EBP: Search for the evidence

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By the end of this lecture, students will be able to:

• Understand the using of EBP in nursing.

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Objectives

What is - Evidence?

Anything that provides material or information on which a conclusion or proof may be based; used to arrive at the truth, used to prove or disprove the point at issue.

(Webster, 2019)

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Evidence-Based Practice

Evidence-Based Practice – Conscientious, explicit and judicious use of current best evidence with clinical expertise, and patient values to make decisions about the care of patients.

(Sackett, 2000)

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Evidence-based nursing practice is the process of shared decision-making between practitioner, patient and significant others, based on research evidence, the patient’s experiences and preferences, clinical expertise, and other robust sources of information.

(STTI , 2007)

5 steps in the EBP process

1. Asking clinical question in PICO format

2. Efficient search for evidence based on the question

3. Critical appraisal of research

4. Implement evidence into practice in combination with clinicians’ expertise and patient preferences.

5. Evaluation of identified outcomes in clinical setting.

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PICO

Mnemonic used to describe the four elements of a good clinical foreground question.

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P-patient (individual or group)

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I-intervention (cause or prognosis) therapy you wish to consider; diagnostic test, treatment, risk factor, etc.

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C-comparison –alternative treatment to compare? absence of risk, placebo, different diagnosis.

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O-outcome- should be measurable and include a time horizon.

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PICO

• Categories: diagnosis, therapy, harm or etiology, prognosis, prevention, qualitative.
• Once question established, can move on to research

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PICO question example:

“ In adult cardiac surgery patients (P) is morphine (I) or fentanyl (C) more effective in reducing postoperative pain (O)?

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Search for Evidence

How to Search for Evidence to Answer the Clinical Question

1. Identify the type of PICOT question.

2. Determine the level of evidence that best answers the question.

3. Select relevant databases to search (such as the CDSR, DARE, PubMed, CINAHL).

4. Use keywords from your PICOT question to search the databases.

5. Streamline your search with the following strategies:

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• Use database controlled vocabulary (such as “MeSH terms”).

• Combine searches by using the Boolean connector “AND.”

• Limit the final search by selecting defining parameters (such as “humans” or “English”).

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1. Identify the type of PICOT question

• Use your PICO question components to identify the search terms that will form the basis of your search strategy.

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• Remember to consider alternative terms, synonyms and alternative spellings.

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• To start with, you can search using one of your PICO elements and see how many records you find, and then decide which other PICO elements you will use to restrict your search.

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To combine search terms we can use the Boolean operators “AND” and “OR”. These terms affect the way that the database retrieves records.

• OR will broaden your search by returning any records that contain either one of your terms e.g. cancer OR neoplasm.
• AND will restrict your search by only returning records that contain both terms e.g. stroke AND aspirin.

Determine the level of evidence that best answers the question

It’s important to consider both the level and quality of the evidence as well as the feasibility of implementing the intervention.

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Searching for evidence that has already been appraised for the quality of the study methodology and the reliability of its findings is desirable. This is called preappraised literature and can range from meta- analytic systematic reviews to synopses of single studies. Since these have already been critically appraised for clinicians.

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Determine the level of evidence that best answers the question

Systematic reviews are the type of preappraised synthesis of studies that is the heart of evidence-based practice (EBP; Stevens, 2001).

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However, there is often not enough quality research to address all clinical issues. Clinicians looking for answers to their questions can access many sources of evidence reviews, synopses, summaries, and primary studies.

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It’s wise to search more than one database.

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Hierarchy of Evidence for Intervention Studies

Hierarchy of Evidence for Intervention Studies

Hierarchy of Evidence for Intervention Studies

Select relevant databases to search

• Choosing the right databases and being familiar with their language are essential to a successful, expedient search for answers to a clinical question.

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• It’s wise to search more than one database. Because databases index different journals, searching several databases will reduce the possibility of missing relevant literature.

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Examples of data bases that you may search

● Cochrane Databases

● NGC = National Guideline Clearinghouse

● MEDLINE

● CINAHL

● Excerpta Medica Online (EMBASE)

● PsycINFO

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• The Cochrane Library’s six databases: Cochrane Database of Systematic Reviews (CDSR), Database of Reviews of Effectiveness (DARE), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register, Health Technology Assessment Database, and NHS Economic Evaluation Database.

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• You can access it at www.cochranelibrary.com

MEDLINE

• MEDLINE is one of the world’s largest searchable bibliographic databases covering health related sciences.

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• PubMed, which includes MEDLINE ( www.ncbi.nlm.nih.gov/pubmed )

SEARCHING STRATEGIES

1. Choose keywords from the PICOT question.

PICOT questions are expressed in everyday clinical terminology

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2. Use database controlled vocabulary.

This will save time and help prevent the chance of missing evidence that could answer the clinical question.

using PubMed’s Medical Subject Heading (MeSH) database to search for the keywords.

a controlled vocabulary is Medical Subject Headings (MeSH), which are the set of terms used by the NLM to describe the content of articles indexed in MEDLINE.

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SEARCHING STRATEGIES

3. Combine searches

Each keyword in the PICOT question is searched individually. However, keyword searches can result in a large number of articles.

combining the searches using the Boolean connector “AND” (for example, cardiac arrest AND rapid response team) yielded a more manageable number of articles that contain both concepts and were more likely to answer the clinical question.

4. Place limits

Appraise articles found for quality and relevance

• When you find an article you want to work out whether:

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 it is a good article and you can use the results

 it is not a good article so you shouldn’t use the results

 the article is OK but with some limitations and you should use the results with discretion

• The process you use to determine if the research you have identified is accurate, reliable and relevant is called critical appraisal.

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Appraise articles found for quality and relevance

There are three basic aspects to appraising an article

1. Is it worth looking at the results of this study?

In order to be valid, the results of the study must be as close to the truth as possible. Also, the study must be conducted using best available research methods.

2. What are the results?

measures the reliability of the study. If it is an intervention study, reliability consists of: whether the intervention worked, how large the effect was, and whether a clinician could repeat the study with similar results. If it is a qualitative study, reliability would be measured by determining if the research accomplished the purpose of the study.

3. Are the results relevant for my patients?

The study may be used in practice when caring for patients if the subjects are similar to the patients being cared for, the benefit outweighs the harm, the study is feasible, and the patient desires the treatment.

Critical Appraisal Guide for Quantitative Studies

1. Why was the study done?

• Was there a clear explanation of the purpose of the study and, if so, what was it?

2. What is the sample size?

• Were there enough people in the study to establish that the findings did not occur by chance?

3. Are the instruments of the major variables valid and reliable?

• How were variables defined?

• Were the instruments designed to measure a concept valid (did they measure what the researchers said they measured)?
• Were they reliable (did they measure a concept the same way every time they were used)?

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Critical Appraisal Guide for Quantitative Studies

4. How were the data analyzed?

• What statistics were used to determine if the purpose of the study was achieved?

5. Were there any untoward events during the study?

• Did people leave the study and, if so, was there something special about them?

6. How do the results fit with previous research in the area?

• Did the researchers base their work on a thorough literature review?

7. What does this research mean for clinical practice?

• Is the study purpose an important clinical issue?

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Critical Appraisal Guide for Qualitative Studies

1. Did the qualitative research describe an important practice–related problem addressed in a clearly formulated research question?

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• Was the qualitative approach appropriate?

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• How were the participants selected?

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• What were the researchers’ roles in conducting the study and has this been taken into account?

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• What methods did the researcher use for collecting data—and are they described in appropriate detail?

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• What methods did the researcher use to analyze the data and what measures were used to ensure that scientific rigor was maintained?

Thanks!

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