This document provides an overview of teaching evidence-based practice resources to nurses and nursing students. It defines evidence-based nursing practice and describes the importance of using evidence to improve patient care outcomes. Several strategies and resources for finding evidence on the web are highlighted, including searching databases like CINAHL and PubMed, as well as resources like DynaMed, Cochrane reviews, and clinical practice guidelines. Barriers to using evidence-based practice in nursing are also discussed.

1. 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

2. 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

3. 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.

4. Evidence-Based Practice

5. 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

6. 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

7. 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.

8. 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.

9. 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.

10. 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

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

12. Lots of Evidence Pyramids!

13. 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

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

15. 5S and 6S Pyramids 5S Model

16. 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

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

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

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

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

21. Search for the Best Evidence to answer the Question

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

23. 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

24. CINAHL: enter search terms

25. CINAHL Limit Your Results Screen CINAHL Limit Your Results Screen

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

27. CINAHL Results link to full text

28. Abstracts

29. Full text article

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

31. 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

32. 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

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

34. MEDLINE Results MEDLINE Results link to full text link to full text

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

37. healthlinks.washington.edu/howto/pubmed

38. 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

39. 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

40. 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

41. 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

42. h heal-wa.org

43. HEAL-WA Toolkit: Registered Nurse

44. HEAL-WA Toolkit: ARNP

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

46. 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.

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

48. 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

49. 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

51. Guideline Comparison

52. Guideline Summary

53. 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:

54. Search for Evidence Summaries DynaMed Evidence-based clinical resource providing summaries of 3,500+ diseases and conditions Nursing Reference Center 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

55. 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

57. DynaMed: Treatment Overview Level 1 evidence

58. DynaMed Treatment, detailed Level 1 evidence Full-text

59. DynaMed: Reviews and Guidelines

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

61. Nursing Reference Center 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

62. Nursing Reference Center: Basic Search

64. Nursing Reference Center Evidence-Based Care Sheet April 2009

65. 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

66. Evidence-Based Nursing review

68. 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

69. Essential Nursing Resources from ICIRN icirn.org

70. 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

71. Natural Medicines Comprehensive Database

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

73. Natural Standard Professional Monograph

74. Aloe Natural Standard

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

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

78. 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.

80. SUMSearch 2 sumsearch.org

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

82. 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.

83. 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

84. Cochrane Search link to full text

85. 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 .

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

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

88. Results for Systematic Reviews

89. 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

90. 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

91. 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

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

93. Advanced Google Results

94. 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

95. Google Scholar

96. 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

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

98. 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

99. 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/

100. 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.