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Evidence-based – Searching
- Nursing
- Practice
- Medicine
Karen Hutchens
&
Debbie O’Reilly
Winter 2016
Objectives
 To understand that there is a process to
systematically search the literature to find the best
available evidence
 To learn how to develop an answerable question
using the PICO approach
 To identify evidence-based practice resources and
learn how to use them efficiently and effectively
What is Evidence based practice?
Best
Research
Evidence
EBN
Clinical
Expertise
Patient
Values
Evidence-based practice is the integration of the best
research evidence with clinical expertise and patient
values to facilitate clinical decision making.
(Sackett et al., 2008 as cited in Neville & Horbatt, 2010)
What areas of nursing practice might we
want to ask EBP questions about?
You might ask questions about a range of categories of practice:
1.
Assessment – how to properly gather and interpret findings?
2.
Causes of the problem – how to identify them?
3.
Deciding what the problem is – where the symptoms/signs indicate a
range of possible problems how do you decide which is most likely?
4.
How to select and interpret tests used to identify problems and to
monitor patient progress?
5.
How to estimate the likely clinical progression of a condition/illness
and any likely complications?
6.
How to select interventions that do more good than harm and that are
worth the effort and cost of doing them?
7.
How to reduce the chance of the problem reoccurring or how to
promote health?
8.
How to keep up to date; improve your skills; and run a more
effective/efficient nursing team?
What is Research in Nursing Practice?
Nursing research is research that provides
evidence used to support nursing practice.
Nursing, as an evidence-based area of practice,
has been developing since the time of Florence
Nightingale to the present day, where
many nurses now work as researchers based in
universities as well as in the health care setting.
4 Steps to Searching
1.
2.
3.
4.
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 the literature
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
I – intervention
C – comparison/control
O – outcome
(among_______)
(does __________)
(versus _________)
(affect __________)
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, …

PICO Model cont’
 C = Comparison of Interest
 Comparison against intervention?/more than on 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?
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
I
C
O
adults experiencing (moderate) depression
St. John’s Wort
antidepressants
relief of symptoms
Clinical Question
 For adult patients with moderate depression, is
St. John’s Wort more effective for symptom
relief than antidepressants?
PICO (TT) Model for Clinical Questions
P Patient, Population, or Problem
How would I describe a group of
patients similar to mine?
I
Which main intervention, prognostic
factor, or exposure am I
considering?
Intervention, Prognostic Factor,
C
Comparison to intervention
What is the mail 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?
Type of Question
 Diagnosis
Evidence supports how to select and interpret diagnostic test, in order to
confirm or exclude a diagnosis, based on their precision, accuracy safety,
expense, etc.
 Intervention/Therapy
Evidence supports how to select treatments to offer your patients that do more good
than harm and that are worth the efforts and costs of using them.
 Prognosis/Predictions/Natural History
Evidence supports how to estimate your patient’s likely clinical course over time
and anticipate likely complications of the disorder.
 Etiology/Harm
Evidence supports how to identify causes for disease (including its iatrogenic
forms).
Type of Question
 Diagnosis
Is a yearly mammogram (I) more effective in detecting breast cancer (O)
compared with every 3 yrs (C) in women under 50 (P)?
 Intervention/Therapy
In school age children (P), what is the effect of a school-based physical activity
program (I) on a reduction in the incidence of childhood obesity (O) compared with
no intervention within a 1 year period (T)?
 Prognosis/Predictions/Natural History
Does monitoring blood glucose 4 times a day (I) improve blood glucose control (O)
in people with Type 1 diabetes (P) during the first 6 months after being diagnosed
with the condition (T)?
 Etiology/Harm
Are women 25-40 (P) who take oral contraceptives (I) at greater risk for developing
blood clots (O) compared to women of the same age (P) who use IUD (C)?
Types of Questions – Examples
Are kids (P) who have obese adoptive parents (I) at increased
risk for obesity (O) compared with kids (P) without obese
adoptive parents (C) during the ages of five and 18 (T)?
Etiology PICO Question
In adult patients with total hip replacements (P) how effective is
PCA pain med (I) compared to prn IM pan med © in contolling
post operative pain (O)?
Intervention PICO Question
Is a PKU test (I) done on two week old infants (P) more accurate
in diagnosing errors in metabolism (O) compared with PKU tests
done at 24 hours of age (C)?
Diagnostic PICO Question
Type of Study
Type of Question/Domain
Type of Study/Methodology
Therapy/Treatment
Double-Blind Randomized
Controlled Trial; Systematic
Review/Meta Analysis of RCT
Diagnosis
Controlled Trial; Systematic
Review/Meta Analysis of CT
Prognosis
Cohort Studies, Case Control, Case
Series
Harm/Etiology
Cohort Studies
Prevention
Randomized Controlled Trial,
Cohort Studies
Quality Improvement
Randomized Controlled Trials
Type of Study
 Meta – Analyses
 Systematic, objective combining many studies – increases
sample size and allows for analyses not otherwise possible
 Systematic Review
 Comprehensive survey of a topic and finds all relevant
studies of highest level of evidence – reduce bias – follows
formal process
 Randomised Controlled Trial/Studies
 One group receives treatment – Control group no treatment
(placebo) or standard treatment – patients randomly
assigned – Double Blind Method
Type of Study con’t
 Cohort Study
 Prospective or historical/retrospective – pop has a
certain exposure or particular treatment
 Case Control Studies
 Patients with certain condition compared with people
who do not – odds of developing condition
 Case Reports
 Collections of reports on treatment of individual
patients with same condition or a single patient
Find the highest
strength of
evidence available
to answer your
clinical question.
www.biomed.lib.umn.edu
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?
What type of clinical question is this?
What is the best study design to answer this type
of clinical question?
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?
Type of Question: Therapy/Treatment
Type of Study/Methodology: Double-Blind Randomized
Controlled Trial; Systematic Review/Meta Analysis of
RCT
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?
 What type of clinical question is this?
 What is the best study design to answer this type
of clinical question?
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?
 Type of Question: Harm/Etiology
 Type of Study/Methodology: Cohort Studies
Limits of PICO
 This model works best for Therapy/Treatment &
Diagnosis questions.
 Remember, PICO is a model, not a rigid structure.
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
Using PubMed
 Go to: www.mun.ca
 Click Libraries link
 Under Research Tools choose Articles
 Under Search by Subject choose Nursing
 Click on PubMed
PubMed Home
MeSH database – medical thesaurus
-Can do searches from here
Search Statement
PubMed Mesh terms:
 Depression
 St. John’s wort
 Antidepressants
Study type?
Limits
Depression
Hypercium
“Depressive Agents”
Subheadings
depression AND (hypericum OR “St. John’s Wort”) AND
“antidepressive agents”
Search Statement
Does hand washing among healthcare workers
reduce hospital acquired infections?
PubMed Mesh terms:
Hospital acquired infection – Cross Infection
Hand Disinfection
Hand washing –
Nurses - Nurses
"cross infection" AND "hand disinfection" AND
nurses
How to save results
To temporarily save and print results:
1. Click the check box to the left of the citations
you want to save.
2. From Send to, select Clipboard.
3. Click Add to Clipboard
4. Click Clipboard: # items to choose citations
5. Click Send to, select File - Format:
Abstract(text) Create File
6. Under File select Print
Remember
 Pick out PICO
 Determine question type
 Determine type of study
 Select appropriate databases & do search