Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures

Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures

Education of Nurses to Specific Catheter Protocols” from this week’s Electronic Reserve Readings

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1-How does the process described in this article compare and contrast to any experiences you have had thus far with evidence-based practice in your work setting? Identify and explain the similarities and differences.

2-How well does the process used in this article compare to the Johns Hopkins Nursing Evidence-Based Practice Model as described on Theoretical Basis for Nursing?

3-Does your work setting use an evidence-based practice model? If so, summarize the process.

4-What are the advantages, if any, of using a model?

Read instructions: ( Attached you will find the chapter and article  of the book that have the information for the discussion. My work setting is a Nursing Home and rehab. am a registered nurse. Discussion must be done from information given.  The discussion must be about the questions given above. thank you. )

CHAPTER 12: Evidence-Based Practice and Nursing Theory

Evelyn M. Wills

Melanie McEwen

Helen Soderstrom was stricken with changes in her vision, disturbances of gait, and occasional periods of severe fatigue during her senior year of nursing school. She experienced intermittent periods of normality as well as illness, and the periods when she had no symptoms lasted many months. During a time when her symptoms were unusually active, she sought medical help, and her physician determined that her symptoms were related to stress. Despite the periods of weakness and fatigue, she was able to complete the nursing program and graduated with honors.

During Helen’s first year of practice, she experienced two periods of symptom exacerbation, but each was short-lived. With full insurance, she was able to see a neurologist who concluded that she was experiencing the beginning stages of a neuromuscular disease. Because there was no “cure,” the neurologist worked with Helen to find interventions that helped her manage the symptoms when they became problematic.

After a few years in practice, Helen enrolled in a graduate program to work toward a career in nursing education. During her first year of graduate studies, she seldom experienced neurologic symptoms, but during her practice teaching course, they returned.

The recurrence of symptoms, along with a new understanding of evidence-based practice from her graduate courses, led Helen to make her personal health experience the topic of her final paper. To learn more, she sought resources that would help her gain better control of the neuromuscular symptoms as well as assist her in her studies. To that end, she contacted her University’s neuroscience department and joined a research team. As she learned more about EBP, she considered what system she would use to develop guidelines on symptom management and selected the Iowa Model because of its extensive use in research.

The idea of evidence-based practice (EBP) was introduced in the 1970s by Dr. Archie Cochrane, an Englishman who wrote a dynamic book questioning the efficacy of non–research-based practices in medicine (Melnyk & Fineout-Overholt, 2011). In particular, Dr. Cochrane emphasized the critical review of research, largely focusing on randomized control trials (RCTs) to support medical practice. His influence eventually led to development of the Cochrane Collaboration, an organization charged with developing, maintaining, and updating systematic reviews of health care interventions (Cochrane Collaboration, 2013). Although the notion of EBP was somewhat delayed in being recognized and implemented in nursing, over the past two decades, EBP has appeared with increasing frequency in the nursing literature and now has essentially become the standard for research-based, informed decision making for nursing care.

EBP is similar to research-based practice and has been called an approach to problem solving that conscientiously uses the current “best” evidence in the care of patients (LoBiondo-Wood & Haber, 2010). EBP involves identifying a clinical problem, searching the literature, critically evaluating the research evidence, and determining appropriate interventions. Nursing scholars note that EBP relies on integrating research, theory, and practice and is equivalent to theory-based practice as the objective of both is the highest level of safety and efficacy for patients (Fawcett & Garity, 2009). Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures


The concept of EBP is widely accepted as a requisite in health care. EBP is based on the premise that health professionals should not center practice on tradition and belief but on sound information grounded in research findings and scientific development (Melnyk & Fineout-Overholt, 2011; Schmidt & Brown, 2012). Until the early part of the 21st century, the concept of EBP was more common in Canadian and English nursing literature than in U.S. nursing literature. Over the last decade, however, the term has become ubiquitous. This is attributed in part to the guideline initiatives of the Agency for Health Care Quality, the Institute of Medicine, and the U.S. Preventative Services Task Force, among others (Hudson, Duke, Haas, & Varnell, 2008; Melnyk & Fineout-Overholt, 2011).

Many nursing scholars (DiCenso, Guyatt, & Ciliska, 2005; Ingersoll, 2000; LoBiondo-Wood & Haber, 2010; Melnyk & Fineout-Overholt, 2011; Rycroft-Malone, 2004) have pointed out that EBP and research are not synonymous. They are both scholarly processes but focus on different phases of knowledge development—application versus discovery. In general, EBP refers to the integration of individual clinical expertise with the best available external clinical evidence from systematic research. It is largely based on research studies, particularly studies using clinical trials, meta-analysis, and studies of client outcomes, and it is more likely to be applied in practice settings that value the use of new knowledge and in settings that provide resources to access that knowledge.

Definition and Characteristics of Evidence-Based Practice

In medicine, EBP has been defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). It is an approach to health care practice in which the clinician is aware of the evidence that relates to clinical practice and the strength of that evidence (Jennings & Loan, 2001; Tod, Palfreyman, & Burke, 2004).

To distinguish nursing from medicine in discussing EBP, a number of definitions have been presented in the literature. Sigma Theta Tau International (2005, para. 4) defined “evidence-based nursing” as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.” Similarly, DiCenso and colleagues (2005) defined EBP as “the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making” (p. 4). Both of these definitions use similar terms (e.g., best evidence, expertise, patient values). Ingersoll (2000) used slightly different terms when she suggested that evidence-based nursing practice “is the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (p. 152).

In nursing, EBP generally includes careful review of research findings according to guidelines that nurse scholars have used to measure the merit of a study or group of studies. Evidence-based nursing de-emphasizes ritual, isolated, and unsystematic clinical experiences; ungrounded opinions; and tradition as a basis for practice and stresses the use of research findings. Other measures or factors, including nursing expertise, health resources, patient/family preferences, quality improvement efforts, and the consensus of recognized experts, are also incorporated as appropriate (Melnyk & Fineout-Overholt, 2011; Schmidt & Brown, 2012).

In summary, EBP has several critical features. First, it is a problem-based approach and considers the context of the practitioner’s current experience. In addition, EBP brings together the best available evidence and current practice by combining research with tacit knowledge and theory. Third, it incorporates values, beliefs, and desires of the patients and their families. Finally, EBP facilitates the application of research findings by incorporating first- and second-hand knowledge into practice.  Link to Practice 12-1  presents information on databases that nurses and others can access to find specific information on current guidelines and other collections of “evidence” that can be used to improve health care.

Link to Practice 12-1: Key Resources for Evidence-Based Practice

Several important databases have been set up over the last 20 years to promote integration of “evidence” in health care. Information on three of the most influential are presented here.

Cochrane Collaboration –

The Cochrane Collaboration is an international network that helps health care practitioners, policy makers, patients, and their advocates make informed decisions about health care. The Cochrane Library prepares, updates, and promotes the accessibility of the Cochrane Database of Systematic Reviews.

Joanna Briggs Institute –

The Joanna Briggs Institute is an international research and development organization from the School of Translational Science at the University of Adelaide, South Australia. The Institute and its collaborating entities promote and support the synthesis, transfer, and utilization of evidence through identifying feasible, appropriate, meaningful, and effective health care practices to assist in the improvement of health care outcomes.

Agency for Healthcare Research and Quality (U.S. Preventative Services Task Force/National Guideline Clearinghouse)

The National Guideline Clearinghouse (NGC) is a database of evidence-based clinical practice guidelines. It is intended to be used by health professionals, practitioners, patients, and others to obtain objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.

Concerns Related to Evidence-Based Practice in Nursing

Despite growing acceptance of application of EBP in nursing, some criticisms and concerns have been voiced in the nursing literature. For example, there is the concern that EBP is more focused on the science of nursing than on the art of nursing. Some authors have expressed concern that strict concentration on empirically based knowledge will lead to the failure to capture the uniqueness of nursing and the importance of holistic care in contemporary practice (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Hudson et al., 2008; Upton, 1999).

Another concern is that strict reliance on EBP will place nurses in the role of medical extender or medical technician, where nursing will be reduced to a technical practice. This concern was voiced as equating EBP with “cookbook care” and a disregard for individualized patient care (Finkelman & Kenner, 2013; Melnyk & Fineout-Overholt, 2011). Indeed, although evidence may provide direction for development of procedures, techniques, and protocols for nursing, it has been established that these are not the only knowledge that informs the nursing practice and that consideration of individual needs and values is essential (Hudson et al., 2008; Mitchell, 2013).

Third, because research involving humans is complex, findings may be open to interpretation and therefore should not be the sole basis for practice. Research must be considered within the context of the practice prescribed by theory, and it must integrate the values and beliefs of nursing philosophy (Chinn & Kramer, 2011; McKenna & Slevin, 2008; Walker & Avant, 2011).

A fourth concern relates to promoting a link with evidence-based medicine and its emphasis on positivist thinking and the dominance of randomized clinical trials as the major evidence. This concern is related to the absence of consideration of evidence gathered through qualitative research and theory development (Fawcett et al., 2001; Jennings & Loan, 2001; Stevens, 2001).

A fifth concern relates to the potential for linking health care reimbursement exclusively to interventions that can be substantiated by a documented body of evidence (Ingersoll, 2000). This leads to a number of ethical questions and issues that should be considered.

Finally, it is argued that not all practice in the health professions can or should be based on science. In many cases, researchers have yet to accumulate a sufficient body of knowledge. In other cases, a different frame of reference provides a different rationale for action (McKenna & Slevin, 2008). In these instances, strict reliance on EBP may result in numerous voids when developing a plan of care.

Concerns such as these have been addressed by DiCenso and colleagues (2005), who assert that a fundamental principle of EBP is that research evidence alone is not sufficient to plan care. Other ethical and pragmatic factors, such as benefits and risks, associated costs, and patient’s wishes, should be considered. Further, they note that “best research evidence” can be quantitative or qualitative and does not necessarily rely on RCTs. These notions are also supported by Rycroft-Malone (2004), who maintains that well-conceived and well-conducted qualitative and quantitative research evidence, clinical experience, and patient experiences, combined with local or organizational influences, are necessary to facilitate EBP.

Evidence-Based Practice and Practice-Based Evidence

Recently, a new concept—“practice-based evidence” (PBE)—was introduced into the discussion of EBP (Horn & Gassaway, 2007). The notion of PBE addresses many of the concerns noted previously and is grounded in the recognition that frequently interventions have limited formal research support, particularly in the number or quality of RCTs.

The premise of PBE is that large databases—not just clinical research—should be reviewed or “mined” to gather data to demonstrate quality and effectiveness. This type of review can provide comprehensive information about patient characteristics, care processes, and outcomes while controlling for patient differences (Walker & Avant, 2011). PBE acknowledges the importance of the environment in determining practice recommendations and recognizes that knowledge can be generated from practice as well as from research (Chinn & Kramer, 2011).

The intent behind PBE is to determine what works best for which patients, under what circumstances, and at what costs by providing a more comprehensive picture than RCTs, which typically examine one intervention with limited populations and under strictly controlled circumstances (Huston, 2011). Additional sources beyond formal research studies that are appropriate as PBE include benchmarking data, clinical expertise, cost-effective analyses, infection control data, medical record data, national standards of care, quality improvement data, and patient and family preferences (Huston, 2011).

Horn and Gassaway (2007) concluded that use of the PBE analyses can uncover better practices more rapidly leading to improved patient outcomes.  Figure 12-1  illustrates one interpretation of the interrelationships among EBP, PBE, research, and theory in nursing.


Figure 12-1: Relationships among practice, theory, research, and the PBE/EBP cycle.

(From Walker, L. O., & Avant, K. C. [© 2011]. Strategies for theory construction in nursing [5th ed., Fig. 2-3; p. 46]. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)

Promotion of Evidence-Based Practice in Nursing

Implementation of EBP in nursing is still evolving, as often, nursing interventions are based on experience, tradition, intuition, common sense, and untested theories. While emphasis on EBP is growing rapidly, the actual incorporation of nursing research findings in practice has lagged. Melnyk and Fineout-Overholt (2011) have outlined barriers to implementation of research and EBP in nursing ( Box 12-1 ). Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures

Box 12-1: Barriers to Evidence-Based Practice in Nursing

·  Lack of EBP knowledge and skills

·  Misperceptions or negative attitudes about research and evidence-based care

·  Lack of belief that EBP will result in more positive outcomes than traditional care

·  Voluminous amounts of information in professional journals

·  Lack of time and resources to search for and appraise evidence

·  Overwhelming patient loads

·  Organizational constraints (e.g., lack of administrative support or incentives)

·  Demands from patients for a certain type of treatment

·  Peer pressure to continue with practices that are steeped in tradition

·  Resistance to change

·  Lack of consequences for not implementing EBP

·  Lack of autonomy over practice and incentives

·  Inadequate EBP content and behav

·  Lack of autonomy over practice and incentives

·  Inadequate EBP content and behavioral skills in educational programs

·  Continued teaching of rigorous research methods in BSN and MSN programs instead of teaching evidence-based approach to care

Source: Melnyk and Fineout-Overholt (2011).

There is significant support for increasing emphasis on EBP in nursing, and many organizations such as the Institute of Medicine, Sigma Theta Tau International, and the Magnet Recognition Program of the American Nurses Credentialing Center, among others, have designed initiatives to advance EBP (Finkelman & Kenner, 2013; Huston, 2011; Melnyk & Fineout-Overholt, 2011). Indeed, practitioners, researchers, and scholars should welcome it because a systematic process of EBP may assist nurses in reducing the gap between theory and practice.

Theory and Evidence-Based Practice

The growing interest and appreciation of EBP in nursing, along with its considerable interconnectedness with research, has served in some ways to de-emphasize theory. As nurses become more aware of and attuned to EBP, however, they are renewing their appreciation of the linkages among research, theory, and practice. It has been observed that nursing focus on EBP has the potential to promote and draw new attention to this connection (Chinn & Kramer, 2011).

Walker and Avant (2011) pointed out that practice is the central and core phenomenon and focus of nursing; arguably, it is the reason for nursing’s existence. Thus, it is critical to remember that theory guides practice and it also generates models of testing in research through both PBE and EBP. Further, research and clinical data provide evidence for EBP or PBE and can generate practice guidelines and/or theories (e.g., situation-specific theories). This process is interactive and iterative (Walker & Avant, 2011). For nursing therefore, practice must not only be evidence-based but also theory-based, for when research validates a theory, it provides the evidence required for EBP. Finally, as more research is conduced about a specific theory, more evidence is provided to support practice (Chinn & Kramer, 2011; George, 2011).

Fawcett and colleagues (2001) wrote of a preference for the term “theory-guided, evidence-based practice,” noting that theory is the reason for, and the value of, evidence. The “evidence,” they stated, must extend beyond an emphasis on empirical research and RCTs to include evidence generated from theories. Indeed, the evidence itself refers to evidence about theories. Further, they contend that theory determines what counts as evidence; thus, theory and evidence are inextricably linked.

Theoretical Models of EBP

Numerous models of EBP have been developed by nurses to encourage translation of nursing research into practice. In many instances, the goal or intent is to create or establish EBP protocols, procedures, or guidelines. In some instances, universities and hospital groups have developed models to assist students or health care professionals in implementing EBP in their setting. In other instances, nurse researchers and scholars have interpreted the transfer of research evidence to nursing education and practice through processes that progressed from theory-based nursing, quality improvement, research utilization, and lately, evidence-based nursing practice. This section reviews five EBP models that are among the most frequently cited in the nursing literature. These have been widely studied and applied, many in multiple settings and for a variety of patient issues, situations, or nursing care processes. These models include:

·  Academic Center for Evidence-Based Practice Star Model (ACE Star Model) (Stevens, 2004)

·  Advancing Research and Clinical Practice Through Close Collaboration (ARCC Model) (Melnyk & Fineout-Overholt, 2011)

·  Iowa Model (Titler et al., 2001)

·  Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse, Dearholt, Poe, Pugh, & White, 2007)

·  Stetler Model of Evidence-Based Practice (Stetler, 2001)

These models can provide guidance for practicing nurses and advanced practice nurses to promote or enhance EBP and to develop practice guidelines, protocols, or interventions as appropriate. Each model will be described briefly and reviewed for its utility in nursing practice and education.

ACE Star Model of Knowledge Transformation

The ACE Star Model was developed by faculty at the University of Texas Health Science Center at San Antonio (UTHSCSA) (Stevens, 2004). The Star Model is depicted by five points of knowledge transformation. The five forms of knowledge transformation occur in “relative sequence” when research evidence progresses through several cycles and is combined with other knowledge and then applied in practice.

Each point of the star represents a step in a process. The step-wise depiction allows for easy comprehension and is therefore useful even for novice nurses. In order, the points are:

· 1. Discovery research

· 2. Evidence summary

· 3. Translation to guidelines

· 4. Practice integration

· 5. Process, outcome evaluation (UTHSCSA, 2012) ( Figure 12-2 )

Figure 12-2:Diagram of the ACE star model for evidence-based practice.

(Used with permission from Stevens, K. R. (2012). ACE Star Model: Knowledge transformation©. Academic Center for Evidence-Based Practice. Available at )

This sequence allows the nurse to move research-based knowledge from one point to the next in sequence to provide a translation of evidence on which to base practice (Stevens, 2004, 2005). Knowledge transformation consists of eight premises that underlie and explain the position of the researchers who created the model. These are presented in  Box 12-2 . The rigor of the process the nurse or committee uses is part of the value of the knowledge transformation that occurs when using this model.

Box 12-2: ACE Star Model: Knowledge Transformation—Underlying Premises

· 1. Knowledge transformation (KT) is necessary prior to using research results in clinical decision making.

· 2. KT derives from multiple sources, including research, experience, authority, trial and error, and theoretical principles.

· 3. Systematic processes control bias; the research process is the most stable source of knowledge.

· 4. Evidence can be classified into a hierarchy of strength of evidence depending on the rigor of the science that produced the evidence.

· 5. Knowledge exists in a variety of forms. As research is converted through a system of steps, other knowledge is created.

· 6. The form in which knowledge exists can be referenced to its use.

· 7. The form of knowledge determines its usability.

· 8. Knowledge is transformed through steps, such as summarization, translation, application, integration, and evaluation. Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures

Abstracted from Stevens, K. R. (2012). ACE Star Model, UT Health Science Center, San Antonio.  (Accessed May 29, 2013).

The model is used at UTHSCSA hospitals, and their nursing program maintains a very detailed and informative online educational site ( ). The website provides an extensive online tutorial on the ACE Star Model complete with detailed information, resources, instructive videos, and slides. A quiz and a certificate of attendance are available for those completing instruction in the model (see  Link to Practice 12-2 ). The ACE Star Model is useful in teaching nurses and nursing students the process of research evidence utilization in practice (Schaffer, Sandau, & Diedrick, 2013). One concern or criticism of the ACE Star Model has been noted by White (2012), who pointed out that it does not use evidence other than research per se.

Link to Practice 12-2: ACE Star Model of Knowledge Transformation

Access the website, take the tutorial, and complete the quiz to obtain a certificate of completion of the program at . This Web site may be useful for teaching the elements of evidence-based practice to nursing students.

Advancing Research and Clinical Practice Through Close Collaboration Model

Melnyk and Fineout-Overholt (2002) developed the ARCC Model through their work with many health care institutions seeking to advance and sustain EBP. This development was a process that involved many iterations and empirical testing of key relationships. The framework of the ARCC Model is taken from control theory and cognitive behavioral theories, which help guide nurses’ behaviors as they gain acumen in EBP (Melnyk & Fineout-Overholt, 2011). Numerous studies and examples of how the ARCC Model has been implemented in clinical practice are available in the literature (Melnyk, 2002; Melnyk, 2004; Melnyk, Feinstein, & Fairbanks, 2002; Melnyk et al., 2011).

The AARC Model relates best to clinical practice, and much of the research supporting its development and implementation was conducted in acute care, pediatric settings. The central constructs are assessment of organizational culture and readiness for EBP, identification of strengths and major barriers to EBP, and development and use of EBP mentors. These constructs are done sequentially and followed by EBP implementation. Outcomes that should be evaluated include health care provider satisfaction, cohesion, intent to leave, turnover, improved patient outcomes, and hospital costs (Melnyk & Fineout-Overholt, 2011).

In employing the ARCC Model, the authors developed several scales to measure the ability to implement EBP. These are the Organizational Culture and Readiness Scale for System-wide Integration of Evidence-based Practice (OCRSIEP) and the EBP Beliefs scale (EBPB) (Melnyk & Fineout-Overholt, 2011). Organizational readiness is first assessed, and when feasible, mentors are identified and developed. The clinical nurses are then mentored through use of the ARCC system. Melnyk and Fineout-Overholt (2011) state that measuring the key constructs along with workshops and academic offerings assist organizations to adopt and sustain EBP. Finally, Melnyk and Fineout-Overholt (2011) developed a flow chart to assist in use of the model.  Box 12-3  gives examples of research that has been conducted employing the ARCC Model of EBP.

Box 12-3: Research Based on the ARCC Model of EBP

· O’Haver, J., Moore, I. M., Reed, P. G., Melnyk, B. M., & Savoie, M. (2010). Parental perceptions of risk and protective factors associated with the adaptation of siblings of children with cystic fibrosis. Pediatric Nursing, 36(6), 284–291.

· Levin, R. F., & Lewis-Holman, S. (2011). Developing guidelines for critical protocol development. Research and Theory for Nursing Practice, 25(4), 233–237.

· Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410–417.

· Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., & Cruz, R. (2010). Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nursing Outlook, 58(6), 301–308.

· Thorsteinsson, H. S. (2013). Icelandic nurses’ beliefs, skills, and resources associated with evidence-based practice and related factors: A national survey. Worldviews on Evidence-Based Nursing, 10(2), 116–126.

The Iowa Model of Evidence-Based Practice to Promote Quality Care

The Iowa Model of EBP was developed in 1994 to promote quality care through research utilization. It is intended to provide guidance for nurses and others in making decisions about practice that affects patient outcomes. The Iowa Model incorporates starting points, which are nursing problems that are termed “triggers.” It continues through multiple decision points and feedback loops to provide for evaluation of any changes (Titler et al., 2001).

The model has been refined over time to produce the current iteration (Titler, 2004; Titler & Adams, 2010). The diagram of the model shows the starting points, decision points, and feedback loops. When implemented, it will assist in providing quality care to clients of clinics, home health agencies, and hospitals (Titler et al., 2001) (see  Figure 12-3 ). The Iowa Model is very detailed and specific and has been applied to address a number of clinical topics. It is also one of the best researched EBP models.  Box 12-4 shows some of the recent research studies that have us Figure 12-3: Diagram of the Iowa method of evidence-based practice.

(Reprinted with permission from University of Iowa Hospitals and Clinics. © 1998. For permission to use or reproduce the model, please contact University of Iowa Hospitals and Clinics at 319-384-9098.)

Box 12-4: Research Based on the Iowa Model of Evidence-Based Practice to Promote Quality Care

· Alexander, L., & Allen, D. (2011). Establishing an evidence-based inpatient medical oncology fluid balance measurement policy. Clinical Journal of Oncology Nursing, 15(1), 23–25.

· Bergstrom, K. (2011). Development of a radiation skin care protocol and algorithm using the Iowa Model of Evidence-Based Practice. Clinical Journal of Oncology Nursing, 15(6), 593–597.

· Chung, K., Davis, I., Moughrabi, S., & Gawlinski, A. (2011). Use of an evidence-based shift report tool to improve nurses’ communication. Medsurg Nursing, 20(5), 255–268.

· Hermes, B., Deakin, K., Lee, K., & Robinson, S. (2009). Suicide risk assessment: 6 steps to a better instrument. Journal of Psychosocial Nursing and Mental Health Services, 47(6), 44–49.

· Kowal, C. D. (2010). Implementing the Critical Care Pain Observation Tool using the Iowa Model. Journal of the New York State Nurses Association, 41(1), 4–10.

· Myrick, K. M. (2011). Improving follow-up after fragility fractures: An evidence-based initiative. Orthopaedic Nursing, 30(3), 174–181.

· Popovitch, M. A., Boyd, C., Dachenhaus, T., & Kusler, D. (2012). Improving stable patient flow through the emergency department by utilizing evidence-based practice: One hospital’s journey. Journal of Emergency Nursing, 38(5), 474–478.

The Johns Hopkins Nursing Evidence-Based Practice Model

The Johns Hopkins Nursing EBP (JHNEBP) Model was developed to accelerate the transfer of research to practice and to promote nurse autonomy, leadership, and engagement with interdisciplinary colleagues (Melnyk & Fineout-Overholt, 2011). The JHNEBP Model was designed as a problem-solving approach to clinical decision making. It combines elements of the nursing process, the American Nurses Association’s Standards of Practice, critical thinking, and research utilization processes (Newhouse et al., 2007). The model has numerous levels of activity, but it is based on practical teaching processes to promote use by novice nurses as well as more experienced nurses.

The JHNEBP process is based on three core elements: a practice question, evidence, and translation (PET) (Newhouse et al., 2007). As presented in  Box 12-5 , 18 steps are included in the model. As shown, each of the PET phases is based on several steps that clarify how the processes are to proceed.

Box 12-5: Steps of The Johns Hopkins Nursing Evidence-Based Practice Model (PET)

P: Practice Question Steps

· 1. Identify an EBP question (PICO).

· 2. Define the scope of the practice question.

· 3. Assign responsibility for leadership.

· 4. Recruit an interdisciplinary team.

· 5. Schedule a team conference.

E: Evidence Steps

· 6. Conduct an internal and external search for evidence.

· 7. Appraise all types of evidence.

· 8. Summarize the evidence.

· 9. Rate the strength of the evidence.

· 10. Develop recommendations for change in systems or processes of care based on the strength of the evidence.

T: Translation Method of Evidence-Based Practice Steps

· 11. Determine the appropriateness and feasibility of translating recommendations into the specific practice setting.

· 12. Create an action plan.

· 13. Implement the change.

· 14. Evaluate outcomes.

· 15. Report the results of the preliminary evaluation to decision makers.

· 16. Secure support from decision makers to implement the recommended change internally.

· 17. Identify the next steps.

· 18. Communicate the findings.

Source: Newhouse et al., 2007, pp. 42–47.

This method begins with an EBP question, and the first step is to generate an answerable Practice question which includes the patient, population, and the problem. It goes on to define an Intervention, makes a Comparison with other treatments if possible, and finally defines the desired Outcome (PICO) (Newhouse et al., 2007). Four other steps in the “practice question” phase include defining the scope of the question, assigning responsibility for leadership, recruiting a team, and scheduling conferences. In the evidence phase, literature searches and appraisal and recommendations come from the team (Newhouse et al., 2007).

In the third phase, translation, the team decides whether or not and how to implement the changes, evaluate any such implementation, and communicate the findings to appropriate individuals or groups (Newhouse et al., 2007). The JHNEBP Model is clearly explained and simple to apply. Related writings include the guidelines and definitions of the background, elements of the process, and the steps of the model (Newhouse et al., 2007).

Stetler Model of Evidence-Based Practice

The Stetler Model of EBP was initiated in the 1970s as a quality improvement (QI) effort using the research utilization (RU) ideals then in widespread use (Melnyk & Fineout-Overholt, 2011). Through several iterations, Stetler updated the approach and clarified the series of phases of the model such that it is readily implemented by practicing nurses and useful at the bedside (Stetler, Ritchie, Rycroft-Malone, Schultz, & Charns, 2007). Stetler and colleagues (1998) and Stetler and Caramanica (2007) argued that all research studies are not ready for use at the bedside. Further, they explained that alternative sources or evidence are necessary to fill the gaps in nursing research evidence.

The Stetler Model is similar to the nursing process; therefore, it is easily assimilated by practicing bedside nurses. The phases of the approach include preparation, validation, comparative evaluation/decision making, translation/application, and evaluation. It provides practitioners with stepwise directions for integrating research into practice. See  Table 12-1  for description of the phases. The Stetler Model incorporates five steps to generate a process that takes into account the many other facets of nursing and the clinical situation prior to using research findings in the nurse’s clinical practice. When implemented, the results should be systematically evaluated to track goal-oriented outcomes and proffer both formative and summative evaluation strategies. The major outcomes of RU or EBP should be improved patient results as well as enhanced professional practice (Stetler & Caramanica, 2007). Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures

Table 12-1: Phases of the Stetler Model

Phase Content Actions
I Preparation (Purpose, control, and sources of research evidence) ·  Define potential issues

·  Seek sources of research evidence

·  Perceive problems

·  Focus on high-priority issues

·  Decide on need for a team

·  Consider other influential factors

·  Define desired outcomes

·  Seek systematic reviews

·  Determine need for explicit research evidence

·  Select research sources with conceptual fit

II Validation (Credibility of findings and potential for/detailed qualifiers of application) ·  Credibility of findings

·  Critique and synthesize resources

·  Critique systematic reviews

·  Reassess ft of individual sources

·  Rate the level and quality of evidence

·  Differentiate statistical and clinical significance

·  Eliminate noncredible sources

·  End the process if there is no evidence or clearly insufficient credible research evidence

III Comparative evaluation/decision making (Synthesis and decisions/recommendations for criteria of applicability) ·  Synthesize the cumulative findings

·  Evaluate the degree and nature of other criteria

·  Make a decision whether/what to use

·  If decide to “not use,” STOP use of the model

·  If decide to use, determine recommendations for a specific practice

IV Translation/application (operational definition of use/actions for change) ·  Types

·  Methods

·  Levels

·  Direct instrumental use

·  Cognitive use

·  Symbolic use

·  Caution: Assess whether translation/product or use goes beyond actual findings/evidence

·  Formal dissemination and change strategies should be planned per relevant research

·  Consider need for appropriate reasoned variation

V Evaluation (alternative types of evaluation) ·  Evaluation can be formal or informal, individual or institutional

·  Consider cost-benefit of evaluation efforts

·  Use RU as a process to enhance credibility of evaluation data

·  For both dynamic and pilot evaluations include two types of evaluative information

From Stetler, C. B. (2001). Updating the Stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49(6), p. 277. From Figure 3B. Stetler Model Part II: Additional, per phase details.

Theoretical Models: A Summary

The five EBP models described above are compared in  Table 12-2  on  page 272  using the following criteria:

Table 12-2: Comparison of Selected Models of EBP

Models of Evidence-Based Practice


Comparison Element ACE Star Model ARCC Model Iowa Model Johns Hopkins Model Stetler Model
Groups of health care professionals (Users) Instructors, students, practicing nurses Advanced practice nurses, practicing nurses Instructors, students, practicing nurses Practicing nurses Practicing nurses or groups of nurses
Environmental factors in which the model is useful (Environment) Learning environments, hospitals Patient care organizations Nursing schools and patient care agencies Learning environments, hospitals Clinical situations
Analysis of the model (Analysis) Five major points similar to the nursing process Five constructs with similarity to nursing process Six steps of the model:

Identify knowledge or problem focused triggers (catalysts to critical thinking).

Priority: organizational

Form a team responsible for development, implementation and evaluation of EBP

PET (see  Box 12-5  p. 269 ) 18 steps are the basis for the model.

Team approach to answer Practice questions, critique Evidence and Translate it into usable form

Five phases:

· (I) Preparation

· (II) Validation

· (III) Comparative evaluation/decision making

· (IV)Translation/application

· (V) Evaluation

Implementation: barriers/facilitators (Implementation) Implementation into practice is the fifth stage and involves bringing evidence to clinical decision making Implementation is based on the mentor’s determination of organizational readiness. Determine sufficiency of evidence.

If yes: Pilot recommended change.

Team determines feasibility and creates an action plan to implement the change. Translation and application is the fourth step.
Evaluation of the effectiveness of the model (Evaluation) Evaluation is the final stage and focuses on verification of the success EBP (Stevens, 2004). Evaluation is the fifth of the constructs and has three levels that provide feedback. (Melnyk & Fineout-Overholt, 2002). Evaluate pilot success and disseminate results; implement into practice. (Titler et al., 2001). Step 14: Evaluate the outcomes, report the results, and communicate findings. (Newhouse et al., 2007). Evaluation is the last step (Stetler, 2001).

·  Groups of health care professionals affected (Groups Affected)

·  Environmental factors in which the model is useful (Environment)

·  Analysis of the model (Analysis)

·  Implementation: barriers/facilitators (Implementation)

·  Evaluation of effectiveness identified by the model (Evaluation)

· As shown, there are a number of similarities among the models. Schafffer and colleagues (2013) recently compiled a review of models for organizational change based on EBP. Similar to what has been presented here, their overview examined the key features of six models with the view to change practice in organizations. Most of the models incorporate the steps of the research process in some way, and all the models are focused on bringing the best in safe and effective nursing care to their major focus: the patient, or recipient of nursing care. Nurses who are actively engaged in promoting EBP are encouraged to review these as well as other published models and to select the one that best fits their needs and desired outcomes.

Helen, the nurse from the opening case study, conducted a systematic review of neuromuscular illnesses and treatments using the Iowa Model of EBP. During this process, she came to better understand her illness and the treatments that would most likely forestall deterioration of her condition. The complexity and high level of information she accumulated through her review of the research guided by theories of EBP and PBE brought Helen to a level of practice where she could not only help herself but also her patients and clients. Following graduation, she based her clinical practice on the expertise she had gained through her extensive study of the research and practice in neuromuscular diseases.


There is little doubt that EBP has become one of the key tenets of quality nursing care. As described, however, it is critical to remember that EBP must go beyond research per se and emphasis on RCT but must also be theory based. Indeed, the growing attention to the concept of PBE has renewed attention to the essential role of theory in excellent nursing practice. Many authors have written about the problems and barriers to EBP, and others have written on how to strengthen the process and make it relevant to practicing nurses.

Over the last decade, a number of models have been constructed to assist nurses to learn how to proceed in the development of evidence-based guidelines and promotion of EBP, as illustrated by the work of Helen in the case study. The five models described here, along with a number of others that have been mentioned in the nursing literature, give nurses information about the steps and processes necessary to elicit the evidence that is needed to provide safe, effective interventions that are effective in nursing practice. Nurses who seek to use research in their clinical areas are advised to seek out a working model of EBP and follow it through to effect reasonable, safe, and effective changes for the benefit of their patients or clients.

Key Points

·  In nursing, research, theory, and practice are integrated; EBP is a key element and outcome of that linkage.

·  EBP is an approach to problem solving that uses the current best evidence in the care of patients.

·  In nursing, EBP has been defined as “the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery … in consideration of individual needs and preferences.”

·  Nursing as a profession has been relatively slow to incorporate EBP; that has changed in recent years.

·  Many nurses are concerned that too much attention to EBP will draw attention away from the art of nursing care—that nursing will become lost in the science.

·  Models of EBP have developed from early studies of research utilization and quality improvement. Many of these models have been developed with the impetus of hospitals or educational institutions’ support.

·  The major impetus for integration and implementation of research evidence—guided by EBP—should be reasonable, effective, and safe care for patients. Prevention of Catheter-Associated Urinary Tract Infections in Patients with Hip Fractures


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