Annotated compilation of models and frameworks of EBP in Nursing
Sarah Jo Brown (2012)
Nursing agencies adopt Evidence-Based Models to guide their EBP programs. These models keep everyone oriented as to what needs to be done so that e-b projects move forward. Several of them also guide development of organizational cultures in which EBP thrives. Nine nursing models will be briefly presented; they are (in reverse alphabetical order):
Ø Stetler Model of Research Utilization
Ø PARIHS Framework
Ø Model of Evidence-Based Practice Change (Larrabee)
Ø Melnyk & Fineout-Overholt Conceptual Model
Ø The Johns Hopkins Nursing Evidence-Based Practice Model
Ø Joannna Briggs Institute Model of Evidence-Based Health Care
Ø The Iowa Model of Evidence-Based Practice to Promote Quality Care
Ø Colorado Patient-Centered Interprofessional Evidence-Based Practice Model
Ø The Ace Star Model of Knowledge Transformation
I will not explain these models in great detail, rather just introduce them and provide references for them. I also suggest a book that includes many of them; it is listed in the references at the end of this paper. Alternatively, do an internet or scholarly search for other information about them. Importantly, there are other sound and useful models that may be more appropriate for a particular setting—a search might turn up a model that is more appropriate to the situation you have in mind.
In examining models you might want to consider the following questions:
1. What is the aim of the model?
2. Does it describe a specific process for e-b projects or a broader organizational aim?
3. Does it address organizational implementation of ebp, use of research evidence by individual nurses, or both?
4. What are the main components or elements of the model?
5. Does the model suggest any actions connections; such as: if action A is undertaken, the likelihood of successful implementation of an e-b change in practice will be increased?
6. Has the model been put to the test in research? Did the reality examined function like the model indicated it would?
7. Identify one or two important principles or proposals of the model?
The Stetler Model of Research Utilization, one of the earliest EBP models, proposes an organizational process for incorporating research evidence into practice. The five phases start with getting clear about the nature and importance of the care problem or deficiency and proceed through evaluation of the outcomes of the e-b change in practice. A key phase in between is the decision to change practice based on the evidence, which is made by considering: a) current practice, b) the evidence itself, c) fit to the setting, and d) feasibility of making the change.
Stetler, C. B. (2010). The Stetler Model. In J. Rycroft-Malone & T. Bucknall, Eds. Models and
frameworks for implementing evidence-based practice: Linking evidence to action (pp. 51-79).. Hoboken, NJ: Wiley-Blackwell
Stetler, C. B. (2001). Updating the Stetler model of research utilization to facilitate evidence-
based practice. Nursing Outlook, 49, 271-279.
The PARIHS* framework services as a planning, implementing, and evaluating guide for agencies that aim to create an evidence-based culture. The heart of the framework is: SI = f (E, C, F), meaning successful implementation is a function of Evidence, Context, and Facilitation. Each of these elements has sub-elements; for instance, under Context, the sub-elements are Culture, Leadership, and Measurement. Various combinations of the elements are possible. Thus, the evidence in support of a change in practice could be strong and applicable to the agency, but if the context is weak in e-b culture and leadership, and the agency has only modest capability to collect quality-related data, there is a low probability of successful implementation of the evidence-based change.
* Promoting Action on Research Implementation in Health Services
Kitson, A., Harvey, G., McCormack, b. (1998). Enabling the implementation of evidence based
practice: a conceptual framework. Quality in Health Care, 7, 149-158. Available on line at:
http://qshc.bmj.com/content/7/3/149
Rycroft-Malone, J., Kitson, A, Harvey, G., McCormack, B., Seers, K., Titchen, A, & Estabrooks, C.
(2002). Ingredients for change: revisiting a conceptual framework. Quality and Safety in Health Care, 11, 174-180.
The PARIHS website is: http://www.parihs.org/
The Model of Evidence-Based Practice Change is a second generation model, having undergone revision as a result of research that was conducted using the original model, the Rosswurm and Larrabee’s Model for Change to Evidence-Based Practice. The most recent book about the model, Nurse to Nurse: Evidence-Based Practice by June Larrabee (McGraw-Hill, 2009), is a practical handbook for direct care nurses in making evidence-based organizational change. The six steps of the model are:
§ Assess the need for change in practice
§ Locate the best evidence
§ Critically analyze the evidence
§ Design practice change
§ Implement and evaluate change in practice
§ Integrate and maintain change in practice
Melnyk & Fineout-Overholt Model
The key steps in Melnyk and Fineout-Overholt’s view of the evidence-based practice process are:
1. Ask the burning clinical question.
2. Collect the most relevant and best evidence.
3. Critically appraise and synthesize the evidence.
4. Integrate all evidence with one's clinical expertise, patient preferences and values in making a practice decision or change.
5. Evaluate the practice decision or change.
These steps are presented slightly differently in a more recent article: Melnyk, B., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51-53. Available free at: http://journals.lww.com/ajnonline/pages/viewallmostpopulararticles.aspx (Accessed 15 June 2010)
The Center for the Advancement of Evidence-Based Practice at Arizona State University College of Nursing uses these steps to teach evidence-based nursing knowledge and skills. The center also speaks to “the integration of internal evidence (i.e., quality & outcome data), external evidence (i.e., research) and practice across multiple settings to improve patient, provider, community, and system outcomes” (http://nursingandhealth.asu.edu/evidence-based-practice/index.htm (Accessed 15 June 2010). Melnyk in & Fineout-Overholt’s conceptual model of EBP within a context of caring is available at:
http://nursingandhealth.asu.edu/evidence-based-practice/resources/process.htm
The Johns Hopkins Nursing EBP Model is based on the cornerstones of practice (the core), education, and research. The model recognizes research evidence as the strongest type of evidence for practice, but also acknowledges non-research evidence as valuable, particularly when research evidence is not available or is very limited. Internal and external forces that influence evidence-based practice are taken into consideration in this model.
Newhouse, R. P., Dearholt, S. L. Poe, S. S., Pugh, L. C., & White K. M. (2007).
Johns Hopkins Nursing - Evidence-Based Practice Model and Guidelines
Indianapolis: Sigma Theta Tau.
The Joanna Briggs Institute Model of Evidence Based Health Care admits a wide variety of evidence as indicated by this statement on their website, “The Institute regards any indication that a practice is effective, appropriate, meaningful or feasible, that is derived from experience, expertise, inference, deduction or the results of rigorous inquiry, as a form of evidence.” (http://www.joannabriggs.edu.au/pdf/about/Approach.pdf)
The JBI approach to Evidence-Based Practice describes the evidence-based health care process as involving four components:
- Evidence Generation;
- Evidence Synthesis;
- Evidence/Knowledge Transfer; and
- Evidence Utilisation.
When appraising evidence, they consider:
· Feasibility
· Appropriateness
· Meaningfulness
· Effectiveness
The Iowa Model of Evidence-Based Practice to Promote Quality Care “provides a guide for clinical decision-making, it provides details regarding implementation of evidence-based practice, and it includes both the practitioner and organizational perspective.” A particularly interesting component of this model is the “triggers” that launch evidence-based practice projects. It also advocates piloting projects before large scale implementation.
Titler, M.G., Kleiber C., Steelman V. J., Rakel, B.A., Budreau, G, Everett, L.Q., Buckwalter, K.C.,
Tripp-Reimer, T., & Goode, C.J. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Nursing Clinics of North America, 13(4):497-509.
http://www.nnpnetwork.org/promotion/iowa-model.html (Download model link in the middle of
the page)
The Colorado Patient-Centered Interprofessional Evidence-Based Practice Model “provides a framework to guide organizations and their clinicians to implement evidence-based policies, protocols, and guidelines” (Goode et al, 2011). The patient is at the center of the model because decisions regarding an individual’s care are made in partnership with the patient and respect the patient’s personal preferences and values. The model is framed by four concepts essential to using research evidence in practice: mentoring, organizational support, leadership, and facilitation.
Goode, C. J., Fink, R. M., Krugman, M., Oman, K. S., and Traditi, L. K. (2011). The Colorado
Patient-Centered Interprofessional Evidence-Based Practice Model: A framework for transformation. WORLDviews on Evidence-based Nursing, 96-105.
The Ace Star Model of Knowledge depicts “the relationships between various stages of knowledge transformation, as newly discovered knowledge is moved into practice.” (http://www.acestar.uthscsa.edu/Learn_model.htm) The five major stages in the evidence-based practice process are:
1) Knowledge discovery
2) Evidence summary
3) Translation into practice recommendations
4) Integration into practice
5) Evaluation
Reference
Rycroft-Malone, J., & Bucknall, T., Eds. (2010). Models and frameworks for implementing
evidence-based practice: Linking evidence to action. Hoboken, NJ: Wiley-Blackwell.
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