EBP Change Process form

Week 6 Assignment:  EBP Change Process form

ACE Star Model of Knowledge Transformation

Follow Nurse Daniel as your process mentor in the weekly Illustration section of the lesson. Please do not use any of the Nurse Daniel information for your own topic, nursing intervention, or change project.  Nurse Daniel serves as an example only to illustrate the change process.


Name: _____________________


Star Point 1:  Discovery (Identify topic and practice issue)

Identify the topic and the nursing practice issue related to this topic. (This MUST involve a nursing practice issue EBP Change Process form.)


Briefly describe your rationale for your topic selection. Include the scope of the issue/problem EBP Change Process form.





Star Point 2:  Summary (Evidence to support need for a change)

Describe the practice problem in your own words and formulate your PICOT question.



List the systematic review chosen from the CCN Library databases. Type the complete APA reference for the systematic review selected.





List and briefly describe other sources used for data and information. List any other optional scholarly source used as a supplement to the systematic review in APA format EBP Change Process form.



Briefly summarize the main findings (in your own words) from the systematic review and the strength of the evidence.




Outline one or two evidence-based solutions you will consider for the trial project.







Star Point 3:  Translation (Action Plan)

Identify care standards, practice guidelines, or protocols that may be in place to support your intervention planning (These may come from your organization or from the other sources listed in your Summary section in Star Point 2).





List your stakeholders (by title and not names; include yourself) and describe their roles and responsibilities in the change process (no more than 5).





What specifically is your nursing role in the change process? Other nursing roles?



List your stakeholders by position titles (charge nurse, pharmacist, etc.).Why are the members chosen (stakeholders) important to your project? EBP Change Process form





What type of cost analysis will be needed prior to a trial?  Who needs to be involved with this?







Star Point 4: (Implementation)

Describe the process for gaining permission to plan and begin a trial.  Is there a specific group, committee, or nurse leader involved?




Describe the plan for educating the staff about the change process trial and how they will be impacted or asked to participate.







Outline the implementation timeline for the change process (start time/end time, what steps are to occur along the timeline).





List the measurable outcomes based on the PICOT.  How will these be measured? EBP Change Process form



What forms, if any, might be used for recording purposes during the pilot change process. Describe.


What resources are available to staff (include yourself) during the change pilot?


Will there be meetings of certain stakeholders throughout the trial?  If so, who and when will they meet?







Star Point 5: (Evaluation)

How will you report the outcomes of the trial?



What would be the next steps for the use of the change process information? EBP Change Process form






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