BUILDING AN EVIDENCE-BASED

NURSING PRACTICE

By: ELVIE A. IMASON-RAMOS, MAN, RN

Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Learning Outcomes:

At the end of the chapter, the

learner should be able to:
Define evidence-based
practice
List source of evidence for
nursing practice

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Learning Outcomes:

Identify barriers to the

adoption of EBP and pinpoint
strategies to overcome them.
Explain how the process of
diffusion facilitates moving
evidence into nursing
practice
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE

Facts are stubborn

things; and whatever
may be our wishes, our
inclinations, or the
dictates of our
passions, they cannot
alter the state of
facts and evidence.
- John Adams

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Started in the field of medicine

Dr. Archie Cochrane (1971)
was concerned that evidence
was not being critically
examined. He stressed that
random clinical trials are the
gold standard for generating
reliable and valid evidence.
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Chap 2: BUILDING AN EVIDENCE-BASED

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Evidence-based Practice

Evidence from clinical

research should be used over
intuition, unsystematic clinical
experience, and
pathophysiology (Cullum, et.
al., 2008)
An important approach to
provide the best quality care
to patients and their families.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Maintained that practice

based on evidence can help
decrease uncertainty
commonly experienced by
both patients and health care
professionals particularly
nurses in todays complex
health care system (Mylnek &
Finecout-Overholt, 2004)
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Research has shown that

patients who receive care
based on evidence from
well designed studies
experience better
outcomes and early
recovery.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Simply the integration of the

best possible research
evidence with clinical
expertise and with patients
needs (Porter-OGrady,
2006)
Three Factors Merge.doc
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice: Five (5) Key Steps

1. Formulation of a clinical
question;
2. Gathering the best evidence to
answer the clinical question;
3. Critical appraisal of the best
evidence or research based
information;
4. Integration of the evidence with
the nurse own expertise,

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice: Five (5) Key Steps

assessment of patients
condition, available resources
and patients preferences and
values to implement a clinical
decision;
5. Evaluation of the practice
change, as a result of
implementing the evidence.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE

PICOT Format

Introduced by Melynk &

Finecout-Overholt (2004)
advocate asking clinical
questions in the PICOT
Format:
P patient population
I intervention of interest
C comparison intervention
O outcome
T time target

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
P Patient Population

It is necessary to have a
clear description of the
patient population and
setting retrieve the most
relevant evidence;

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Chap 2: BUILDING AN EVIDENCE-BASED

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I Intervention of Interest

This may include, but is not

limited to any treatment,
patient perception, exposure
or diagnostic test.
The more defined the
intervention, the more
focused the search for
evidence will be;
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Chap 2: BUILDING AN EVIDENCE-BASED

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C Comparison Intervention

The standard of care is

compared to a new
treatment or procedure.
The comparison can be
a true control such as
placebo;
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Chap 2: BUILDING AN EVIDENCE-BASED

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O - Outcome

Specific identification of
the outcome variable
facilitates the search for
evidence that has
investigated the same
outcome;
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Chap 2: BUILDING AN EVIDENCE-BASED

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T Time Target

Specific time for the

intervention to achieve the
best outcome.

The authors maintained that asking

the questions in this format will
yield the most relevant and best
evidence.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Remember: it is common
for nurses to implement
change fail to evaluate the
effectiveness based on
evidence but of that
change.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Evaluation of practice
change is paramount in
order to determine how a
particular treatment worked
or the effectiveness of
clinical decision.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Problem solving approach,

EBP therefore incorporates
research based information,
nurses clinical expertise and
research skills, patients
reference, values and
expectations within the
context of caring to generate
the best patient outcome.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Combined the three nature

of EBNP.

Level I: Evidence obtained

from at least one properly
designed randomized
controlled trials;
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Level II: Evidence obtained

from well designed
controlled trials without
randomization, well
designed case control
analytic studies or multiple
time series with or without
intervention; and
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence-based Practice

Opinions of respected
authorities based on clinical
experiences, descriptive
studies or report of experts.

Nature of EBN Practice 2.doc

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

The nurse clinical decision

required for evidence-based
health care. It is informed by
factors such as valid, relevant
research findings or best
evidence, client preferences,
sound judgment, skills and
expertise of the nurse as well as
the resources available to the
nurse and the client.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Is about providing care that is

supported by research and
clinical trials.
Not all practice can be
evidence based, nurses must
used the best available
information on which to base
their interventions.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

To incorporate research findings

into practice is essential in
developing a science based
practice.
Evidence for research studies
encourage nurse practitioners to
adopt the practices that have been
found useful and to abandon those
usefulness has not been
supported by evidence.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Nurses should discriminate

between those that studies have
been characterized as:
Beneficial forms of care
Care that are likely beneficial
Care with trade off between
beneficial and adverse effects
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Chap 2: BUILDING AN EVIDENCE-BASED

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The

of Evidence-based Nursing Practice

Care with unknown

effectiveness
Care that are unlikely beneficial,
and
Care that are likely to be
ineffective or harmful.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

To justify the worth of

evidence:
Systematic review of
randomized controlled trials
are conducted to determine
biased or consistent findings.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Latest protocol guideline

issued by WHO through
DOH issued A.O. 20090025 Essential Newborn
Care (ENC) under the
umbrella of the Unang
Yakap
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Issued by DOH,
mandating all hospital to
implement the four (4)
steps of newborn care
time-bound intervention to
lessen neonatal deaths.
WHO-DOH.doc
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

As a result of systematic
reviews, the best practice
and better ways to achieve
nursing goals in its
operational, clinical and
financial perspective can
be improved.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Nurses have now the

resources with which to
identify successful
practices and use them as
standards for safe
practice.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Similar to benchmarking
which supports and
promotes continual quality
improvement and helps
nurses remain steadfast
and competitive in the
health care market.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Evidenced based research

also uses collaborative
benchmarking which
involves sharing of strategies
and outcomes.
Evidence was arranged in a
hierarchy according to level
of credibility (Ferguson &
Day, 2005) Pyramid of evidence.doc

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
The

of Evidence-based Nursing Practice

Each sources of evidence is

necessary within the context
on which type of evidence
are suggested.
The primary challenge for
nurses is the establishment
of criteria for assessing and
determining acceptable
evidence.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Characteristics Evidence-based Practice in Nursing

EBP is a problem solving

approach to nursing
practice that involve the
conscientious use of
current best evidence in
making decisions about
patient care.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Characteristics Evidence-based Practice in Nursing

It is also consider the nurse

expertise and patients
values and expectations.
The nurse capacity to
identify each patients
unique health status and
diagnosis, potential risks,
and benefits of nursing
interventions.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Characteristics Evidence-based Practice in Nursing

It can come up with best

available evidence by using
research in combination with
theory. Research and theory
allows for accuracy of the
nursing care plans, diagnostic
tests, prognosis, and safety
of therapeutic and preventive
interventions.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Characteristics Evidence-based Practice in Nursing

It allows client preferences

and values to be heard. As
nurses and clients interact,
the preferences, concerns,
and expectations of each
client are all integrated into
making clinical decisions.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

RU is the process of
synthesizing, disseminating,
and using research-generated
knowledge into the nurse
clinical practice.
RU facilitates the transfer of
innovation and purposive
application of research findings
to the current nursing practice
(Polit & Beck, 2008)

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

RU is often used
interchangeably with
evidence-based practice
since research utilization is
but a part of evidence-based
practice

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

DISSEMINATION is a
part of RU, is the process
of knowledge transfer. It
includes consideration of
what, when, and how of
moving ideas and
information from the
source(s).
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

e.g. researchers to intended

recipient(s) such as client or
patients.
Research findings remain
out of the reach for their
intended users such as
health workers and patients.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

Knowledge and
interventions produced by
nursing research remain
untapped due to
researchers limited
resources and lack of
identified utilization goals
and targets.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

Purpose of research is to
confirm current practice or to
change it.
The process of
understanding and applying
research findings into
practice usually takes years,
decades, or even
generations.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

It is necessary to move
carefully, new research output
needs to evaluated, replicated
and refined.
The change process is
evaluated, not by a rigorous
review and refinement, but the
gap between the research
community and the standard of
practice.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

e.g. it took some time, 264

years, from the discovery of
citrus juice as preventive
measure for scurvy and its
use on British ship before it
was widely accepted.
(Glaser, Abelson, &
Garrison, 1993, cited by
Houser, 2008)

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

First Asia Pacific

Conference in Nursing
Research held in 2008
sought to address the issue
and proposed measures to
bridge the gap between
research and its utilization in
the Philippines.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Research Utilization (RU) & Evidence-based Practice

Gathering and accounting

for research outcomes and
analyzing them for viability
requires considerable
financial resources.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Guide to Evidence-based Practice in Nursing

Seven (7) models

Stetler, Iowa and Rogers
Theory of Diffusion of
Innovations has gained the
general acceptance.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Guide to Evidence-based Practice in Nursing

Common elements of
these models which
include: synthesis of
evidence, implementation,
evaluation of impact on
patient care, and
consideration of the
context/setting in which
evidence is implemented.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Guide to Evidence-based Practice in Nursing

Stetler Model of Research

Utilization (Stetler, 2001)
Iowa Model of Research in
Practice (Titler et. al., 2001)
Rogers Theory of Diffusion
of innovations (1995)
Ottawa Model of Research
Use (Logan & Graham, 1998)

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Guide to Evidence-based Practice in Nursing

Evidence-based
Multidisciplinary Practice Model
(Goode & Peidalue, 1999)
Model for Change to Evidencebased Practice (Rosswurm &
Larrabee, 1999)
Center for Advanced Nursing
Practice Model (Soukup, 2000)

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL
Presents a structure for using
the research outcomes and
suggests a vehicle for changing
policies and procedures.
Nurse practitioner, educators,
and policymakers, make a
summary of research done and
use it to influence educational
programs, make practice
decision, and policies.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL

Encompasses several steps:

Preparation
Validation
Comparative Evaluation
Decision Making
Translation/Application
Evaluation
(Burns & Grove, 2007)

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Preparation

Involves identifying the

purpose and focus of the
literature review
Research literature may be
reviewed to solve a difficult
clinical, managerial, or
educational problem

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Preparation

To provide the basis for

policy, standard or protocol
To prepare for an in-service
program or other type of
professional presentation

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Validation

A key consideration in
validation is to determine
whether the information is
applicable and relevant to
the current needs and
problems of the nursing
profession.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Comparative Evaluation

A review of findings of
similar studies.
The end result of the
comparative evaluation is to
make a decision about using
the study findings for
practical purposes
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Decision Making

The researcher chooses

from four possible options:
To use; To consider use;
To delay use; Reject the
findings altogether
If the decision is negative, no
further steps are necessary
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Translation/Application

The preparation for the

actual implementation of the
findings in the practice.
The main question here is
how research knowledge
should be applied? keeping
in mind always the beneficial
effects to all consumers of
health care.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Evaluation

Final stage which

determines the impact of
research findings on
practice, policy, and
patient care

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
STETLER MODEL: Evaluation

Identifying validated
research findings and
utilizing the model,
possible administrative
policies could be
designed to address the
needs and problems of
the nurse practitioner.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
IOWA MODEL

Provides direction for the

development of evidencebased practice in clinical
agency
Initially developed by Titler
and colleagues in 1994,
revised in 2001.

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
IOWA MODEL

The health agency, there are

triggers that initiate the need
for change, which is best
made based on research
evidence.

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IOWA MODEL: Knowledge-focused triggers

The pressure to change can

be generated by a heightened
awareness of new research
findings derived from journal
readings, participation in
scientific conferences, and
exposure to EBP guidelines

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
IOWA MODEL: Knowledge-focused triggers

e.g. pain management,

prevention of skin breakdown,
assessing placement NGT or
nasogastro-intestinal tube

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
IOWA MODEL: Problem-focused triggers

It has its roots in a clinical or

organizational problem.
Discovery of these problems
are usually by-products of
quality improvement activities,
risk surveillance, data
benchmarking, review of
financial performance among
others.
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
IOWA MODEL: Three Critical Decision Points

1. The problem is a sufficient

priority for the organization
exploring possible changes;
2. There is a sufficient research
base; and
3. The change is appropriate
for adoption in practice
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Rogers Theory of Diffusion Model

Is a theory of How, Why, and

At What rate new ideas and
technology spread through
cultures
Concept was first studied by
(French) Gabriel Tarde and
by (German) Friedrich Ratzel
or Leo Frobenius (1890)
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Rogers Theory of Diffusion Model

Everette Rogers (1995) first

discussed this theory in his
textbook
Rogers defines diffusion as
the process by which an
innovation is communicated
through certain channels over
time among members of a
social system
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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Rogers Theory of Diffusion Model

Diffusion of Innovations
theory by Rogers includes five
stage process:
1.
2.
3.
4.
5.

Knowledge Stage
Persuasion Stage
Decision Stage
Implementation Stage
Confirmation Stage
K-P DIC Process

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Rogers Theory of Diffusion Model: Knowledge Stage

These consists of the

initial awareness of the
existence of an innovation
or a new idea for use in
practice

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Rogers Theory of Diffusion Model: Persuasion Stage

The nurse develop

an attitude toward the
innovation

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Rogers Theory of Diffusion Model: Decision Stage

A choice is made to
adopt or reject the
innovation

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Rogers Theory of Diffusion Model: Implementation Stage

This involves using

the new idea to
change the current
practice.

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NURSING PRACTICE
Rogers Theory of Diffusion Model: Confirmation Stage

Nurses seeks
reinforcement of their
decision leading to either
a continuance of the
adoption of the evidence
or its rejection.

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NURSING PRACTICE
Rogers Theory of Diffusion Model

Rogers model could

serve as useful guide
during the early stages of
research and can provide
direction in implementing
research-based
intervention in nursing
practice.
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NURSING PRACTICE
Ottawa Model of Research

The use of strategies to

apply innovations into
practice such as the use of
evidence and other research
findings to practice
environment (Logan &
Geraham, 1999)
There six components of
this model.

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NURSING PRACTICE
Ottawa Model of Research
1. Practice environment
2. Potential research use
3. Evidenced based
innovations
4. Strategies to apply
innovations
5. Use of evidence
6. Health and other
outcomes

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Evidence Based Model
Similar to Rogers theory
of diffusion of innovation
Involves comprehensive
information on certain
issues and weighing
pieces of evidence in
relation to literature
reviewed as basis to draw
conclusion

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Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE
Evidence Based Model
Nurses to get the best from
research findings, they must
take into account much of
the evidences possible,
organized and synthesized
in a rigorous manner geared
towards making accurate
decisions for safe and
effective patient care.

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NURSING PRACTICE

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