A nurse's professional performance is guided by American Nurses Association (ANA) standards, which include such competencies as participating in quality improvement (QI) initiatives, using innovation to enhance nursing care, incorporating evidence to change nursing practice, and identifying health care–related questions that can be answered by research studies.1 These competencies may be part of a research study, an evidence-based practice (EBP) or QI project, or innovation initiative. In this article, the authors describe the process of evaluating a nursing department's current EBP model and then developing and implementing a comprehensive model for research, EBP, QI, and innovation.
When EBP became a recognized part of nursing practice, many models were developed and published in the late 1990s and early 2000s. Nursing departments often adopt an EBP model to promote a culture of practice based on evidence and to guide EBP projects. In 2009, our medical center's nursing-shared governance hospitalwide councils adopted 1 EBP model and received permission to use it. When an updated version of this model was available, the EBP/QI/Research Council questioned the usefulness of having only an EBP model when nurses also participate in research studies, QI projects, and innovation. In addition, as part of the Magnet Model, hospitals also need to demonstrate that nurses are engaged in research, QI, and EBP.2 Council members wanted to examine alternative models, which incorporated these ANA professional performance standards and Magnet Recognition Program components.1,3
Since 2014, our medical center has been successfully using a flow sheet to guide EBP projects completed by nurse workgroups and postbaccalaureate newly licensed registered nurses (RNs) in a nurse residency program, which provides a transition experience into clinical practice, leadership, and professional development. The EBP Flow Sheet is a table with 12 items that need to be addressed, such as describing the problem, identifying why it is a problem, stating the goal of the best evidence summary, forming a team, outlining PICOT components (Population or Problem, Intervention, Comparison, Outcome, Timeframe), and making a practice recommendation. An initial suggestion by the council was to use the EBP Flow Sheet as a model. However, other aspects of professional performance, which address research studies, QI projects, and innovation, were not included in the flow sheet.
Steps for a research study are specific and well-known to researchers. However, few direct care clinical nurses lead research studies or write initial proposals. Hospital-employed nurse researchers or consultants contracted by hospitals are uncommon, especially in rural areas or smaller facilities. In addition, council members were frequently asked by clinical nurses, “I want to do a research study, how do I start?” Even though our medical center employs 1 full-time nurse scientist, barriers continued to limit nurse participation in research studies. Nurses believed a simple and easy-to-access resource to guide decision-making would be helpful.
Steps for QI projects depend on the framework adopted by the organization, such as Plan-Do-Study-Act (PDSA, part of Lean) or Define-Measure-Analyze-Improve-Control (DMAIC, part of Six Sigma), as well as newer models that emphasize implementation and sustainability.4 Recently, a team demonstrated their integrated model of EBP and Lean through several successful projects,5 while an earlier team also integrated EBP and QI.6 Although rapid cycle improvement using PDSA and other Lean methods were already in place at our medical center, nurses wanted more information about these processes. Several QI workshops for nurses had been held over the years, yet staff still struggled with differentiating EBP, QI, and research, which is a common problem in health care facilities.
To support all forms of inquiry, including research, EBP, QI and innovation, a model that encompasses these relevant professional performance activities was needed. Innovation occurs when clinicians create or discover a unique solution to a problem. Synthesizing disparate information to create a new view of a problem is at the heart of innovation.7 Therefore, the EBP/QI/Research Council approved a workgroup to address the next steps toward this end.
Volunteer members of the council convened to form a workgroup. Members included 2 clinical nurse specialists, a direct care RN, a nurse educator, the EBP coordinator, and the nurse scientist. Key criteria for evaluating available EBP models were developed.8 Criteria included being accessible or understandable, easy to use, and addressing relevant professional performance competencies.1,3 These professional performance competencies included participating in EBP and QI projects, research studies, and innovation.
The workgroup reviewed available EBP models and the EBP Flow Sheet. No single model included all relevant professional performance competencies of EBP, QI, research, and innovation. It was important to include all competencies in 1 model, as these activities do not occur in isolation. The workgroup decided to develop a new model incorporating these aspects of professional performance. The I3 Model for Advancing Quality Patient Centered Care was the resulting product. This model guides nurses in their quest for new knowledge (research studies and best evidence projects), continuous improvement, and innovation (see Supplemental Digital Content, Figure 1, available at: https://links.lww.com/JNCQ/A616). The model is an algorithm with steps to follow based on a question from a clinical issue or problem.
Professional performance competencies are incorporated within the 3 “I's” of the model: Inquiry, Improvement, and Innovation. Inquiry encompasses research studies and best evidence projects. Improvement includes QI projects, and innovation is discovery. The ANA standards1 as well as the Magnet Model3 provide competencies for the I3 Model and are outlined in the Table. Since these competencies are professional performance standards, the workgroup believed it was essential to provide a model that facilitated nursing staff engagement in these types of activities.
Professional Performance Competencies Supporting Inquiry, Improvement, and Innovation of the I3
|Uses current evidence-based knowledge, including research findings, to guide practice.
Appraises nursing research for optimal application in practice.
Promotes ethical principles of research.1(p77)
Applies existing evidence to practice.3
|Contributes in efforts to improve health care efficiency
Collaborates with the interprofessional team to implement quality improvement plans and interventions.1(p79)
|Uses creativity and innovation to enhance nursing care.1(p79)
Contributes to patient care, the organization, and the profession in terms of innovations.3
The workgroup recognized nursing staff preferred a step-by-step process. Each process (Inquiry, Improvement, and Innovation) begins with a focused question, such as, “Why are we doing it this way?” or “Is there a new way?” (see Supplemental Digital Content, Figure 1, available at: https://links.lww.com/JNCQ/A616). The initial question guides clinicians in deciding what type of project would best answer their clinical question or issue. The next step helps the clinician get started with instructions to identify the clinical issue, develop a goal/aim, define the problem, or identify opportunity, depending on the process.
A common thread for each process is the inclusion of a step to obtain pre-data or best evidence. With this step, the I3 Model empowers clinicians to incorporate the voice of the customer (VOC) and best evidence into practice. Obtaining VOC is a common activity for most QI projects at this organization. For example, while gathering evidence about bedside report, hospitalized Veterans were asked 4 questions such as, “Would you like to be involved in the change of shift report?” With information from the VOC, the QI team found that most Veterans wanted to be involved in bedside report and saw many benefits for this practice.
Subsequent steps, unique to Inquiry, Improvement, and Innovation, guide users through the process. Inclusive for all processes, a set of steps, illustrated by a string of squares at the right of the model, are pertinent to all studies or projects. For example, researchers cannot get started if stakeholders do not support them. This model can be used by clinicians in any setting including hospitals, clinics, community, or academia to guide their project.
The team consulted staff RNs to establish clarity and usability of the model. First, it was reviewed by several newly licensed RNs with no recommendations for change. Second, the team asked 20 RNs from 9 areas of our medical center, irrespective of experience, to answer 3 questions about the model. All RNs agreed the model was useful; they also believed it was clear and helpful in answering a clinical question. Nurses were asked if they had comments, suggestions, or advice. No changes were recommended, and comments were positive, such as, “I'll use this when informing potential users how to start a project!” and “It's easy to follow.”
Next, the EBP/QI/Research Council reviewed and endorsed the model with minimal revision. After endorsement from this council, the model was reviewed and approved by the remaining nursing-shared governance councils. Since the first EBP model was approved within the Bylaws, a hospitalwide nursing vote was required. The new model, I3 Model for Advancing Quality Patient Centered Care, was overwhelmingly approved.
Reports in the literature substantiate the need for leadership support and clinician buy-in to advance EBP and research. Endorsement by leadership is critical for an organizational culture of inquiry, improvement, and innovation.9–13 One chief nursing officer stated, “As a visionary nurse and organizational leader, I need to demonstrate the ability to advance a research agenda, especially within a clinical practice environment.”14(p11) In addition, the research agenda needs to be linked to the organization's mission.14 Other teams identified that shared decision-making is essential for change to move forward from inquiry and evidence to change and implementation.12,13,15
An implementation plan was approved by the Education & Professional Development Council. After implementation, some questions were raised, and a few minor revisions were made to the model. One change was having the arrow move directly from Practice Recommendation under Inquiry to the activity of Improvement (Supplemental Digital Content, Figure 1, available at: https://links.lww.com/JNCQ/A616). This reflects the actual practice at our medical center, where a team summarizes best evidence and makes a Practice Recommendation. This recommendation includes the change in practice with evidence and a request for a workgroup, either a new group or the continuation of the current group, to implement the change through the QI process. Many published EBP project models include the practice change as part of the EBP project process. With the clearly marked move to QI after a Practice Recommendation, clinicians are prompted to consider the context or environment in which the practice is to be implemented. This reflects the blending of EBP with QI.5 This also indicates the interdependence of EBP, QI, and research, which do not occur in silos.2
To assist clinicians with understanding and using the I3 Model, a companion document of Frequently Asked Questions (FAQs) was developed and linked to the model (Supplemental Digital Content, Figure 2, available at: https://links.lww.com/JNCQ/A617). This document, FAQs about the I3 Model for Advancing Quality Patient Centered Care, answers basic questions about the model. Information includes why the model is needed, who can use it, and how to get started.
The final version of the I3 Model is posted on our medical center intranet on 3 web pages titled: Evidence Based Practice, Quality Improvement, and Research. The I3 Model, as the guiding document, is the first item in each web page's information section. For example, in the QI Information section on the web page (Supplemental Digital Content, Figure 3, available at: https://links.lww.com/JNCQ/A618), the nurse is guided in a sequence of documents to learn more about QI through: the I3 Model; a comparison of EBP, QI, and Research; and an overview of the QI process.
The model is incorporated into the EBP and QI curriculum of our nurse residency/transition-to-practice program; it also introduces all EBP, QI, and research education sessions. The model was shared with nursing staff using several methods: via announcements at all nursing-shared governance councils; with an article and image of the model in the internal nursing newsletter; and a presentation at a Nursing Grand Rounds. Most recently, EBP education has been added to the VA Nurse Manager Academy for new nurse managers and the I3 Model guides the presentation.
The I3 Model for Advancing Quality Patient Centered Care has been in place for over 1 year. Questions raised by nursing staff were addressed in the FAQs and in some of the web-based tutorials. The flow between the steps in the I3 Model was reviewed to ensure it reflects the current process for making practice recommendations or QIs. The final phase of reviewing the I3 Model is in process to examine the innovation algorithm and develop education about the process of innovation.
The workgroup evaluated how the model was used in guiding projects and in teaching EBP, QI, and research content. The I3 Model guides nurse residents' EBP projects as well as illustrates the process for QI projects and research studies. For example, nurse residents and staff RNs provided best evidence and a practice recommendation for bedside report involving the patient. This practice was fully implemented for all inpatients and was sustained using audit/feedback with positive patient responses. Another issue was the use of disinfection caps with peripheral IV tubing; the vendor representative recommended using the cap on all IV tubing and on all ports. Nurses questioned the evidence for this practice from a number of perspectives involving cost and breaking the system when a tubing port was not needed. The team summarized the meager evidence related to peripheral IV tubing; after lengthy Nursing Practice Council discussion, a practice change was agreed on based on the evidence and embedded into the IV policy.
The EBP/QI/Research Council includes the I3 Model on all agendas to advance a culture of inquiry and innovation. For example, council agenda topic headings mirror the model and are listed accordingly: research, EBP, QI, and innovation. The model is used as a guide when beginning all projects; it is reviewed prior to project implementation to ensure that all aspects of planning are addressed. The EBP coordinator and nurse scientist use the model as a framework to guide education sessions for the council and for web-based tutorials about research, EBP, QI, and innovation.
Sharing information with colleagues is an important competency identified in ANA standards and is often measured as an outcome.1,16,17 Dissemination is a clearly identified step in the I3 Model for all processes: Inquiry, Improvement, and Innovation. The nurse scientist tracks presentations and publications and has developed web-based tutorials and experiential workshops; going forward, this outcome will be measured as it relates to the new model.
Active support by leadership is essential to a clinician's participation in creative and dynamic teams that advance innovation and EBP.18 Specific examples of organizational support for nursing staff participation in EBP and research including budgeting for EBP and research councils, nurse researchers employed by the organization, a nursing director on the EBP or research council, EBP mentors and champions, EBP projects by nurse residents, paid time for education as well as participating on EBP and research teams, computers and literature databases for evidence searching, EBP and research are expected as part of a clinician position, and a positive attitude toward EBP by supervisors.11–13,19–24
Nurses need to feel supported in questioning current practice and have the freedom and ability to make care decisions at the clinical and organizational level. The I3 Model supports this autonomy, but strong leadership, education, and mentors are also necessary.10,19 Prior to 1996, EBP content was not part of an academic nursing curriculum, so creative strategies are necessary to educate leaders and staff nurses as well as support inquiry and improvement efforts. Mentors provide project facilitation and support to teams, as they work to answer practice questions and implement changes to improve patient care.
The I3 Model guides the nurse in a process of inquiry or improvement while supporting a culture of innovation in professional nursing practice. It demonstrates the linkages and interdependence among these professional performance competencies. The model is used for teaching EBP, QI, and research, and to steer relevant projects. The model empowers staff to question current practice and lead evidence-based change. Having a guide with these steps easily available facilitates clinical nurses to participate in or lead such projects.
Although this article focuses on nurses, the model can be used by anyone who would use the steps for a research study, an EBP or QI project, or an innovation. Many teams are interprofessional; thus, this is a useful tool as it can serve as a resource for any clinician. All health care staff can support research studies, participate in EBP and improvement projects, and think of innovative solutions.
1. American Nurses Association. Nursing: Scope and Standards of Practice. 3rd ed. Silver Spring, MD: American Nurses Association; 2015.
2. Carter EJ, Mastro K, Vose C, Rivera R, Larson EL. Clarifying the conundrum: evidence-based practice, quality improvement, or research
? J Nurs Admin. 2017;47(5):266–270.
3. American Nurses Credentialing Center. Magnet Recognition Program® Magnet Model. https://www.nursingworld.org/organizational-programs/magnet/magnet-model/
Accessed February 19, 2019.
4. Talsma A, McLaughlin M, Bathish M, Sirihorachai R, Kuttner R. The quality, implementation, and evaluation model: a clinical practice model for sustainable interventions. West J Nurs Res. 2014:36(7):929–946.
5. Halm MA, Alway A, Bunn S, et al. Intersecting evidence-based practice with a lean improvement model. J Nurs Care Qual. 2018;33(4):309–315.
6. Levin RF, Keefer JM, Marren J, Vetter M, Lauder B, Sobolewski S. Evidence-based practice improvement: merging 2 paradigms. J Nurs Care Qual. 2010;25(2):117–126.
7. Yoder-Wise PS. The unintended consequences of innovation. J Contin Educ Nurs. 2013;44(1):7.
8. Gawlinski A, Rutledge D. Selecting a model for evidence-based practice changes: a practical approach. AACN Adv Crit Care. 2008;19(3):291–300.
9. Aasekjaer K, Waehle HV, Ciliska D, Nordtvedt MW, Hjälmhult E. Management involvement—a decisive condition when implementing evidence-based practice. Worldviews Evid Based Nurs. 2016;13(1):32–41.
10. Echevarria IM, Teegarden G, Kling J. Promoting a culture of evidence-based practice through a change request process. Nurse Lead. 2017;15(4):281–285.
11. Kelly KP, Turner A, Gabel Speroni K, McLaughlin MK, Guzzetta CE. National survey of hospital nursing research
, part 2: facilitators and hindrances. J Nurs Adm. 2013;43(1):18–23.
12. McKeever S, Twomey B, Hawley M, Lima S, Kinney S, Newall F. Engaging a nursing workforce in evidence-based practice: introduction of a nursing clinical effectiveness committee. Worldviews Evid Based Nurs. 2016;13(1):85–88.
13. Wilson B, Kelly L, Reifsnider E, Pipe T, Brumfield V. Creative approaches to increasing hospital-based nursing research
. J Nurs Adm. 2013;43(2):80–88.
14. Erickson JI. Creating a culture of inquiry within a healthcare medical center. In: Erickson JI, Ditomassi M, Jones DA, eds. Fostering a Research
-Intensive Organization: An Interdisciplinary Approach for Nurses From Massachusetts General Hospital. Indianapolis, IN: Sigma Theta Tau International; 2015:1–15.
15. Fisher CA, Hubbard ML. Extending evidence through shared governance. Nurs Manage. 2015;46(7):16–18.
16. Jones DA. Promoting nursing research
through the Yvonne L. Munn Center. In: Erickson JI, Ditomassi M, Jones DA, eds. Fostering a Research
-Intensive Organization: An Interdisciplinary Approach for Nurses From Massachusetts General Hospital. Indianapolis, IN: Sigma Theta Tau International; 2015:39–74.
17. Kooker BM, Latimer R, Mark DD. Successfully coaching nursing staff to publish outcomes. J Nurs Adm. 2015;45(12):636–641.
18. Malloch K, Porter-O'Grady T. Innovation and evidence: a partnership in advancing best practice and high quality care. In: Melnyk BM, Fineout-Overholt E, eds. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2015:255–273.
19. Carter EJ, Rivera RR, Gallagher KA, Cato KD. Targeted interventions to advance a culture of inquiry at a large, multicampus hospital among nurses. J Nurs Adm. 2018;48(1):18–24.
20. Cline GJ, Burger KJ, Amankwah EK, Goldenberg NA, Ghazarian SR. Promoting the utilization of science in healthcare (PUSH) project: a description of the perceived barriers and facilitators to research
utilization among pediatric nurses. J Nurses Prof Develop. 2017;33(3):113–119.
21. Melnyk BM, Fineout-Overholt E, Giggleman M, Choy K. A Test of the ARCC© model improves implementation of evidence-based practice, healthcare culture, and patient outcomes. Worldviews Evid Based Nurs. 2017;14(1):5–9.
22. Royer HR, Crary P, Fayram E, Heidrich SM. Five-year program evaluation of an evidence-based practice scholars program. J Contin Educ Nurs. 2018;49(12):547–554.
23. Wang MY, Kao CC, Lin CF. The EPCOR model: a model for promoting the successful implementation of evidence-based nursing in hospital-based settings. J Nurs Res. 2015;23(1):15–24.
24. White K, Dang D. Creating a supportive EBP environment. In: Dang D, Dearholt SL, eds. Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. 3rd ed. Indianapolis, IN: Sigma Theta Tau International; 2018:187–218.