Being able to describe the differences between research, quality assurance (QA), performance improvement (PI), and evidence-based practice (EBP) is no small feat, but this is what nursing staff members are called to do when their organization embarks on the American Nurses Credentialing Center Magnet Recognition journey. This issue became particularly evident when the three hospital campuses within Meridian Health (Jersey Shore University Medical Center, Neptune, N.J.; Ocean Medical Center, Brick, N.J., and Riverview Medical Center, Red Bank, N.J.) underwent preparation for Magnet recertification. As nurses within the system prepared for their site visits, it became apparent that it wasn't clear to them how concepts such as research, QA, PI, and EBP were related because these terms were often used interchangeably. After evaluating several commonly used nursing models of EBP, the Academic Center for Evidence-Based Practice (ACE) Star Model of Knowledge Transformation was chosen to illustrate how these processes are different, but integral, to the cycle of translating knowledge into practice.1
This article describes how EBP flashcards based on the ACE Star Model of Knowledge Transformation were developed to assist nurses in a healthcare system articulate the relationships between research, QA, PI, and EBP while preparing for Magnet recertification.
The ACE Star Model of Knowledge Transformation
The ACE Star Model describes five major points in the transformation of knowledge into practice. Represented as a five-pointed star, the cycle begins at the top point (Discovery) with the discovery of new knowledge, which represents the research process. The second star point (Evidence Summary) represents the development of evidence summaries, which is a step unique to the EBP process. When research has produced sufficient evidence, a summary of conclusions based on that body of evidence can be produced, which generates a higher level of knowledge. It's on this new knowledge that the third star point (Translation) depends. This phase occurs when the evidence summaries are used to develop clinical practice guidelines, protocols, and procedures. The fourth star point (Integration) occurs when the clinical guidelines are implemented. This is the phase in which change theory and its related processes are used to create and sustain the changes called for in guideline implementation. The fifth point (Evaluation) is when QA and PI processes are most evident. QA processes are used to monitor for expected outcomes; PI processes are initiated when the outcomes fall short of those expected from the evidence.
Development of an EBP flashcard template
As our hospitals prepared for their Magnet survey visits, it became apparent that a practical mechanism would be needed to assist nursing staff members in discussing their practice changes, the evidence upon which these changes were based, and the outcomes produced. A template was developed for an EBP flashcard that could be used by staff to more clearly describe their journey through knowledge translation into practice. The EBP flashcards used the points of the ACE Star Model to highlight where the concepts of research (Discovery), EBP (Evidence Summary), change processes (Translation and Integration), and QA and PI (Evaluation) intersect to create the platform of evidence on which nursing practice is based. Each flashcard contained four sections:
[white diamond suit] the Background section briefly presented benchmark data and the rationale for why further action was needed related to the clinical issue (Star point 5: Evaluation)
[white diamond suit] the Evidence section presented the best available research evidence with a concluding summary statement (Star points 1 and 2: Discovery and Evidence Summary)
[white diamond suit] the Action section described the change processes and PI activities related to guideline development and implementation (Star points 3 and 4: Translation and Integration)
[white diamond suit] the Outcomes section described the outcomes attained from the changes as measured by QA mechanisms (Star point 5: Evaluation).
Process of EBP flashcard development
Because it was felt that the unit-based nurse educators were the individuals who had the most knowledge of their unit's PI initiatives, the author met with some of the nurse educators at Ocean Medical Center (OMC) to present the EBP flashcard template and asked for their assistance in developing at least one flashcard per nursing unit. Working as a team, the group brainstormed current PI projects that were based on evidence and were representative of the units they supported. Potential flashcard topics included deep vein thrombosis prevention, ventilator-associated pneumonia bundles, and pressure ulcer prevention. Background sections of the flashcards were developed that described the QI/benchmark data that triggered the need for change. Available research related to the topics was sought and evidence summary statements were found or developed for the Evidence sections of the flashcards. Descriptions of the PI and change process activities related to guideline development and implementation were written for the Action sections, and QA data were used in the Outcomes sections to highlight the improvement related to the EBP change.
Staff education and final results
After completion, the EBP flashcards with clinical issues appropriate to the clinical unit were distributed to nursing staff. In addition to distributing the 4 x 6 flashcards, posters were developed and hung on each unit that described the ACE Star Model of Knowledge Transformation. These were used by the nurse educators for staff education. By the time of the Magnet site visit, most of the nurses could speak easily about at least one example of EBP and also discuss related PI initiatives and outcomes. At the summary meeting on the last day of the OMC Magnet visit, one of the appraisers described how a staff member steered her over to the unit's ACE Star Model poster and began to describe how knowledge was translated into practice, discussing the evidence on which her nursing practice was based, and proudly citing the unit's outcomes. The final result? Magnet recertification was achieved and nursing staff members have a better grasp of the process of translating evidence into practice.
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