Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project
Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project
Evidence-Based Practice Model Selection
Evidence-based practice (EBP) is a process of taking knowledge and converting it into the delivery of care (Schaffer, Sandau, & Diedrick, 2013).  Most nurses know that EBP improves the quality of patient care in a cost-effective manner.  Most nurses want to base their patient care decisions on the best evidence available (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012).  It takes more than this knowledge and desire, however, to implement EBP into clinical nursing practice.  Multiple barriers exist that make the realization of EBP challenging.  These roadblocks include inadequate financial support, limited resources, inadequate computer skills, dissatisfaction with supervisors’ assistance in participating in EBP, absence of an academic degree, and unclear and unrealistic workplace goals (Kajermo et al., 2008; Melnyk et al., 2004).  More recently, Melnyk et al. (2012) identified other barriers such as lack of education, inadequate access to information, and time to implement and use EBP.  In 2001, the Institute of Medicine estimated that translating research evidence into clinical practice takes over 17 years.  Even 13 years later, the process is lengthy and full of hurdles (Brown, 2014).  Evidence-based practice models are tools that health care organizations can use to overcome the challenges. Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project
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Evidence-Based Practice Model Selected
Multiple theoretical models have been developed to help turn research discoveries into clinical practice and assist organizations to implement evidence-based practice into their routines. In organizational settings, leadership must decide which evidence-based changes to make and how to do it.  These models present a methodical approach and break the complex process into smaller steps.  Using these models enhances the chance of success, promotes complete implementation, improves resource allocation, and provides a mechanism to evaluate outcomes (Schaffer, Sandau, & Diedrick, 2013).
The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2002) is one such conceptual model that has been used in numerous academic and organizational settings to facilitate the implementation of EBP (Gawlinski & Rutledge, 2008).  Multiple facilities have documented its success and value.  The Iowa Model utilizes an algorithm with decision points and feedback loops (Schaffer, Sandau, & Diedrick, 2013).  Within the algorithm is a feedback mechanism that helps question current practices and determine if evidence exists that can improve those practices.  The model can focus efforts based on either observed problems or new knowledge (White & Spruce, 2015). Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project
After reviewing other EBP models, the Iowa Model was chosen as the best way to explore new triage methods that could improve patient flow through the emergency department.  Many reasons support this decision.  First, the Iowa Model works well with organizational change (White & Spruce, 2015).  Second, it focuses on an interdisciplinary approach.  The Iowa Model uses input from a team that represents the system in question and collaborates to implement EBP (Schaffer, Sandau, & Diedrick, 2013).  Emergency department processes involve multiple disciplines that work closely together- physicians, nurses, ancillary departments, and administration.  A model that depends on the collaboration of many is a logical choice.  Third, Gawlinski and Rutledge (2008) describe the Iowa model as being intuitively understandable or, in other words, user-friendly.  Finally, the Iowa model is attractive because it allows a trial run of the proposed change before final implementation (White & Spruce, 2015).
The Iowa Model and Improving Emergency Department Patient Flow
Applying the Iowa Model will facilitate the implementation of an evidence-based triage system in the emergency department.  The algorithm in the model has three decision points.  The first decision point is to determine whether the topic is a priority for the organization.  Some topics are triggered by knowledge while some are triggered by problems.  Implementing a new, evidence-based triage model is a priority for the organization, which has been brought to light because of the emergency department crowding issue.  Therefore, the next step is to form an interdisciplinary team (Titler et al., 2002; White & Spruce, 2015).
The team should consist of all interested stakeholders, representatives of every discipline that is directly involved in the EBP implementation (Titler et al., 2002).  It is well documented that change is more successful when initiated by frontline practitioners rather when management imposes it on them (Doody & Doody, 2011).  For the emergency department, the team will include direct patient care nurses, the nurse manager, the nurse educator, a physician, a nurse practitioner, nurses’ aide, and a patient registrar.
According to the Iowa Model, the team is first tasked with searching for evidence (Titler et al., 2002).  They should brainstorm together and determine key words for database searches regarding triage models.  This literature search should include research evidence and existing evidence-based guidelines.  For emergency medicine, there are multiple professional organizations and governmental agencies that have studied triage models.  After evidence has been gathered, the team needs to critique and synthesize the evidence.  If members of the team are not experienced with literature searches and assessing the strength of evidence, they should enlist the help of someone in their organization who is (Titler et al., 2002).  Ideally, the team will find pre-appraised research, systematic reviews, and even guidelines that have already been developed for triage systems.  Existing guidelines will help the team identify gaps in knowledge (White & Spruce, 2015).  This work brings the team to the next decision. Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project
The second decision point in the algorithm is whether there is enough evidence to guide evidence-based practice.  If the team believes there is a sufficient amount of quality research evidence on triage models, they can move on to piloting an evidence-based change.  If they do not have a solid research base, they may decide to proceed using other types of evidence, such as case studies, expert opinion, scientific principles, or theory.  Alternatively, the team may choose to conduct the research that is lacking (Titler et al., 2002).
If the team proceeds with the development of a new triage model, the next phase is to pilot the change in practice.  There are six steps to follow at this stage.  First, the desired outcomes should be determined (Titler et al., 2002).  Modifying triage is an attempt to improve patient flow through the emergency department; therefore, potential outcomes to measure might be length of stay, time it takes until a patient sees a physician, or number of patients who leave without a physician assessment.  The second step is to obtain baseline data; measure the outcomes before implementing change (Titler et al., 2002).
The third step is to develop the written guidelines that establish the new process and protocols for triage.  The fourth step involves testing the new process on a sample of patients.  In the emergency department, the team could decide to test the new triage process for two weeks, or they could use the new process on alternate days for a month.  Regardless, this step involves training all of the personnel involved and communicating the expectations well.  The fifth step is to evaluate the new process by comparing the outcome measures to the baseline data obtained in step two.  This establishes if the new process affected patient flow positively.  Finally, the last step includes modifying the guidelines based on the outcomes.  It is possible that the team needs to tweak the process based on an unexpected factor or a specific need of this particular emergency department that was not foreseen (Titler et al., 2002).
Conclusion
In today’s health care environment, it has never been more important to practice evidence-based care.  Nurse leaders have a responsibility to ensure that high-quality care is delivered in a cost effective way, and EBP leads to improved health care and lower costs.  The Iowa Model of Evidence-Based Practice to Promote Quality Care “serves as a guide for nurses and health care providers to use research findings for improvement of patient care” (Titler et al., 2002, p. 498).  The Iowa Model will be especially useful in directing the implementation of a new triage process to improve emergency department patient flow.
 
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