Updated: June' 2014


 Action Plan:                       EBM Module                             Present Status


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 Clinical practice & patient care will be based on the most recent and available scientific evidence. It is the process of systematically findings and using contemporary research findings as the basis for clinical decision making.

 It is essential that all system, process and infrastructure and health professional will be developed using the predetermined principles and EVP.

 To facilitate the development and implement  of EVP, the processes need to apply and Identify area from where the quality clinical management will be ensured and measure performance against the expected outcome.

For example to develop an EVP we have already developed the organization strategy by Risk management programme to minimize the clinical risk.

 What is Evidence Based Practice?

Evidence based practice (EBP) has many definitions. The most widely cited definition of EBP is adapted from Sackett et al's definition of evidence based medicine (EBM). This states that EBM is:

"the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research"            
                                                                                                                                                                   (Sackett et al, 1996)

The definition above, highlights the need to draw on both the professional's clinical experiential knowledge and the best external evidence. Neither is enough on its own. As Sackett and his colleagues point out, clinical practices become out of date if new evidence is not drawn upon. However, the clinician must be aware of what evidence is appropriate to integrate into their practice. This can prove to be a difficult and time-consuming task but it is an essential skill in implementing evidence based practice.

The Five Stages of Evidence Based Practice

Evidence based practice can be broken down into five key stages. These are:

  • The Question. The first step in evidence based practice is recognising that there is a need for new information. This information need has to be converted into an answerable question.
  • Finding the Evidence. Choosing the right evidence is of fundamental importance.
  • Appraisal. The evidence must be critically appraised to determine its validity and potential usefulness.
  • Acting on Evidence. Once you have concluded that the evidence is of sound quality, you will have to decide whether the evidence should be incorporated into your clinical practice.
  • Evaluation & Reflection. Evaluation and reflection are necessary to determine whether the action you have taken has achieved the desired results. This is now a fundamental part of nursing practice.

Evidence based practice is a continuous process. Once you have worked through each of the stages, you are likely to find that new questions have arisen that need to be answered. The diagram below illustrates this continuous process:

  The Question?

The drive to find evidence should come from a need to make a decision. Often, a problem will arise that needs to be answered, such as deciding what treatment should be given to a particular patient. The first step in evidence based practice is therefore recognising that there is a need for new information.

This information need is likely to be vague. It therefore needs to be converted into an answerable question in order to facilitate an efficient search for the answer. A precise answer can only be provided in response to a precisequestion. Carefully framing the question can also help you determine what type of evidence you need to find. Sackett and his colleagues suggest that well-built clinical questions can be divided into 'background' and 'foreground' questions:

         Background Questions

        Foreground Questions

Less experienced nurses are likely to focus on background questions. However, with increasing experience and responsibility there will be a greater need to concentrate on foreground questions.

Often, a number of questions will crop up at the same time and it will not be possible to answer them all at once. It is usually best to concentrate on one at a time. To decide where to begin, it may be helpful to consider whether the question is:

  • More essential to the patient's well-being
  • Of most importance according to the patient
  • Most feasible to be answered in the available time
  • Most likely to recur at a later date
  • Most interesting.


The inability to ask a focused and precise clinical question can be a major impediment to evidence based practice.

Background Questions

Background questions ask for general knowledge about a disorder and contain two essential components. These are:

  • A question root (who, what, where, when, how, why)
  • A disorder or an aspect of a disorder.

Two examples of background questions are:

  • What causes depression?
  • When do complications of appendicitis usually occur?

Foreground Questions

Foreground questions ask for specific knowledge about managing patients with a disorder. These type of questions also have a number of essential components. These are:

  • Patient and/or problem
  • Intervention
  • Comparison intervention (if relevant)
  • Clinical outcomes.

The foreground question is often referred to as the PICO question structure (Patient/Problem, Intervention, Comparison, Outcome).

An example of a PICO question is:

  • In an older patient with X disorder, is giving Y treatment rather than Z treatment more likely to result in a shorter stay in hospital?
                       (Adapted from Sackett et al 2000)


Finding the Evidence

Choosing the right evidence is of fundamental importance. There are many sources of evidence, and it can be difficult to know where to begin. Many nurses will probably be used to finding evidence from two main sources. These are:

  • More experienced colleagues
  • Textbooks.

However, there are similar problems with both these sources of information.

When using evidence from more experienced colleagues:

  • How can you be sure that the information they give you is reliable?
  • Where have they obtained their opinions from?
  • Is their knowledge up to date?

When using evidence from textbooks:

  • Sometimes textbooks are written in such a way that it is unclear how the authors reached their conclusions
  • Sometimes the opinions that are expressed in textbooks may be out of date before the book is even published, or be inconsistent with current best evidence (Antman et al, 1992).

When examining the evidence it will be helpful to consider the so-called Hierarchy of



Once you have found some potentially useful evidence it must be critically appraised to determine its validity and find out whether it will indeed answer your question.

When appraising the evidence the main questions to ask, therefore, are:

  • Can the evidence (e.g. the results of the research study) be trusted?
  • What does the evidence mean?
  • Does this answer my question?
  • Is it relevant to my practice?

Different appraisal and interpreting skills must be used depending on the kind of evidence being considered. A good place to gain an overview of understanding and appraising research studies is the book by Tricia Greenhalgh (2000). This is entitled:

  • How to read a paper: the basics of evidence-based medicine BMJ Publishing Group, 2000.

Additionally, guidance and training on appraising different types of evidence are


Acting on Evidence

Once you have concluded that the evidence is of sound quality, you will need to draw on your own expertise, experience and knowledge of your unique patient and clinical setting. This will help you to decide whether the evidence should be incorporated into your clinical practice.

You must consider both the benefits and risks of implementing the change, as well as the benefits and risks of excluding any alternatives. This decision should be made in collaboration with your patient, and in consultation with your manager or multidisciplinary team where appropriate.

Remember !

Resistance to change can be a big problem. Involving all stakeholders (colleagues, patients, carers, budget-holders, etc.) can ensure the change is made and sustained.


Evaluation and Reflection

Reflection is now an established part of nursing practice. With regard to evidence based practice, some questions you could reflect on may be:

Stage 1. Asking the Question:

  • Was my question answerable?
  • Was my question stated explicitly enough to help me in my search for the evidence?

Stage 2. Finding the evidence:

  • Did I search the right sources for the evidence or was there somewhere else I should have looked?
  • Did I manage to find sound evidence quickly and efficiently?

Stage 3. Appraising and Interpreting the Evidence:

  • Did I appraise the evidence effectively?
  • Do I need to improve my critical appraisal skills?

Stage 4. Acting on the Evidence:

  • Did I involve the patient (and appropriate others) in the decision to act on the evidence?
  • Should I have attempted to answer my initial query a different way (eg. considered an alternative treatment to the one evidence was sought for)?

By this stage you may be heaving a sigh of relief, feeling that you have successfully completed the five stages of evidence based practice. However, it is likely that answering (or failing to answer) your initial question has resulted in the generation of further questions.

Even if this is not the case, new information needs occur with every new challenge. Every patient is unique, and learning the skills necessary to engage in evidence based practice will help you deal with uncertainties in your practice as they arise.

Remember !

Evidence based practice is all about having a questioning approach to your work. It is not a 'one off'. It is a continuous process to both provide the best quality care for your patients and develop you as a nurse, personally and professionally.



 Action Plan:                                                    Present Status