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

Models for Practice Change and Quality Improvement

In the rapidly evolving landscape of healthcare, changes are predominantly driven by factors such as patient safety, evidence-based practices, and overall quality improvement. Nurses play a pivotal role in understanding and implementing these changes to enhance healthcare services. This DNP project, focusing on reducing the high fall rate of long-term care residents, identifies the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the Six Sigma model as suitable frameworks for implementation.

Application of (JHNEBP) and the Six Sigma Model

The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, as described by Dang and Dearholt (2017), is a robust tool for problem-solving and decision-making in the realm of nursing practice. Its three-step process, known as Practice Question, Evidence, and Translation (PET), ensures the incorporation of the latest research findings into practice, facilitating prompt adoption of best practices in patient care (Dang & Dearholt, 2017). In parallel, the Six Sigma model directs its focus on quality improvement, emphasizing statistical data analysis to eliminate defects that might pose harm to patients (McGonigal, 2017). This model, through rigorous data collection and analysis, aims to establish standardized practices, leading to near-perfect services and reduced costs for healthcare organizations (McGonigal, 2017).

Examples of Application

The application of the (JHNEBP) model involves defining the scope of questioning, conducting research, and creating an action plan. This aligns with the model’s three-step process, emphasizing the importance of staying current with the latest research findings (Dang & Dearholt, 2017). On the other hand, the Six Sigma model’s application involves critical cross-referencing of data and continuous updates based on the gathered information, contributing to a more refined and standardized healthcare delivery approach (McGonigal, 2017).

Conclusion

Expert application of the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the Six Sigma model ensures the swift incorporation of best practices into patient care while concurrently reducing overall costs incurred by healthcare 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 Evidence-Based Practice Model

In the contemporary healthcare landscape, evidence-based practice (EBP) stands as a fundamental competency for healthcare professionals (IOM, 2003). Leaders in academia and service must synchronize their educational and practice environments to foster evidence-based practices, instill a culture of continuous inquiry, and translate the highest quality evidence into practice. This chapter aims to describe The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) and introduce the Practice Question, Evidence, and Translation (PET) process to guide nurses through the steps of applying EBP.

The Johns Hopkins Nursing Evidence-Based Practice Model

The JHNEBP model, illustrated in Figure 3.1, delineates three crucial cornerstones forming the foundation for professional nursing: practice, education, and research.

  • Practice: This foundational component represents the translation of nursing knowledge into actionable care. It encompasses the entirety of nursing activities, addressing the who, what, when, where, why, and how aspects of patient care. Practice is integral to healthcare organizations.
  • Education: Reflecting the acquisition of nursing knowledge and skills, education is essential for building expertise and maintaining competency.
  • Research: Generating new knowledge for the profession, research enables the development of practices based on scientific evidence. Nurses rely on this evidence to guide policies, practices, and quantify their impact on healthcare outcomes.

Nursing Practice Standards and Evidence-Based Approach

Nurses adhere to standards set by professional nursing organizations, such as the American Nurses Association (ANA), which outlines six standards of nursing practice and ten standards of professional performance. These standards, based on the nursing process, define the scope of practice and expectations for evaluating performance. Specialty nursing organizations further establish standards of care for specific patient populations. The integration of evidence-based approaches into practice is now a standard set by professional nursing organizations and is a crucial element of organizations aspiring to Magnet recognition.

In conclusion, The Johns Hopkins Nursing Evidence-Based Practice Model, with its emphasis on practice, education, and research, serves as a guiding framework for embedding evidence-based practices into the fabric of healthcare organizations.

The Magnet Model, illustrated in Figure 3.2, comprises five key components: (a) transformational leadership; (b) structural empowerment; (c) exemplary professional practice; (d) new knowledge, innovations, and improvements; and (e) empirical outcomes. To exhibit transformational leadership, nursing leaders must possess vision, influence, clinical knowledge, and expertise (Wolf, Triolo & Ponte, 2008). They play a pivotal role in creating a vision and an environment conducive to evidence-based practice (EBP), fostering continuous questioning of nursing practice, translating existing knowledge, and generating new knowledge.

Structural empowerment, another crucial component, involves nursing leaders promoting professional staff involvement and autonomy in identifying best practices and utilizing the EBP process to drive practice change. Magnet organizations set the standard for exemplary professional practice by maintaining robust professional practice models, collaborating with patients, families, and interprofessional teams, and emphasizing systems that enhance patient and staff safety.

The component of new knowledge, innovations, and improvements challenges Magnet organizations to design novel care models, apply existing and new evidence to practice, and contribute visibly to the science of nursing (American Nurses Credentialing Center [ANCC], 2011). Furthermore, these organizations are mandated to prioritize empirical outcomes to evaluate quality. The EBP process aids in utilizing data sources such as quality improvement results, financial analysis, and program evaluations to address EBP questions.

In conjunction with the Magnet Model, the American Nurses Association (ANA) Standards of Practice (Table 3.1) outline the benchmarks for nursing activities, ensuring systematic and evidence-based approaches in assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These standards underscore the importance of evidence-based interventions, coordination of care, health teaching, consultation, prescriptive authority, and ongoing evaluation of outcomes.

Overall, the Magnet Model, coupled with the ANA Standards of Practice, establishes a comprehensive framework that fosters transformational leadership, structural empowerment, exemplary professional practice, knowledge innovation, and empirical outcomes within healthcare organizations.

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

Table 3.2 presents the American Nurses Association Standards of Professional Performance, delineating the expectations for nursing professionals across various domains. These standards encompass ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. Adhering to these standards ensures the delivery of care that upholds consumer autonomy, professionalism, and safety.

Figure 3.2 illustrates the American Nurses Credentialing Center Magnet Model Components, featuring transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovations, and improvements, as well as empirical outcomes. These components collectively contribute to an organization’s pursuit of Magnet status, emphasizing the importance of creating opportunities for nurses to engage in evidence-based practice (EBP). The Magnet Model posits that involving nurses in the EBP process enhances their sense of empowerment, job satisfaction, and readiness to embrace changes informed by evidence.

The section on Nursing Education highlights the continuum of nursing education, starting with basic education (associate or bachelor’s degree) and progressing to advanced education (master’s or doctorate degree). Advanced education places a greater emphasis on applying research and evidence to influence or transform nursing practice and care delivery systems. Lifelong learning is emphasized, recognizing the dynamic and complex nature of healthcare. Ongoing education, including conferences, seminars, workshops, and in-services, is crucial for staying abreast of new knowledge, technologies, and skills. The contemporary healthcare landscape necessitates a commitment to individual and interprofessional lifelong learning, fostering collaboration and preparing healthcare professionals for effective teamwork in patient-centered environments.

Nursing Research

Nursing research employs both qualitative and quantitative systematic methods, adopting an Evidence-Based Practice (EBP) approach aimed at studying and enhancing patient care, care systems, and therapeutic outcomes. Despite the widely acknowledged belief that optimal practices should be rooted in decisions validated by robust scientific evidence, the translation of current research into nursing practice often progresses at a slow pace. Nurses may be influenced, to varying degrees, by a phenomenon known as knowledge creep, wherein they gradually recognize the need to modify practice based on limited research and anecdotal information (Pape & Richards, 2010). Bridging this evidence-practice gap requires the establishment of structures and support mechanisms that empower nurses to integrate evidence into their clinical practice (Oman, Duran, & Fink, 2008). Nursing leaders play a crucial role in championing and cultivating proficiency in nursing research, generating new knowledge, informing practice, and advancing quality patient outcomes. To achieve this, organizations must build a robust infrastructure by developing mentors, implementing skills-building programs, providing financial support, ensuring computer access, and offering research consultative services.

The Core of the JHNEBP Model

At the heart of the Johns Hopkins Nursing EBP model lies evidence, drawing from both research and non-research data to guide practice, education, and research initiatives. While research provides the strongest evidence for informing nursing practice decisions, its applicability to different clinical settings or patient populations may vary. Nurses must critically assess research evidence, considering factors such as the type of research, consistency of findings, quantity and quality of supporting studies, and relevance to the clinical setting. In instances where research on a specific nursing practice question is limited, nurses should explore and evaluate non-research evidence sources, including clinical guidelines, literature reviews, recommendations from professional organizations, regulations, quality improvement data, and program evaluations. Additionally, expert opinion, clinician judgment, and patient preferences contribute to non-research evidence. Patient interviews, focus groups, and satisfaction surveys reflect preference-related evidence, aligning with the evolving trend of active patient involvement in healthcare decision-making. Understanding a patient’s values, beliefs, and preferences becomes pivotal in influencing their adherence to treatments, even in the presence of robust evidence.

Internal and External Factors in the JHNEBP Model

The JHNEBP Model functions as an open system with interconnected components, where practice, education, and research are shaped not only by evidence but also by internal and external factors. This dynamic approach acknowledges the multifaceted influences on healthcare practices and emphasizes the need for a comprehensive understanding of the interplay between evidence and contextual elements.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 41

also influenced by both internal and external factors. External factors encompass accreditation bodies, legislation, quality measures, regulations, and standards. Accreditation bodies such as The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities set high standards for organizational practice and quality. Legislative and regulatory bodies at local, state, and federal levels enact laws to safeguard the public and ensure access to safe, high-quality healthcare services. Non-compliance with these laws and regulations can have adverse financial consequences for organizations. Regulatory agencies like the Centers for Medicare and Medicaid Services, the Food and Drug Administration, and state boards of nursing play key roles in overseeing healthcare practices. Quality measures, encompassing outcome and performance data, along with professional standards, serve as benchmarks for assessing current practices and identifying areas for improvement or change. External entities, including the American Nurses Credentialing Center through its Magnet Recognition Program®, contribute criteria for evaluating nursing quality and excellence in organizations. Furthermore, various stakeholders such as healthcare networks, interest groups, vendors, patients and families, the community, and third-party payors exert influence on healthcare organizations. Despite the diversity among these external factors, there is a common expectation for organizations to base their healthcare practices and standards on solid evidence.

Internal factors include organizational culture, values, beliefs, the practice environment (leadership, resource allocation, patient services, organizational mission and priorities, technology availability, library support), equipment and supplies, staffing, and organizational standards. Implementing Evidence-Based Practice (EBP) within an organization necessitates:

  • A culture that believes EBP leads to optimal patient outcomes
  • Strong leadership support at all levels with necessary resource allocation (human, technological, and financial) to sustain the process
  • Clear expectations incorporating EBP into standards and job descriptions

Knowledge and evaluation of the patient population, the healthcare organization, and internal and external factors are crucial for the successful implementation and sustainability of EBP within an organization.

The JHNEBP Process: Practice Question, Evidence, and Translation

The 18-step JHNEBP process (Appendix D) unfolds in three phases and can be distilled into Practice Question, Evidence, and Translation (PET) (see Figure 3.3). Initiated by identifying a practice problem or concern, the process is driven by how the problem is articulated. Based on the problem statement, the practice question is formulated, refined, and followed by a comprehensive evidence search. The identified evidence is then critically appraised and synthesized. This synthesis informs a decision on whether the evidence supports a change or improvement in practice. If affirmative, evidence translation begins, involving the planning, implementation, and evaluation of the practice change. The final translation step involves disseminating results to patients and families, staff, hospital stakeholders, and, if relevant, the local and national community.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 43

Practice Question

The initial phase of the process (steps 1–5) involves assembling a team and crafting a well-defined Evidence-Based Practice (EBP) question. An interprofessional team collaborates to scrutinize a practice concern, formulate and refine a specific EBP question, and delineate its scope. The Project Management Guide (refer to Appendix A) serves as a reference throughout the process, providing guidance for the team’s tasks and tracking progress. The tool outlines the following steps.

Step 1: Assemble Interprofessional Team

The inaugural step in the EBP process is the formation of an interprofessional team to investigate a particular practice concern. It is crucial to enlist members with a vested interest in the question’s relevance. Team members who are engaged and interested in addressing a specific practice concern tend to be more effective collaboratively. Bedside clinicians (frontline staff) play a pivotal role, bringing firsthand knowledge of the problem, its context, and impact. Other pertinent stakeholders may include clinical specialists (nursing or pharmacy), committee or ancillary department members, physicians, dieticians, pharmacists, patients, and families. These individuals contribute discipline-specific expertise or insights to provide a comprehensive view of the problem, shaping the most relevant practice question. Maintaining a group size of 6–8 members facilitates meeting scheduling and enhances overall participation.

Step 2: Formulate and Refine the EBP Question

The subsequent step involves the development and refinement of the clinical, educational, or administrative EBP question. The team must invest ample time in meticulously identifying the actual problem (refer to Chapter 4). They must discern the disparity between the current state and the envisioned future state, essentially bridging the gap between what the team observes and experiences versus what they aspire to observe and experience. It is crucial for the team to articulate the question in various ways, seeking feedback from non-members to validate the existence of an agreed-upon problem and assess the accuracy of the question in reflecting the problem. The time dedicated to challenging assumptions, examining the problem from multiple perspectives, and obtaining feedback proves invaluable. Incorrectly identifying the problem can result in futile efforts in searching and appraising evidence that ultimately fails to provide the knowledge needed to achieve desired outcomes.

Furthermore, maintaining a narrowly focused question streamlines the search for specific and manageable evidence. For instance, the question “What is the best way to stop the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?” is overly broad and could encompass numerous interventions and all practice settings. In contrast, a more focused question like “What are the best environmental strategies for preventing the spread of MRSA in adult critical-care units?” narrows the focus to environmental interventions, such as room cleaning, specifies the age group as adults, and confines the practice setting to critical care. The Practice Question, Evidence, and Translation (PET) process employs the PICO mnemonic (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000) to outline the four elements of a focused clinical question: (a) patient, population, or problem, (b) intervention, (c) comparison with other treatments, and (d) measurable outcomes (refer to Table 3.3).

Table 3.3 Application of PICO Elements

  • Patient, Population, or Problem: Team members identify 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 pinpoint 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 specify what they are comparing the intervention to, such as 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.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 45

The Question Development Tool (refer to Appendix B) serves as a guide for the team in delineating the practice problem, scrutinizing current practice, identifying the rationale for selecting the problem, refining the scope of the problem, and narrowing down the Evidence-Based Practice (EBP) question using the PICO format. This tool also aids the team in devising their search strategy by identifying the sources of evidence to be explored and suggesting potential search terms. It is crucial to acknowledge that the EBP team has the flexibility to revisit and further refine the EBP question as more information emerges during the evidence search and review. Further details on the development and refinement of an EBP practice question are available in Chapter 4.

Step 3: Define the Scope of the EBP Question and Identify Stakeholders

The scope of the EBP question may pertain to the care of an individual patient, a specific patient population, or the general patient population within the organization. Clearly defining the scope aids the team in identifying the relevant individuals and stakeholders who should be engaged and informed throughout the EBP project. A stakeholder, defined as an individual or organization with a personal or professional interest in the topic under consideration (Agency for Healthcare Research and Quality, 2011), may include various clinical and nonclinical staff, departmental and organizational leaders, patients and families, insurance payors, or policymakers. The inclusion of appropriate EBP team members and keeping key stakeholders informed can significantly contribute to successful change. The team must assess whether the EBP question is specific to a unit, service, or department, or if it involves multiple departments. In the latter case, recruiting a broader group of individuals for the EBP team, with representatives from all relevant areas, is essential. Key leadership in affected departments should be kept abreast of the team’s progress. If the problem affects multiple disciplines (e.g., nursing, medicine, pharmacy, respiratory therapy), each discipline should also be involved.

Step 4: Determine Responsibility for Project Leadership An essential success factor is identifying a leader for the EBP project.

The leader plays a pivotal role in facilitating the process and ensuring its forward momentum. The leader should possess knowledge of evidence-based practice, experience, and a proven track record in leading interprofessional teams. Familiarity with the organizational structure and strategies for implementing change within the organization is also beneficial.

Step 5: Schedule Team Meetings Initiating the first EBP team meeting involves several tasks, including:

  • Reserving a room with sufficient space conducive to group discussion
  • Requesting team members to bring their calendars for scheduling subsequent meetings
  • Assigning a team member to document discussion points and group decisions
  • Keeping track of essential items (e.g., copies of EBP tools, additional paper, dry erase board, etc.)
  • Designating a location for project files
  • Establishing a timeline for the process

Evidence The second phase (steps 6–10) of the PET process revolves around searching for, appraising, and synthesizing the best available evidence. Based on these results, the team formulates recommendations regarding practice changes.

Step 6: Conduct Internal and External Search for Evidence Team members decide on the type of evidence to search for (refer to Chapter 5) and assign responsibility for conducting the search, with subsequent items brought back to the committee for review. Collaboration with a health information specialist (librarian) is crucial, as it saves time and ensures a comprehensive and relevant search. In addition to library resources, other sources of evidence include:

  • Clinical practice guidelines
  • Quality improvement data

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 49

Translation The final phase of the JHNEBP process (steps 11–18) focuses on the implementation of the practice change, evaluation of outcomes, and dissemination of results.

Step 11: Plan for Implementation

In this step, the team develops a detailed implementation plan outlining the who, what, when, where, and how of the proposed change. The Implementation Planning Tool (see Appendix J) assists the team in organizing these crucial details. The plan should address potential barriers to change and strategies for overcoming them. It is essential to include key stakeholders in the planning process to ensure a smooth and coordinated implementation.

Step 12: Initiate Change

Once the implementation plan is finalized, the team initiates the change. This involves putting the plan into action and monitoring the process closely. Effective communication and collaboration among team members and stakeholders are critical during this stage.

Step 13: Monitor Implementation

Continuous monitoring of the change implementation is crucial for identifying issues, addressing challenges, and making necessary adjustments. The Implementation Monitoring Tool (see Appendix K) helps the team track the progress of the change and evaluate whether it aligns with the initial plan.

Step 14: Evaluate Outcomes

The team assesses the impact of the practice change on patient outcomes, clinical processes, and other relevant measures. The Evaluation Tool (see Appendix L) guides the team in collecting and analyzing data to determine the success of the change. It is essential to compare outcomes with the expected results outlined during the planning phase.

Step 15: Document and Share Outcomes

Thorough documentation of the outcomes and sharing this information with key stakeholders, including patients and families, is vital. The Documentation and Sharing Tool (see Appendix M) assists the team in summarizing the results and preparing for dissemination.

Step 16: Disseminate Results

Dissemination involves sharing the outcomes, lessons learned, and recommendations with a wider audience. The team decides on appropriate channels for sharing results, such as presentations, reports, or publications. The Dissemination Planning Tool (see Appendix N) helps organize the dissemination strategy.

Step 17: Celebrate Successes and Address

Challenges Recognizing and celebrating successes, as well as addressing any challenges encountered during the process, contribute to a positive and supportive culture of evidence-based practice. The Success Celebration and Challenge Addressing Tool (see Appendix O) assists the team in reflecting on the overall experience.

Step 18: Continuous Improvement

The final step emphasizes the importance of continuous improvement. The team reflects on the entire JHNEBP process, identifies areas for improvement, and considers how to enhance future initiatives. The Continuous Improvement Tool (see Appendix P) provides a structured framework for this reflection and planning.

The comprehensive JHNEBP process outlined in these 18 steps guides healthcare teams through the systematic integration of evidence-based practice into clinical settings, fostering improved patient outcomes and advancing the quality of care. The provided appendices offer valuable tools and resources to support teams at each stage of the process.

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 51

Translation Pathways for EBP Projects
EvidenceCompelling, consistent
Good, consistent
Good, but conflicting
Insufficient/absent
Make recommended change?Yes
Consider pilot of change
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 analysisBenefit clearly outweighs risk
Benefit may outweigh risk
Benefit may or may not outweigh risk
Insufficient information to make determination

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 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.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 54

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 ensure the successful implementation of the EBP action plan.

Step 14: 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 the team desires positive outcomes, unexpected outcomes often provide opportunities for learning. 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. 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.

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