Overview

Welcome to Evidence-Based Practice in Action: Comprehensive Strategies, Tools, and Tips From the University of Iowa Hospitals and Clinics. This book uses the newly modified Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care (Iowa Model Collaborative, 2017). The original Iowa Model (Titler et al., 1994) was an outgrowth of the Quality Assurance Model Using Research (Watson, Bulechek, & McCloskey, 1987). As the importance of including different levels of evidence became clear, it was modified as the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001). Each version of the Iowa Model was designed to provide guidance for nurses and other clinicians to make decisions about day-to-day practices that affect patient outcomes. Select published project reports that used the Iowa Model are located in Appendix C.

Changes to the Iowa Model were made based upon new knowledge about the EBP process and recommendations from over 600 users of the model (Iowa Model Collaborative, 2017). Major refinements to the model are expansion of the sections on (1) designing and pilot testing the practice change and (2) integrating and sustaining the practice change. The implementation strategies included in this book were created to provide specific guidance for implementing and sustaining change. An additional companion workbook (Evidence-Based Practice in Action: Workbook) was developed to enhance EBP planning and implementation. It offers a selection of practical tools that correspond to each chapter of this book.

Selecting an EBP model is an important first step for any organization (Gawlinski & Rutledge, 2008; Schaffer, Sandau, & Diedrick, 2013). Various models have been developed to guide organizational and project leaders through the EBP process (see Appendix D). Most EBP process models include similar overarching steps such as identifying a problem, critiquing the evidence, selecting and implementing interventions recommended from research, evaluating the change, and disseminating results. Because EBP process models use the same basic problem-solving process, this book will be useful regardless of the EBP model.

The Institute of Medicine (IOM) goal is that 90% of healthcare will be evidence-based by 2020 (2010a). In order to achieve this goal, resources are needed to promote adoption of evidence-based clinical practice recommendations. This book was developed to assist clinicians and those responsible for leading EBP to work through the EBP process with associated strategies, tools, and tips.

EBP begins when clinicians identify practice issues, challenges, or desired changes in outcome metrics. In the Iowa Model, an issue or “trigger” is identified from a clinical problem, organizational initiative, or new knowledge. The purpose of EBP is to solve the problem or compare new knowledge to current practice. Identification of triggers may originate from any member of the healthcare team but often comes from clinicians questioning current practice.

This is a new formal step in the Iowa Model. The chapter explains how to formulate actionable questions using the PICO (P = patient/problem/population, I = intervention, C = comparison, O = outcome) framework (Schardt, Adams, Owens, Keitz, & Fontelo, 2007). The PICO components are used to develop the project’s purpose statement, which helps set boundaries around project work.

Identification of priority topics is essential as not every clinical question can be addressed through the EBP process. Higher priority may be given to topics that address high volume, high risk, or high cost issues; those that are closely aligned with the institution’s strategic plan; or other institutional or market forces (e.g., patient or clinician safety, changing reimbursement). If the topic is not an organizational priority, clinicians may want to consider a different focus, different project outcomes, or other opportunities for improving practice. This and similar feedback loops within the Iowa Model highlight that the work is not linear, so feedback loops are suggested.

Once there is commitment to address the topic, an EBP team should be formed to develop, implement, and evaluate the practice change. EBP team membership requires several considerations to ensure the correct clinicians are involved and to maximize use of the team members’ skills and organizational linkages. This chapter provides an example of team formation and tips for successfully leading a team.

The EBP team selects, critiques, and synthesizes the best available evidence. A comprehensive literature search must be completed before all the available evidence is critically reviewed and synthesized to make a recommendation for practice. A step-by-step guide with numerous resources is provided.

At this point, the entire body of evidence—including research, case studies, quality data, expert opinions, and patient input—is synthesized. This chapter covers the steps to take to determine when the evidence is considered sufficient, or not sufficient, for pilot testing.

Piloting is an essential step in the EBP process. Outcomes achieved in a controlled research environment may result in different outcomes than those found when EBP is used in a real-world clinical setting. Piloting the EBP change is essential for identifying issues with the intervention, implementation, and rollout to multiple clinical areas. An overview of pilot testing activities is provided in this chapter, with more in-depth information on implementation and evaluation in Chapters 8 and 9.

Implementation is fluid, complex, and highly interactive, and it changes over the course of the pilot period. Multiple implementation strategies are selected and used cumulatively (see Appendix B) to create a comprehensive plan based on the four phases of implementation: creating awareness and interest, building knowledge and commitment, promoting action and adoption, and pursuing integration and sustainability (Cullen & Adams, 2012).

Evaluation of the pilot must focus on select key indicators related specifically to the practice change and for input to guide implementation. Both process and outcome indicators are collected before and after implementation of the practice change. This chapter provides suggestions on data to collect and data analysis.

This decision point requires the EBP team to either recommend adoption of the practice change or pursue other courses of action. This chapter outlines the key issues that should be addressed when making this decision and describes possible actions to take.

This step promotes integration and sustainability of the practice change over time and prevents regression to previous practices. The importance of “hardwiring” the change into the system, tracking and evaluating data over time, and planning for periodic reinfusion is emphasized.

Dissemination of project results is a key step in the EBP process to promote the adoption of EBPs within the larger healthcare community (Sigma Theta Tau International 2005–2007 Research and Scholarship Advisory Committee [STTI], 2008). Sharing project reports within and outside the organization through presentation and publication supports the growth of an EBP culture in the organization, expands nursing knowledge, and encourages EBP updates in other settings.

Steps in the EBP process build progressively to inform subsequent actions. The Iowa Model and other EBP process models provide direction, yet adoption in practice remains challenging. Application of EBP achieves improvements for patients, their families, clinicians, and healthcare organizations. This book is designed as a guide with application-oriented tools and resources for the journey.