Key Steps of Evidence-Based Practice
What type of question are you asking and what will
the evidence support?
Therapy/Treatment questions:
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 questions: evidence
supports how to estimate your
patients likely clinical course
over time and anticipate likely
complications of the disorder.
Diagnosis questions:
evidence supports how to select and
interpret diagnostic tests, in order to
confirm or exclude a diagnosis,
based on considering their
precision, accuracy, acceptability,
expense, safety, etc
Harm/Etiology questions:
Evidence supports how to identify
causes for disease (including its
iatrogenic forms).
 Key Steps of Evidence-Based Practice

Types of Evidence

Primary Studies:
Clinical Trials
Randomized Controlled Trials
Multicenter studies

Secondary Studies:
Reviews
Meta-analyses
 Key Steps of Evidence-Based Practice
Type of Question/Domain Type of Study/Methodology

Therapy/Treatment Double-Blind Randomized Controlled Trial

Selection of treatments or interventions that
do more good than harm and that are worth Systematic Review/Meta Analysis of RCT
the effort cost
Diagnosis Controlled Trial
Selection and interpretation of diagnostic
tests, in order to confirm or exclude a Systematic Review/Meta Analysis of
diagnosis, based on considering their Controlled Trial
precision, accuracy, acceptability, expense,
safety, etc

Prognosis Cohort Studies,

Estimation of a patients likely clinical course Case Control,
over time and anticipation of likely Case Series
complications of disease
Harm/Etiology Cohort Studies
Identification of causes or risk factor for
disease
Prevention Randomized Controlled Trial,
Cohort Studies
Quality improvement Randomized Controlled Trials
Key Steps of Evidence-Based Practice

Strength
Strength of
of Study
Study Design:
Design: The
The Evidence
Evidence Pyramid
Pyramid
 Key Steps of Evidence-Based Practice

Systematic Review
- Is a summary 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. Conclusion are then drawn
about the data gathered through process.
Meta-Analyses Review
-yields an overall summary statistic that represents the
effect of the intervention across multiple studies.
-combines the samples of each study included in the
review to create one larger study, the summary study is
more precise than the individual findings from any one of
the contributing studies alone (Ciliska, Cullum,& Marks,
2001).
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Critical appraisal of evidence is a hallmark of
EBP. Although critical appraisal is not new, it
has become a core skill for those who plan to
use evidence to support healthcare decisions.
The Purpose of critically appraising the
sources is to determine the certainty and
applicability of knowledge, regardless of
source.
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Terminologies
Null Hypothesis

P-value

Confidence intervals

Relative vs. Absolute Risk Reduction

 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Null Hypothesis
Tylenol is better than
States that there is no Advil for headaches
relationship between the
variables being studied. Exercising 30 minutes
a day is good for your
Opposite of what you are health
trying to find out.
Lefthanders are prone
to accidents
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
P-value
Probability that the Small p-value
outcomes are due to dismiss chance
chance
Large p-value means
Accepted reference that anything is
point is .05 possible (chance,
actual effect, or
Less than .05 is confounding factors)
statistically significant
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Confidence intervals
The ranges of values within which a researcher
can be confident that the population value falls.
A 95% confidence interval (CI 95) means that
one can be 95% confident that the population
value falls within a certain range
Example: A study states that 40% of a sample
of 1000 people are smokers with a CI of 95%
+/- 3% means the frequency of smoking is
between 37% and 43%.
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Relative vs. Absolute Risk Reduction
RR (Relative Risk) is the risk for achieving an
outcome in the treatment group relative to that
in the control group
RRR (Relative Risk Reduction) is the increase in
outcome with the treatment compared to the
control (often expressed as a percentage)
ARR (Absolute Risk Reduction) is the difference
in outcome rates for two groups, usually
treatment and control
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Relative Risk Reduction
Not a good way to compare outcomes
Amplifies small differences and makes insignificant
findings appear significant
Does not reflect the baseline risk of the outcome
event
Can make weak results look good
Making weak results look good makes them
popular, thus they are reported in many journal
articles
RRR can mislead DO NOT USE
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Absolute Risk Reduction
A better statistic to evaluate outcome
Does not amplify small differences, but
shows the true difference between the
experimental and control interventions
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
Although professionals typically view critical
appraisal as an exhaustive, time-consuming
process, it can be efficiently accomplished by
answering three key questions:
1. What were the results study?
2. Are the results valid?
3. Will the results help me in caring for
my patients?
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
1. What were the results study?
e.g., in intervention trials, this includes how large
are the treatment effects; in qualitative studies,
this includes evaluating whether the research
approach fits the purpose of the study.
2. Are the results valid?
e.g., in intervention trials, it would be important to
determine whether the subjects were randomly
assigned to treatment or control groups and
whether they were equal on key characteristics
prior to the treatment.
 Key Steps of Evidence-Based Practice
Step 3: Critical Appraisal
3. Will the results of the study facilitate the
care of the practitioners patients?
Should include asking whether the subjects in
the study were similar to the patients for whom
care is being delivered and whether the
benefits are greater than the risks of treatment.
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence

Evidence is now viewed and scrutinized from a

clinical epidemiological perspective. This means
that the practitioner takes into account the
validity and stability of the specific evidence
when clinical recommendations are made.
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
The meaning of evidence is more fully appreciated
within the context of best practice, which reflects
the following:

- Research evidence
- Clinical knowledge gained via the individual
practitioners experience
- The patients and practitioners preferences and
situations
-Basic principles from logic and theory
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
Reliance on inexplicit or inferior knowledge
sources (e.g., tradition) is rapidly becoming
unacceptable practice in todays quality- focused
climate of healthcare. Rather, such practice are
being replaced with a quality of knowledge said
to include certainty.
Certainty- the key criterion for quality of
underlying knowledge. It is the level of sureness
that the clinical action will produce the intended
or desired outcome.
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
Is integrating the evidence found from the
literature search with the healthcare providers
expertise, clinical assessment of the patient and
available healthcare resources, as well as
patient preferences and values to implement a
decision.
In addition, to ethical considerations related to
involving patients in treatment decisions,
consumer of healthcare services want to
participate in the clinical-decision making
process.
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
EBP experts have developed a number of
taxonomies to rate a varying levels of strength of
evidence. These assessments of the strength of
scientific evidence provide a mechanism to guide
practitioners in evaluating research for its
applicability to healthcare decision making.
Grading the strength of a body of evidence should
incorporate three domains:
Quality,
Quantity, and
Consistency.
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
Quality
The extent to which a studys design, conduct, and analysis
has minimized selection, measurement, and confounding
biases ( internal validity)
Quantity
The number of studies that have evaluated the question,
overall sample size across all studies, magnitude of the
treatment effect, strength from causality assessment,
such as relative risk or odds ratio.
Consistency
Whether investigations with both similar and different study
designs report similar findings.
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
Situation:
Even if the evidence found from a rigorous search
and critical appraisal strongly supports that a certain
treatment is beneficial (e.g., Hormone replacement
therapy [HRT] to prevent osteoporosis in a very
high-risk woman).
Moreover, as part of the history-taking process or
physical examination, a cormobidity or
contraindication may be found that increases the
risks of HRT (e.g., prior history of stroke).
 Key Steps of Evidence-Based Practice
Step 4: Integrate the Evidence
Situation:
Therefore, despite compelling evidence to
support the benefits of HRT in preventing
osteoporosis in high-risk women, a decision
against its use may be made after a thorough
assessment of the individual and a discussion of
the risks and benefits of treatment.
 Key Steps of Evidence-Based Practice
Step 5: Evaluate Effectiveness
Is 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 type of evaluation is essential in
determining whether the change based on
evidence resulted in the expected outcomes.
 Evidence-based Practice
Without current best evidence, practice is
rapidly outdated, often to the detriment of
patients.
e.g., for years, pediatric primary care providers
advised parents to place their infants in a prone
position while sleeping, with the underlying
reasoning that this is the best position to
prevent aspiration in the event of vomiting. With
evidence indicating that prone position
increases the risk
of sudden infant
death syndrome.
 > Polit, D., Hungler, P. (1991). Nursing Research
Principles and Methods 4th edition. United States of America.
J.B. Lippincott Company.
>Polifko, K. (2007). Concepts of the Nursing Profession.
United States of America. Thompson Delmar Learning.
> Melnyk, B.M., & Fineout-Overholt, E. Evidence-Based
Practice in Nursing & Healthcare: a guide to best practice.
United States of America. Lippincott Williams & Wilkins.
> Hughes, R. (2008). Patient Safety and Quality
An Evidence-Based Handbook for Nurses.
United States of America. Agency of Healthcare
Research and Quality.
 Shah, H., & Chung, K. (2009). Archie Cochrane and his vision for
evidence-based medicine. National Institute of Health. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746659/
Bolender. Provide evidence-based clinically competent care. Pacific
Lutheran University. Retrieved from
http://www.plu.edu/~bolendrm/evidence-based/home.html
Moyer, V. (2008). Weighing the Evidence: PICO Questions: What are
they, and Why Bother?. American Academy of Pediatrics. Retrieved from
http://aapgrandrounds.aappublications.org/content/19/1/2.full
Clinical Effectiveness Education Specialist. (2006). Tutorial: How to Form
an Answerable Clinical Question [PowerPoint slides]. Retrieved from
http://www.cincinnatichildrens.org/assets/0/78/176/4711/4715/fca30651-
b07c-43be-a28a-80e171e7cca4.pdf
 Never Stop
Questioning!
Susan L. Hendrix