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Research studies show thatevidence-based practice(EBP) leads to higher qual-

ity care, improved patient out-comes, reduced costs, and greater

nurse satisfaction than traditionalapproaches to care.1-5 Despitethese favorable findings, manynurses remain inconsistent in theirimplementation of evidence-basedcare. Moreover, some nurses,whose education predates the in-clusion of EBP in the nursing cur-riculum, still lack the computerand Internet search skills neces-sary to implement these practices.As a result, misconceptions aboutEBPthat its too difficult or tootime-consumingcontinue toflourish.

In the first article in this series(Igniting a Spirit of Inquiry: AnEssential Foundation for Evidence-Based Practice, November 2009),we described EBP as a problem-solving approach to the deliveryof health care that integrates thebest evidence from well-designedstudies and patient care data,and combines it with patient

preferences and values and nurseexpertise. We also addressed thecontribution of EBP to improvedcare and patient outcomes, de-scribed barriers to EBP as well as

factors facilitating its implementa-tion, and discussed strategies forigniting a spirit of inquiry in clin-ical practice, which is the founda-tion of EBP, referred to as StepZero. (Editors note: althoughEBP has seven steps, they arenumbered zero to six.) In thisarticle, we offer a brief overviewof the multistep EBP process.Future articles will elaborate oneach of the EBP steps, usingthe context provided by the

Case Scenario for EBP: RapidResponse Teams.

Step Zero: Cultivate a spirit ofinquiry.If youve been followingthis series, you may have already

started asking the kinds of ques-tions that lay the groundworkfor EBP, for example: in patientswith head injuries, how doessupine positioning comparedwith elevating the head of thebed 30 degrees affect intracranialpressure? Or, in patients withsupraventricular tachycardia,how does administering the-blocker metoprolol (Lopressor,Toprol-XL) compared with ad-ministering no medicine affect

By Bernadette Mazurek Melnyk, PhD,RN, CPNP/PMHNP, FNAP, FAAN,Ellen Fineout-Overholt, PhD, RN,

FNAP, FAAN, Susan B. Stillwell, DNP,RN, CNE, and Kathleen M.

Williamson, PhD, RN

The Seven Steps of Evidence-Based PracticeFollowing this progressive, sequential approach will leadto improved health care and patient outcomes.

This is the second article in a new series from the Arizona State University College of Nursing and Health Innova-

tions Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving

approach to the delivery of health care that integrates the best evidence from studies and patient care data with clini-

cian expertise and patient preferences and values. When delivered in a context of caring and in a supportive organi-

zational culture, the highest quality of care and best patient outcomes can be achieved.

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 will appear every two months to allow you time to incorporate information as you work

toward implementing EBP at your institution. Also, weve scheduled Ask the Authors calls every few months to pro-

vide a direct line to the experts to help you resolve questions. See details below.

ajn@wolterskluwer.com AJN January 2010 Vol. 110, No. 1 51

Ask the Authors on January 22!

On January 22 at 3:30 PMEST, join the Ask the Authorscall. Its your chance to get personal consultation from theexperts! And it's limited to the first 50 callers, so dial-in early!U.S. and Canada, dial 1-800-947-5134 (International, dial001-574-941-6964). When prompted, enter code 121028#.

Go to www.ajnonline.comand click on Podcasts and thenon Conversations to listen to our interview with the authors.

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the frequency of tachycardicepisodes? Without this spirit ofinquiry, the next steps in the EBPprocess are not likely to happen.

Step 1: Ask clinical questionsin PICOT format.Inquiries in thisformat take into account patientpopulation of interest (P), inter-vention or area of interest (I),comparison intervention or group(C), outcome (O), and time (T).

The PICOT format provides anefficient framework for searchingelectronic databases, one designedto retrieve only those articles rel-evant to the clinical question.Using the case scenario on rapidresponse teams as an example,the way to frame a question aboutwhether use of such teams would

result in positive outcomes wouldbe: Inacute care hospitals(patient population), how doeshaving arapid response team(intervention) compared withnothaving a response team(compar-ison) affect thenumber of car-diac arrests(outcome) during athree-month period(time)?

Step 2: Search for the bestevidence.The search for evidenceto inform clinical practice is tre-mendously streamlined whenquestions are asked in PICOTformat. If the nurse in the rapidresponse scenario had simplytyped What is the impact ofhaving a rapid response team?into the search field of the data-base, the result would have beenhundreds of abstracts, most ofthem irrelevant. Using the PICOTformat helps to identify key wordsor phrases that, when enteredsuccessively and then combined,

validity centers on whether theresearch methods are rigorousenough to render findings asclose to the truth as possible.For example, did the re-searchers randomly assignsubjects to treatment or con-trol groups and ensure thatthey shared key characteristicsprior to treatment? Were validand reliable instruments usedto measure key outcomes?

What are the results and arethey important?For interven-tion studies, this question of

study reliability addresseswhether the interventionworked, its impact on out-comes, and the likelihood ofobtaining similar results in theclinicians own practice set-tings. For qualitative studies,this includes assessing whetherthe research approach fits thepurpose of the study, alongwith evaluating other aspectsof the research such as wheth-er the results can be confirmed.

Will the results help me care

for my patients?This questionof study applicability coversclinical considerations such aswhether subjects in the studyare similar to ones own pa-tients, whether benefits out-weigh risks, feasibility andcost-effectiveness, and patientvalues and preferences.After appraising each study, the

next step is to synthesize the stud-ies to determine if they come tosimilar conclusions, thus support-ing an EBP decision or change.

Step 4: Integrate the evidencewith clinical expertise and pa-tient preferences and values.Research evidence alone is notsufficient to justify a change inpractice. Clinical expertise, basedon patient assessments, laborato-ry data, and data from outcomesmanagement programs, as wellas patients preferences and val-ues are important components of

expedite the location of rele-vant articles in massive researchdatabases such as MEDLINE orCINAHL. For the PICOT ques-tion on rapid response teams,the first key phrase to be enteredinto the database would be acutecare hospitals, a common subjectthat will most likely result in thou-sands of citations and abstracts.The second term to be searched

would berapid response team,followed bycardiac arrests andthe remaining terms in thePICOT question. The last step ofthe search is to combine theresults of the searches for eachof the terms. This method nar-rows the results to articles perti-nent to the clinical question, often

resulting in fewer than 20. It alsohelps to set limits on the finalsearch, such as human subjectsor English, to eliminate animalstudies or articles in foreign lan-guages.

Step 3: Critically appraisethe evidence.Once articles areselected for review, they must berapidly appraised to determinewhich are most relevant, valid,reliable, and applicable to the clin-ical question. These studies are thekeeper studies. One reason cli-nicians worry that they dont havetime to implement EBP is thatmany have been taught a labori-ous critiquing process, includingthe use of numerous questions de-signed to reveal every element ofa study. Rapid critical appraisaluses three important questions toevaluate a studys worth.6-8

Are the results of the studyvalid?This question of study

Research evidence alone is not sufficient to

justify a change in practice.

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which patients are most likely tobenefit. When results differ fromthose reported in the researchliterature, monitoring can helpdetermine why.

Step 6: Disseminate EBP re-sults. Clinicians can achieve won-derful outcomes for their patientsthrough EBP, but they often failto share their experiences with

colleagues and their own or otherhealth care organizations. Thisleads to needless duplication ofeffort, and perpetuates clinicalapproaches that are not evidencebased. Among ways to dissemi-nate successful initiatives are EBProunds in your institution, pres-entations at local, regional, andnational conferences, and reportsin peer-reviewed journals, profes-sional newsletters, and publica-tions for general audiences.

When health care organiza-tions adopt EBP as the standardfor clinical decision making, thesteps outlined in this article nat-urally fall into place. The nextarticle in our series will feature astaff nurse on a medicalsurgicalunit who approached her hospi-tals EBP mentor to learn howto formulate a clinical questionabout rapid response teams inPICOT format.

Bernadette Mazurek Melnyk is dean anddistinguished foundation professor of

nursing at Arizona State University inPhoenix, where Ellen Fineout-Overholtis clinical professor and director of theCenter for the Advancement of Evidence-Based Practice, Susan B. Stillwell is clinicalassociate professor and program coordi-nator of the Nurse Educator Evidence-Based Practice Mentorship Program, andKathleen M. Williamson is associate direc-tor of the Center for the Advancementof Evidence-Based Practice. Contactauthor: Bernadette Mazurek Melnyk,bernadette.melnyk@asu.edu.

REFERENCES

1. Grimshaw J, et al. Toward evidence-

based quality improvement. Evidence(and its limitations) of the effective-ness of guideline dissemination andimplementation strategies 1966-1998.J Gen Intern Med2006;21 Suppl2:S14-S20.

2. McGinty J, Anderson G. Predictors ofphysician compliance with AmericanHeart Association guidelines for acutemyocardial infarction.Crit Care NursQ2008;31(2):161-72.

3. Shortell SM, et al. Improving patientcare by linking evidence-based medi-cine and evidence-based management.JAMA2007;298(6):673-6.

4. Strout TD. Curiosity and reflectivethinking: renewal of the spirit. Indi-anapolis, IN: Sigma Theta Tau Inter-national; 2005.

5. Williams DO. Treatment delayed istreatment denied.Circulation2004;109(15):1806-8.

6. Giacomini MK, Cook DJ. Usersguides to the medical literature: XXIII.Qualitative research in health care A.Are the results of the study valid?Evidence-Based Medicine WorkingGroup.JAMA2000;284(3):357-62.

7. Giacomini MK, Cook DJ. Usersguides to the medical literature: XXIII.Qualitative research in health care B.What are the results and how do theyhelp me care for my patients? Evidence-

Based Medicine Working Group.JAMA2000;284(4):478-82.

8. Stevens KR. Critically appraisingquantitative evidence. In: Melnyk BM,Fineout-Overholt E, editors.Evidence-based practice in nursing and health-care: a guide to best practice.Philadelphia: Lippincott Williams andWilkins; 2005.

9. Dacey MJ, et al. The effect of a rapidresponse team on major clinical out-come measures in a community hos-pital.Crit Care Med2007;35(9):2076-82.

EBP. There is no magic formulafor how to weigh each of theseelements; implementation of EBPis highly influenced by institution-al and clinical variables. For ex-ample, say theres a strong bodyof evidence showing reduced in-cidence of depression in burn pa-tients if they receive eight sessionsof cognitive-behavioral therapy

prior to hospital discharge. Youwant your patients to have thistherapy and so do they. But budg-et constraints at your hospitalprevent hiring a therapist tooffer the treatment. This resourcedeficit hinders implementationof EBP.

Step 5: Evaluate the out-comes of the practice decisionsor changes based on evidence.After implementing EBP, its im-portant to monitor and evaluateany changes in outcomes so thatpositive effects can be supportedand negative ones remedied. Justbecause an intervention was ef-fective in a rigorously controlledtrial doesnt mean it will workexactly the same way in the clin-ical setting. Monitoring the effectof an EBP change on health carequality and outcomes can helpclinicians spot flaws in implemen-tation and identify more precisely

Case Scenario for EBP: Rapid Response TeamsYoure a staff nurse on a busy medicalsurgical unit. Over the pastthree months, youve noticed that the patients on your unit seem tohave a higher acuity level than usual, with at least three cardiac arrestsper month, and of those patients who arrested, four died. Today, you

saw a report about a recently published study in Critical Care Medi-

cineon the use of rapid response teams to decrease rates of in-hospitalcardiac arrests and unplanned ICU admissions. The study found a sig-

nificant decrease in both outcomes after implementation of a rapid re-sponse team led by physician assistants with specialized skills.9 Youreso impressed with these findings that you bring the report to your nurse

manager, believing that a rapid response team would be a great ideafor your hospital. The nurse manager is excited that you have come toher with these findings and encourages you to search for more evidence

to support this practice and for research on whether rapid responseteams are valid and reliable.

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