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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Volume 1, Issue 1

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 committee’s 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).

Nursing Excellence IconSince 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.

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. Children’s Hospital Central California’s 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.

Star Model
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. 


Reproduced with permission from K. Stevens 08/06


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
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 & Fineout-Overholt, 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.

Iowa Model


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 today’s 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 Children’s Hospital are encouraged to contact members of the Nursing Research Committee.


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 & Wilkens.

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.

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