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Evidence-based Nursing

The practice of nursing in which the nurse makes clinical decisions on the basis of the best available current research evidence, her or his own clinical expertise, and the needs and preferences of the patient.*

Evidence-Based Practice

A 5-step process

A. Construct a relevant, answerable question from a clinical case.
B. Plan and carry out a search of the literature for the best external evidence. [the "6S" hierarchy]
C. Critically appraise the literature for validity and applicability.
D. Apply the evidence to your clinical practice.
E. Evaluate your performance.

from Health Sciences Library, McMaster University. An Introduction to Evidence-Based Practice for Nursing & Midwifery Students.

The Literature Search (step B)

This page is concerned with conducting the literature search (step B), and the Learning Commons resources that are available for the search.

Many methods have been suggested for categorizing the literature for evidence-based practice, and for organizing the search methods into a hierarchy as to which ones to search first.

The following 6-level ("6S") hierarchy is based on publications from McMaster University (Haynes, 2006; DiCenso et al., 2009; and An Introduction to Evidence-Based Practice for Nursing & Midwifery Students).

Cautionary Note for UCQ Students: The organization and the categorization of the search resources, as presented here, are intended to help clinicians (and senior nursing students) reach evidence-based decisions in as quick and efficient a method as possible. It is not the method to follow if you are simply looking for research articles on a particular topic, in which case you could start at nursing databases or the subject pages available from the UCQ Nursing Portal.

Hierarchy of Resource Levels

The search resources are organized in a hierarchy, with each level requiring increasing time and effort to search effectively to find the best clinical evidence.

A busy clinician would start at the first level. If that does not provide the evidence required, the search would be continued to the second level. The search would continue through the levels until the best evidence is found or the available search resources are exhausted.

Note: Examples are provided of the output for each of the search levels 2-6. The examples have been obtained using the search term "therapeutic hypothermia"

Level 1. Systems

A computerized evidence-based clinical-information decision-support system that "integrates and concisely summarizes all relevant and important research evidence about a clinical problem, is updated as new evidence becomes available, and automatically links (through an electronic record) a specific patient's circumstances to the relevant information." (DiCenso et al., 2009).

Currently there are very few Level 1 systems available, and no examples can be shown here.

Level 2. Summaries

"These include clinical pathways or textbook summaries that integrate evidence-based information about specific clinical problems and provide regular updating... Evidence-based current clinical practice guidelines ... are also examples of 'summary' level evidence." (DiCenso et al., 2009)

Evidence-Based Summaries
Clinical Evidence (access from 2003 - 24 month delay to date)
DynaMed
First Consult

Level 2 example (from Clinical Evidence) and updated details are available in DynaMed.

Clinical Practice Guidelines (CPG)
Note: Check that CPG is current and that recommendations include level of evidence.
CMA Infobase: Clinical Practice Guidelines
Joanna Briggs Institute EBP Database Choose, under Publication Types, Best Practice Information Sheets.
WHO Guidelines
National Guidelines Clearinghouse
NICE Clinical Guidelines
Nursing Best Practice Guidelines (RNAO)
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines

Level 3. Synopses of Syntheses

"...a synopsis that summarizes the findings of a high-quality systematic review can often provide sufficient information to support clinical action..." (DiCenso et al., 2009)
Database of Abstracts of Reviews of Effects (DARE)
Health Technology Assessment Database
NHS Economic Evaluation Database

The following databases provide both synopses of syntheses (Level 3) and synopses of studies (Level 5)
ACP Journal Club
Evidence-Based Medicine
Evidence-Based Mental Health
Evidence-Based Nursing

Level 3 examples - see Level 4 examples for the reviews that are synopsized here
example 1 (from DARE) | example 2 (from DARE)

Level 4. Syntheses: Systematic Reviews

"A synthesis or systematic review is a comprehensive summary of all the research evidence related to a focused clinical question." (DiCenso et al., 2009)
Cochrane Database of Systematic Reviews
EPC Evidence Reports (AHRQ)
Joanna Briggs Institute EBP Database Choose, under Publication Types, Systematic Reviews.
ACPJC PLUS (free, but you must register)
Evidence Updates (free, but you must register)
Nursing+ (free, but you must register)
Worldviews on Evidence-Based Nursing
Cancer Treatment Reviews

Level 4 examples - see Level 3 examples for synopses of the first two reviews
example 1 (from JAMA) | example 2 (from J Neurosci Nurs)
example 3 (from Cochrane Database - no synopsis available)

Level 5. Synopses of Studies

"...the synopsis of a single study provides a brief, but often sufficiently detailed, summary of a high-quality study that can inform clinical practice" (DiCenso et al., 2009)

The following databases provide both synopses of studies (Level 5) and synopses of syntheses (Level 3)
ACP Journal Club
Evidence-Based Medicine
Evidence-Based Mental Health
Evidence-Based Nursing

Level 5 example (from ACP Journal Club) - see Level 6 example for the study that is synopsized here

Level 6. Studies

These are the original research studies. The databases below have search methods for retrieving the high-quality studies that can be used for clinical practice.
CINAHL (limit your search to Clinical Queries)
Cochrane Central Register of Controlled Trials
EMBASE (limit your search through Edit Limits)
Medline [Ebsco] (limit your search to Clinical Queries)
Medline [Ovid] (then click Edit Limits)
PubMed (link directly goes to Clinical Queries)
BioMed Central (BMC) studies
The World Health Organization (WHO)
Public Health Nursing

Level 6 example (from N Eng J Med) - see Level 5 example for a synopsis of this study

Search Across the Levels

It is possible with these federated search engines to search across many resources, with the retrieval sorted according to the source of the evidence. Haynes (2006) cautions, however, that "the quality of the retrieval depends on the source, and many sources do not provide critical appraisal of evidence."
EBM Reviews
SUMSearch 2 (School of Medicine Wichita, The University of Kansas)
Trip Database

Some Web Resources for Evidence-based Practice

Suggestions of useful sites
ClinicalTrials.gov - a registry/database of trails done internationally, in the clinical environment, which are publically and privately funded.
National Collaborating Centre for Methods and Tools (NCCMT) - a Canadian focus of what works in public health based on evidence-based methods.

Tutorials
Evidence-Based Practice (Bio-Medical Laboratory, University of Minnesota)
Introduction to Evidence-Based Medicine (Duke University Medical Center Library and Health Sciences Library, UNC-Chapel Hill)

Asking Clinical Questions (step 1)
Asking Focused Questions (Centre for Evidence Based Medicine, University of Oxford)
Formulating Answerable Clinical Questions (Centre for Evidence-Based Medicine, Toronto)
Asking Answerable Clinical Questions (Health Sciences Library, University of Calgary)
The Well-Built Clinical Question (Duke University Medical Center Library and Health Sciences Library, UNC-Chapel Hill)

Searching the Literature (step 2)
Finding the Evidence (Centre for Evidence Based Medicine, University of Oxford)

Critically Appraising the Evidence (step 3)
Critical Appraisal (Centre for Evidence Based Medicine, University of Oxford)
Critical Appraisal of Evidence (Centre for Evidence-Based Medicine, Toronto)

Applying the Evidence to Clinical Practice (step 4)
Making a Decision (Centre for Evidence Based Medicine, University of Oxford)

Evaluating Your Performance (step 5)
Evaluating Performance (Centre for Evidence Based Medicine, University of Oxford)
Self-Evaluation (Centre for Evidence-Based Medicine, Toronto)

Other Resources
Users' Guides to the Medical Literature

Electronic Books from UCQ

Beginner's guide to evidence based practice in health and social care professions
Best Practices: Evidence-Based Nursing Procedures
Clinical context for evidence-based nursing practice
Determinants of the Sustained Use of Research Evidence in Nursing
Evidence-based practice manual for nurses
Evidence Based Standards for Measuring Nurse Staffing and Performance
Evidence-Based Teaching in Nursing: A Foundation for Educators
How Government Invests in Research to Advance Policy: Evolution of Evidence
Johns Hopkins Nursing Evidence-based Practice: Implementation and Translation
Johns Hopkins Nursing Evidence-based Practice: Model and Guidelines
Nursing Policy Research: Turning Evidence-Based Research into Health Policy
PDA Evaluation, Phase 2: The Emerging Role of PDAs in Evidence Based Practice: An Evaluation Among Frontline Nurses
Vital Notes for Nurses: Research for evidence-based practice in healthcare
Reviewing Research Evidence for Nursing Practice: Systematic Reviews
Using Knowledge and Evidence in Health Care: Multidisciplinary Perspectives

From: Evidence-based Nursing. (2009). Mosby's dictionary of medicine, nursing & health professions, 8 ed. St. Louis: Mosby/Elsevier. DiCenso, A., Bayley, L., and Haynes, R.B. (2009). Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evidence Based Nursing 12(4): 99-101.
Haynes, R.B. (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club 145(3): A8-A9.

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