Evidence-Based Practice (EBP) is a

thoughtful integration of the best available

evidence, coupled with clinical expertise.

EBP allows the practitioner to assess current

and past research, clinical guidelines, and
other information resources in order to
identify
relevant
literature
while
differentiating between high-quality and
low-quality findings.

Step 1: Formulating a well-built question

Step 2: Identifying articles and other
evidence-based resources that answer the
question
Step 3: Critically appraising the evidence to
assess its validity
Step 4: Applying the evidence
Step 5: Re-evaluating the application of
evidence and areas for improvement

1. Explosion of
Literature

2. Unmet
Information Needs

3. Implementation
Delays

EBP solution: there many evidence-based

review that synthesized & critically appraise
current healthcare literature. By using these
EBP resources, clinicians can make
evidence-based decisions about patient
care in a focused and time-efficient manner.

EBP solution: Synthesized EBP resources

are easy to use and help to quickly connect
practitioners with evidence-based answers
to their clinical questions.

EBP solution: EBP resources take into

account evidence from a wide variety of
fields and provide clinicians with the
opportunity for greater exposure to clinical
evidence.

With clinical cases, there is often a barrage of details to digest. To effectively

search EBP resources, you first need to decide what details are important to the
question at hand so you can formulate the question.
Convert your information need into an answerable question

Formulating Questions
The fundamental skill necessary to conduct evidence-based practice is learning
to design aWell-Built Clinical Question.
Once you decide what you are interested in learning about, you need to change
that thought into a question.
You can develop this important question by using PICO. PICO is an acronym for
population, intervention, comparison, and outcome.
By answering four questions
what about the population?
what about the intervention?
what about the comparison?
what about the outcome?
you will have the key terms you need to search the literature

The first part of formulating the question is about the population.

What individual or group are you interested in studying?
For example:
In our first example, you may be interested in studying newlygraduated registered nurses.
A second example might be a colleague working in pediatrics
interested in looking at a population of preterm infants.
A third example might be a team studying post-operative CABG
patients.
We will use these three examples to illustrate the PICO process.

Questions to ask
On what patient group do you want information?
Starting with your patient, ask "how would I describe a group of
patients similar to mine?"

The second part of formulating the question is about the intervention

you are considering.
An intervention can be an action you are taking to change a situation
or a medical event on which you want to study the effect.
In our first example about newly graduated registered nurses, the
intervention might be baccalaureate preparation for these nurses.
In the second example about pre-term infants, the intervention is the
administration of oral sucrose by your pediatric colleague for pain
management.
In the third example, the intervention being considered by the team is
the effect of a combined nurse and cardiovascular DVD approach on
discharge teaching.

Questions to ask
What medical event do you want to study the effect on?
Ask, "What key intervention am I considering?"

The third part of formulating the question looks at the comparison of

the intervention you just described to another intervention.
In our first example, the diploma preparation of nurses is being
compared to the baccalaureate preparation of nurses.
In our second example, it must be noted that some interventions do
not have comparisons. So, for the administration of oral sucrose for
pediatric pain management the comparison is made to the standard
of care, which is no treatment.
And in the third example, the combined nurse and cardiovascular DVD
approach for discharge teaching is being compared to the nurse led
discharge teaching approach.

Questions to ask
Compared to what? Better or worse than no intervention at all or than
another intervention?
Ask, "What is the main alternative to compare with the intervention?"

The fourth part of the PICO method of question formulation addresses

outcomes. What do you anticipate as an outcome?
For example one, an expected outcome might be that newly graduated
registered nurses obtaining baccalaureate degrees in nursing more frequently
choose careers in med-surg units.
In example two, an expected outcome might be that the administration of oral
sucrose for pediatric pain results in a decrease in behavioral pain response
scores.
And in our third example, an expected outcome might be that the combined
approach to discharge teaching decreases hospital readmissions

Questions to ask
What is the effect of the intervention?
Ask, "What do I hope to accomplish?" or
"What could this exposure affect?"

Infections in hospitals can be spread on the hands

of healthcare workers. It takes minutes to follow the
hand hygiene policy exactly before entering a room
to deliver patient care. On a busy hospital unit
where nurses care for many critically ill patients,
those minutes add up. Many hospitals have turned
to alcohol-based handrubs to save time and put
hand cleaners closer to patients. You are wondering
if alcohol based handrubs placed inside the patients
rooms would increase the incidence of handwashing
and decrease nosocomial infection.

P = Population

In hospitalized patients

I = Intervention is the use of hand sanitizers

as effective as traditional
C = Comparison

handwashing

O = Outcome

in controlling
infection?

PICO is a state of mind.

Applying PICO is a systematic way to identify important
concepts in a case, and formulate a question for
searching. However, you will often not have a
comparison intervention. Also, different types of EBP
resources require different levels of specificity, so
depending on the type of resource youre using, you
might not search with all the PICO components at first.
Remember, no matter what type of resource youll
ultimately use to look for answers, you should always
start by applying PICO to your question so you can think
about it strategically.

Find relevant evidence.

Locating evidence to answer a clinical nursing question or to

support the development of a nursing policy requires an
understanding of the information resources available to you
through the Penn State Libraries system and elsewhere.

The following resources are organized sequentially to assist

you in a systematic approach to searching for Evidence-based
information. If the first resource doesnt help you with your
question, try the next on the list, keeping in mind that there
may not be evidence available for your question(s) in the
exact format you envision. If no one has studied or published
research results on your topic, you may need to infer from
research on similar or related topics.

Research studies and clinical trials published in the journal literature form the foundation
of scientific evidence, but not all research meets the highest standards of quality.

Systematic Reviews/Meta-analyses

If one research study or clinical trial provides good evidence, several studies with similar
results may provide even stronger evidence or negate previous findings. This logic is
applied by researchers to systematically identify, appraise and synthesize evidence from
individual studies on a particular topic.

A vigorous review process with standardized protocols is applied to multiple studies,

often utilizing meta-analysisof data from several studies, combined with statistical
analyses techniques to minimize the bias of the conclusions. These processes translate
into the literature assystematic reviewsand summaries of evidence.

Resources
Cochrane Database of Systematic Reviews
DARE (Database of Abstracts of Reviews of Effects)
Joanna Briggs Institute
Clinical Evidence
Agency for Healthcare Research and Quality (AHRQ)
National Guidelines Clearinghouse

After identifying an article or resource that

seems appropriate to your question (step 2),
you must appraise the information critically. If
the study is from a primary sourceone that
provides original data on a topic with no
commentaryyou should do a validity
(closeness-to-truth) check. To check for validity,
ask questions related to diagnosis, therapy,
harm, and prognosis.

While there are more detailed questions that you would need to ask depending
onthe type of study(therapy, diagnosis, etiology, or prognosis), you can begin
by asking these general questions to determine if the evidence is applicable to
your clinical question.
Are the results of the study good enough?
Is it clear what the research question is?
Were appropriate study methods used?
Do the authors give you enough information about how the data was collected?
Is there enough analysis of the data to determine if the study is valid?
Was the data interpreted and the conclusions clearly stated?
Are there other studies with similar conclusions?
Do the findings apply to this clinical setting and patient population?
Were the patients in the study similar to patients here?
Are the findings applicable to more than one clinical setting?
Is the evidence strong enough to warrant a change in practice?
Where does this study type fall on theHierarchy of Evidence?
Appraising the evidence is a complex issue. TheTools for Critically Appraising
the Literaturemay help you identify the study design, type of question, level of
evidence for an individual research article.

Type of Question/Type of Study

Therapy how to select treatments for patients that do more
good than harm and that are worth the efforts and costs of using
them.
Diagnosis how to select and interpret diagnostic tests, in
order to confirm or exclude a diagnosis, based on considering
their precision, accuracy, acceptability, expense, safety, etc.
Prognosis how to estimate our patient's likely clinical course
over time and anticipate likely complications of the disorder.
Etiology how to identify causes for disease
* Adapted from Sackett et al.Evidence-Based Medicine: How to
Practice and Teach EBM(London: Churchill Livingstone, 2000):
19.

Type of Study/Study Design

Randomized Controlled Trial RCT)
A true experiment, (one that delivers an intervention or treatment), the strongest
design to support cause and effect relationship, in which subjects are randomly
assigned to control and experimental groups.
Cohort Study
A prospective longitudinal study that begins with the gathering of two groups of
patients (the cohorts), one that received the exposure (e.g., to a disease) and one
that does not, and then following these groups over time to measure the
development of different outcomes (diseases).
Case Study
An intensive investigation of a case involving a person or small group of persons,
an issue, or an event.
Case-Control Study
A type of research that retrospectively compares characteristics of an individual
who has a certain condition with one who does not; often conducted for the
purpose of identifying variables that might predict the condition.

Question about

Look for this type of study

THERAPY

Randomized Controlled Trial

(RCT)

DIAGNOSIS

RCT or other Controlled Trial

PROGNOSIS

Cohort Studies, Case-Control

Studies, Case Studies

ETIOLOGY

Cohort Studies

* Adapted from Sackett et al.Evidence-Based Medicine: How to

Practice and Teach EBM.London: Churchill Livingstone,
2000:19.

Level I
Level II
Level III
Level IV
Level V
Level VI
Level VII

Evidence for a systematic review or meta-analysis

of all relevant RCTs or evidence-based clinical
practice guidelines based on systematic reviews of
RCTs.
Evidence obtained from at least one well-designed RCT
Evidence obtained from one well-designed controlled
trials without Randomization
Evidence from well-designed case-control and cohort
studies
Evidence from systematic reviews of descriptive or
qualitative study
Evidence from single descriptive or qualities study
Evidence from the opinion of authorities and/or reports of
expert committees

* Table from Melnyk, Bernadette Mazurek and Ellen Fineout-Overholt.Evidence-based

practice in nursing and healthcare. Philadelphia : Lippincott Williams & Wilkins,
2005:10.

The resources at the top of the pyramid are considered the

best evidence. However, you will not always find your
topic addressed in one of these resources and you will
need to use a resource lower on the pyramid.

Summaries of the Evidence:Systematic Reviews, MetaAnalyses, Evidence-Based Clinical Practice Guidelines,

Evidence Summaries.
Critically Appraised Research Studies:Evidence
Summaries and Reviews, Critical Research Critiques,
Randomized Controlled Clinical Trials, Cohort and Case
Control Studies which have been appraised by a peerreview process and published in an evidence-based
journal.
Individual Research Studies:Randomized Controlled
Clinical Trials, Cohort and Case Control Studies, Case
Reports, Case Studies.If you use one of these resources,
please see the page onlevels of evidenceand also
critically appraise the article as described inStep 3of the
tutorial.
Textbooks:Textbooks provide another level of evidence
albeit a lower level of evidence and can be helpful when
updating policies. Electronic textbooks tend to be more
current and are evidence-based to varying degrees.

Clinical Scenario 1
Currently every child who presents in the
emergency room has a rectal temperature
taken. Are other methods of temperature
assessment as accurate as rectal
temperatures?
Clinical Scenario 2
It is common that women are put into the
lithotomy position during delivery. Are there
better outcomes if women are allowed to
remain in an upright position during delivery?

Diagnosis:
Did the patient sample include an appropriate spectrum
of patients similar to those found in the general practice?
Was the gold standard applied to all cases?
Therapy:
Was the assignment of patients to treatment groups
randomized?
Were all enrolled patients accounted for at the conclusion
of the study?
Were the treatment groups similar at the start of the
study?

Harm:
Were exposures and outcomes measured similarly in the
groups compared?
Were the comparison groups similar in outcome in all
respects except for the variable studied?
Was the follow-up adequate?
Prognosis:
Was the patient sample representative at a well-defined
point in the course of the disease or disorder?
Was the length of follow-up adequate?
Was the follow-up complete?

Once you have determined that a study is

internally valid (step 3), you must decide how
the study and/or other information applies to
your question. To reach your conclusion you
may consult questions related to diagnosis,
therapy, harm, and prognosis. Keep in mind that
you must interpret the information based on a
number of criteria and depending on your skill
and experience, you may need to confer with a
peer.
Click each icon to see questions you may ask to
help determine how evidence applies.
Click the References button for additional
information about applying evidence

Diagnosis:
Is the test affordable, accurate, and available in
my hospital?
Can I estimate the pretest probability of the
disease in question?
Will the posttest probability affect my
management?
Therapy:
Is my patient so different from those in the
study group that the results cannot be applied?
According to the study results, how much would
my patient benefit from the treatment?

Harm:
Can the study results be applied to my
patient?
What is my patients risk for adverse effect?
Are there alternative therapies?
Prognosis:
Is my patient similar to the patients in the
study group?
How will the evidence influence my choice
of treatment?

In the process of executing evidence-based practice, you

have developed a clinical question (step 1), sought out
answers to verify and support your clinical decision
(steps 2 and 3) and ultimately applied the findings to
your patient (step 4).
The last step in this process is to evaluate the
effectiveness and efficacy of your decision in direct
relation to your patient.
You may ask questions such as:
Was the diagnosis and treatment successful?
Is there new information/data in the literature?
How can I improve and/or update my clinical decisions?
All of these questions require thoughtful action and
keeping up-to-date with the current literature.