue it helps keeps your knowledge up to date supplement clinical judgement can save time and most
important can improve care and even save lives.
The major sources of research for use in EBP:
1) The Cochrane collaboration
2) The camphell collaboration
3) C2 specter
4) C2 RIPE (register intervention and policy evaluation.)
5) On going government sponsored clinical trial
Evidenced based practice model:
The common EBP models are:
1) The Iowa Model for Evidence-Based Practice to Promote Quality Care.
2) The Advancing Research and Clinical Practice Through Close Collaboration Model.
3) The Johns Hopkins Nursing Evidence-Based Practice Model.
4) The Promoting Action on Research Implementation in Health Services (PARIHS) Framework.
5) Stetlar model
6) Academic center for evidenced based practise (ACE) star mode
 THE IOWA MODEL FOR EVIDENCE-BASED PRACTICE TO PROMOTE
QUALITY CARE:
The Iowa Model for Evidence-Based Practice to Promote Quality Care has been revised to better address
sustainability of EBP, interprofessional change implementation, and patient-centric care for clinicians at all
levels of practice, guiding them through a team-based, multiphase process. The path initiates with a clinical
“trigger” that identifies a clinical problem and includes decision points with evaluative feedback loops when
recommending and implementing practice change. The model phases are interprofessional team formation;
evidence review, critique, and synthesis; change implementation through piloting; ongoing evaluation; and
outcomes dissemination.
Steps in IOWA model:
1. Identify either a “problem-focused trigger” or “knowledge-focused trigger” that will generate the
need for a practice change.
2. Determine whether the “trigger” is a healthcare organization priority.
3. Reflect a team’s topic of interest and include interested stakeholders. The team will search, appraise,
and synthesize literature related to the topic.
4. Evaluate the availability and merit (e.g., level of evidence, quality of evidence) of evidence. If
evidence availability and merit are lacking, conduct research.
5. If credible and reliable evidence is available, pilot the practice change.
6. Appraise pilot for level of success. If pilot is successful, disseminate findings within the organization
and implement recommended change into practice.

THE ADVANCING RESEARCH AND CLINICAL PRACTICE THROUGH CLOSE

COLLABORATION MODEL:
The Advancing Research and Clinical Practice Through Close Collaboration Model is for building resources
and training mentors who play a central role in facilitating and sustaining EBP at the point-of-care and
throughout the organization. The model has seven steps: cultivating a spirit of inquiry; asking a PICOT-
formatted clinical question; collecting, critically appraising, and integrating the best evidence with clinical
expertise and patient preferences; and evaluating and disseminating practice change outcomes.
This model mainly addresses implementations of EBP and is mostly likely seen large organizations
such as hospitals and community practices. It really is difficult to choose one model over the other as each one
brings something different to the table. The ACE model is effective in that it uses current research as a
foundation and takes the patient/family into account. It takes what we have learned from our research to help
change patient outcomes through EBP. The ARCC model benefits an organization as a whole..
 THE JOHNS HOPKINS NURSING EVIDENCE-BASED PRACTICE MODEL:
The Johns Hopkins Nursing Evidence-Based Practice Model is clinician-focused, allowing rapid and
appropriate application of current research and best practices. It simplifies the EBP process and cultivates a
culture of care based on evidence. It has three overall steps: practice question, evidence, and translation. Its
directive tools are intended for practicing clinicians working individually or in a group to address clinical
inquiries.

Steps involved are:

 Practice Question: Using a team approach, the EBP question is identified.
 Evidence: The team searches, appraises, rates the strength of evidence, describes quality of evidence,
and makes a practice recommendation on the strength of evidence.
 Translation: In this stage, feasibility is determined, an action plan is created, and change is
implemented and evaluated. Findings are presented to the healthcare organization and broader
nursing community.
THE PROMOTING ACTION ON RESEARCH IMPLEMENTATION IN HEALTH
SERVICES (PARIHS) FRAMEWORK:
The Promoting Action on Research Implementation in Health Services (PARIHS) Framework has been
revised into the integrated or i-PARIHS framework. The framework refers to evidence-based change as
practice innovation. It contends the core elements of successful implementation of practice innovation is
dependent on the type of evidence available, context of the care setting, and how the process is facilitated.
The framework emphasizes the importance of taking into consideration the perspectives of all recipients of
the intended change.
The PARiHS (Promoting Action on Research Implementation in Health Services) framework provides a
way to implement research into practice. With case studies of teams implementing evidence, it examines the
interactions between three key elements for knowledge translation.
Three factors determine research use:

 Evidence (E)
 Context (C)
 Facilitation (F)

Significantly, this framework argues that successful implementation (SI) of evidence into practice had as
much to do with the context or setting where the new evidence was being introduced and how that new
evidence was introduced (facilitated into practice) as it had to do with the quality of the evidence.
The PARIS framework incorporates themes from the literature on research use, such as:

 Implementing research into practice is an organizational issue rather than an individual issue.
 The research evidence must be strong (such as a systematic review of methodologically sound studies)
before implementation is justified.
 Strategies for implementation require careful planning and need to consist of a range of interventions
that address the need for education, audit and the management of change.
 Criteria for evaluating the impact of the intervention must be identified and agreed upon before
implementing any change.

The main features of the PARiHS framework include:

 Evidence encompasses codified and non-codified sources of knowledge, including research evidence,
practitioner experience, community preferences and experiences, and local information.
 Melding and implementing such evidence in practice involves negotiating and developing a shared
understanding about the benefits, disadvantages, risks and losses of the new practice over the old.
 Some contexts are more conducive to the successful implementation of evidence into practice than
others, such as organizations that have transformational leaders, elements of learning organizations
and evaluation mechanisms.
 The framework emphasizes the need for appropriate facilitation to improve the likelihood of success.
The needs of the organization determine the type of facilitation and the role and skill of the facilitator.
Facilitators work with individuals and teams to enhance the implementation process.

STETLER MODEL
The Stetler Model was the first to be published in the USA in the 1970s. The purpose of the model was to
direct nursing postgraduates on how to apply research results to their professional performance. This model
presents guidelines for the translation of evidence and the implementation steps. It was conceived as an
advanced instrument for EBP guidance and an important reference for the training of specialist nurses. The
author presented reformulations of the model with publications aimed mainly at the political use of research
results for decision-making in hospitals.

Steps involved are:

Step=I. Preparation: Identify a priority need. Identify the purpose of the EBP project, context in which the
project will occur, and relevant sources of evidence.

Step=II. Validation: Assess sources of evidence for level and overall quality. Determine whether source has
merit and goodness of fit and whether to accept or reject the evidence in relation to project purpose.
Step=III. Comparative Evaluation/Decision Making: Evidence findings are logically summarized and
similarities and differences among sources of evidence are evaluated. Determine whether it is acceptable and
feasible to apply summation of findings to practice.

Step=IV. Translation/Application: Develop the “how to’s” for implementation of summarized findings.
Identify practice implications that justify application of findings for change.

Step=V. Evaluation: Identify expected outcomes of the project and determine whether the goals of EBP
were successfully achieved.
ACADEMIC CENTER FOR EVIDENCED BASED PRACTISE( ACE) STAR MODE:
As a framework, the ACE Star Model aids in systematically integrating best evidence into practice. The
model has five major stages that depict forms of knowledge in relative sequence. Research moves through
the cycles to combine with other forms of knowledge before integration into practice occurs.
Stages:
 Discovery: This stage involves searching for new knowledge found in traditional quantitative and
qualitative methodologies.
 Evidence Summary: The primary task is to synthesize the body of research knowledge into a
meaningful statement of evidence for a given topic. This is a knowledge-generating stage, which
occurs simultaneously with new findings that may arise from the synthesis.
 Translation: The aim of translation is to provide clinicians with a practice document (e.g., clinical
practice guideline) derived from the synthesis and summation of research findings.
 Integration: Practitioner and healthcare organization practices are changed through formal and
informal channels.
 Evaluation: An array of EBP outcomes are evaluated on impact, quality, and satisfaction.

As learners go from one point on the star to the next- they begin to have a context withinwhichto place
the various aspects of EBP. Evidenced based processes and methods vary from one pointof the Star model to
the next and depend on the “form” of knowledge at that particular stage of transformation. For example-
research findings represented on the first point are transformed intoa single statement by combining all
research (point 2 of the Star). The ACE Star model places precious research utilisationwork within
the context of the more comprehensive EBP paradigmand serves as an organiser for examining and applying
EBP.

Conclusion:
Although these are just a few models for translating evidence into practice, each outlines and
promotes the need for a systematic approach to evidence-based change. Each addresses the sustainability of
EBP through organizational culture change, stakeholder engagement, comprehensive literature review and
appraisal, barrier identification, impact evaluation, and outcomes dissemination. Regardless of the preferred
model, the EBP process should tell the story of how a problem was recognized, addressed, and improved,
and that story should be shared.It seems clear that while there are still kinks to be worked out, evidence-
based practice models are here to stay and all of the benefits it can provide, we will certainly all be able to
reap many benefits from this models.

Bibliography:
1) P. shabeer ,sheer syaheen khan text book of “Advanced nursing practise” 2012 first edition
published by EMMESS medical publication page no 751 -759.

2) https://www.coursehero.com/file/p64bb9q/ARCC-Model-a-five-step-process-that-is-used-for-
organization-use-based-on/
3) https://www.scribd.com/document/330879324/ACE-Star-Model