EBP begins when clinicians identify issues, challenges, or desired changes in outcome. In the Iowa Model, triggering issues/opportunities are identified from a clinical or patient identified issue; organization, state, or national initiative; data/new evidence; accrediting agency requirements/regulations; and philosophy of care. Based on the issues/opportunities, key stakeholders are identified. The EBP process is used to apply new knowledge to current practice and resolve issues/opportunities.
The next step in the EBP process is to clearly define the scope and state the purpose of the project. This chapter boldly encourages readers to move beyond the research-focused PICO (P = patient/problem/population, I = intervention, C = comparison, O = outcome) question and proposes a new acronym—PURPOSE (P = population, U = users, R = responsible team, P = problem, O = outcome, S = setting, and E = effort or time frame)—to guide development of the purpose statement and outline the scope of an EBP initiative.
This decision point to determine priority topics is essential, as not every 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 organization’s strategic plan; or other organizational 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 or project outcomes and consider looking at other opportunities for improving practice. This chapter highlights the non-linear nature of EBP, 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. This chapter will help you apply team science, including exploring how effective teams work, setting ground rules, forming a shared mental model, and creating psychological safety. Clear roles and responsibilities for members of the team—including the EBP project director, project manager, EBP facilitator, organizational leader, and champions—are identified. Note that throughout this book, we broadly use the word “clinician” to indicate the interprofessional team, including unlicensed team members.
The EBP team conducts a systematic search to assemble the best evidence. Clinical practice guidelines, systematic reviews, research articles, and other types of evidence are gathered and then appraised, weighing the quality, quantity, consistency, and risk. This chapter introduces the Evidence Funnel Approach, a systematic, sequential way to gather and filter evidence for synthesizing the body of evidence by quality and consistency, strength of recommendation, certainty of benefit, local feasibility, and application.
This decision point relates to weighing the body of evidence. Although evidence is rarely “perfect,” we must determine if it is sufficient to make practice recommendations and move forward. If the body of evidence is not sufficient for guiding practice, consider research methods and monitor safety.
In this chapter, you will use practice recommendations to design a localized EBP protocol and pilot the change. Design of the EBP change includes: engage patients and verify preferences; consider resources, constraints, and approval; and develop the localized EBP protocol. Pilot of the localized EBP protocol includes: create an evaluation plan, collect baseline data, develop an implementation plan, prepare clinicians and materials, promote adoption, and collect and report post-pilot data.
In this chapter, we introduce the Precision Implementation Approach®. You will use the EBP Evaluation Framework (KABOB) to gather actionable local data related to processes (knowledge, attitudes, behaviors), outcomes, and balancing measures. We provide guidance for collecting, analyzing, and reporting pre- and post-pilot data. This unique approach also strategically positions baseline evaluation ahead of implementation.
In this chapter, you will apply the Precision Implementation Approach, using local evaluation data to drive selection of implementation strategies targeted to needs. You will also use the Iowa Implementation for Sustainability Framework to develop a comprehensive, targeted, and cohesive implementation plan, selecting from 75 strategies across four phases of implementation outlined in 10 domains. Each of the 75 implementation strategies includes name, phase, additional phases, domain, definition, actor, action procedure, considerations for application, function, target, EBP Evaluation Framework (KABOB), clinician example, patient example, and applicable citations. We provide guidance for working across implementation phases and domains as you prepare clinicians and materials and promote adoption.
This decision point requires the EBP team to either recommend adoption of the EBP change or pursue other courses of action. Process and outcome evaluation data are used to guide the decision to adopt. If the change is not appropriate, it may require redesigning and repilot, reassembling evidence, or considering other issues.
In this chapter, you will work to make the EBP change an ongoing habit. Planning for sustainability uses the Precision Implementation Approach and systematic steps in the Iowa Model to be more effective and efficient when hardwiring the EBP change. Integrating and sustaining the practice change includes work to identify and engage key personnel, hardwire change into the system, monitor key indicators through quality improvement, and reinfuse as needed.
Finally, you need to share your results. This chapter guides you in internal and external dissemination. Optimize internal reporting to maximize impact. 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 to improve patient and organizational outcomes.
Note: The examples provided in this book are context-specific and present the best evidence at that time. The intent is not to guide practice but to demonstrate how you can develop recommendations to fit your context using current evidence.