Based on the synthesis of the evidence from my PICO [In adult patients diagnosed with hepatitis C [P], how does the use of AST platelet ratio index (APRI) score [I] compared to liver biopsy [C] influence early detection of liver fibrosis [O]?

I am interested in implementing the use of aspartate platelet index ratio which determines the extent of hepatitis infection. At this point, I am thinking the purpose of my DNP project is to develop, and implement the cost-effectiveness and early detection of using APRI score in staging liver fibrosis in jail. evidence-based practice models comparison – PICOT.



Evidence-Based Practice Models

When a patient enters a healthcare setting, they expect and deserve the best care available. While many, if not all, believe they are doing what is best for their patient, the best care standard must be from an evidence-based approach. Evidence-based practice can challenge or require a change in practice standards. evidence-based practice models comparison – PICOT. Changing practice guidelines can be difficult if there is a lack of sufficient interest and support to make the transition. There are several models that have been developed to assist with successful evidence-based practice modifications. The eight following models aid in the establishment and maintenance of EBP:  The Stetler Model of Evidence-Based Practice, The Iowa Model of Evidence-Based Practice to promote quality care, The Model for Evidence-Based Practice Change, The Advancing Research and Clinical practice through close Collaboration (ARCC©) model for implementation and sustainability of EBP, The Promoting Action on Research Implementation in Health Services (PARIHS) framework, The Clinical Scholar model, The Johns Hopkins Nursing Evidence-Based Practice model, The ACE Star Model of Knowledge Transformation (Dang et al., 2015).

The primary principles common among all of the models are 1) the recognition of a problem, 2) the inclusion of advocates to foster the change, 3) researching and identifying any necessary change in practice, 4) overcoming barriers to the change, 5) disseminating the information about the change to anyone involved in its realization, 6) Carry out the change in practice, 7) Evaluating the results of the implantation, and 8) formulate ideas to help preserve the established change in practice (Dang et al., 2015 p. 278).  While all eight models have a common core, there are differences that allow them to be applied in a variety of practice settings. The Stetler Model of Evidence-Based Practice outlines a five-step process to actualize a desired change. The process is fluid, meaning the practitioner may need to move back and forth between steps to reexamine or amend previous findings. This model is practitioner friendly due and can be applied to individual patients.  evidence-based practice models comparison – PICOT. The Iowa Model of Evidence-Based Practice to Promote Quality Care also uses a multi-step process but involves the forming of a team and a pilot program to evaluate a desired change on a broader scale. This model is better suited for the institution as it provides guidance through the implementation process to guide organizational practice changes. It involves the creation of an interdisciplinary team for the implementation and evaluation of the project (Mitchell, Fisher, Hastings, Silverman, & Wallen, 2010). The Model for Evidence-Based Practice Change also provides clinician guidance to EBP. This model, however, was formed to guide multiple changes or projects. This model also uses an EBP team and a pilot to start the implementation. After the evaluation of the change, the EBP team disseminates the results to all pertinent providers (Dang et al., 2015).  Similarly, The ARCC© model involves a team. However, because this model is designed for a system-wide implementation, it is implemented via a twelve-month program. EBP mentors are selected/trained to assist with implementation and sustaining changes. The Johns Hopkins Nursing Evidence-Based Practice Model promotes beside nursing and accelerates knowledge dissemination and EBP adoption.  The ACE Star Model integrates patient preferences with research and clinical expertise. It also explains how to overcome challenges related to the application of research in practice.  The PARIHS model has three elements (evidence, context, and facilitation) and are the focus of success. By moving these three elements from low to high there is an increase in successfulness. evidence-based practice models comparison – PICOT. The Clinical Scholar Model encourages the constant search of knowledge, the dissemination of knowledge, guided mentorships, and research conduction (Mitchell et al., 2010). evidence-based practice models comparison – PICOT.

The implementation of EBP related to my project will be most benefited by using the Stetler model. The Stetler model focuses on critical thinking and “reflects a practitioner-oriented approach” (Stetler, 2001 p. 272). While my project focuses on a change in the practice of our whole department, the use of the ultrasound will be individualized between patients and the practitioner. In 1976 the Stetler Model, then called the Stetler/Marram Model, was developed as a research utilization (RU) model. When EBP emerged in the 90’s, the Stetler/Marram Model was refined to better align with EBP and became known as the Stetler Model. In 2001, the model was refined further to better define its use as an EBP model.  As discussed above, the Stetler Model fluidly moves through five steps or phases (Stetler, 2001). The following is a discussion of the Stetler Model phases and how I’ll use them in practice.

The first step in the model is preparation (Stetler, 2001). During this phase, the user will think critically about their practice and how they can improve it with EBP.  In my practice, I recognized that we do not currently use ultrasound assistance for neuraxial anesthesia which is recommended by the American Association of Nurse Anesthetists (AANA, 2017).  I formed a related PICO: In parturients receiving neuraxial anesthesia, how does the use of ultrasound to identify landmarks, compare to standard techniques? I did an initial literature search to answer this question. I focused my search on systematic reviews and meta-analysis and randomized controlled trials. I filtered the results for articles that answered my PICO and met my inclusion criteria.

During the second phase of the model, validation, I will critique the articles. I will synthesize the information from the studies into review tables (Stetler, 2001). The use of these tables will give me the opportunity to organize the studies and recognize if there are any relationships across the them.

The third phase of the model is comparative evaluation/decision making (Stetler, 2001).  During this phase I will evaluate the findings and determine if making a change is appropriate. In addition, I will be determining any needs or barriers to applying the change in practice. Political barriers with administration is not a concern as the implementation will not incur any extra cost (Our department already has an ultrasound machine). evidence-based practice models comparison – PICOT. The need to educate staff on using ultrasound assistance is the biggest challenge but ultrasound is already regularly used for peripheral nerve blocks and central line placement, so the majority already have a working base knowledge.

During the fourth phase, translation/application, I will formulate a plan from my findings to recommend a change in practice (Stetler, 2001).  I will formulate recommendations and guidelines detailing how and when ultrasound should be utilized. However, the need for ultrasound assistance will ultimately be decided by the individual practitioners. evidence-based practice models comparison – PICOT.

The final phase of the Stetler model is evaluation (Stetler, 2001). Following the application phase, I will provide an evaluation form for all the CRNAs that received the education. It will be using a Likert-type scale for them to evaluate the change in their knowledge and ask for specific examples when ultrasound guidance was used.  I will provide an evaluation form for the providers to reflect on the effectiveness of the change and collect the data for a month. I will then compare the complication rate to prior months.

Using each step in the Stetler model will provide a clearly organized plan for the implementation of my project. Considering the benefits of revitalizing a preceptor program, Romp and Kiehl (2009) applied the Stetler phases throughout their project. After listing each of the five phases, they discussed how they applied each phase. This detailed a well planned and properly executed project which ultimately supported the development of preceptors for new nurses. By following their example, I will methodically apply the Stetler phases throughout my project. This will result in the proper application of the research results and help avoid barriers to the implementation process. Evidence-based practice models comparison – PICOT.