Module

 6.  Evidence-­‐Based  Research  

Evidence  Based  Research  

 
“Knowing  is  not  enough;  we  must  apply.  Willing  in  not  enough,  we  must  do.”  
-­‐Johann  Wolfgang  von  Goethe  
   
Foundation  for  Research  and  Knowledge  Development  in  Nursing  
As  our  health  care  system  is  evolving,  nurses  play  a  vital  role  in  improving  the  quality  of  health  
care.    Nurses  are  not  just  task-­‐oriented  health  care  personnel,  but  professionals  who  use  their  
knowledge,  skills,  and  clinical  judgment  and  decisions  to  care  for  patients.    The  unique  body  of  
knowledge  of  the  nursing  profession  is  crucial  to  the  health  care  system,  as  it  is  necessary  for  
the  improvement  and  efficiency  of  care.    The  identification  of  the  knowledge  base  for  nursing  
practice  contributes  to  achieving  better  patient  outcomes  and  making  practice  credible.    Nurses  
have  used  multiple  sources  of  knowledge  to  guide  nursing  practice.      These  sources  include  
tradition,  authority,  borrowing,  trial  and  error,  personal  experience,  role  modeling  and  
mentorship,  intuition,  reasoning,  and  research  (Burns  &  Grove,  2001).    Although  nursing  
knowledge  is  multifaceted,  scientific  research  has  proven  to  be  the  most  objective  and  reliable  
source  of  knowledge  (Nieswiadomy,  2007).  
   
• Definition  of  Nursing  Research-­‐  Nursing  research  is  “a  scientific  process  that  validates  and  
refines  existing  knowledge  and  generates  new  knowledge  that  directly  and  indirectly  
influences  nursing  practice”  (Burns  &  Grove,  2001  p.4).      Nursing  research  is  important  in  
the  delivery  of  health  care,  as  it  provides  a  foundation  on  which  to  make  clinical  practice  
decisions.    Evidence  from  research  can  be  utilized  to  make  clinical  decisions  and  guide  care.    
For  example,  a  nurse  can  use  evidence  from  research  to  help  determine  the  best  treatment  
for  a  patient’s  wound  care.  Therefore,  it  is  essential  for  nurses  to  be  informed  on  the  latest  
research  findings  in  order  to  provide  the  most  up-­‐to-­‐date  care  for  their  patients.    Moreover,  
nurses  from  all  levels,  especially  those  at  the  bedside,  need  to  actively  participate  in  the  
research  process  as  their  roles  are  central  to  patient  care.      
 
• Research-­‐Practice  Gap-­‐  Nursing  research  is  essential  for  the  profession  in  building  the  
scientific  foundation  for  clinical  practice.    However,  the  application  of  research  into  practice  
continues  to  be  a  challenge.  One  may  ask,  if  the  research  studies  are  available,  why  are  
nurses  not  utilizing  the  findings  to  improve  patient  care?  Many  factors  contribute  to  the  
insufficiency  in  research  utilization.    First,  educational  preparation  of  nurses  can  influence  
their  interest  in  research.    The  literature  has  suggested  that  the  greater  the  level  of  
education  of  a  nurse,  the  greater  the  chance  of  using  research  in  practice  (Omery  &  
Williams,  1999).    Second,  the  attitudes  and  beliefs  of  nurses  or  organizations  can  influence  
the  use  of  research.    A  negative  attitude  about  research  can  be  a  barrier  to  incorporating  
the  evidence  into  clinical  practice  (Omery  &  Williams,  1999).    Third,  support  and  resource  
availability  can  be  an  obstacle  to  incorporating  research  into  practice.    For  example,  lack  of  
support  from  nursing  leadership,  access  to  research  materials,  and  computer  literacy  can  
influence  the  use  of  research  findings.  In  order  to  increase  the  body  of  knowledge  for  the  
nursing  profession,  it  is  imperative  for  nurses  to  overcome  these  individual  and  
organizational  barriers.  

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Module  6.  Evidence-­‐Based  Research  

 
• Evidence-­‐Based  Practice-­‐  Evidence  Based  Practice  (EBP)  has  been  gaining  momentum  since  
the  mid  1990’s  as  an  approach  to  bridge  the  gap  between  research  and  practice.    The  EBP  
movement  started  with  nurses  recognizing  a  need  to  translate  their  knowledge  into  a  form  
that  can  be  used  in  clinical  settings  to  achieve  better  patient  outcomes  (Stevens,  2013).    It  is  
important  for  nurses  to  know  about  evidence  based  practice  in  order  to  close  the  research  
practice  gap,  keep  current  on  the  latest  research,  and  prevent  nurses  from  using  outdated  
information  in  patient  care.  The  goal  of  evidence  based  practice  in  nursing  is  to  provide  
nurses  with  the  best  evidence  based  information,  resolve  problems  in  the  clinical  setting,  
minimize  variations  in  nursing  care,  achieve  excellence  in  care  delivery,  and  introduce  
innovation  (Grinspun,  Virani,  &  Bajnok,  2001/2002).    
 
• Definition  of  Evidence-­‐Based  Practice  -­‐  Evidence-­‐based  practice  (EBP)  has  many  definitions.    
Although  these  definitions  share  many  similarities,  each  adds  another  aspect  to  the  concept  
of  EBP.    The  most  common  definitions  are  the  following:    
 
o (a)  The  conscientious  integration  of  best  research  evidence  with  clinical  expertise  
and  patient  values  and  needs  in  the  delivery  of  quality,  cost-­‐effective  health  care  
(Burns  &  Grove,  2005,  p.  736);    
o (b)  The  conscientious,  explicit,  and  judicious  use  of  current  best  evidence  in  
making  decisions  about  the  care  of  the  individual  patient  (Sackett,  1996);    
o (c)  A  problem  solving  approach  to  clinical  practice  and  administrative  issues  that  
integrates:    1)  a  systematic  search  for  and  critical  appraisal  of  the  most  relevant  
evidence  to  answer  a  burning  clinical  question;  2)  one’s  own  clinical  expertise;  3)  
patient  preferences  and  values  (Melnyk,  &  Fineout-­‐Overholt,  2011).  
 
Process  of  Evidence  Based  Practice  (EBP)  
 
Evidence  based  practice  consists  of  7  steps  that  range  from  step  0  to  step  6:  
 
Step  0:  Cultivate  a  spirit  of  inquiry  
Step  1:  Ask  the  burning  clinical  question  in  the  PICOT  format  
Step  2:  Search  for  and  collect  the  most  relevant  best  evidence  
Step  3:  Critically  appraise  the  evidence  
Step  4:  Integrate  the  best  evidence  with  one’s  clinical  expertise  and  patient  preferences  and  
                       values  in  making  a  practice  decision  or  change  
Step  5:  Evaluate  outcomes  of  the  practice  decision  or  change  based  on  evidence  
Step  6:  Disseminate  the  outcomes  of  the  EBP  decision  or  change  
Figure  1:  Melnyk,  &  Fineout-­‐Overholt,  2011  
 
• Step  0:  Cultivate  a  spirit  of  inquiry  
A  spirit  of  inquiry  is  an  essential  foundation  for  evidence  based  practice.  In  other  words,  
nurses  must  have  a  curious  mind  before  initiating  any  research  effort.    This  means  that  the  

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Module  6.  Evidence-­‐Based  Research  

nurse  must  possess  an  attitude  of  inquiry  in  which  he  or  she  is  comfortable  with  asking  
questions  regarding  clinical  issues.    In  addition  to  having  a  spirit  of  inquiry,  another  essential  
foundation  to  EBP  is  having  a  supportive  organizational  culture.    Nurses  are  more  likely  to  
be  intimidated  about  asking  question  in  a  culture  that  does  not  support  a  spirit  of  inquiry.  
Therefore,  a  culture  of  EBP  must  be  cultivated  to  encourage  nurses  to  ask  clinical  questions  
of  interest.  The  following  provides  an  overview  of  the  steps  involved:  
 
• Step  1:  Ask  the  burning  clinical  question  in  the  PICOT  format  
Once  the  clinical  question  is  generated,  it  should  be  formulated  using  the  PICOT  format.  
Using  this  format  leads  to  a  more  effective  search  for  evidence  and  the  most  current  and  
relevant  information.  PICOT  stands  for:  
o P=  Patient  population  or  problem:  Who  is  the  patient  (Disease  or  health  status,  
age,  ethnicity,  gender)?  
o I=  Intervention  or  interest  area:  What  do  you  plan  to  do  for  the  patient?  
(Specific  tests,  therapies,  medications)  
o C=  Comparison  intervention  or  group:  What  is  the  alternative  to  your  plan?  (i.e.  
no  treatment,  different  type  of  treatment,  etc.)  
o O=  Outcome:  The  clinical  outcome  of  interest  (i.e.  fewer  symptoms,  no  
symptoms,  full  health,  etc.)  
o T=  Timeframe  to  determine  an  outcome  (This  element  is  not  always  included)  
 
This  is  an  example  of  a  clinical  question  in  the  PICOT  format:  
In  adult  patients  with  total  hip  replacement  (P),  how  effective  is  early  ambulation  (I)  
compared  to  bed  rest  (C)  on  decreasing  post-­‐op  Deep  Vein  Thrombosis  (O)?  
 
• Step  2:  Search  for  and  collect  the  most  relevant  best  evidence  
 
After  the  clinical  question  has  been  formulated,  a  search  of  the  literature  should  be  
conducted  in  an  effort  to  find  relevant  information.    This  process  starts  by  entering  key  
words  or  phrases  from  the  PICOT  question  into  electronic  databases  such  as  MedLine,  
PubMed,  or  Cumulative  Index  of  Nursing  and  Allied  Health  Literature  (CINAHL).  Then  the  
results  of  the  search  should  be  rated  to  determine  the  strongest  level  of  evidence.    There  
are  7  levels  of  evidence,  with  a  level  1  being  the  strongest  quality  of  evidence  and  level  7  
being  the  weakest  quality  of  evidence  (Melnyk  &  Fineout-­‐Overholt,  2011).  
 
Level  1  -­‐  Systematic  review  &  meta-­‐analysis  of  randomized  controlled  trials;  clinical    
                               guidelines  based  on  systematic  reviews  or  meta-­‐analyses  
Level  2  -­‐  One  or  more  randomized  controlled  trials  
Level  3  -­‐  Controlled  trial  (no  randomization)  
Level  4  -­‐  Case-­‐control  or  cohort  study  
Level  5  -­‐  Systematic  review  of  descriptive  &  qualitative  studies  
Level  6  -­‐  Single  descriptive  or  qualitative  study  
Level  7  -­‐  Expert  opinion  

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 Module  6.  Evidence-­‐Based  Research  

Figure  2:  Melnyk  &  Fineout-­‐Overholt,  2011  

 
• Step  3:  Critically  appraise  the  evidence  
 
Once  the  articles  are  selected  for  review,  the  next  step  is  to  conduct  a  rapid  critical  
appraisal.    This  will  determine  the  research  studies  that  are  most  relevant,  valid,  reliable,  
and  applicable  to  the  clinical  question.  There  are  3  key  general  critical  appraisal  questions  
that  should  be  answered  (Melnyk  &  Fineout-­‐Overholt,  2011):  
1. Are  the  results  of  the  study  valid?  (Validity)-­‐  For  the  results  to  be  
considered  as  valid,  they  must  be  close  to  the  truth,  and  the  study  must  
have  been  conducted  using  the  best  available  research  methods.      
2. What  are  the  results?  (Reliability)  –  For  example,  in  an  intervention  study,  
this  includes  whether  the  intervention  worked,  the  size  of  the  effect,  and  
whether  a  clinician  could  expect  to  obtain  similar  results  if  the  study  were  
repeated  in  their  own  clinical  practice  setting.  
3. Will  the  results  help  me  in  caring  for  my  patients?  (Applicability)  –  The  third  
question  of  the  appraisal  process  includes  the  following:  (a)  the  subjects  in  
the  study  are  similar  to  the  patients  being  cared  for;  (b)  the  benefits  
outweigh  the  risks  of  treatment;  (c)  the  study  is  feasible  to  implement;  (d)  
the  patient  desires  the  treatment.  
The  answers  to  these  3  questions  provide  the  researcher  the  opportunity  to  make  informed  
decisions  about  the  quality  of  evidence.    Besides,  it  confirms  the  relevance  and  transferability  of  
the  evidence  to  the  patient  population  to  whom  care  is  being  provided.  
 
• Step  4:  Integrate  the  best  evidence  with  one’s  clinical  expertise  and  patient  preferences  and  
values  in  making  a  practice  decision  or  change  
 
The  evidence  alone  cannot  determine  a  need  for  practice  change.  To  decide  whether  a  practice  
change  is  to  be  made,  the  evidence  needs  to  be  integrated  with  clinician  expertise  and  patient  
preference  and  values.    
 
• Step  5:  Evaluate  outcomes  of  the  practice  decision  or  change  based  on  evidence  
 
After  the  implementation  of  the  practice  change,  it  is  essential  to  evaluate  the  result  to  
determine  positive  outcome  from  the  Evidence-­‐Based  Practice  (EBP)  change.  
 
• Step  6:  Disseminate  the  outcomes  of  the  EBP  decision  or  change  
 
The  last  step  of  the  EBP  process  is  to  share  the  outcome  of  the  practice  change  with  others  if  
positive  outcomes  are  achieved.    It  is  important  to  share  the  result  so  that  others  can  benefit.  
Some  of  the  methods  that  can  be  used  to  disseminate  the  results  include  presentations  at  
conferences,  journal  and  newsletter  publications,  and  rounds  within  their  own  institutions  
(Melnyk,  B.  &  Fineout-­‐Overholt,  E.,  2011).  
 

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Module  6.  Evidence-­‐Based  Research  

Evidence-­‐Based  Practice  Models  in  Nursing  

 
The  use  of  evidence-­‐based  research  to  transform  clinical  practice  can  be  complex  and  
challenging.  In  order  to  facilitate  the  process,  nurses  have  developed  numerous  models  to  
guide  evidence  based  practice  in  an  organized  approach.  Currently,  the  literature  has  
documented  various  models  to  assist  with  the  implementation  of  evidence  into  practice.  This  
section  will  provide  an  overview  of  four  models  that  are  recognized  internationally  to  change  
practices  based  on  evidence.  The  four  models  include:  
1. The  Johns  Hopkins  Evidence-­‐Based  Practice  Model  
2. ACE  Star  Model  of  Knowledge  Transformation  
3. Iowa  Model  of  Evidence-­‐Based  Practice  to  Promote  Quality  Care  
4. Rosswurm  and  Larrabee  Model  of  Evidence-­‐Based  Practice  
 
Johns  Hopkins  Nursing  Evidence-­‐Based  Practice  Model  
 
Johns  Hopkins  Nursing  Evidence-­‐Based  Practice  Model  (JHNEBPM)  was  designed  to  help  nurses  
translate  evidence  into  practice.    The  model  consists  of  three  phases:  Practice  Question,  
Evidence,  and  Translation  (PET).  The  phases  are  subdivided  into  different  steps  (Newhouse,  
Dearholt,  Poe,  Pugh,  &  White,  2007).    Figure  3  depicts  the  steps  of  the  JHNEBPM  process:  
Johns  Hopkins  Nursing  Evidence-­‐Based  Practice  Model  
Practice  Question,  Evidence,  and  Translation  (PET)  

 
 
 
PRACTICE  QUESTION  
 
Step  1:  Recruit  interprofessional  team  
Step  2:  Develop  and  refine  the  EBP  question  
Step  3:  Define  the  scope  of  the  EBP  question  and  identify  stakeholders  
Step  4:  Determine  responsibility  for  project  leadership  
Step  5:  Schedule  team  meetings  

EVIDENCE  

Step  6:  Conduct  internal  and  external  search  for  evidence    

Step  7:  Appraise  the  level  and  quality  of  each  piece  of  evidence  

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Module  6.  Evidence-­‐Based  Research  

Step  8:  Summarize  the  individual  evidence  

Step  9:  Synthesize  overall  strength  and  quality  of  evidence  
Step  10:  Develop  recommendations  for  change  based  on  evidence  synthesis  
Strong,  compelling  evidence,  consistent  results    
Good  evidence,  consistent  results  
Good  evidence,  conflicting  results  
Insufficient  or  absent  evidence  
 
TRANSLATION  
Step  11:  Determine  fit,  feasibility,  and  appropriateness  of  recommendation(s)  
                           for  translation  path  
Step  12:  Create  action  plan  
Step  13:  Secure  support  and  resources  to  implement  action  plan  
Step  14:  Implement  action  plan  
Step  15:  Evaluate  outcomes  
Step  16:  Report  outcomes  to  stakeholders  
Step  17:  Identify  next  steps  
Step  18:  Disseminate  findings  
Figure  3  ©  The  Johns  Hopkins  Hospital/Johns  Hopkins  University.    May  not  be  used  or  reprinted  
without  permission.      
 
ACE  Star  Model  of  Knowledge  Transformation  
The  ACE  Star  Model  of  Knowledge  Transformation  was  developed  by  Dr.  Kathleen  Stevens  at  
the  University  of  Texas  School  of  Nursing  to  translate  evidence  into  practice.  The  model  depicts  
five  points  or  stages  through  which  research  knowledge  must  progress  as  newly  discovered  
knowledge  is  moved  into  practice  (Stevens,  2004).      
 
Five  major  stages  of  the  ACE  Model  of  Knowledge  Transformation:  
Star  point  1.  Knowledge  Discovery  
Star  point  2.  Evidence  Summary  
Star  point  3.  Translation  into  guidelines  
Star  point  4.  Integration  into  practice  
Star  point  5.  Evaluation  of  process  and  outcome  
Figure  4:  Stevens,  2004  

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Module  6.  Evidence-­‐Based  Research  

 
Figure  4:  Copyrighted  material  (Stevens,  2012).  Reproduced  with  expressed  permission  

Iowa  Model  of  Evidence-­‐Based  Practice  to  Promote  Quality  Care  

The  Iowa  Model  of  Evidence-­‐Based  Practice  to  Promote  Quality  Care  was  developed  by  Marita  
Titler  at  the  University  of  Iowa  Hospitals  and  Clinics.  The  model  describes  seven  essential  steps  
to  move  research  evidence  into  practice  with  the  goal  of  improving  the  quality  of  care  (Titler,  et  
al.,  2001).  
 
Seven  steps  of  Iowa  Model  of  Evidence-­‐  Based  Practice  to  Promote  Quality  Care:  
Step  1:  Selection  of  a  topic  
Step  2:  Forming  a  team  
Step  3:  Evidence  Retrieval  
Step  4:  Grading  the  evidence  
Step  5:  Developing  an  EBP  standard  
Step  6:  Implement  the  EBP  
Step  7:  Evaluation  
Figure  6:  Titler  el  al,  2001  
 
Rosswurm  and  Larrabee  Model  of  Evidence-­‐Based  Practice  
Rosswurm  and  Larrabee’s  Model  was  designed  to  guide  nurses  and  healthcare  professionals  
through  a  systematic  process  for  the  change  to  evidence-­‐based  practice.  The  model  consists  of  
six  steps  (Rosswurm  &  Larrabee,  1999).  
 
Six  steps  of  Rosswurm  and  Larrabee  Model:  
Step  1:  Assess  the  need  for  change  in  practice  
Step  2:  Link  the  problem  with  interventions  and  outcomes  
Step  3:  Synthesize  the  best  evidence  

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Module  6.  Evidence-­‐Based  Research  

Step  4:  Design  a  change  in  practice  

Step  5:  Implement  and  evaluate  the  practice  
Step  6:  Integrate  and  maintain  the  practice  change  

Figure  7:  Rosswurm  &  Larrabee,  1999  

 
Summary  
Research  is  the  foundation  on  which  nursing  knowledge  is  established  and  practice  decisions  
are  made.  Evidence  from  research  can  be  utilized  to  make  clinical  decision  and  guide  care.    
However,  applying  nursing  research  into  clinical  practice  remains  a  challenge  in  today’s  health  
care.    In  order  to  provide  quality  care,  evidence  based  practice  is  a  formal  method  used  by  
nurses  to  close  the  gap  between  research  and  practice.    With  the  challenges  and  complexity  of  
changing  clinical  practice,  nurses  have  developed  numerous  models  to  guide  the  
implementation  of  evidence  into  practice.    Nurses  from  all  levels  are  encouraged  to  be  
educated  on  the  skills  and  knowledge  of  incorporating  the  best  evidence  into  the  provision  of  
nursing  care  in  order  to  assure  quality  care  to  their  patients.  
   

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