The book this course is using is: Gray, J. R. & Grove, S. K. (2021). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (9th ed.). St. Louis, MO: Elsevier Saunders. ISBN: 978-0-323-67317-4.
Instructions: Visit the website for the Agency for Healthcare Research and Quality (AHRQ)
https://www.ahrq.gov/prevention/guidelines/index.html
Choose a topic that you are truly interested in this assignment as you will be basing all future assignments on this topic.
Locate your area of interest for Evidence-Based Practice in the EPC Reports section (found under the Research tab) on the website. What does it focus on?
In the EBP section within the Evidence Report, what are the primary recommendations? Summarize these in-depth for your initial post for the discussion board. Must be 500 words or more. 2 Scholarly Sources, APA Format
Please provide a Christian world view perspective on the topic you have chosen. Support this perspective with Scripture.
Introducing evidence into nursing
practice: using the IOWA model
Ms Catriona M Doody is Registered Intellectual
Disability Nurse, Daughters of Charity Service,
Ireland and Mr Owen Doody is Lecturer,
Department of Nursing and Midwifery, University of
Limerick, Ireland
Accepted for publication: May 2011
E
vidence-based practice has gained
increasing popularity since its
introduction in the latter part of
the twentieth century, aspiring to
be a dominant theme of practice, policy,
management and education within health
services across the world (Rycroft-Malone et
al, 2004; Ryan et al, 2006). Nurses are urged
to use up-to-date research evidence to deliver
the best possible care (Haynes et al, 1996;
Barnsteiner and Prevost, 2002; LoBiondo-
Wood and Haber, 2006). Research-based
practice has better patient outcomes than
routine, procedural nursing care (Heater et
al, 1988; Thomas, 1999) and informs nursing
decisions, actions and interactions with patients.
Nurses in practice are increasingly challenged
by patients and healthcare organizations to
provide clearly measurable care of the highest
quality (Holleman et al, 2006).
Decision making in health care has changed
dramatically, with nurses expected to make
choices based on the best available evidence and
continually review them as new evidence comes
to light (Pearson et al, 2007). Evidence-based
practice involves the use of reliable, explicit and
judicious evidence to make decisions about
the care of individual patients (Sackett et al,
1996), combining the results of well-designed
research, clinical expertise, patient concerns
and patient preferences (Sackett et al, 1996;
Flemming et al, 1997;Grol and Grimshaw,
1999; Holleman et al, 2006). A major criticism
of evidence-based practice is the lack of
available evidence or inconclusive research.
While a lack of evidence can be perceived as a
barrier, it should be recognized that the need
to base practice on evidence has only become
a concern for health professionals relatively
recently (Pearson et al, 2007). Although the
dtive for evidence-based practice has gained
momentum, it is still dependent on the nurse’s
ability to gather and appraise the evidence on
which they base their care.
The results of well-designed research
provide an obvious source of evidence but
these are by no means the only data used in
everyday practice (Pearson et al, 2007). The
limitations of research conducted became
use of research, along with other types of
evidence (Titler et al, 2001). Since its origin
in 1994, it has been continually referenced in
nursing journal articles and extensively used
in clinical research programmes (LoBiondo-
Wood and Haber, 2006). This model allows us
to focus on knowledge and problem-focused
triggers, leading staff to question current
nursing practices and whether care can be
improved through the use of current research
findings (Titler, 2006). In using the Iowa
model, there are seven steps to follow. These
are outlined in Figure 1.
Step 1: Selection of a topic
In selecting a topic for evidence-based
practice, several factors need to be considered.
These include the priority and magnitude
of the problem, its application to all areas of
practice, its contribution to improving care,
the availability of data and evidence in the
problem area, the multidisciplinary nature of
the problem, and the commitment of staff.
Catriona M Doody, Owen Doody
Abstract
Evidence-based practice has gained increasing popularity in all healthcare
settings. Nurses are urged to use up-to-date research evidence to ensure
better patient outcomes and inform decisions, actions and interactions with
patients, to deliver the best possible care. Within the practice setting, there is an
increasing challenge to provide clearly measurable care of the highest quality,
which is evidence-based. In order for nurses to operate from an evidence-based
perspective, they need to be aware of how to introduce, develop and evaluate
evidence-based practice. This article presents how evidence may be introduced
into practice using the Iowa model, offering practical advice and explanation of
the issues concerning nurses in practice.
Key Words: Evidence based practice n Nursing n IOWA model
obvious when the nursing profession began to
adopt an evidence-based model. Biomedical
knowledge alone is inadequate for the practice
of nursing. A holistic approach is necessitated,
which acknowledges all aspects of people
while also understanding their experiences
(Pearson et al, 2007).
All knowledge and information used to
make decisions can be referred to as evidence;
however, the validity of this evidence may be
variable. There is no necessary relationship
between quantity and quality, nor between
either of these and evidence usage (Newell
and Burnard, 2006). Therefore, nurses must
take into account the quality of evidence,
assessing the degree to which it meets the
four principles of feasibility, appropriateness,
meaningfulness and effectiveness (National
Institute for Health and Clinical Excellence,
2003; Gagan and Hewitt-Taylor, 2004; Pearson
et al, 2007). In order for nurses to operate in
an evidence-based manner, they need to
be aware of how to introduce, develop and
evaluate evidence-based practice. This article
presents how evidence may be introduced
into practice using the Iowa model, offering
practical advice and explanation of the issues
concerning nurses in practice.
Process of introducing Evidence-
based practice
The Iowa model focuses on organization
and collaboration incorporating conduct and
British Journal of Nursing, 2011, Vol 20, No 11 661
Professional focus
Step 2: Forming a team
The team is responsible for development,
implementation, and evaluation (LoBiondo-
Wood and Haber, 2006). The composition of
the team should be directed by the chosen
topic and include all interested stakeholders.
The process of changing a specific area of
practice will be assisted by specialist staff team
members, who can provide input and support,
and discuss the practicality of guideline
implementation (Frost et al, 2003; Gagan and
Hewitt-Taylor, 2004). A bottom-up approach
to implementing evidence-based practice is
essential as change is more successful when
initiated by frontline practitioners, rather than
imposed by management (Gough, 2001). Staff
support is also important. Junior staff require
support from senior staff to effect change,
as senior members or institutions often
impede junior members from implementing
evidence-based practice (Bhandari et al,
2003). Without the necessary resources and
managerial involvement, the team will not
feel they have the authority to change care
or the support from their organization to
implement the change in practice (Feasey and
Fox, 2001).
To develop evidence-based practice at
unit level, the team should draw up written
policies, procedures and guidelines that are
evidence based (LoBiondo-Wood and Haber,
2006). Interaction should take place between
the organization’s direct care providers and
management such as nurse managers, to
support these changes (Retsas, 2000; Nagy
et al, 2001; Berwick, 2003; LoBiondo-Wood
and Haber, 2006). As social and organizational
factors interfere with the application of
research findings, they need to be identified
and addressed prior to the development
of evidence based practice or application
of an evidence based practice initiative to
other practice areas within the organisation.
The factors identified within the literature
include workload, support of management and
colleagues, level of education, experience of
research, lack of exposure to research, lack of
training in research use, preference for practice
wisdom rather than research evidence, time
availability, accessibility to research, champion
to assist efforts, organisation support to use and
conduct research (Gerrish and Clayton, 2004;
Brown et al, 2009). Nurses or management
may perceive task performance as a more
justifiable use of time than seeking evidence
for action or designing guidelines for existing
practice (Gagan and Hewitt-Taylor, 2004;
Pearson et al, 2007).
Step 3: Evidence retrieval
From the team formation and topic selection,
a brainstorming session should be held to
identify available sources and key terms to
guide the search for evidence. Evidence should
be retrieved through electronic databases
such as Cinahl, Medline, Cochrane, Web of
662 British Journal of Nursing, 2011, Vol 20, No 11
Science and Blackwell Synergy, utilizing key
terms. Other sources of evidence such as the
National Institute of Health and Clinical
Excellence (NICE) and Quality Improvement
and Innovation Partnership (QIIP) should
be consulted with regards to relevant care
standards and guidelines.
Step 4: Grading the evidence
To grade the evidence, the team will address
quality areas of the individual research and
the strength of the body of evidence overall.
There is a tendency to classify research as
quantitative or qualitative. Qualitative data
is collected in order to derive understanding
of phenomena from a subjective perspective.
The focus is on description, understanding,
and empowerment. The theory is developed
based on inductive reasoning, and is grounded
in reality as it is perceived and experienced
by the participants involved. Conversely,
quantitative data is based on the process of
deduction, hypothesis testing and objective
methods in order to control phenomena with
its focus on theory testing and prediction.
The relative merits of both of these forms
of data are the subject of much heated debate.
On one hand, qualitative methods are seen
to most certainly increase understanding but
they are often criticized as being biased,
subjected to the question, ‘Well, now that we
understand, so what?’ (Pearson et al, 2007).
On the other hand, quantitative methods are
seen to give an apparently unbiased, objective
picture of a situation or phenomenon, but
they are often criticized as being ‘only half
the story’ or of being overly concerned
with numbers and statistics (Pearson et al,
2007). Central to the debate however, must
be the paradigmatic stance from which the
researcher works, and the stance from which
the consumer of research reads. As long as
the method is consistent with, or true to,
the paradigm that underpins the research,
and is the appropriate method to address
the research question, in theory the debate
becomes redundant. However, the debate
still continues to rage largely because of
deeply entrenched allegiances to a particular
paradigm.
The research question influences the
research methodology, which influences the
way in which data is collected and analysed,
as the methods are also dependent on the
methodology adopted. Table 1 identifies a
range of methodological approaches, which
are consistent with the philosophical view of
knowledge embodied in each paradigm and
may guide staff in the appraisal of evidence.
1. Selection of a
Topic
2. Forming a
Team
3. Evidence
retrieval
4. Grading the
Evidence
6. Implement
the EBP
7. Evaluation
5. Developing
an EBP
Standard
Figure 1. Seven steps of the IOWA model
British Journal of Nursing, 2011, Vol 20, No 11 663
Review protocols are vital to ensuring
practices are based on the most current
research evidence. Criteria should be set for
retrieval of the evidence so each team member
identifies areas for grading and grading criteria
sheets should be given to each staff member
to complete on relevant studies. Addressing
areas of effectiveness, appropriateness and
feasibility, Table 2 highlights the areas and
criteria involved. A three-tier grading system
can be used: A. Strong support that merits
application, B. Moderate support that merits
application, C. Not supported (Joanna Briggs
Institute, 2008).
Step 5: Developing an Evidence-
Based Practice (EBP) standard
After a critique of the literature, team members
come together to set recommendations for
practice. The type and strength of evidence
used in practice needs to be clear (LoBiondo-
Wood and Haber, 2006) and based in the
consistency of replicated studies. The design of
the studies and recommendations made should
be based on identifiable benefits and risks to
the patients. This sets the standard of practice
guidelines, assessments, actions, and treatment
as required. These will be based on the group
decision, considering the relevance for practice,
its feasibility, appropriateness, meaningfulness,
and effectiveness for practice (Pearson et al,
2007). To support evidence-based practice,
guidelines should be devised for the patient
group, health screening issues addressed, and
policy and procedural guidelines devised
highlighting frequency and areas of screening.
Evidence-based practice is ideally a patient-
centred approach, which when implemented
is highly individualized. However, poor
implementation has the potential to give rise
to ‘cookbook care’ where clinical guidelines
are used simply as a recipe for healthcare
delivery without due consideration for the
individual patient (Pearson et al, 2007). Any
practice failing to consider the preferences of
the individual patient is not evidence-based,
so a partnership approach is needed which
takes into account patient autonomy, choice
and preference to be expressed (van Hooren
et al, 2002).
Step 6: Implementing EPB
For implementation to occur, aspects such
as written policy, procedures and guidelines
that are evidence based need to be considered
(LoBiondo-Wood and Haber, 2006). There
needs to be a direct interaction between the
direct care providers, the organization, and
its leadership roles (eg. nurse managers) to
support these changes (Retsas, 2000; Nagy et
al. 2001; Berwick 2003; LoBiondo-Wood and
Haber, 2006). The evidence also needs to be
diffused and should focus on its strengths and
perceived benefits (Berwick, 2003; Rogers,
2003), including the manner in which it
is communicated (Rogers, 1995; Titler and
Everelt, 2001). This can be achieved through
in-service education, audit and feedback
provided by team members (Jamtvedt et al,
2004; Titler, 2004). Social and organizational
factors can affect implementation and there
needs to be support and value placed on the
integration of evidence into practice and the
application of research findings (Gagan and
Hewitt-Taylor, 2004; Pearson et al, 2007).
Step 7: Evaluation
Evaluation is essential to seeing the value and
contribution of the evidence into practice. A
Table 1. Paradigms, methodologies and methods for research
studies (Pearson et al, 2007)
Positivist paradigm Randomized controlled trials Methods that measure outcomes
such as temperature, blood
pressure, and attitudes
Cohort studies Methods that measure outcomes
(as above)
Case series studies Methods that measure outcomes
(as above)
Time series studies Methods that measure outcomes
(as above)
Interpretive paradigm Phenomenology Interviews
Historiography Textual analysis; interviews
Participant observation; interviews
of key informants
Ethnography Textual analysis; interviews
Participant observation; interviews
of key informants
Grounded theory Participant observation; interviews
Critical paradigm Action research Participative group interaction;
observation; interviews
Feminist research Participative group interaction;
observation; interviews
Paradigm Methodology Method
Table 2. Grading criteria
Effectiveness Relates to whether the intervention • Does the intervention work?
achieves the intended outcomes. • What are the benefits and harm?
• Who will benefit from its use?
Appropriateness Concerned more with the psychosocial • What is the experience of the
aspects of care than with the consumer?
physiological. • What health issues are important
to the consumer?
• Does the consumer view the
outcomes as beneficial?
Feasibility Addresses the broader environment • What resources are required for
in which the intervention is situated the intervention to be successfully
and involves determining whether implemented?
the intervention can and should be • Will it be accepted and used by
implemented. healthcare workers?
This focus acknowledges that the • How should it be implemented?
process of intentional change in large • What are the economic
organizations is very complex. implications of using the
intervention?
Area Concern Criteria
Professional focus
664 British Journal of Nursing, 2011, Vol 20, No 11
baseline of the data before implementation would
benefit, as it would show how the evidence has
contributed to patient care. Audit and feedback
through the process of implementation should
be conducted (Thomson O Brien et al, 2003;
Jamtvedt et al, 2004) and success will not
be achieved without support from frontline
leaders and the organization (Baggs and Mick,
2000; Carr and Schott, 2002; Stetler, 2003).
Evaluation will highlight the programme’s
impact but its consistency can only be assessed
against an actual change occurring and having
the desired effect (Pearson et al, 2007). For any
change to take place, barriers that could hinder
its progress need to be identified. Information
and skill deficit are common barriers to
evidence-based practice. A lack of knowledge
regarding the indications and contraindications,
current recommendations, and guidelines or
results of research, has the potential to cause
nurses to feel they do not have sufficient
training, skill or expertise to implement the
change (Pearson et al, 2007). Lack of awareness
of evidence will inhibit its translation into
practice (Scullion, 2002). A useful method for
identifying perceived barriers is the use of
a force field analysis conducted by the team
leader. Impact evaluation, which relates to the
immediate effect of the intervention, should be
carried out (Naidoo and Wills, 2002). However,
some benefits may only become apparent
after a considerable period of time. This is
known as the sleep effect. On the contrary,
the back-sliding effect could also occur where
the intervention has a more or less immediate
effect, which decreases over time. If we evaluate
too late, we will miss measuring the immediate
impact. Even if we do observe the early effect,
we cannot assume it will last (Green, 1977;
Nutbeam, 1998). Therefore, evaluation should
be carried out at different periods during and
following the intervention.
Conclusion
The effectiveness of clinical care and treatment
is central to the quality of health care
(Thompson, 2000) and providing a high quality
care based on best practice is the responsibility
of nurses. In many clinical settings, nurses are
under increased time pressure and evidence-
based practice may fail, having a low priority
among competing duties (Lawrie et al, 2000;
Bhandari et al, 2003; Frost et al, 2003; Thomas
et al, 2003). Quality improvement is often
seen as an additional task to an already busy
workload (Long, 2003). However, it may be
that nurses perceive activity to be a more
worthy use of time than seeking evidence
upon which to act (Gagan and Hewitt-
Taylor, 2004). For evidence-based practice to
be implemented, this value system and the
norms that lead to it need to be addressed as
a priority, and this is the responsibility of each
practitioner in any given situation (Gagan and
Hewitt-Taylor, 2004). As the largest group
providing care to patients and having the
most contact with them, nurses have the
opportunity to influence the course of their
illness and recovery. If care is not evidence-
based, the potential of harm increases (Newell
and Burnard, 2006). Therefore, nurses must
actively engage in reading, critiquing and
grading the evidence to continually challenge
the practice.
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KEy POInTs
n Nurses need to continuously update their knowledge and act from an evidence-based
approach rather than working solely from practice wisdom
n There is a constant challenge for nurses in the practice setting to provide measurable care
and outcomes of the highest standard in an evidence-based manner
n Evaluation of evidence and development of evidence-based practice will empower nurses
n Collective work and the use of tools such as the IOWA model can assist nurses with EBP
BJN
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permission. However, users may print, download, or email articles for individual use.
Original Article
Iowa Model of Evidence-Based Practice:
Revisions and Validation
Authored on behalf of the Iowa Model Collaborative
Keywords
evidence-based
practice,
Iowa Model,
model,
translation research,
implementation,
evaluation,
change
ABSTRACT
Background: The Iowa Model is a widely used framework for the implementation of evidence-
based practice (EBP). Changes in health care (e.g., emergence of implementation science, em-
phasis on patient engagement) prompted the re-evaluation, revision, and validation of the model.
Methods: A systematic multi-step process was used capturing information from the literature
and user feedback via an electronic survey and live work groups. The Iowa Model Collabora-
tive critically assessed and synthesized information and recommendations before revising the
model.
Results: Survey participants (n = 431) had requested access to the Model between years 2001
and 2013. Eighty-eight percent (n = 379) of participants reported using the Iowa Model and
identified the most problematic steps as: topic priority, critique, pilot, and institute change. Users
provided 587 comments with rich contextual rationale and insightful suggestions. The revised
model was then evaluated by participants (n = 299) of the 22nd National EBP Conference in
2015. They validated the model as a practical tool for the EBP process across diverse settings.
Specific changes in the model are discussed.
Conclusion: This user driven revision differs from other frameworks in that it links practice
changes within the system. Major model changes are expansion of piloting, implementation,
patient engagement, and sustaining change.
Linking Evidence to Action: The Iowa Model-Revised remains an application-oriented guide
for the EBP process. Intended users are point of care clinicians who ask questions and seek a
systematic, EBP approach to promote excellence in health care.
INTRODUCTION
Using the best evidence to guide clinical practice has been im-
portant for decades, but full adoption of evidence-based practice
(EBP) remains a challenge. In the early 1990s, a team of nurses
from the University of Iowa Hospitals and Clinics (UIHC) and
College of Nursing developed a framework called The Iowa
Model of Research-Based Practice to Promote Quality Care to
guide clinicians in evaluating and infusing research findings
into patient care (Titler et al., 1994). The Iowa Model was
based on Roger’s (1983) theory, Diffusion of Innovations, and
was an outgrowth of the Quality Assurance Model Using Re-
search (QAMUR; Watson, Bulechek, & McCloskey, 1987). It is
a heuristic model, developed by nurses incorporating success-
ful strategies learned when undertaking research utilization
projects. Subsequently, research utilization evolved into EBP,
incorporating the use of multiple levels of evidence, and the
Iowa Model was revised to reflect this expansion as well as
provide more detail about infusing change (Titler et al., 2001).
The Iowa Model is widely used and has stood the test of
time as a pragmatic guide for the EBP process. Since 2001,
over 3,900 requests for permission to use the Iowa Model
have come from clinicians, educators, administrators, and re-
searchers from all 50 states and 130 countries. Additionally,
the model has been translated into German, Japanese, and
Portuguese.
Since the last revision, dramatic changes have evolved in
health care, including an explosion of synthesized evidence,
national and international initiatives promoting adoption of
EBP, enhanced interprofessional collaboration, widespread use
of electronic data, emergence of implementation science, pay
for performance, and enhanced patient engagement. In 2012,
the Iowa Model Collaborative was formed to assess the need
for model revision. All prior authors and key stakeholders were
invited to participate in the Iowa Model Collaborative.
PURPOSE
The purpose of this initiative was to revise and validate the
Iowa Model. This paper describes the systematic, multi-phase
process used to collect and critically analyze user suggestions.
Specific changes in the Iowa Model-Revised are presented.
Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182. 175
C© 2017 University of Iowa Hospitals and Clinics, Worldviews on Evidence-Based Nursing C© 2017 Sigma Theta Tau International
Iowa Model-Revised
PHASE I: DEVELOPMENT OF THE
REVISED MODEL
The first step involved generating and assembling potential
revisions for the model from multiple sources: (a) literature,
including critical analyses of the Iowa Model as well as other
EBP models (Rycroft-Malone & Bucknall, 2010); (b) Collabo-
rative members’ experiences using the model in clinical and
academic settings; and (c) results from a survey of Iowa Model
users. The second step involved Collaborative members break-
ing into small workgroups to critically assess and synthesize
the recommendations, then reaching consensus as a whole.
Procedure
Users of the Iowa Model were surveyed to assess its utility,
identify challenges, and obtain suggestions for revisions. Par-
ticipants were drawn from the UIHC database containing re-
quests for the model between 2001 and 2013. The University
of Iowa Human Subjects Review Board ruled that this survey
did not require IRB approval.
A 41-item electronic REDCapTM (Vanderbilt University) sur-
vey was sent to 2,052 individuals with unique e-mail addresses
in the database. Each of 13 steps in the model was listed for
participants to indicate if that step was problematic (yes or
no), identify problem(s), and make suggestions (free text) for
revision. A final open-ended question elicited additional sug-
gestions for the model overall. A total of 431 useable surveys
(21% response rate) were received from respondents who were
primarily from the United States (96.3%), had a graduate de-
gree (87.9%), worked in a hospital or academic setting (79%),
and were either an educator or clinician (52%). Experience us-
ing the model varied from novice (9%) to expert (15%), with
the vast majority being in-between.
Results
Most participants found the model to be very useful (68.4%),
stating that it was easy to follow, straightforward, and helped
them implement practice changes. A few expressed concern
that the model was too complex for novices and needed to be
simplified. A total of 94% were interested in a revised model.
Most participants (n = 379, 88%) reported they had used
the Iowa Model. Users identified problems in each of the 13
steps of the model. Steps most often identified as problematic
were: topic a priority (n = 52, 14%), critique of research (n = 65,
17%), pilot the change (n = 47, 12%), and institute the change
(n = 49, 13%). Participants provided 587 comments, both pos-
itive and negative, with rich contextual rationale for the prob-
lems and made insightful suggestions for each component of
the model (see Figure 1 and Supplemental Table S1).
Following collective review of survey results, members of
the Collaborative moved revisions forward by forming four
workgroups based on decision points in the model. Focusing
on specific model components allowed for more in-depth anal-
ysis of the data and a review of the literature in that area.
Work groups identified high frequency problems or sug-
gestions from survey data and major recurring themes from
qualitative data. These themes evolved into specific recommen-
dations and rationale for change in respective sections as well
as suggestions for overall model improvements. Suggested re-
visions were taken back to the whole Collaborative for further
discussion and a draft of the Iowa Model-Revised was created.
PHASE II: VALIDATION AND
REFINEMENT OF THE IOWA MODEL
REVISED
The second phase involved validation and refinement of the
revised model. The annual National EBP conference at UIHC
provided a participant pool with a particular interest in and
knowledgeable about EBP processes and issues. Conference
attendees were invited to participate in activities designed to
validate and further refine the Iowa Model-Revised.
Procedure
The “Iowa Model-Revised: Evidence-Based Practice to Promote
Excellence in Health Care” was presented as the conference
keynote at UIHC’s 22nd National EBP Conference on April
23–24, 2015. The presentation described the process used to
revise the model, changes made, and rationale for the revi-
sions. Participants (n = 299) individually reflected upon an
actual or ideal evidence-based project at their institution and
walked through the steps of the revised Iowa Model. They then
identified strengths and weaknesses of the model revisions,
resources needed for application of the model, and made other
suggestions. Participants also met in small groups to work
through a specified EBP initiative using the revised model.
Questions, issues, and suggestions were reported back and
considered during a panel discussion the following day. Panel
leaders fielded questions and solicited further feedback for re-
finement and clarification of the model.
Results
Participants felt the revised model was streamlined and easy to
follow. They liked the linear format and added detail under pi-
loting the practice change. Specific suggestions were to return
“Conduct Research” to a stand-alone step, simplify the arrows,
and provide more clarification regarding knowing when evi-
dence is sufficient to change practice. Results of all conference
activities were tabulated into strengths and issues, and themes
identified (available in Supporting Information). These data
were used by the Collaborative during a follow-up meeting to
further refine the Model.
EXPLANATION OF MODEL REVISIONS
The Iowa Model-Revised is presented in Figure 2. The revisions
and associated rationale for making changes in each of the
Model components are described sequentially from identifying
issues through dissemination.
176 Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182.
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Original Article
Figure 1. Users who identified steps in Iowa Model as problematic.
Note. Of 379 users in survey, percent that indicated yes, this step of the Iowa Model is problematic.
Identifying Triggering Issues and Opportunities
The model began with parallel boxes listing nine Problem and
Knowledge Focused Triggers. This was revised and simplified
to five triggering issues and opportunities, which combined
triggers from both prior categories.
The reworded bullet “data/new evidence” expanded beyond
the original “new research or other literature” to include risk
management data, process improvement data, financial data,
and internal and external benchmarking data. Two new bullets
were added: “Accrediting agency requirements/regulations”
and “clinical or patient identified issues.” These topics reflect
national quality strategies such as the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey, and initia-
tives from accrediting agencies such as the Joint Commission,
as well as the growing attention to patient preferences. Re-
sponding to patient preferences might involve a palliative care
patient requesting pet therapy or massage, or implementation
of bedside handoff by nursing staff in response to patient satis-
faction surveys. Finally, an existing bullet (i.e., National Agen-
cies or Organizational Standards & Guidelines) was modified
to “organization, state, or national initiative” which includes
initiatives such as the World Health Organization’s surgical
checklist (Garcia-Paris, Cohena-Jimenez, Montano-Jimenez, &
Cordoba-Fernandez, 2015), and outcome-based quality report-
ing and changing reimbursement of potentially avoidable hos-
pital acquired conditions (e.g., pressure injury).
State the Question or Purpose
A frequent request from users was to add a step for stating the
question or purpose of the EBP project, which was included in
the revised model. Formally stating the purpose enables a more
focused approach to synthesizing the body of evidence and
better informs the next decision point, “Is this topic a priority?”,
as well as subsequent steps. Users of the model may apply
the PICO (Population, Intervention, Comparison, Outcome)
or other formats to better frame searchable questions.
Decision Point 1: Is This Topic a Priority?
This step remains an important decision point in the revised
model, because a low priority project (i.e., one that is not aligned
with the organization’s mission and vision or not linked to the
organization’s strategic plan) is unlikely to obtain resources
necessary to bring it to fruition. However, the words, “for the
organization” were eliminated in the revision to extend the
model’s applicability to other settings, such as the community,
to better incorporate smaller non-organization wide clinical
changes and to make the model responsive to projects that are
not resource intensive. If the topic is not a priority, the model
suggests selecting another question.
(No) Consider Another Issue.
This step was unchanged from the last version of the model.
Survey participants understood that if a topic could not
Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182. 177
C© 2017 University of Iowa Hospitals and Clinics, Worldviews on Evidence-Based Nursing C© 2017 Sigma Theta Tau International
Iowa Model-Revised
The Iowa Model Revised: Evidence-Based
Practice to Promote Excellence in Health Care
©University of Iowa Hospitals and Clinics, Revised June 2015
To request permission to use or reproduce, go to
DO NOT REPRODUCE WITHOUT PERMISSION http://www.uihealthcare.org/nursing-research-and-evidence-based-practice/
= a decision point
Identify Triggering Issues / Opportunities
• Clinical or patient identified issue
• Organization, state, or national initiative
• Data / new evidence
• Accrediting agency requirements / regulations
• Philosophy of care
State the Question or Purpose
Is this topic a
priority?
No
Form a Team
Assemble, Appraise and Synthesize Body of Evidence
• Conduct systematic search
• Weigh quality, quantity, consistency, and risk
Is there
sufficient
evidence?
Yes
No
Conduct research
Yes
Design and Pilot the Practice Change
• Engage patients and verify preferences
• Consider resources, constraints, and approval
• Develop localized protocol
• Create an evaluation plan
• Collect baseline data
• Develop an implementation plan
• Prepare clinicians and materials
• Promote adoption
• Collect and report post-pilot data
Is change
appropriate for
adoption in
practice?
Consider alternativesNo
Yes
Integrate and Sustain the Practice Change
• Identify and engage key personnel
• Hardwire change into system
• Monitor key indicators through quality improvement
• Reinfuse as needed
Disseminate Results
Consider another
Issue / opportunity
Reassemble
Redesign
Figure 2. The Iowa Model-Revised. Used/reprinted with permission from the University of Iowa Hospitals and
Clinics, Copyright 2015.
178 Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182.
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Original Article
generate energy and resources, it would not be prudent to
pursue.
(Yes) Form a Team.
Form a Team
The next box was described as challenging by some survey re-
spondents and conference attendees, who requested guidance
on team composition. Because a discussion of teams cannot
practically be incorporated into a model, the following discus-
sion is offered for guidance. The team may change over time.
Selection of team members requires attention to interprofes-
sional involvement, as well as the skill sets needed to plan, con-
duct, and evaluate the project. Important activities of the team
include, reviewing existing literature, obtaining baseline data,
and engaging key stakeholders. However, not all stakehold-
ers have to be involved in every aspect of the practice change
process. For example, while IT personnel might provide insti-
tutional data or evidence for review by the team to assist in
decision making, they may not participate in the systematic
literature search process. Correspondingly, more focused or
targeted tasks may be handled by key personnel (e.g., librarian)
who may not be a formal member of the team. It may be pru-
dent to include naysayers who might be resistant to the change,
as well as opinion leaders, as part of the team. Regardless of
composition, key stakeholders need to believe the project is
worthy.
Assemble, Appraise, and Synthesize Body of
Evidence
This was outlined as two steps that are now combined in the
revised model to reflect the iterative and non-linear nature of
this process. Changes were made to emphasize the importance
of evaluating the whole body of evidence, not solely research.
Other types of evidence are now included as part of the body of
evidence. An additional bullet point was added to remind users
about four criteria for weighing evidence: quality, quantity,
consistency, and risk (Guyatt et al., 2008; Institute of Medicine,
2011; U.S. Preventive Services, 2016).
Some participants suggested moving this step prior to
“forming a team,” but after consideration this was rejected.
While key project leaders may gather evidence to this point, it
is important for the team to conduct a systematic search and be
involved in evaluating the evidence to guide subsequent work.
The most frequent suggestions for language changes included
expanding the term research to include other evidence and
replacing critique with appraise.
Some participants wanted to know how to evaluate
research, grade, score, and determine the extent of evi-
dence. Survey participants identified this step as an area of
difficulty, noting that they or their teams lack skills for ap-
praising and synthesizing evidence. Readers are advised to seek
resources (e.g., http://www.hopkinsmedicine.org/gim/training/
Osler/osler_JAMA_Steps.html; http://www.ahrq.gov/; http://
www.gradeworkinggroup.org/)
Participants also identified barriers to resources (including
time, a library, and librarian) and a need for tools, checklists and
charts to assist with search strategies, retrieval, and critique of
relevant evidence. It is beyond the scope of the model to address
many of these difficulties.
Decision Point 2: Is There Sufficient Evidence?
Similar to the preceding step, some participants reported
that they do not know how to determine if there is sufficient
evidence for a practice change. Furthermore, concern was
raised that the lack of this skill may lead to premature decisions
to implement a practice change without full consideration of
risks. Participants asked for clarification of this step including
the meaning of sufficient, what questions to ask, when to
consider other evidence and factors to consider in weighing
evidence. Readers are referred to resources for this step
(http://www.uspreventiveservicestaskforce.org/Page/Name/
methods-and-processes; http://www.gradeworkinggroup.org/
publications/JCE_series.htm).
The decision point (i.e., Is there sufficient research base?)
was revised. Suggestions included incorporating multiple types
of evidence as part of the initial evidence review, evaluating
evidence quality, quantity and consistency as well as risk. Thus,
the strongest evidence of any type is considered prior to making
a decision about changing practice.
(No) Conduct Research.
When the body of evidence is not sufficient to
guide a practice change, the next step is to conduct
research. The Collaborative had considered leaving
the research step out because many clinicians are
not comfortable with developing research studies.
However, users of the model felt strongly that this
step remain in. While some participants suggested
including the research process in this step, the
Collaborative chose to keep the focus and scope of
the model on EBP. As an alternative to conduct of
research, additional topic development may guide
the team toward sufficient evidence to proceed.
Conduct of research leads to the “Reassemble” feedback
loop, bringing new findings to bear. The new research findings
are assembled with other new evidence from an updated
search. This leads to reappraisal of the body of evidence to
make a decision about the sufficiency of the evidence.
(Yes) Design and Pilot the Practice Change.
Design and Pilot the Practice Change
As expected, there were multiple comments about the “pilot
the change in the practice” section of the model. One of
the most significant gaps in this section was the lack of
engagement of patients and families and incorporation of
their values and preferences. This shift from institution
centered to patient-centered has been discussed extensively
in the research, practice and policy literature, as well as being
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Iowa Model-Revised
a long-standing component of the definition of EBP (Sackett,
Richardson, Rosenberg, & Haynes, 1997; Sigma Theta Tau
International Research and Scholarship Advisory Committee,
2008). Berwick’s (2009) definition of patient-centered care
is a shift in power “ . . . out of the hands of those who give
care and into the hands of those who receive it” (p. 555).
Patient preferences and experiences are key priorities for
healthcare providers and organizations (Centers for Medicare
and Medicaid Services, 2015). Further, evidence demonstrates
that patient engagement can lead to better health outcomes
and that cost containment must include patients as a core part
of the solution (Carman et al., 2013).
A second important change recommended by users was
the need to address necessary resources, constraints, and
approvals (e.g., organization or human subject’s committees).
Committee review promotes linkages within organizational in-
frastructure to avoid wasting resources on unsuccessful change
initiatives but also to avoid inconsistency and variation in
practice.
A third critique of this section was the paucity of guidance
for piloting the practice change. Given the complexity of this
multi-step process, many users requested more detail. In the
revised model, there is added guidance on localizing the prac-
tice protocol to fit the unique unit and setting and that further
modifications may be needed when the protocol is applied
elsewhere. Localization was first introduced by Rogers (1983)
and elaborated by Titler (2008) and others (Harrison et al.,
2013) for EBP projects. This strategy also supports the bullet
“promote adoption” added to this revision of the Iowa Model.
Users requested more detail as to what should be included
when adapting for other units as well as what criteria should
be in place to move to widespread adoption.
The final bullets added to this section included developing
an implementation plan and preparing clinicians and materi-
als. This step reflects the phased approach needed for planned
change. Because selecting from an extensive list of implemen-
tation strategies and knowing when to apply them is chal-
lenging for most bedside clinicians, Cullen and Adams (2012)
developed a guide to assist clinicians. In this guide, four phases
of implementation are presented for clinicians to use when
determining the most effective implementation strategies. In
the revised Model, a specific step, “develop an implementation
plan,” to guide the implementation process was added.
Decision Point 3: Is the Change Appropriate for
Adoption?
Relatively few comments were made for this step in the process.
Suggestions were to provide assistance with this decision point
(e.g., create a checklist as a guide). Scholarly evaluation with
pilot data will guide this decision by determining if the practice
change worked, if the implementation plan was effective and if
rollout to other areas would be beneficial. If results are not as
anticipated, the team will want to reconsider additional steps
prior to scaling up.
(No) Consider Alternatives and Redesign. Results of
the pilot will guide the next steps. If findings do not
match those anticipated from the evidence, a feed-
back loop guides the team to consider alternatives
to the practice protocol or revision to the implemen-
tation plan. The redesigned practice change is re-
evaluated through the piloting process.
(Yes) Integrate and Sustain the Practice Change.
Integrate and Sustain the Practice Change
Survey respondents found this step one of the most difficult
and they offered numerous comments. They wanted more spe-
cific instructions on how to make the change sustainable.
Again, we used implementation science literature and our
own experience to specify key elements for integrating and
sustaining change. A major suggestion was to show the link-
age with quality improvement methods, as a foundational step
for sustaining change (Rocker & Verma, 2014). Although a
comprehensive discussion of how to sustain change is be-
yond the capabilities of this model, several additions were
made. The step “Identify and engage key personnel” was
added to the action steps, because integration throughout an
organization requires building new teams and identifying
new change champions. Adding this component for integra-
tion creates linkages within the governance structure (Maher,
Gustafson, & Evans, 2010; Milat, Bauman, & Redman, 2015).
This promotes essential influence needed from senior leader-
ship (Maher et al., 2010; Milat et al., 2015).
The term “Hardwiring change into the system” means
that the new practice is embedded into the fabric of the or-
ganization. For example, implementing a new fall prevention
practice might involve mandatory screening of patients during
clinic visits, documentation of fall risk in the electronic health
record, and tracking of individual clinicians’ compliance with
trending of process and outcome data. Hardwiring occurs
when EBP is the default approach, done automatically within
the work flow. To address sustaining the change, we added
“Re-infuse as needed.” Old habits often resurface, even when
they are outdated or dangerous (Maher et al., 2010; Milat
et al., 2015). While literature on sustaining change is scant,
extant sources and our own experiences with implementing
and sustaining EBP indicates that on-going monitoring of key
processes and outcomes, providing re-infusion, and actively
promoting sustainment beyond the pilot period are key aspects
to success, so we revised those steps in the model. Audit and
feedback of key indicators remains a necessary component of
an integration plan (Maher et al., 2010). Outcomes to monitor
in the previous model: environment, staff, cost, and patient and
family, were eliminated to maintain brevity. Key indicators to
monitor are drawn from the pilot findings and include
structure (e.g., staffing, available equipment), process (i.e.,
knowledge, attitudes, and practices) and outcomes (Bick &
Graham, 2010), including balancing measures (Institute for
Healthcare Improvement, 2016). Change can only be complete
with a combination of implementation strategies. For more
180 Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182.
C© 2017 University of Iowa Hospitals and Clinics, Worldviews on Evidence-Based Nursing C© 2017 Sigma Theta Tau International
Original Article
comprehensive discussions of specific changes strategies we
refer readers to other materials (Cullen, Hanrahan, Tucker,
Rempel, & Jordan, 2012; Maher et al., 2010; Cullen et al.,
in press).
DISSEMINATE RESULTS
We left this step of the model unchanged, although there
were several requests for more information on how to dissem-
inate results. Strategic internal dissemination continues to be
needed with clinicians and within the governance structure.
Sharing lessons learned externally is also valuable. A tip for
publishing is to negotiate with journal editors for peer review
using EBP and not research criteria.
DISCUSSION AND CONCLUSIONS
More than 600 users of the Iowa Model had a voice in this
revision, attesting to the validity of this framework in the prac-
tice setting. The Iowa Model-Revised, presented in this paper,
was disseminated internationally at the 2015 Sigma Theta Tau
International convention. It was made available on the UIHC’s
web-site on June 24, 2015, and in the first four days was re-
quested by over 750 users from 23 countries.
The Iowa Model-Revised remains an application oriented
step-by-step guide for the EBP process. It is intended for use
by point of care clinicians asking important clinical questions
and then seeking to improve quality through the systematic
use of evidence. It is adaptable for novice to expert users and
its usefulness has been demonstrated in a variety of settings.
An important practice implication of the revised model is the
explicit inclusion of patient and family values and preferences.
The model continues to expand on what is considered evidence
and how to determine if practice changes are indicated. Most
importantly, revisions address sustainability of EBP changes
that improve outcomes.
Evidence to Action
Results of the survey conducted for this project have implica-
tions for education. Practitioners need knowledge and skills
for EBP, particularly regarding appraising evidence and insti-
tuting a sustainable practice change using a phased approach.
The Iowa Model-Revised can be used to teach students or clini-
cians the EBP process. However, additional training is needed
to assure clinicians have the skills needed to appraise all types
of evidence and lead EBP. Users of this version of the Iowa
Model-Revised are encouraged to read previous versions of the
Model (Titler et al., 1994; Titler et al., 2001) to understand the
supporting rationale for each of the steps. The largest changes
in this version of the model are expansion of the sections on
piloting and instituting change. The model is designed to be a
guide rather than a comprehensive manual for change. In order
to keep the model succinct and useful for a broad audience, the
Collaborative chose to continue the use of bulleted suggestions
rather than step-by-step instructions. The Iowa Model Collab-
orative remains committed to ongoing formative evaluation of
the revised model, and welcomes feedback from readers and
users. WVN
LINKING EVIDENCE TO ACTION
� The Iowa Model is widely used as a practical pro-
cess for promoting EBP.
� Revisions to the Iowa Model capture advances in
translation research and patient engagement.
� Use of a systematic approach is essential to deter-
mine impact of EBP on patient and health system
outcomes.
� Access permission to use Iowa Model-Revised at
https://www.uihealthcare.org/otherservices.aspx?
id = 1617.
Author information
Iowa Model Collaborative, University of Iowa Hospitals
and Clinics, Department of Nursing Services and Patient
Care Office of Nursing Research, Evidence-Based Practice,
and Quality and University of Iowa College of Nursing;
Kathleen C. Buckwalter, PhD, RN, FAAN, Professor Emeri-
tus, University of Iowa College of Nursing, Iowa City, IA,
USA; Laura Cullen, DNP, RN, FAAN, Evidence-Based Prac-
tice Scientist, Department of Nursing Services and Patient
Care, University of Iowa Hospitals and Clinics, Iowa City,
IA, USA; Kirsten Hanrahan, DNP, ARNP, PNP, Associate
Research Scientist, Department of Nursing Services and Pa-
tient Care, University of Iowa Hospitals and Clinics, Iowa City,
IA, USA; Charmaine Kleiber, PhD, RN, CPNP, FAAN, As-
sociate Research Scientist, Department of Nursing Services
and Patient Care, University of Iowa Hospitals and Clinics,
Iowa City, IA, USA; Ann Marie McCarthy, PhD, RN, PNP,
FAAN, University of Iowa College of Nursing, Iowa City, IA,
USA; Barbara Rakel, PhD, RN, FAAN, Professor, University of
Iowa College of Nursing, Iowa City, IA, USA; Victoria Steel-
man, PhD, RN, CNOR, FAAN, Associate Professor, University
of Iowa College of Nursing, Iowa City, IA, USA; Toni Tripp-
Reimer, PhD, RN, FAAN, Professor, University of Iowa Col-
lege of Nursing, Iowa City, IA, USA; Sharon Tucker, PhD, RN,
PMHCNS-BC, FAAN, Director, Office of Nursing Research,
Evidence-Based Practice and Quality, Department of Nursing
Services and Patient Care, University of Iowa Hospitals and
Clinics, Iowa City, IA, USA; Authored on behalf of the Iowa
Model Collaborative,
Address correspondence to Dr. Laura Cullen, Department
of Nursing Services and Patient Care, University of Iowa
Hospitals and Clinics, 200 Hawkins Dr. RM T100 GH, Iowa
City, IA 52242, USA; laura-cullen@uiowa.edu
Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182. 181
C© 2017 University of Iowa Hospitals and Clinics, Worldviews on Evidence-Based Nursing C© 2017 Sigma Theta Tau International
Iowa Model-Revised
Accepted 8 October 2016
C© 2017 University of Iowa Hospitals and Clinics, Worldviews on
Evidence-Based Nursing C© 2017 Sigma Theta Tau International
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Table S1. Summary of Participant Feedback From Survey and EBP Conference
182 Worldviews on Evidence-Based Nursing, 2017; 14:3, 175–182.
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