Updating the Stetler Model of Research Utilization
to Facilitate Evidence-Based Practice
Cheryl B. Stetler, PhD, RN, FAAN
The evidence-based practice movement raises ques-
tions about the continuing viability of research utiliza-
tion models. This manuscript describes the updated,
practitioner-oriented Stetler Model. First developed in
1976 with Marram, it was refined in 1994 with
conceptual underpinnings and a set of assumptions.
The model has been further refined on the basis of a
related utilization-focused integrative review meth-
odology, targeted evidence concepts, and continuing
experience through use of the model with clinical
nurse specialists. The revised model continues to
focus on a series of judgmental activities about the
appropriateness, desirability, feasibility, and manner
of using research findings in an individual’s or
group’s practice.
T he concept of research utilization (RU) emerged in nursing
in the early 1970s.1-3 Since that time, several RU models
have been incorporated into basic research texts,4,5 and appli-
cation of such models have been published in nursing jour-
nals.6 In the 1990s a “new” concept, evidence-based practice
(EBP),7 appeared. Its emergence raises questions about the
relationship of RU and EBP. Also, with publication of models
for evidence-based nursing, the status and relevancy of tradi-
tional RU models need to be addressed.
A frequently cited RU model is the Stetler/Marram Model.1
Now referred to as the Stetler Model, on the basis of a 1994
refinement,8 this model reflects a practitioner-oriented approach,
that has been updated within the context of EBP. This article
outlines model refinements, including an expanded set of assump-
tions, and affirms its core as a critical-thinking process, whether
used by an individual or by individuals operating within a group.
BACKGROUND
RU is the process of transforming research knowledge into
practice. There are 2 types of research knowledge, specifically,
knowledge regarding the products of research and knowledge
regarding the process of research. In turn, there are 2 types of
RU, specifically, use of research as a set of products and use of
research as a set of processes.9 Use of research products refers
to use of research findings, including validated measuring
Cheryl B. Stetler is a consultant of evidence-based practice, Amherst,
Massachusetts.
Nurs Outlook 2001;49:272-9.
Copyright © 2001 by Mosby, Inc.
0029-6554/2001/$35.00 + 0 35/1/120517
doi:10.1067/mno.2001.120517
272 Stetler
instruments. Use of research-as-a-process refers to use of indi-
vidual components of the research method for the purpose of
routine problem-solving rather than for the conduct of
research. Both research products and research-as-a-process
come into play in the Stetler Model of RU, but the model’s
primary focus is use of research findings.
Evidence-Based Practice
Neither evidence nor EPB is uniformly defined. Although many
of the emerging nursing-related models for EBP build on prac-
titioner-oriented definitions from medicine,10,11 their focus is
usually creation of formal change within an organizational
setting for groups of nurses and/or interdisciplinary groups.12,13
Nursing at Baystate Medical Center14 developed an EBP
model that de-emphasizes practice based on tradition and
instead stresses use of research findings as well as other sources
of credible information or data. Other sources include reliable,
verifiable data from quality improvement, operational, or eval-
uation projects; consensus of national or local experts; and
affirmed clinical experience. Stetler15 has clarified this EBP
model by further differentiating external and internal
evidence. External evidence refers primarily to research findings
but also includes consensus of national experts. Internal
evidence refers to the aforementioned “other sources of credible
information or data.” The credibility of the latter data is
enhanced through use of research-as-a-process.
Although the terminology of evidence was adopted,14 this
nursing department’s goal was to enhance use of research—
both as a product and as a process. The Stetler Model8 and the
Stetler approach to use of research-as-a-process16 provided
conceptual underpinnings for this EBP model. Use of evidence
to create formal change for groups of practitioners thus was
seen as important but so, too, was use by individual nurses as
part of critical thinking and reflective practice.17
Relationship of Research Utilization and
Evidence-Based Practice
The relationship of EBP and RU is somewhat murky in the
literature, especially since nursing’s long-term efforts with RU
are apparently unknown to the medical profession, which is
leading the EBP movement. The 2 concepts are not the same,
but their integration, as occurred at Baystate Medical Center,
provides an enhanced approach to the overall application of
research in the service setting. Figure 115 illustrates this rela-
tionship, with RU providing the requisite preparatory steps for
research-related actions that, when implemented and
sustained, result in EBP. In addition, both EBP as defined
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Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice
Figure 1. From research to outcomes with EBP.
earlier14 and the Stetler RU model are grounded in critical
thinking. They both are “mindsets” for professional practice
and are enhanced by a culture of clinical scholarship.17
The 2 concepts are not the same,
but their integration, as occurred
at Baystate Medical Center,
provides an enhanced approach to
the overall application of research
in the service setting.
EVOLUTION OF THE STETLER MODEL
Unlike other models, the Stetler Model1,8 was developed as a
prescriptive approach that, again, emphasizes the key role of
critical thinking in RU. Specifically, this model formulated a
series of critical-thinking and decision-making steps designed
to facilitate safe and effective use of research findings.
The 1994 version was based on research on the concept of
RU and outlined a set of underlying assumptions that clarified
the complex and varied nature of RU. It also included a set of
applicability criteria that are used to determine the desirability
and feasibility of applying a validated study or studies to an
identified issue or catalyst. These criteria are substantiating
evidence; current practice, which relates in part to the extent of
the need or desire to change; fit, of the substantiated findings
for the targeted user(s) and related setting; and feasibility, of
implementing the substantiated findings. Feasibility involves,
first and foremost, assessment of the degree of risk, as
compared to the expected benefit of research-based change.
Feasibility also includes determination of the availability of
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Stetler
needed resources and, if applicable, the cooperation, support,
or readiness of stakeholders. Finally, both versions of the
model1,8 contained the term “evidence,” and the 1994 model
used concepts currently identified with EBP, eg, strength of
findings and a systematic review.
The updated model retains the elements just described but
now highlights, as detailed later, the synthesis process and
additional concepts of evidence. Other changes in the model
include increased specification of the preparatory phase,
increased attention to the application and evaluation processes
at a group level, and refinement of assumptions on the basis of
concepts of evidence and variations in practice. Most refine-
ments to the model are the result of the following:
1. The author’s development, with clinical nurse specialists
and other nursing leadership at Baystate, of an in-depth
method for utilization-focused integrative reviews.18
2. Experience with an alternative model of evaluation19 for
cases in which use is at a group or organizational level.
3. Continuing model experience through use with clinical
nurse specialists.18,20,21
4. Literature on EBP relative to both individual clinicians and
planned organizational change.22,23
Other changes in the model include
increased specification of the
preparatory phase, increased atten-
tion to the application and evalua-
tion processes at a group level, and
refinement of assumptions on the
basis of concepts of evidence and
variations in practice.
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Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice
Table 1. Assumptions of the practitioner-oriented Stetler Model of RU
Assumptions
1. The formal organization may or may not be
involved in an individual’s utilization of research.
2. Utilization may be instrumental, conceptual
and/or symbolic.
3. Other types of evidence and/or nonresearch-related
information are likely to be combined with
research findings to facilitate decision-making
or problem-solving.
4. Internal and external factors can influence an
individual’s or group’s view and use of evidence.
5. Research and evaluation provide us with probabilistic
information, not absolutes.
6. Lack of knowledge and skills pertaining to research
utilization and EBP can inhibit appropriate and
effective use.
*Other individuals may be the target of application, such as staff nurses, managers, students, families, administrators, etc.
ASSUMPTIONS AND CONCEPTUAL BASE
The refined set of assumptions underlying the 2001 version is
presented in Table 1. As before, a core assumption is that RU
is not operationalized only in the form of organizational poli-
cies, procedures, or protocols. Rather, research on knowledge
utilization and case examples provide evidence of informal use
by individual clinicians and managers.8,24
Although noted in the 1994 narrative, the fact that use can
take different forms, often in terms of cognitive changes or
enlightenment,8,24 has now been listed as an assumption.
Estabrooks25 recently affirmed this multiple use of research
findings among a nursing population.
RU [research utilization] is the
process of transforming research
knowledge into practice.
Two other key assumptions relate to the observation that RU
is not an activity that necessarily results in the use purely of
research findings or even in commonly perceived research results:
• Assumption No. 3 is a refinement, per the language of
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Stetler
Comments
Use of research findings can occur informally and routinely at the level of an
individual clinician, manager, educator, or other specialist when that individual has
relevant competencies and continuously updates his or her knowledge base. Use by
individuals can also be directed by the organization through research-based policies,
procedures, and additional prescriptive documents or facilitated by organizational
education, use of experts, or other strategies.
Use of research findings may be direct and observable or indirect and difficult to
identify. Use can change one’s way of thinking or influence a direct, observable plan
of action. It also can, appropriately or inappropriately, be used to persuade others to
shift their thinking and behavior.
Theoretical, experiential, and other forms of information are more likely to be used to
supplement research findings than they are to be ignored. Some of this information
may take the form of alternative sources of evidence, eg, consensus of national
experts (external evidence) or local program data and local consensus per affirmed
experience14,15 (internal evidence).
RU is influenced not only by scientific criteria but also by
characteristics of the individual user(s) and the related environment—both local and
external to the setting.
Findings from research, as well as results from local evaluations, are often expressed in
terms of means, standard deviations, or other inferential statistics. Also, at times
research explains only “some of the variance.” Such data do not provide
unconditional direction for application to all patients* in all situations. Targeted
individuals’ preferences, needs, disease experience, or biologic or cultural status may
require reasoned variation from a generally applicable finding.
Given the complex nature of RU and the often complex nature of practice, the
following are essential to effective and safe utilization: knowledge of basic concepts
of research; RU knowledge and skills, including use of prescriptive models and
utilization-focused appraisal/synthesis; EBP knowledge and skills, including use of
EBP models and tables of evidence; knowledge and interpretive skills regarding
inferential statistics and the applicability of findings at the individual level, including
appropriate vs inappropriate variation; knowledge of the substantive area under
consideration; and critical-thinking skills.
evidence, of the original statement that “experiential and
theoretical information are more likely to be combined with
research information than they are to be ignored.”8 Available
research often does not completely answer relevant ques-
tions. Thus, research-related decisions may be made on the
basis of a compilation of evidence, including consensus, as
well as other information, such as a conceptual framework.
• Assumption No. 4 (see Table 1) converts the 1994 version’s
narrative discussion of environmental inputs and internal
throughputs8 into an added assumption, ie, that factors
external to available science can influence utilization deci-
sions. Such factors include an individual’s knowledge, atti-
tudes, and adopter style,23,26 as well as environmental and
organizational characteristics.23 A related factor is that
research findings are interpreted, and such interpretations are
not free from the “documented ... wide range of weaknesses
and flaws in unaided human thought processes.”27 This is
true whether the user is an individual, group, or organization.
The next assumption in Table 1, regarding probabilistic
information, relates to the necessity of determining the applic-
ability of generalized findings or related recommendations to
an individual patient, staff member, or other target of use. As
noted in the 1994 version, “Specific intervention characteris-
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Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice
Figure 2. 1994 Stetler Model.
tics are most often not viewed as determining outcomes but
rather as affecting the probability of specific effects.”28 Two
refinements to this assumption are as follows:
• The concept of appropriate, versus inappropriate, variation
is introduced. Not all variation in practice from a general
research finding is inappropriate; rather, it can indicate
reasoned individualization. Appropriate variation is made
on the basis of pragmatic reporting by the researcher and
skillful reading by the potential user of exclusion criteria
and data regarding standard deviations, confidence inter-
vals, or reports of outliers or clinically significant
subgroups. Appropriate variation also is made on the basis
of the application of findings and related qualifiers18,29 by
an RU-competent practitioner who understands the need
to assess a target’s preferences,30 issues of risk versus benefit,
and other relevant conditions.8 The bottom line of RU,
given this assumption, is the application of findings to indi-
vidual patients, staff members, or other targets through a
critical-thinking process. Without such thinking, applica-
tion of research can become a mechanistic, unthinking task
that sometimes leads to inappropriate practice.
• The term “evaluation” is included in the probabilistic infor-
mation assumption to remind users that internal data, eg,
from an RU pilot, usually are derived on the basis of a
sample of targeted individuals or units and must be treated
with the same caution as research findings.
The final assumption, as with the 1994 version, states the
requirement that users of the model have a certain level of
competency15 or the support of individuals with such compe-
tencies. Competencies directly relevant to EBP have been added.
MODEL REFINEMENTS
The 1994 model is provided in Figure 2 for comparison.
Those unfamiliar with that version8 may find a review helpful
because all relevant conceptual details and related examples are
not repeated in this article.
The refined visual mode (Figures 3A and 3B) has 2 sections
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Stetler
rather than 1. The first is the traditional graphic, which now
contains 5 rather than 6 phases. The new section contains, per
phase, clarifying information and options, parts of which come
from the 1994 phase IV and narrative. Once again, individuals
or individuals operating as a group can use the model, and all
phases apply to both sets of users. However, specific content
within some phases, especially phase IV, now provides alterna-
tives clearly applicable to planned organizational use. There also
are certain decisions that are now iteratively made as the user
moves through the model. For example, although highlighted in
phase III, the concept of fit is addressed more clearly on multiple
occasions.
Phase I Refinements
Initiating RU should be a “conscious, critical thinking
process.”8 The preparatory phase, therefore, is more specific
about the need for clarity of purpose and potential significance
of internal or external factors. It reminds the user to consider,
upfront, the following:
• External, environmental factors that can influence potential
application, eg, politics, an imposed deadline, or the prior-
itized goals of the organization.
• Internal, personal factors that can diminish objectivity, eg,
personal beliefs or the intuitive appeal of new interventions.
The model now directs users to be conscious of the types of
research18 to be sought and selected for review. For example,
users need to consider whether a specific type of catalyst or
specific stakeholders demand use of only experimental research.
More likely, for a nursing-related problem, a mix of research
will provide valuable insights, at times along with other types of
information such as consensus guidelines. In any case, users
should clearly differentiate the sources of relevant information
identified in a literature search and select appropriately.
Phase II Refinements
The focus of this phase continues to be a utilization-focused
versus traditional research critique of each source of evidence.
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Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice
Figure 3A. Stetler Model, Part I: Steps of research utilization to facilitate EBP.
In a utilization review, as Brown31 notes, “unlike critiques you
may have done in the past, when seeking research-based
answers for clinical questions it is the findings that are
appraised not the study per se.”
A major revision to this phase is use of a set of utilization-
focused review tables, available in a companion publication.18
Specifically, reference is made to both a methodologic factor
table and a utilization factor table, each with a related set of
detailed instructions.18 These instructions deal with proba-
bilistic meanings and the need to “reflect studied relationships or
variables in terms that could pragmatically be used in daily activ-
ities.”8 This includes the need to specify caveats or qualifiers for
application. The methodologic factor table makes reference to
strength of findings8 and uses the EBP contribution of strength
of evidence tables.14 The utilization factor table integrates the
original “statement of findings”8 concept for individual studies.
Over time, advanced practice nurses can integrate table instruc-
tions into their critical-thinking processes. However, groups
should complete the review tables for each selected study to
enhance the decision process and to facilitate group member in-
volvement and understanding of RU.
Phase III Refinements
This phase combines the 1994 phases III and IV. It also inte-
grates the 1994 synthesis concept from phase V to better link
276
Stetler
with substantiation and supplants the integrative utilization
review process initiated in 19948 through reference to the
newer, more developed method.18 The 4 comparative applica-
bility criteria still form the core of this phase. However, the
synthesis process now is highlighted because it is often a black
box, with critical conceptual processes unspoken and integra-
tive interpretations at times seemingly ungrounded.
It is still possible that experts with a specialized, evolving
knowledge base can use a single study, but the likelihood is
that multiple studies will be reviewed and their findings
synthesized. The model also suggests that users seek already
published systematic reviews. These too must be critiqued18
and supplemented with more recent, additional research.
The detailed tables noted in phase II enable users to iden-
tify, organize, and thence integrate information readily across
multiple studies. Integration, or the “art” of synthesis, ie, the
process of organizing, condensing, and deriving meaning from
collated information, was noted in 1994 but now is more fully
explored through the referenced integrated review article.18
Part of the utilization decision is articulation of not only the
conceptual but also the pragmatic meaning of synthesized find-
ings, in terms of what the research cumulatively tells us about
practice. This may be done mentally by an individual expert for
his or her own practice, or it can involve a team of individuals
making recommendations regarding the implications of
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Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice
Figure 3B. Stetler Model, Part II: Additional, per phase details.
research for a change in practice. Their recommendations may
transform synthesized findings into an action plan or general
policy statement21 and should include relevant qualifiers.21
Once users complete this synthesis of findings, the strength
of that accumulated evidence or derived meaning is explicitly
judged through reference to an evidence-related table of
recommendations.18,21 The overall strength of the reviewed
evidence will be affected not only by the types and quality of
available research, but also by the degree to which other,
supplemental types of evidence, such as consensus and local,
affirmed experience,15 are considered. As in the 1994 model,
well-substantiated evidence is a desired goal, but more limited
findings and supplemental sources of evidence may be inter-
preted to meet an identified need. In either case, reviewers now
have a language to enable reflection, designation, and sharing
of the explicit basis of RU decisions.
The overall nature of the utilization decision—to use,
consider use, or to not use—is still a gestalt process made on
the basis of both the preponderance/strength of the evidence
and the nature of the other applicability criteria. It is impor-
tant to note the definitions of these utilization terms because
they influence phase IV decision-making. To not use means a
decision to reject the findings totally, to use means to accept
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Stetler
and thereby use the findings immediately, and to consider use
means the final decision to apply the findings is delayed until
additional information or internal evidence is obtained by the
individual or group. A “consider use” decision is likely when,
for example, the change is significantly different from current
practice, significant risks are involved, and/or findings are of a
low strength.15 The outcome of the “consider use” decision,
after phase IV evaluation, would be to “not use,” “use,” or “use
with modification.”
Phase IV Refinements
The translation/application phase now focuses on the how-to’s
of implementation of the synthesized findings or recommen-
dations, including cases in which planned change is required.
It starts with confirmation of type, method, and level of use
(Figure 3B) and then requires review of the operational details
of application. For example, who should do what, when, and
how? With some findings and expert individual users, little if
any translation is required. For example, the articulated find-
ings may be concrete and easy to implement. On the other
hand, research may provide only some of the details required
to create a guideline, detailed procedure, policy, or plan of
action. As indicated in 1994, users may have to “fill in some of
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Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice
the blanks”8 with consensus, theoretical information, or expert
judgment. In that case, some aspects of the resulting docu-
ment or action may be research-based, whereas others are not.
As a consequence, the model suggests designation of the actual
and differential levels of evidence within a set of actions, as
well as “a clear understanding of how far from the scientific
base the ... (user) ... is going or how much the findings are
being ‘adapted,’ rather than adopted.”8
Another aspect of translation/application, when relevant, is
development of plans for formal organizational change. Such
plans should reflect RU in terms of evidence-based strategies
for dissemination of translated findings and facilitation of
behavioral change in targeted users.19,22,23,32 A component of
these formal change plans is evaluation, and thus the lines
between phases IV and V have become blurred.
Phase V Refinements
As in the 1994 version, a contingency approach to evaluation is
provided, given the fact that use varies according to different
levels, types, and methods. An individual clinician still should
evaluate his or her application of findings and, if considering
The model now provides more
explicit direction both for indi-
viduals and for individuals oper-
ating within groups responsible
for RU/EBP.
use, “obtain additional practical information (through) obser-
vation/evaluation, consensus, (or) an action test.”8 However, in
the revised model, planned change evaluation relevant to the
“use” decision is differentiated from the evaluative implications
of a formal “consider use” decision. The latter option requires a
pilot test of the findings’ application. Such “consideration” is
designed, as the Iowa model suggests, to enable testing of the
“feasibility of the change, monitoring the effects on a small
group of patients to minimize possible adverse occurrences,
revising the research-based interventions if needed and evalu-
ating the process of the change at the unit level.”33 Pilot data
are used to decide whether the findings are acceptable and thus
can be extended to other units within the setting, whether they
should be substantially modified and perhaps even further
piloted, or whether they should be rejected and the RU process
stopped. Again, a gestalt decision must be made on the basis of
these probabilistic data of varying strength.
The formal “use” decision leads to alternative forms of evalu-
ation. Evaluation might be integrated into routine mechanisms,
eg, after evidence-based removal of a skin product or drug from
the formulary where alternative products are available and in
use. However, an alternative “use” decision, eg, on the basis of
strong evidence and a high level of need, might involve a highly
complex organizational change. In this case, formal evaluative
data are needed but become part of the process of a goal-
directed, iterative implementation and a dynamic evalua-
tion.15,19 This involves a deliberate, systematic, and continuous
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Stetler
evaluation process, during which internal evidence is identified,
collected, fed back to users, and used to enhance application of
translated findings. Multiple refinements in the implementation
plan or the translation products may be needed over time to
obtain continuous, unit-to-unit improvement and ultimate
achievement of the targeted organizational goal.
With either formal approach to RU evaluation, the model
now notes 2 types of evaluative information. First, formative
data are needed to provide information on the integrity of the
innovation, ie, whether the findings are in fact being used as
intended. Then, summative data are needed to assess outcome
or goal achievement.15 RU-as-a-process provides direction to
these evaluative efforts. Lastly, formal evaluation requires
adherence to an organization’s standards for approval for such
RU activity. Some organizations require only administrative
approval, whereas others might see any formal evaluation as an
issue for an Institutional Review Board.
SUMMARY
Kim34 categorized the Stetler Model as an individual assimila-
tion model because of its individual practitioner focus. The
model now provides more explicit direction both for individ-
uals and for individuals operating within groups responsible for
RU/EBP. This direction, as before, is in the form of a series of
critical-thinking steps designed to buffer the potential barriers
to objective, appropriate, and effective utilization of research
findings.
The 2001 version of the Stetler Model of RU describes its rela-
tionship to EBP. The term “evidence” was actually incorporated
into the model in 1976, and related concepts were described in
1994. Now, the term and concepts of evidence have been fully
integrated, and the RU model can be said to facilitate EBP.
The enthusiasm and feedback of many clinical nurse specialists and other
nursing leaders made this revision possible. The editorial input of Kristina
Engstrom was also invaluable. ■
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