Introduction: What is a practice change model?

Before we discuss our chosen practice change model, it only makes sense to discuss the definition and
purpose of a practice change model.

Most practitioners want to provide the best, most appropriate, and evidence-based care possible, but
knowing how to put evidence into practice is another matter entirely. To assist clinicians with creating
evidence-based practice changes that can be sustained over time, and to enhance the appropriateness
and effectiveness of those changes, guidelines were developed. These guidelines help to clarify the ways
of looking at and thinking about clinical problems and outline the steps needed to overcome individual
and institutional barriers to change. These different guidelines became known as practice change
models, and the Stetler model, which we will be discussing today, is one of several.

History: As public and payor expectations for application of evidence in practice grew, it was discovered
that clinicians had a lot to learn about implementing practice changes and about making those changes
stick. The Stetler Model was originally published in 1976 to assist with applying research findings to
clinical practice in the real world. Since initial publication, the model has been updated several times to
reflect refinement of definitions and methodology.

Application: The Stetler model is considered a practitioner-oriented model because it relies heavily on
critical thinking. It is assumed that awareness of evidence-based practice is not enough – knowing when
it is applicable, for whom it is most appropriate or not appropriate, and how to take the patient’s
preferences into account – are all key factors in clinical decision making. In short, a practitioner’s clinical
experience will play a part in how evidence is interpreted and employed, and the Stetler model uses this
experience and judgment as one component of practical decision-making.

Key Terms: To fully understand the Stetler model, it is necessary to have a firm understanding of how
certain terms are used. It is important to bear in mind that these concepts are within the context of
healthcare and are not broadly applicable outside of this model.

Evidence: Information that is gathered in a systematic, “replicable, observable, credible, verifiable”

manner (Melnyk & Fineout-Overholt, 2019). It is important to consider the source and the method of
obtaining evidence in order to weigh its credibility: all evidence is not equally credible! There are two
main sources of evidence: external and internal.

External evidence: This is information that is generated outside of the practice setting and usually
consists of research findings. In the case that inadequate research evidence exists, expert opinions and
published program findings can be considered; however, these are typically not strong sources of
evidence (Melnyk & Finout-Overholt, 2019).

Internal evidence: This is information that is generated within an organization or setting. This includes
systematically obtained data from various performance and outcome assessments and evaluations. It
can also include the opinion and experience of local groups and individuals, provided that they have
been explored and verified (Melnyk & Fineout-Overholt, 2019). It is important to remember that local
“truisms” or the untested opinion of even an experienced individual is not considered internal evidence.
Five Key Steps: The Stetler model is made up of five steps, or phases; however, it functions rather more
like a flowchart, where the results of one step may direct you to move on, stop, or go back. Despite its
somewhat complex appearance, the Stetler model is actually simple and intuitive. The five steps are:

1. Preparation: This is where a problem is recognized and defined. The parameters of how findings
would be used are created. In this step, the roles of the people involved, as well as their
responsibilities, are planned and organized. A research plan is generated and then initiated.

2. Validation: Evidence is reviewed, and the relevant findings are critiqued, chosen, and
summarized. Levels of evidence are rated and displayed. The process is ended at this point if it
becomes clear that there is insufficient evidence.

3. Comparative evaluation/decision making: In this step, findings are synthesized, including

similarities and differences between studies. Feasibility, practicality, urgency, and readiness for
making the proposed changes are considered. A decision is made about whether or not
proposed changes will be used.

4. Translation/Application: This is where the findings are “translated” into a practical application
or change. The application is planned - this can be complex if it is a policy or procedural change,
or more straightforward if using for an individual practice change.

5. Evaluation: Assessing both the change process and the outcome of the change are included in
this step. Was implementation successful? Were goals met? Will the change be continued?

Implications for Practice:

The Stetler model is appropriate for use by individual practitioners, particularly advanced practice
nurses, or also by an organization to investigate and implement a change in policy or practice. Once a
clinical problems is identified and named using a PICO format, the model can help in organizing thoughts
about the problem. Following the Stetler model will help guide through organizing search parameters,
identifying resources and barriers to practice change, as well as evaluating and comparing the evidence
once found and assessing the success of the changes made. The Stetler model is a relatively simple and
useful tool for making evidence-based changes in practice.