1. Evidence-Based Nursing
Practice
Clinical Lab
Nursing V
Summer 2009
Judith Van Sant, PhD, RN, CNE

2. Objectives
 Describe evidence-based practice (EBP)
 Discuss the five steps of EBP
 Ask at least one clinical question to be
researched
 Search, collect, and evaluate level of
evidence on a clinical question
 Disseminate search findings to lab
participants

3. What is Evidence-Based Practice?
 Definition: “…a systematic approach to
problem solving for health care providers”
(Pravikoff, Tanner, & Pierce, 2005).
 Integrated components:
 clinical expertise (best practice)
 external evidence from systematic research
 patient preferences
(Sackett, et al., 1996)

4. Process of Evidence-Based
Practice
 Assess and define problem.
 Formulate specific question.
 Locate and evaluate appropriate evidence.
 Integrate evidence into planning and
implementing interventions.
 Evaluate process and results.
(Sackett, et al., 1996)

5. Sources for Evidence-Based
Practice
 Guidelines and Best Practices
 Data base of evidence-based clinical practice guidelines
 Best practice information sheets
 Systematic Literature Reviews
 Research method which produces a synthesis of the literature on
a specific question and a discussion of concomitant implications
 Cochrane Data-base of Systematic Reviews
 Other Resources
 Abstracted information and commentary on research studies
from various international journals

6. Why Evidence Based Practice?
 Knowledge explosion
+
 Nursing shortage
Mandate
 Timely research evidence translation into
best practice.
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

7. Why Evidence Based Practice?
 Traditional practice
 Knowledge gained in school
 Pathophysiological rationale
 Intuition
 Experiences (past & usual practice)
 Workplace colleagues
17-year lag between research findings and
practice application
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

8. Why Evidence Based Practice?
 EBP can lead to:
 Increased practitioner satisfaction
 Decreased “burnout” and turnover
 Third party reimbursement
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

9. Why Evidence Based Practice?
 Evidence continually evolves
Evidence-based practice
Opinion-based
Melnyk & Fineout-Overholt, 2005; Salmon, 2007

10. WARNING!!!!!
 “EBP does not replace clinical reasoning or
judgment.”
 20% medical practice Supported by
<20% nursing practice solid evidence
(Gray, et al., 2002)
Evidence Gaps >Primary Research
(Salmon, 2007)

11. What is Evidence Based Practice?
 Conscientious use of best evidence in
clinical decision making:
 Systematic search for best evidence
 Critical appraisal of most relevant evidence to
answer clinical question
 Clinical context or circumstances
 One’s own clinical experience
 Patient preferences and values
EBP is more than research utilization
(Melnyk & Fineout-Overholt, 2005; Salmond,2007)

12. History of EBP Movement
 Dr. Archie Cochrane, British epidemiologist
 In 1972 criticized medical profession for lack
of systematic review of available evidence to
direct clinical decision making
 Landmark case – several RCTs supporting
effectiveness of corticosteroid therapy to halt
premature labor in high risk women had not been
systematically analyzed
 1,000’s of low-birth-weight premature infants continued
to die needlessly
 Review data showed therapy decreased death from 30%
to50%
Melnyk & Fineout-Overholt, 2005

13. History of EBP Movement
 2000 IOM report, To Err is Human
 Preventable medical errors were 8th leading
cause of death in US
 2002 IOM report, Crossing the Quality
Chasm
 Major lag between medical science and
technology advancements and healthcare
delivery
Salmon, 2007

14. Steps in EBP
1. Ask the “burning” question (PICO).
2. Collect the most relevant & best
evidence.
3. Critically appraise evidence
4. Integrate all evidence with one’s clinical
expertise/patient preferences/values.
5. Evaluate the practice decision or change.
Melnyk & Fineout-Overholt, 2005

15. 1. Ask the “burning” question using
PICO
 P: Patient, population, or problem being
addressed
 I: Intervention or dimension of interest
 C: Comparison intervention
 O: Outcome
 Format helps focus the question by
determining the important concepts
 Not necessary to follow above order
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

16. PICO Examples
 Intervention focused clinical question:
 “In teenagers (patient population), how effective is
Depo-Provera (intervention) in the prevention of
pregnancy (outcome)?
 Non-intervention focused question:
 What is the duration of breast feeding (outcome) in
new mothers (population) who have breast-related-
complications (area of interest) in the first 3 months
after the infants birth versus those who do not have
breast related complications (comparison)?
(Salmon, 2007)

17. 2. Collect most relevant and
best evidence
1. Systematic review/meta-analysis of all RCTs or
evidence-based clinical practice guidelines
2. At least one well-designed RCT
3. Well-designed controlled trials without
randomization
4. Well designed case-control and cohort studies
5. Systematic review of descriptive and qualitative
studies
6. Single descriptive or qualitative study
7. Opinion of authorities and/or reports of expert
committees
(Melnyk & Fineout-Overholt; 2005)

18. 2. Collect most relevant and
best evidence
 Evidence Based Clinical Practice Guideline
 Based on scientific literature
 Explicitly documents process used to develop
statement
 Grades strength of evidence used
(www.chestnet.org/education/guidelines/currentGuidelines.php; cited in Melnyk
& Fineout-Overholt, 2005)

19. 2. Collect most relevant and
best evidence
 Systematic Review:
 Rigorous systematic review of primary studies
 Preplanned comprehensive search strategy
 Relevant articles
 appraised
 data synthesized
 results interpreted
 summary of best available evidence provided
Precise; minimizes error & bias
(Salmon, 2007)

20. 2. Collect most relevant and
best evidence
 Meta-analysis:
 Integrates results of similar descriptive or
qualatitative studies
 Meta-synthesis:
 Statistical method
 Integrates results of several independent studies
addressing a set or related research hypotheses
 Objective appraisal
 Precise estimate of treatment effect
(Salmon, 2007)

21. 2. Collect most relevant and
best evidence
 RCT:
 “Gold Standard” for intervention studies
 Most reliable
 Treatment randomization eliminates large amount of
bias
 Cohort Study:
 Observational longitudinal study with 2 patient groups
 One group receives treatment
 Groups measured over time for development of
outcomes
(Salmon, 2007)

22. 2. Collect most relevant and
best evidence
 Case-control studies:
 Compares patients who have a specific
condition to people who do not
 Uses medical records and/or patient recall
 Less reliable than RCTs and cohort studies
 showing a statistical relationship does not
necessarily mean clinical causal relationship
(Salmon, 2007)

23. 2. Collect most relevant and
best evidence
 Qualitative Research:
 Collects data through observations and interviews
 Generates ideas and hypotheses through inductive
 Descriptive Studies:
 Can be quantitative or qualitative
 Describe what is going on
 Expert Opinion
(Salmon, 2007)

24. Search Strategy
1. Determine appropriate data base for question
2. Determine type of study design that would best
answer question
3. Enter a subject heading (e.g., MeSH in PubMed)
and/or textword search guided by the PICO
components of the question
4. Combine searches to find relevant evidence
5. Further restrict combined searches for study design,
methods, indicators of clinical meaningfulness, English,
human
6. Apply pre-established inclusion & exclusion criteria to
studies gathered by the search
Pre-appraised literature is golden
(Salmon, 2007)

25. 3. Critically Appraise Evidence
RCT
 Rapid Screening
 Random allocation of interventions?
 Blindness to interventions by
 Researchers?
 Participants?
 Involved health care professionals?
(Melnyk & Fineout-Overholt; 2005)

26. 3. Critically Appraise Evidence
Systematic Review
 Rapid Appraisal
 Relevant papers identified?
 Method of assessing quality of papers?
 Method of summarizing results?
(Melnyk & Fineout-Overholt; 2005)

27. 3. Critically Appraise Evidence
Qualitative Research
 Lincoln & Guba’s Evaluative Criteria:
 Trustworthiness
 Credibility (internal validity)
 Transferability (external validity)
 Dependability (reliability)
 Confirmability (objectivity)
(Melnyk & Fineout-Overholt; 2005)

28. 4.Integrate Evidence/Patient Preferences/
Values/Clinical Experience
 Evidence assists but does not replace
sound clinical reasoning.
 Evidence
 Analogy
 Experience
 Meaning
 Theory
Salmon, 2007)

29. 4.Integrate Evidence/Patient
Preferences/Values/Clinical Experience
 Is evidence useful for this particular
patient?
 Cost effective?
 Patient values and preferences?
 Clinician expertise?
Best clinical decision making
is
integrative and collaborative! Salmon, 2007)

30. 5. Implement & Evaluate Impact
 Track outcomes
 Include patients’ evaluations
 Requires informatics for imputing & tracking
 Patient
 Treatment
 Outcome