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Evidence-Based Practice Portfolio

The goal of this guide is to provide nurses a resource to understand and carryout the steps of performing an evidence-based practice (EBP) project.

VCU Health

Updated: March 27, 2018 

Stop Point 4: Discuss Progress with Your EBP Mentor/Advisor



Before moving on, meet with your mentor/advisor concerning your question.  The purpose of this meeting is to ensure that your question and path forward are one that will allow you to be successful.  Do not move forward before your mentor/advisor sign off on the meeting sheet.  


Stop 4  - Documents:

Creating a Action Plan

The purpose of an action plan is to provide steps to implement change and assigns responsibility to members of the team to ensure the project/change is implemented.  The plan needs to be one that is manageable with a clear timeline.  The timeline is one that is not written in stone and should be revisited and revised by the team as the implementation plan unfolds.  The main job of the team is to evaluate the evidence, develop the action plan and implement the practice change.

An effective action plan includes:

  • The development of a protocol, guideline, critical pathway, system or process related to the evidence-based practice question.  This could also be a change to an already existing protocol, guideline, critical pathway, etc. 
  • Specific definitions of what change or the steps are to take place
  • Which team member is responsible or will carry out each step.  
  • Clear timeline of when each step will be completed and what might be needed to carry it out (personnel, resources, etc.) 

While constructing and once the plan is completed it is important to solicit feedback from stakeholders and others in the organization in order to ensure that the plan can be implemented effectively and successfully.  It is key that team members actively engage those who will be affected and involved in the practice change to get buy-in and to learn what is and is not working. Some people that need to be consulted are:

  • Organizational & Unit Leadership
  • Bedside Clinicians  - Both Nursing and Medical 
  • Social Works, Occupational Therapists, Dieticians & other stakeholders as applicable. 

Once the plan is put into operation be sure to evaluate and adjust as necessary.  

Gather Pre-Invention Data

The key to being able to understand the success of a practice change is being able to evaluate it.  This means that data must be not only gathered at the end of the intervention but also at the beginning.  When thinking about what pre-intervention data should be gathered, think about what  measures/sources will accurately reflect the intended aims of the intervention.  

Some sources could include:

  • Patient Satisfaction Scores 
  • Nurse Satisfaction Scores
  • Hospital Statistics -  Accidental Falls, Needle Sticks, Wait Times, Etc. 
  • Survey Responses 

When determining the type of data you should ask the following questions.  

1.What data or measures do you need?
2.What data do you have available and how frequently can you access it?
3.What data do you not have available that you need, and how will you get it?
4.How frequently are you going to examine data?
5.Who is going to do what, with regards to collecting data and tracking improvements?
(Cox, 2015)
What data or measures do you need?
What data do you have available and how
frequently can you access it?
What data do you not have available that you need,
and how will you get it?


Cox, M.E. (2015) Introduction to continuous quality improvement (CQI) for home visiting programs. Presentation in Baltimore, MD. 

Cvach , M. "Chapter 8: Selecting Pathway to Translation." Johns Hopkins Nursing Evidence-Based Practice: Implementation and Translation. Ed. Stephanie Poe and Kathleen M. White. Indianapolis, IN: Sigma Theta Tau International, 2010.