A Test of the ARCC⃝C Model Improves Implementation of Evidence-Based Practice, Healthcare Culture, and Patient Outcomes

A Test of the ARCC⃝C Model Improves
Implementation of Evidence-Based Practice,
Healthcare Culture, and Patient Outcomes
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FAANP, FNAP, FAAN •
Ellen Fineout-Overholt, RN, PhD, FNAP, FAAN • Martha Giggleman, RN, DNP,
NEA-BC • Katie Choy, RN, DNP, CNS, NEA-BC
Keywords
ARCC,
evidence-based
practice,
organizational
culture,
patient outcomes
ABSTRACT
Background: Although several models of evidence-based practice (EBP) exist, there is a paucity
of studies that have been conducted to evaluate their implementation in healthcare settings.
Aim: The purpose of this study was to examine the impact of the Advancing Research and
Clinical practice through close Collaboration (ARCC) Model on organizational culture, clinicians’
EBP beliefs and EBP implementation, and patient outcomes at one healthcare system in the
western United States.
Design: A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up
immediately following full implementation of the ARCC Model.
Setting and Sample: The study was conducted at a 341-bed acute care hospital in the western
region of the United States. The sample consisted of 58 interprofessional healthcare professionals.
Methods: The ARCC Model was implemented in a sequential format over 12 months with the
key strategy of preparing a critical mass of EBP mentors for the healthcare system. Healthcare
professionals’ EBP beliefs, EBP implementation, and organizational culture were measured with
valid and reliable instruments. Patient outcomes were collected in aggregate from the hospital’s
medical records.
Results: Findings indicated significant increases in clinicians’ EBP beliefs and EBP implementation
along with positive movement toward an organizational EBP culture. Study findings also indicated
substantial improvements in several patient outcomes.
Linking Evidence to Action: Implementation of the ARCC Model in healthcare systems can enhance clinicians’ beliefs and implementation of evidence-based care, improve patient outcomes,
and move organizational culture toward EBP.
INTRODUCTION AND BACKGROUND
It is well known that evidence-based practice (EBP) improves
healthcare quality, safety, and patient outcomes as well as fosters clinicians’ active engagement in their practices. Nurses
who use an evidence-based approach to care and practice in
cultures that support EBP are more empowered as they are
able to make a difference in the care of their patients. Although
the positive impact of EBP has been demonstrated through
multiple studies, major barriers exist that prevent EBP from
becoming the standard of care throughout the world. These
barriers include (a) inadequate EBP knowledge and skills of
clinicians, (b) misperceptions that EBP takes too much time,
(c) organizational culture and politics, (d) lack of support from
nurse leaders and managers, and (e) inadequate resources and
investment in EBP (Jun, Kovner, & Stimpfel, 2016; Melnyk
et al., 2016; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Aside from equipping clinicians with the knowledge and skills needed to attain the EBP competencies and consistently implement evidence-based care, findings from studies
have indicated that clinician access to EBP mentors can play a
key role in their implementation of EBP and the development
of organizational cultures that support the delivery of evidencebased care (Fineout-Overholt & Melnyk, 2015; Melnyk, 2007).
Although several EBP models exist, most are process models that outline the steps of EBP or the sequence of conducting
an EBP project. EBP process models include the Johns Hopkins
Nursing Evidence-Based Practice Model (Dearholt & Dang,
2012), the Iowa Model of Evidence-Based Practice to Promote
Quality Care (Titler et al., 2001), the Model for Evidence-Based
Practice Change (Rosswurm & Larabee, 1999), and the ACE
Star Model of Knowledge Transformation (Stevens, 2012).
Unlike EBP process models, the Advancing Research and
Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. 5
⃝C 2016 Sigma Theta Tau International
A Test of the ARCC⃝C Model Improves Implementation of Evidence-Based Practice
Figure 1. The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model.
Clinical practice through close Collaboration (ARCC) Model is
a system-wide model to advance and sustain EBP in healthcare
systems (see Figure 1). The first step in implementing the
ARCC Model is an organizational assessment of the current
EBP culture in order to identify strengths and major barriers
to EBP in the healthcare system so that strategies can be
implemented to remove those barriers. At the core of the
ARCC Model is a critical mass of EBP mentors who, through
intentional strategic initiatives, assist point of care clinicians
in enhancing their beliefs about the value of EBP and their
confidence in implementing it. As a result, ARCC contends
that heightened EBP beliefs in clinicians result in greater
implementation of evidence-based care, which ultimately
leads to higher job satisfaction, less staff turnover, and
improved patient outcomes. Several studies now support the
relationships among key constructs in the ARCC Model (Levin,
Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk,
2012; Melnyk & Fineout-Overholt, 2002; Melnyk et al., 2004;
Melnyk, Fineout-Overholt, & Mays, 2008; Melnyk, FineoutOverholt, Giggleman, & Cruz, 2010; Wallen et al., 2010).
AIM
The purpose of this study was to examine the impact of the
ARCC Model on organizational culture, clinicians’ EBP beliefs
and EBP implementation, and patient outcomes at one healthcare system in the western region of the United States.
DESIGN
A pre-test, post-test longitudinal pre-experimental study was
conducted with follow-up immediately following full implementation of the ARCC Model. Institutional Review Board approval was obtained from the authors’ institution as well as the
organization’s research subject review board.
SETTING AND SAMPLE
This study was conducted at Washington Hospital Healthcare
System, a 341-bed acute care hospital in the San Francisco
bay area. The sample consisted of 58 interprofessional healthcare professionals, with complete follow-up data for 45 participants. Participants were point of care nurses, administrators,
nurse managers, clinical nurse specialists, respiratory therapists, occupational therapists, physical therapists, dieticians,
social workers, and pharmacists. Although physician champions participated in the projects, they were not part of the
data collection. Only the project teams participated in data
collection.
METHODS
The ARCC Model was implemented in a sequential format
over 12 months with the key strategy of preparing a critical
mass of EBP mentors for the healthcare system. Intensive EBP
workshops were first provided to the 58 participants in order
to enhance their knowledge and skills in the seven steps of
6 Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9.
⃝C 2016 Sigma Theta Tau International
Original Article
Table 1. Examples of PICOT Questions Formulated
by the EBP Teams
! In ventilated intensive care unit patients (P), how does early
ambulation (I) compared to routinely scheduled ambulation
(C) affect length of stay and episodes of ventilator
associated pneumonia while in the intensive care unit (T) ! In congestive heart failure patients (P), how does
comprehensive pre-discharge education (I) compared to
standard pre-discharge education (C), affect readmission
rates to the hospital (O)?
EBP. In addition, content and skills building in the workshops
focused on how to facilitate individual behavior change of clinicians to implement EBP and how to facilitate an EBP organizational culture. The 58 participants were divided into working
teams of six to eight members who were to collaborate on
an EBP change project to improve patient outcomes within
the hospital. Each team was then charged with formulating
a PICOT (Patient population, Intervention or Issue of interest, Comparison intervention or issue, Outcome, and Time for
the intervention to achieve the outcome if relevant) question
about an important clinical issue, systematically searching for
the best evidence, and critically appraising and synthesizing
the evidence culminating in a recommendation for practice.
See Table 1 for examples of PICOT questions developed by
the teams. Strategic plans were then developed by the interprofessional EBP mentor teams to implement and evaluate the
impact of the EBP changes on clinical outcomes within their
organization. After implementation and evaluation of the practice changes were completed, the final step for the teams was
to submit their projects for presentation at local, regional, or
national conferences to disseminate their successes to others
within the healthcare community.
OUTCOMES
Study variables were measured with the following valid and reliable instruments. The Evidence-Based Practice Beliefs (EBPB)
Scale Melnyk & Fineout-Overholt, 2003a) measured clinicians’
beliefs about EBP and their ability to implement it. The 16-item
Likert scale has established face, content, and construct validity with internal consistency reliabilities greater than .85 across
multiple studies (Melnyk et al., 2008). Responses on the scale
range from 1 (strongly disagree) to 5 (strongly agree). Examples
of items on the scale include (a) I am clear about the steps in
EBP, (b) I am sure that I can implement EBP, and (c) I am sure
that evidence-based guidelines can improve care.
The Evidence-Based Practice Implementation (EBPI) Scale
measured delivery of evidence-based care (Melnyk & FineoutOverholt, 2003b). Participants respond to each of the 18 Likert
scale items on the EBPI by answering how often in the last
eight weeks they have performed certain EBP activities, such as
(a) generated a PICOT question about my practice, (b) used evidence to change my clinical practice, (c) evaluated the outcomes
of a practice change, and (d) shared the outcome data collected
with colleagues. The EBPI has established face, content, and
construct validity as well as internal consistency reliabilities
greater than .85 across multiple studies (Melnyk et al., 2008).
The Organizational Culture and Readiness Scale for
System-Wide Integration of Evidence-Based Practice (OCRSIEP) measured the organization’s culture and its readiness
for system-wide EBP (Fineout-Overholt & Melnyk, 2006). This
instrument contains 26 Likert scale items that identify a description of the existing support in the current culture for EBP,
which offers insight into the strengths and opportunities for
fostering evidence-based care within a healthcare system. The
OCRSIEP scale has established face and content validity along
with excellent internal consistency reliability of greater than .85
across multiple samples (Melnyk & Fineout-Overholt, 2015).
Examples of items on the OCRSIEP include the following:
(a) To what extent is EBP clearly described as central to the
mission and philosophy of your institution? (b) To what extent
do you believe that EBP is practiced in your organization? And
(c) To what extent is the nursing staff with whom you work
committed to EBP?
Patient Outcomes
Aggregate data were gathered by the teams, including data
from the hospital’s medical records (e.g., number of cases of
ventilator associated pneumonia, hospital readmission rates)
before and after implementation of the ARCC Model to evaluate
relevant patient outcomes as results of the EBP projects.
Analyses
T tests and effect sizes were calculated for study variables to
evaluate pre-to-post differences. A p value of .05 was set for
statistical significance.
RESULTS
Findings indicated that the clinicians’ EBP beliefs, EBP implementation, and movement of organizational culture toward
EBP significantly increased over the 12-month project. Specifically, clinicians’ EBP beliefs (n = 45) increased significantly
from baseline (M = 60.7, SD = 7.6) to follow-up (M = 64.9,
SD = 6.7; t = 4.2; p = .00; effect size = .62, which is a medium
to large positive effect for ARCC). EBP implementation also
significantly increased from baseline (M = 17.8, SD = 10.3) to
follow-up (M = 51.9, SD = 16.8; t = 12.9; p = .00; effect size =
2.3, indicating a large positive effect for ARCC). In addition,
organizational culture and readiness for EBP increased significantly from baseline (M = 80.9; SD = 90.8) to follow-up (M =
90.8; SD = 14.7; t = 3.9; p = .00; effect size = .70, which
is a medium to large positive effect for ARCC). In addition,
as a result of implementing the ARCC Model, evidence-based
interventions improved key patient outcomes (see Table 2).
Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. 7
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A Test of the ARCC⃝C Model Improves Implementation of Evidence-Based Practice
Table 2. Project Outcomes From Implementation
of the EBP Changes
! A practice change to early ambulation in the ICU led to a 2.7
reduction in ventilator days (11.6–8.9) and no ventilator
associated pneumonia. ! With the implementation of a pressure ulcer prevention
nursing standardized procedure on a medical-surgical unit,
the acquired pressure ulcer rate was significantly decreased
from 6.07% to 0.62% 1 year later. ! Comprehensive education of congestive heart failure
patients led to a 14.7% reduction in hospital readmissions. ! After implementation of family centered care on the
pediatric unit, 75% of parents perceived the overall quality
of care as excellent compared to 22% pre-implementation. ! The percentage of mothers not supplementing their breast
milk with formula increased from 61.7% to 71.1% after the
evidence-based baby friendly hospital initiative was
implemented. ! After implementation of a nurse-initiated pain protocol in
the emergency room (ER), wait time for pain medication
decreased from 46 minutes to 13 minutes and length of stay
in the ER also decreased from 120 minutes to 91 minutes.
DISCUSSION
Findings support the positive impact of implementing the
ARCC Model on clinicians’ EBP beliefs and a dramatic increase in EBP implementation in those who participated in the
project. Organizational culture at the hospital shifted greatly
toward system-wide EBP. Most important, as a result of implementing ARCC, there were multiple improvements in patient
outcomes.
The establishment of a cadre of EBP mentors is central to building an organizational culture of EBP and implementing evidence-based care. The EBP mentors in this
study garnered the knowledge and skills needed to successfully
implement and evaluate EBP changes within the hospital as
well as to work with their colleagues in creating an EBP culture
in which to deliver high-quality evidence-based care. These
findings affirm that culture eats strategy and assists clinicians in making EBP the social norm within a system (Melnyk, 2016b). Without a culture and environment that supports
EBP, high-quality evidence-based care will not sustain (Melnyk,
2016a).
Numerous healthcare systems and hospitals throughout the
United States and globe have implemented the ARCC Model in
their efforts to build and sustain an EBP culture and environment in their organizations. As a part of building this culture,
position descriptions have been created or changed to include
responsibilities as an EBP mentor. For example, at The Ohio
State University Wexner Medical Center, the primary responsibility of the clinical nurse specialists throughout the healthcare
system is to serve as EBP mentors for point of care staff in
improving patient outcomes. Part of this role is ensuring
compliance with the EBP competencies for advanced practice
nurses (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2016;
Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2015).
Research is needed to further confirm the advantages of
using particular EBP models in real-world practice settings,
including how implementation of these models impact both
clinician, leader and patient outcomes (Dang et al., 2015). Comparative effectiveness studies that evaluate the benefits of individual models as well as combining models also are needed.
Those hospitals and systems who use an EBP model to guide
implementation of evidence-based care should document their
experiences and outcomes in order to better understand the
model’s usefulness in facilitating EBP and share this important information with others who might use the model (Graham, Tetroe, & KT Theories Research Group, 2007). Return
on investment by including cost outcomes also should be evaluated. WVN
LINKING EVIDENCE TO ACTION
! The ARCC Model is an evidence-based systemwide model for advancing the implementation and
sustainability of EBP.
! A key strategy in the ARCC model is the development of a critical mass of EBP mentors who assist
point of care clinicians in the consistent implementation of evidence-based care.
! Use of ARCC EBP mentors enhances the EBP beliefs and EBP implementation of clinicians and
strengthens the EBP culture of an organization.
! An organizational culture of EBP is central to supporting sustainable high quality evidence-based
care.
! Implementation of the ARCC Model can substantially improve patient outcomes.
Author information
Bernadette Mazurek Melnyk, Associate Vice President for
Health Promotion, University Chief Wellness Officer, Dean
and Professor, College of Nursing, Professor of Pediatrics &
Psychiatry, and College of Medicine, The Ohio State University, Columbus, Ohio; Ellen Fineout-Overholt, Mary Coulter
Dowdy Distinguished Professor of Nursing, College of Nursing & Health Sciences University of Texas at Tyler, Tyler, Texas;
Martha Giggleman, Healthcare Consultant & Advocate Livermore, California; Katie Choy, Senior Director, Nursing Practice
and Education, Washington Hospital Healthcare System, Fremont, California
8 Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9.
⃝C 2016 Sigma Theta Tau International
Original Article
Address correspondence to Dr. Bernadette Mazurek Melnyk,
The Ohio State University, 145 Newton Hall, 1585 Neil Avenue,
Columbus, OH 43210; Melnyk.15@osu.edu
Accepted 16 September 2016
Copyright ⃝C 2017, Sigma Theta Tau International
References
Dang, D., Melnyk, B. M., Fineout-Overholt, E., Ciliska, D., DiCenso, A., Cullen, L., . . . & Stevens, R. K. (2015). Models to
guide implementation and sustainability of evidence-based practice. In B. M. Melnyk & E. Fineout-Overholt (Eds.) Evidence-based
practice in nursing & healthcare. A guide to best practice (3rd ed.,
pp. 274–315). Philadelphia, PA: Wolters Kluwer.
Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidencebased practice model and guidelines (2nd ed.). Indianapolis, IN:
Sigma Theta Tau International.
Fineout-Overholt, E., & Melnyk, B. M. (2015). ARCC evidencebased practice mentors: The key to sustaining evidence-based
practice. In B. M. Melnyk & E. Fineout-Overholt (Eds.) Evidencebased practice in nursing & healthcare. A guide to best practice (3rd
ed., pp. 376–385). Philadelphia, PA: Wolters Kluwer.
Fineout-Overholt, E., & Melnyk, B. M. (2006). Organizational culture and readiness scale for system-wide integration of evidence-based
practice. Gilbert, AZ: ARCC, llc.
Graham, I. D., & Tetroe, J. & the KT Theories Research Group.
(2007). Some theoretical underpinnings of knowledge translation. Academic Emergency Medicine, 14(11), 936–941.
Jun, J., Kovner, C. T., & Stimpfel, A. W. (2016). Barriers and
facilitators of nurses’ use of clinical practice guidelines: An
integrative review. International Journal of Nursing Studies, 60,
54–68.
Levin, R. F., Fineout-Overholt, E., Melnyk, B. M., Barnes, M., &
Vetter, M. J. (2011). Fostering evidence-based practice to improve
nurse and cost outcomes in a community health setting: A pilot
test of the advancing research and clinical practice through close
collaboration model. Nursing Administration Quarterly, 35(1), 21–
33.
Melnyk, B. M. (2007). The evidence-based practice mentor: A
promising strategy for implementing and sustaining EBP in
healthcare systems. Worldviews on Evidence-Based Nursing, 4(3),
123–125.
Melnyk, B. M. (2012). Achieving a high-reliability organization
through implementation of the ARCC model for system wide
sustainability of evidence-based practice. Nursing Administration
Quarterly, 36(2), 127–135.
Melnyk, B. M. (2016a). An urgent call to action for nurse leaders to establish sustainable evidence-based practice cultures and
implement evidence-based interventions to improve healthcare
quality. Worldviews on Evidence-Based Nursing, 13(1), 3–5.
Melnyk, B. M. (2016b). Culture eats strategy every time: What
works in building and sustaining an evidence-based practice culture in healthcare systems. Worldviews on Evidence-Based Nursing, 13(2), 99–101.
Melnyk, B. M., & Fineout-Overholt, E. (2002). Putting research
into practice. Reflections on Nursing Leadership, 28(2), 22–25.
Melnyk, B. M., & Fineout-Overholt, E. (2003a). Evidence-based practice beliefs scale. Gilbert, AZ: ARCC Publishing.
Melnyk, B. M., & Fineout-Overholt, E. (2003b). Evidence-based practice implementation scale(3rd ed.). Gilbert, AZ: ARCC Publishing.
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia,
PA: Lippincott, Williams & Wilkins.
Melnyk, B. M., Fineout-Overholt, E., Fischbeck Feinstein, N., Li,
H., Small, L., Wilcox, L., & Kraus, R. (2004). Nurses’ perceived
knowledge, beliefs, skills, and needs regarding evidence-based
practice: Implications for accelerating the paradigm shift. Worldviews on Evidence-Based Nursing, 1(3), 185–193.
Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan,
L. (2012). The state of evidence-based practice in U.S. nurses:
Critical implications for nurse leaders and educators. Journal of
Nursing Administration, 42(9), 410–417.
Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., & Cruz, R.
(2010). Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in
evidence-based practice mentors from a community hospital
system. Nursing Outlook, 58(6), 301–308.
Melnyk, B. M., Gallagher-Ford, L., & Fineout-Overholt, E. (2016).
Implementing the evidence-based practice competencies in healthcare.
A practical guide for improving quality, safety and patient outcomes.
Indianapolis, IN: Sigma Theta Tau International.
Melnyk, B. M., Fineout-Overholt, E., & Mays, M. (2008). The
evidence-based practice beliefs and implementation scales: Psychometric properties of two new instruments. Worldviews on
Evidence-Based Nursing, 5(4), 208–216.
Melnyk, B. M., Gallagher-Ford, L., Thomas, B. K., Troseth, M.,
Wyngarden, K., & Szalacha, L. (2016). A study of chief nurse
executives indicates low prioritization of evidence-based practice
and shortcomings in hospital performance metrics across the
United States. Worldviews on Evidence-based Nursing, 13(1), 6–14.
Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change
to evidence-based practice. Image: Journal of Nursing Scholarship,
31(4), 317–322.
Stevens, K. R. (2012). Star model of EBP: Knowledge transformation.
Academic Center for Evidence-based Practice, TX: The University of Texas Health Science Center at San Antonio.
Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau,
G., Everett, L. Q., & . . . Goode, C. J. (2001). The Iowa Model
of evidence-based practice to promote quality care. Critical Care
Nursing Clinics of North America, 13(4), 497–509.
Wallen, G. R., Mitchell, S. A., Melnyk, B. M., Fineout-Overholt, E.,
Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implementing evidence-based practice: Effectiveness of a structured multifaceted mentorship programme. Journal of Advanced Nursing,
66(12), 2761–2771.
doi 10.1111/wvn.12188
WVN 2017;14:5–9
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⃝C 2016 Sigma Theta Tau International
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