Finding the Evidence

The evidence needed in an EBP effort may be found in a variety of sources, from computerized bibliographical databases to your own quality improvement department. In trying to find evidence, nurses are urged to get help. For one reason, finding evidence is very time consuming even when done with maximum efficiency and (theoretically) the more persons involved, the less any one person has to do. And second, those familiar with a method may search and find better sources of information.

1. Have a clearly defined topic (What specific question is being asked? What specific clinical problem is to be solved?).
2. Review all existing hospital/agency policies/procedures for current practice standards (What is the recommended practice? Is this happening? What is the basis for the recommended current practice?).
3. Determine if the recommended practice is being implemented. Quality improvement data may give you this information or a QI project may be needed.
4. Check for external standards/policies on the topic (Are there existing clinical practice guidelines on the topic? See http://www.guidelines.gov).
5. Find any systematic or integrative reviews on the topic or meta-analyses (See Critique under Process Model). Depending upon the currency and completeness of systematic review(s) found, you may or may not choose to go to step 6, although it is recommended whenever possible.
6. Search for primary research literature using one of the computerized bibliographic databases described below.

If you are a novice in doing searches, when possible, get assistance from a librarian. If this is not possible, the resources below may be helpful.

MEDLINE^®
MEDLINE^® is the National Library of Medicine's bibliographic database. It covers the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences. MEDLINE^® contains bibliographic citations and author abstracts from more than 4,000 biomedical journals published in the United States and 70 other countries. The file contains over 11 million citations dating back to the 1966. Coverage is worldwide, but most records are from English-language sources or have English abstracts (Verhey, 1998-link with reference list). MEDLINE^® can be accessed as PubMed^® on the Internet at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi.

CINAHL^®
CINAHL^® (Cumulative Index of Nursing and Allied Health Literature) is oriented towards nursing and allied health but also accesses biomedical and consumer information. Most English-language nursing journals are indexed along with journals in 17 allied health fields. Unique to CINAHL^® is coverage of books and book chapter, pamphlets, standards of professional practice, conference proceedings, educational software, audiovisuals, nurse practice acts, critical paths, research instruments, legal cases, accreditation records, and clinical innovation integrative reviews. The database covers records from 1982 to the present. CINAHL^® is not a free service but may be available through your organization or school's library (www.cinahl.com).

The Cochrane Library

HealthSTAR

HealthSTAR indexes literature in the areas of health services, technology, administration, research. Topics include: accreditation, health facilities administration, effectiveness studies, evaluation of patient outcomes, health policy, legal issues, licensure issues, quality assurance, human resources. Literature coverage is from 1975 to the present and includes books and book chapters, government documents, conference proceedings, newspaper articles, and technical reports. Access HealthSTAR at http://gateway.nlm.nih.gov/gw/Cmd

Topic-Focused Searches
Step-by-step details on doing topic-focused searches using MEDLINE^® (accessed by http://www.ncbi.nlm.nih.gov/PubMed/), CINAHL (accessed through software in a library or directly by http://www.cinahl.com), and the Cochrane Library (http://www.cochrane.org). This guide was written for British nurses at a workshop so the user must read around certain information (e.g., computers available, etc.). Please go beyond the first page, which looks rather daunting.

PubMed offers an online tutorial on its use (http://www.nlm.nih.gov/bsd/pubmed_tutorial/m1001.html). It is simple to use and covers many topics.

1. Verhey, MP, Levy, J.R., Schmidt, R. (1998). Information RN. Glendale, CA: Cinahl Information Systems. A book written by two advanced practice nurses and a medical librarian (1-800-949-7167 ISBN: 0-910478-60-0; available for purchase at http://www.cinahl.com/cstore/cstore.htm)
2. Brown, SJ. (1999). Knowledge for health care practice. A guide to using research evidence. Philadelphia: WB Saunders. This 270-page handbook guides readers, step by step, through the process of applying research evidence to clinical decision-making and patient care. It explores how to locate, understand, and critically appraise research evidence and evaluate its clinical significance, applicability, and scientific credibility. (ISBN: 0-721678-03-3, available for purchase at http://www.wbsaunders.com)

1. Plan your search and break your topic down into pieces. Example: patient education in ovarian cancer patients may be searched by
   1) seeking literature about patient education,
   2) seeking literature about ovarian cancer, and then, having the database list any articles that are in both search results. You can limit your search (e.g, by information about patients (specific gender, age, ethnicity, etc) or type of publication (clinical, research, instrument, etc).


2. In each database, check the terms you use in a subject heading list. In PubMed for MEDLINE^®, this is called the MeSH (Medical Subject Heading) Browser http://www.ncbi.nlm.nih.gov/entrez/meshbrowser.cgi). In CINAHLDirect^® (http://www.cinahl.com/cdirect/cdirect.htm), you are led to various subject headings.
3. Many publications found will have an abstract. Read the abstracts of several articles found in your search. Do these abstracts describe articles that may help you in answering your clinical problem? Do the research studies concern phenomenon you need to understand in your search for evidence?

• Information about one or more articles that seem pertinet to your EBP Project.
• Seek the full text version of each pertinent article and proceed to appraising the findings.

• Go through this process several times and may need to get assistance.
• Questions to ask if search is not successful: Using the correct terms to search? Using the most appropriate databases or sites?
• Be aware that some topics have little published research and therefore, will lead you to an “unsuccessful” search.

When searching the internet it is important to determine the credibility of the site as well as the information. Health On the Net Foundation (HONF) has published one set of voluntary guidelines for health-related Web sites in an attempt to improve the reliability and credibility of such sites. The HONF Code of Conduct (http://www.hon.ch/HONcode/) is voluntary. Web sites that meet the Code are permitted to display the HONF logo. (Basic principles regarding how to do such an assessment can be found in the following references.

• Refer to the Clark & Gomez article "Details on demand: consumers, cancer information and the Internet" for more specifics on web-based searching.
• Another excellent resource is Mehta & Jain's "Finding evidence-based answers to clinical questions online" (2001).