Evidence Based Practice: Nursing

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."

"The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
From: Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996 Jan 13;312(7023):71-2.

Image from: Florida State University, College of Medicine

Five-Steps of the Evidence Cycle

Ask: Formulate a clinical question "
Acquire: Search for the best evidence to answer your question
Appraise:Critically review the evidence for validity and applicability
Apply:Implement findings with your patient
Assess: Evaluate the results

• Cochrane Lexicon
• Glossary of EBM Terms -Centre for Evidence-Based Medicine, Toronto

• Centre for Evidence Based Medicine, University of Oxford

1. Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based
practice step by step: Critical appraisal of the evidence: part I. Am J Nurs.
2010 Jul;110(7):47-52. doi: 10.1097/01.NAJ.0000383935.22721.9c. PubMed [citation]
PMID: 20574204

2. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based
practice, step by step: asking the clinical question: a key step in
evidence-based practice. Am J Nurs. 2010 Mar;110(3):58-61. doi:
10.1097/01.NAJ.0000368959.11129.79. PubMed [citation] PMID: 20179464

3. Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based
practice, step by step: critical appraisal of the evidence: part II: digging
deeper--examining the "keeper" studies. Am J Nurs. 2010 Sep;110(9):41-8. doi:
10.1097/01.NAJ.0000388264.49427.f9. Erratum in: Am J Nurs. 2010 Nov;110(11):12.
PubMed [citation] PMID: 20736710

4. Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based
practice, step by step: Critical appraisal of the evidence: part III. Am J Nurs. 
2010 Nov;110(11):43-51. doi: 10.1097/01.NAJ.0000390523.99066.b5. PubMed
[citation] PMID: 20980899

5. Fineout-Overholt E, Gallagher-Ford L, Mazurek Melnyk B, Stillwell SB.
Evidence-based practice, step by step: evaluating and disseminating the impact of
an evidence-based intervention: show and tell. Am J Nurs. 2011 Jul;111(7):56-9.
doi: 10.1097/01.NAJ.0000399317.21279.47. PubMed [citation] PMID: 21709484

6. Gallagher-Ford L, Fineout-Overholt E, Melnyk BM, Stillwell SB. Evidence-based
practice, step by step: implementing an evidence-based practice change. Am J
Nurs. 2011 Mar;111(3):54-60. doi: 10.1097/10.1097/01.NAJ.0000395243.14347.7e.
PubMed [citation] PMID: 21346469

7. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based
practice, step by step: searching for the evidence. Am J Nurs. 2010
May;110(5):41-7. doi: 10.1097/01.NAJ.0000372071.24134.7e. PubMed [citation] PMID: 20520115

8. Melnyk BM, Fineout-Overholt E, Gallagher-Ford L, Stillwell SB. Evidence-based
practice, step by step: sustaining evidence-based practice through organizational
policies and an innovative model. Am J Nurs. 2011 Sep;111(9):57-60. doi:
10.1097/01.NAJ.0000405063.97774.0e. PubMed [citation] PMID: 21865934

9. Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based
practice: step by step: igniting a spirit of inquiry: an essential foundation for
evidence-based practice. Am J Nurs. 2009 Nov;109(11):49-52. doi:
10.1097/01.NAJ.0000363354.53883.58. PubMed [citation] PMID: 19858857

10. Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based
practice: step by step: the seven steps of evidence-based practice. Am J Nurs.
2010 Jan;110(1):51-3. doi: 10.1097/01.NAJ.0000366056.06605.d2. PubMed [citation] 
PMID: 20032669

11. Fineout-Overholt E, Williamson KM, Gallagher-Ford L, Melnyk BM, Stillwell SB.
Following the evidence: planning for sustainable change. Am J Nurs. 2011
Jan;111(1):54-60. doi: 10.1097/01.NAJ.0000393062.83761.c0. No abstract available.
PubMed [citation] PMID: 21191236

12. Gallagher-Ford L, Fineout-Overholt E, Melnyk BM, Stillwell SB. Rolling out the
rapid response team. Am J Nurs. 2011 May;111(5):42-7. doi:
10.1097/01.NAJ.0000398050.30793.0f. PubMed [citation] PMID: 23722382

To formulate a clinical question, use the PICO format.
PICO or PICOT stands for the following:

P= Patient or Problem

I= Intervention

C= Comparison

O= Outcome

T= Time (optional)

Different types of questions are answered best by different types of studies.
The following table will help you identify the best studies for your clinical question.

View definitions for these study types in the Glossary.

• 2009 CEBM Levels of Evidence and Grades of Recommendation
• 2011 CEBM Levels of Evidence Table also read:  2011 Introductory Document and 2011 Background Document

• AORN eGuidelines for Perioperative Practice
• ClinicalKey
• Guideline Central
• Lippincott Advisor 
• National Institute for Health and Care Excellence (NICE) UK Guidelines
• TRIP Database (No advanced search.Use default or PICO)

• CINAHL Evidence-Based Care Sheets  Select CINAHL from the list of databases.  In CINAHL, select Evidence-Based Care Sheets from the top menu.
• Cochrane Library
• UpToDate

• PubMed @ Cleveland Clinic Regional Hospitals
• TRIP Database (No advanced search.Use default or PICO)

1: Hoe J, Hoare Z. Understanding quantitative research: part 1. Nurs Stand. 2012
Dec 12-2013 Jan 1;27(15-17):52-7; quiz 58. doi:
10.7748/ns2012.12.27.15.52.c9485. PMID: 23346707.

2: Hoare Z, Hoe J. Understanding quantitative research: part 2. Nurs Stand. 2013
Jan 2-8;27(18):48-55; quiz 57. doi: 10.7748/ns2013.01.27.18.48.c9488. PMID:
23431654.

3: Sorrell JM. Qualitative research in clinical nurse specialist practice. Clin
Nurse Spec. 2013 Jul-Aug;27(4):175-8. doi: 10.1097/NUR.0b013e3182990847. PMID:
23748988.

4: Miller WR. Qualitative research findings as evidence: utility in nursing
practice. Clin Nurse Spec. 2010 Jul-Aug;24(4):191-3. doi:
10.1097/NUR.0b013e3181e36087. PMID: 20526118; PMCID: PMC3021785.

• Absolute Risk Reduction (ARR) 
  • The difference in the rate of outcomes between the control group of a study and the intervention group. For example, if 30% of people experience a serious event in the control group and 20% in the intervention group, the ARR is 10% (30%-20%).
• Relative Risk Ratio (RRR)  
  • A measure expressed by the risk of an event in the group receiving the intervention divided by the risk in the control group. A value of one implies no effect of treatment; less than one that the intervention reduced the risk of an event; and greater than one that the occurrence of the event is increased.This measure of risk is often expressed as a percentage increase or decrease, for example ‘a 20% increase in risk’ of treatment A compared to treatment B. If the relative risk is 300%, it may also be expressed as ‘a three-fold increase’.
• Number Needed to Treat (NNT) 
  • A statistical measure of the number of people who need to be given an intervention in order to observe a beneficial effect for one extra person. It is calculated from the risk difference. It is the inverse of the absolute risk difference.

• Critical Appraisal Worksheets from CEBM (Centre for Evidence Based Medicine)
• JAMAEvidence  Click Learning Tools from top menu

• CEBM Calculators
• EBMcalc  Select EBMcalc from Stat!Ref's Main Page
• JAMAEvidence  Select Calculators from the top menu

• Evidence-based practice for nurses: appraisal and application of research, 2019
• Statistics for evidence-based practice in nursing, 2017

• Evidence-Based Practice - Part 1 - 19 minutes
• Evidence-Based Practice - Part 2 - 21 minutes
• Beyond the Search: Maximizing the Quality of Systematic Reviews - 53 min
• Quality vs. Evidence vs. Research vs. Innovation: Embracing All Types of Clinical Inquiry - 42 minutes
• Doing it All with Evidence: Meeting Standards and Maximizing Patient Outcomes - 32 minutes
•  Using PubMed in Evidence-Based Practice Training Course

• Becker Library -- Washington University in St. Louis
• Evidence-Based Medicine -- Dartmouth College
• Evidence-Based Medicine -- Weill Cornell Medical College
• Evidence-Based Practice -- Duke University