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    What is Evidence-Based Practice in Nursing? Evidence-based practice (EBP) is an approach to healthcare that utilizes the most current research available in order to improve the health and safety of patients while reducing overall costs and variation in health outcomes, according to the Journal of Nursing Administration.

    It is applied problem-solving, combining best practices from the latest medical literature with clinical experience and the values and preferences of the patients under treatment (University of Main Fort Kent).

    5 Steps of the EBP Process: 

    • Assess the patient and your own knowledge gaps. 
    • Ask a well-built clinical question derived from the case. 
    • ACQUIRE the evidence by selecting an appropriate resource and conducting a search. 
    • APPRAISE the evidence for its validity and applicability. 
    • APPLY what you have learned, talk to the patient, and integrate the evidence with your clinical expertise and patient preference. 

    EBP Interactive Tutorial-Medical Center Library at Duke University and the Health Sciences Library at the University of North Carolina at Chapel Hill

    An Introduction to Evidence-Based Practice

    This self-paced, interactive tutorial will take you through the complete EBP process, emphasizing the elements of a well-built clinical question and the key issues that help determine the validity of evidence. This program was developed by the Medical Center Library at Duke University and the Health Sciences Library at the University of North Carolina at Chapel Hill.

    Centre for Evidence-Based Medicine (Toronto)

    The goal of this website is to help develop, disseminate, and evaluate resources that can be used to practice and teach EBM for undergraduate, postgraduate, and continuing education for health care professionals from a variety of clinical disciplines. This site also serves as a support for the book entitled, Evidence-based Medicine: How to Practice and Teach EBM by Sharon E. Straus, W. Scott Richardson, Paul Glasziou, and R. Brian Haynes (3rd edition).

    BMJ EBM Toolkit

    The BMJ's free EBM toolkit enables individuals to learn, practice, and discuss EBM, and provides EBM tools. There is information introducing the key methods of EBM such as clarifying a clinical question, designing a search and appraising, synthesizing, and assessing the quality of the evidence. Additionally, this information is intended to support and promote discussion around EBM.

    Forming Focused Questions with PICO: About PICO

    This guide from the University of North Carolina at Chapel Hill introduces the PICO question framework for evidence-based practice. It explores PICO’s history, purpose, and limitations. This guide also introduces other question frameworks and provides example questions from across many health professions.

    Parts of this information were adapted from Duke University Medical Center Library & Archives. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.

    A clinical question needs to be directly relevant to the patient or problem at hand and phrased in such a way as to facilitate the search for an answer. PICO makes this process easier. It is a mnemonic for the important parts of a well-built clinical question. It also helps formulate the search strategy by identifying the key concepts that need to be in the article that can answer the question.

    The image of this PICO Chart is from the San Jose State University Library Research Guide: NURS 144 Clinical Nursing Applications

     

    Types of Questions

    Clinical questions typically fall into one of four main categories: 

    • Etiology: What causes the problem?
    • Diagnosis: Does the patient have this problem?
    • Therapy: What is the best treatment for this problem?
    • Prognosis: What will the outcome of the problem be?

    Nursing Practice Questions

    In nursing, many other questions about the practice will arise, with some of the questions resulting from the nursing principle of work with rather on a patient. These questions can be quantitative or qualitative in nature. Here are a few examples:

    • What other, validated instruments for measuring this condition or phenomenon (e.g. pain) exist and how do they compare to the one we currently use?
    • Should a nurse deliver patient education on the patient's disease/condition at the beginning or at the end of an appointment or consultation?
    • How do caregivers of patients with [x] cope with the burden of care and how can nurses assess the level of caregiver burden and/or support the caregivers?
    The content on Types of Questions was adapted from the PennState University Libraries Nursing Libguide.

     

    Hierarchy of Evidence

    The definition of EBM states the importance of obtaining the "best available evidence." The evidence hierarchy is an attempt to rank the health information resource/study designs with the highest quality sitting atop and the lower levels descending below. This hierarchy is helpful to guide evidence acquisition (literature searching) as well as providing clearer communication when discussing the landscape of health literature.

    When it comes to prioritizing the evidence in any specific situation, clinicians will need to understand the nuances of the evidence (reviews, studies) obtained. It is not uncommon for lower levels of evidence on the hierarchy to trump evidence sitting above a hot-off-the-press large RCT over an older meta-analysis containing small studies (UM-Madison Libraries Research Guides on Evidence-Based Medicine). 

    Hierarchy of evidence

    This image is from North Virginia Community College, Evidence-Based Practice Research Guide.

    Choosing the Right Database

    Filtered Resources-When searching for evidence-based information, begin by searching for the highest level of evidence possible, which is considered to be systematic reviews or meta-analyses where the literature on a topic has already been searched to provide the best answer to a clinical question or practice issue.

    In other words, experts have 1) located all the available evidence they could find on a topic from individual studies and reports; 2) analyzed the validity and reliability of the studies to determine whether each study should be included; and 3) summarized the findings from the available research to present the data, conclusions, and recommendations for clinical questions and nursing practice based on the best available evidence.

    Unfiltered Resources-Information that has not been critically appraised is considered "unfiltered". You’ll also need to search unfiltered resources (the primary literature) to locate studies that answer your question. Unfiltered resources are individual articles that provide the most recent information from clinical and practice research, such as case studies, comparative studies, or clinical trials. With unfiltered resources, it is up to the nurse to evaluate each study to determine its validity and applicability to the patient or the practice question.

    Meta-Analysis

    Filtered Information: Suggested Resources

    Systematic Reviews 

    Critically Appraised Articles/Topics (Evidence Syntheses)

    Unfiltered Information: Suggested Resources

    RCTs, Cohort Studies, Case Studies/Reports

    Background Information/Expert Opinion: Suggested Resources

    Background Information/Expert Opinion

    What is Critical Appraisal?

    After finding articles, we need to determine what is worth keeping and including in our research. We do this through a critical appraisal of each piece of evidence. Critical appraisal is the process of carefully and systematically examining research to judge its trustworthiness, its value, and its relevance in a particular context (Daemen College Nursing Research Guide).

    You want to ask:

    • What are the results?
    • Are the results valid?
    • How useful is it to your patient/population/practice?

    Critical Appraisal Tools

    Calculators

    These tools will help you interpret the clinical and statistical significance of data reported in clinical research.