The stages that make up the practice of EBEC are the following:
- Formulation of a structured question.
- Bibliographic search.
- Critical evaluation of the documents.
- Application of the best evidence to nursing practice.
- Evaluation of the action carried out.
1.- Formulation of the research problem
In CD, the structured question can refer to any type of etiological, therapeutic issues, side effects, etc. This question can be reformulated according to the results of the next stage, which is the bibliographic or documentary search. The structured question has four components that can be arranged in a table or table. It is said to follow the PICO structure (from English: Problem, Intervention, Comparison and Outcome)
2.- Literature review and formulation of the theoretical framework
The bibliographic or documentary search can be started in Medline, whose consultation is free. In the search, in addition to keywords or descriptors, limiters can be used that define the fields (title, abstract, etc.), the type of publication (review, clinical practice guideline, etc.), the language, the period revised, etc. to apply on the descriptors. Naturally, the more specific the search strategy, the fewer documents will be recovered.
However, the base of choice for scientific evidence (SC) is the Cochrane Library, because it offers quality systematic reviews on the effectiveness of health interventions. The Library is produced by the Cochrane Collaboration, whose mission is to “prepare, maintain and disseminate systematic reviews on the effects of health interventions.” Specifically, Cochrane Plus is free to access and has a Spanish version.
Another resource of maximum interest are evidence-based journals . These are secondary publications, for the preparation of which both original articles and SR, published in journals of different specialties, are reviewed, evaluated, summarized and commented on.
Other sources of information that provide CE are the Clinical Practice Guides, for the preparation of which a multidisciplinary team follows a process that includes the review and evaluation of the literature on a health intervention, with respect to which it ends up formulating recommendations for its implementation or rejection.
The Joanna Briggs Institute is another indispensable source for obtaining highly valid care reports and documents. In our country, the Spanish Collaborating Center of the Joanna Briggs Institute for evidence-based health care stands out, which is located in the Nursing Research Coordination and Development Unit (Investén). Its activities are mainly aimed at the disciplines of nursing, midwives, physiotherapy, nutrition and dietetics, occupational therapy and, in general, health professionals as well as users of health services, their families and caregivers.
3.- Critical evaluation of the documents.
Critical appraisal or reading (CV) is the third stage and serves to analyze the validity and applicability of the published results on patient care. The VC:
- It allows articles to be discriminated according to the strengths and weaknesses of the methodology used.
- It helps professionals make decisions appropriate to a specific clinical or management situation.
An essential resource for VC are the Users’ Guides to the Medical Literature , prepared in 1981 by the Department of Clinical Epidemiology and Biostatistics of McMaster University (Canada) and of which there are translations to several languages. These guides have been reviewed, updated and disseminated thanks to the CASP project ( Critical Appraisal Skills Programme ) that emerged in the United Kingdom in 1993. The CASP has an international scope; In Spain it is represented by CASPe: Skills Program for Critical Reading in Spanish, based at the University of Alicante.
The guides are checklists made up of a total of 10 to 12 questions that are adapted to the different methodologies (quantitative and qualitative) and designs (clinical trial, cohort study, etc.). However, all guides contain three key questions that, in turn, are answered with the help of other questions that give clues to answer correctly. These questions, which we will discuss in more depth, are:
Are the results of the study valid? They include elimination questions and detail questions.
What are the results?
Are they applicable (will they help) my patient, population, situation…?
4.- Application of the best evidence to nursing practice.
The fourth stage in a practice based on CE consists of acting or applying the intervention that has been assessed as the most effective, also taking into account the CE:
- The experience of the professional in managing the intervention.
- Patient preferences.
- The available resources.
- The specific context in which the action takes place.
The application of evidence can be limited to the advice of a professional or a recommendation that is part of the use of a Clinical Practice Guideline (CPG).
Clinical Practice Guidelines are a set of recommendations developed systematically to help clinicians and patients in the decision-making process about which are the most appropriate interventions to solve a clinical problem in specific health circumstances. Its main purpose is to offer the professional a series of guidelines with which to solve, through CE, the problems that arise daily in practice. CPGs have the potential to:
- Reduce variability.
- Improve clinical practice.
In recent years, and especially since the publication of the AGREE instrument, the rigor and quality in the preparation of CPGs has improved. In Spain, the launch in 2006 of the Program for the Development of Clinical Practice Guides in the National Health System (SNS), coordinated by GuíaSalud, has represented a qualitative leap in the development of CPGs in our environment. This program, through a ministerial agreement between the SNS Quality Agency and the Health Technology Assessment agencies and units, committed to the development of a common methodology both for the preparation of CPGs and for their implementation and updating. Some of its guides have special interest in the field of childhood and adolescence, such as those on “Eating Disorders”, “Depression in childhood and adolescence”, “Childhood and adolescent diabetes”, etc.
5- Evaluation of the action carried out.
In the last stage of a practice based on CE, the health action or intervention is evaluated according to clinical, social and economic criteria. The evaluation is carried out based on a research project that, once completed and published, will provide new evidence or CE.
In this way, the EC feeds back.
- To answer the initial question, the literature has been reviewed in search of evidence that supports or, perhaps, advises against certain practices.
- When an intervention has already been applied, it is a matter of evaluating its consequences.