Evidence-based practice models for post-liver transplant patient outcomes

¶ … Evidence-Based Practice

Theory and Concepts

Model Comparison

Synthesis of Results

The EPB (Evidence-based practice) is identified as the problem-solving approach assisting clinicians to integrate patient's values and preference to achieve patients' outcomes. When EPB is implemented with the context of culture, caring, and environment, it has the ability to deliver effective patients outcomes. Evidence have revealed that EPB is an effective tool enhance healthcare efficiencies as well as reducing variation in costs and care. (Melnyk, Fineout-Overholt, Gallagher-Ford et al. 2012). Despite the tremendous benefits of EBP to the healthcare organizations, many clinicians in the United States do not practice an effective standard care laid down by the EBP (McGinty & Anderson, 2008). Tremendous barriers still exist that prevent healthcare organizations from achieving effective health outcomes. Based on the identification of barriers to the application of the EBP, this paper evaluates different models that can assist in answering the PICOT question.

PICOT Question

"In post liver transplant patients (P) how does lifestyle modification such as physical activity (I) compare to a sedentary lifestyle (C) affects patient quality of life (O) within 4 months (T)."

Model Comparison

This section compares and contrasts different evidence-based practice models to identify the best model that can be used to modify lifestyle of post liver transplant patients using the physical activity, which will assist the patients enhancing the quality of life compared to a sedentary lifestyle, There is an increased evidence that clinical practice should be guided by conceptual framework or models, the evaluation of the models is very critical to identify an appropriate model to answer the PICOT question. The evidence-based practice has gained an increased popularity within the healthcare setting. Despite the benefits to be derived from the health practice, there is still an increasing challenge to deliver a measurable highest quality care. Evidence-based practice is defined as a problem-solving approach to assist healthcare professionals in answering clinical questions. To assist nurses using the evidence-based practice to operate effectively within the clinical setting, they are required to develop, introduce, as well as evaluating the evidence-based practice. Typically, evidence-based practice judiciously and conscientiously uses the current-based evidence combined with the clinical practice to guide the healthcare decisions.

Several models have conceptually contributed to the evidence-based practice; however, analysis of these models is very critical to collect evidence to achieve effective changes within the clinical settings. Different models have been developed for the implementation of the EBP (evidence-based practice). "The Stetler Model in Evidence-based Practice" (Stetler, 2001 p 1) can assist public healthcare practitioners using the evidence-based practice in enhancing an effective planning and implementation. Despite the clinical benefits of the Stetler model, the use of its prescriptive approach is complex and may be difficult for nursing practitioners to develop and interpret. In the contemporary health environment, a major responsibility of nurses is to deliver health education to patients to assist them applying effective physical activity at post-liver transplantation. However, the Stetler model is not effective to design the physical activity for patients with post-liver transplantation.

Similar to the Stetler model, Iowa model has been used to develop a quality of healthcare in numerous clinical setting by providing guidance for clinicians and nursing professionals to make an effective decision regarding the clinical practice. Similar to the Stelter model that uses 5-step stages to implement the evidence-based practice, Iowa model also uses the problem-solving steps approach for the application of EBP within the healthcare settings. The 5-step phases of the Stelter model are preparation, validation, decision making/comparative evaluation, application/translation, and evaluation. However, the Iowa model stages are longer than the phases of Stelter model. The phases of Iowa mode are trigger problem, organization priority, team formation; collect evidence, research critique and synthesis, pilot changes, decision, implementation and dissemination of results. The fundamental difference between Iowa model and Stelter model is that Stelter model focuses on the method individual practitioners implement research, however, Iowa model discusses on how organizations are able to change practice based on research. Moreover, Stelter model uses prescriptive approach for evidence-based practice; however, Iowa model focuses on the systematic approach.

Unlike Stelter model that may be difficult for the nurses to implement, the Iowa model logically flows, intuitive design, and easily understood by the nurse's professionals. Moreover, the Iowa model assists nurses to accumulate knowledge and developing problem-solving skills to evaluate administrative and clinical practice. Similar to the Stetler model that promotes nursing research, and reflects the contemporary to achieve an evidence evaluation for the clinical practice, Iowa model promotes a nursing research when there is a lack of evidence. Similar to the Iowa model, the Stelter model assists in using the research utilization to facilitate the EPB, and safe effective research findings.

Similar to the Stetler model that use the five-phase step to describe the evidence-based practice, the Ace Star model also uses the 5-point step to deliver the knowledge transformation. The Acer Star model discusses the concepts translation, summary integration and evaluation of EBP to enhance a transformation of knowledge within the clinical practice. Despite the benefit of the Acer Star model within the clinical setting, the model is less prescriptive when compared to another EPB model. The ACE Star model is also similar to the Stelter model that uses the five-stage phases for the evidence-based practice. The stages of the ACE Star model are knowledge discovery, evidence summary, translation into practice, integration into practice, and evaluation.

Similar to other EPB models that have been analyzed, the John Hopkins model uses the logical, and intuitive approach to demonstrate the usefulness and clarity of the direct nursing practice. The John Hopkins model is similar Iowa model that focuses on the organizational process revealing the strategy to manage the department unit. Moreover, John Hopkins model uses the evidence-based research to implement the research results. The model also uses the problem-solving approach with an aspect of clinical decision-making. The John Hopkins model is similar to other models that use the research approach to demonstrate the EBP within the clinical setting, the John Hopkins model also focuses on the core of experimental research approach. Unlike the Iowa model that uses the systematic design and Stelter model that uses the prescriptive research approach, the John Hopkins model uses the experimental, quasi-experimental, non-experimental and qualitative research for the evidence-based approach.

"With an exception of the ACE Star model," (Melnyk, Gallagher-Ford, Long, et al. 2014) all other models use the step-wise, evidence-based approach to translating evidence into practice. Contrary to the approach of other models, the Star model explains the strategy of translating the knowledge into practice. Thus, the model assists in using knowledge accumulation for a direct care. Thus, the ACE Star model assists in enhancing a greater understanding the method of using knowledge for a clinical decision.

The ARCC ("Advancing Research and Clinical Practice through Close Collaboration") model (Melnyk, & Fineout-Overholt, 2014 p 289) identifies different barriers to the EPB within the healthcare practice. The model argues that inadequate skills and knowledge of the EPB practitioner is one of the barriers. The model also points that many healthcare organizations are not ready to implement the EBP to improve the patient's outcomes. Contrary to other models that do not discuss the behavioral change to improve the evidence-based practice in the hospital setting, the ARCC model discusses the behavioral change, which is an effective strategy that can change an individual clinician towards the application of the evidence-based practice. Contrary to the other models, ARCC believes in strengthening the beliefs of the clinicians towards the EBP. It is critical to understand that the support of the clinicians is very critical for an effective implementation of the EBP within the healthcare environment. Thus, the model argues that the foundation of the EBP is to change the behaviors of clinicians positively towards the application of the evidence-based practice.

Similar to the Stelter model and Iowa model, the PARIHS "(the promoting Action on Research Implementation in Health services) model)" (Melnyk, & Fineout-Overholt, 2014 p 294) also uses the research approach to understand the evidence-based practice. The elements of the model are research, clinical experience, patient experience, local data and information. The PARIHS model departs itself from the other models by pointing out that a cultural practice is very critical to the application of evidence-based practice. Typically, the model believes that understanding the values and belief of patients are very important for the application of the EBP. Similar to the Iowa model that identifies the organizational value to the EBP, the PARIHS model argues that organizational resources such as human resources, financial and equipment have been the effective tools for the implementation of the evidence-based practice.

Similar to the Iowa model, Stelter model and other models of the evidence-based practice, the Clinical Scholar Model is also adapted to the evidence-based practice approach. The model identifies the clinical and empirical research for the organizational changes. Moreover, the Scholar model argues that it is very critical to educate the health care providers to use the EPB and research for the point of care. Similar to the Iowa model and Stelter model that focuses on research for the application of the evidence-based practice, the Scholar model also uses the research practice to achieve an interactive educational program to achieve a direct care for patients.

Moreover, "The model for evidence-based practice" (Melnyk, & Fineout-Overholt, 2014 p 287) also uses the six-step approach to understanding the evidence-based practice similar to the Iowa model and Stelter model. The six-step approach is to assess a need for a change in the clinical practice. The next stage is to locate the effective and best evidence, followed by analyzing the evidence effectively. The next step is to plan for the practice change by evaluating the change in practice. The last stage is to maintain and integrate the change in practice.

5. Synthesizing the Results

The comparative analysis of all the eight models reveals that nearly all the models support the use of a research approach for the evidence-based clinical practice. However, the outcome of the analysis reveals that ARCC model is the best EBP approach to answering the PICOT question. Although the John Hopkins model can also be used to modify the lifestyle of the patients through the physical activity compared to sedentary life because the model identifies the behavioral modification of the practitioners as an appropriate strategy for the EBP, however, the review of the ARCC model reveals that it is more beneficial to the clinical practice. Several criteria have made this study to identify the ARCC model as the appropriate model for the lifestyle modification for the post liver transplant patients. The ARCC model identifies different barriers to the effective implementation of the EBP within the clinical practice, which include the lack of belief in the EBP, inadequate knowledge and skills in EBP, "lack of administrative support," nurse manager and leader resistance, "lack of an EBP mentor," perceived lack of authority to change patients' care procedure" (Melnyk, & Fineout-Overholt, 2011 p 290). According to ARCC model, an organization is required to choose the EBP mentors who have accumulated an in-depth knowledge of organization change to assist in removing the barriers. Moreover, the mentors should use the role modeling to facilitate the skills and knowledge of clinicians and improve their beliefs towards EBP implementation. As the barriers diminish, clinicians will have the opportunity to implement an evidence-based practice to achieve patient's outcomes.

The goal of the ARCC model is to enhance a "behavioral change in individual clinician towards EBP" (Melnyk, & Fineout-Overholt, 2011 p 290). The ARCC model also uses the CBT (cognitive behavioral therapy) to assist effective change of clinician's idea to achieve patient's outcomes. The CBT stresses the benefits of social, environmental factors to influence cognition, emotion, learning and behavior. The ARCC model is better than other EBP models because the model focuses on the cognitive behavioral changes, which is very critical to answer the PICOT question. Essentially, behavioral changes are very important because it influences healthcare professionals to make policy that will favor the patients' physical activity, which will assist in removing barriers to the experimental research to answer the PICOT question. The mainstream of behavioral therapy is to identify maladaptive behaviors. After identifying the behaviors that need changing, the therapist will use CBT technique to assist the individuals to modify the pattern of behaviors. As being pointed out by the ARCC model, the individual behaviors are determined by their beliefs, and the tenet of the ARCC model is that when clinicians have changed their beliefs positively towards EBP, their abilities, and intentions to strengthen the education and skill building increase. Thus, the goal of the EBP mentors is to work with the clinicians and strengthen their beliefs towards achieving the EBP.

The aims of Clinical Scholar model is similar to the goal of the ARCC model because it promotes the spirit of inquiry, develop an EBP mentorship program as well as conducting a research towards achieving the EPB within the clinical setting. The model believes in conducting research to attain the evidence of care to improve patient's outcomes. Despite the benefits associated with the Clinical Scholar model, the shortcoming of the model is that it does not provide the strategy to remove the barriers to the research outcome.

Moreover, the Stetler model serves as a useful health guide for the healthcare practitioners to develop common policies, tools, and standards. Moreover, the model assists organizations to create formal changes using informal basis to deliver reflective practice. The Stetler model also believes that integration of research and evidence-base practice enhances research application. The model identifies instrumental use as a direct and concrete application of knowledge, and a symbolic use of research occurs when using the information to justify a decision or policy. The Stetler model can be applied in both clinical and educational practice. For example, the model can be used to improve student pass rate. Moreover, it can assist in an effective application of clinical practice. Despite the benefits associated with the Stetler model, its application can be cumbersome for the nursing practitioners, which will serve as a barrier to answering the PICOT question

While the clinical research can assist a healthcare organization to achieve patient's outcomes, nevertheless, the administrative problems can serve as a barrier to the research and development. Eberhart, (2014) supports the arguments of the previous authors with reference to the ARCC model by pointing out that an effective implementation of the EBP is to remove the barriers. Insufficient financial resources are one of the barriers to the EBP, thus, guiding clinicians to have a greater understanding of the value of the EBP is an effective strategy to remove the barriers.

Melnyk, Gallagher-Ford, English Long et al. (2014) argue that the best strategy that can be employed in achieving an effective EBP within a healthcare environment is to follow the following steps:

"Step 0: Cultivate a spirit of inquiry along with an EBP culture and environment Step 1: Ask the PICO (T) question Step 2: Search for the best evidence Step 3: Critically appraise the evidence Step 4: Integrate the evidence with clinical expertise and patient preferences to make the best clinical decision Step 5: Evaluate the outcome(s) of the EBP practice change Step 6: Disseminate the outcome(s)" (Melnyk, Gallagher-Ford, English Long et al. 2014 p 6).

According to the ARCC model, the strategy that can be used to answer the PICOT question is to integrate the evidence-based practice within an organization by eliminating the barriers to achieving the effective health outcomes. Eberhart, (2014) points out that as the facilitator works to remove the barriers from the clinical practice, the ability of organizations to deliver the best health care outcomes improves. Using the ARCC model, an effective strategy to answer the PICOT question is use the research inquiry that can explain the effectiveness of the physical activity compared to a sedentary lifestyle. The PARISH model reveals that many clinicians have not been able to achieve EPB because they refuse to use the research evidence for their healthcare practice. Thus, a designed, well-conceived and executed research has been identified as a strategy to answer the research questions. The Scholar model also believes that an effective research is a tool to realize health outcomes.

However, the Scholar model believes in the critique and synthesizing the current research to assist clinicians realizing the core evidence. (Melnyk & Fineout-Overholt, 2011). On the other hand, Iowa model believes in using a team to evaluate and implement practice changes. However, the synthesis of the published studies reveals that the ARCC model is an effective tool to improve the EBP, sustain both patients, and staff outcomes.

(Melnyk & Fineout-Overholt, 2011)

The method of using the ARCC model to answer the PICOT question is by selecting the participants for the research experiment. The organization will remove the barrier to the research by allocating sufficient financial and human resources, and it is recommended to select nurses as the key personnel to carry out the experiment. The participants will consist of patients who have undergone successful liver transplant surgery. The participants should be adults aged between 25 and 65. Moreover, the participants can male or female who come from any ethnic groups. The selected participants will be divided into two group. The first group will be an experimental group, and this group will be asked to go through lifestyle modifications through the physical exercise. The second group will be a control group will engage in a sedentary lifestyle.

The ARCC model points out that there should be a move to achieve organizational readiness towards to the EBP as well as improving staff beliefs towards the implementation of the EBP. Thus, the organization should organize a training or workshop for the staff who will conduct the experiment to enhance their knowledge about the health benefits of physical exercise for the post-liver transplant patients. Nobili, Carter-Kent, & Feldstein, (2011) argue that a therapeutic lifestyle change is very important for the post liver transplant patient since obesity is a major complication of post liver surgery. Thus, "obesity management not only contributes to weight loss but also enhances insulin sensitivity, modifies the serum lipid profiles and contributes to improved quality-of-life." (Nobili, Carter-Kent, & Feldstein, 2011 p 5). Essentially, a weight loss of a few kilograms can have beneficial effects for patients. This paper presumes that the participants who have received lifestyle modification through the physical exercise for 4 months will have the chance of enhancing insulin sensitivity and reducing the risks of diabetes mellitus compared to controlled group who have undergone a sedentary lifestyle. Promrat, Kleiner, Niemeier, et al. (2010) carries out a random control trial to test the effectiveness of a lifestyle modification after 48 weeks of physical exercise, the results reveals that experimental group record a 9.3% of weight loss compared to 0.2% weight loss for the control group.

Conclusion

The study attempts to answer the following PICOT question:

"In post liver transplant patients (P) how does lifestyle modification such as physical activity (I) compare to a sedentary lifestyle (C) affects patient quality of life (O) within 4 months (T)?" The outcome of the comparative analysis of all the eight models reveals that the ARCC model possesses the best attributes to assist the clinicians implementing the evidence-based practice within the healthcare environment. The ARCC model is selected to answer the PICOT question because the model identifies different barriers to the EBP. The model also identifies and discusses different strategies to remove the barriers to assist the post liver transplant patients achieving an effective health outcome.

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