Posted: September 18th, 2023
The seven steps of evidence-based practice
The seven steps of evidence-based practice.
How to Apply the Seven Steps of Evidence-Based Practice
Evidence-based practice (EBP) is a process of using the best available research and clinical expertise to make informed decisions about patient care. EBP can improve the quality, safety, and effectiveness of health care, as well as reduce costs and variations in practice. However, implementing EBP can be challenging, especially for busy clinicians who may lack the time, skills, or resources to search for and appraise evidence. To help overcome these barriers, the following seven steps of EBP can guide clinicians in integrating evidence into their practice.
Step 0: Cultivate a spirit of inquiry within an EBP culture and environment.
The first step of EBP is to foster a culture and environment that supports inquiry and innovation. This means creating a climate where clinicians are encouraged to ask questions, seek answers, and share their findings with others. A spirit of inquiry can be cultivated by:
– Providing education and training on EBP principles and methods
– Providing access to online databases, journals, and other sources of evidence
– Providing time and resources for conducting literature searches and appraisals
– Providing feedback and recognition for EBP activities and outcomes
– Providing opportunities for collaboration and mentorship among colleagues
– Providing leadership support and role modeling for EBP
Step 1: Ask the burning clinical question in PICOT format.
The second step of EBP is to formulate a clear and focused clinical question that addresses a problem or issue in practice. A well-defined question can help narrow down the search for relevant evidence and guide the appraisal and application of the evidence. A useful tool for developing a clinical question is the PICOT format, which stands for:
– Population: Who are the patients or groups of interest?
– Intervention: What is the intervention or exposure of interest?
– Comparison: What is the alternative or comparison intervention or exposure?
– Outcome: What are the outcomes or effects of interest?
– Time: What is the time frame or duration of interest?
For example, a PICOT question for a nurse who wants to compare the effectiveness of two wound dressings for diabetic foot ulcers could be:
In patients with diabetic foot ulcers (population), how does hydrocolloid dressing (intervention) compare with saline gauze dressing (comparison) in terms of wound healing (outcome) over four weeks (time)?
Step 2: Search for and collect the most relevant best evidence.
The third step of EBP is to search for and collect the best available evidence that answers the clinical question. This involves:
– Identifying the type and level of evidence needed, such as systematic reviews, randomized controlled trials, cohort studies, case-control studies, etc.
– Choosing the appropriate databases, keywords, filters, and limits to conduct a comprehensive and efficient search
– Retrieving and organizing the search results according to relevance, quality, and quantity
– Selecting the most relevant and highest quality studies for further appraisal
For example, to search for evidence on the PICOT question above, a nurse could use databases such as PubMed, CINAHL, Cochrane Library, etc., and use keywords such as “diabetic foot ulcer”, “hydrocolloid dressing”, “saline gauze dressing”, “wound healing”, etc., with filters such as “clinical trial”, “systematic review”, “meta-analysis”, etc., and limits such as “English language”, “last 5 years”, etc.
Step 3: Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, synthesis, and recommendations).
The fourth step of EBP is to critically appraise the selected evidence for its validity, reliability, relevance, and applicability. This involves:
– Assessing the methodological quality and rigor of each study using standardized tools or criteria
– Assessing the results and conclusions of each study for their accuracy, consistency, significance, and clinical importance
– Synthesizing the findings from multiple studies using quantitative or qualitative methods
– Making recommendations based on the strength and consistency of the evidence
For example, to appraise the evidence on the PICOT question above, a nurse could use tools such as the Critical Appraisal Skills Programme (CASP) checklists or the Joanna Briggs Institute (JBI) critical appraisal tools to evaluate each study for its design, sample size, randomization, blinding, intervention fidelity, outcome measurement, statistical analysis, risk of bias, confounding factors, etc. The nurse could then use methods such as meta-analysis or narrative synthesis to combine the results from different studies and calculate an overall effect size or estimate. The nurse could then make recommendations based on the level of evidence (such as grade A to D) or strength of recommendation (such as strong or weak).
Step 4: Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change.
The fifth step of EBP is to integrate the best evidence with one’s own clinical expertise and the patient’s preferences and values in making a practice decision or change. This involves:
– Comparing and contrasting the evidence with one’s own knowledge, skills, and experience
– Considering the patient’s characteristics, needs, expectations, and preferences
– Considering the feasibility, acceptability, and cost-effectiveness of the intervention or change
– Communicating the evidence and the decision or change to the patient and other stakeholders
– Obtaining informed consent and agreement from the patient and other stakeholders
For example, to integrate the evidence on the PICOT question above, a nurse could compare and contrast the evidence with his or her own experience and expertise in wound care, consider the patient’s preferences and values regarding wound dressing, consider the availability, accessibility, and affordability of hydrocolloid dressing versus saline gauze dressing, communicate the evidence and the decision or change to the patient and other health care providers, and obtain informed consent and agreement from the patient and other health care providers.
Step 5: Evaluate outcomes of the practice decision or change based on evidence.
The sixth step of EBP is to evaluate the outcomes of the practice decision or change based on evidence. This involves:
– Defining and measuring the outcomes of interest, such as clinical outcomes, patient satisfaction, quality of life, etc.
– Collecting and analyzing data on the outcomes using appropriate methods and tools
– Comparing and interpreting the results with the expected outcomes and the evidence
– Identifying and addressing any barriers, facilitators, or unintended consequences of the decision or change
– Making adjustments or modifications to the decision or change as needed
For example, to evaluate the outcomes of the practice decision or change on the PICOT question above, a nurse could define and measure wound healing as the primary outcome of interest, using tools such as wound assessment scales or digital photography. The nurse could collect and analyze data on wound healing over four weeks using methods such as descriptive statistics or inferential statistics. The nurse could compare and interpret the results with the expected outcomes and the evidence, such as whether hydrocolloid dressing is more effective than saline gauze dressing in promoting wound healing. The nurse could identify and address any barriers, facilitators, or unintended consequences of the decision or change, such as patient adherence, infection risk, cost implications, etc. The nurse could make adjustments or modifications to the decision or change as needed, such as changing the frequency or duration of dressing changes.
Step 6: Disseminate the outcomes of the EBP decision or change.
The seventh step of EBP is to disseminate the outcomes of the EBP decision or change to others who may benefit from it. This involves:
– Summarizing and reporting the findings and implications of the decision or change
– Choosing the appropriate audience, format, and channel for dissemination
– Sharing the findings and implications with others through oral presentations, written publications, posters, webinars, etc.
– Seeking feedback and suggestions from others for improvement or further research
– Incorporating feedback and suggestions into practice improvement or future research
For example, to disseminate the outcomes of the practice decision or change on the PICOT question above, a nurse could summarize and report the findings and implications of using hydrocolloid dressing versus saline gauze dressing for diabetic foot ulcers. The nurse could choose an appropriate audience, format, and channel for dissemination, such as other nurses in his or her unit or organization, a journal article or a poster presentation at a conference, an email newsletter or a blog post on a website. The nurse could share the findings and implications with others through oral presentations, written publications, posters, webinars, etc., using clear language, visuals, tables, graphs, etc. The nurse could seek feedback and suggestions from others for improvement or further research on wound care for diabetic foot ulcers. The nurse could incorporate feedback and suggestions into practice improvement or future research.
EBP is a process of using the best available research and clinical expertise to make informed decisions about patient care. EBP can improve health care quality, safety, effectiveness,
costs,and variations in practice. However,E BP can be challenging to implement in busy clinical settings. To help clinicians apply EBP in their practice,the seven steps of EBP can guide them in formulating a clinical question ,searching for collecting,and appraising evidence,integrating evidence with clinical expertise,and patient preferences,making a practice decision or change ,evaluating outcomes,and disseminating findings.
CASP (Critical Appraisal Skills Programme). “CASP Checklists.” CASP UK ,2020 ,https://casp-uk.net/casp-tools-checklists/. Accessed 18 Sep 2023.
Joanna Briggs Institute . “Critical Appraisal Tools.” JBI ,2021 ,https://jbi.global/critical-appraisal-tools. Accessed 18 Sep 2023.
Melnyk,Bernadette Mazurek,and Ellen Fineout -Overholt . Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice .4th ed., Wol