1. Evidence-based – Searching
- Nursing
- Practice
- Medicine
Karen Hutchens
&
Debbie O’Reilly
Efficiency is Key
Finding the right information in the most efficient manner is key to successfully practicing evidence-based decision making.
Knowing what key components to use in your search strategy will help you develop that efficiency.
Last revised January 2018

2. Objectives To define Evidence-Based Practice
To understand that there is a process to systematically search the literature to find the best available evidence
Using PICOT; develop an answerable question, build a literature search, evaluate the evidence
To identify evidence-based practice resources and learn how to use them efficiently and effectively
To encourage high-quality patient care guided by the best evidence, many medical and nursing schools and clinical areas are teaching techniques for critically evaluating the nursing literature. While a large step forward, these skills of evidence-based nursing are necessary but not sufficient for the practice of contemporary nursing. Incorporating the best evidence into the real world of busy clinical practice requires the applied science of information management. Students must learn the techniques and skills to focus on finding, evaluating, and using information at the point of care. This information must be both relevant to themselves and their patients as well as being valid.

3. What is Evidence based practice?
Evidence-based practice (EBP) is a life-long problem-solving approach to the delivery of health care that integrates the best evidence from well-designed studies and integrates it with a patient’s preferences and values and a clinician’s expertise, which includes internal evidence gathered from patient data (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014)
Research evidence & evidence-based theories e
EBP culture & environment
Clinical Expertise and evidence from assessment of the patient’s history and condition as well as healthcare resources
Clinical decision-making
Quality patient outcomes
Patient Values/
Preferences
Neville, K & S. Horbatt. (2008). Creating a Spirit of Inquiry to solve clinical nursing problems. Orthopaedic Nursing, 27(6),
“The goal of EBP is to use the highest quality of knowledge in providing care to have the greatest impact on patients’ health status and healthcare (Melynk & Fineout-Overholt, 2005). EBP involves a systematic search for the most relevant evidence, as well as a critical appraisal of this evidence to answer a clinical question (see table 1; Bennett, 2007, p.19).”

4. What areas of nursing practice might we want to ask EBP questions about?
You might ask questions about a range of categories of practice:
Assessment – how to properly gather and interpret findings?
Causes of the problem – how to identify them?
Deciding what the problem is – where the symptoms/signs indicate a range of possible problems how do you decide which is most likely?
How to select and interpret tests used to identify problems and to monitor patient progress?
How to estimate the likely clinical progression of a condition/illness and any likely complications?
How to select interventions that do more good than harm and that are worth the effort and cost of doing them?
How to reduce the chance of the problem reoccurring or how to promote health?
How to keep up to date; improve your skills; and run a more effective/efficient nursing team?
We might want to ask questions about nursing procedures and practices as well as about specific illnesses or conditions. We might also want to explore best practice from the perspective of our clients/patients or their caretakers or other key stakeholders (Eastern Health or NL Dept. of Health).

5. The Seven Steps of EBP
Step 0: Cultivate a spirit of inquiry along with an EBP culture and environment
Step 1: Ask the PICO(T) question
Step 2: Search for the best evidence
Step 3: Critically appraise the evidence
Step 4: Integrate the evidence with clinical expertise and patient preferences to make the best clinical decision
Step 5: Evaluate the outcome(s) of the EBP change
Step 6: Disseminate the outcome(s)
(Melnyk & Fineout-Overholt, 2011)

6. 4 Steps to Searching Design an answerable question
Determine the type of question that you are posing
Determine the type of study that will best answer your question
Search and evaluate the literature

7. Designing an Answerable Question
A well-built clinical question should have 4 components. The PICO model is a helpful tool that assists you in organizing and focusing your question into a searchable query. Dividing into the PICO elements helps identify search terms/concepts to use in your search of the literature. PICO P – population/patient/problem (among_______) I – intervention (does __________) C – comparison/control (versus _________) O – outcome (affect __________)
P – population/patient – How would you describe a group of patients similar to yours? What are the main characteristics of the patient (disease, condition, co-existing conditions, sex, age, race, etc.)?
Examples: elderly hypertensive female; infant with colic; morbidly obese adolescent
I – intervention – Which intervention or exposure are you considering? What do you want to do for the patient? What factor may influence the prognosis of the patient?
Examples of therapies: specific pharmacotherapy; diet; psychotherapy; information
C- comparison/control – What is the alternative that you are comparing with the identified intervention or exposure? Are you comparing two drug treatments or two diagnostic tests? Are you comparing exposure to no exposure?
Examples: blood vs. urine test; SSRI vs. psychotherapy; exposure to peanut products vs. no exposure; pamphlet vs. no information.
O- outcome – What do you hope to accomplish measure, improve or affect? What are you trying to do for the patient? Reduce adverse effects? Improve function or test scores?
Examples: smoking cessation; MI risk; patient satisfaction
Once you have your PICO, you can put this into question format.

8. PICO Model P = Patient/Population Who/age group/gender/health concern
Example: for persons entering a health care facility…
I = Intervention or Exposure
therapeutic/diagnostic/preventive/health care management strategies
Example: for persons entering a health care facility, is hand rubbing with a waterless, alcohol-based solution, …

9. PICO Model cont’ C = Comparison of Interest
Comparison against intervention?/more than one or no intervention
Example: for persons entering a health care facility, is hand rubbing with a waterless, alcohol-based solution, as effective as standard hand washing with antiseptic soap…
O = Outcome of Interest
Desired outcome/patient affected or not affected by intervention
Example: for persons entering a health care facility, is hand rubbing with a waterless, alcohol-based solution, as effective as standard hand washing with antiseptic soap for reducing hand contamination?

10. Designing an Answerable Question
Clinical scenario: Our patient is a 45-year old female who is experiencing moderate depression. After surfing the web, she believes St. John’s Wort will cure her symptoms with less risk than conventional antidepressant medications.
P adults experiencing (moderate) depression
I St. John’s Wort
C antidepressants
O relief of symptoms

11. Clinical Question
For adult patients with moderate depression, is St. John’s Wort more effective for symptom relief than antidepressants?
Write out your clinical question using the PICO components.

12. PICO (TT) Model for Clinical Questions
P Patient, Population, or Problem
How would I describe a group of patients similar to mine?
I Intervention, Prognostic Factor,
Which main intervention, prognostic factor, or exposure am I considering?
C Comparison to intervention
What is the main alternative to compare with the intervention?
O Outcome to measure or achieve
What can I hope to accomplish, measure, improve, or affect?
T What type of question asking?
Therapy/Treatment, Diagnosis, Prognosis, Harm/Etiology (or “domains” in PubMed)
T Type of study you want to find
What would be the best study design/methodology?

13. Find the highest strength of evidence available to answer your clinical question.
Note that meta-analyses are placed at the highest level of evidence in this pyramid along with systematic reviews. It is widely accepted that systematic reviews provide the best evidence as they include all applicable studies on a particular topic. The studies, therefore are heterogeneous and results of each study vary. Systematic reviews provide no quantitative summary but rather provide conclusive statements regarding the validity and accuracy of the studies. Meta- analyses, on the other hand, take selected like studies, pool the results and provide a statistical synthesis. A meta-analysis, therefore, is only as good as the studies it includes.

14. Clinical Scenario #1
Clinical Scenario #1 • On morning rounds in the Oncology unit, a first year student turns to you for consultation. She wants to discuss options for managing moderate nausea and vomiting that result following chemotherapy. She shares an experience a relative had taking ginger when prochlorperazine didn’t provide effective relief and asks for your input. What is your clinical question in PICO format?

15. Answer Clinical Question #1
PICO: • P – In patients receiving chemotherapy who are experiencing moderate nausea and vomiting • I – is the use of ginger • C – as effective as prochlorperazine • O – in reducing nausea and vomiting?

16. Clinical Scenario #2 Working on the Developmental Assessment Team for
school-aged children of mothers who used cocaine
during their pregnancy, you are interested in learning the
developmental outcomes for these children as they
begin school compared to children not exposed to
cocaine during pregnancy.
What is your clinical question in PICO format?

17. Answer Clinical Question #2
PICO: • P – (controlling for confounding factors) Do school-aged children • I – exposed in utero to cocaine, • C – compared to children not exposed to cocaine • O – have increased incidence of learning disabilities at age six years?

18. Limits of PICO
This model works best for Therapy/Treatment & Diagnosis questions
Remember, PICO is a model, not a rigid structure

19. Sources of Evidence Original research and reviews published in journals
The Cochrane Library
Intl organization makes available systematic reviews of effects of healthcare interventions
Up-to-date
PubMed/CINAHL
Free provided by NLM
MUN access
UpTODate
Evidence based clinical info
Quick and easy/point of care

20. Using PubMed Go to: www.library.mun.ca/hsl
Under Research Tools choose HSL Databases
Click on PubMed under Top Picks

21. PubMed Home MeSH database – medical thesaurus
-Can do searches from here

22. Search Statement PubMed Mesh terms: Depression Depression
St. John’s wort
Antidepressants
Study type?
Limits
Subheadings
Depression
Hypercium
“Antidepressive Agents”
Mesh St. J wort is hypericum
Limits set 5yrs, English, 19+
Article type – meta-analysis
depression AND (hypericum OR “St. John’s Wort”) AND “antidepressive agents”

23. Search Statement
Does hand washing among healthcare workers reduce hospital acquired infections?
PubMed Mesh terms:
Hospital acquired infection –
Hand washing –
Nurses -
"cross infection" AND "hand disinfection" AND nurs*
Cross Infection
Hand Disinfection
Nurses OR Nursing

24. How to save results To temporarily save and print results:
Click the check box to the left of the citations you want to save.
From Send to, select Clipboard.
Click Add to Clipboard
Click Clipboard: # items to choose citations
Click Send to, select File - Format: Abstract(text) Create File
Under File select Print

26. Remember Pick out PICO Select appropriate databases Do search
Evaluate your research