A Closer Look at The IOWA Model
of Evidence-Based Practice
Huntington Hospital EBP/NRC
Council
Janell Lehman-Lerille
Rita Nathan
Linda Nawa
Lulu Rosales
Beverly Schwerin
Objectives
• Review of the IOWA Model of EBP
• Describe the each step of the IOWA
Model Algorithm in detail
Review of IOWA Model
• Developed by Marita G. Titler in 1994
• Infuses research into practice to
improve quality of care
• Algorithm is easily applied to practice
• Utilizes a multidisciplinary team
approach
• Utilizes feed-back loops
• EBP experts act as mentors and
resources for EBP projects
The IOWA Model Algorithm
• Represents the process of EBP
• Viewed as a step process
• The flow of the algorithm depends
on three key decision points
Steps of the IOWA Model Based
on Algorithm
1. Identify the trigger
2. Determine organizational priority
3. Form a team
4. Gather evidence
5. Critique and synthesize evidence
6. Determine if evidence is sufficient
7. Pilot change
8. Determine if change appropriate for
practice
9. Implement and monitor
10.Disseminate results
Decision-Making Points
Decision
Time!
1. Is there an institutional reason to focus
on the problem or knowledge deficit?
2. Is there a sufficient research base?
3. Is the change appropriate for adoption
into practice?
Here is a closer look at the step process
and decision points…….
The Iowa Model- Steps 1 - 3
Problem Focused Triggers
Consider other
triggers
NO
Knowledge Focused Triggers
Priority for
Organization
YES
Form a team
Step 1: Identify the trigger
Knowledge-focused trigger
• A knowledge deficit exists
• The need for a new research guideline or new
evidence
• Ex: How often should oral care be performed to
decrease the incidence of ventilator acquired
pneumonia?
Problem-focused trigger
• Usually a clinical problem
• Current evidence prompts the need to change
practice
• Ex: The number of patient falls in one unit have
been trending up over the past year
PICO (Step 1)
Once the trigger has been identified,
develop a statement in the PICO
format
• P- Patient, population, problem
• I- Intervention
• C- Comparison
• O- Outcome
Note: PICO is not part of the IOWA Model but an important part of EBP.
Formulating a well designed clinical question is a fundamental skill
needed to conduct EBP.
PICO- Example
For CCU patients (population), does oral
care every two hours (intervention) or
every four hours (comparison) decrease
the incident of ventilator associated
pneumonia (outcome) in the CCU?
Important Note
You must identify the outcome that
will measure your success!
For example:
• Nurse sensitive indicators
• Patient satisfaction scores
• Survey results
• The number of falls, infections, etc.
Step 2: Determine
Organizational Priority
Decision
Time!
The first decision point:
• Will Huntington Hospital benefit from
the change by focusing on the
problem or gaining new knowledge?
• Will the hospital support the project?
• Will the benefits outweigh the costs?
• Contact EBP/NRC if unsure
Step 3: Form a Team
• This is a multidisciplinary process
• Members must be committed to the
change
• Members will develop, implement, and
evaluate the EBP project
• Managers must approve
The Iowa Model- Steps 4-7
Assemble Relevant Research & Related Literature
Critique and Synthesize Research for Use in Practice
yes
Pilot Change in
Practice
Sufficient
Research?
no
Base Practice on other
Types of Evidence
Conduct
Research
Step 4: Gather Evidence
• Conduct a literature review to find
relevant research
• Conduct search of peer reviewed
journals in databases such as OVID and
MEDLINE
• Access through the library’s intranet site
on SharePoint
• Contact the librarian for additional
assistance
Step 4: Gather Evidence
Also helpful on the WWW:
• Agency for Healthcare Research and
Quality (AHRQ)
• http://www.ahrq.gov/
• Joanna Briggs Institute
• http://www.joannabriggs.edu.au/
Step 5: Critique and Synthesize
Evidence
First, consider the quality of individual
studies:
• Rate each study using the Forsyth NURSE
Scale to determine the level of evidence
• Locate the Forsyth NURSE Scale and article
review forms in the EBP toolkit and at the
Nursing Research Center on SharePoint
• Higher levels of research provide a higher
quality of evidence for use in practice
Levels of Evidence (Step 5)
Forsyth Nurse Scale
• Level I- Multiple well designed studies
• Level II- One well designed study
• Level III- Studies with significant
limitations
• Level IV- Internal data
• Level V- Early evidence
Note: The Forsyth Scale is not part of the IOWA Model- it is an evidence rating scale
designed to evaluate and rank research according to methodological rigor. This is the
preferred scale for Huntington Hospital even though many scales exist.
Step 5: Critique and Synthesize
Evidence
After looking at individual studies, consider the
following to indicate the strength of the
evidence gathered in the literature review:
• Quality- Collection of quality ratings
from each study.
• Quantity- The number of studies found.
A greater number of quality studies will
increase the magnitude of effect and add
strength
• Consistency- Similar results are
reported with similar and different types
of studies
Step 6: Determine if
Evidence is Sufficient
Decision
Time!
The second decision point, consider:
• Quality & strength of studies
• Do the studies’ samples share similar
characteristics to the patient population?
• Are the research findings relevant to
practice?
• Is the evidence feasible for use in
practice?
• Do the benefits outweigh the costs?
Step 7: Pilot Change
If there IS NOT a sufficient research
base, expand literature search to
include other types of evidence
• Look at case reports, expert opinions,
theories, scientific principles
• If there is still not a sufficient research
base, then conduct a research study
Step 7: Pilot Change
If there IS a sufficient research base,
then pilot the change in practice.
• Determine the outcome to be achieved
• Outcomes must be measurable and
attainable
• Collect baseline data
• Design EBP guidelines, such as an
intervention based on the best evidence
• Implement EBP as unit pilot project
• Evaluate outcomes- Compare baseline
data with post implementation data
The Iowa Model- Steps 8-10
Continue to
Evaluate quality
Care and New
Knowledge
No
Should we
Adopt this change
into practice?
Disseminate
Results
Yes
Institute
Change
Monitor and Analyze
Structure, Process, and
Outcome Data
Step 8: Determine if Change
Appropriate for Practice
Decision
Time!
The third decision point:
• Did the results of the pilot indicate
improved patient outcomes or
increased quality of care?
• Consider the feasibility of
implementing the change into
practice
• Will the benefits outweigh the costs?
Step 9: Implement and Monitor
• If NO, then continue to evaluate quality
care and new knowledge
• If YES, then expand pilot and institute the
change into practice
• Analyze outcome data
• Examples of outcome metrics:
•
•
•
•
•
environment
staff
costs
patient and family
quality
Step 10: Disseminate results
• Communicate to stakeholders
• Integrate into policy and procedure the
new standard of practice
• Write abstract
• Create poster presentation
• Publish
• Present at professional conference
• Bring to the water cooler
If you have any questions about your
EBP project or the IOWA Model….
Contact Huntington Hospital’s EBC/NRC membersEBP experts
ebpresearchcouncil@huntingtonhospital.com
References
Cullen, L. & Griffin, E. (2007, September 12). Synthesis and use of evidence. [PowerPoint
slides]. Presentation at the National Iowa Model Conference, Iowa City, Iowa.
Cullen, L. & Griffin, E. (2007, September 13). Evidence-based practice synthesis reportsoverview. [PowerPoint slides]. Presentation at the National Iowa Model Conference,
Iowa City, Iowa.
Fineout-Overholt, E., Melnyk, B. M., & Schultz, A. (2005). Transforming healthcare from
the inside out: Advancing evidence-based practice in the 21st century. Journal of
Professional Nursing, 21(6), p. 335-344.
Gawlinski, A., & Rutledge, D. (2008). Selecting a model for evidence-based practice
changes: A practical approach. AACN Advanced Critical Care, 19 (3), p. 291-300.
Kring, D. L. (2009, November1). The NURSE Scale: Nursing's Unique Rating Scale of
Evidence. Retrieved from
https://stti.confex.com/stti/bc40/webprogram/Paper42854.html
Pennsilvania State University. (2013). Evidence-based practice tutorial. Retrieved from
http://www.libraries.psu.edu/psul/tutorials/ebpt/question.html.
Titler, M. G. (2007, September 13). Evaluation Methodologies. [PowerPoint slides].
Presentation at the National Iowa Model Conference, Iowa City, Iowa.
Titler, M. G., Kleiber, C., Steelman, V., J., Rakel, B. A., Budreau, G., Everett, L. Q.,
Buckwalter, K., C., & Goode, C. J. (2001, December). The IOWA model of evidencebased practice to promote quality care. Critical Care Nursing Clinics of North America,
13(4), p. 497-509.
Youngblut, J. M., & Brooten, D. (2001). Evidence-based nursing practice: Why is it
important. AACN Clinical Issues, 12(4), p. 468-476.
Quiz
1. What does PICO stand for?
a) Performance, improvement, committee,
outcome.
b) Professionalism, integrity, compassion,
observation.
c) Problem, intervention, comparison,
outcome.
d) Person, inquiry, collaborative, opportunity
Quiz
1. What is the Forsyth NURSE scale used
for?
a) Rate levels of evidence
b) Assign value to nursing research
c) Grade nurses on their performance
d) Provide outcome data for research
Quiz
3. What is the difference between
problem-focused trigger and
knowledge-focused trigger?
a) One causes a problem and the other solves it
b) One triggers nurses to act on a problem and
one triggers professors to act on a problem
c) One triggers the need to use evidence to
change practice and the other triggers the need
to provide new knowledge
d) One addresses clinical questions and the other
addresses theoretical questions
Quiz
4.Who do you contact for help with
your literature search?
a) Your manager
b) Lulu Rosales
c) A librarian
d) Your unit’s CNS
Quiz
5. What is an example of an outcome
metric?
a) Staff
b) Costs
c) Environment
d) Patients
e) Quality
f) All of the above