Translating Theory into Clinical ExcellenceUsing the Johns Hopkins EBP Model

Erin A. Eckhart MSN, MSOL, RN, CCRNIowa City VA Medical Center

Iowa City, Iowa

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Our Challenge: Moving Out of Our Comfort Zone!

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Creating an EBP Culture What is culture?• “Shared beliefs, values, attitudes, institutions, and behavior

patters that characterize the members of a community or organization”

What is your culture?Building a shared VA culture-EBP culture!

1,233 healthcare facilities (168 VA Medical centers & 1.053 outpatient sites)

Serving > 8.9 million Veterans annuallyQuality Culture:• “Emphasizes continuous improvement of processes, results

in a healthy workplace, satisfied customers, and a growing profitable organization”

How do nurses base their practice:• Pravikoff et al. (2005) surveyed 760 RN’s:

• 67% from other nurses• 58% do not use research reports• 82% NEVER use library• 54% not familiar with EBP• 67% never searched CINAHL database• 72% have not evaluated research reports

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What is Quality? Who is Asking?Structure-Process-Outcomes

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Definitions of “Quality” in Healthcare

•Joint Commission defines “Quality” as “the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm.”

•Another definition: “degree of conformity with accepted principles and practices (standards), the degree of satisfying the patients needs, and the degree of attainment of acceptable outcomes, while making appropriate use of resources.”

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Integration of QI, EBP, and Nursing Research

QI

Met Not Met

EBP

Evidence

NursingResearch

No Evidence

Taylor, (n.d.) Atlanta VA Medical Center

Integration of research, EBP & QI is a means of “preparing the workforce, developing competencies in QI, EBP, research, informatics, patient centered care, and interdisciplinary collaboration” (Seidl and Newhouse, 2012)

MAGNET requirements: • Nursing CEU courses within past 24

months & beyond orientation/in-service education

• Should include ethical, QI, Data, and information analysis competencies.

The Evidence Based Practice Journey Begins

Program your GPS (Model)• What is our destination?• How do we get there?• What do we bring?• What’s the weather?• The who, what, when, where, why of

any journey begins with you…. • And how much fun you have is up to

you!

You Are Visiting A Foreign Land• Just in time training!

• New Language

• New skills (driving on the right side of the road)

• Translate into everyday language

• Make the time to ensure your practice in based on best evidence

• ASK FOR HELP

• Never Give Up!

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Major Steps in EBP, Regardless of Model

1. Asking questions that can be answered by evidence

2. Finding relevant evidence

3. Evaluating evidence

4. Integrating the evidence with expert opinion, and patient/family preference within local context

5. Assess/evaluate how effective the plan was

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Johnson, 2008

The 5 Steps of Evidence-

based Practice

Step 1:Ask a question

Step 2:Find best evidence

Step 3:Evaluateevidence

Step 4:Apply information in combination with clinical experience and patient values

Step 5:Evaluateoutcomes

Five Steps of Evidence-based PracticeBased on Sackett et al Model

Several Models for Nursing EBP(Your GPS & Means of Transportation for EBP Journey)

Which is the Best Fit with Your Organization?

• Stetler Model (1976; 2001)**• Iowa Model (2001)**• Johns Hopkins Model (2007)**• ACE STAR Model (Academic Center for

Evidence Based Practice) (2004)**• ARCC Model (2005)• Rosswurm & Larrabee’s Model (1999)• Caledonian Development Model (2008)• Evidence Based Practice Model for Staff

Nurses (2008)• Rogers’ Diffusion of Innovation-Decision

Model (2003)• PARIHS Framework (1998)

(Polit & Beck, 2017; Gawlinski & Rutledge, 2008)

Goals of JHNEBP Model• Promote effective nursing

interventions• Promote efficient care• Promote improved outcomes• Provide best available evidence• Target areas:

• Clinical• Administrative• Education• Decision making

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What is the Johns Hopkins Nursing EBP Model?

JHNEBP is a powerful problem solving approach to clinical decision making and provides user friendly tools for use

1.Clinical expertise/expert opinion2.External scientific evidence3.Patient/caregiver perspectives

2005 National Research Utilization Award, Sigma Theta Tau

(Dearholdt & Dang, 2012)

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ResearchEvidence

Client & Situation

Own Expertise & Experience

EBP

Evidence TranslationPractice Question

Evidence-Based Practice ProcessPractice Question, Evidence, Translation

(PET)

Dearholt & Dang, 2012

Practice Question Evidence Translation

1: Recruit interprofessionalteam

2. Develop and refine question

3. Define scope of question & identify stakeholders

4. Determine responsibility for project leadership

5. Schedule team meetings

6: Conduct internal & external search for evidence

7: Appraise all types of evidence 8: Summarize the evidence9: Rate strength and quality of

evidence10: Develop recommendations for

change in processes or systems of care based on evidence synthesis:How strength described:

a. Strong, compelling evidence, consistent results

b. Good evidence, consistent resultsc. Good evidence, conflicting resultsd. Insufficient or absent evidence

11: Determine appropriateness & feasibility of translating recommendations into the specific practice setting

12: Create action plan13: Implement the change14: Evaluate outcomes15: Report results of preliminary

evaluation to decision makers16: Secure support from decision

makers to implement recommended change internally

17: Identify next steps18: Communicate findings

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Evidence TranslationPractice Question

Evidence-Based Practice Process

Dearholt & Dang, 2012

Project Management

• Powerful tool to evaluate EBP effectiveness

• Establishes controls for project• Provides exemplars of milestones• Monitors project plan• Tracks Costs• Defines communication plan

• Five competency domains:• Communication• Task Management• Situational awareness• Decision making• Leadership

• (Clay-Williams & Braithwaite, 2009)

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Using the Johns Hopkins Nursing EBP Model

Getting Copyright Use Permission • Copyright Permission to use the Model

and Tools:

• http://www.hopkinsmedicine.org/evidence-based-practice/jhn_ebp.html

• Very simple request form

• They send you copies of all tools

• Requirement to not modify the tools

• Join their mailing list

• Educational programs and EBP boot camp

Once You Have Permission: Tools JHNEBP Model provides a series of tools to facilitate project operationsA.Project Management Guide and

worksheetB.Question development (PICOT)C. Evidence Level and Quality GuideD.PET ProcessE. Research Evidence Appraisal ToolF. Non-Research Evidence Appraisal ToolG.Individual Evidence Summary Tool.H.Synthesis & RecommendationI. Synthesis of Evidence Guide

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Examples of EBP Projects(IOWA & JHNEBP Models)

Mountain Home, TN: (JHNEBP model)• Establishing PBNRP program• Establishing simulation learning environment• CAUTI reduction• Establishing EBP Council• Capstone Projects for PBNRP

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Iowa City VA Medical Center: (Iowa & JHNEBP models)

• Marriage of Professional Nursing Council with EBP Council – policies and procedures are maintained using EBP process

• Construction planning of new critical care unit

• Early identification and treatment of sepsis• 51% increase in staff nurse knowledge of sepsis

after educational interventions, ED nursing staff now screening for sepsis at time of triage

• Clinical Care Pathway for Total Joint Arthroplasty• LOS decrease from 3.2 days to 1.7 days

• Fall Prevention: Translating EBP into Practice • Reduction in falls from 4.46 falls per 1,000 days to

3.14 falls per 1,000 patient days

• Decreasing C. Difficile Rates: An EBP and Quality Improvement Approach

• Improving End-of-Life Care for Veterans• Satisfaction score improvement from families of

veterans who passed away at ICVAMC

Christiana Healthcare System: (Iowa & JHEBP models)• Achieving Beacon designation (ICU)• RN-III practice council• EBP journal club• Patient information board• Staff identification board• Construction planning for new ICU• Throughput initiative: reduce boarding time (ED to ICU)

• End of life• ED 1”1 observations• MRSA screening• Drawing medication trough

levels • Bedside report vs standard

practice• Primary vs team nursing models

• Save the arm (dialysis)• Equipment reorganization• Process revision• Hand hygiene• Use of spacers with inhalers• Pain management• Pressure ulcer reduction

Questions?

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Erin A. Eckhart MSN, MSOL, RN, CCRN

• Iowa City VA Medical Center Iowa City, IA

• Erin.Eckhart@va.gov

For information about the Iowa City EBP Nursing Council & Projects:• Emily Holderness MSN, RN

• Chair, EBP Nursing Council & Assistant Nurse Manager, ICU

• Emily.Holderness@va.gov

References Clay-Williams, R. & Braithwaite, J. (2009) APM Body of Knowledge definitions, 5th ed. Bedfordshire, UK: APM

Publishing.Dearholt, S. L. & Dang, D. (2012). Johns Hopkins nursing evidence based practice: Model and guidelines, 2nd ed.

Indianapolis, IN: Sigma Theta Tau InternationalEckhart, J. E. (2014) Effectively implementing evidence based practice in the nurse residency program and

emergency department operations improvement. Unpublished internal document, James H. Quillen VA Medical Center, Mountain Home, TN.

Eckhart, J.E. (2016). Implementing evidence based practice using the Johns Hopkins nursing evidence based practice model. Presentation ENA Leadership Conference: Fort Lauderdale, FL.

Eckhart, J.E. & Eckhart, E.A. (2017) Translating theory into practice excellence using the Johns Hopkins EBP Model. Presentation ENA National Conference: Louisville, KY.

Gawlinski, A. & Rutledge, D. (2008). Selecting a model for evidence-based practice changes. Advanced Critical Care, 19(3), 291-300.

Johnson, C. (2008). Evidence-based practice in 5 simple steps. Journal of Manipulative and Physiological Therapeutics, 31(3), 169-170.

Poe, S.S. & White, K.M. (2010). Johns Hopkins nursing evidence based practice: Implementation and translation.Indianapolis, IN: Sigma Theta Tau International.

Polit, D.F. & Beck, C.T. (2017). Nursing research: Generating and assessing evidence for nursing practice, 10th ed. Philadelphia: Wolters Kluwer.

Pravikoff, D. S., Tanner, A. B., Pierce, S. T. (2005, September). Readiness of U.S. nurses for evidence-based practice. American Journal of Nursing, 105(9), 40-51, quiz 52.

Seidl, K. & Newhouse, R. (2012, June). The intersection of evidence-based practice with 5 quality improvement methodologies. Journal of Nursing Administration, 42(6), 299-304.

Taylor, R. (n.d.). Understanding and articulating the differences between QI, research, or evidence based practice. Presentation.

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