INTRODUCTION:

Strategy:

A method or plan Chosen to bring about a desired future, such as achievement of a goal or solution to a problem The art and science of planning and marshalling resources for their most efficient and effective use. The term is derived from the Greek word ‘Strategia’ for generalship or leading an army. By Businessdictionary.com

Evidence Based Practice-

Evidence Based Practice is both a process and a product.. Requiring that the evidence which is produced is also applied to practice. ( Rutledge D,- 2002).

Evidence based nursing practice is the conscientious, explicit and judicious use of theory derived, research based information in making decision about care delivery to individuals or group of patients and in consideration of individual needs and preferences( Ingersoll-2000)

Evidence based Practice is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences

A model for evidence based clinical decisions (adapted from Haynes et al.)

This article explores the Strategies in bringing desired changes in nursing practice through Evidence based Practices for individual nurses and organization.

Stetler model:

The Stetler model of research utilization helps practitioners assess how research findings and other relevant evidence can be applied in practice. This model examines how to use evidence to create formal change within organizations, as well how individual practitioners can use research on an informal basis as part of critical thinking and reflective practice. The model links research use, as a first step, with evidence-informed practice.

The Stetler model provides a way to think about the relationship between research use and evidence-informed practice. These two concepts are not the same. Integrating both concepts enhances the overall application of research. Research use, in light of available supplemental evidence to aid decision making, provides the first step for research-related actions that result in evidence-informed practice. Research use occurs in three forms (Stetler, 1994):

ü Instrumental use refers to the concrete, direct application of knowledge.

ü Conceptual use occurs when using research changes the understanding or the way one thinks about an issue.

ü Symbolic use or political/strategic use happens when information is used to justify or legitimate a policy or decision, or otherwise influence the thinking and behaviour of others.

These different kinds of research use can occur together and can be influenced by multiple factors at the individual level. The Stetler model of research use is based on the notion that the user's internal characteristics, as well as external environmental factors, influence use of knowledge. The Stetler model of evidence-based practice based on the following assumptions (Stetler, 2001, p. 274; Stetler, 2010, p. 59-60):

1. The formal organization may or may not be involved in an individual's use of research or other evidence.

2. Use may be instrumental, conceptual and/or symbolic/strategic.

3. Other types of evidence and/or non-research-related information are likely to be combined with research findings to facilitate decision making or problem solving.

4. Internal or external factors can influence an individual's or group's review and use of evidence.

5. Research and evaluation provide probabilistic information, not absolutes.

6. Lack of knowledge and skills pertaining to research use and evidence-informed practice can inhibit appropriate and effective use.

Key organizational elements needed to support evidence-informed practice at the organizational level include (Stetler, 2003):

ü Leadership's support for an evidence-informed practice culture;

ü Capacity to engage in evidence-informed practice, including an effective implementation framework;

ü Infrastructure to support and maintain a culture of evidence-informed practice and related activities. The Stetler model of evidence-based practice outlines criteria to determine the desirability and feasibility of applying a study or studies to address an issue. These criteria are:

ü Substantiating evidence;

ü Current practice (relates to the extent of need for change);

ü Fit of the substantiated evidence for the user group and settings; and

ü Feasibility of implementing the research findings (risk/benefit assessment, availability of resources, stakeholder readiness).

This model consists of five phases (Stetler, 2001, p. 276):

Phase I: Preparation

Phase II: Validation

Phase III: Comparative Evaluation/Decision Making

Phase IV: Translation/Application

Phase V: Evaluation

Implementing the Tool:

Who is Involved?:

Many individuals could be involved as participants in this method, although a core group may be needed in planning various stages of the model.

Steps for Using Tool:

The Stetler model of evidence-based practice consists of five phases (Stetler, 1994; Stetler, 2001; Stetler, 2010). Each phase is designed to:

ü Facilitate critical thinking about the practical application of research findings;

ü Result in the use of evidence in the context of daily practice; and

ü Mitigate some of the human errors made in decision making.

Phase I: Preparation:

Purpose, Context and Sources of Research Evidence

Identify the purpose of consulting evidence (such as need to solve a problem or revising an existing policy) and relevant related sources. Recognize the need to consider important contextual factors that could influence implementation. Note that the reasons for using evidence will also identify measurable outcomes for Phase V (Evaluation).

Phase II: Validation:

Credibility of Findings and Potential for/Detailed Qualifiers of Application Assess each source of the evidence for its level of overall credibility, applicability and operational details, with the assumption that a methodologically weak study may still provide useful information in light of additional evidence. Determine whether a given source has no credibility or fit and thus whether to accept or reject it for synthesis with other evidence (rather than simply determine whether the evidence is weak or strong). Summarize relevant details regarding each source in an 'applicable statement of findings' to look at the implications for practice in Phase III. A summary of findings should:

ü Reflect the meaning of study findings for the issue at hand; and

ü Reflect studied variables or relationships in ways that could be practically used (eg. in terms of the actual operational nature of interventions and potential qualifiers or conditions of application that may be key to future use).

Phase III: Comparative Evaluation/Decision Making:

Synthesis and Decisions/Recommendations per Criteria of Applicability Logically organize and display the summarized findings from across all validated sources in terms of their similarities and differences. Determine whether it is desirable or feasible to apply these summarized findings in practice, based on applicability criteria, i.e. substantiating evidence, in terms of the overall strength of the accumulated findings. The criteria are fit to the targeted setting; current practice; and feasibility ("r, r, r" = evaluation of risk factors, need for resources, readiness of others involved). Based on the comparative evaluation, the user makes one of four choices:

ü Decide to use the research findings by putting knowledge into effect and moving forward in terms of the appropriate types of uses (instrumental, conceptual, symbolic).

ü Consider use by gathering additional internal information before acting broadly on the evidence.

ü Delay use since more research is required which you may decide to conduct based on local need (no further action is considered with the information available at this point).

ü Reject or not use (no further consideration).

Phase IV: Translation/Application:

Operational Definition of Use/Actions for Change Write generalizations that logically take research findings and form action terms (using the summary statements from Phase II/III). Specifically, articulate the how-to's of implementation of the synthesized findings, identifying the practice implications that answer the overall question, "So what?".

ü Identify type of research use (cognitive, symbolic and instrumental).

ü Identify method of use (informal/formal, direct/indirect).

ü Identify level of use (individual, group, organization).

ü Assess whether translation or use goes beyond actual findings/evidence.

ü Consider the need for appropriate, reasoned variation in certain cases.

ü Plan formal dissemination and change strategies.

Phase V: Evaluation:

ü Clarify expected outcomes relative to purpose of seeking evidence and whether the evaluation is related to a direct use or consider use decision.

ü Differentiate formal and informal evaluation of applying findings in practice.

ü Consider cost-benefit of various evaluation efforts.

ü Use Research Utilization as a process (Stetler, 2001) to enhance the credibility of evaluation data.

ü Include two types of evaluation data: formative and outcome.

This method was first developed as the Stetler/Marram Model of Research Utilization (Stetler and Marram, 1976) and later revised and renamed the Stetler Model of Research Utilization (Stetler 1994, 2001). Most recently, the model has been modified and named the Stetler Model of Evidence-Based Practice. The last two version of this model consists of two parts: five phases of Research/evidence use; and clarifying information and options for each phase.

Strategy for an Individual to adapt Evidence based Practice in a given Setting (Private / Public health System) Framework for an individual to implement EBP. (Dr. G. Radhakrishnan-2014)

Evidences

(Obtained through Research/ projects/ Meta analysis/ Meta Synthesis)

Satisfied to be effective at the present system/ better than the Existing practice

Communicate the decision

(With peer/ immediate superior authority)

Obtain permission from the concerned authority

Implement the new method

(With patient preference)

Evaluate the effectiveness

Communicate with statistical evidence

Convince the Authorities for the change in practice

Get a written approval

Circulate among the nursing practitioners in that setting

Make them practice the new method

Evaluate (formative and outcome)

Document and Make a manual

Submit to the top level management

Becomes a standardized practice

The Evidence Based Practice implementation is basically a process involves several steps, revisions, meetings, consultations, approvals and many other activities. Hence a person intended to bring about change through research evidences should have the fallowing characteristics

ü Leadership and vision

ü strong determination,

ü energy,

ü capacity to convince people on the merit,

ü communication skills,

ü Ability to handle criticism and pressure

ü Ability to form and work with team

Strategy for an Organization to adapt Evidence based Practice in a given Setting (Private / Public health System):

Strategy for an Organization to adapt Evidence based Practice in a given Setting starts typically with an individual effort, then depending on the merit of the Evidences and up on the felt need and advantage of the decision the organization adapts the new procedures/ protocols/ nursing care decisions.

The management tends to adapt the new practices when the fallowing criteria are met:

1. Acceptable to the Organizational value and Philosophy

2. Beneficial to the recipient at large

3. Cost effective/ Economical

4. Does not harm subjects/ clients (Ethically/ legally safe and sound)

5. Efficient to produce desired patient care outcomes (than the existing practice)

Framework for an organization to implement EBP. (Dr. G. Radhakrishnan-2014

CONCLUSION:

Research in implementation of the Evidence based practices had proven that healthcare professionals are motivated and more often integrate evidence into clinical decision-making when the suitable conditions prevail. It’s in the hand of the individual nurse in bringing the change based on the available research evidences in the clinical practices and demonstrates the leadership qualities. The organizations have the primary responsibility in providing support, conducive environment for the nurses in implementation of the Evidence Based Practices for the larger benefit of the patients and ensure quality nursing care.

REFERENCES:

1. Mary Courntey, Helen McCutcheon. Using Evidence to Guide Nursing Practice. 2^nd Edi, Australia: Elsevier Publication; 2010.

2. Stetler, C. (2010). Chapter 3: Stetler Model. In J. Rycroft-Malone and T. Bucknall (Eds.)

1. Evidence-based Practice Series. Models and frameworks for implementing evidence-based

2. practice: Linking evidence to action. Oxford: Wiley-Blackwell.

JOURNAL:

1. Stetler, C. (2001). Updating the Stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49, 272-279.

2. Stetler, C. (2003). Role of the organization in translating research into evidence-based practice. Outcomes Management, 7 (3), 97-103.

3. Stetler, C. (1994). Refinement of the Stetler/Marram model for application of research findings to practice. Nursing Outlook, 42, 15-25.

4. Haynes RB, Sackett DL, Gray JAM, et al. Transferring evidence from research into practice. 1. The role of clinical care research evidence in clinical decisions [editorial]. ACP Journal Club 1996 Nov-Dec; 125:A14–6.

5. Yi-Hao Weng et al. Implementation of evidence-based practice across medical, nursing, pharmacological and allied healthcare professionals: a questionnaire survey in nationwide hospital settings. Implementation Science 2013, 8:112.

6. Alba DiCenso, Nicky Cullum, Donna Ciliska. Implementing evidence-based nursing: some misconceptions. Evid Based Nursing 1998; 1:38-39.

7. Wallis, Laura. Barriers to Implementing Evidence-Based Practice Remain High for U.S. Nurses. American Journal of Nursing, Dec- 2012. Vol-112: Issue-12, P15.

Received on 23.12.2014 Modified on 01.01.2015

Int. J. Nur. Edu. and Research 3(1): Jan.-March, 2015; Page 83-86

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