Evidence Based Practice in Nursing
NRSG 354
2- Process of evidence based
practice
OBJECTIVES
At the end of this session, each student should be able to:
1. Discuss the seven (7) steps of the evidence based
practice process.
2. Integrate the Evidence Based Practice competencies.
THE SEVEN STEPS OF EVIDENCE-BASED PRACTICE
0. cultivate a spirit of inquiry within an evidence-based practice
(EBP) culture and environment.
1. Ask the burning clinical question in PICOT format.
2. Search for and collect the most relevant best evidence.
3. Critically appraise the evidence (i.e., rapid critical appraisal,
evaluation, and synthesis).
4. Integrate the best evidence with one’s clinical expertise and
patient/family preferences and values in making a practice decision
or change.
5. Evaluate outcomes of the practice decision or change based on
evidence.
6. Disseminate the outcomes of the EBP decision or change.
STEP 0: CULTIVATE A SPIRIT OF INQUIRY WITHIN AN
EBP CULTURE AND ENVIRONMENT
Before embarking on the well-known steps of EBP, it is
critical to cultivate a spirit of inquiry (i.e., a consistently
questioning attitude toward practice) so that clinicians are
comfortable with and excited about asking questions
regarding their patients’ care as well as challenging current
institutional or unit-based practices.
STEP 0: CULTIVATE A SPIRIT OF INQUIRY WITHIN AN
EBP CULTURE AND ENVIRONMENT
Key elements of an EBP culture and environment
A spirit of inquiry where all health professionals are
encouraged to question their current practices
A philosophy, mission, clinical promotion system, and
evaluation process that incorporate EBP and the EBP
competencies
A team of EBP mentors, who have in-depth knowledge and
skills in EBP
STEP 0: CULTIVATE A SPIRIT OF INQUIRY WITHIN AN
EBP CULTURE AND ENVIRONMENT
Key elements of an EBP culture and environment
Tools to enhance EBP (e.g., computers for searching at the point
of care, access to key databases and librarians, ongoing EBP
educational and skills-building sessions, EBP rounds and journal
clubs)
Administrative support and leadership
Regular recognition of individuals and groups who
consistently implement EBP
STEP 1: FORMULATE THE BURNING CLINICAL PICOT
QUESTION
PICOT format (sometimes called (PICO)
P: patient population
I: intervention or issue of interest
C: comparison intervention or group
O: outcome
T: time frame
STEP 1: FORMULATE THE BURNING CLINICAL
PICOT QUESTION
For example
In teenagers how does cognitive behavioral skills building compared
with yoga affect anxiety after 6 weeks of treatment
P: (the patient/ population) : teenagers
I: Intervention: (the experimental) : how does cognitive
behavioral skills building
C: the comparison intervention (cognitive behavioral skills
building compared with yoga)
O: outcome : affect anxiety
T: the time taken for the interventions to achieve the
outcome)? after 6 weeks of treatment
STEP 1: FORMULATE THE BURNING CLINICAL
PICOT QUESTION
For other clinical questions that are not focused on intervention,
the meaning of the letter I can be “issue of interest” instead of
“intervention
For example
How do new mothers who have breast-related complications
perceive their ability to breastfeed past the first 3 months after
their infants’ birth
P: patient/population (How do new mothers)
I: issue of interest: who have breast-related complications
C: outcome: perceive their ability to breastfeed
T: time: past the first 3 months after their infants’ birth
STEP 2: SEARCH FOR THE BEST EVIDENCE
The search for best evidence should first begin by considering
the elements of the PICOT question.
The type of study that would provide the best answer to an
intervention or treatment question would be systematic reviews
or metaanalyses which are regarded as the strongest level of
evidence on which to base treatment decisions
STEP 2: SEARCH FOR THE BEST EVIDENCE
Rating System for the Hierarchy of Evidence for Intervention/Treatment
Questions
1- Evidence from a systematic review or meta-analysis of all relevant
randomized controlled trials (RCTs)
2- Evidence obtained from well-designed RCTs
3- Evidence obtained from well-designed controlled trials without
randomization
4- Evidence from well-designed case-control and cohort studies
5- Evidence from systematic reviews of descriptive and qualitative studies
6- Evidence from a single descriptive or qualitative study
7- Evidence from the opinion of authorities and/or reports of expert
committees
STEP 2: SEARCH FOR THE BEST EVIDENCE
1- Evidence from a systematic review
A systematic review is a synthesis of evidence on a particular topic,
typically conducted by an expert that uses a rigorous process for
identifying, appraising, and synthesizing studies, to answer a
specific clinical question
For example: In adult women with arthritis, how does massage
compare with pharmacologic agents to reduce pain after 2 weeks
of treatment?
STEP 2: SEARCH FOR THE BEST EVIDENCE
1- Evidence from a systematic review
For example: In women, how does an early lifestyle
adoption of a healthy diet and exercise predict heart
disease in older adulthood?
Many systematic reviews incorporate quantitative
methods to compare the results from multiple studies
STEP 2: SEARCH FOR THE BEST EVIDENCE
Evidence from meta-analysis of all relevant randomized
controlled trials (RCTs)
A meta-analysis generates an overall summary statistic that
represents the effect of the intervention across multiple studies.
When a meta-analysis can combine the samples of each study
included in the review to create one larger study, the summary
statistic is more precise than the individual findings from any
one of the contributing studies alone
STEP 2: SEARCH FOR THE BEST EVIDENCE
If systematic reviews and meta-analyses are not available to
answer a clinical practice treatment question, the next step should be
a search for original RCTs found in databases such as:
MEDLINE or the Cumulative Index of Nursing and Allied Health
Literature (CINAL)
If RCTs are not available, the search process should then include other
types of studies that generate evidence to guide clinical decision making
(e.g., nonrandomized, descriptive, or qualitative studies) to determine the
best available body of evidence
STEP 3: CRITICAL APPRAISAL OF EVIDENCE
Step 3 in the EBP process is vital in that it involves critical
appraisal of the evidence obtained from the search process.
the first steps of critical appraisal can be efficiently
accomplished by answering three key questions as part of a
rapid critical appraisal process in which studies are
evaluated for their validity, reliability, and applicability to
answer the posed clinical question
STEP 3: CRITICAL APPRAISAL OF EVIDENCE
1- Are the results of the study valid? (Validity)
Are the results as close to the truth as possible?
Did the researchers conduct the study using the best
research methods possible.
2- What are the results? (Reliability)
For example, in an intervention trial, this includes (a) whether the
intervention worked; (b) how large a treatment effect was
obtained; and (c) whether clinicians could expect similar results if
they implemented the intervention in their own clinical practice
setting (i.e., the preciseness of the intervention effect).
STEP 3: CRITICAL APPRAISAL OF EVIDENCE
3- Will the results help me in caring for my patients?
(Applicability)
This includes asking whether:
(a) the subjects in the study are similar to the patients for whom
care is being delivered
(b) the benefits are greater than the risks of treatment (i.e.,
potential for harm);
(c) the treatment is feasible to implement in the practice setting;
(d) the patient desires the treatment.
STEP 4: INTEGRATE THE EVIDENCE WITH CLINICAL
EXPERTISE AND PATIENT/FAMILY PREFERENCES TO
MAKE THE BEST CLINICAL DECISION
The next key step in EBP is integrating the best evidence found from the
literature with the healthcare provider’s expertise and patient/family
preferences and values to implement a decision (i.e., putting evidence
into action).
Clinical expertise includes how clinicians understand the given
population for whom they care and known sequelae of clinical issues,
the available healthcare resources, their personal experiences with
healthcare decision making, and their competence in critical appraisal.
STEP 4: INTEGRATE THE EVIDENCE WITH CLINICAL
EXPERTISE AND PATIENT/FAMILY PREFERENCES TO MAKE
THE BEST CLINICAL DECISION
For Example:
hormone replacement therapy [HRT] to prevent osteoporosis in a
very high-risk woman), a discussion with the patient may reveal
her intense fear of developing breast cancer while taking HRT or
other reasons that the treatment is not acceptable. Moreover, as
part of the history-taking process or physical examination, a
comorbidity or contraindication may be found that increases the
risks of HRT
STEP 4: INTEGRATE THE EVIDENCE WITH CLINICAL
EXPERTISE AND PATIENT/FAMILY PREFERENCES TO MAKE
THE BEST CLINICAL DECISION
For example
on follow-up evaluation, a clinician notes that the first-line
treatment of acute otitis media in a 3-year-old patient was not
effective. The latest evidence indicates that antibiotic A has
greater efficacy than antibiotic B as the second-line treatment for
acute otitis media in young children. However, because antibiotic
A is far more expensive than antibiotic B and the family of the
child does not have prescription insurance coverage, the
practitioner and parents together may decide to use the less
expensive antibiotic to treat the child’s unresolved ear infection.
STEP 5: EVALUATE THE OUTCOMES OF THE PRACTICE
CHANGE BASED ON EVIDENCE
How the change affected patient outcomes
How effective the clinical decision was with a particular
patient or practice setting.
This type of evaluation is essential to determine whether the
change based on evidence resulted in the expected outcomes
when implemented in the real-world clinical practice setting.
Measurement of outcomes (e.g., length of stay, readmission
rates, patient complications, turnover of staff, costs)
is important to determine and document the impact of the EBP
change on healthcare quality and/or patient outcomes
STEPS OF THE EVIDENCE-BASED PRACTICE (EBP) PROCESS
LEADING TO HIGH-QUALITY HEALTHCARE AND BEST PATIENT
STEP 6: DISSEMINATE THE OUTCOMES OF THE EVIDENCE-
BASED PRACTICE CHANGE
It is important for clinicians to disseminate outcomes of their
practice changes based on evidence through such venues as:
oral and poster presentations at local, regional, and national
conferences
EBP rounds within their own institutions
journal and newsletter publications
lay publications
EVIDENCE BASED PRACTICE COMPETENCIES
Competence is defined as “the ability to do something well”
The American Nurses Association (ANA, 2010) defines competency
as “an expected and measurable level of nursing performance that
integrates knowledge, skills, abilities, and judgement, based on
established scientific knowledge and expectations for nursing
practice”
Competencies are necessary in order to deliver high-quality safe
care
Use of competencies also can enhance clinical effectiveness,
decrease variability across healthcare systems, and improve
education of clinicians
EVIDENCE BASED PRACTICE COMPETENCIES
1. Quality and Safety Education for Nurses (QSEN, 2013)
established competencies for nursing pre-licensure and
graduate education.
QSEN competencies focus on the following practice areas:
Patient-centered care
Teamwork and collaboration
EBP
Quality improvement
Safety
Informatics
EVIDENCE BASED PRACTICE COMPETENCIES
(CON’T)
2. Stevens developed EBP competencies for nursing education through a
consensus process to support faculty in preparing their students for EBP
and to “provide a basis for professional competencies in clinical practice”
(2005):
Define EBP in terms of evidence, expertise, and patient values.
Critically appraise original research reports for practice implications.
Classify clinical knowledge as primary research, evidence summary,
or practice guideline.
EVIDENCE BASED PRACTICE COMPETENCIES (CON’T)
Recognize ratings of strength of evidence when reading
literature.
Use evidence summary databases to locate systematic reviews
and evidence summaries on clinical topics.
Participate on a team to develop agency-specific evidence-
based clinical guidelines.
Deliver care using evidence-based clinical practice guidelines.
Choose evidence-based approaches over routine as basis for
own clinical decision-making.
EVIDENCE BASED PRACTICE COMPETENCIES (CON’T)
3. AACN Essential Competencies (1998) (American Association
of College of Nursing)
Related to Critical Thinking
Apply research-based knowledge from nursing and sciences as
the basis for practice.
Evaluate nursing care outcomes through the acquisition of data
and questioning of inconsistencies.
Integrate theory and research-based knowledge from the arts,
humanities and sciences to develop a foundation for practice.
Participate in research that focuses on the effectiveness of
nursing interventions.
Utilize outcome measures to evaluate effectiveness of care.
