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A Guide for Nurses and Nursing Students



EBP is the integration of clinical expertise, patient values, and the best research evidence available into the decision making process for patient care.  Clinical expertise refers to the clinician's cumulated experience, education, and clinical skills.  The patient brings to the encounter his or her own personal and unique concerns, expectations, and values.  The best evidence is usually found in clinically relevant research that has been conducted using sound methodology (Sackett, 2002).                                                    

Evidence-Based Practice, Step by Step

This collection of articles authored by Melynk, Fineout-Overholt, et al., are from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice.  

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time.  Articles appeared every two months to allow time for staff to incorporate information as they worked toward implementing EBP at their institutions.

Evidence-Based Practice, Step by Step: 

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The Five A's of the Evidence Cycle:

Building a PICO/PICOT/PICOTS Framework

Incorporating best evidence into nursing requires a systematic approach.  A clear series of steps, known as the Evidence Cycle, can provide an excellent paradigm to guide you through this process.  It involves knowing the right question to ask, turning that question into a good search, knowing the best place to look, finding what is available, appraising the results, and then using the evidence you find to care for your patient population.  Use the "5 A's" as a step-by-step guide to locate best evidence.

  1. Assess:  Identify the health problem.  What is it you want to know?
  1. Ask:  Use the PICOT formula to create a good question
    • P = Patient:  Who is your patient population?  Describe the most important characteristics of the patient.  (e.g., age, disease/condition, gender)
    • I = Intervention:  What type of intervention are you trying to assess?  An educational intervention, a prevention initiative such as immunization, a policy change?  Describe the main intervention.  (e.g., exposure to disease, a prognostic factor, drug or other treatment, diagnostic/screening test)
    • C = Comparison:  Is there a control?  Describe the main alternative being considered.  (e.g., placebo, standard therapy, no treatment, no disease or absence of risk factor, the gold standard)
    • O = Outcome:  What do you hope to accomplish?  Better/best prevention method(s)?  Describe what you're trying to accomplish, measure, improve, affect, including a time horizon if relevant.  (e.g., clinical outcome, reduced mortality or morbidity, improved memory, accurate and timely diagnosis)
    • = Time:  Is there a time frame to reach the desired outcome with chosen intervention?
    • S = Setting:  Sometimes you will see "S" in a PICOT framework which can stand for Setting (e.g. primary, specialty, inpatient, nursing homes, or other long-term care setting) where the study is implemented and the relevance of the study setting to real world use. You may also see "S" used for Study Design (e.g. Randomized Controlled Trial) as an important factor in your PICOT question.
  1. Acquire: Use your PICOT formula to search for good evidence.  Start your search using only two to three terms - you can always add more.  Create a chart and write down your primary search terms/synonyms/MeSH terms/CINAHL headings for each section of your PICOT.
  1. Appraise:  What have you found?  Where did you find it?  Are the results significant to your patient population?  How strong is the evidence?  Are there any confounding variables such as bias present?
  1. Apply:  Now apply and discuss the evidence you have found with your patient population.
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