1. Barry, Jean PhD, RN

Article Content

An excellent book has just been added to the growing list of literature focused on evidence-based practice (EBP).1 What Janet Houser, PhD, RN, and Kathleen S. Oman, PhD, RN, CEN, FAEN, have accomplished in their new book, Evidence-Based Practice: An Implementation Guide for Healthcare Organizations, is the creation of a very pragmatic guide for nursing administrators who are committed and passionate about EBP but uncertain on how to design and implement a successful program. The book is also highly relevant for nursing administrators who wish to continuously improve an existing program and faculty when designing curriculum for EBP.


The authors have successfully wrapped their scholarly arms around a very complex, programmatic endeavor hitting all the "right organizational notes" from making a powerful case for an EBP program to providing multiple strategies for guiding, implementing, and integrating the program into the very fabric of an organization. The chapters are organized with the beginning ones focusing on defining and describing what EBP is and its importance to quality outcomes. One of the most helpful early chapters concentrates on how to make an organizational case for EBP. Identification of the various forums and articulation of important topics to address for the various constituencies are included. Specific messages to deliver when dialoguing with the chief financial officer, the chief medical officer, and the chief information officer were of great help.


Research-based information regarding key leadership behaviors for moving from the dream of EBP to its organizational reality is clearly identified and described. Emphasis is placed on the importance of culture as the contextual determinant of whether this dream is indeed brought to reality. Leadership behaviors to influence culture include creating and sustaining the vision for EBP, role modeling that clearly demonstrates the unwavering commitment to the use of evidence in everyday practice, and having strong mentors available to help staff become adept in the use of such evidence.


Structure, Processes, and Resources

Developing the structure, the processes, and the resources needed to be successful are covered in a number of chapters. The importance of articulating an EBP mission statement and the values associated with it is a critical structural element. An EBP definition that reflects the thoughts and values of key organizational stakeholders (including staff nurses) is emphasized with suggestions on how to conduct a thematic search and analysis of stakeholders' comments to achieve this type of definition. Pragmatic guidance on how to design an EBP governance structure that is integrated with other standing committees and unit-based councilor structures is very concretely elucidated.


Other critical areas that are thoroughly covered include determining human and technological resources that must be available for the successful implementation of EBP. Expert staff resources such as nursing research specialists, informatics specialists, and/or health science librarians are identified with roles clearly described. Of course, the foundational role that the chief nurse executive plays in the successful EBP programmatic accomplishment and sustainability is given in-depth coverage.


Required technology applications that provide access to relevant databases, clinical and administrative data repositories, decision support software, and statistical analysis software are explained in a specific and tangible style. Guidelines for orientation and ongoing staff development programs are presented with important content areas delineated. The inclusion of the most widely used organizational EBP models with a clear interpretation of each model is particularly helpful. Also provided with these various models is a table with evaluation criteria to assist in the selection of an organizational EBP model.


Along with the various organizational models are clear guidelines on defining and appraising evidence including examples of grading metrics for evaluating the level of evidence for reviewed studies. A chapter regarding the design of studies for EBP is also included. Topics include conducting systematic reviews, developing clinical practice guidelines (CPGs), and designing clinical science projects. A specific grading scale for CPGs is also provided. Although this chapter presents material in a clear and concise fashion, the content should be considered introductory in nature, and additional references may be needed.


Implementation and Sustainability Methods

Remaining chapters concentrate on specific implementation and sustainability methods for an EBP program. The authors' coverage of how to help staff recognize opportunities for EBP projects is highly valuable. Creating a culture of inquiry is described with specific guidance given on how to precisely accomplish this. The notion of EBP projects being undertaken by administrators at the macro level of the organization as well by staff nurses at the micro level is presented clearly and provides an excellent strategy for integration of EBP into the organizational fabric. As in other chapters, this section is replete with examples.


In addition, the conduct of search strategies is covered. Important information regarding the construct of the EBP question using the PICO (population, intervention, comparison, and outcome) framework is provided. Guidance regarding "knowing where to look" directs the reader to available databases and where to look for clinical point-of-care resources versus systematic reviews versus original studies. The 5S levels of evidence are discussed and diagrammed in a hierarchical figure. The levels (studies, syntheses, synopses, summaries, and systems) are defined with relevant databases linked to each level. Other topics include how to construct a search strategy, free access sources for research results, and clinical trial registries. This section provides invaluable help to staff when a health science librarian is not available to provide guidance and assistance in literature searches.


Other topics included in the final chapters are how to design a mentoring program with the key characteristics that both the mentor and mentee must bring to this relationship identified. The "champions of change" are listed by professional roles with their contribution as the local influence for effective EBP project implementation and dissemination clearly described. Examples of 2 EBP endeavors are used to elucidate what champions of change achieve during EBP projects.


To further clarify important steps in the design of EBP programs, the Agency for Healthcare Research and Quality conceptual framework is provided. This framework takes the form of a pathway composed of 3 stages with related activities to help guide the reader across the stage of knowledge creation to the second stage of distillation, diffusion, and dissemination to final stage of adoption, implementation, and institutionalization. How to create and implement journal clubs, integrate evidence into policies and procedures, and translate research into practice via the TRIP (translating research into practice) model is discussed, accompanied by the TRIP algorithm, its check sheet, and an example of a TRIP flier promoting a specific change. Further dissemination strategies cover the practical strategies for preparing an abstract, a poster presentation, and an effective podium lecture and would be very helpful for the novice presenter.


Case Study

The culminating chapter is a case study of the integration of EBP into complex organizational systems at Lehigh Valley Health Network (LVHN). This case study walks the reader through all the steps expounded in the text. This is an outstanding chapter replete with examples of LVHN models for the organizational integration of EBP, the design of the EBP governance structure and tools to evaluate its effectiveness, and methods to create and sustain a robust EBP-based quality improvement model. In addition, this chapter is augmented by 4 "Voices From the Field" reports. The director of an emergency department in the LVHN network, an advanced practice nurse, and 2 staff nurses explain their roles and actions they took to enhance the EBP at the macro, meso, and micro levels of the organization.



Although mentioned intermittently in this book review, I would be remise in not specifically noting the presence of detailed figures, tables, Voices From the Field reports, and conceptual models, integrated throughout this text. In addition, 10 appendices are included at the end of the text. The appendices include checklists for evaluating research and needed EBP resources, a prioritization matrix to aid in selecting EBP projects, and worksheets for appraising guidelines, for rating the strength of a body of literature, or for planning an EBP review. In addition, mock survey questions and materials to have on hand related to the new knowledge, innovations, and improvement section of the Magnet(R) site survey are available. Because of extensive use of such tools, this book qualifies as "one-stop shop" for those readers needing further clarification of the concepts, processes, methods, and strategies included in this book.


This text is highly recommended for all nursing administrators who have the vision of improving patient and family care and enhancing the work environment for nursing staff. Those in academia will find it helpful when teaching EBP at both the undergraduate and graduate levels. Houser and Oman1 should be highly commended for writing such a pragmatic, well-written guide for the development, implementation, and ongoing enhancement of EBP in complex organizations.




1. Houser J, Oman K, eds. Evidence-Based Practice: An Implementation Guide for Healthcare Organizations. Sudbury, MA: Jones & Bartlett; 2011. [Context Link]