Running head: EVIDENCE-BASED NURSING JOURNAL 2

Evidence-based Nursing Journal 2

Raymund Christopher R. dela Pea
Saint Louis University

EVIDENCE-BASED NURSING JOURNAL 2

Transforming Health Care Through the Use of Evidence-Based Practice
Carole Cooper, MHA, BSN, RN, CPN, NE-BC
In 1998, the Committee on the Quality of Health Care in America was appointed to
identify strategies for achieving a substantial improvement in the quality of health care delivered
to Americans. The committees first report, released in 1999, To Err Is Human: Building a Safer
Health System, primarily focused on patient safety. The second report released in 2001, Crossing
the Quality Chasm, focused more broadly on how the quality of healthcare must be redesigned to
ensure all Americans receive care that is safe, effective, patient centered, timely, efficient and
equitable. These six aims should be the focus of nurses and clinicians and pursued in all health
care settings (Institute of Medicine, 2001).
Since the release of these two landmark reports, the Institute of Medicine (IOM) has
released nine additional related reports known as the IOM Quality Chasm Series, linking quality
to a range of issues applicable to all healthcare professionals. The IOM reports have created a
call for action, the need to transform healthcare. These reports are not the first efforts to call
attention to the use of evidence to support changes in the healthcare environment. More than 150
years earlier, Florence Nightingale, the founder of modern nursing, raised these same issues. In
her quest to improve the conditions of hospitals during the Crimean War, Nightingale assessed
the environment, collected data, identified interventions and monitored patient outcomes. In less
than six months her interventions significantly decreased the mortality of soldiers who were
dying from wounds, infections, cholera and lack of adequate care. Nightingale utilized
supporting evidence to transform healthcare.

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Effective nursing care rests on the development and use of nursing evidence. Today
evidence is derived from many sources such as clinical trials, observational studies, outcomes
research and case reports. Evidence-based nursing practice is identified as the integration of best
research evidence with clinical expertise and patient values to facilitate clinical decision making.
The concept of evidence-based practice (EBP) is dependent upon synthesizing evidence from a
variety of sources and applying it appropriately to the care needs of populations and individuals.
One of the challenges in pediatric nursing is the limited amount of evidential research specific to
the care of children. Research findings must be transformed into knowledge before the results are
useable in clinical decision making. Identifying the most effective care for children requires a
systematic approach. Childrens Hospital Central Californias Nursing Research Committee has
identified two models of EBP, the Ace Star Model and the Iowa Model of Evidence-Based
Practice, to provide the framework for systematically putting our EBP processes into operation to
improve care.
The Ace Star Model is a conceptual model that identifies key stages to transform
knowledge (i.e. research) into practice. The model illustrates five major stages of knowledge
transformation: 1) knowledge discovery, 2) evidence summary, 3) translation into practice
recommendations, 4) integration into practice, and 5) evaluation. Evidence-based processes and
methods vary from one point of the Star Model to the next.

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Explanation of Each Stage

Star point 1. Discovery
This is the knowledge generating stage. In this stage new knowledge is discovered through the
traditional research methodologies and scientific inquiry. Research designs can range from
randomized control trials to qualitative studies.
Star point 2. Evidence Summary
Evidence summary is the first unique step in EBP. This is the knowledge generating stage in
which research is synthesized into a single meaningful statement. Evidence summaries integrate
the results from multiple studies to yield more credible results. Systematic reviews, similar to
those found in the Cochrane Database, are considered the highest level of evidence:
Level I:
Evidence from a systematic review or meta analysis of all relevant randomized control trials
(RCTs), or evidence-based clinical practice guideline based on systematic reviews of RCTs
Level II:
Evidence obtained from at least one well-designed RCT

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Level III:
Evidence obtained from well-designed controlled trials without randomization
Level IV:
Evidence from well-designed case control and cohort studies
Level V:
Evidence from systematic reviews of descriptive and qualitative studies
Level VI:
Evidence from a single descriptive or qualitative study
Level VII:
Evidence from the opinion of authorities and/or reports of expert committees(Melnyk & FineoutOverholt, 2005)
Star point 3. Translation
The transformation of evidence summaries into actual practice requires two stages: translation of
evidence into practice recommendations and integration into practice. The aim of transformation
is to provide useful tools to support care. Recommendations are generically termed clinical
practice guidelines and embedded in care standards, protocols and algorithms.
Star point 4. Integration
The integration stage is perhaps the most challenging as this stage involves changing both
individual and organizational practices. Changes in practice are adopted and integrated into care.
The rate of adoption is dependent upon individual and organizational factors and may require
multiple cycles of change over a period of time. The Iowa Model identifies the steps of
integrating evidence into practice.

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Star point 5. Evaluation
The final stage in knowledge transformation is evaluation of outcomes. The impact of EBP on
patient outcomes, provider and patient satisfaction, efficacy, efficiency, and economic analysis
are evaluated.
The steps taken by Florence Nightingale to integrate evidence into practice are very
similar to those outlined in the Ace Star Model and Iowa Model of EBP. Providing effective care
in todays healthcare system is a complex process. Using a systematic approach to improve
patient care can yield effective and reproducible results that are sustained through the test of
time. Nursing staff interested in learning how EBP is making an impact on the care provided at
Childrens Hospital are encouraged to contact members of the Nursing Research Committee.
Reaction
The ACE Star Model of Knowledge Transformation (Stevens, 2004) was developed to
offer a simple yet comprehensive approach to translate evidence into practice. As explained in
the ACE Star Model, one approach to understanding the use of EBP in nursing is to consider the
nature of knowledge and knowledge transformation necessary for utility and relevance in clinical
decision making. Rather than having clinicians submersed in the volume of research reports, a
more efficient approach is for the clinician to access a summary of all that is known on the topic.
Likewise, rather than requiring frontline providers to master the technical expertise needed in
scientific critique, their point-of-care decisions would be better supported by evidence-based
recommendations in the form of clinical practice guidelines.
The ACE Star Model of Knowledge Transformation highlights barriers encountered
when moving evidence into practice and designates solutions grounded in EBP. The model

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explains how various stages of knowledge transformation reduce the volume of scientific
literature and provide forms of knowledge that can be directly incorporated in care and decision
making. The ACE Star Model emphasizes crucial steps to convert one form of knowledge to the
next and incorporate best research evidence with clinical expertise and patient preferences
thereby achieving EBP. Point 1 Discovery, representing primary research studies; Point 2
Evidence Summary, which is the synthesis of all available knowledge compiled into a single
harmonious statement, such as a systematic review; Point 3 Translation into action, often
referred to as evidence-based clinical practice guidelines, combining the evidential base and
expertise to extend recommendations; Point 4 Integration into practice is evidence-in-action, in
which practice is aligned to reflect best evidence; and Point 5 Evaluation, which is an inclusive
view of the impact that the evidence-based practice has on patient health outcomes; satisfaction;
efficacy and efficiency of care; and health policy.
In Stevens ACE Star Model (http://www.acestar.uthscsa.edu/Goals/model1325.html),
Discovery is the original research. During Summary of the evidence, the task is to synthesize all
research into a single meaningful whole. This step is what differentiates research utilization from
evidence-based nursing, so it is a critical step to understand. Summary is sometimes termed
evidence synthesis, systematic review, integrative review or meta-analysis. The advantages of
summary are many, according to Stevens. A good summary will increase the power and effect of
the data, and it will reduce bias. Similarly, consistencies across a variety of studies are assessed
during the summary step. Generalizability is established when the evidence is synthesized, and
the information is reduced into a manageable form during this step. Translation is the next step
of the ACE Star Model, and here is where the scientific evidence is considered in the context of
clinical expertise and values, thus resulting in clinical practice guidelines, best practices,

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protocols, standards or clinical pathways. The Implementation step in the ACE Star Model
considers the translation of research into practice. It is here where changes in practice take place,
either at the individual or organizational level. The last step in the ACE Star Model is
Evaluation, where the impact of the change is measured. A number of variables could be
assessed during this step, including health outcomes, efficiency, cost or satisfaction. In Stevens
ACE Star Model the establishment of best practices, based on evidence-based nursing, would be
termed translation. Therefore, when CORE identifies best practices in regulation, it is
addressing the translation step of Stevens ACE Star Model.
Nursing research has been impacted by recent far-reaching changes in the healthcare
research enterprise. Never before in healthcare history has the focus and formalization of moving
evidence-into-practice been as sharp as is seen in todays research on healthcare transformation
efforts. Nascent fields are emerging to understand how to increase effectiveness, efficiency,
safety, and timeliness of healthcare; how to improve health service delivery systems; and how to
spur performance improvement. These emerging fields include translational and improvement
science, implementation research, and health delivery systems science.
Investigation into uptake of evidence-based practice is one of the fields that has deeply
affected the paradigm shift and is woven into each of the other fields. Investigation into EBP
uptake is equivalent to investigating Star Point 4 (integration of EBP into practice). Several
notable federal grant programs have evolved to foster research that produces the evidential
foundation for effective strategies in employing EBP. Among the new research initiatives are the
Clinical Translational Science Awards and the Patient-Centered Outcomes grants.

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References
Institute of Medicine (2001). Crossing the Quality Chasm. Washington D.C.; National Academy
Press.
Stevens, K.R. (2004). Ace Star Model of EBP: Knowledge Transformation.Academic Center for
Evidence-Based Practice. The University of Texas Health Science Center at San Antonio.
Melnyk,B., & Fineout-Overholt, E (2005). Evidence-Based Practice in Nursing & Healthcare.
Philadelphia: Lippincott Williams & Wilkins.
Titler etal, (2001). The Iowa model of evidence-based practice to promote quality care. Critical
Care Nursing Clinics of North America, 13(4) 497-507.