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

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

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 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

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

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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

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

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 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

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

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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

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

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

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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

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 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.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

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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.

cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=698

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

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 53

American Nurses Credentialing Center. (2011). Announcing the model for ANCC’s magnet

recognition program. Retrieved from http://www.nursecredentialing.org/Magnet/

ProgramOverview/New-Magnet-Model.aspx

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC:

The National Academics Press.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington,

DC: The National Academics Press.

Krahn, M., & Naglie, G. (2008). The next step in guideline development, incorporating patient

preferences. Journal of the American Medical Association, 300(4), 436-438.

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Igniting a spirit

of inquiry: An essential foundation for evidence-based practice. American Journal of Nursing,

109(11), 49-52.

Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, L. (2005). Evidence-based practice. Journal

of Nursing Administration, 35(1), 35-40.

Oman, K. S., Duran, C., & Fink, R. (2008). Evidence-based policy and procedure. Journal of

Nursing Administration, 38(1), 47-51.

Pape, T. M., & Richards, B. (2010). Stop “knowledge creep.” Nursing Management, 41(2), 8-11.

Poe, S. S., & White, K. M. (2010). Johns Hopkins nursing evidence-based practice: Implementation

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.

Wolf, G., Triolo, P., & Ponte, P. R. (2008). Magnet recognition program: The next generation.

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

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

Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

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