There are many definitions of Evidence Based Practice, a few of which I’m going to show you today. It is an approach to clinical practice which recognizes a few important facts: That scientific advances in medicine and nursing will not stop the day YOU graduate! That some studies have indicated it would take over 600 hours of reading every month to stay current with new developments By applying the concepts of evidence based practice you’ll get the evidence you need, when you need it!
This definition emphasizes that evidence must be used to influence the decisions you make.
Key concepts: LIFE LONG = You will, if all goes well, still be practicing nursing 30-40 years from now. Imagine how much will change in that time. To compare, it has been 40 years (1967) since the first heart transplant or the first coronary bypass surgery. Would you want a nurse today to be unfamiliar with these procedures because they didn’t exist when she was in school? SELF DIRECTED = There will be no syllabus for you to follow. You won’t need to know this for an exam. Depending on you interests and the needs of your job, you’ll need to stay informed about developments in your area, as well as any related disciplines that impact your area. Patients often have co-morbidities!
As mentioned earlier, it would take approximately 600 hours every month to stay current with new research. You could do nothing, but you’d soon be out of date. You could depend on courses you sign up for or attendance at conferences, but that isn’t always possible. Time, money and distance are major barriers for this method of keeping up. Reading professional journals from cover to cover each month means you may not have the information right when you need it. The special issue on immune disorders may not come in the same month you have a patient with a specific concern in that area. Finding and appraising evidence to answer questions that arise during practice is the most time-saving method of keeping up to date.
Why else should you learn about Evidence Based Practice? It is part of the Knowledge Standard of the Ontario College of Nurses. Evidence Based Practice provides you with a strategy for continuing your learning with knowledge relevant specifically to your practice.
What are the Knowledge Standard Indicators? An evidence based rationale for all decisions Complex clients may have several co-morbidities. What do you do when your patient with lupus is also diabetic? How does that effect the standard treatment? Where do you go for the answers to these questions and how do you use the resources?
Beyond just searching the resources, you need to critically evaluate the results.
You need to continually apply the knowledge you gain to your provision of care.
Ensure practice is based in theory and evidence means all practice needs to be reviewed periodically to ensure it meets new knowledge. Assessing the client situation, by using a method such as PICO, which I will go over later. It is a way of formulating questions that aids in structuring your search for evidence.
This diagram is an analysis of something called the cognitive continuum, in this instance based on research among nurses in the UK. It shows 6 steps of information used in decision making, from using intuition on the left, to the most highly analytic and structured information: the scientific experiment, on the right. In this study they followed nurses around and kept track of their decision making processes. What determines whether a nurse uses intuitive decision-making (or NOT evidence based practice) or a more rational decision making (EBP) depends on where the decision task lies on this chart. So, the more structured the decision is, such as through forming a PICO question, by learning how to search in a structured way, the more likely the nurse will use rational decision making. Short time frames for decision turn around encourage intuitive decision making, so learning how to search databases efficiently reduces that time and makes nurses more likely to use EBP. Other factors that increase the likelihood that a nurse will use EBP: whether the information has been broken down into components The need to demonstrate decision making reasoning to others, such as developing a policy or budget rationale to administrators.
MEDLINE and the other online medical literature databases try to be as comprehensive as possible in their coverage. As a result, indexed material may have little direct application to present-day medical practice. The different types of material indexed in MEDLINE are labelled in the pyramid diagram, with the least clinically relevant at the bottom and the most clinically relevant at the top. The four layers above case reports and case series represent actual clinical research; the layers below are least clinically relevant and can be useful as background resources.
Information must have three attributes to make it useful in daily clinical practice: it must be relevant to everyday practice, it must be correct, and it should require little work to obtain it. Your goal while Navigating the Maze of evidence-based information sources is to remember the &quot;Usefulness of Medical Information Equation&quot; that conceptually relates these three attributes in this manner: Relevance x Validity Work
So taking our previous equation, Search Protocol: The pyramid above is a graphical representation of how to search efficiently for the best evidence. The examples of EBM information sources in this pyramid are placed from top to bottom according to the &quot;Usefulness of Medical Information&quot; equation illustrated below: Usefulness =Relevance x Validity Work This model suggests that you start your search at the top of the pyramid with systematic reviews from the Cochrane Database of Systematic Reviews. Cochrane is small in the amount of information it currently contains, making it easier to search, but large in the validity and relevance of the information it contains for answering therapeutic questions. Depending on the success of your search in Cochrane, you would work your way down the pyramid of resources in order of decreasing relevance/validity and increasing work, until you find an answer. Journal articles form the base of the pyramid because they represent large amounts of &quot;unrefined&quot; information, and the burden of determining the validity and relevance is up to the user. The work part of the &quot;Usefulness Equation&quot; is also very high for journal articles as it may require a lengthy MEDLINE database search to locate them. Searching and Alerting Tools: With the ever-growing number of pre-validated information sources available, clinicians now need two tools to help them identify information that is highly relevant and valid: an Alerting Tool and Searching Tool. A good Alerting Tool would notify the clinician whenever new relevant information becomes available. An example of such a tool would be Daily InfoPOEMs - a companion product to InfoRetriever (a searching tool) from the company InfoPOEMs: The Clinical Awareness System. A good Searching Tool would search multiple databases or sources of information simultaneously and present the results in an easy-to-use format based on relevance and validity. The pyramids below illustrate several such Searching Tools. Not all search tools are equal, and when using one it helps to evaluate it by asking the following questions: Does it search information sources that have a high usefulness score (higher on the pyramid)? Does it search multiple information sources simultaneously? Does it rank its search results according to usefulness (top of pyramid sources listed first)? Does it answer the highest percentage of questions in the least amount of time?
Here is how the tool applies to some of the Ovid databases. We have Cochrane at the top and Medline/CINAHL at the bottom.
Process to Practice
Roxanne L. Ebo
An approach to clinical practice
A way to keep current with new
An integration of the best evidence
available, nursing expertise, and the values
and preferences of the individuals, families,
and communities who are served.
… a methodological approach to clinical
practice where evidence is used to inform
decision-making about making a diagnosis (or
interpreting a diagnostic test), selecting an
intervention, or evaluating prognostic
… an approach to health care practice in
which the clinician is aware of the evidence
that bears on her clinical practice, and the
strength of that evidence
… an approach to decision making in which the
clinician uses the best evidence available, in
consultation with patient, to decide upon the
option which suits that patient best
Evidence based health care
the integration of individual
the best available external
clinical evidence and
the values and expectations of
Involves life-long, self-
Involves exploring the
relationship between clinical
reasoning and research
Do nothing … and get out of date
Depend solely on courses/conferences
Choose the main professional journal(s) and
read them cover to cover every month
Learn how to find and appraise the evidence
to answer questions that come from clinical
Each nurse possesses, through basic education and
continuing learning, knowledge relevant to her/his
Knowledge Standard Indicators
Providing a theoretical and/or evidence-based
rationale for all decisions
Understanding the knowledge required to meet the
needs of complex clients
Knowing where/how to access learning resources
Knowledge Standard Indicators
Seeking and reviewing research in nursing, health
sciences and related disciplines
Using research to inform practice/professional service
Knowledge Application Standard
Each nurse continually improves the application of
Ensuring practice is based in
theory and evidence and meets
all relevant standards/guidelines
Assessing/describing the client
situation using a theory,
framework or evidence-based
Managing multiple nursing
Evaluating/describing the outcome
of specific interventions and
modifying the plan/approach
Integrating research findings
into professional service and
Thompson, C. et al. Evid Based Nurs 2004;7:68-72
The cognitive continuum.
Define the Question
Identify Question ~ Search and Screen Literature ~
Collect the Evidence
Critically Appraise the Evidence for Validity
Integrate the Evidence and Patient Factors
Make & Carry Out the Decision
Evaluate the Process
Results ~ Self-reflection
A clinical question should incorporate at least
Age, sex, ethnicity, etc.
Condition, diseases, general health status
Education, diagnostics, treatment plan, self-care,
Expected and actual effects on patient
Do nurse led tobacco cessation interventions
result in decreased smoking rates after
hospital admission for coronary heart disease?
(Non-nurse led tobacco cessation programmes
Self-administered, non-nurse administered, etc.)
Lower rates of tobacco use among Patient group
Not all questions are of a clinical nature
Intervention can be interpreted very broadly
“Important medical questions are typically studied
more than once, often by different research teams in
different locations. A meta-analysis combines results
from different studies, hopefully averaging out any
differences caused by random change or local variation
and getting at something close to the real truth. In
general a meta-analysis, if you can find one, will be a
better guide to practice than an individual article.”
SUNY Downstate Medical Center, 2003