The science and art of holistic nursing honor an individual’s subjective experience about health, health beliefs, and values and develop therapeutic partnerships with individuals, families, and communities that are grounded in nursing knowledge, theories, research expertise, intuition, and creativity.¹ Evidence-based practice (EBP) is the conscientious use of the best available evidence combined with the clinician’s expertise and judgment and the patient’s preferences and values to arrive at the best decision that leads to high-quality outcomes.²,³ Research has shown that when these conceptual components of EBP are integrated within a context of caring (Figure 35-1), components that are consonant with the science and art of holistic nursing, they lead to the best clinical decision making, as well as best outcomes for patients, families, communities, and populations.⁴

Knowledge translation or the use of research evidence to improve clinical outcomes is not a 21st-century phenomenon. Neither is the difficulty with or resistance to the application of new scientific knowledge to practice. For example, the usefulness of citrus juice for the treatment of scurvy was noted in the 16th century, although it would be another 100 years for these findings to be put into practice by the British Admiralty.⁵ Another example is that of the work of Ignatz Semmelweis, who recognized that obstetricians were carrying the contagion for puerperal fever from the morgue to the delivery room.⁵ His recommendation to reduce maternal mortality by hand-washing was rejected by the Viennese medical society in the mid-18th century with a mantra used today that contradicts evidence to practice, “Because we’ve always done it that way.”

As the disease transmission theory was being rejected by practicing physicians, Florence Nightingale, as a nurse in the Crimean War
(1853-1856), found that washing hands between patients along with other public health measures reduced morbidity and mortality among the soldiers.⁶ Recognized as the first nurse to conduct and use research, Nightingale showed that the quality of care can be improved through sanitary conditions, careful data collection, and critical thinking.⁷ More than 150 years later, Nightingale’s insight into the need for research laid the groundwork for evidence-based practice in holistic nursing when she wrote:

For 75 years, research has been recognized as important for improving nursing education and practice. Sigma Theta Tau International (STTI), the only nursing honor society, offered the first nursing research grant in 1936. Thirty-five years later, research became a required course in baccalaureate nursing programs. As research skills and knowledge became a requirement for the professional nurse, concern for use of research findings in practice and strategies to increase research utilization became a top priority. In the mid-1970s, federal grants supported the Western Interstate Commission on Higher Education (WICHE) Regional Program for Nursing Research Development, the Conduct and Utilization of Research in Nursing (CURN), and Nursing Child Assessment Satellite Training (NCAST).⁹ The Regional Program for Nursing Research Development was conducted in the 13 western states to teach practicing nurses how to identify researchable practice issues, critique the current research literature, initiate and lead practice changes, and evaluate their outcomes.¹⁰ The CURN project was designed to develop practice protocols based on the synthesis of the best available science. Ten research-based protocols were completed and evaluated for their applicability.¹¹ NCAST, based on the early findings of Dr. Kathryn Barnard, focused on teaching cues to maternal-child interaction to nurses in Washington using the new satellite system. Stetler and Marram, as young doctoral students, published the original version of their research utilization model for use by advanced practice nurses as leaders and mentors for changing clinical nursing practice.¹² An early meta-analysis showed that patients who received research-based interventions experienced outcomes that were 28% better than patients receiving routine care.¹³ These findings strongly supported the efforts to increase the use of research by direct care providers.

Despite this foundation of nursing knowledge built on practice based on evidence, Ketefian concluded that nurses who conducted research and nurses who practiced at the bedsides lived in separate “subcultures” and that to narrow this gap, researchers must publish research findings in a format that practicing nurses could read and use.¹⁴ It was apparent that even though individual nurses learned and supported the concepts of research utilization, there were many barriers to actually implementing and maintaining research-based practice changes.¹⁵,¹⁶,¹⁷

Further studies exploring barriers to and facilitators of research use were conducted in the 1980s, the 1990s, and continue today.⁹,¹⁸ Funk and colleagues, using the concepts within Rogers’ Diffusion of Innovation model, explored the individual and the organizational challenges to the use of research in the early 1990s. They reported barriers associated with the characteristics of the adopter, the organization, the innovation itself, and the communication and dissemination of the findings. These findings encouraged the development of models and programs addressing organizational and dissemination barriers. Using the Dissemination Model, Funk et al. held a series of national conferences on use of research in practice.¹⁹ Cronenwett implemented research utilization conferences at Dartmouth-Hitchcock Hospitals that focused on integrative reviews for promoting research use by direct care nurses.²⁰ An early model for addressing organizational challenges was implemented in a rural Iowa hospital that was later adapted at the University of Iowa Hospitals and Clinics.²¹ Four educational videos on research utilization for direct care nurses were developed to support the Organizational Process Research
Utilization Model.²²,²³,²⁴,²⁵ Titler and colleagues expanded on this organizational model in their development of the Iowa Model for Research in Practice.²⁶ Rutledge and Donaldson received federal funding to develop and implement the Orange County Research Utilization in Nursing (OCRUN) project, focusing on building organizational capacity as a tool for increasing research utilization.²⁷

As it became evident that much of nursing care was based on best practice and the methodology for and emphasis on quality improvement was increasing, more forms of evidence began to be used as the basis for practice. In the early 1990s, Sackett and colleagues coined the term evidencebased medicine to add credibility to internal quality improvement data and common practices that were providing good patient outcomes.²⁸ Evidence-based practice soon became the term used to describe practices by all healthcare professionals. One of the early interdisciplinary models for evidence-based practice was developed at the University of Colorado to provide the framework for quality improvement activities.²⁹ From the mid-1990s to the present, a number of new quality improvement and evidence-based practice models and frameworks have been developed.

From these early underpinnings, a variety of conceptual models has emerged for EBP, including models that focus on the EBP process for individual clinicians, such as the model of DiCenso and colleagues,³⁰ the Stetler Model,³¹ and the Clinical Scholar Model.³² Several models focus on system-wide implementation of EBP, including the Iowa Model,³³ the Promoting Action on Research Implementation in Health Services (PARIHS) Model,³⁴ and the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model.⁴ Although these models are useful in conceptually guiding the implementation of EBP for individuals and within systems, there is a pressing need for further testing to support them empirically. Exemplars for the individual system-wide models are described in this chapter.