DISCUSSION PAPER

Evidence-based practice models for organizational change: overview

and practical applications

Marjorie A. Schaffer, Kristin E. Sandau & Lee Diedrick

Accepted for publication 19 July 2012

Correspondence to M.A. Schaffer:

e-mail: m-schaffer@bethel.edu

Marjorie A. Schaffer PhD RN

Professor of Nursing

Bethel University, St. Paul, Minnesota, USA

Kristin E. Sandau PhD RN CNE

Professor of Nursing

Bethel University, St. Paul, Minnesota, USA

Lee Diedrick MAN RN C-NIC

Clinical Educator

Children’s Hospitals and Clinics of

Minnesota, St. Paul, Minnesota, USA

SCHAFFER M .A . , SANDAU K .E . & D IEDR ICK L . ( 2 0 1 3 ) Evidence-based

practice models for organizational change: overview and practical applications. Jour-

nal of Advanced Nursing 69(5), 1197–1209. doi: 10.1111/j.1365-2648.2012.06122.x

Abstract Aim. To provide an overview, summary of key features and evaluation of

usefulness of six evidence-based practice models frequently discussed in the

literature.

Background. The variety of evidence-based practice models and frameworks,

complex terminology and organizational culture challenges nurses in selecting the

model that best fits their practice setting.

Data sources. The authors: (1) initially identified models described in a

predominant nursing text; (2) searched the literature through CINAHL from

1998 to current year, using combinations of ‘evidence’, ‘evidence-based practice’,

‘models’, ‘nursing’ and ‘research’; (3) refined the list of selected models based on

the initial literature review; and (4) conducted a second search of the literature on

the selected models for all available years to locate both historical and recent

articles on their use in nursing practice.

Discussion. Authors described model key features and provided an evaluation of

model usefulness based on specific criteria, which focused on facilitating the

evidence-based practice process and guiding practice change.

Implications for nursing. The evaluation of model usefulness can be used to

determine the best fit of the models to the practice setting.

Conclusion. The Johns Hopkins Model and the Academic Center for Evidence-

Based Practice Star Model emphasize the processes of finding and evaluating

evidence that is likely to appeal to nursing educators. Organizations may prefer

the Promoting Action on Research Implementation in Health Services

Framework, Advancing Research and Clinical Practice Through Close

Collaboration, or Iowa models for their emphasis on team decision-making. An

evidence-based practice model that is clear to the clinician and fits the

organization will guide a systematic approach to evidence review and practice

change.

Keywords: evidence-based practice, nursing education, nursing models, research

in practice

© 2012 Blackwell Publishing Ltd 1197

JAN JOURNAL OF ADVANCED NURSING

Introduction

In recent years, nursing scholars have developed a variety

of evidence-based practice (EBP) models to facilitate the

implementation of research findings into nursing practice

(van Achterberg et al. 2008, Mitchell et al. 2010, Rycroft-

Malone & Bucknall 2010, Wilson et al. 2010, Melnyk &

Fineout-Overholt 2011). Application of EBP models is

intended to break down the complexity of the challenge of

translating evidence into clinical practice. Effective models

to guide translation of research into practice are needed to

avoid failure accompanied by a costly investment of time

and resources. However, enthusiastic efforts by clinicians

and educators to use EBP are often dampened by a confus-

ing array of terms, a plethora of models and a growing

variety of approaches to implementation of EBP.

To help the practitioner decide which EBP model is most

appropriate for a clinical or educational setting, an over-

view of commonly used nursing models is needed to assist

the clinician in comparing, contrasting, and eventually

selecting the model best-fit for their organization and a

specific clinical problem. This article provides definitions of

common EBP-related terms, a description of major EBP

models with examples of use in practice and an evaluation

of each model.

Background

Clarification of terms

It is important to begin with a clarification of related terms.

The first term, EBP, has been defined a variety of ways.

However, Melnyk and Fineout-Overholt’s (2011) definition

captures the essence:

Evidence-based practice is a paradigm and life-long prob-

lem solving approach to clinical decision-making that

involves the conscientious use of the best available evidence

(including a systematic search for and critical appraisal of

the most relevant evidence to answer a clinical question)

with one’s own clinical expertise and patient values and

preferences to improve outcomes for individuals, groups,

communities and systems (Melnyk & Fineout-Overholt

2011, p. 575).

A similar definition is provided by Ciliska and colleagues,

who described EBP as integration of the best available

research evidence with information about patient prefer-

ences, clinical skill level and available resources to make

decisions about care (Ciliska et al. 2001).

Table 1 provides definitions for terms commonly used in

EBP discussions. ‘Research utilization’, an older term, is

now recognized as just one piece of the broader concept of

EBP. EBP theories have undergone a change in focus over

the past two decades, which is reflected in use of terms.

Straus and Haynes (2009) delineated this process into

‘knowledge creation’ achieved through research, ‘knowledge

distillation’ through systematic reviews and construction of

guidelines and ‘knowledge dissemination’ through journal

articles and presentations. Attempts have been made in EBP

and change theory literature to distinguish between defini-

tions of diffusion and dissemination. Diffusion is considered

a natural and passive process, while dissemination is an

active and planned persuasion and spread of knowledge.

Straus and Haynes stated that these process components are

not adequate for knowledge use in clinical decision-making

and what is needed is ‘knowledge translation’.

Thus, the current EBP focus has shifted to the process of

moving existing knowledge into the daily routines of

practice. ‘EBP is the process of integrating evidence into

Table 1 Definitions of key terms.

Term Definition

Evidence-based

practice (EBP)

‘…a paradigm and life-long problem solving

approach to clinical decision-making that

involves the conscientious use of the best

available evidence (including a systematic

search for and critical appraisal of the most

relevant evidence to answer a clinical

question) with one’s own clinical expertise

and patient values and preferences to

improve outcomes for individuals, groups,

communities and systems’ (Melnyk &

Fineout-Overholt 2011, p. 575)

Integrating best available research evidence

with information about patient preferences,

clinical skill level and available resources to

make decisions about care (Ciliska et al.

2001)

Research utilization Use of research findings in clinical practice,

often based on a single study (Melnyk &

Fineout-Overholt 2011)

[Note: Research utilization is a sub-set of

EBP]

Adoption A continuum of the rate and amount of

practice change, starting with a decision of

a practice change, moving to

implementation and sustained, routine use

in practice (Titler et al. 2007)

Translation

research

‘…the study of how to promote adoption of

evidence in health care’ (Titler 2011, p. 1)

Implementation

science

‘…scientific study of methods to promote the

uptake of research findings into routine

healthcare in both clinical and policy

contexts’ (Implementation Science 2012)

1198 © 2012 Blackwell Publishing Ltd

M.A. Schaffer et al.

healthcare delivery, whereas, translation science is the study

of how to promote adoption of evidence into health care’

(Titler 2011, p. 291). It is important to note that the term

‘adoption’ has been used differently by scholars as if on a

continuum. At the beginning of the continuum, adoption is

described as a simple decision to accept a practice change

(Greenhalgh et al. 2004, van Achterberg et al. 2008, Gale

& Schaffer 2009). At the other end of the continuum,

adoption has been described as a more complete incorpora-

tion of the practice change to the extent that is has become

routine (Mitchell et al. 2010). Titler’s model for translation

research uses the terms ‘rate’ and ‘extent of adoption’, sug-

gesting a potential continuum of adoption starting with a

decision of a practice change, moving to implementation

and sustained, routine use in practice (Titler et al. 2007).

The terms ‘translation research’ and ‘implementation sci-

ence’ include a growing body of study – that of how to

effectively facilitate full adoption of best practice into an

organization. These terms have been used synonymously; it

may be helpful to point out that usage of terms has been

somewhat dependent on geographical region. The term

research translation has been more prevalent in the U.S.

(National Institutes of Health 2012). Since 2006, the NIH

has prioritized translational research, creating centres for

translational research at its institutes. The term implemen-

tation science has been used more in the UK and may

become more commonly used due to ‘Implementation

Science’, an open-access journal from the UK; implementa-

tion science is defined as the ‘scientific study of methods to

promote the uptake of research findings into routine health-

care in both clinical and policy contexts’ (Implementation

Science 2012).

Aim

The EBP models can support an organized approach to

implementation of EBP, prevent incomplete implementa-

tion, improve use of resources, and facilitate evaluation of

outcomes (Gawlinski & Rutledge 2008). However, clini-

cians find there is not one model that meets the needs of all

the settings where nurses provide care.

The purpose of this discussion is to present a succinct

overview of selected EBP models that can be applied to

nursing practice and to evaluate their usefulness in clinical

and educational settings. It is beyond the scope of this

paper to present an in-depth analysis of each EBP model

for nursing practice. Rather, this review provides a concise

description and evaluation of selected models that occur

most frequently in the literature and are used in practice.

In addition, this paper may serve as a guide to the

evidence-based nursing practice of staff nurses, educators,

and healthcare organizations.

Data sources

Selection of data sources to identify relevant EBP models

involved four steps. First, Melnyk and Fineout-Overholt’s

text on EBP provided an initial list of models to consider

for application to nursing EBP projects (Melnyk & Fineout-

Overholt 2011). They described seven models that ‘have

been created to facilitate change to EBP’ (Ciliska et al.

2011, p. 245). This approach was selected because the

authors of the text have considerable expertise in

application of models and frameworks for EBP.

Second, to gain a broad perspective on EBP models used

in nursing, CINAHL was searched using various combina-

tions of terms: ‘evidence’, ‘evidence-based practice’, ‘mod-

els’, ‘nursing’ and ‘research’. Articles that described EBP

models used in only one setting or were infrequently used

in EBP projects were excluded.

Third, following the initial review of the literature, two

models described in the Melynk and Fineout-Overholt text

(Ciliska et al. 2011) were excluded and one other model

was added. An EBP change model, originally developed by

Rosswurm and Larrabee (1999), was excluded because it

was not predominant in current literature. Also, the Clinical

Scholar Model (Schultz 2005) was excluded because it

focused on strategies for preparing nurses to conduct and

use research. The ACE Star Model, which was included in

Melynk and Fineout-Overholt’s chapter on teaching EBP in

academic settings (Melnyk & Fineout-Overholt 2011), but

not in their chapter on EBP models, was added to the final-

ized list of EBP models because it was featured in several

articles found in the literature.

Fourth, once models were selected, specific names of

models were used in the search process. The final list

selected for inclusion were: (1) the ACE Star Model of

Knowledge Transformation; (2) Advancing Research and

Clinical Practice Through Close Collaboration (ARCC); (3)

the Iowa Model; (4) the Johns Hopkins Nursing Evidence-

Based Practice Model (JHNEBP); (5) Promoting Action on

Research Implementation in Health Services Framework

(PARIHS); and (6) the Stetler Model. Literature was

searched in CINAHL to understand the history of model

development from 1998 to the current year.

Discussion

The following concise overview presents six major EBP

models that can be used by staff nurses, educators, and

© 2012 Blackwell Publishing Ltd 1199

JAN: DISCUSSION PAPER Evidence-based practice models for organizational change

healthcare organizations to guide evidence-based nursing

practice. Readers should note that although ‘model’ is the

term used in this paper and was also used in the Melynk

and Fineout-Overholt text, different terminology such as

framework (PARIHS) or guidelines may be more appropri-

ate. Table 2 includes a description of model steps and key

features; abbreviated summaries of each model are pro-

vided, allowing for a general overview useful for comparing

model features. The last column in Table 2 provides a sim-

ple classification of each model according to its original

design for use. For example, some are designed for individ-

ual use, while others place more emphasis on organizational

processes.

Table 3 provides a brief evaluation of each EBP model

using the four criteria for selecting an EBP model identified

by Newhouse and Johnson (2009). Although other criteria

exist for evaluation of model selection, the following crite-

ria are particularly relevant to the needs of nurses in prac-

tice. The EBP model should: (1) facilitate the work required

for completing an EBP project; (2) have educational compo-

nents that help nurses to critique and assess the strength

and quality of the evidence; (3) guide the process of imple-

menting practice changes; and (4) potentially be imple-

mented across specialty practice areas (Table 3). In

addition, an implementation or application example is

provided for each model.

Overview and evaluation of evidence-based practice

models

ACE Star Model of Knowledge Transformation

The Academic Center for Evidence-Based Practice (ACE)

developed the ACE Star Model as an interdisciplinary strat-

egy for transferring knowledge into nursing and healthcare

practice to meet the goal of quality improvement (Stevens

2004). This model addresses both translation and imple-

mentation aspects of the EBP process. The five model steps

are: (1) discovery of new knowledge; (2) summary of the

evidence following a rigorous review process; (3) translation

of the evidence for clinical practice; (4) integration of the

recommended change into practice; and (5) evaluation of

the impact of the practice change for its contribution to

quality improvement in health care. The model emphasizes

applying evidence to bedside nursing practice and considers

factors that determine likelihood of adoption of evidence

into practice.

The Ace Star Model has been used in both educational

and clinical practice. In an educational example, the Uni-

versity of Wisconsin-Eau Claire used the ACE Star Model

to design an evidence-based approach to promote student

success on the NCLEX-RN® exam. Authors reviewed

trends in exam pass rates, conducted a review of the litera-

ture on student success strategies, made recommendations

to improve student performance, implemented the strate-

gies, and achieved a statistically significant increase in stu-

dent pass rate (Bonis et al. 2007). Other educational

projects that have applied the ACE Star Model include

identification of EBP competencies for clinical nurse special-

ists (Kring 2008) and use of the ACE Star Model as an

organizing framework for teaching EBP concepts to under-

graduates (Heye & Stevens 2009). Clinically, practitioners

have used the model to guide development of a clinical

practice guideline for ventilator-associated pneumonia

(Abbot et al. 2006) and apply knowledge on social support

and positive health practices to working with adolescents in

community and school settings (Mahon et al. 2007).

The ACE Star Model can be used by both individual

practitioners and organizations to guide practice change in

a variety of settings. The model has been used as a guide to

incorporate EBP into nursing curriculum and is also easily

understood by staff nurses, in part due to similarity to the

nursing process. The emphasis on knowledge transforma-

tion contributes to validating the contribution of nursing

interventions to quality improvement. Additionally, the

translation stage includes clinician expertise and has poten-

tial to discuss patient expertise, but is not addressed in the

model. Strategies for successful implementation of a prac-

tice change are less well defined, such as the organizational

culture and context that influence adoption of a practice

change.

Advancing Research and Clinical Practice through Close

Collaboration

The ARCC model focuses on EBP implementation and pro-

motes sustainability at a system wide level (Melnyk & Fine-

out-Overholt 2002, Melnyk et al. 2010, Levin et al. 2011).

The model has five steps: (1) assessment of organizational

culture and readiness for implementation in the healthcare

system; (2) identification of strengths and barriers of the

EBP process in the organization; (3) identification of EBP

mentors; (4) implementation of the evidence into organiza-

tional practice; and (5) evaluation of the outcomes resulting

from the practice change (Ciliska et al. 2011). The key fea-

ture is the use of an EBP mentor to facilitate nurses’ devel-

opment of skills and knowledge to implement EBP projects

effectively. In addition, scales have been developed based

on the model for assessment of the organizational culture

and measurement of effectiveness of EBP in practice.

Levin et al. (2011) piloted the implementation of the

ARCC model with nurses working in a community health

1200 © 2012 Blackwell Publishing Ltd

M.A. Schaffer et al.

Table 2 Evidence-based practice models for guiding change.

Model/EBP steps Key features Model classification

ACE Star Model of Knowledge Transformation

(Stevens 2004, Kring 2008)

Focuses on finding nursing evidence for bedside

nursing practice, including qualitative evidence

Addresses factors that influence adoption of

innovation

Major focus is knowledge transformation

Organizational or individual use

1. Discovery – search for new knowledge through

traditional research

2. Evidence Summary – a rigorous systematic

review process of multiple studies to formulate a

statement of evidence

3. Translation – creation of a practice document or

tool that guides practice, such as a clinical

practice guideline

4. Integration – change in practice; supports EBP

through influencing individual and

organizational change

5. Evaluation – consider impact of EBP practice

change on quality improvement in health care

Advancing Research and Clinical Practice Through

Close Collaboration (ARCC) (Ciliska et al. 2011)

Cognitive Behavioural Theory guides clinicians to

change behaviour towards adopting EBP

Organizational and Readiness Scale for EBP for

assessment of organizational culture

Evidence-Based Implementation Scale for

measurement of EBP in practice

Emphasis on organizational use

1. Assess organizational culture and readiness for

system-wide implementation

2. Identify organizational strengths and barriers to

EBP

3. Identify EBP mentors within the organization to

mentor direct care staff on clinical units

4. Implement evidence into practice

5. Evaluate outcomes

Iowa Model (Titler et al. 2001) Flowchart used to guide decision-making

Uses problem-solving steps

Uses feedback loops to guide change process (e.g.

lack of evidence leads to conducting research)

Includes a trial of the practice change before

implementation occurs across the system

Designed as an interdisciplinary approach

Emphasis on organizational use

1. Identify practice questions (problem-focused or

knowledge-focused ‘triggers’)

2. Determine whether or not the topic is an

organizational priority

3. Form a team to search, critique, and synthesize

available evidence

4. Determine the sufficiency of the evidence (if

insufficient, conduct research)

5. If evidence base is sufficient and the change

appropriate, pilot the recommended practice

change

6. Evaluate pilot success and if successful,

disseminate results and implement into practice

Johns Hopkins Nursing Evidence-Based Practice

Model (JHNEBP) (Newhouse et al. 2007)

A practical guide for the bedside nurse to use the

best evidence for care decisions

Provides tools for process and critique, including

question development, evidence rating scale, and

research and non-research evidence appraisal

Applicable to a variety of healthcare settings

Emphasis on individual use

1. Practice Question – identify the EBP question

using a team approach

2. Evidence – search, critique, summarize, rate

evidence strength, and develop recommendations

for change based on evidence strength

3. Translation – determine feasibility, create an

action plan, implement change, evaluate, and

communicate findings

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JAN: DISCUSSION PAPER Evidence-based practice models for organizational change

home care setting. The researchers randomized a conve-

nience sample of 46 nurses to experimental and control

groups. The experimental group received didactic content

on EBP, an EBP toolkit, posters on EBP, and an available

EBP mentor, while nurses in the control group were given

didactic content on physical assessment. The EBP mentored

group had a significant improvement in EBP beliefs, demon-

strated increased implementation of EBP, and had nearly a

50% reduction in the group turnover rate during the study

time period.

The ARCC model has been used in hospital and commu-

nity practice settings and has been tested as a strategy for

improving practice outcomes. The emphasis on identifying

organizational strengths and barriers to EBP and identifying

mentors to work with direct care staff contributes to an

organizational culture that supports EBP. As the ARCC

model emphasizes organizational environment and factors

that support EBP, there is less emphasis in the model on

evaluating evidence. The model’s authors caution that while

the model emphasizes organizational processes to advance

EBP in care delivery, it is important to note that decision-

making at the point of care includes clinician expertise and

patient preference (Melnyk & Fineout-Overholt 2011).

Iowa Model

The Iowa Model, originally developed as a research utiliza-

tion model at the University of Iowa Hospitals and Clinics,

has been revised to focus on implementation of EBP at the

organizational level (Titler et al. 2001). The model is repre-

sented as an algorithm with defined decision points and

feedback loops. The first decision is whether the problem or

knowledge-focused trigger is a priority for the organization.

An affirmative decision leads to formation of a team which

searches, critiques, and synthesizes the literature. The sec-

ond decision point considers the adequacy of evidence to

change practice. Inadequate evidence leads the practitioner

to a choice between conduction of research or utilization of

alternative types of evidence (i.e. case reports and expert

opinion). When adequate evidence is found, a pilot of the

change is conducted. Evaluation of the pilot leads to the

third decision point – whether to adopt the change in prac-

tice. Ongoing evaluation of the change and dissemination

of results are further components of the Iowa Model.

There are numerous examples of application of the Iowa

Model to organizational practice change. A New York hos-

pital applied the Iowa Model to the implementation of a

critical care pain observation tool for pain assessment of

Table 2 (Continued).

Model/EBP steps Key features Model classification

Promoting Action on Research Implementation in

Health Services Framework (PARIHS) (Rycroft-

Malone 2004)

Can use framework to evaluate progress in

implementing practice change

For each element, model provides sub-elements or

factors that predict the likelihood of success (high

to low continuum)

Emphasis on organizational use

Successful implementation of a practice change is

based on the following interacting elements:

1. Evidence – search for evidence from research,

clinical experience, patient experience, and local

data and information

2. Context– adoption of an innovation is

influenced by the organizational culture,

leadership support, and evaluation practices

3. Facilitation – individuals in the organization use

their knowledge and skills to assist with

implementation of the practice change

Stetler Model (Stetler 2001, Ciliska et al. 2011) Focuses on critical thinking and use of evidence by

individual clinician

Categorizes evidence as external (from research)

and internal (systematic locally obtained evidence,

such as outcome data, consensus opinion,

experiential information)

Emphasis on individual nurse as

critical thinker, but may

include groups of clinicians

1. Preparation – define priority need and initiate a

search for evidence

2. Validation – systematically critique and

summarize evidence

3. Comparative Evaluation and Decision-Making –

make a decision about what evidence to use to

respond to the identified need

4. Translation and Application – plan change and

implement evidence-based change plan

5. Evaluation – determine whether goals for using

the evidence were accomplished

1202 © 2012 Blackwell Publishing Ltd

M.A. Schaffer et al.

non-verbal patients in an intensive care unit (Kowal 2010).

Nurses identified the problem trigger as a lack of an accu-

rate pain assessment tool to rate pain levels in non-verbal

patients. The unit governance committee from the surgical

intensive care unit collaborated with a clinical nurse spe-

cialist to develop the question focus and search for evi-

dence. After a thorough review of the literature, a decision

was made to pilot a specific pain assessment tool. The

group concluded that use of the measure resulted in

improved patient outcomes and the use of the pain assess-

ment tool was approved. A search of the literature demon-

strated a wide variety of applications for the Iowa Model

(Madsen et al. 2005, Gordon et al. 2008, Farrington et al.

2009, 2010, Hermes & Lee 2009, Missal et al. 2010).

Multiple reports by researchers have demonstrated suc-

cessful use of the Iowa Model in a variety of settings to

guide decisions and implementation for practice change.

Practitioners, regardless of prior EBP experience, find the

Iowa Model algorithm helpful. The model considers input

from the entire organizational system, including the patient,

providers, and organizational infrastructure, and involves

nurses in each of the steps (Kowal 2010). An additional

strength is the inclusion of a trial of the practice change

before making the decision about implementation. Although

Table 3 Application of criteria* for selecting an EBP Model.

EBP Model

Facilitates completion of an

EBP Project

Educational components

to guide evaluation of the

evidence Guidance for practice change

Applicable across specialty

areas

ACE Star

Model

Rigorous systematic review

process

Addresses translation and

implementation

Not emphasized Creates a tool for guiding

practice (practice guideline)

Examples include acute care

and school health

ARRC

Model

Takes into account

organizational culture and

readiness

Primarily addresses

implementation

Available on CD-ROM with

Melnyk and Fineout-

Overholt (2011) text

Offers tools to assess

organizational feasibility

and evaluate EBP outcomes

Used for hospital and

community practice; best fit

is for large organizations

Iowa Model Decision points and feedback

loops throughout process

Addresses translation and

implementation

Not emphasized Pilot of the change and

evaluation are essential

components

Useful in a wide variety of

specialty areas, most notably

acute care; best fit is for

large organizations

Johns

Hopkins

EBP

Model

Detailed attention to

identifying practice questions

and evaluating evidence

Greater emphasis on

translation – creation of an

action plan

Offers tools for question

development, rating the

evidence, and appraising

research and non-research

evidence; text by Newhouse

et al. (2007) provides a

simplified, clear description

of the EBP process

Includes an action plan with

implementation, evaluation

and dissemination steps; less

emphasis on organizational

culture and change

Potential usefulness in a

variety of settings; useful for

teaching the EBP process to

nursing students

PARIHS

Framework

Highlights the often under-

recognized effect of the

‘context’ (e.g. leader support)

as one influence impacting

success of EBP

implementation

Addresses translation and

implementation

Newly published guide

available online, along with

tools such as the successful

implementation tool (Stetler

et al. 2011)

Three elements (evidence,

context, and facilitation)

provide a process for

practice change

Has been retrospectively

applied in a variety of

settings; may be good

strategy for teaching

doctoral students to test a

developing model; look for

connections to

complementary models

Stetler

Model

Comprehensive guide for

implementation which

includes practitioner

expertise, context and

evidence

Addresses translation and

implementation

Evaluation tools for

critiquing literature for

potential use in guideline

development available in

Stetler et al. (1998)

Contains detailed guidance

for practice change

including operational

definitions and evidence-

based dissemination and

change strategies

Provides valuable guidance

for the experienced EBP

practitioner in any setting

*Criteria selected from Newhouse and Johnson (2009).

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JAN: DISCUSSION PAPER Evidence-based practice models for organizational change

implied, the model does not specifically address the process

of making staff aware of the practice change (Kowal 2010).

Johns Hopkins Nursing Evidence-Based Practice Model

The Johns Hopkins Nursing EBP Model resulted from the

collaborative work of leaders in nursing education and

practice at Johns Hopkins Hospital and the Johns Hopkins

University School of Nursing (Newhouse et al. 2007). The

major focus of the model is translation of best evidence for

nurses at the bedside to use in care decisions. The model

provides three major steps with subcategories in each of the

steps: (1) identification of the practice question, using a

team approach; (2) collection of the evidence, which

involves searching, critiquing, summarizing, determining

strength of evidence, and making recommendations; and (3)

translation of the evidence for use in practice, which

includes determining feasibility of adopting the change and

creating an action plan for implementation. The model

includes tools for assisting the user: a question development

tool, an evidence rating scale, and appraisal criteria for

research and non-research evidence.

The clear, concise text (Newhouse et al. 2007) describing

the Johns Hopkins model has been adopted in a university

setting for use among baccalaureate and graduate students

as a method for searching and appraising the literature.

University professors and hospital nurse researchers

describe collaboration between the university and the

research councils of two hospitals on EBP projects (Missal

et al. 2010). Clinical nursing leaders identified ‘burning’

clinical practice questions offered by staff nurses for which

the university master’s students performed critical apprais-

als of the literature and made practice recommendations

using the model. Examples of practice changes included

venous thromboembolism prevention for same-day postop-

erative surgery patients, RN interventions to prevent read-

mission of adults related to health literacy, and EBP

protocols for opiate drug withdrawal of chemically depen-

dent adult patients (M. A. Schaffer, personal communica-

tion, 10 June 2011).

The Johns Hopkins EBP Model is comprehensive,

addressing all important components of the EBP process.

Specific steps are provided for identifying the practice ques-

tion and leadership responsibility, evaluating the evidence

and developing recommendations and translating evidence

for practice change. This model includes a rating scale for

strength of evidence and quality for both research and non-

research evidence. Practitioner expertise and patient experi-

ence are included in the rating scale. The critical appraisal

tools provide a helpful guide for educators teaching the

process of review of evidence to students. However, there is

a lack of literature on the use of the JHNEBP Model in a

variety of clinical settings and the model has less emphasis

on organizational culture and change.

Promoting Action on Research Implementation in Health

Services Framework

Readers new to the PARIHS framework may find early

studies describing retrospective application of the frame-

work confusing unless they understand that the framework

was developed over several years by a variety of authors

with practice improvement and guideline implementation

experience. The authors refer to their work as a framework,

rather than a model, which is perhaps most appropriate as

a model is expected to have undergone more rigorous

explanation and testable hypotheses (Titler et al. 2007).

The PARIHS framework’s three key elements mutually

influence one another during a successful implementation of

EBP (Stetler et al. 2011). The first element, evidence, is

described as sources of knowledge as perceived by multiple

stakeholders. The second element, context, describes the

quality of the environment where the research is being con-

ducted. The third element, facilitation, is a technique to

support people to change (i.e. attitude and skills). A predic-

tion for degree of success in EBP implementation is based

on the strength and appropriateness of the three elements.

In a critical synthesis of the literature on the PARIHS

framework, Helfrich et al. (2010) identified six overview

articles presenting core concepts in the new framework,

along with 18 empirical articles from 2001–2008 where the

framework was applied. With the exception of the survey

development studies, studies reviewed by Helfrich and col-

leagues were retrospective in their application of the PARI-

HS framework. However, authors demonstrated that the

framework could be used to guide an analysis of evidence

and the context for dissemination.

Recently, a group of researchers applied the PARIHS

framework to prospectively guide an implementation study

on the use of consultation recording in oncology so patients

could access the digital recording later to review what was

said during the consult (Hack et al. 2011). In planning the

study, researchers considered the interrelationship of evi-

dence, context and facilitation aspects through analysis of

the pre-implementation, implementation, and postimple-

mentation phases. Investigators in New Zealand used the

PARIHS framework to interpret focus groups of nurses,

physicians, and managers to explore a nation-wide cardio-

vascular risk factors guidelines implementation in a primary

healthcare setting, and concluded that the study supported

the validity and applicability of the PARIHS framework

(McKillop et al. 2011).

1204 © 2012 Blackwell Publishing Ltd

M.A. Schaffer et al.

The PARIHS framework has been used to facilitate the

work required for completing an EBP project. Indeed, one

of the strengths of this framework is its emphasis on con-

textual application (i.e. consideration of the leader’s will-

ingness to support activities and a proposed practice

change). The framework allows for a complex process of

EBP implementation that recognizes unpredictable and

changing factors and includes evidence from patients and

practitioners. In terms of educational components, the

framework initially appeared more theoretical than practi-

cal and earlier publications often focused on framework

refinement and development rather than prospective clinical

application. Recently, attempts have been made to clarify

and strengthen the framework. A revision (Stetler et al.

2011) offers users online tools with a User Guide. In terms

of a process guide to implement practice change, the PARI-

HS framework has great applicability for engaging stake-

holders across healthcare disciplines; collaboration is

needed for making financial, quality, and administrative

decisions that lead to successful implementation.

Stetler Model

The Stetler Model, which in its original development

focused on research utilization, has been updated and

refined to fit in the EBP paradigm. The model emphasizes

the critical thinking process and although practitioner-ori-

ented, is also used by groups for implementing formal orga-

nizational change (Stetler 2001). An important assumption

for the model revision is that internal factors such as the

characteristics of individual EBP users and organizational

practices influence implementation of evidence along with

external factors that include formal research and organiza-

tional standards and protocols. The Stetler Model consists

of five phases. Phase I, preparation, includes definition of

the purpose, contextual assessment and search for sources

of evidence. Phase II is validation of the evidence found.

Phase III is comparative evaluation/decision-making, where

the evidence found is critiqued, synthesized, and a decision

for use is made with consideration of external and internal

factors. Phase IV refinements provide implementation/trans-

lation guidance for change in practice. Finally, Phase V is

evaluation, which includes outcomes met and the degree to

which the practice change was implemented (Ciliska et al.

2011).

Romp and Kiehl (2009) used the Stetler Model to guide

the redesign of a preceptor program with the goal of

improving satisfaction levels of new nurses and reducing

the turnover rate. They described how each of the five steps

or phases of the Stetler Model led to program redesign.

After reviewing literature on preceptor education, decision

makers disseminated recommendations to administrators,

managers, and preceptors through committee meetings,

individual meetings, or direct mailings. New nurse satisfac-

tion with their preceptors showed a significant improvement

and the turnover rate decreased by 3�9%. Additional appli- cation examples of the Stetler Model include analysis of evi-

dence for using humour with cancer patients, evaluation of

evidence on a screening tool for anxiety in patients with

Parkinson’s disease, and development of a screening tool

for postpartum depression (Christie & Moore 2005, Bishop

2007, Snyder et al. 2011).

The Stetler Model, although oriented to the individual

practitioner, can also be used by a team that is making a

practice change decision. The model takes into account

characteristics of the individual EBP user. The Stetler

Model uses critical thinking and a logical process that

emphasizes evaluation of the evidence. In the model, evi-

dence includes quality improvement data, operational and

evaluation data, and consensus of experts. Authors caution

that experiential information from individual professionals

should receive critical reflection before use as evidence

(Stetler 2001, Melnyk & Fineout-Overholt 2011).

An updated diagram of the model is used to convey the

key points and relationships of the model. However, read-

ers may be confused by the details and complexity. The

comprehensive approach of the Stetler Model makes it best

suited for practitioners with skills in EBP (Stetler 2010).

The intersection of quality improvement and EBP

Nursing administrators and staff nurses should consider

how the selection of a specific EBP model fits with the con-

cept of quality improvement. While the concept of continu-

ous quality improvement (CQI) has been used for decades,

it is most appropriate to include it under the larger

umbrella of EBP. CQI and EBP work in tandem; CQI may

trigger a review of EBP. Conversely, a review of evidence

can lead to new CQI initiatives. Thus, it is more vital now

than ever before for administrators, clinicians, and research-

ers to work together, using EBP models to evaluate need

for practice change, feasibility, context, barriers, facilita-

tors, cost and benefit, and most importantly, patient

outcomes.

Implications for nursing

The six models discussed all contribute in unique ways

to the realization of EBP in everyday practice. Two models

in particular may be attractive to nurse educators. The

Johns Hopkins EBP Model offers evidence rating scales and

© 2012 Blackwell Publishing Ltd 1205

JAN: DISCUSSION PAPER Evidence-based practice models for organizational change

critical appraisal forms that are helpful in assisting bacca-

laureate and master’s students to understand the EBP cri-

tique process. The ACE Star Model can be readily

understood by undergraduate students due to its similarity

to the nursing process.

Individual clinicians may find both the Johns Hopkins

and Stetler models helpful because of their emphasis on

critical thinking and a logical decision-making process.

Organizations may find a best-fit with the PARIHS, ARCC,

and Iowa models because of the emphasis on team deci-

sion-making processes. The Iowa model is prominent in the

literature for organizational decisions about adoption of

specific clinical practice guidelines. The PARIHS and ARCC

models stress the practical and contextual application of

evidence, including sustainability.

The PARIHS model considers factors that contribute to

likelihood of success for the practice change and, with fur-

ther refinement in clarity and succinct presentation, has

potential for judging the merit of cost and time expendi-

tures.

In addition to considering the setting for the best-fit EBP

model, the reader may wish to consider the degree of guid-

ance for reviewing and critiquing evidence. In this regard,

only the Johns Hopkins and ARCC models provided clear

criteria to rate level and quality of evidence. While all six

models mentioned patient experience and clinician exper-

tise, there was variation on the emphasis and process for

appraising these experiences.

Future scholars should focus not on development of new

EBP models but rather on the review, testing, and refinement

of existing models. Consistent use of terminology will help

counteract the challenge of navigating the array of terms and

models faced by educators and clinicians. Finally, clinicians

need to consider EBP recommendations in light of patients’

unique characteristics and values. Baumann (2010) cautions,

‘nurses need to recognize that the generalizations of EBP

findings must always be checked by listening to and respecting

the views and choices of each individual’ (p. 229).

Limitations

The process used to identify EBP models for discussion,

although systematic, may have resulted in overlooking

models with potential for application to practice. It should

also be pointed out that the article featuring the four crite-

ria used to evaluate the selected EBP models in Table 3 is

co-authored by Newhouse who has also been instrumental

in development of the Johns Hopkins Nursing Evidence-

Based Practice Model. This discussion of EBP models and

application in practice is not exhaustive; more in-depth dis-

cussion is provided by others (Gawlinski & Rutledge 2008,

Rycroft-Malone & Bucknall 2010).

Conclusion

This discussion, which has provided an overview of EBP

models in practical use, application examples, and an

evaluation of model usefulness, will facilitate the reader in

identifying the model that best fits the clinician, organiza-

tion, and the desired goal. Consideration of how the model

facilitates EBP projects, provides guidelines for evidence cri-

tique, guides the process for implementing practice change,

and can be used across practice areas will assist clinicians

in selecting a model that is understood, used, and leads to

improved practice.

What is already known about this topic

● Evidence-based practice promotes using best evidence

to make decisions to improve health outcomes for

individuals, groups, communities, and systems.

● Evidence includes research, clinical expertise, and

patient values and preferences.

● Many models have been developed for guiding imple-

mentation of evidence into nursing practice.

● Translation of evidence is a critical step for imple-

menting practice change.

What this paper adds

● This review provides an overview and summary of key

features and usefulness of six evidence-based practice

models frequently discussed in the literature.

● Each model is analysed based on specific criteria for

selecting an evidence-based practice model, including

applicability to academic and practice settings.

Implications for practice and/or policy

● This summary of evidence-based practice models will

inform nursing and healthcare organizational decisions

about applicability to their setting and potential model

application.

● Model features should be considered when selecting a

model to provide the best fit for clinical and educa-

tional settings.

● Healthcare organizations can support nurses in imple-

menting evidence-based practice by selecting a model

that provides clear guidance for critiquing, selecting,

and implementing best evidence.

1206 © 2012 Blackwell Publishing Ltd

M.A. Schaffer et al.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors meet at least one of the following criteria

(recommended by the ICMJE: http://www.icmje.org/

ethical_1author.html) and have agreed on the final version:

● substantial contributions to conception and design,

acquisition of data, or analysis and interpretation of

data;

● drafting the article or revising it critically for important

intellectual content.

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