Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the Six Sigma Model

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Practice Change and Quality Improvement Models

Recent changes in healthcare services largely focus on patient safety, evidence-based practices, and quality enhancement. Various models rooted in factual data have helped nurses deepen their understanding and significantly improved the delivery of appropriate healthcare services. For this DNP project, which addresses the high fall rate among long-term care residents, the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the Six Sigma model are identified as the most suitable frameworks.

Application of JHNEBP and the Six Sigma Model

The JHNEBP model, as outlined by Dang and Dearholt (2017), is an effective tool for problem-solving and decision-making in nursing practice. Designed to meet the needs of practicing nurses, it follows a three-step process — Practice Question, Evidence, and Translation (PET) — ensuring the integration of the latest research findings. When applied effectively, this model facilitates the swift and appropriate incorporation of best practices into patient care.

Conversely, the Six Sigma model emphasizes quality improvement through data analysis. Its primary goal is to identify and eliminate defects that could potentially harm patients (McGonigal, 2017). By collecting and critically analyzing information, this model establishes a standardized approach, ultimately resulting in nearly flawless service delivery and reduced operational costs for healthcare organizations.

Examples of Application

The JHNEBP model’s three-step process (PET) provides a structured approach for change, involving defining the scope of inquiry, conducting research, and formulating an actionable plan (Dang & Dearholt, 2017). An example of applying the Six Sigma model includes the critical cross-referencing of data and continuous updates based on the findings (McGonigal, 2017).

Conclusion

When expertly implemented, both the JHNEBP model and the Six Sigma model ensure the rapid and effective integration of best practices into patient care while simultaneously lowering costs for healthcare organizations (McGonigal, 2017).

References

• Dang, D., & Dearholt, S. L. (2017). Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. Sigma Theta Tau.
• McGonigal, M. (2017). Implementing a 4C Approach to Quality Improvement. Critical Care Nursing Quarterly, 40(1), 3–7.

The Johns Hopkins Nursing EBP Model

Evidence-based practice (EBP) has become a core competency for all healthcare professionals (IOM, 2003). This necessitates that leaders in academia and healthcare align their educational and practice environments to promote evidence-based practice, foster a culture of continuous inquiry, and translate high-quality evidence into practical applications. Choosing a suitable model for EBP encourages user adoption and integrates evidence-based practice into the organization’s culture.

The objectives of this chapter are to:

• Describe the Johns Hopkins Nursing Evidence-Based Practice Model.
• Introduce bedside nurses and nurse leaders to the PET process (Practice Question, Evidence, and Translation) as a guide for applying EBP.

Overview of the Johns Hopkins Nursing Evidence-Based Practice Model and Process

The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP; see Figure 3.1) is built on three essential cornerstones that underpin professional nursing: practice, education, and research.

• Practice is the fundamental component of all nursing activities, reflecting how nurses translate their knowledge into action. It addresses the who, what, when, where, why, and how of patient care (American Nurses Association [ANA], 2010) and is integral to healthcare organizations.
• Education encompasses the acquisition of knowledge and skills necessary for nursing professionals to maintain competence and expertise.
• Research creates new knowledge for the nursing profession, enabling the development of evidence-based practices. Nurses utilize this evidence to guide their policies and practices, quantifying their impact on healthcare outcomes (ANA, 2010).

The JHNEBP Model

Figure 3.1 illustrates the JHNEBP model.

Nursing practice is governed by standards set forth by professional nursing organizations. For instance, the ANA has identified six standards of nursing practice based on the nursing process (see Table 3.1) and ten standards of professional performance (see Table 3.2). These standards define the scope of practice, set expectations for evaluating performance, and guide the care provided to patients and families. All healthcare settings must translate these expectations into specific organizational policies, protocols, and procedures. Nurses must question the foundations of their practice and employ an evidence-based approach to validate or modify their practices based on current evidence. Traditionally, nursing practice was often based on unsubstantiated policies and protocols (Melnyk et al., 2009). The shift towards an evidence-based approach is now a standard set by professional nursing organizations and is a key component of the Magnet Model for organizations seeking Magnet recognition (Reigle et al., 2008).

The Magnet Model

The Magnet Model consists of five key components:

1. Transformational Leadership: Nursing leaders need vision, influence, clinical knowledge, and expertise to foster an environment that supports EBP activities, such as questioning current practices and translating knowledge into practice.
2. Structural Empowerment: Leaders promote staff involvement and autonomy in identifying best practices and utilizing the EBP process to implement change.
3. Exemplary Professional Practice: Magnet organizations maintain strong professional practice models, partner with patients and families, and focus on systems that enhance safety for both patients and staff.
4. New Knowledge, Innovations, and Improvements: Magnet organizations challenge themselves to develop new care models, apply evidence to practice, and contribute to nursing science (American Nurses Credentialing Center [ANCC], 2011).
5. Empirical Outcomes: A heightened focus on empirical outcomes is necessary to evaluate quality, supported by data from quality improvement results, financial analyses, and program evaluations in addressing EBP questions.

American Nurses Association Standards of Practice

1. Assessment: Collect comprehensive data relevant to the healthcare consumer’s situation, utilizing evidence-based tools as appropriate.

2. Diagnosis: Analyze assessment data to determine the diagnoses or issues.

3. Outcomes Identification: Identify expected outcomes for a plan tailored to the healthcare consumer’s needs, considering associated risks, benefits, costs, and current scientific evidence.

4. Planning: Develop a plan outlining strategies and alternatives to achieve expected outcomes, integrating scientific evidence and trends.

5. Implementation: Execute the plan while partnering with the patient and caregivers, utilizing evidence-based interventions and treatments.

• Coordination of Care: Organize and document the plan of care.
• Health Teaching and Promotion: Implement strategies to promote health and a healthy environment.
• Consultation: Advanced practice nurses provide consultation to enhance others’ abilities and effect change.
• Prescriptive Authority and Treatment: Advanced practice nurses prescribe evidence-based treatments, considering comprehensive healthcare needs.

6. Evaluation: Assess progress toward achieving outcomes through systematic, ongoing evaluations based on established criteria and timelines.

1. Ethics: Delivering care that upholds and safeguards the autonomy, dignity, rights, values, and beliefs of healthcare consumers.
2. Education: Acquiring knowledge and skills that align with contemporary nursing practices. Engaging in continuous educational activities and committing to lifelong learning through self-reflection and inquiry to address personal and professional growth.
3. Evidence-Based Practice and Research: Incorporating evidence and research findings into practice by utilizing current, evidence-based knowledge, including research outcomes, to guide nursing actions.
4. Quality of Practice: Enhancing nursing practice through participation in quality improvement activities, documenting the nursing process ethically and accountably, and employing creativity and innovation to improve nursing care.
5. Communication: Effectively communicating in various formats across all areas of practice.
6. Leadership: Providing leadership within professional practice settings and the broader nursing profession.
7. Collaboration: Working collaboratively with healthcare consumers, families, and other stakeholders in nursing practice.
8. Professional Practice Evaluation: Assessing one’s nursing practice against professional standards, guidelines, and relevant laws and regulations.
9. Resource Utilization: Leveraging appropriate resources to plan and deliver nursing services that are safe, effective, and financially responsible.
10. Environmental Health: Practicing in a manner that prioritizes safety and environmental health. Utilizing scientific evidence to determine potential environmental threats posed by products or treatments.

Johns Hopkins Nursing Evidence-Based Practice Overview:

An organization’s capability to provide nurses with opportunities, as part of an interprofessional team, to formulate evidence-based practice (EBP) questions, assess evidence, promote critical thinking, implement practice changes, and encourage professional development significantly influences its attainment of Magnet status. Anecdotal evidence indicates that nursing staff engaged in the EBP process experience increased empowerment and job satisfaction from contributing to practice changes driven by evidence. Changes based on evaluated evidence are also more likely to be embraced within the organization and among other disciplines.

Nursing Education:

Nursing education typically starts with foundational training (an associate or bachelor’s degree) covering essential nursing skills, knowledge, and professional values. Advanced education (master’s or doctoral degrees) builds on this foundation, refining practice and often leading to specialization. Ongoing education — through conferences, seminars, workshops, and in-services — is vital for keeping up with new knowledge, technologies, and skills. Given the complexity of healthcare, it is essential for nurses to engage in lifelong learning and continuous competency development. This learning extends beyond individual efforts to include interprofessional, collaborative education, such as simulation and web training, which prepares nursing and medical students to work effectively in patient-centered teams.

Nursing Research:

Nursing research employs qualitative and quantitative methods to enhance patient care, systems, and outcomes. While best practices should be grounded in solid scientific evidence, the translation of current research into nursing practice often occurs slowly. Nurses may be influenced by “knowledge creep,” gradually feeling the need to change practices based on limited research and anecdotal evidence. Creating supportive structures for nurses to utilize evidence in clinical practice is crucial to bridging the evidence-practice gap. Nursing leaders must foster an environment that promotes nursing research to generate new knowledge, inform practice, and enhance patient outcomes.

The JHNEBP Model: Core Concepts:

At the heart of the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model lies evidence, drawn from both research and non-research data that inform practice, education, and research. While research provides the strongest evidence, its application can be limited to specific contexts. Therefore, nurses must carefully evaluate various types of evidence, including clinical guidelines and quality improvement data, before implementing changes in practice. Additionally, understanding patient preferences and values is crucial, as these factors significantly influence treatment adherence.

Internal and External Influences:

The JHNEBP model functions as an open system influenced by both internal and external factors. External influences include accreditation requirements, legislation, quality measures, and standards, which guide organizations toward maintaining high practice standards. Internal factors encompass organizational culture, resource allocation, leadership, and staffing. For successful implementation of evidence-based practice, organizations must cultivate a culture supportive of EBP, backed by strong leadership, and clearly defined expectations.

The JHNEBP Process: Practice Question, Evidence, and Translation:

The JHNEBP process comprises 18 steps organized into three phases: Practice Question, Evidence, and Translation (PET). It starts with identifying a practice problem or concern, crucial for guiding subsequent steps. Following the formulation of a practice question, a search for evidence is conducted, and the evidence is appraised and synthesized. If the evidence indicates a need for change, the translation phase begins, encompassing planning, implementing, and evaluating practice changes. The final step involves disseminating results to stakeholders, including patients, staff, and the broader community.

Identification of Patient/Population/Problem Team members specify the particular patient, population, or issue being examined. Relevant characteristics may include age, gender, ethnicity, medical condition, disease, and care setting.

Intervention Team members outline the specific intervention or strategy under investigation, which could encompass various approaches such as educational initiatives, self-care techniques, or best practices.

Comparison If applicable, team members identify the intervention’s comparison point, such as current practices or alternative interventions.

Outcomes The team defines anticipated outcomes resulting from the implementation of the intervention. These outcomes must include metrics that will be used to assess effectiveness if changes to practice are made.

The Question Development Tool (see Appendix B) assists the team in clarifying the practice problem, evaluating existing practices, understanding the rationale for selecting the problem, limiting its scope, and refining the evidence-based practice (EBP) question using the PICO format. This tool also aids in crafting a search strategy by pinpointing evidence sources and potential search terms. It is important to acknowledge that the EBP team can revisit and further refine the EBP question as new information arises from the evidence search and review. Refer to Chapter 4 for additional details on developing and refining an EBP practice question.

Step 3: Define the Scope of the EBP Question and Identify Stakeholders The EBP question can pertain to individual patient care, a specific patient population, or the broader patient population within the organization. Clearly defining the problem’s scope helps the team identify the relevant individuals and stakeholders who should be involved and informed throughout the EBP project. A stakeholder is defined as any individual or organization with a vested interest, whether personal or professional, in the topic under consideration (Agency for Healthcare Research and Quality, 2011). Stakeholders may include a diverse range of clinical and non-clinical personnel, departmental and organizational leaders, patients and their families, insurance providers, and policymakers. Engaging the appropriate EBP team members and keeping key stakeholders informed is vital for successful change. The team should evaluate whether the EBP question pertains to a specific unit, service, or department, or if it spans multiple departments. If the latter, a broader group of representatives from all involved areas should be recruited for the EBP team, with key leadership from the affected departments kept updated on the team’s progress. If the issue impacts multiple disciplines (e.g., nursing, medicine, pharmacy, respiratory therapy), representatives from each discipline should also be included.

Step 4: Determine Project Leadership Responsibilities Selecting a leader for the EBP project is crucial for its success. The leader facilitates the process and ensures its progress. Ideally, this individual should be knowledgeable about evidence-based practice and have experience leading interprofessional teams. Familiarity with the organizational structure and strategies for implementing change is also advantageous.

Step 5: Schedule Team Meetings Organizing the inaugural EBP team meeting can pose challenges and involves several activities, including:

• Reserving a spacious meeting room conducive to group discussions
• Requesting that team members bring their calendars to schedule future meetings
• Assigning a team member to document discussion points and decisions
• Keeping track of essential materials (e.g., EBP tools, extra paper, dry erase boards)
• Establishing a location for project files
• Creating a timeline for the process

Evidence Phase The second phase (steps 6–10) of the PET process involves searching for, appraising, and synthesizing the best available evidence. Based on these findings, the team makes recommendations for practice changes.

Step 6: Conduct Internal and External Searches for Evidence Team members identify the type of evidence to search for (see Chapter 5) and designate individuals to conduct the search, bringing findings back to the committee for review. Engaging a health information specialist (librarian) is critical, as this assistance saves time and ensures a thorough and relevant search. Beyond library resources, other evidence sources include:

• Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the Six Sigma model
• Clinical practice guidelines
• Quality improvement data
• Position statements from professional organizations
• Expert opinions from internal and external sources
• Regulatory, safety, or risk management information
• Community standards
• Patient and staff surveys and satisfaction data

Step 7: Appraise Evidence Quality and Level In this step, both research and non-research evidence are evaluated for quality and level. The Research Evidence Appraisal Tool (see Appendix E) and the Non-Research Evidence Appraisal Tool (see Appendix F) support the team in this task. Each tool includes questions designed to assess the type, level, and quality of evidence. The PET process employs a five-level scale, with Level I being the highest and Level V the lowest (see Appendix C). Each piece of evidence is rated based on quality — high, good, or low with major flaws — and any evidence deemed to have low quality is excluded from the process. The Individual Evidence Summary Tool (see Appendix G) tracks the team’s evaluations, including author, date, evidence type, sample size, setting, study findings, limitations, level, and quality.

Step 8: Summarize Individual Evidence The team summarizes the total number of evidence sources addressing the practice question for each level (I–V) and records these totals in the Synthesis and Recommendations Tool (see Appendix H). Relevant findings for each level are summarized adjacent to the corresponding level.

Step 9: Synthesize Overall Strength and Quality of Evidence Next, the team assesses the overall quality for each level (I–V) and documents it on the Synthesis and Recommendations Tool (see Appendix H). During synthesis, the team determines the overall strength and quality of the compiled evidence, considering (a) level, (b) quantity, © consistency of findings across all evidence sources, and (d) applicability to the relevant population and setting. The quality criteria used for individual evidence appraisal can guide this assessment. This process involves both objective and subjective evaluation. The EBP team should invest time to carefully analyze the evidence and reach a consensus on the overall strength and quality. Further details on evidence synthesis can be found in Chapters 6 and 7 and Appendix I.

Step 10: Develop Evidence-Based Recommendations for Change Drawing from the overall appraisal and synthesis of the evidence, the team explores potential pathways for translating evidence into practice. There are four common pathways to consider when crafting a recommendation (Poe & White, 2010):

• Compelling evidence with consistent results supports a practice change.
• Good evidence with consistent results supports a practice change.
• Good evidence exists, but conflicting results may or may not support a practice change.
• Insufficient or absent evidence precludes support for a practice change.

Based on the chosen translation pathway, the team decides whether to proceed with the recommended change or to investigate further (see Table 3.4). Recommendations are noted on the Synthesis and Recommendations Tool, along with a careful analysis of the risks and benefits associated with making the change. It is advisable to initiate changes as pilot studies (with a smaller sample size) to identify any unanticipated adverse effects.

Benefits vs. Risks

There may be instances where benefits do not outweigh risks due to insufficient information for a conclusive determination.

Translation of Findings

In the third phase (steps 11–18) of the Evidence-Based Practice (EBP) process, the EBP team evaluates whether the proposed changes are feasible, appropriate, and suitable for the target setting. If they are deemed appropriate, the team will create an action plan, implement and assess the change, and communicate the results to relevant internal and external stakeholders.

Step 11: Assessing Fit, Feasibility, and Appropriateness The team gathers feedback from organizational leaders, bedside clinicians, and all relevant stakeholders to evaluate whether the change is feasible, appropriate, and aligns with the practice setting. They analyze the associated risks and benefits of implementing the recommendations and consider the available resources and the organization’s readiness for change (Poe & White, 2010).

For instance, when an EBP team suggested adding post-insertion x-rays to the protocol for verifying enteral tube placement — based on the evidence that this method was 100% accurate — the recommendation faced rejection due to concerns about costs, patient safety, workflow delays, and staffing availability. Consequently, risk management data indicating no documented incidents of incorrect tube placement led the organization to decide against implementing this change at that time.

Step 12: Creating an Action Plan If the recommendations fit well within the organization, the team formulates an action plan that may include:

• Development or revision of protocols, guidelines, or processes related to the EBP question.
• A detailed timeline assigning responsibilities for tasks, including evaluation and reporting.
• Soliciting feedback from organizational leaders and stakeholders.

The team must address the who, what, when, where, how, and why while crafting the action plan.

Step 13: Securing Support and Resources The team needs to identify and secure the necessary human, material, and financial resources to implement the action plan successfully. Collaborating closely with departmental and organizational leaders can facilitate this process.

Step 14: Implementing the Action Plan During implementation, all affected staff and stakeholders should receive comprehensive communication, both verbal and written, regarding the practice change and the implementation and evaluation processes. EBP team members should be available to address questions and resolve issues as they arise.

Step 15: Evaluating Outcomes The team evaluates the extent to which the identified outcomes (see Appendix B) have been achieved. While the goal is to achieve positive results, unexpected outcomes can provide valuable learning opportunities, prompting adjustments to either the practice change or the implementation process. Evaluation outcomes should be integrated into the organization’s quality improvement framework for ongoing measurement and reporting.

Step 16: Reporting Outcomes to Stakeholders Results, both positive and negative, should be communicated to relevant organizational leaders, bedside clinicians, and other stakeholders. Sharing outcomes can disseminate new knowledge and generate further practice or research questions. Feedback from stakeholders can help identify barriers to implementation and inform strategies for improving less favorable results.

Step 17: Identifying Next Steps EBP team members review the entire process and findings to extract lessons learned and determine any additional actions needed. This may include formulating new research questions, addressing topics requiring further investigation, or preparing for presentations or articles on the process and outcomes. For instance, when the post-x-ray validation recommendation for enteral tube placement was not accepted, the EBP team considered designing a research study using colorimetric carbon dioxide detectors for tube placement verification.

Step 18: Disseminating Findings This final step often requires substantial organizational support. The EBP project results should be communicated within the organization, and depending on the findings’ significance, sharing them externally through professional journals or presentations at conferences should be considered.

Summary

This chapter introduces the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model and the steps of the PET process. Nursing staff with diverse educational backgrounds have successfully utilized this process with appropriate mentorship and organizational support, enhancing their understanding of current interventions and integrating evidence-based changes into their practice (Newhouse et al., 2005).