RML Rendezvous - Evidence Based Nursing

Janet G Schnall, MS, AHIP Library Liaison to the UW School of Nursing Health Sciences Libraries Affiliate Instructor, UW School of Nursing University of Washington, Seattle, WA [email_address] Teaching Evidence-Based Practice Resources to Nurses and Nursing Students

Objectives
Describe how to teach web resources to nurses and nursing students to use for evidence-based nursing practice
Highlight importance of EBNP to improve patient care
Identify evidence-based nursing resources on the web
Describe strategies to find evidence on the web for EBNP

What is evidence-based practice?
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
Sackett DL et al. Evidence based medicine: what it is and what it isn't.
BMJ 1996 Jan 13; 312 (7023): 71-2.

Evidence-Based Practice

What is evidence-based nursing practice?
"Evidence-based nursing (EBN) means using the best available evidence from research, along with patient preferences and clinical experience, when making nursing decisions."
Cullum N. Users' guides to the nursing literature: an introduction.
Evid Based Nurs 2000 Jul;3(3):71-2. doi:10.1136/ebn.3.3.71

Why do nurses need to do EBP?
Results in better patient outcomes
Failure to use evidence results in lower quality, less effective, more expensive care
Berwick DM . Disseminating innovations in health care. JAMA 2003 Apr 16;289(15):1969-75
Keeps practice current and relevant
Increases confidence in decision making
Experience greater autonomy in practice
Increases level of job satisfaction

Barriers to Nurses using EBP
Lack of TIME
Lack of value of research in practice
Lack of understanding of electronic databases to find evidence
Lack of computer skills
Lack of EBP mentors at point of care
Difficulty understanding research articles
Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for
evidence-based practice. Amer J Nurs 2005 Sep;105(9): 40-52.

5 (7) Steps for EBN Practice
1. Convert your information into an answerable question ( PICO )
2. Search the literature for the best available evidence
3. Critically appraise the evidence for validity and usefulness
4. Apply the findings to your clinical practice along with clinical expertise and patient’s perspective to plan care
5. Evaluate the outcomes of your practice decisions or changes based on evidence.

2 Additional Steps for EBP=7 Steps
Step 0: Cultivate a spirit of inquiry
Step 6: Disseminate EBP results
Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs 2010 Jan;110(1):51-3. PMID: 20032669.

What makes good evidence?
Based on scientific research
RCT
Systematic review
Meta-analysis
Clinical guidelines
Opinion
Consensus
Because it’s been done this way for 100 years
Good Shoddy

See’s Chocolates Slide adapted from Edward G. Miner Library, University of Rochester School of Medicine and Dentistry Chocolate Decadence Pyramid

Lots of Evidence Pyramids!

Searching for Evidence Pyramid: Basic MetaSearch Engines ex. TRIP ex. Cochrane ex. DynaMed, Nursing Reference Center, NGC ex. MEDLINE/PubMed, CINAHL ex.Textbooks, UptoDate Systematic Reviews, Meta-Analyses Evidence Summaries, Evidence Guidelines Randomized Controlled Trials (RCTs), Cohort Studies, Qualitative Studies Background Information, Expert Opinion

Searching for Evidence Pyramid: Detailed healthlinks.washington.edu/ebp/ebptools.html Modified from University of Virginia Health Sciences Library

5S and 6S Pyramids 5S Model

Read about 5S and 6S Models
The 5S Model Haynes B. Of studies, syntheses, synopses, summaries, and systems: The "5S" evolution of information services for evidence-based healthcare decisions. ACP J Club 2006 Nov-Dec;145(3):A8.
The 6S Model DiCenso A, Bayley L, Haynes RB. Accessing pre-appraised evidence:fine-tuning the 5S model into a 6S model. Evid Based Nurs 2009 Oct;12(4):99-101. doi:10.1136/ebn.12.4.99-b

HealthLinks: DNP Toolkit healthlinks.washington.edu.offcampus.lib.washington.edu/nurse/dnp

HealthLinks: Basic Introduction to Evidence-Based Practice Resources healthlinks.washington.edu/hsl/classes/evidence

Create your own Evidence Pyramid www.ebmpyramid.org/home.php EBM Page Generator

EBN Resources Flow Chart
Kendall S. Evidence-based resources simplified. Can Fam Physician 2008 Feb; 54(2):241-3.

Search for the Best Evidence to answer the Question

Search Databases Efficiently for Research Journal Articles
MEDLINE
or PubMed pubmed.gov
CINAHL/CINAHL Plus

CINAHL or [CINAHL Plus] cinahl.com
Cumulative Index to Nursing and Allied Health Literature
Provides coverage from 1982 [1937] to date, of nursing and 17 allied health disciplines literature
1700+ [3800+] journals indexed including virtually all English-language nursing journals
Can easily search for Research articles

CINAHL: enter search terms

CINAHL Limit Your Results Screen CINAHL Limit Your Results Screen

CINAHL Publication Type Limits
Clinical trial
Critical path
Practice guidelines
Research
Standards
Systematic review

CINAHL Results link to full text

Abstracts

Full text article

Searching CINAHL Plus Help web page healthlinks.washington.edu/howto/cinahlplus

Search MEDLINE or PubMed
PubMed includes MEDLINE (1940’s+)
Indexes 5,000 biomedical journals
Covers all aspects of biosciences and healthcare
75%-80% of citations have abstracts
Updated 5x/week

2 MEDLINE/PubMed Strategies for Finding Evidence-Based Citations
1. Use Limits: Publication Type of Article
Randomized Controlled Trial
Meta-Analysis
Practice Guideline
Clinical Trial
Consensus Development Conference
2. Use Clinical Queries section

MEDLINE Search Screen Randomized controlled trial Strategy #1: Limit to RCTs under Publication Type

MEDLINE Results MEDLINE Results link to full text link to full text

Strategy #2: Clinical Queries – Link on Advanced Search or Home page

healthlinks.washington.edu/howto/pubmed

CINAHL vs MEDLINE
CINAHL
Coverage: 1982+
Indexes 1700 journals
Focuses on nursing and allied health literature
CINAHL Thesaurus with more nursing terms
Has peer-reviewed limit
Includes cited references at end of many refs
MEDLINE
Coverage: late 1940’s+
Indexes 5000 journals
Focuses on biomedical literature
Uses MeSH as its controlled vocabulary
No peer-reviewed limit
No cited references

Locating E-Journals
Check with your library for access to
full-text e-journals
Use HEAL-WA for WA State nurses
Includes CINAHL and MEDLINE full-text
A-Z Journals: 2,600 full-text journals
UW Affiliates : use the Proxy service to access full-text ejournals from off-campus

HEAL-WA Health Electronic Resource for Washington heal-wa.org
Began: January 2009
Website: offers online access to a collection of health information resources
Who has access? selected health care providers in Washington YES, NURSES !
Funded by: license fees
Mission: provide evidence-based information to support patient care

What is included in HEAL-WA?
Resources: electronic databases, online texts, and e-journals
Includes information resources specific to nurses, such as CINAHL and the Nursing Reference Center
Other excellent resources: MEDLINE , DynaMed, Cochrane, Natural Standard
Gives practitioners access to timely,
evidence-based answers to patient care Q’s

h heal-wa.org

HEAL-WA Toolkit: Registered Nurse

HEAL-WA Toolkit: ARNP

HEAL-WA Journals A-Z 2,600 full-text health-related journals

Open Access and Free Journal Sites
BioMed Central biomedcentral.com
Independent publishing house providing immediate free access to peer-reviewed biomedical research
Includes BMC Nursing, etc.
PubMed Central pubmedcentral.gov
National Library of Medicine's free digital archive of biomedical and life sciences journal literature
Free Medical Journals freemedicaljournals.com
Highwire Press highwire.stanford.edu
Provides full-text to over 1,000 peer-reviewed scientific, medical and social science journals.

Search Clinical Practice Guideline Resources
National Guideline Clearinghouse
Nursing Reference Center
MEDLINE/PubMed
CINAHL/CINAHL Plus
Advanced Google or Google Scholar

Clinical Practice Guidelines
Systematically developed statements of appropriate care designed to assist the practitioner and patient make decisions about appropriate health care for specific clinical circumstances
Usually based on the most current available research if from reputable, authoritative organizations
Developed using widely varying standards
Cost may be considered as well as health outcomes or politics

National Guideline Clearinghouse guideline.gov
Initiative of the Agency for Healthcare Research and Quality (AHRQ)
Database of clinical practice guidelines and related documents
Free
Updated weekly
Voluntary participation

Guideline Comparison

Guideline Summary

Searching for Practice Guidelines in:
MEDLINE/PubMed
CINAHL
Limit to Practice Guidelines under Publication Type
Limit to Practice Guideline
In MEDLINE , under Pub Type : In PubMed, under Type of Article:

Search for Evidence Summaries
DynaMed
Evidence-based clinical resource providing summaries of 3,500+ diseases and conditions
Comprehensive point-of-care resource for nurses, including Evidence-based Care Sheets
Evidence-Based Nursing
Quarterly journal that assesses clinical relevance of research studies from international journals

DynaMed
Provides summaries of the best evidence for over 3,500 clinical topics
Can quickly browse and find key recommendations
Updated daily
Monitors content of over 500 journals and systematic review databases
Available for PDA and mobile devices

DynaMed: Treatment Overview Level 1 evidence

DynaMed Treatment, detailed Level 1 evidence Full-text

DynaMed: Reviews and Guidelines

Levels and Grades of Evidence REPROLINE, Johns Hopkins University www.reproline.jhu.edu

Evidence-based Care Sheets
Evidence-based summaries on key topics incorporating the best available evidence through vigorous systematic surveillance
Diseases & Conditions
Quick Lessons
Drug information
Skills & Procedures
Practice Guidelines
Patient Education materials
CE modules

Nursing Reference Center: Basic Search

Nursing Reference Center Evidence-Based Care Sheet April 2009

Evidence-Based Nursing
Surveys a wide range of international medical journals applying strict criteria for the quality and validity of research
Practicing clinicians assess the clinical relevance of the best studies
Key details of these essential studies are presented in a succinct, informative abstract with an expert commentary on its clinical application

Evidence-Based Nursing review

Additional Point of Care Evidence-Based Resources for Nursing: [have some level of evidence-based information]
Clini-eguide Nursing Advisor www.clineguide.com/nursing-standards-care-plan.aspx
Lippincott’s Nursing Procedures & Skills www.healthstream.com/Lippincott/
Mosby’s Nursing Consult www.nursingconsult.com
Mosby’s Nursing Skills mosbysnursingskills.com
UptoDate uptodate.com

Essential Nursing Resources from ICIRN icirn.org

Search for Evidence in Natural Medicines and Herbal Resources
Natural Medicines Comprehensive Database
naturaldatabase.com
Natural Standard naturalstandard.com
high quality, evidence-based information about complementary and alternative therapies
Also available partially through
MedlinePlus: Drugs, Herbs, and Supplements
www.nlm.nih.gov/medlineplus/druginformation.html

Natural Medicines Comprehensive Database

Natural Standard Professional reading level 12 th grade reading level Patient handout 5 th grade Aloe

Natural Standard Professional Monograph

Aloe Natural Standard

Use a Meta-Search Engine to find evidence sites Allows you to search multiple other search engines simultaneously and combine the results

Special Meta -Search Engines that find evidence sites TRIP tripdatabase.com SUMSearch 2 sumsearch.org SUMSearch

TRIP Database tripdatabase.com
Metasearch engine
Performs a simple search of more than
75 databases
Finds evidence based resources
Searches Cochrane, National Guideline Clearinghouse, Bandolier , etc.

SUMSearch 2 sumsearch.org

Search for Systematic Reviews and Meta-Analyses Resources
Cochrane Database of Systematic Reviews
MEDLINE or PubMed
Clinical Queries
CINAHL

Systematic review vs Meta-analysis
Systematic review :
a literature review of RCTs focused on a single question which tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question.
Uses explicit methods to identify, select and critically evaluate relevant research.
Meta-analysis:
- systematic review combining results of several studies using quantitative statistics.

Cochrane Database of Systematic Reviews
‘ Gold standard’ for high quality systematic reviews
Includes full-text reviews and protocols
Cochrane Abstracts available in CINAHL and MEDLINE/PubMed

Cochrane Search link to full text

Systematic Review Authors’ conclusions Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days. However, 80% of participants treated without antibiotics improve within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and the general population level .

Finding Systematic Reviews and Meta-Analyses in CINAHL
Limit search to Pub Type: Systematic Review
Search for Meta Analysis as a Subject Heading

Finding Systematic Reviews and Meta-Analyses in PubMed
Use Clinical Queries: Systematic Reviews
Limit to Type of Article: Meta-Analysis
Systematic reviews

Results for Systematic Reviews

Searching for Evidence Pyramid MetaSearch Engines ex. TRIP ex. Cochrane ex. DynaMed, Nursing Reference Center, NGC ex. MEDLINE/PubMed, CINAHL ex.Textbooks, UptoDate Systematic Reviews, Meta-Analyses Evidence Summaries, Evidence Guidelines Randomized Controlled Trials (RCTs), Cohort Studies, Qualitative Studies Background Information, Expert Opinion

So, you want to use Google?
CINAHL results
150 articles
Top result:
Schatz M, Dombrowski MP. Clinical practice: asthma in pregnancy. NEJM 2009 Apr 30; 360(18):1862-9
Google results
2, 530,00 hits
Top result:
Asthma in pregnancy. eMedicine Health . Last editorial review 10/24/2005
Search June 2009: asthma and pregnancy by Dolores Judkins, OHSU Library, Portland, OR

Navigating the Web Beyond Basic Google to Find Evidence?
Google google.com
Largest search engine: over 25 billion pages
Relevance ranking based on link analysis
Google Advanced Search
www.google.com/advanced_search?hl=en
Google Scholar scholar.google.com

Searching Advanced Google for Guidelines Searching Advanced Google for Guidelines .gov, .edu pdf in title pressure ulcer prevention guidelines pressure ulcer prevention guidelines

Advanced Google Results

Google Scholar scholar.google.com
Searches for scholarly literature , including peer-reviewed papers, theses, books, abstracts and technical reports
Finds articles from academic publishers, professional societies, universities, etc. as well as scholarly articles on the web
" Cited by" link identifies # that have cited the original
Access to full text only available with subscription
Caution: Not a reliable sole source for searching scholarly literature

Google Scholar

Must Evaluate Web Resources: Evaluation Strategies
Evaluate using Criteria for Evaluating Web Resources
Determine the type of site by analyzing Web Site Addresses
A User's Guide to Finding and Evaluating Health Information on the Web www.mlanet.org/resources/userguide.html

Criteria for Evaluating Web Sites healthlinks.washington.edu/howto/navigating/criteria.pdf
Authority
Accuracy
Objectivity
Currency
Coverage
Design

Analyze the Website Address
edu
org
com
gov
net
The URL (Uniform Resource Locator) includes the name of the host computer which can indicate the purpose of the web site.
http :// www.cdc.gov / nip / child.htm sub directory name of host computer how information is transmitted filename

Resources
Basic Introduction to Evidence-Based Practice (UW HSL) healthlinks.washington.edu/hsl/classes/evidence
Video (2009,60 min) based on Basic Intro to EBP Res healthlinks.washington.edu/hsl/classes/evidence/EBP_2009/EBP_2009.html
DNP Toolkit (UW HSL) healthlinks.washington.edu.offcampus.lib.washington.edu/nurse/dnp
Essential Nursing Resources (ICIRN) www.icirn.org/Homepage/Essential-Nursing-Resources/Essential-Nursing-Resources.aspx
Schnall Liaison page with links under Presentations
healthlinks.washington.edu/hsl/liaisons/schnall/

Overview of EBP for Nurses Series full-text available FREE on AJN website: journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalCollectionId=10
1: Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based practice, step by step: critical appraisal of the evidence: part II: digging deeper--examining the "keeper" studies. Am J Nurs. 2010 Sep;110(9):41-8. PMID: 20736710.
2: Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based practice step by step: Critical appraisal of the evidence: part I. Am J Nurs. 2010 Jul;110(7):47-52. PMID: 20574204.
3: Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice, step by step: searching for the evidence. Am J Nurs. 2010 May;110(5):41-7. PMID: 20520115.
4: Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice, step by step: asking the clinical question: a key step in evidence-based practice. Am J Nurs. 2010 Mar;110(3):58-61. PMID: 20179464.
5: Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs. 2010 Jan;110(1):51-3. PMID: 20032669.
6: Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: igniting a spirit of inquiry: an essential foundation for evidence-based practice. Am J Nurs. 2009 Nov;109(11):49-52. PMID: 19858857.

RML Rendezvous - Evidence Based Nursing

by National Network of Libraries of Medicine, Pacific Northwest Region on Sep 23, 2010

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