Models and Frameworks for Implementing Evidence-Based Practice
Johns Hopkins Evidence-Based Practice Model and Guidelines, Second Edition by EBP is a problem-solving approach to clinical decision-making within a health care organization. It integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence. EBP considers internal and external influences on practice and encourages critical thinking in the judicious application of such evidence to the care of individual patients, a patient population, or a system (Newhouse, Dearholt, Poe, Pugh, & White, 2014).
Translate the PICO framework into a search strategy
Brainstorm and gather synonyms
Construct the search strategy
Save search & export results to a reference manager (Zotero or Research Matrix)
First you need to define a problem and formulate a clinical question. In the research process, this is the research question or statement. In the clinical setting, ‘asking a question’ may become part of a research study, a quality improvement project, or lead to evidence-based practice.
A commonly used format for creating a clinical question is known as PICO or PICO(T), which refers to: Patient/Problem, Intervention, Comparison, Outcome and occasionally Timeframe/Type of Study.
Most common type of clinical questions: Therapy, Diagnosis, Harm, Prognosis
| Therapy | determining the effect of interventions on patient-important outcomes | |
| Diagnosis | establishing the power of a test to differentiate between those with and without a target condition or disease | |
| Etiology/Harm |
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| Prognosis |
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You have a patient who has difficulty exercising due to COPD and you wonder if pursed lip breathing techniques may improve their endurance.
P = patients with COPD
I = pursed lip breathing
C = regular breathing
O = improved exercise endurance
Clinical Question: In patients with COPD, does using pursed lip breathing, as compared to regular breathing, improve exercise endurance?
You are working with a recent stroke patient who is having balance issues and you are considering using virtual reality in their therapy.
P = recent stroke, balance issues
I = virtual reality
C = no virtual reality
O = improved balance
Clinical Question: In recent stroke patients, how does using virtual reality affect or improve balance?
Search strings are constructed searches that combine concepts with Boolean operators (AND, OR, NOT). You can start building a search string by using keywords from your list of PICO terms and synonyms or related terms of them and then move to established subject terms that databases use to tag item records.
The following databases are ideal for finding evidence-based literature:
Cochrane Database of Systematic Reviews – contains full-text articles and protocols focusing on the effects of healthcare.
Depending on your research question, you need to address what type of study would provide the best evidence. When searching for articles, databases often have filters allowing you to acquire specific types of studies.
Systematic Review: It is an intensive review of the literature on a given topic. It uses explicit and rigorous methods to identify the studies included in the review. It also critically appraises and synthesizes all the studies included in the review. - secondary research
Meta-Analysis: Similarly to a systematic they overview extensively the literature on a topic, but they combine the results of all the studies identified in a quantitative way. They synthesizing summaries and make a conclusion that may be used to evaluate therapeutic effectiveness. - secondary research
Randomized Controlled Trial: It is a clinical trial that involves at least one test treatment and one control treatment. There was concurrent enrollment and follows up of the test- and control-treated groups, and in which the treatments were administered by a random process.- primary research
Cohort Study: A study in which subsets of a defined population are identified and studies over a period of time to see the effects of something. - primary research
Cross-sectional Study: A study that describes the relationship between diseases and other factors at one point in time in a defined population. They are often used for comparing diagnostic test.
Retrospective Cohort: A study that follows the same direction of inquiry as a cohort study, but this study design uses information that has been already collected in the past and kept in files or data sets.
Case Control Study: A study that starts with the identification of persons with a specific condition then compared with a control group who do not have the condition. The relationship of an attribute to the disease is examined by comparing often relying on medical records of and patient recall for data collection. Documenting the frequency or levels of the attribute in each group. These type of studies are often less reliable because showing a statistical significance is harder. - primary research
Case Series / Reports: Articles written about one patient or a series of patients with the same issue. Great for rare diseases, disorders, and drug/treatment reactions. Not the best source of evidence because it focuses on a small group of people, but sometimes it's the only source.
Uses words to describe human behaviors. It answers a wide variety of questions related to human responses to actual or potential health problems. The purpose of qualitative research is to describe, explore and explain the health-related phenomena being studied.
Uses numbers to obtain precise measurements that can later be statistically analyzed. Many quantitative studies test hypotheses. It follows a systematic, subjective approach to examine the relationship between variables with the primary goal being to analyze and represent that relationship mathematically through statistical analysis. This is the type of research approach most commonly used in scientific research problems.
When reading articles and determining which studies to use, appraise the strength and quality of the research studies using the John Hopkins Nursing Evidence-Based Practices which evaluate the validity and reliability thru various levels of evidence. See appendix C for full list.
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Below you will find tools from Johns Hopkins University, that would help you critically asses studies:
