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Library Services
In some ways, evidence based nursing is not new, but the term signifies a systematic, yet holistic and patient-oriented approach to nursing. EBN is an offshoot of evidence
based medicine (EBM), defined in Sackett’s key article:
"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 evidence from systematic research."
Sackett, David L., et al. (1996, January 13). Evidence based medicine: what it is and what it isn't . BMJ 312, 71-72. Retrieved July 27, 2006, from http://bmj.bmjjournals.com/cgi/content/full/312/7023/71
Also found at the Oxford Centre for Evidence-based Medicine http://www.cebm.net/ebm_is_isnt.asp
This definition of EBM requires integration of three major components for medical decision making: the best external evidence, individual practitioner’s clinical expertise, and
patients' preference.
Evidence-based nursing (EBN) goes beyond those three, adding more extended consideration of patient values, and including access to adequate resources. EBN has
been said to incorporate
- the patient’s clinical state, clinical setting and circumstances
- the patient’s preferences and actions
- the best research evidence, defined as:
“methodologically sound, clinically relevant research about the effectiveness and safety of nursing interventions, the accuracy and precision of nursing assessment
measures,
the power of prognostic markers, the strength of causal relationships, the cost effectiveness of nursing interventions, and the meaning of illness or patient
experiences.”
DiCenso, A., Guyatt, G. and Ciliska, D. Eds. (2005). Evidence-Based nursing; A guide to clinical practice. St. Louis, MO: Mosby, p.4 (FGCU Library - RT42 .E92 2005)
- clearly identify the patient problem based on accurate analysis of current nursing knowledge and practice
- search the literature for relevant research
- evaluate the research evidence using established criteria regarding scientific merit
- choose interventions and justify those selections with the most valid evidence
Sears, S. (2006, January/February). The Role of information technology in evidence-based practice. (Information technology and the clinical nurse specialist.)
Clinical nurse specialist, The Journal for advanced nursing practice. 20, 7-8.
Stone, P.H... (2003). Popping the (PICO) question in research and evidence-based practice. Applied Nursing Research. 15, 197-198. Retrieved from
ScienceDirect doi:10.1053/apnr.2002.34181 (direct link will work only from on-campus connections)
Further Reading
DiCenso A, Cullum N, Ciliska D. (1998, April.) Implementing evidence-based nursing: some misconceptions [implementation forum]. Evidence-Based Nursing. 1,
38–40. Retrieved July 27, 2006, from http://ebn.bmjjournals.com/cgi/content/full/1/2/38
MacPhee, M. & Pratt, P. (2005 ). Evidence-based practice. Journal of Pediatric Nursing. 20, 396-398. Retrieved from, ScienceDirect doi:10.1016/j.pedn.2005.03.015
(direct link will work only from on-campus connections)
Thomas, L. (1999). Clinical practice guidelines. Evidence-Based Nursing 2,38-9.
Thompson, C., Cullum, N., et al. (2004). Nurses, information use, and clinical decision making—the real world potential for evidence-based decisions in nursing.
Evidence-Based Nursing 7, 68-72. Retrieved August 3, 2006, from http://ebn.bmjjournals.com/cgi/content/full/7/3/68
[Tutorial].Duke University Medical Center Library. Introduction to Evidence-Based Medicine.
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Individual journals publishing articles on research studies.
Traditionally, keeping up to date with recent research evidence on treatments and therapies meant conducting continual and iterative literature searches of Medline
or PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), to search through the articles within hundreds of biomedical or nursing
journals. This requires a good understanding of methodologically sound research, as well as skilled database searching techniques.
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Practice Guidelines
More recently, practice guidelines from various medical specialties have become available via Internet. When available they are a critical component of medical
decision making, yet practice guidelines require time and analysis of best practices for their development, and not every medical condition or health issue is
covered. The National Guideline Clearinghouse is a U.S. initiative to aggregate evidence-based clinical practice guidelines; there are others found below under
EBM Clinical Reference Tools. For a discussion of clinical practice guidelines, see: Thomas, L. (1999). Clinical Practice Guidelines. Evidence Based Nursing. 2,
38-39.Retrieved, October 25, 2006, http://ebn.bmjjournals.com/cgi/content/full/2/2/38
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Evidence-based practice journals
EBP journals, that is, secondary sources which filter and synthesize research with evaluative abstracts, are now published. The journal editors and authors use
predetermined criteria to select original research and review articles that report scientifically sound and clinically relevant results. Clinical experts provide
value-added comments, describing the objectives, methods, results, and conclusions of the research, and then evaluation of the studies relative to the clinical
context.
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Secondary journals and resources, with access through FGCU Library noted.
(These sources “filter” evidence-based and research articles from a large number of research journals.)
Evidence Based Nursing
1998 forward in OVID (accessed via E-journals.)
“A journal of quality appraised abstracted research relevant to nursing practice.” BMJ Publishing Group.
ACP Journal Club. (includes the journal Evidence Based Medicine).
2002 forward included in Academic Search Premier (ACP Journal Club accessed via E-journals.)
“ACP Journal Club's general purpose is to select from the biomedical literature articles that report original studies and systematic reviews that warrant immediate
attention by physicians attempting to keep pace with important advances in internal medicine. These articles are summarized in value-added abstracts and
commented on by clinical experts.” “The content is carefully selected from over 100 clinical journals through reliable application of explicit criteria for scientific merit,
followed by assessment of relevance to medical practice by clinical specialists.” American College of Physicians.
Additional EPB journals are:
Evidence-Based Mental Health http://ebmh.bmjjournals.com/ Bandolier: Evidence-Based Health Care (Internet version: http://www.jr2.ox.ac.uk/bandolier/ )
International Journal of Evidence-Based Health Care, incorporating Evidence in Health Care Reports
| How does the clinician find the latest evidence? |
More recently EBM tools have been developed, such as DynaMed, Up-to-date, InfoRetriever, etc.
~ designed for use at the point of care
~ many are viewable on PDAs.
These sources do the literature searching automatically, seeking to quickly summarize the latest evidence.
Caveat: EBM tools cannot summarize literature that is not there, that is, if quality studies have not yet been published on a therapy, treatment, syndrome or condition, then the EBM tools will not yet cover that issue.
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Now the first sources to locate the best available evidence on diseases, conditions, treatment and therapies.
A resource that filters the EBM literature daily to create a clinical reference tool providing value-added syntheses of existing evidence for diagnoses and therapies. This
source scours 5 other EBM tools including the Cochrane Database of Systematic Reviews, the National Guideline Clearinghouse, NIH Consensus Statements, and
AHRQ Evidence Reports, as well as 500 key primary and secondary biomedical journals. See DynaMed instructions below.
- Agency for Healthcare Research and Quality (AHRQ). AHRQ Evidence Reports.
http://www.ahrq.gov/clinic/epcindex.htm
Evidence-based Practice Centers (EPC) contract with AHRQ to provide evidence reports and technology assessments, by reviewing “all relevant scientific literature on
clinical, behavioral, and organization and financing topics.” The EPCs develop these reports “based on rigorous, comprehensive syntheses and analyses of relevant
scientific literature, emphasizing explicit and detailed documentation of methods, rationale, and assumptions.”
- National Guideline Clearinghouse (Agency for Healthcare Research and Quality)
http://www.guideline.gov/
The National Guideline Clearinghouse is a comprehensive database, updated weekly, of evidence-based clinical practice guidelines and related documents. Features of
the website are structured summaries and links to full-text of guidelines, when available; the ability to compare guidelines side-by-side; and “Guideline Syntheses” to
compare guidelines covering similar topics, highlighting areas of similarity and difference.
Free abstracts of EBM reports from the Cochrane Collaboration. Access to the complete Cochrane databases is via subscription only, but their Database of Systematic
Reviews is covered by DynMed (above).
http://www.bmjupdates.com/
A searchable database of best evidence from the medical literature which is free (as of July 2006) with personal registration. A product of BMJ and the Health Information
Research Unit at McMaster University , location of the editorial office of Evidence Based Nursing.
Additional free EBM websites:
Nursing research journals
When the filtering and synthesizing databases above do not provide summary reports on a particular health issue or therapy, individual research journals in nursing
or medicine can be searched, most through the CINAHL database. CINAHL is the Cumulative Index to Nursing and Allied Health Literature with Full-text of circa 350
periodicals, available to FGCU through Online Databases. For CINAHL and additional databases see Databases of Research Literature below.
Some Key Journals
(FGCU Library Call numbers are noted for print volumes, also the database title that contains full-text. If articles are needed from the journals not owned by FGCU*,
the articles can be obtained through Interlibrary Loan.)
Advances in Nursing Science
Expanded Acad. 1996
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*Online Journal of Knowledge Synthesis
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Annual Review of Nursing Research
1983-2005 print , 2005- CINAHL
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Research in Nursing and Health
Print RT81.5 .R46 1983
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Applied Nursing Research
1995 - ScienceDirect
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Scholarly Inquiry for Nursing Practice > Research and Theory for Nursing Practice - CINAHL 2005+
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*Biological Research for Nursing
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Western Journal of Nursing Research
print 1990- RT1 .W3
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*Canadian Journal of Nursing Research
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Worldviews on Evidence-based Nursing
CINAHL 2004 – (1 year embargo)
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Clinical Nursing Research ( 1996-98 only)
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Nursing Science Quarterly
print RT 1 .78
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Journal of Nursing Measurement
CINAHL 2004 -
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Oncology Nursing Forum
CINAHL 2000
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Journal of Nursing Scholarship
PQ-Nursing 2000-
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*Online Journal of Knowledge Synthesis
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*NT Research
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Research in Nursing and Health
Print RT81.5 .R46 1983
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Nurse Researcher
1998-2006 PQ-Nursing
2002 - CINAHL
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Scholarly Inquiry for Nursing Practice > Research and Theory for Nursing Practice CINAHL 2005+
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Nursing Research
OVID 1996 –
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Western Journal of Nursing Research
print 1990- RT1 .W3
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*CINAHL with Full-text (Cumulative Index to Nursing and Allied Health Literature)
(Available for FGCU through Online Databases (through the EBSCOHost system).
Search Tips for locating the best evidence:
1. Searches can be filtered using the Limit feature for “Evidence-Based Practice” found on an Advanced Search page.
2. Limit to Publication Type=Systematic Review
3. Limit to Publication Type = Practice Guidelines
* A tutorial for The CINAHL database through EBSCOHost, designed for FGCU researchers. (http://library.fgcu.edu/Instruction/CINAHL/CINAHL_tutorial_viewlet_swf.html)
PubMed (includes Medline)
The large medical database, free via Internet from the National Library of Medicine. Provides citations & abstracts from the world's medical and health related journals, dating
back to 1966.
A search feature found in the left navigation bar, Clinical Queries automatically filters searches on questions of therapy, diagnosis, etiology or prognosis by searching for the
highest levels of evidence in the literature. From the Clinical Queries webpage, a search for Systematic Reviews can be begun. Clinical queries provide four study categories
(therapy, diagnosis, etiology, prognosis) with the capability of selecting an emphasis of sensitivity (high recall) or specificity (high precision).
A chart of various PubMed filters for research, including randomized clinical trials can be found at this site: http://www.uic.edu/depts/lib/lhsp/resources/filters.shtml .
Detailed guidance in using advanced PubMed features for research is found at Yale Medical Library’s website: http://info.med.yale.edu/library/reference/publications/pubmed/
Two key concepts in evidence based health care are Levels of Evidence (LOEs) and Grades of Recommendation.
Levels of evidence relate to ranking the validity of the most recent research studies, i.e. the strength of the evidence.
Portrayed on a scale of 1 - 3, 1 - 4 or 1 - 5, with 1 being the best.
Grades of Recommendation are derived from the Levels of Evidence and are usually portrayed on a scale of A - C, or A - D, with A being the strongest
recommendation for disease-oriented outcomes or patient-oriented outcomes
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EBM tools such as DynaMed and InfoRetriever synthesize and summarize the latest research studies, putting them in clinical context, and will often signify the “level of evidence”
that a research study or finding provides clinical decision makers. EBM tools vary in their precise models for LOEs, but the levels of evidence are based on the rigor, i.e. quality and
type, of research studies, signified best by a pyramid or hierarchy of research evidence. Research reports that are systematic reviews or meta-analyses are considered to be the
most valid evidence.
SUNY Downstate Medical Center ’s Evidence Pyramid
http://library.downstate.edu/EBM2/2100.htm
Ebell, M.H.. et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature.
Am Fam Physician 2004 Feb 1;69(3):548-56. http://www.aafp.org/afp/20040201/548.html
Level 1 (likely reliable) Evidence
Level 2 (mid-level) Evidence
Level 3 (lacking direct) Evidence |
- Grade A recommendation (consistent high-quality evidence)
- Grade B recommendation (inconsistent or limited evidence)
- Grade C recommendation (lacking direct evidence)
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EBM Clinical Reference Tool
DynaMed, available to FGCU researchers as an Online Database uses the SORT (Strength of Recommendation Taxonomy) method of grading research evidence.
Sample DynaMed search on Carpal Tunnel Syndrome
Source: DynaMed through EBSCOHost.
A detailed description of DynaMed’s use of SORT for indicating strength of evidence, essential for understanding the significance of reports retrieved from DynaMed,
is found in the database, under “Systematic Literature Surveillance/ Determining Validity & Level of Evidence.
Level 1 (likely reliable) Evidence - represents the most valid reports addressing patient-oriented outcomes. Achieving a level 1 evidence label means that specific quality criteria
were met based on the study type.
- randomized trials with at least 80% follow-up
- inception cohort studies for prognostic information
- systematic reviews of level 1 evidence reports.
Level 2 (mid-level) Evidence - representing reports addressing patient-oriented outcomes, and using some method of scientific investigation, yet not meeting the quality criteria
to achieve level 1 evidence labeling. Level 2 evidence does not imply reliable evidence. For example, hormone replacement therapy was associated with reduced cardiovascular
- randomized trials with less than 80% follow-up
- non-randomized comparison studies
- diagnostic studies without adequate reference standards. events in large cohort studies (level 2 evidence), but then shown not to be preventive (and possibly increase the
cardiovascular risk) in randomized trials (level 1 evidence).
Level 3 (lacking direct) Evidence - representing reports that are not based on scientific analysis of patient-oriented outcomes.
- case series
- case reports
- expert opinion
- conclusions extrapolated indirectly from scientific studies.
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For Further Reading
~ Additional, Comprehensive Taxonomies for Research Evidence
- Develop a clinical question.
- Search for relevant evidence based reports in:
DynaMed, then if further information is needed:
National Guidelines Clearinghouse
AHRQ Evidence Reports (especially for technology assessments) Bmjupdates or
Other EBP sources if necessary
- Analyze the evidence based reports by scrutinizing the Levels of Evidence and the Grades of Recommendation, when available.
- Search literature databases such as CINAHL and PubMed, if insufficient EBP reports that are relevant to the individual patient problem are not yet found.
- Read and analyze articles located through the literature search, for relevance and strength of evidence.
- Choose interventions and justify them based on the best available evidence.
- Continuously evaluate your decisions and decision-making.
Web Resources for Evidence Based Practice
Nursing
Centre for Evidence Based Nursing. York University. http://www.york.ac.uk/healthsciences/centres/evidence/cebn.htm
Evidence Based Nursing and Midwifery. Joanna Briggs Institute.
http://www.joannabriggs.edu.au/about/home.php
Syllabi for Evidence Based Nursing. Center for Evidence Baed Medicine. University of Toronto.
http://www.cebm.utoronto.ca/syllabi/nur/
Medicine
Centre for Health Evidence
http://www.cche.net/usersguides/main.asp
Tutorials here, termed "User's Guides", are presented in the form of case studies.
| If you have comments, questions, or suggestions about these web pages, contact the Health & Social Sciences Librarian: Mary Kay Hartung: mhartung@fgcu.edu |
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