Stetler model of evidence based practice

CHAPTER 12: Evidence-Based Practice and Nursing Theory

Evelyn M. Wills

Melanie McEwen

Helen Soderstrom was stricken with changes in her vision, disturbances of gait, and occasional periods of severe fatigue during her senior year of nursing school. She experienced intermittent periods of normality as well as illness, and the periods when she had no symptoms lasted many months. During a time when her symptoms were unusually active, she sought medical help, and her physician determined that her symptoms were related to stress. Despite the periods of weakness and fatigue, she was able to complete the nursing program and graduated with honors.

During Helen’s first year of practice, she experienced two periods of symptom exacerbation, but each was short-lived. With full insurance, she was able to see a neurologist who concluded that she was experiencing the beginning stages of a neuromuscular disease. Because there was no “cure,” the neurologist worked with Helen to find interventions that helped her manage the symptoms when they became problematic.

After a few years in practice, Helen enrolled in a graduate program to work toward a career in nursing education. During her first year of graduate studies, she seldom experienced neurologic symptoms, but during her practice teaching course, they returned.

The recurrence of symptoms, along with a new understanding of evidence-based practice from her graduate courses, led Helen to make her personal health experience the topic of her final paper. To learn more, she sought resources that would help her gain better control of the neuromuscular symptoms as well as assist her in her studies. To that end, she contacted her University’s neuroscience department and joined a research team. As she learned more about EBP, she considered what system she would use to develop guidelines on symptom management and selected the Iowa Model because of its extensive use in research.

The idea of evidence-based practice (EBP) was introduced in the 1970s by Dr. Archie Cochrane, an Englishman who wrote a dynamic book questioning the efficacy of non–research-based practices in medicine (Melnyk & Fineout-Overholt, 2011). In particular, Dr. Cochrane emphasized the critical review of research, largely focusing on randomized control trials (RCTs) to support medical practice. His influence eventually led to development of the Cochrane Collaboration, an organization charged with developing, maintaining, and updating systematic reviews of health care interventions (Cochrane Collaboration, 2013). Although the notion of EBP was somewhat delayed in being recognized and implemented in nursing, over the past two decades, EBP has appeared with increasing frequency in the nursing literature and now has essentially become the standard for research-based, informed decision making for nursing care.

EBP is similar to research-based practice and has been called an approach to problem solving that conscientiously uses the current “best” evidence in the care of patients (LoBiondo-Wood & Haber, 2010). EBP involves identifying a clinical problem, searching the literature, critically evaluating the research evidence, and determining appropriate interventions. Nursing scholars note that EBP relies on integrating research, theory, and practice and is equivalent to theory-based practice as the objective of both is the highest level of safety and efficacy for patients (Fawcett & Garity, 2009).

Overview of Evidence-Based Practice

The concept of EBP is widely accepted as a requisite in health care. EBP is based on the premise that health professionals should not center practice on tradition and belief but on sound information grounded in research findings and scientific development (Melnyk & Fineout-Overholt, 2011; Schmidt & Brown, 2012). Until the early part of the 21st century, the concept of EBP was more common in Canadian and English nursing literature than in U.S. nursing literature. Over the last decade, however, the term has become ubiquitous. This is attributed in part to the guideline initiatives of the Agency for Health Care Quality, the Institute of Medicine, and the U.S. Preventative Services Task Force, among others (Hudson, Duke, Haas, & Varnell, 2008; Melnyk & Fineout-Overholt, 2011).

Many nursing scholars (DiCenso, Guyatt, & Ciliska, 2005; Ingersoll, 2000; LoBiondo-Wood & Haber, 2010; Melnyk & Fineout-Overholt, 2011; Rycroft-Malone, 2004) have pointed out that EBP and research are not synonymous. They are both scholarly processes but focus on different phases of knowledge development—application versus discovery. In general, EBP refers to the integration of individual clinical expertise with the best available external clinical evidence from systematic research. It is largely based on research studies, particularly studies using clinical trials, meta-analysis, and studies of client outcomes, and it is more likely to be applied in practice settings that value the use of new knowledge and in settings that provide resources to access that knowledge.

Definition and Characteristics of Evidence-Based Practice

In medicine, EBP has been defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). It is an approach to health care practice in which the clinician is aware of the evidence that relates to clinical practice and the strength of that evidence (Jennings & Loan, 2001; Tod, Palfreyman, & Burke, 2004).

To distinguish nursing from medicine in discussing EBP, a number of definitions have been presented in the literature. Sigma Theta Tau International (2005, para. 4) defined “evidence-based nursing” as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.” Similarly, DiCenso and colleagues (2005) defined EBP as “the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making” (p. 4). Both of these definitions use similar terms (e.g., best evidence, expertise, patient values). Ingersoll (2000) used slightly different terms when she suggested that evidence-based nursing practice “is the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (p. 152).

In nursing, EBP generally includes careful review of research findings according to guidelines that nurse scholars have used to measure the merit of a study or group of studies. Evidence-based nursing de-emphasizes ritual, isolated, and unsystematic clinical experiences; ungrounded opinions; and tradition as a basis for practice and stresses the use of research findings. Other measures or factors, including nursing expertise, health resources, patient/family preferences, quality improvement efforts, and the consensus of recognized experts, are also incorporated as appropriate (Melnyk & Fineout-Overholt, 2011; Schmidt & Brown, 2012).

In summary, EBP has several critical features. First, it is a problem-based approach and considers the context of the practitioner’s current experience. In addition, EBP brings together the best available evidence and current practice by combining research with tacit knowledge and theory. Third, it incorporates values, beliefs, and desires of the patients and their families. Finally, EBP facilitates the application of research findings by incorporating first- and second-hand knowledge into practice. Link to Practice 12-1 presents information on databases that nurses and others can access to find specific information on current guidelines and other collections of “evidence” that can be used to improve health care.

Link to Practice 12-1: Key Resources for Evidence-Based Practice

Several important databases have been set up over the last 20 years to promote integration of “evidence” in health care. Information on three of the most influential are presented here.

Cochrane Collaboration - http://www.cochrane.org/

The Cochrane Collaboration is an international network that helps health care practitioners, policy makers, patients, and their advocates make informed decisions about health care. The Cochrane Library prepares, updates, and promotes the accessibility of the Cochrane Database of Systematic Reviews.

Joanna Briggs Institute - http://www.joannabriggs.edu.au/

The Joanna Briggs Institute is an international research and development organization from the School of Translational Science at the University of Adelaide, South Australia. The Institute and its collaborating entities promote and support the synthesis, transfer, and utilization of evidence through identifying feasible, appropriate, meaningful, and effective health care practices to assist in the improvement of health care outcomes.

Agency for Healthcare Research and Quality (U.S. Preventative Services Task Force/National Guideline Clearinghouse) http://www.guideline.gov/

The National Guideline Clearinghouse (NGC) is a database of evidence-based clinical practice guidelines. It is intended to be used by health professionals, practitioners, patients, and others to obtain objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.

Concerns Related to Evidence-Based Practice in Nursing

Despite growing acceptance of application of EBP in nursing, some criticisms and concerns have been voiced in the nursing literature. For example, there is the concern that EBP is more focused on the science of nursing than on the art of nursing. Some authors have expressed concern that strict concentration on empirically based knowledge will lead to the failure to capture the uniqueness of nursing and the importance of holistic care in contemporary practice (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Hudson et al., 2008; Upton, 1999).

Another concern is that strict reliance on EBP will place nurses in the role of medical extender or medical technician, where nursing will be reduced to a technical practice. This concern was voiced as equating EBP with “cookbook care” and a disregard for individualized patient care (Finkelman & Kenner, 2013; Melnyk & Fineout-Overholt, 2011). Indeed, although evidence may provide direction for development of procedures, techniques, and protocols for nursing, it has been established that these are not the only knowledge that informs the nursing practice and that consideration of individual needs and values is essential (Hudson et al., 2008; Mitchell, 2013).

Third, because research involving humans is complex, findings may be open to interpretation and therefore should not be the sole basis for practice. Research must be considered within the context of the practice prescribed by theory, and it must integrate the values and beliefs of nursing philosophy (Chinn & Kramer, 2011; McKenna & Slevin, 2008; Walker & Avant, 2011).

A fourth concern relates to promoting a link with evidence-based medicine and its emphasis on positivist thinking and the dominance of randomized clinical trials as the major evidence. This concern is related to the absence of consideration of evidence gathered through qualitative research and theory development (Fawcett et al., 2001; Jennings & Loan, 2001; Stevens, 2001).

A fifth concern relates to the potential for linking health care reimbursement exclusively to interventions that can be substantiated by a documented body of evidence (Ingersoll, 2000). This leads to a number of ethical questions and issues that should be considered.

Finally, it is argued that not all practice in the health professions can or should be based on science. In many cases, researchers have yet to accumulate a sufficient body of knowledge. In other cases, a different frame of reference provides a different rationale for action (McKenna & Slevin, 2008). In these instances, strict reliance on EBP may result in numerous voids when developing a plan of care.

Concerns such as these have been addressed by DiCenso and colleagues (2005), who assert that a fundamental principle of EBP is that research evidence alone is not sufficient to plan care. Other ethical and pragmatic factors, such as benefits and risks, associated costs, and patient’s wishes, should be considered. Further, they note that “best research evidence” can be quantitative or qualitative and does not necessarily rely on RCTs. These notions are also supported by Rycroft-Malone (2004), who maintains that well-conceived and well-conducted qualitative and quantitative research evidence, clinical experience, and patient experiences, combined with local or organizational influences, are necessary to facilitate EBP.

Evidence-Based Practice and Practice-Based Evidence

Recently, a new concept—“practice-based evidence” (PBE)—was introduced into the discussion of EBP (Horn & Gassaway, 2007). The notion of PBE addresses many of the concerns noted previously and is grounded in the recognition that frequently interventions have limited formal research support, particularly in the number or quality of RCTs.

The premise of PBE is that large databases—not just clinical research—should be reviewed or “mined” to gather data to demonstrate quality and effectiveness. This type of review can provide comprehensive information about patient characteristics, care processes, and outcomes while controlling for patient differences (Walker & Avant, 2011). PBE acknowledges the importance of the environment in determining practice recommendations and recognizes that knowledge can be generated from practice as well as from research (Chinn & Kramer, 2011).

The intent behind PBE is to determine what works best for which patients, under what circumstances, and at what costs by providing a more comprehensive picture than RCTs, which typically examine one intervention with limited populations and under strictly controlled circumstances (Huston, 2011). Additional sources beyond formal research studies that are appropriate as PBE include benchmarking data, clinical expertise, cost-effective analyses, infection control data, medical record data, national standards of care, quality improvement data, and patient and family preferences (Huston, 2011).

Horn and Gassaway (2007) concluded that use of the PBE analyses can uncover better practices more rapidly leading to improved patient outcomes. Figure 12-1 illustrates one interpretation of the interrelationships among EBP, PBE, research, and theory in nursing.

Figure 12-1: Relationships among practice, theory, research, and the PBE/EBP cycle.

(From Walker, L. O., & Avant, K. C. [© 2011]. Strategies for theory construction in nursing [5th ed., Fig. 2-3; p. 46]. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)

Promotion of Evidence-Based Practice in Nursing

Implementation of EBP in nursing is still evolving, as often, nursing interventions are based on experience, tradition, intuition, common sense, and untested theories. While emphasis on EBP is growing rapidly, the actual incorporation of nursing research findings in practice has lagged. Melnyk and Fineout-Overholt (2011) have outlined barriers to implementation of research and EBP in nursing ( Box 12-1 ).

Box 12-1: Barriers to Evidence-Based Practice in Nursing

· Lack of EBP knowledge and skills

· Misperceptions or negative attitudes about research and evidence-based care

· Lack of belief that EBP will result in more positive outcomes than traditional care

· Voluminous amounts of information in professional journals

· Lack of time and resources to search for and appraise evidence

· Overwhelming patient loads

· Organizational constraints (e.g., lack of administrative support or incentives)

· Demands from patients for a certain type of treatment

· Peer pressure to continue with practices that are steeped in tradition

· Resistance to change

· Lack of consequences for not implementing EBP

· Lack of autonomy over practice and incentives

· Inadequate EBP content and behav

· Lack of autonomy over practice and incentives

· Inadequate EBP content and behavioral skills in educational programs

· Continued teaching of rigorous research methods in BSN and MSN programs instead of teaching evidence-based approach to care

Source: Melnyk and Fineout-Overholt (2011).

There is significant support for increasing emphasis on EBP in nursing, and many organizations such as the Institute of Medicine, Sigma Theta Tau International, and the Magnet Recognition Program of the American Nurses Credentialing Center, among others, have designed initiatives to advance EBP (Finkelman & Kenner, 2013; Huston, 2011; Melnyk & Fineout-Overholt, 2011). Indeed, practitioners, researchers, and scholars should welcome it because a systematic process of EBP may assist nurses in reducing the gap between theory and practice.

Theory and Evidence-Based Practice

The growing interest and appreciation of EBP in nursing, along with its considerable interconnectedness with research, has served in some ways to de-emphasize theory. As nurses become more aware of and attuned to EBP, however, they are renewing their appreciation of the linkages among research, theory, and practice. It has been observed that nursing focus on EBP has the potential to promote and draw new attention to this connection (Chinn & Kramer, 2011).

Walker and Avant (2011) pointed out that practice is the central and core phenomenon and focus of nursing; arguably, it is the reason for nursing’s existence. Thus, it is critical to remember that theory guides practice and it also generates models of testing in research through both PBE and EBP. Further, research and clinical data provide evidence for EBP or PBE and can generate practice guidelines and/or theories (e.g., situation-specific theories). This process is interactive and iterative (Walker & Avant, 2011). For nursing therefore, practice must not only be evidence-based but also theory-based, for when research validates a theory, it provides the evidence required for EBP. Finally, as more research is conduced about a specific theory, more evidence is provided to support practice (Chinn & Kramer, 2011; George, 2011).

Fawcett and colleagues (2001) wrote of a preference for the term “theory-guided, evidence-based practice,” noting that theory is the reason for, and the value of, evidence. The “evidence,” they stated, must extend beyond an emphasis on empirical research and RCTs to include evidence generated from theories. Indeed, the evidence itself refers to evidence about theories. Further, they contend that theory determines what counts as evidence; thus, theory and evidence are inextricably linked.

Theoretical Models of EBP

Numerous models of EBP have been developed by nurses to encourage translation of nursing research into practice. In many instances, the goal or intent is to create or establish EBP protocols, procedures, or guidelines. In some instances, universities and hospital groups have developed models to assist students or health care professionals in implementing EBP in their setting. In other instances, nurse researchers and scholars have interpreted the transfer of research evidence to nursing education and practice through processes that progressed from theory-based nursing, quality improvement, research utilization, and lately, evidence-based nursing practice. This section reviews five EBP models that are among the most frequently cited in the nursing literature. These have been widely studied and applied, many in multiple settings and for a variety of patient issues, situations, or nursing care processes. These models include:

· Academic Center for Evidence-Based Practice Star Model (ACE Star Model) (Stevens, 2004)

· Advancing Research and Clinical Practice Through Close Collaboration (ARCC Model) (Melnyk & Fineout-Overholt, 2011)

· Iowa Model (Titler et al., 2001)

· Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse, Dearholt, Poe, Pugh, & White, 2007)

· Stetler Model of Evidence-Based Practice (Stetler, 2001)

These models can provide guidance for practicing nurses and advanced practice nurses to promote or enhance EBP and to develop practice guidelines, protocols, or interventions as appropriate. Each model will be described briefly and reviewed for its utility in nursing practice and education.

ACE Star Model of Knowledge Transformation

The ACE Star Model was developed by faculty at the University of Texas Health Science Center at San Antonio (UTHSCSA) (Stevens, 2004). The Star Model is depicted by five points of knowledge transformation. The five forms of knowledge transformation occur in “relative sequence” when research evidence progresses through several cycles and is combined with other knowledge and then applied in practice.

Each point of the star represents a step in a process. The step-wise depiction allows for easy comprehension and is therefore useful even for novice nurses. In order, the points are:

· 1. Discovery research

· 2. Evidence summary

· 3. Translation to guidelines

· 4. Practice integration

· 5. Process, outcome evaluation (UTHSCSA, 2012) ( Figure 12-2 )

Figure 12-2:Diagram of the ACE star model for evidence-based practice.

(Used with permission from Stevens, K. R. (2012). ACE Star Model: Knowledge transformation©. Academic Center for Evidence-Based Practice. Available at http://www.acestar.uthscsa.edu/acestar-model.asp )

This sequence allows the nurse to move research-based knowledge from one point to the next in sequence to provide a translation of evidence on which to base practice (Stevens, 2004, 2005). Knowledge transformation consists of eight premises that underlie and explain the position of the researchers who created the model. These are presented in Box 12-2 . The rigor of the process the nurse or committee uses is part of the value of the knowledge transformation that occurs when using this model.

Box 12-2: ACE Star Model: Knowledge Transformation—Underlying Premises

· 1. Knowledge transformation (KT) is necessary prior to using research results in clinical decision making.

· 2. KT derives from multiple sources, including research, experience, authority, trial and error, and theoretical principles.

· 3. Systematic processes control bias; the research process is the most stable source of knowledge.

· 4. Evidence can be classified into a hierarchy of strength of evidence depending on the rigor of the science that produced the evidence.

· 5. Knowledge exists in a variety of forms. As research is converted through a system of steps, other knowledge is created.

· 6. The form in which knowledge exists can be referenced to its use.

· 7. The form of knowledge determines its usability.

· 8. Knowledge is transformed through steps, such as summarization, translation, application, integration, and evaluation.

Abstracted from Stevens, K. R. (2012). ACE Star Model, UT Health Science Center, San Antonio. http://www.acestar.uthscsa.edu/acestar-model.asp (Accessed May 29, 2013).

The model is used at UTHSCSA hospitals, and their nursing program maintains a very detailed and informative online educational site ( http://www.acestar.uthscsa.edu/ ). The website provides an extensive online tutorial on the ACE Star Model complete with detailed information, resources, instructive videos, and slides. A quiz and a certificate of attendance are available for those completing instruction in the model (see Link to Practice 12-2 ). The ACE Star Model is useful in teaching nurses and nursing students the process of research evidence utilization in practice (Schaffer, Sandau, & Diedrick, 2013). One concern or criticism of the ACE Star Model has been noted by White (2012), who pointed out that it does not use evidence other than research per se.

Link to Practice 12-2: ACE Star Model of Knowledge Transformation

Access the website, take the tutorial, and complete the quiz to obtain a certificate of completion of the program at http://www.acestar.uthscsa.edu/acestar-model.asp . This Web site may be useful for teaching the elements of evidence-based practice to nursing students.

Advancing Research and Clinical Practice Through Close Collaboration Model

Melnyk and Fineout-Overholt (2002) developed the ARCC Model through their work with many health care institutions seeking to advance and sustain EBP. This development was a process that involved many iterations and empirical testing of key relationships. The framework of the ARCC Model is taken from control theory and cognitive behavioral theories, which help guide nurses’ behaviors as they gain acumen in EBP (Melnyk & Fineout-Overholt, 2011). Numerous studies and examples of how the ARCC Model has been implemented in clinical practice are available in the literature (Melnyk, 2002; Melnyk, 2004; Melnyk, Feinstein, & Fairbanks, 2002; Melnyk et al., 2011).

The AARC Model relates best to clinical practice, and much of the research supporting its development and implementation was conducted in acute care, pediatric settings. The central constructs are assessment of organizational culture and readiness for EBP, identification of strengths and major barriers to EBP, and development and use of EBP mentors. These constructs are done sequentially and followed by EBP implementation. Outcomes that should be evaluated include health care provider satisfaction, cohesion, intent to leave, turnover, improved patient outcomes, and hospital costs (Melnyk & Fineout-Overholt, 2011).

In employing the ARCC Model, the authors developed several scales to measure the ability to implement EBP. These are the Organizational Culture and Readiness Scale for System-wide Integration of Evidence-based Practice (OCRSIEP) and the EBP Beliefs scale (EBPB) (Melnyk & Fineout-Overholt, 2011). Organizational readiness is first assessed, and when feasible, mentors are identified and developed. The clinical nurses are then mentored through use of the ARCC system. Melnyk and Fineout-Overholt (2011) state that measuring the key constructs along with workshops and academic offerings assist organizations to adopt and sustain EBP. Finally, Melnyk and Fineout-Overholt (2011) developed a flow chart to assist in use of the model. Box 12-3 gives examples of research that has been conducted employing the ARCC Model of EBP.

Box 12-3: Research Based on the ARCC Model of EBP

· O’Haver, J., Moore, I. M., Reed, P. G., Melnyk, B. M., & Savoie, M. (2010). Parental perceptions of risk and protective factors associated with the adaptation of siblings of children with cystic fibrosis. Pediatric Nursing, 36(6), 284–291.

· Levin, R. F., & Lewis-Holman, S. (2011). Developing guidelines for critical protocol development. Research and Theory for Nursing Practice, 25(4), 233–237.

· Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410–417.

· Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., & Cruz, R. (2010). Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nursing Outlook, 58(6), 301–308.

· Thorsteinsson, H. S. (2013). Icelandic nurses’ beliefs, skills, and resources associated with evidence-based practice and related factors: A national survey. Worldviews on Evidence-Based Nursing, 10(2), 116–126.