Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
Practice Change and Quality Improvement Models
Most of the changes taking place in the healthcare services are related to the factors dealing with patient safety, evidence-based practices, and quality. The various models which are entirely factual and related to quality have aided the nurses in conceptualizing their understanding, and to a greater extent enhanced the issuing of appropriate health services. In consideration of this DNP project which primarily deals with the high fall rate of long-term care residents, the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the six sigma model are identified as the appropriate models which can be used in this DNP project. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model.
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Application of (JHNEBP) and the Six Sigma Model
In the view of a change being evident in the practicum and the efforts of the project, the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, according to Dang and Dearholt (2017), is compelling in the process of problem-solving and decision making. Its design is placed in the scope of meeting the needs of the practicing nurses and has a three-step process, practice question, evidence, and translation (PET) which ensures latest research finding. Once this model is applied effectively, there is the quick and appropriate incorporation of best practices into patients care (Dang & Dearholt, 2017). Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model. The six sigma model, on the other hand, provides guidance on the part relating to quality. Here, this model directs the spotlight on statistical data, as such, its primary aim being to eliminate the defects which may eventually cause harm to the patients in question (McGonigal, 2017). Information is collected and critically analyzed to ensure a standardized platform is established. Its implementation not only offers services which can be termed as nearly perfect but also a reduction in costs incurred by healthcare organizations is evident (McGonigal, 2017).
Examples of Application
In consideration of the (JHNEBP) model being linked to three step process, practice question, evidence, and translation (PET) which ensures latest research finding, the methods such as definition of the questioning scope, conducting the research, and creating a plan of action are the primary examples enumerated in the application of the change model (Dang & Dearholt, 2017). Critical cross-referencing of data, which also involves the offering of updates based on the data gathered is considered an example when dealing with the six sigma model (McGonigal, 2017). Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
Conclusion
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the six sigma model, once applied expertly will ensure quick and appropriate incorporation of best practices into patients care and also reduce the cost incurred by the health care organizations (McGonigal, 2017).
References
Dang, D., & Dearholt, S. L. (2017). Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. Sigma Theta Tau.
McGonigal, M. (2017). Implementing a 4C Approach to Quality Improvement. Critical care nursing quarterly, 40(1), 3-7.
The Johns Hopkins Nursing EBP Model
Evidence-based practice (EBP) is now a core competency for all
health care professionals (IOM, 2003). This requires leaders in both
academia and service to align their educational and practice environments to promote practice based on evidence, to cultivate a spirit
of continuous inquiry, and to translate the highest quality evidence
into practice. Selecting a model for EBP fosters end-user adoption of
evidence and embeds this practice into the fabric of the organization.
The objectives for this chapter are to:
■ Describe The Johns Hopkins Nursing Evidence-based Practice
Model
■ Introduce bedside nurses and nurse leaders to the PET process
(Practice Question, Evidence, and Translation), a tool to guide
nurses through the steps in applying EBP Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
3
The Johns Hopkins Nursing
Evidence-Based Practice
Model and Process Overview
Sandra L. Dearholt, MS, RN
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34 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
The Johns Hopkins Nursing Evidence-Based Practice
Model
The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP; see Figure
3.1) depicts three essential cornerstones that are the foundation for professional
nursing: practice, education, and research.
• Practice, the basic component of all nursing activity (Porter-O’Grady,
1984), reflects the translation of what nurses know into what they do. It
is the who, what, when, where, why, and how that addresses the range of
nursing activities that define the care a patient receives (American Nurses
Association [ANA], 2010). It is an integral component of health care
organizations.
• Education reflects the acquisition of nursing knowledge and skills
necessary to build expertise and maintain competency.
• Research generates new knowledge for the profession and enables the
development of practices based on scientific evidence. Nurses not only
“rely on this evidence to guide their policies and practices, but also
as a way of quantifying the nurses’ impact on the health outcomes of
healthcare consumers” (American Nurses Association, 2010, p. 22).
Figure 3.1 The Johns Hopkins Nursing Evidence-Based Practice Model
RESEARCH
• Experimental
• Quasi-experimental
• Non-experimental
• Qualitative
NON-RESEARCH
• Clinical Practice Guidelines
• Expert Opinion
• Organizational Experience
• Clinical Expertise
• Consumer Preferences
Internal
Factors
External
Factors
Culture
Environment
Equipment/Supplies
Staffing
Standards
Accreditation
Legislation
Quality Measures
Regulations
Standards
PRACTICE
EDUCATION
RESEARCH ©The Johns Hopkins Hospital/The Johns Hopkins University
Johns Hopkins Nursing Evidence-Based Practice Model
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 35
Nursing Practice Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
Nurses are bound by, and held to, standards established by professional nursing organizations. For example, the American Nurses Association (2010) has
identified six standards of nursing practice (scope) that are based on the nursing process (see Table 3.1) and ten standards of professional performance (see
Table 3.2). In addition to the ANA, professional specialty nursing organizations
establish standards of care for specific patient populations. Collectively, these
standards define scope of practice, set expectations for evaluating performance,
and guide the care provided to patients and families. Because these standards
provide broad expectations for practice, all settings where health care is delivered
must translate these expectations into organization-specific policies, protocols,
and procedures. As part of this process, nurses need to question the basis of their
practice and use an evidence-based approach to validate or change current practice based on the evidence. Conventionally, nurses have based their practice on
policies, protocols, and procedures often unsubstantiated by evidence (Melnyk,
Finout-Overholt, Stillwell, & Williamson, 2009). The use of an evidence-based
approach, however, is now the standard set by professional nursing organizations
and is an essential component of the Magnet Model for organizations aspiring to
Magnet recognition (Reigle et al., 2008).
The Magnet Model (see Figure 3.2) has five key components: (a) transformational leadership; (b) structural empowerment; (c) exemplary professional
practice; (d) new knowledge, innovations, and improvements; and (e) empirical
outcomes. To provide transformational leadership, nursing leaders need to have
vision, influence, clinical knowledge, and expertise (Wolf, Triolo & Ponte, 2008).
They need to create the vision and the environment that supports EBP activities, such as continuous questioning of nursing practice, translation of existing
knowledge, and development of new knowledge. Through structural empowerment nursing leaders promote professional staff involvement and autonomy in identifying best practices and using the EBP process to change practice. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model. Magnet
organizations demonstrate exemplary professional practice such as maintaining
strong professional practice models; partnering with patients, families, and interprofessional team members; and focusing on systems that promote patient and
staff safety. New knowledge, innovations, and improvements challenge Magnet
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36 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
organizations to design new models of care, apply existing and new evidence
to practice, and make visible contributions to the science of nursing (American
Nurses Credentialing Center [ANCC], 2011). Additionally, organizations are required to have a heightened focus on empirical outcomes to evaluate quality. The
EBP process supports the use of data sources such as quality improvement results, financial analysis, and program evaluations when answering EBP questions.
Table 3.1 American Nurses Association Standards of Practice
1. Assessment: The collection of comprehensive data pertinent to the health care
consumer’s health and/or situation. Data collection should be systematic and
ongoing. As applicable, evidence-based assessment tools or instruments should be
used, for example, evidence-based fall assessment tools, pain rating scales, or wound
assessment tools.
2. Diagnosis: The analysis of assessment data to determine the diagnoses or issues.
3. Outcomes identification: The identification of expected outcomes for a plan
individualized to the health care consumer or the situation. Associated risks, benefits,
costs, current scientific evidence, expected trajectory of the condition, and clinical
expertise should be considered when formulating expected outcomes.
4. Planning: The development of a plan that prescribes strategies and alternatives to
attain expected outcomes. The plan integrates current scientific evidence, trends, and
research.
5. Implementation: Implementation of the identified plan, which includes partnering
with the person, family, significant other, and caregivers as appropriate to implement
the plan in a safe, realistic, and timely manner. Utilizes evidence-based interventions
and treatments specific to the diagnosis or problem.
a. Coordination of Care: Coordinates/organizes and documents the plan of care.
b. Health Teaching and Health Promotion: Employing strategies to promote health
and a healthy environment.
c. Consultation: Graduate-level prepared specialty nurse or advanced practice
registered nurse provides consultation to influence the identified plan, enhance
the abilities of others, and effect change.
d. Prescriptive Authority and Treatment: Advanced practice registered nurse
prescribes evidence-based treatments, therapies, and procedures considering
the health care consumer’s comprehensive health care needs.
6. Evaluation: Progress towards attainment of outcomes. Includes conducting a
systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the
structures and processes prescribed by the plan of care and the indicated timeline.
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 37
Table 3.2 American Nurses Association Standards of Professional Performance
1. Ethics: The delivery of care in a manner that preserves and protects health care
consumer autonomy, dignity, rights, values, and beliefs.
2. Education: Attaining knowledge and competency that reflects current nursing
practice. Participation in ongoing educational activities. Commitment to lifelong
learning through self-reflection and inquiry to address learning and personal growth
needs.
3. Evidence-Based Practice and Research: The integration of evidence and research
findings into practice by utilizing current evidence-based knowledge, including
research findings, to guide practice.
4. Quality of Practice: Contributing to quality nursing practice through quality
improvement activities, documenting the nursing process in a responsible,
accountable, and ethical manner, and using creativity and innovation to enhance
nursing care.
5. Communication: Communicating effectively in a variety of formats in all areas of
practice.
6. Leadership: Providing leadership in the professional practice setting and the
profession.
7. Collaboration: Collaboration with health care consumer, family, and others in the
conduct of nursing practice.
8. Professional Practice Evaluation: Evaluation of one’s nursing practice in relation
to professional practice standards and guidelines, relevant statutes, rules, and
regulations.
9. Resource Utilization: Utilizes appropriate resources to plan and provide nursing
services that are safe, effective, and financially responsible.
10. Environmental Health: Practicing in a safe and environmentally safe and healthy
manner. Utilizes scientific evidence to determine if a product or treatment is an
environmental threat.
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38 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
Figure 3.2 American Nurses Credentialing Center Magnet Model Components
(© 2008 American Nurses Credentialing Center. All rights reserved. Reproduced with the permission of the
American Nurses Credentialing Center.)
An organization’s ability to create opportunities for nurses, as part of an interprofessional team, to develop EBP questions, evaluate evidence, promote critical thinking, make practice changes, and promote professional development has
a major impact on achieving Magnet status. Anecdotal evidence suggests nursing
staff who participate in the EBP process feel a greater sense of empowerment and
satisfaction as a result of contributing to changes in nursing practice based on
evidence. Change may also be more readily accepted within the organization and
by other disciplines when it is based on evidence that has been evaluated through
an interprofessional EBP process.
Nursing Education
Nursing education begins with basic education (generally an associate or a bachelor’s degree) in which fundamental nursing skills and knowledge, natural and
behavioral sciences, professional values, behaviors, and attitudes are learned. Advanced education (a master’s or doctorate degree) expands knowledge based on
theory, refines practice, and often leads to specialization in a particular practice
Global Issues in Nursing & Health Care
Empirical
Outcomes
Structural
Empowerment
Exemplary
Professional
Practice
New Knowledge,
Innovations, &
Improvements
Transformational
Leadership
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 39
area. Advanced nursing education incorporates an increased emphasis on the application of research and other types of evidence to influence or change nursing
practice and care delivery systems.
Ongoing education, such as conferences, seminars, workshops, and inservices,
are required to remain current with new knowledge, technologies, and skills or to
establish ongoing clinical competencies. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model. Because the field of health care is becoming increasingly more complex and technical, no one individual can know everything about how best to provide safe and effective care, and no one degree can
provide the necessary knowledge needed to span an entire career. It is, therefore,
an essential expectation that nurses participate in lifelong learning and continued
competency (IOM, 2011). Lifelong learning is not only individual learning, but
also interprofessional, collaborative, and team-oriented learning. For example, using simulation and web training to educate nursing and medical students together
on roles and responsibilities, effective communication, conflict resolution, and
shared decision-making is expected to result in collaborative graduates ready to
work effectively in patient-centered teams. Further, the use of interprofessional
education is thought to foster collaboration in implementing policies, improving
services, and preparing teams to solve problems that exceed the capacity of any
one professional (IOM, 2011).
Nursing Research
Nursing research uses qualitative and quantitative systematic methods and an
EBP approach directed toward the study and improvement of patient care, care
systems, and therapeutic outcomes. Although it is commonly accepted that best
practices are based on decisions validated by sound, scientific evidence, in fact,
the rate at which current research is translated into nursing practice is often slow.
Many nurses are influenced to some extent by what is known as knowledge creep,
in which they gradually see the need to change practice based on limited research
and word of mouth (Pape & Richards, 2010). Creating structures and support
for nurses to use evidence in their clinical practice will help narrow this evidencepractice gap (Oman, Duran, & Fink, 2008). Nursing leaders need to support and
encourage proficiency in and use of nursing research to generate new knowledge,
inform practice, and promote quality patient outcomes. To accomplish this, the
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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40 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
organization needs to build a strong infrastructure through the development of
mentors, skills-building programs, financial support, computer access, and availability of research consultative services.
The JHNEBP Model—The Core
At the core of the Johns Hopkins Nursing EBP model is evidence. The sources
of evidence include both research and non-research data which inform practice,
education, and research. Research produces the strongest type of evidence to
inform decisions about nursing practice. However, because research evidence answers a specific question under specific conditions, outcomes may not always be
readily transferable to another clinical setting or patient population. Before translating research evidence into practice, nurses need to carefully consider the type
of research, consistency of findings, quantity of supporting studies, quality of the
studies, relevance of the findings to the clinical practice setting, and the benefits
and risks of implementing the findings.
In many cases, research relevant to a particular nursing practice question
may be limited. Consequently, nurses need to examine and evaluate other sources
of non-research evidence, such as clinical guidelines, literature reviews, recommendations from national and local professional organizations, regulations,
quality improvement data, and program evaluations. These, along with expert
opinion, clinician judgment, and patient preferences, are sources of non-research
evidence. Patient interviews, focus groups, and patient satisfaction surveys are all
examples of preference-related evidence. Patients are taking a more active role in
making decisions for their health care; therefore, clinicians need to discover what
patients want, help them find accurate information, and support them in making
these decisions (Krahn & Naglie, 2008). A patient’s values, beliefs, and preferences will also influence the patient’s desire to comply with treatments, despite
the best evidence.
Internal and External Factors
The JHNEBP Model is an open system with interrelated components. As an open
system, practice, education, and research are influenced not only by evidence, but
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 41
also by external and internal factors. External factors can include accreditation
bodies, legislation, quality measures, regulations, and standards. Accreditation
bodies (e.g., The Joint Commission, Commission on Accreditation of Rehabilitation Facilities) require an organization to achieve and maintain high standards of
practice and quality. Legislative and regulatory bodies (local, state, and federal)
enact laws and regulations designed to protect the public and promote access to
safe, quality health care services. Failure to follow these laws and regulations has
adverse effects on an organization, most often financial. Examples of regulatory
agencies include the Centers for Medicare and Medicaid Services, Food and Drug
Administration, and state boards of nursing. State boards of nursing regulate
nursing practice and enforce Nurse Practice Acts, which serves to protect the
public. Quality measures (outcome and performance data) and professional standards serve as yardsticks for evaluating current practice and identifying areas for
improvement or change. The American Nurses Credentialing Center, through its
Magnet Recognition Program®, developed criteria to assess the quality of nursing
and nursing excellence in organizations. Additionally, many external stakeholders such as health care networks, special interest groups/organizations, vendors,
patients and families, the community, and third-party payors exert influence on
health care organizations. Despite the diversity among these external factors, one
common trend is the expectation that organizations base their health care practices and standards on sound evidence.
Internal factors can include organizational culture, values, and beliefs;
practice environment (e.g., leadership, resource allocation, patient services,
organizational mission and priorities, availability of technology, library support);
equipment and supplies; staffing; and organizational standards. Enacting EBP
within an organization requires
■ A culture that believes EBP will lead to optimal patient outcomes
■ Strong leadership support at all levels with the necessary resource allocation (human, technological, and financial) to sustain the process
■ Clear expectations that incorporate EBP into standards and job descriptions
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42 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
Knowledge and evaluation of the patient population, the health care
organization, and the internal and external factors are essential for successful
implementation and sustainability of EBP within an organization.
The JHNEBP Process: Practice Question, Evidence, and
Translation
The 18-step JHNEBP process (Appendix D) occurs in 3 phases and can be simply
described as Practice question, Evidence, and Translation (PET) (see Figure 3.3).
The process begins with the identification of a practice problem, issue, or concern. This step is critically important because how the problem is posed drives
the remaining steps in the process. Based on the problem statement, the practice
question is developed and refined, and a search for evidence is conducted. The evidence is then appraised and synthesized. Based on this synthesis, a determination
is made as to whether or not the evidence supports a change or improvement in
practice. If the data supports a change, evidence translation begins and the practice change is planned, implemented, and evaluated. The final step in translation
is dissemination of results to patients and families, staff, hospital stakeholders,
and, if appropriate, the local and national community.
Figure 3.3 The JHNEBP PET Process: Practice Question, Evidence, and Translation
(© The Johns Hopkins Hospital/The Johns Hopkins University)
Practice
Question Evidence Translation
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 43
Practice Question
The first phase of the process (steps 1–5) includes forming a team and developing
an answerable EBP question. An interprofessional team examines a practice concern, develops and refines an EBP question, and determines its scope. The Project
Management Guide (see Appendix A) should be referred to frequently throughout the process to direct the team’s work and gauge progress. The tool identifies
the following steps.
Step 1: Recruit Interprofessional Team
The first step in the EBP process is to form an interprofessional team to examine
a specific practice concern. It is important to recruit members for which the question holds relevance. When members are interested and invested in addressing
a specific practice concern, they are generally more effective as a team. Bedside
clinicians (or frontline staff) are key members because they likely have firsthand
knowledge of the problem, its context, and impact. Other relevant stakeholders
may include team members such as clinical specialists (nursing or pharmacy),
members of committees or ancillary departments, physicians, dieticians, pharmacists, patients, and families. These may provide discipline-specific expertise
or insights to create the most comprehensive view of the problem and, thus, the
most relevant practice question. Keeping the group size to 6–8 members makes it
easier to schedule meetings and helps to maximize participation.
Step 2: Develop and Refine the EBP Question
The next step is to develop and refine the clinical, educational, or administrative
EBP question. It is essential that the team take the necessary time to carefully
determine the actual problem (see Chapter 4). They need to identify the gap between the current state and the desired future state—in other words, between
what the team sees and experiences and what they want to see and experience.
The team should state the question in different ways and get feedback from
nonmembers to see if any agreement on the actual problem exists and if the question accurately reflects the problem. The time devoted to challenging assumptions
about the problem, looking at it from multiple angles and obtaining feedback
is always time well spent. Incorrectly identifying the problem results in wasted
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44 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
effort searching and appraising evidence that, in the end, does not provide the
knowledge that allows the team to achieve the desired outcomes.
Additionally, keeping the question narrowly focused makes the search for evidence specific and manageable. For example, the question “What is the best way
to stop the transmission of methicillin-resistant staphylococcus aureus (MRSA)?”
is extremely broad and could encompass many interventions and all practice settings. In contrast, a more focused question is, “What are the best environmental
strategies for preventing the spread of MRSA in adult critical-care units?” This
narrows the question to environmental interventions, such as room cleaning;
limits the age group to adults; and limits the practice setting to critical care. The
PET process uses the PICO mnemonic (Sackett, Straus, Richardson, Rosenberg,
& Haynes, 2000) to describe the four elements of a focused clinical question:
(a) patient, population, or problem, (b) intervention, (c) comparison with other
treatments, and (d) measurable outcomes (see Table 3.3).
Table 3.3 Application of PICO Elements
Patient, population, or
problem
Team members determine the specific patient,
population, or problem related to the patient/population
under examination. Examples include age, sex,
ethnicity, condition, disease, and setting.
Intervention Team members identify the specific intervention
or approach to be examined. Examples include
interventions, education, self-care, and best practices.
Comparison with other
interventions, if applicable
Team members identify what they are comparing the
intervention to, for example, current practice or another
intervention.
Outcomes Team members identify expected outcomes based on
the implementation of the intervention. The outcomes
must include metrics that will be used to determine the
effectiveness if a change in practice is implemented.
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 45
The Question Development Tool (see Appendix B) guides the team in defining the practice problem, examining current practice, identifying how and why
the problem was selected, limiting the scope of the problem, and narrowing the
EBP question using the PICO format. The tool also helps the team develop their
search strategy by identifying the sources of evidence to be searched and possible
search terms. It is important to recognize that the EBP team can go back and further refine the EBP question as more information becomes known as a result of
the evidence search and review. Refer to Chapter 4 for more details regarding the
development and refining of an EBP practice question.
Step 3: Define the Scope of the EBP Question and Identify Stakeholders
The EBP question may relate to the care of an individual patient, a specific population of patients, or the general patient population within the organization.
Defining the scope of the problem assists the team in identifying the appropriate
individuals and stakeholders who should be involved and kept informed during
the EBP project. A stakeholder can be defined as an individual or organization
that has an interest, personal or professional, in the topic under consideration
(Agency for Healthcare Research and Quality, 2011). Stakeholders may include a
variety of clinical and nonclinical staff, departmental and organizational leaders,
patients and families, insurance payors, or policy makers. Identifying and including appropriate EBP team members and keeping key stakeholders informed can
be instrumental to successful change. The team should consider whether the EBP
question is specific to a unit, service, or department, or if it involves multiple departments. If the latter, a much broader group of individuals need to be recruited
for the EBP team, with representatives from all areas involved. Key leadership in
the affected departments should be kept up-to-date on the team’s progress. If the
problem affects multiple disciplines (e.g., nursing, medicine, pharmacy, respiratory therapy), each discipline should also be included.
Step 4: Determine Responsibility for Project Leadership
Identifying a leader for the EBP project is a key success factor. The leader
facilitates the process and keeps it moving forward. The leader should be
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46 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
knowledgeable about evidence-based practice and have experience and a proven
track record in leading interprofessional teams. It is also helpful if this individual
knows the organizational structure and strategies for implementing change within the organization.
Step 5: Schedule Team Meetings
Setting up the first EBP team meeting can be a challenge and includes activities
such as:
■ Reserving a room with adequate space conducive to group discussion
■ Asking team members to bring their calendars so that subsequent meetings can be scheduled
■ Ensuring that a team member is assigned to record discussion points and
group decisions
■ Keeping track of important items (e.g., copies of the EBP tools, extra paper, dry erase board, and so on)
■ Providing a place to keep project files
■ Establishing a timeline for the process
Evidence
The second phase (steps 6–10) of the PET process deals with the search for, appraisal of, and synthesis of the best available evidence. Based on these results, the
team makes recommendations regarding practice changes.
Step 6: Conduct Internal and External Search for Evidence
Team members determine the type of evidence to search for (see Chapter 5) and
who is to conduct the search and then bring items back to the committee for
review. Enlisting the help of a health information specialist (librarian) is critical.
Such help saves time and ensures a comprehensive and relevant search. In addition to library resources, other sources of evidence include: Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
■ Clinical practice guidelines
■ Quality improvement data
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 47
■ Position statements from professional organizations
■ Opinions of internal and external experts
■ Regulatory, safety, or risk management data
■ Community standards
■ Patient and staff surveys and satisfaction data
Step 7: Appraise the Level and Quality of Each Piece of Evidence
In this step, research and non-research evidence is appraised for level and quality.
The Research Evidence Appraisal Tool (see Appendix E) and the Non-Research
Evidence Appraisal Tool (see Appendix F) assist the team in this activity. Each
tool includes a set of questions to determine the type, level, and quality of evidence. The PET process uses a five-level scale to determine the level of the evidence, with level I evidence as the highest and level V as the lowest (see Appendix
C). Based on the questions provided on the tools, the quality of each piece of evidence is rated as high, good, or low-major flaws. The team reviews each piece of
evidence and determines both the level and quality. Evidence with a quality rating
of low-major flaws is discarded and not used in the process. The Individual Evidence Summary Tool (see Appendix G) tracks the team’s appraisal of each piece
of evidence, including the author, date, evidence type, sample, sample size, setting,
and study findings, that helps to answer the EBP question, limitations, level, and
quality. Chapters 6 and 7 provide a detailed discussion of evidence appraisal.
Step 8: Summarize the Individual Evidence
The team numerically sums the pieces (sources) of evidence that answer the
practice question for each level (I–V) and records the totals on the Synthesis and
Recommendations Tool (see Appendix H). The relevant findings that answer
the EBP question for each level are then written in summary form next to the
appropriate level.
Step 9: Synthesize Overall Strength and Quality of Evidence
Next, the team determines the overall quality for each level (I–V) and records
it on the Synthesis and Recommendations Tool (see Appendix H). Through
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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48 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
synthesis, the team makes a determination as to the overall strength and quality of the collected body of evidence, taking into consideration the: (a) level, (b)
quantity, (c) consistency of findings across all pieces of evidence, and (d) applicability to the population and setting. The team can use the quality criteria for
individual evidence appraisal as a guide for determining overall quality. Making
decisions about the overall strength and quality is both an objective and subjective process. The EBP team should devote the necessary time to thoughtfully
evaluate the body of evidence and come to agreement on the overall strength and
quality. Refer to Chapters 6 and 7 and Appendix I for more information on evidence synthesis.
Step 10: Develop Recommendations for Change Based on Evidence Synthesis
Based on the overall appraisal and synthesis of the evidence, the team considers
possible pathways to translate evidence into practice. A team has four common
pathways to consider when developing a recommendation (Poe & White, 2010):
■ Evidence may be compelling, with consistent results that support a
practice change
■ Evidence may be good, with consistent results that support a practice
change
■ Evidence may be good, but with conflicting results that may or may not
support a practice change
■ Evidence may be nonexistent or insufficient to support a practice change
Based on the selected translation pathway, the team then determines whether
to make the recommended change or investigate further (see Table 3.4). The
team lists its recommendations on the Synthesis and Recommendations Tool.
The risks and benefits of making the change should be carefully considered.
Initiating a change as a pilot study (with small sample size) to determine possible
unanticipated adverse effects is strongly recommended.
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 49
Table 3.4 Translation Pathways for EBP Projects Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model
Evidence
Compelling,
consistent
Good,
consistent
Good, but
conflicting
Insufficient/
absent
Make
recommended
change?
Yes Consider pilot
of change
No No
Need for further
investigation?
No Yes,
particularly
for broad
application
Yes, consider
periodic
review for new
evidence or
development
of research
study
Yes, consider
periodic
review for new
evidence or
development of
research study
Risk-benefit
analysis
Benefit clearly
outweighs risk
Benefit may
outweigh risk
Benefit may
or may not
outweigh risk
Insufficient
information
to make
determination
Reprinted from Poe and White, 2010
Translation
In the third phase (steps 11–18) of the process, the EBP team determines if the
changes to practice are feasible, appropriate, and a good fit given the target setting. If they are, the team creates an action plan, implements and evaluates the
change, and communicates the results to appropriate individuals both internal
and external to the organization.
Step 11: Determine Fit, Feasibility, and Appropriateness of Recommendation for
Translation Pathway
The team communicates and obtains feedback from appropriate organizational
leaders, bedside clinicians, and all other stakeholders affected by the practice
recommendations to determine if the change is feasible, appropriate, and a
good fit for the specific practice setting. They examine the risks and benefits of
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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50 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
implementing the recommendations. They must also consider the resources available and the organization’s readiness for change (Poe & White, 2010). Even with
strong, high-quality evidence, EBP teams may find it difficult to implement practice changes in some cases. For example, an EBP team examined the best strategy
for ensuring appropriate enteral tube placement after initial tube insertion. The
evidence indicated that x-ray was the only 100% accurate method for identifying
tube location. The EBP team recommended that a post-insertion x-ray be added
to the enteral tube protocol. Despite presenting the evidence to clinical leadership
and other organizational stakeholders, the recommendation was not accepted
within the organization. Concerns were raised about the additional costs and adverse effects that may be incurred by patients (appropriateness). Other concerns
related to delays in workflow and the availability of staff to perform the additional X-rays (feasibility). Risk management data showed a lack of documented
incidents related to inappropriate enteral tube placement. As a result, after weighing the risks and benefits, the organization decided that making this change was
not a good fit at that time.
Step 12: Create Action Plan
If the recommendations are a good fit for the organization, the team develops a
plan to implement the recommended practice change. The plan may include:
■ Development of (or change to) a protocol, guideline, critical pathway,
system or process related to the EBP question
■ Development of a detailed timeline assigning team members to the tasks
needed to implement the change (including the evaluation process and
reporting of results)
■ Solicitation of feedback from organizational leaders, bedside clinicians,
and other stakeholders
Essentially, the team must consider the who, what, when, where, how, and
why when developing an action plan for the proposed change.
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 51
Step 13: Secure Support and Resources to Implement Action Plan
The team needs to give careful consideration to the human, material, or financial
resources needed to implement the action plan. Obtaining support and working
closely with departmental and organizational leaders can help to ensure the successful implementation of the EBP action plan.
Step14: Implement Action Plan
When the team implements the action plan, they need to ensure that all affected
staff and stakeholders receive verbal and written communication, as well as education about the practice change, implementation plan, and evaluation process.
EBP team members should be available to answer any questions and troubleshoot problems that may arise during implementation.
Step 15: Evaluate Outcomes
Using the outcomes identified on the Question Development Tool (see Appendix
B), the team evaluates the degree to which the outcomes were met. Although, of
course, the team desires positive outcomes, unexpected outcomes often provide
opportunities for learning, and the team should examine why these occurred.
This examination may indicate the need to alter the practice change or the implementation process, followed by re-evaluation. The evaluation should also be
incorporated into the organization’s quality improvement process when ongoing
measurement, evaluation, and reporting are indicated.
Step 16: Report Outcomes to Stakeholders
The team reports the results to appropriate organizational leaders, bedside
clinicians, and all other stakeholders. Sharing the results, both favorable and unfavorable, helps disseminate new knowledge and generate additional practice or
research questions. Valuable feedback obtained from stakeholders can overcome
barriers to implementation or help develop strategies to improve unfavorable
results.
Step 17: Identify Next Steps
EBP team members review the process and findings and consider if any lessons
have emerged that should be shared or if additional steps need to be taken.
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52 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition
These lessons or steps may include a new question that has emerged from the
process, the need to do more research on the topic, additional training that may
be required, suggestions for new tools, the writing of an article on the process
or outcome, or the preparation of an oral or a poster presentation at a professional conference. The team may identify other problems that have no evidence
base and, therefore, require the development of a research protocol. For example,
when the recommendation to perform a chest X-ray to validate initial enteral
tube placement was not accepted (see the scenario discussed in step 11), the EBP
team decided to design a research study to look at the use of colormetric carbon
dioxide detectors to determine tube location.
Step 18: Disseminate Findings
This final step of the process is one that is often overlooked and requires strong
organizational support. The results of the EBP project, at a minimum, need to be
communicated to the organization. Depending on the scope of the EBP question
and the outcome, consideration should be given to communicating findings external to the organization in appropriate professional journals or through presentations at professional conferences.
Summary
This chapter introduces the JHNEBP Model and the steps of the PET process.
Nursing staff with varied educational preparation have successfully used this
process with mentorship and organizational support. They have found it very
rewarding both in understanding the basis for their current nursing interventions
and incorporating changes into their practice based on evidence (Newhouse,
Dearholt, Poe, Pugh, & White, 2005).
References
Agency for Healthcare Research and Quality. (2011). Engaging stakeholders to identify and
prioritize future research needs. Retrieved from http://www.effectivehealthcare.ahrq.gov/index.
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American Nurses Association. (2010). Nursing: Scope and standards of practice. Washington, DC:
Author.
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.
The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 53
American Nurses Credentialing Center. (2011). Announcing the model for ANCC’s magnet
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Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, L. (2005). Evidence-based practice. Journal
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Pape, T. M., & Richards, B. (2010). Stop “knowledge creep.” Nursing Management, 41(2), 8-11.
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and translation. Indianapolis, IN: Sigma Theta Tau International.
Porter-O’Grady, T. (1984). Shared governance for nursing: A creative approach to professional
accountability. Rockville, Maryland: Aspen Systems Corporation.
Reigle, B. S., Stevens, K. R., Belcher, J. V., Huth, M. M., McGuire, E., Mals, D., & Volz, T. (2008).
Evidence-based practice and the road to Magnet status. Journal of Nursing Administration, 38
(2), 97-102.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidencebased medicine: How to practice and teach EBM. Edinburgh: Churchill.
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Journal of Nursing Administration, 38(4), 200-204.
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920
Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.
Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from
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