EVIDENCE-BASED PRACTICE

What is EBP?

Acronyms

John Hopkins Evidence-Based Practice Model

The 3 Phases of EBP

John Hopkins Model Resources

What is EBP?

Dearholt, Sandra L., and Dang, Deborah. Johns Hopkins Nursing Evidence-Based Practice: Models and Guidelines (2nd Edition).

EBP is a problem-solving approach to clinical decision-making within a health care organization. It integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence. EBP considers internal and external influences on practice and encourages critical thinking in the judicious application of such evidence to the care of individual patients, a patient population, or a system (Newhouse, Dearholt, Poe, Pugh, & White, 2007).

Acronyms 

Many different terms and acronyms are used to describe Evidence-Based Clinical Practice. 

- Evidence-Based Medicine (EBM)
- Evidence-Based Practice (EBP)
- Evidence-Based Health Care (EBHC)
- Evidence-Based Dentistry (EBD)
- Evidence-Based Nursing (EBN)
- Evidence-Based Public Health (EBPH)

Johns Hopkins Evidence-Based Practice Model

From John Hopkins Nursing Evidence-Based Practice: Model and Guidelines
Dearholt, S., Dang, Deborah, & Sigma Theta Tau International. (2012). Johns Hopkins Nursing Evidence-based Practice : Models and Guidelines.

The 3 Phases of EBP

The JH Evidence-based Practice Model consists of three phases:
 

Practice - Develop and refine your question and your team

Evidence - Search, appraise, summarize and synthesize internal and external sources of evidence.

Translation - Create and implement an action plan, evaluate outcomes, disseminate findings.

Johns Hopkins Model Resources

These books describe how to conduct evidence-based practice. There are chapters on the various steps in the Hopkins model, outlining how and when they should be completed. The appendixes include printable worksheets that can be used to track your progress. Reading the book(s) first is recommended if you're unsure how to proceed with your project.

ASKING YOUR QUESTION & PICO

Identify the Problem

PICO (Translating the Question into Searchable Parts)

PICO Question Formats

Background vs. Foreground

Types of Questions

Study Design (Clinical Questions)

The Literature Review Process

Identify the Problem

The most important step in Evidence-Based Practice (EBP) is to correctly identify a problem through patient assessment or practice assessment, processes that require reflection by the nurse on clinical practice, in conjunction with a knowledge of the patient's present circumstances. The information below describes how to frame the question once the patient or practice assessment and the resulting problem identification have occurred.

PICO (Translating the Question into Searchable Parts)

Clinical and healthcare practice questions can be broken down into the PICO(T) format, which breaks a question apart into searchable parts:

P – Patient, population, problem
I – Intervention or Exposure
C – Comparison 
O – Outcome 
T – Time (May not be available in every instance)

Example: A small, rural hospital's primary population has become elderly patients and the nurses are working together to update patient safety procedures. When they look at hospital records, they realize that falls are their number one risk factor among their patients. The question might be: what is the effectiveness of restraints in reducing the occurrence of falls in patients 65 and over? , which can be broken apart into descriptors, written in noun forms, such as:

• P – elderly, inpatient, accidental falls
• I – restraint, physical restraint
• C – no restraint
• O – to be determined once the literature has been found and in conjunction with an understanding of the patient’s specific situation and the underlying causes of sleep loss.
• T– not applicable in this example

PICO Question Formats

Fill in the blanks with information from your clinical scenario:

THERAPY
In_______________, what is the effect of ________________on _______________ compared with _________________?

PREVENTION
For ___________ does the use of _________________ reduce the future risk of ____________ compared with ______________?

DIAGNOSIS OR DIAGNOSTIC TEST
Are (Is) ________________ more accurate in diagnosing _______________ compared with ____________?

PROGNOSIS
Does ____________ influence ______________ in patients who have _____________?

ETIOLOGY
Are ______________ who have _______________ at ______________ risk for/of ____________ compared with _____________
with/without______________?

MEANING
How do _______________ diagnosed with _______________ perceive __________________?

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Background vs. Foreground

Background questions ask for general knowledge and do not normally arise from the need to make a clinical decision.

• Background questions usually have two essential components:
  • A question root (who, what, when, etc.) with a verb
  • A disorder, treatment, test, or other aspect of healthcare
    • e.g. What causes obesity? When should children be introduced to sexual education?  Who is most susceptible to nursing burn out?

• Background information can be found in: 
  • reference book entries
  • textbooks, chapters, appendices
  • drug monographs, guides to diagnostic tests

​Foreground questions ask for specific knowledge to inform clinical decisions or actions.

• ​Foreground questions usually have 3 or 4 essential components, from the PICO format:
  • ​Patient/population characteristics, problem
  • Interventions or Exposures 
  • Comparison
  • Outcome

Types of Questions

Clinical questions

Clinical questions typically fall into one of four main categories:

• Etiology (or harm/risk factors): What causes the problem?
• Diagnosis: Does this patient have this problem?
• Therapy: What is the best treatment for this problem?
• Prognosis: What will the outcome of the problem be?

* Knowing the type of clinical question is important later in the EBN process--once the nurse goes to look for studies that will answer his/her question.

Practice Questions

Many other questions about practice will also arise, with some of the questions resulting from working with rather than on the patient. These questions can be quantitative or qualitative in nature. Examples include:

• What other, validated instruments for measuring this condition or phenomenon (e.g. pain) exist and how do they compare to the one we currently use? 
• Should a nurse deliver patient education on the patient's disease/condition near the beginning or the end of an appointment or consultation?
• How do caregivers of patients with [x] cope with the burden of care and how can nurses assess the level of caregiver burden and/or support the caregivers?

Study Design (Clinical Questions)

Different types of clinical questions are best answered by different types of research studies. Understanding what types of studies are best suited for your question can improve your search for information to answer your question.

All types of clinical questions can be answered by systematic reviews or meta-analysis, when available. When these filtered resources are not available, look for unfiltered resources (individual studies), focusing on the study types appropriate to your question. The table below suggests study designs best suited to answer each type of clinical question.

The Suggested Research Designs refer to the resource types in the John Hopkins Nursing EBP: Levels of Evidence diagram in the next tab.

The Literature Review Process

1. Write down your topic in a way to identify the key concepts and issues that you want to address. You may find it helpful to structure the topic in a PICOT format (P = Patient, Population, I = Intervention, C = Comparison or Control, O = Outcomes T = Time). Although it is not necessary to use all elements of the PICO in the search strategy, this will help you frame the topic into a translatable framework. Use the PICO worksheet and the Search Building Worksheets below to help keep track of your research concepts and search terms. For more information on PICOT, see the PICOT section above. 
2. Do some background research to see what's already been written about the topic. You may find it helpful to search books and journals through the library catalog, as well as databases that may be relevant to your topic.
3. Narrow down the topic, if necessary. You may find that the original question is too broad. After you have done the background research, you will have a better idea of what specifically you are interested in.
4. Decide on the scope and nature of your review. What types of research are you interested in? Are you prepared to do title and abstract screening? What are you hoping to address with your research?
5. Create and execute your database searches. Searching is an iterative process, so you may need to test and refine before settling on your final search strategy. Your search strategy should use a combination of keywords and controlled vocabulary terms to represent each concept of your research topic. Combine your search concepts using AND, OR, or NOT to refine or broaden your search. For more information on combining search terms, see the Combining Search Terms to Locate Information section in the Databases & Searching Help tab in this guide.  
6. Examine and evaluate your results to make sure that they could potentially answer your research question. This is the point to make changes before proceeding.
7. Export and screen your results. Using a citation manager will allow you to remove duplicates when you screen. 
8. Extrapolate the data and evidence to draw conclusions about your research topic. For more information see the Tools for Translation tab in this guide. 

EVALUATING THE EVIDENCE

Levels of Evidence 

Types of Resources

Criteria 

John Hopkins Nursing EBP: Levels of Evidence 

Levels of Evidence

Levels of evidence (sometimes called hierarchy of evidence) are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. These decisions give the "grade (or strength) of recommendation".

The systematic review or meta-analysis of randomized controlled trials (RCTs) and evidence-based practice guidelines are considered to be the strongest level of evidence on which to guide practice decisions. (Melnyk, 2004) The weakest level of evidence is the opinion from authorities and/or reports of expert committees.

Types of Resources

When searching for evidence-based information, one should select the highest level of evidence possible--systematic reviews or meta-analysis. Systematic reviews, meta-analysis, and critically-appraised topics/articles have all gone through an evaluation process: they have been "filtered". 

Information that has not been critically appraised is considered "unfiltered".

As you move up the pyramid, however, fewer studies are available; it's important to recognize that high levels of evidence may not exist for your clinical question.  If this is the case, you'll need to move down the pyramid if your quest for resources at the top of the pyramid is unsuccessful.

• Meta-Analysis: A systematic review that uses quantitative methods to summarize the results.

• Systematic Review: An article in which the authors have systematically searched for, appraised, and summarized all of the medical literature for a specific topic.

• Critically Appraised Topic: Authors of critically-appraised topics evaluate and synthesize multiple research studies.

• Critically Appraised Articles: Authors of critically-appraised individual articles evaluate and synopsize individual research studies.

• Randomized Controlled Trials: RCT's include a randomized group of patients in an experimental group and a control group. These groups are followed up for the variables/outcomes of interest.

• Cohort Study: Identifies two groups (cohorts) of patients, one which did receive the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest.

• Case-Control Study: Involves identifying patients who have the outcome of interest (cases) and control patients without the same outcome, and looking to see if they had the exposure of interest.

• Background Information / Expert Opinion: Handbooks, encyclopedias, and textbooks often provide a good foundation or introduction and often include generalized information about a condition. While background information presents a convenient summary, often it takes about three years for this type of literature to be published.

• Animal Research / Lab Studies:  Information begins at the bottom of the pyramid: this is where ideas and laboratory research takes place. Ideas turn into therapies and diagnostic tools, which then are tested with lab models and animals.

Criteria

When appraising research, keep the following three criteria in mind:

Quality 
Trials that are randomized and double-blind, to avoid selection and observer bias, and where we know what happened to most of the subjects in the trial.

Validity
Trials that mimic clinical practice, or could be used in clinical practice, and with outcomes that make sense. For instance, in chronic disorders, we want long-term, not short-term trials. We are [also] ... interested in outcomes that are large, useful, and statistically very significant (p < 0.01, a 1 in 100 chance of being wrong).

Size
Trials (or collections of trials) that have large numbers of patients, to avoid being wrong because of the random play of chance. For instance, to be sure that a number needed to treat (NNT) of 2.5 is really between 2 and 3, we need results from about 500 patients. If that NNT is above 5, we need data from thousands of patients.

These are the criteria on which we should judge evidence. For it to be strong evidence, it has to fulfill the requirements of all three criteria.

Johns Hopkins Nursing EBP: Levels of Evidence

Level I
Experimental study, randomized controlled trial (RCT)
Systematic review of RCTs, with or without meta-analysis

Level II
Quasi-experimental Study
Systematic review of a combination of RCTs and quasi-experimental, or quasi-experimental studies only, with or without meta-analysis.

Level III
Non-experimental study
Systematic review of a combination of RCTs, quasi-experimental and non-experimental, or non-experimental studies only, with or without meta-analysis.
Qualitative study or systematice review, with or without meta-analysis

Level IV
Opinion of respected authorities and/or nationally recognized expert committees/consensus panels based on scientific evidence.
    Includes:
         - Clinical practice guidelines
         - Consensus panels

Level V
Based on experiential and non-research evidence.
    Includes:
      - Literature reviews
      - Quality improvement, program or financial evaluation
      - Case reports
      - Opinion of nationally recognized expert(s) based on experiential evidence

From Johns Hopkins nursing evidence-based practice : models and guidelines
Dearholt, S., Dang, Deborah, & Sigma Theta Tau International. (2018). Johns Hopkins Nursing Evidence-based Practice : Models and Guidelines.

DATABASES & SEARCHING HELP

OCLS Health Sciences Databases

Combining Search Terms to Locate Information

Practice Guidelines in OCLS Databases

OCLS Search Help

OCLS Health Sciences Databases

For a complete list of health sciences databases that are available through OCLS, visit OCLS Health Sciences databases.

Combining Search Terms to Locate Information (an overview)

Once you choose your database, you will need to combine the search terms you chose using the PICO method. This is often done by selecting matching subject headings in the database and by using AND, OR, and NOT to combine the search terms.

Subject headings are controlled vocabulary created by organizations to give consistency to the way that literature is described. Often, the initial words chosen when constructing a PICO(T) question are simply keywords, which are natural language words and not used consistently by all researchers who produce literature. Whenever possible, locate and use the subject headings within a database in order to search for articles. An example of the difference is:

In this example, one researcher may use the term 'childbirth', another researcher uses the term 'birth' and another researcher uses the term 'parturition'. All three researchers are describing the same concept, but using different terms to do so. Within a database, a subject heading of 'Parturition' would have been assigned to all three articles, making all three articles easy to find with the subject heading. Without this subject heading, if you had searched using the keyword 'birth', you probably would have missed the articles in which the researchers had used either 'childbirth' or 'parturition'. 

Using subject headings helps you to retrieve articles that are more relevant to your question, while gathering in articles that keyword searching would have missed.

AND, OR, NOT are used to combine search terms (keywords or subject headings) within a database. 

AND is used when you want an article to contain both (or several) concepts--it tells the database that you only want articles that include all your terms. E.g. [Sutures AND staples AND pain] would only give you articles that discuss all three of those keywords or concepts.

OR is used when you want articles on two different concepts or think more than one keyword or subject heading would be appropriate. E.g. [(Sutures OR staples) AND pain] would give you articles that either discuss just sutures AND pain as well as articles that just discuss staples AND pain. Notice that the words with an OR between them live inside parentheses, which is necessary in order for the database to interpret your search correctly. Keep this in mind when using OR.

NOT is used to exclude concepts from searches, however, using NOT often results in missed articles. One example might be: [sepsis NOT mice], which would eliminate articles on 'sepsis in mice.'

Practice Guidelines in OCLS Databases

In many of the IWU OCLS Health Sciences databases (MEDLINE and CINAHL), you can limit your search to just practice guidelines - look for a limiter called "guidelines" or "practice guidelines", often found under "Publication Types".

OCLS Search Help

Do you need help with a specific research topic?  Contact Online Campus Library Services and request a Personalized Search Plan!

Personalized Search Plans (PSPs) tell you where to go; what to do; and how to do it. Your PSP will suggest the best online database(s) and search term(s) to use. Depending on what kinds of information you need, your PSP might help you to find appropriate print books, e-books, or journal articles. 

Each PSP includes step-by-step directions so that you can find trusted sources for your assignments and is customized to your needs.

To request your Personalized Search Plan, fill out our Online Request Form and let us know your topic and what kinds of information you need – books, e-books, journal articles, websites, or if you need peer-reviewed or research-based information. 

PSP requests are answered within one (1) business day, not including weekends. Requests that are received by 12:00 noon (ET) on Friday will be answered that same day. 

OCLS provides limited service on Saturday and is closed Sunday and all university holidays and holiday weekends, so we encourage you to ask for your Personalized Search Plan early in your workshop weeks whenever possible.

TOOLS FOR TRANSLATION

Standards for Quality Improvement Reporting Excellence (SQUIRE)

Standards for Quality Improvement Reporting Excellence (SQUIRE) Guidelines

SQUIRE 2.0 Guidelines
The SQUIRE guidelines provide a framework for reporting new knowledge about how to improve healthcare. They are intended for reports that describe system level work to improve the quality, safety, and value of healthcare, and used methods to establish that observed outcomes were due to the intervention(s).

RESOURCES

Do It Yourself Evidence-Based Medicine Reviews

Free Online Resources

Practice Guidelines from Specific Organizations

EBP Metasearch

Practice Guidelines in OCLS Databases

Calculators

Do It Yourself Evidence-Based Medicine Reviews

If no official EBM review has been done on your topic, these filters and hedges may be helpful in reducing the amount of literature you need to analyze.

Free Online Resources

National Guidelines Clearinghouse

A public resource for evidence-based clinical practice guidelines from more than 100 institutions and organizations. It is sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the U.S. Department of Health and Human Services, in partnership with the American Medical Association and the American Association of Health Plans.
 

Professional Organizations such as the American Heart Association, the National Cancer Institute, the American Psychiatric Association or the American Academy of Pediatrics may post relevant evidence-based medicine reviews or practice guidelines based on EBM reviews on their Web sites.

At least some of these will be picked up by the National Guidelines Clearinghouse.

Practice Guidelines from Specific Organizations

• American Academy of Neurology - Practice Guidelines & Tools
• American Academy of Pediatrics - Clinical Practice Guidelines
• American Association for Respiratory Care - Clinical Practice Guidelines
• American College of Cardiology - Practice Guidelines & Quality Standards
• American College of Chest Physicians - Evidence-Based Clinical Practice Guidelines
• American College of Physicians - ACP Clinical Recommendations
• American Diabetes Association - Practice Guidelines Resources
• American Society of Health-System Pharmacists - Policy Positions & Guidelines (Best Practices)
• Canadian Medical Association Infobase

EBP Metasearch

Trip Database

A free clinical search engine, designed to allow users to quickly and easily find and use high-quality research evidence to support their practice and/or care.  As well as research evidence Trip also allow clinicians to search across other content types including images, videos, patient information leaflets, educational courses and news. Trip stands for "Translating Research Into Practice".

Practice Guidelines in OCLS Databases

In many of the IWU OCLS Health Sciences databases (MEDLINE and CINAHL), you can limit your search to just practice guidelines - look for a limiter called "guidelines" or "practice guidelines", often found under "Publication Types".

Calculators

These tools will help you to interpret the clinical and statistical significance of data reported in clinical research.

EBM Calculators

• ​Odds Ratio to NNT Converter
• Diagnostic Test Calculator
• Prospective Study Calculator
• Case Control Study Calculator
• Randomized Controlled Trial Calculator

Diagnostic Test Calculator 

• This calculator can determine diagnostic test characteristics (sensitivity, specificity, likelihood ratios) and/or determine the post-test probability of disease given given the pre-test probability and test characteristics. Given sample sizes, confidence intervals are also computed.

Clinical Calculator I

• From an Observed Sample: Estimates of Population Prevalence, Sensitivity, Specificity, Predictive Values, and Likelihood Ratios

Clinical Calculator II

• Predictive Values and Likelihood Ratios

AOTA RESOURCES

AOTA Evidence-Based Practice & Research

Evidence-based practice (EBP) is based on integrating critically appraised research results with the practitioner’s clinical expertise, and the client’s preferences, beliefs, and values. To promote EBP, AOTA has developed a number of resources to help members find and utilize clinically relevant literature to respond to both their clients’ needs and external demands for information from the scientific literature.

AOTA Evidence Exchange

AOTA's Evidence Exchange is a central repository for Critically Appraised Papers (CAPs) and related resources. The Evidence Exchange includes opportunities for members to participate as CAP Submitters as well as CAP Reviewers on an ongoing basis. 

AOTA EBP Resource Directory

The American Occupational Therapy Association's Evidence-Based Practice (EBP) Resource Directory is an online service that links users to Internet sites related to the evidence-based practice of occupational therapy.

You must be an AOTA member to access the EBP Resource Directory.