Nursing and EBP: From asking questions to evaluating results

By Laura Cullen, Kirsten Hanrahan, and Charmaine Kleiber | 09/27/2018

Evidence-Based Practice in Action takes readers through entire process.

Nursing and EBP: From asking questions to evaluating results

Laura Cullen, Kirsten Hanrahan, and Charmaine Kleiber, coauthors of Evidence-Based Practice in Action: Comprehensive Strategies, Tools, and Tips From the University of Iowa Hospitals and Clinics, respond to questions from the editor of Reflections on Nursing Leadership (RNL).

Evidence-Based Practice in ActionMany books have been published about evidence-based practice (EBP) in nursing in recent decades. Why did you feel it was important to publish another one? What sets Evidence-Based Practice in Action: Comprehensive Strategies, Tools, and Tips From the University of Iowa Hospitals and Clinics apart from the others?

Cullen, Hanrahan, and Kleiber:
Other books and resources are available to help nurses provide evidence-based care. However, they tend to provide very general guidance that makes application difficult. The University of Iowa Hospitals and Clinics is well-known for being a leader in applying evidence-based practice (EBP). The book and resources come from that perspective. The tools and resources focus on guiding successful adoption while understanding how to navigate within the complexity and reality of healthcare.

Laura CullenThe healthcare economic environment remains—and will likely continue to be—uncertain for the foreseeable future. Nurses can no longer assume funds will be available to meet nursing priorities. EBP provides nurses with a scholarly method that articulates nursing’s impact on patient and organizational outcomes. Nurses must be familiar with the best evidence, implement evidence-based care improvements, and measure their impact through evaluation. These are the most challenging steps in EBP.

Evidence-Based Practice in Action provides simple-to-read directions and adaptable tools for use with any evidence-based practice. This book is unique in that tools are available for every step—from the beginning of questioning practice through its dissemination. The goal is to help nurses use a scholarly approach to EBP that helps them improve care for patients and demonstrate nursing’s impact. 

Kirsten HanrahanThe book provides specific direction for steps that are particularly challenging, including synthesis, implementation, and evaluation of best evidence. Other books provide tools for generating questions and tools for critiquing research and other best evidence. This book offers tools that go beyond the early step of research critique. It takes the user through the entire process, including implementation and evaluation of evidence-based change.

Evidence-Based Practice in Action has innovative and first-of-a-kind resources for implementation. The text provides a unique and extensive set of strategies, tools, and tips for applying implementation science in complex healthcare settings. Definitions, procedures, and examples are provided for more than 60 implementation strategies.

Charmaine Kleiber The book also provides direction and tools for a scholarly evaluation process—including measuring knowledge, attitudes, and behaviors of clinicians and patients—that impacts implementation and outcomes. A scholarly approach to evaluation establishes when results are clinically significant and is thus important for patients and families.

I understand that the Iowa Model has been revised and serves as the basis for the EBP protocols advanced in this book. What are major enhancements of the modified Iowa Model?

Cullen, Hanrahan, and Kleiber:
The original model at Iowa, developed in 1987, was the Nursing Quality Assurance Model Using Research (QAMUR). This model was the result of shared work by nursing scholars from UI Hospitals and Clinics and UI College of Nursing (see full titles and authors below). 

The first Iowa Model, based on Rogers’ Diffusion of Innovations Theory and clinical experiences, was developed in 1994. First revised in 1998, this model continued to be a collaborative effort between UI Hospitals and Clinics and UI College of Nursing. 

In 2015, another revision of the Iowa Model—the Iowa Model Revised—was completed, prompted by a rapidly evolving healthcare environment, emerging evidence in implementation science, and questions from users. Based on new research and evidence as well as the authors’ expertise and experience, this model’s revisions also reflected feedback from 379 users, validated by 299 participants in the 22nd National EBP Conference, which convened in 2015. Because the Iowa Model Revised reflects the work of many people, including previous authors and users, authorship of the Iowa Model Revised is attributed to the Iowa Model Collaborative.

Advancements of the Iowa Model Revised over previous versions include explicit inclusion of a problem statement, more detail on designing and piloting the practice change (targeting implementation strategies), and addition of new steps for integrating and sustaining the practice change. The revised model is more linear but provides important feedback loops for cycling back when barriers present.

The organization of Evidence-Based Practice in Action, which follows the steps of the Iowa Model Revised, highlights the EBP work of many UI nurses and interprofessional teams who have used the process over the years. The book also expands on some of the most challenging steps in the process, including synthesis of evidence, implementation, and evaluation. The many implementation strategies, tools, and tips in the book are useful for navigating the EBP process. Examples of actual projects in real-world practice support pragmatic application.

But the Iowa Model is not just for Iowa! Cited more than 650 times, the Iowa Model is the basis of EBP protocols in many institutions and settings. Its reputation and reach are demonstrated by the nearly 5,500 recorded requests for the Iowa Model, which have come from every U.S. state and more than 40 countries. In 2017, the Iowa Model Revised article had over 3,000 downloads in just six months, making it one of the most downloaded articles published in Worldviews on Evidence-Based Nursing.

1994 Model
The Iowa Model of Research-Based Practice to Promote Quality Care
Infusing research into practice to promote quality care. Nursing Research, 43(5), 307-313. 

Authors: Marita G. Titler, PhD, RN; Charmaine Kleiber, MS, RN; Victoria Steelman, MA, RN; Colleen Goode, PhD, RN; Barbara Rakel, MA, RN; Jean Barry-Walker, MS, RN, CNA; Susan Small, MA, RN; Kathleen Buckwalter, PhD, RN, FAAN

1998 Model
The Iowa Model of Evidence-Based Practice to Promote Quality Care
Critical Care Nursing Clinics of North America, 13(4), 497-509.

Authors: Marita G. Titler, PhD, RN, FAAN; Charmaine Kleiber, PhD, MS, RN, CPNP; Victor J. Steelman, PhD, RN; Barbara A. Rakel, PhD, RN; Ginette Budreau, MA, MBA, RN, C; Linda Q. Everett, PhD, RN, CNAA; Kathleen C. Buckwalter, PhD, RN, FAAN; Toni Tripp-Reimer, PhD, RN, FAAN; Colleen J. Goode, PhD, RN, CNAA, FAAN

2015 Model Revised
The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care
Iowa Model of Evidence-Based Practice: Revisions and Validation
Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wv.12223 

Iowa Model Collaborative (authors in alphabetical order): Kathleen C. Buckwalter, PhD, RN, FAAN; Laura Cullen, DNP, RN, FAAN; Kirsten Hanrahan, DNP, ARNP, PNP; Charmaine Kleiber, PhD, RN, CPNP, FAAN; Ann Marie McCarthy, PhD, RN, PNP, FAAN; Barbara Rakel, PhD, RN, FAAN; Victoria Steelman, PhD, RN, CNOR, FAAN; Toni Tripp-Reimer, PhD, RN, FAAN; Sharon Tucker, PhD, RN, PMHCNS-BC, FAAN

You remind readers in the book that the Institute of Medicine has established a goal that 90 percent of healthcare will be evidence-based by 2020. That’s two years or less from now. Do you see nursing achieving its part of that goal in time? What do you consider the primary hurdles to achieving that goal?

Cullen, Hanrahan, and Kleiber:
There are specific things we can do as a discipline to move forward and overcome hurdles. A primary hurdle is lack of skill. The solution requires action from both academics and clinicians. Both have a role in stepping up development of nurse leaders with the skills needed to develop new evidence-based care guidelines and promote adoption of evidence-based healthcare. 

Priorities for academia include teaching the skills of reading, critiquing, synthesizing, and applying research. If graduate nurses are not learning to read and apply best evidence in academic programs, doing so in practice will be all the more difficult. Faculty members need to carefully consider learning resources and methods. Using textbooks and other pre-digested evidence as a primary source limits the learner’s future ability to stay current and lead evidence-based care initiatives. Students need to be reading and evaluating more research throughout their academic preparation.

Academic nursing programs have growing numbers of DNP-prepared faculty. Traditional criteria for tenure could be revised to reflect their expertise in the development and application of evidence-based practice. Recognizing faculty-led scholarly EBP within the academic tenure process would accelerate commitment to and adoption of EBP.

Perhaps research dissemination should also be reimagined. Research reports are written for researchers, not clinicians. New formats could accelerate clinician reading, critiquing, synthesizing, and adopting best evidence. Academic-practice collaborations should be solidified and recognized for the value they bring. These collaborations increase faculty and student opportunities for EBP, while increasing clinician opportunities for both EBP and research.

Unique collaborations with human factors engineers, computer and informatics scientists, business, and other specialists outside of healthcare can create innovative implementation and evaluation solutions for practice. Collaborations are needed with patients and families to better understand their preferences and ways to engage them in making healthcare decisions and improving health behaviors.

The practice setting also has a responsibility to support adoption and sustained use of EBP. One important challenge is to expand clinical nurses’ skill in finding, evaluating, and using best evidence. Building reading and discussion of research into clinical workflow would require work redesign—no small task. Unnecessary tasks must be offloaded, and dedicated work time spent on EBP must be supported. Clinicians need to also understand effective implementation strategies and promote scholarly evaluation of EBP.

A well-designed evaluation will demonstrate important improvements in clinical and organizational outcomes. Reporting the impact—the return on investment—is critical to demonstrating nursing leadership through EBP. That return on investment validates the importance of allocating resources to the development of nursing skill and EBP leadership.

We have a long way to go to reach 90 percent of healthcare practices being evidence-based. This is not an easy road, nor is there an easy solution. However, this is a call to action. Our patients and families deserve the highest quality evidence-based care. RNL

Laura Cullen, DNP, RN, FAAN, is evidence-based practice scientist, Office of Nursing Research, Evidence-Based Practice and Quality, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, in Iowa City, Iowa, USA. Kirsten Hanrahan, DNP, ARNP, CPNP-PC, is interim director of the Office of Nursing Research, Evidence-Based Practice and Quality, at University of Iowa Hospitals and Clinics. Charmaine Kleiber, PhD, RN, CPNP, FAAN, is associate professor emeritus in the Parent, Child, and Family Area at University of Iowa College of Nursing.

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