Chapter15 power point july132012

Transitioning
Evidence to
Practice

Evidence Based Practice
Models

 Conduct and Utilization of Research in
Nursing (CURN)
 Stetler Model
 Iowa Model

CURN Model

 Designed by the Michigan Nurses
Association to develop and test the
facilitation of scientific nursing
knowledge in clinical practice settings.

CURN Model
Assists nurses to incorporate new research into
clinical practice:

 Identify a patient care problem.
 Find and assess research-based knowledge to apply
to the problem.
 Adapt and design a nursing practice innovation from
the research base.
 Decide whether to adopt, alter or reject the
innovation.
 Develop the means to extend the new practice
beyond the trial.
 Develop mechanism to maintain the innovation over
time.
Retrieved from
www.medicalcityhospital.com/CustomPage.asp?guidCustomContentIDhttp://={ABD30A7E-3A16-4
After navigating to this site, type in ‘CURN’ in the search box in the upper right corner.

Stetler Model
 This is a model of research utilization
to facilitate evidence-based practice
(EBP).
 The model formulated a series of
critical-thinking and decision-making
steps designed to facilitate safe and
effective use of research findings.

Resource: Stetler, C.B. (2001). Updating the Stetler model of research utilization to
facilitate evidence-based practice. Nursing Outlook, 49(6), 272-279.

Stetler Model of Research Utilization to Facilitate EBP, Part I

Stetler Model (Cont.)
 Phase I – Preparatory phase – Define
the need for clarity of purpose and
potential significance of internal or
external factors.
 Search, sort and select sources of
research evidence
 Consider influential factors
 Affirm priority
 Define purpose and outcomes per issue or
catalyst

 Phase II – Validation – Reflect studied
relationships or variables in terms that
could pragmatically be used in daily
activities
 Perform utilization focused critique &
synopsis
 Identify and, if applicable, record key study
details and qualifiers

 Phase III – Comparative
Evaluation/Decision Making –
Synthesize findings and evaluate per
criteria -
 Fit of setting
 Feasibility
 Current practice
 Substantiating evidence
 Decide to use, consider use or not use

 Phase IV – Translation/Application – Describes
how to implement findings or recommendations
–
 Confirm type, level and method of application
 Use – Review operational details -
 Informally – Use in practice
 Formally – Identify/design evidence-based documents;
package for dissemination; develop EBP change plan,
including evaluation
 Consider Use
 Informally – Obtain targeted practice information; evaluate
 Formally – Do formal details as in “Use”; plan and
implement a pilot project of use, including evaluation
 Decide to accept and extend, with or without
modification or reject and stop

 Phase V – Evaluation –
 Evaluate dynamically –
 Identify goal for each use
 Obtain evidence re: change process and goal-
related progress, as well as end
result/outcomes
 Use iterative evidence to achieve goals
 Evaluate as part of routine practice

Iowa Model
 Provides a guide for clinical decision-
making
 Provides details regarding
implementation of evidence-based
practice
 It includes both the practitioner and
organizational perspective.

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

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

 Problem Focused Triggers
 Risk Management Data
 Process Improvement Data
 Internal/External Benchmarking Data
 Financial Data
 Identification of Clinical Problem


 Knowledge Focused Triggers
 New Research or Other Literature
 National Agencies or other Organizational
Standards and Guidelines
 Philosophies of Care
 Questions from Institutional Standards
Committee


 Is this topic a priority for the
organization?
 If no, consider other triggers
 If yes –
 Form a team
 Assemble relevant research and related
literature
 Critique and synthesize research for use in
practice

 Is there a sufficient research base?
 If no:
 Conduct research
 Base practice on other types of evidence such as
case reports, expert opinion, scientific principles or
theory
 If yes – Pilot the change in practice:
 Select outcomes to be achieved
 Collect baseline data
 Design EBP guidelines
 Implement EBP on pilot units
 Evaluate process and outcomes
 Modify the practice guidelines

 Is change appropriate for adaptation to
practice?
 If no – Continue to evaluate quality of care and
new knowledge
 If yes – Institute the change in practice
 Monitor and analyze structure, process and
outcome data, including environment, staff,
cost, and effect on patient and family
 Disseminate Results
Source: Titler, M.G., Steelman, V.J., Budreau, G., Buckwalter, K.C., Goode, C.J. (2001). The Iowa Model of
Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America. 13(4)
13(4)
497-508.

Comparison of the Stetler &
Iowa Models
 Stetler  Iowa
 Focus is on how  Explains how
individual organizations
practitioner change practice
implements the based on
research research
 Prescriptive (step-  Systematic
by-step) design design

Read, Think, Do Method of
Implementation
 Not a model, but is a method
 Acknowledges the complexity of
problem-solving processes by looking
for –
 The evidence
 Assessing the value to practice
 Addressing the social and cultural milieu
of the practice setting to ascertain the best
strategies for initiating and sustaining
practice changes

Read, Think, Do Method of
Implementation
 Read – Access the breadth of research
findings that will sufficiently inform the
change process
 Think – Give critical thought about
applicability to the clinical setting
 Do – Organize the effective
implementation of the practice change
within a local culture
Resource: Winch, S., Henderson, A., & Creedy, D.(2005). Read, think, do!: A method for
fitting research evidence into practice. Journal of Advanced Nursing, 31(3), pp. 20-
26.

Barriers to Connecting Research
and Practice

 Organizational Culture
 Belief Systems
 Research Related Barriers

Perceived Barriers to Research Utilization:
Organizational Culture, Nurses’ Belief Systems and the
Research-related Barriers

 Insufficient time on the job to implement new
ideas
 Nurses feel they do not have the authority to
change practice
 Facilities are inadequate for implementation
 Statistical analyses are not understandable
 Insufficient time on the job to read research

Source: Retsas, A. (2000). Barriers to using research evidence in nursing practice. Journal of Advanced
Nursing, 31, 599-606.

Perceived Barriers to Research Utilization:
Organizational Culture, Nurses’ Belief Systems and the
Research-related Barriers

 Physicians will not cooperate with
implementation
 Nurses are isolated from colleagues with
whom to discuss research findings
 Nurse does not feel capable of evaluating the
quality of the research
 Nurses feel the results cannot be generalized
to their setting
 Other staff are not supportive of
implementation

Source: Retsas, A. (2000). Barriers to using research evidence in nursing practice. Journal of Advanced
Nursing, 31, 599-606.

Strategies Related to
Organizational Culture Barriers
 To facilitate organizational support of
EBP –
 Allow time for nurses to conduct activities that
foster EBP such as time for library searches
 Ensure availability of adequate library resources
 Start a journal club

Resource: Ciliska, et al. as cited in DiCenso, A., Guyatt, G., Ciliska, D. (2005). Evidence-based nursing: A
guide to clinical practice. Mosby, St. Louis, MO. P. 16.

Journal Clubs
 Purpose –
 To help staff stay abreast of clinical research
 To improve clinicians’ ability to critically evaluate
published research
 Process –
 Develop a format that will entice busy staff to
attend
 Select a challenging clinical situation and topic
 Select a journal article
 Hold the meeting

Journal Club (Continued)
Sample Guidelines and Format –
 Purpose –
 To foster excellence in nursing practice by
promoting evidence-based practice
 Goals –
 Improve nursing knowledge of current research
findings
 Foster the application of clinical research and
best practice models to nursing practice
 Provide a means by which to address clinical
issues

 Format for meetings and presentations -
 Introduce topic and presenter
 Test baseline knowledge and/or seek
opinions, attitudes of audience (optional).
 Give brief synopsis of following
parameters –
 Title of article
 Study’s purpose
 Setting
 Population

 Discuss major findings of study
 Discuss other relevant research that
supports or does not support this study
 Discuss implications of article in terms of
impact on nursing practice
 Documentation
 Delegation
 Patient education
 Patient satisfaction
 Patient/Family centered care
 Interdisciplinary collaboration

 What is the relevance of this article to
our practice? Should we change our
practice based on this information? If
yes, then –
 Group discussion/Questions
 Evaluations

Resource: St. Pierre, J. (2005). Changing nursing practice through a nursing journal club. MedicalSurgical
Nursing, 14(5). 390 – 392.

Strategies Related to Belief
System Barriers
 Simple dissemination of information is
generally ineffective.
 Multi-faceted approaches are more likely to
succeed.
 One-to-one sessions between experts such as
nurse facilitators and the staff who will implement
changes
 Manual and computerized reminders of the
change
 Educational meetings that are interactive
 Audit and feedback on a regular basis
Resource: DiCenso, A., Guyatt, G., Ciliska, D. (2005). Evidence-based nursing: A guide to clinical
practice. St. Louis, MO: Mosby, p. 17.

Strategies Related to Research-
related Barriers
 Research related barriers include
nurses’ lack of understanding of how
to read and critique research studies
 Foster nurse researcher positions or nursing
research committees
 Link staff nurses and advanced practice nurses
with nursing researcher faculty at universities
 Provide training on how to conduct searches,
read and critique research studies

Resource: Ciliska, et al. as cited in DiCenso, A., Guyatt, G., Ciliska, D. (2005). Evidence-based nursing: A
guide to clinical practice. St. Louis, MO: Mosby. P. 16.

Making Change Happen
What is change?
 To give a completely different form or
appearance to; transform

Resource: The American Heritage® Dictionary of the English Language, Fourth
Edition. Retrieved from Dictionary.com website:
http://dictionary.reference.com/browse/change


 Engaging others to change
 Kotter’s Change Model
 Change has an emotional and a
situational component

Source: Campbell, R.J. (2008). Change management in health care. Health Care Manager. 27(1), 23-39.
Manager. 27(1),

 Kotter’s Change Model
 Phase 1 - Creating a climate for change
 Establish Urgency
 Create Coalition
 Develop Vision
 Phase 2 - Engaging and enabling the whole
organization
 Communicate Vision
 Empower Action
 Generate short-term wins
 Phase 3 - Implementing and sustaining change
 Consolidate Gains/Produce more
 Anchor Approaches

Kotter’s Change Model

 Establish Urgency – “Making sure that
sufficient people act with sufficient
urgency – with on your toes behavior
that looks for opportunities and
problems, that energizes colleagues,
that beams a sense of let’s go!”

 Create Coalition – Build a guiding team.
 Members must –
 Have relevant knowledge about the change.
 Be willing to establish credibility with peers.
 Have expertise regarding the inner workings of
the organization.
 Have formal authority.
 Have Leadership skill.

 Develop Vision – The vision must be
expressed in a clear, concise statement
about the direction in which the
organization is headed.
 Paint a picture of the future.
 Focus on how service will be improved.
 Must call on emotion and motivate to
action.

 Communicate Vision –
 Develop methods of communication that
address any negative feelings.
 Help employees to think and act in
accordance with the new direction.
 Identify groups affected by the change and
project their needs, concerns and roles.
 Continuum of feelings: Awareness,
Understanding, Collaboration,
Commitment, Advocacy.


 Empower Action – Give team the power
to eliminate barriers such as
supervisors, the system, mental
barriers and lack of information.


 Generate short-term wins – Choose
and complete tasks that show the
change management project is
succeeding.
 Teams should achieve visible,
meaningful and unambiguous progress
quickly.


 Consolidate Gains/Produce More –
Include ongoing comparison to
competitors to re-energize the change.
 Anchor approaches – Culture change
comes when a new way of operating
has been shown to succeed over a
period of time.

Kotter’s Phases of Change Model
Worksheet– Sample Completed Tool
Intervention to be implemented:
A distraction-free zone for medication administration will be
established.

Stakeholders identified:
Nurses, Support staff, Physicians, patients, families.

Policy and procedures identified as needed or updated:

Medication Administration policy – Add: Nurses will wear a red vest
when administering medications. When the vest is on, there may be
no interruptions of the nurse.

Kotter’s Phases of Change Model
Worksheet– Sample Completed Tool
Project Establish Create Develop Communicate Empower Generate Consolidate Anchor
Coalition Vision Action Short Gains Approaches
Name Urgency Vision term Produce
Wins More
Pilot - Creating Develop Assemble How does Develop a Team Compile Expand pilot Discuss at
a Distraction Power Point Team – this affect: Power Point works 1:1 and to additional staff meeting
Free Zone presentation – Director of Nurses, presentation with staff present units after 3 monthly for
During Med #1 leading Nurses, Support staff, showing the on first med error months. 6 months.
Administration cause of med Nurse Physicians, process of med day of rates Team
errors in nation Manager, Patients, administration pilot. monthly conducts
& our hospital. Staff nurse Care, in distraction Blog set and report audit of
Include from each Competitors, free zone up where at unit implementati
statistics. shift on Revenues staff can meeting. on monthly
Highlight pilot unit Develop anonymously Publish by direct
specific errors. vision send
article observation
questions of med pass.
statement or about pilot
concerns in hospital
to team. newsletter

Chapter15 power point july132012

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