Skip to Main Content

NISH (NITAG Support Hub) 1 - General: Five steps in EBP

What are library guides? Library guides are helpful resources that provide users with information and guidance on how to effectively use resources and services.

1. Ask the question

The first step in the evidence-based practice process is to formulate a clinical question.

The clinical question should be relevant to the patient or the problem and constructed so as to help you search for an answer.

There are tools that help make this process easier. These "mnemonics" or "frameworks" help you to:

  • put together the parts of the clinical question
  • identify the key concepts that need to be in articles that will help answer the question
  • formulate your search strategy.

These mnemonics include PICO and SPIDER, and the lesser-used PEO, SPICE, and ECLIPSE.

In evidence-based healthcare, there can be different types of questions:

  • Therapy/Intervention
  • Diagnosis/Screening
  • Prognosis
  • Aetiology/Causation
  • Prevention

 

3. Appraise the evidence

What is Critical Appraisal?

Once you have asked the clinical question and searched for evidence, you need to appraise the evidence. This helps to:

  • cut down on information overload
  • find studies relevant to your situation
  • reject studies which have scientific flaws.

 

There are a number of tools and checklists that are available (and free) to help with critical appraisal. Please note that, just as the type of question being asked (therapy, aetiology, diagnosis etc) might determine the type of study or research (RCT, case study, cohort study etc) being used or sought, the type of study or research might in turn determine the process of critical appraisal.

There are various critical appraisal tools available free and online. As already noted, these checklists and worksheets can vary according to the type or study or research that is being appraised ...
 

 

 

The list of 8 CASP checklists, with one each for systematic review, randomised controlled trial, diagnostic, economic evaluation, qualitative, case control, cohort study, and clinical prediction rule

 

CASP is best known for its checklists, a set of eight critical appraisal tools designed to be used when reading research. These eight tools match eight different study or research types.

This highlights that the checklist you use should depend on the type of study you are appraising.

The checklists are free to download, and can be used by anyone under the Creative Commons licence.

 

 

2. Acquire the evidence

The second step in the EBP process is to find evidence-based resources that will help to answer your clinical question.

Before embarking on searching, it helps if you have an understanding of the different types of research, and the different levels of evidence.

This section includes pages on:

  • Types of Research
  • Levels of Evidence
  • Where to search for evidence
  • How to search for evidence, including information on Grey Literature
  • Literature Reviews / Systematic Reviews, including how to find Systematic Reviews
  • Clinical Colleagues as a Source of Evidence
  • More Resources on Acquiring the Evidence.

4. Apply the evidence

So Step 4 - Apply the evidence - involves working out how the results of your research apply to the patient, taking into consideration your own clinical expertise and the patient's situation.

Glasziou, Salisbury, & Del Mar (2009, p. 133) suggest that this is sometimes called the "external validity", or "generalisability" of the research results, and that it might be carried out before, or concurrently with, Step 3 (Appraising the evidence).

Questions to ask at this stage include:

  • Is the intervention feasible in my setting?
  • What else do I need in order to apply this evidence?
  • Is my patient similar enough to the subjects of the study so that the results can apply?
  • Will the potential benefits of treatment outweigh any potential harm?
  • What are the views of my patient?

Salisbury, J., Glasziou, P.P. and Del Mar, C., 2009. Evidence-based practice workbook: bridging the gap between health care research and practice. (No Title).

5. Assess and audit the process

There are two strands to this fifth step:

  • Self-evaluation and evaluation of the EBP process
  • Evaluation of change in practice.

Self-evaluation and evaluation of the EBP process

This involves assessing/auditing the effectiveness and efficiency of the evidence-based practice process, identifying strengths and weaknesses and ways that it might be improved the next time.

Self-reflective questions might include:

  • Did I ask a well-formulated clinical question?
  • Did I consider the best sources of evidence for the type of clinical question?
  • Have I searched the databases efficiently? 
  • Did I use the hierarchy of evidence as my guide for the type of evidence that I should be searching for?
  • Where possible, did I search for and use information that is higher up in the pyramid of levels of organisation of evidence (for example, syntheses, synopses, summaries and pre-appraised original studies)? 
  • Am I integrating the critical appraisal into my clinical practice? 
  • Can I clearly explain what the evidence means to my patients and involve them in shared decision making where appropriate?
  • Am I proactively monitoring for newly emerging evidence in my field of practice? (Hoffmann, Bennett, & Del Mar, 2013, p. 11).

Evaluation of change in practice

This involves evaluating the outcomes and impact of an evidence-based intervention.

Questions might include:

  • What were the effects of the change?
  • Was the application of the new information or procedure effective?
  • Should this new information and/or clinical practice procedure continue to be included in day-to-day applications? 

This final step completes the cycle of Evidence-Based Practice, as the evaluation of the change/implementation/outcomes might lead to further clinical questions.