Chelsea Rein, BS, MLIS
Reference and Instruction Librarian, Phillips School of Nursing at Mount Sinai
There are many online resources where nursing professionals can find evidence-based practice information. Evidence-based practice (EBP), known as “judicious use of current best evidence in conjunction with clinical expertise and patient values” is an instrument of great utility in nursing care, helping to reduce both cost and variability in clinical practice. 1,2 Evidence-based Nursing (EBN) integrates best evidence available, nursing expertise, and preferences of individuals, families, and communities in a holistic care model that broadly encompasses patient preferences as well as effectiveness of treatment. EBN is often a five-step systematic process including: asking the clinical question, evidence acquisition, evidence appraisal, evidence-application, and outcome evaluation. 3 It is also known as a 5-step model - Assess, Ask, Acquire, Appraise, and Apply. 4
Asking the Clinical Question:
The first step of the evidence-based nursing process involves taking the clinical issue under consideration and formulating it into a searchable and answerable question. 5 The model which is frequently used for this part of the process is termed “PICO,” containing the following components:
P – Patient or Population or Problem
I – Intervention of Interest, Proposed Intervention
C – Comparison or Control, (there might be no Intervention)
Also may be included:
T – Type of Question (Diagnosis, Prognosis, Therapy etc.)
T – Type of Study Design (RCT, Cohort Study, Case Series etc.)
Example: In POPULATION does INTERVENTION as compared to COMPARISON/CONTROL result in OUTCOME?5
In adult patients hospitalized in a long-term acute care facility (P), how does the use of a nurse-driven protocol for evaluating the appropriateness of short-term urethral catheter continuation or removal (I), compared with no protocol (C), affect the number of catheter-days (O1) and CAUTI rates (O2) over a six-month post-intervention period (T)? 6
Internet Resources for Creating a Well-Built Clinical Question:
Duke University Medical Center Library and Archives - Evidence-Based Practice: PICO
Icahn School of Medicine at Mount Sinai Levy Library – PICO and the Question Statement
Yale University Harvey Cushing/John Hay Whitney Medical Library – Framing Questions with PICO
The hierarchy of evidence is a core principle of Evidence-Based Medicine. EBM hierarchies rank study types based on the strength and precision of the research methods done. Most experts consider well done systematic reviews, with or without meta-analysis, to provide the best evidence for all question types. If a current, well designed systematic review is not available, primary studies can sometimes answer a PICO question. 7
The type of PICO question will often dictate the best study design to address the question. For example, a suggested study for a PICO question based on a diagnosis could be a prospective, blind comparison to the gold standard, whereas a PICO question on a therapy intervention could be to use an RCT or Practice Guideline. The EBM Pyramid shown lists a variety of evidence types and levels. The quality of evidence is highest among filtered information and lowest among unfiltered information with degrees of evidence level. 8
Internet Resources for Evidence Acquisition:
Icahn School of Medicine at Mount Sinai – Evidence Based Medicine Guide: What’s Best: The Evidence Hierarchy
Sigma Repository – Browsing by Evidence
University of Michigan Library – Sources for Evidence Based Research – Hierarchy of Evidence
Databases – Finding Evidence:
Using available databases, journals and point-of-care tools are good places to start while looking for evidence. Some databases have items available like evidence-based care sheets (CINAHL) or clinical content synthesized into graded evidence based recommendations (UptoDate). In PubMed, the Clinical Queries page allows you to enter one search query and launch two EBM filters: Clinical Study Categories and Systematic Reviews. Mount Sinai’s Levy Library provides access to a multitude of resources accessible online including databases, clinical mobile apps, e-journals, and e-books.
Internet Resources for Finding Evidence:
Icahn School of Medicine at Mount Sinai Levy Library – Filtering PubMed for Best Evidence
Icahn School of Medicine at Mount Sinai Levy Library – Using MeSH to Find Evidence
Icahn School of Medicine at Mount Sinai Levy Library – Databases A – Z
Icahn School of Medicine at Mount Sinai Levy Library – Journal Search
When appraising websites, some important criteria to consider include - authority, accuracy, bias, currency, and comprehension. 10
Authority – is the author listed, domain (org, edu, com)?
Accuracy – is the information reproducible?
Objectivity - are there any conflicts of interest? Are the goals and aims of the website clear?
Currency – when was the webpage updated? Are the links up to date?
Coverage - can you view the information properly? 10
Critical appraisal worksheets can help guide evidence appraisal among different topics.
Internet Resources for Apprising Evidence:
CASP Checklist – Critical Appraisal Skill Program
Duke University Medical Center Library and Archives – Evidence-Based Practice: Appraise
Duke University Medical Library and Archives – Teaching Table for Common Summary Articles
Evidence-Based Medicine Toolkit - Critical Appraisal Worksheets Logbook
Icahn School of Medicine at Mount Sinai Levy Library – Appraise Evidence
When you have asked your question, found the evidence, and critically appraised the evidence, it is time to implement that evidence. Implementation of evidence into practice may be challenging and usually involves working out how the results of your research apply to the patient, taking into consideration your own clinical expertise and the patient's situation and preferences. This is sometimes called the "external validity", or "generalizability" of the research results.11
Questions to ask at this stage include:
Is the intervention feasible in my setting?
What else do I need to apply this evidence?
Is my patient similar enough to the subjects of the study so that the results can apply?
Will the potential benefits of treatment outweigh any potential harm?
What are the views of my patient?11
Internet Resources for Models of Evidence-Based Nursing Practice and Applying Evidence:
Iowa Model of Evidence-Based Practice to Promote Quality Care
Johns Hopkins Nursing Evidence-Based Practice Model
Larabee Emerging Model of Quality
PARiHS Framework for Putting Research Into Practice
Stetler Model of Evidence-Based Practice
The final step involves Assessing or “Auditing” the research process. This involves evaluating the effectiveness and efficiency of the process and practice of evidence-based practice, identifying strengths and weaknesses and ways that it might be improved the next time.12
Self-reflective questions that might be asked include:
Did I ask a well-formulated clinical question?
Did I consider the best sources of evidence for the type of clinical question?
Have I searched the databases efficiently?
Did I use the hierarchy of evidence as my guide for the type of evidence that I should be searching for?
Am I integrating critical appraisal? 12
Internet Resources for Outcome Evaluation:
Cochran Audit and Feedback: Effects on Professional Practice and Patient Outcomes
Evidence-Based Medicine Toolkit – EMB Calculators
Evidence-Based Medicine Toolkit – Self-Evaluation
Other Online Resources for EBM/EBN:
AHRQ Clinical Guidelines and Recommendations
American Association of Critical Care Nurses Clinical Resources
American Journal of Nursing: Evidence-Based Practice Step-by-Step
Duke University Medical Center Library and Archives: EBP Tutorial
Ichan School of Medicine at Mount Sinai Levy Library: Evidence Based Medicine Guide
Ichan School of Medicine at Mount Sinai Levy Library: Nursing Resources – Evidence Based Practice
Phillips School of Nursing Information Commons: Evidence Based Medicine in Nursing
PubMed: Evidence-Based Practice Training
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