on the manufacturer’s recommendations because this may not be very strong
evidence. Many associations define beforehand what level of evidence to
require when identifying evidence-based standards, guidelines, or recom-
mendations. For instance, the American Association of Critical-Care Nurses
defines levels of evidence as follows:
» Level A: Evidence includes meta-analysis of multiple controlled studies or
systematic review of RCTs with results that consistently support a specific
action, intervention, or treatment.
» Level B: Evidence includes well-designed controlled studies, both random-
ized and nonrandomized, with results that consistently support a specific
action, intervention, or treatment.
» Level C: Recommendations are based on qualitative studies; systematic
reviews of qualitative, descriptive, or correlational studies; integrative
reviews; or randomized controlled trials with inconsistent results.
» Level D: Recommendations are based on peer-reviewed professional or-
ganizational standards, with clinical studies to support recommendations.
» Level E: Recommendations are based on theory-based evidence from
expert opinion or multiple case reports, and level M are manufacturer’s
recommendations only.
» Level M: Manufacturer’s recommendations only (Peterson et al., 2014).
By the end of this third phase in the Stetler model, a decision is made about
whether to use the evidence to guide practice.
In the fourth phase, the challenge is to translate or apply the research in the
practice setting (Stetler, 2001). For many organizations this may be easier said
than done. For example, consider the difficulties encountered when integrat-
ing into practice knowledge about discharge planning for patients with heart
failure (HF). While many nurses understand the concept of discharge planning
and the practice of beginning discharge planning upon admission, the abil-
ity to develop processes that support discharge are lacking as demonstrated
by all-cause readmissions of 10–50% for this patient population (Joynt & Jha,
2011). This illustrates how difficult it can be to adopt innovations in a social
system. When applying research to practice, it is important for nurses to think
carefully about how the evidence will be communicated, disseminated, and
applied. In this example, relevant questions to consider include who will be
responsible for implementing HF guidelines into practice, what resources
(time, money, personnel) are available to operate the program, and how will
the success of the program be measured? Change is at the heart of this phase.
In the fifth and final phase of the Stetler model (2001), nurses evaluate the
outcomes of the change in practice. Continuing with the example of HF discharge
planning, questions from the fourth phase provide a means for evaluating how430 CHAPTER 16 Transitioning Evidence to Practice