STEPS OF EBP

KEY STEPS OF EVIDENCE BASED PRACTICE

Asking the clinical question.

Collecting the most relevant and best evidence to answer the clinical
question.

Critically appraising the evidence.

Integrating the evidence with one’s clinical expertise, assessment of the

patient’s condition and available healthcare resources along with the
patient’s preferences and values to implement a clinical decision.

Evaluating the change resulting from implementing the evidence in

practice.
 STEP 1 : ASK

FORMULATE THE CLINICAL QUESTION

Clinical questions should be asked in PICO/PICOT
FORMAT to yield the most relevant and best
evidence....
Patient/population problem of interest
Intervention of interest
Comparison
Outcome of interest
Time frame (optional)
 The PICO format
Patient problem or disease of •Age
interest •Gender
•Ethnicity
•With certain disorder ( Eg
Hepatitis)

The intervention of interest Exposure to disease

Prognostic factor A
Risk behavior( Eg smoking)
Comparison •No disease
•Placebo or no
intervention/therapy
•Prognostic factor B
•Absence of risk factor ( Eg non
smoking)
Outcome of interest Risk of disease
Accuracy of diagnosis
Rate of occurrence of adverse
outcome(Eg death)
 THE BASIC PICOT QUESTION:

In or among your patient or population

, does your intervention ,(versus your
comparison ), result in or affect your
outcome?
 EXAMPLE: SCENARIO

You are interested in reducing the number

of elderly patients patients fall during their
hospital stay .Currently the rate of falls is
higher in your unit than in other units .There
are variety of interventions currently being
used in the hospital and you want to know
where to start on your unit to address this
problem.
 WHAT IS THE PICO QUESTION?

POPULATION: ELDERLY HOSPITALIZED

PATIENTS

INTERVENTION: FALL ASSESSMENT

COMPARISON: USUAL CARE

OUTCOME: PREVENT OR REDUCE THE

NUMBER AND SEVERITY OF FALLS
QUESTION TEMPLATES FOR ASKING PICO QUESTIONS

THERAPY
In __________, what is the effect of _________ on __________ compared with
____________?
ETIOLOGY
Are _____________ who have _____________ at ___________ risk for / of
_______________compared with ____________ with / without
______________?
DIAGNOSIS OR DIAGNOSTIC TEST
Are (Is) ______________ more accurate in diagnosing __________ compared with
_____________?
PREVENTION
For ____________ does the use of _____________ reduce the future risk of
______________ compared with ______________
PROGNOSIS
Does ____________influence _______________ in patients who have
_____________?
MEANING
How do ______________ diagnosed with ___________ perceive ____________?
 STEP 2: ACCESS
SEARCH FOR THE BEST EVIDENCE
o With systematic reviews or meta-analysis

o With evidence based clinical practice guidelines

which are regarded as the strongest level of evidence….
 A SYSTEMATIC REVIEW
It is a summary of evidence on a particular topic, typically by
an expert or expert panel that uses a rigorous process for
identifying, appraising and synthesizing studies to answer a
specific clinical question.
Conclusions are then drawn about the data gathered
through this process.
Using a rigorous process of well-defined, preset criteria to
select studies for inclusion in the review, bias is overcome,
and results are more credible.
 A META-ANALYSIS
A systematic review which incorporates quantitative
methods to summarize the results from multiple
studies.
It often yields an overall summary statistic that
represents the effect of the intervention across
multiple studies.
Because a meta-analysis combines the samples of
each study included in the review to create one larger
study, the summary statistic is more precise than the
individual findings from any one of the contributing
studies alone.
 RATING SYSTEM FOR THE HIERARCHY OF EVIDENCE

Evidence from a systematic review or meta-analysis of

Level I :
all relevant randomized controlled trials (RCTs), or
evidence-based clinical practice guidelines based on
systematic reviews of RCTs
Level II :
Evidence obtained from at least one well-designed RCT
Evidence obtained from well-designed controlled trials
Level III :
Level IV :
without randomization
Evidence from well-designed case-control and cohort

Level V :
studies.
Evidence from systematic reviews of descriptive and

Level VI
qualitative studies.
:
Evidence from a single descriptive or qualitative study.

Level VII Evidence from the opinion of authorities and/or reports

:
  of expert committees.
 STEP 3: APPRAISE

CRITICAL APPRAISAL
It involves critical appraisal of
the evidence obtained from the
search process.
Determine the value of
evidence for practice.
 It can be efficiently
accomplished by answering the
key questions:
 QUESTIONS FOR APPRAISING THE EVIDENCE

What is the quality of the evidence-that is , how

rigorous and reliable is it?
What is the evidence –what is the magnitude of
effects?
How precise is the estimate of effects?
What evidence is there of any side effect or side
benefits?
What is the financial cost of applying ( and not
applying ) the evidence?
Is the evidence relevant to my particular clinical
situation?
 STEP 4: APPLY

INTEGRATE THE EVIDENCE

the literature search
healthcare provider's expertise
clinical assessment of the patient
 available healthcare resources
patient preferences and values.

TO IMPLEMENT A DECISION.
 MOVING FORWARD APPLYING THE EVIDENCE
TO THE PRACTICE

 Develop recommendations for practice

 Integrate the evidence recommendation, with

collaboration with patients, into a plan of care

 Complete human subject protection requirements

 Step 5: ASSESS

EVALUATE EFFECTIVENESS
Evaluating the evidence-based intervention in terms
of how the treatment worked or
how effective the clinical decision was with a
particular patient or practice setting.
This step involves answering the questions:

 Did you do what you set out to?

 Were there any unintended consequences of the

change in practice?
COMPARISON OF EBP STEPS
WITH NURSING PROCESS
NURSING ACTION EBP ACTION
PROCESS
ASSESSMENT COLLECT DATA ASKING THE CLEAR
QUESTION IDENTIFICATION
OF PATIENT
PROBLEM
NURSING ANALYZE DATA SEARCHING FOR COLLECT DATA
DIAGNOSIS DETERMINE NSG EVIDENCE RELEVANT TO
DIAGNOSIS PATIENTS
PROBLEM OR
NEED
OUTCOME DETERMINE/PRIO SUMMARIZE THE ORGANISE
RITIZE GOALS EVIDENCE LITERATURE
REVIEW
PLANNING DEVELOP CARE ANALYSE THE CRITICALLY
PLAN EVIDENCE TO APPRAISES THE
PRACTICE LITERATURE
IMPLEMENTATION INITATE APPLYING INTEGRATE
INTERVENTION EVIDENCE TO EVIDENCE WITH
PRACTICE CLINICAL
EXPERTISE
EVALUATION EVALUATE EVALUATE EVALUATE
PATIENT EFFECTIVENESS EFFECTIVENESS
PROGRESS
FACILITATORS OF EVIDENCE-BASED PRACTICE

Support and encouragement from administration

Time to critically appraise studies and implement
their findings
Clearly written research reports
Organizational capacity for change that includes
strong support and interest at all levels of leadership
Implementation infrastructure (e.g., adequate
resources and time)
Characteristics of the healthcare team (e.g., a shared
vision and mission)
BARRIERS TO EVIDENCE-BASED PRACTICE

Lack of knowledge regarding EBP strategies.

Misperceptions or negative views about research
and evidence-based care.
Lack of belief that EBP will result in more positive
outcomes than traditional care.
Lack of time and resources to search for and
appraise evidence.
Overwhelming patient loads.
 BARRIERS TO EVIDENCE-BASED PRACTICE

Organizational constraints, such as lack of

administrative support or incentives.
Demands from patients for a certain type of
treatment.
Peer pressure to continue with practices that are
steeped in tradition.
Inadequate content and behavioral skills regarding
EBP in educational programs
 OVERCOMING BARRIERS TO EVIDENCE-BASED
PRACTICE

Promoting Acceptance.
Correcting Misperceptions.
Questioning Clinical Practices: Developing
Guidelines.
 FOR EBP TO EVOLVE MORE QUICKLY:

 Commitments to advancing evidence based care must be

made by both individuals and organizations.
 Basic and graduate professional programs must teach the
value and processes of EBP, leveled appropriately.
 Doctoral programs must create researchers and leaders
who advance EBP through the generation of new
knowledge from research to support the most effective
practices.
 Researchers and practitioners across disciplines also must
unite to produce evidence on the effectiveness of numerous
practices and to answer high-priority, clinical questions, as
well as to determine how best those interventions can be
translated into practice
 STRATEGIES FOR IMPLEMENTING EBP

 1. Assess the extent to which your practice is evidence

based.
 2. Review literature that provides evidence to strengthen
your belief that EBP results in better patient outcomes.
 3. Ask questions about the current practice strategies (eg.
Is use of distraction really effective in reducing children’s
distress during intrusive procedures? )
 4. Determine whether other colleagues at our practice site
have an interest in the same clinical question so that we can
form a collaboration to search for and review the evidence.
 STRATEGIES FOR IMPLEMENTING EBP

5. Conduct a research for studies or systematic

reviews in the specific area of our clinical question.
6. Critique the studies from our search to
determine whether we have the “best evidence” to
guide your practice.
 7. Develop a practice guideline using the “best
evidence”
8. Establish measureable outcomes that we can
use to determine the effectiveness of your
guideline
 STRATEGIES FOR IMPLEMENTING EBP

9. Implement the practice guideline.

10. Measure the established outcomes.
11. Evaluate the effectiveness of the practice guideline
and determine whether you should continue the
practice guideline as established or whether there is
need for a revision.
12.Develop a mechanism for routinely disseminating
and discussing evidence based literature upon which
decisions can be made to improve practice at your
clinical site (eg.EBP rounds).