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Guide to Nursing ResourcesGuide to Nursing ResourcesEBN : Accessing the ResearchEBN : Accessing the Research


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Learning ObjectivesLearning Objectives

Introduce student to evidence-Introduce student to evidence-based nursing literature andbased nursing literature and

effective strategies for searchingeffective strategies for searching

for and accessing evidence-for and accessing evidence-

based research in nursing.based research in nursing.


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06/18/09 IUON - Library Research 3

What is EBM?What is EBM?

Evidence based medicine is theEvidence based medicine is theconscientious, explicit, and judiciousconscientious, explicit, and judicioususe of current best evidence inuse of current best evidence in

making decisions about the care ofmaking decisions about the care ofindividual patients. The practice ofindividual patients. The practice ofevidence based medicine meansevidence based medicine meansintegrating individual clinicalintegrating individual clinicalexpertise with the best availableexpertise with the best availableexternal clinical evidence fromexternal clinical evidence fromsystematic research.systematic research.

Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB,Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB,

Richardson WS.Richardson WS.Evidence based medicine: what it is and what it isn'tEvidence based medicine: what it is and what it isn't..
http://bmj.com/cgi/content/full/312/7023/71?view=full&pmid=8555924http://bmj.com/cgi/content/full/312/7023/71?view=full&pmid=8555924http://bmj.com/cgi/content/full/312/7023/71?view=full&pmid=8555924


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Evidence Based MedicineEvidence Based Medicine

EBM Decision Model:EBM Decision Model:

"Evidence-based medicine (EBM) is"Evidence-based medicine (EBM) is

the integration of best researchthe integration of best researchevidence with clinical expertiseevidence with clinical expertise

and patient values."and patient values."

EBM Cycle:EBM Cycle:

Ask, Acquire, Appraise, Apply andAsk, Acquire, Appraise, Apply and

ActAct


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Primary EvidencePrimary Evidence

Primary evidence includes thePrimary evidence includes the

original reportsoriginal reports of researchof researchstudies and are included instudies and are included in

journal citation databases:journal citation databases: MEDLINE: randomized controlledMEDLINE: randomized controlled

trialstrials

CINAHL: researchCINAHL: research

EMBASEEMBASE

SCIRUSSCIRUS
http://www.embase.com/http://www.embase.com/http://www.scirus.com/http://www.scirus.com/http://www.scirus.com/http://www.embase.com/


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Secondary EvidenceSecondary Evidence

Secondary evidence is theSecondary evidence is the analysisanalysisof research studies and is foundof research studies and is found

in:in: MEDLINE: meta-analysis, practiceMEDLINE: meta-analysis, practice

guidelines, consensus developmentguidelines, consensus development

conferencesconferences

CINAHL: meta-analysis, practice guidelines,CINAHL: meta-analysis, practice guidelines,

research based nursing practiceresearch based nursing practice

Cochrane Database of Systematic ReviewsCochrane Database of Systematic Reviews

Database of Reviews of EffectivenessDatabase of Reviews of Effectiveness

(DARE)(DARE)

National Guidelines Clearin houseNational Guidelines Clearinghouse


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Information PyramidInformation Pyramid

06/18/09 IUON - Library Research 7

EBM journals

Cochrane DBSystemic reviews

Clinical Practice

Guidelines

primary research articles

CINAHL, Medline

Assoc. websites,textbooks

Google

Adapted from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514


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Evolution of LiteratureEvolution of Literature

Evidence PyramidEvidence PyramidThe base of the pyramid is whereThe base of the pyramid is where

information usually starts with an ideainformation usually starts with an idea

or laboratory research. As these ideasor laboratory research. As these ideas

turn into drugs and diagnostic toolsturn into drugs and diagnostic tools

they are tested in laboratories models,they are tested in laboratories models,then in animals, and finally in humans.then in animals, and finally in humans.

The human testing may begin withThe human testing may begin with

volunteers and go through severalvolunteers and go through several

phases of clinical trials before the drugphases of clinical trials before the drug

or diagnostic tool can be authorizedor diagnostic tool can be authorized

for use within the general population.for use within the general population.

Randomized controlled trials are thenRandomized controlled trials are then

done to further test the effectivenessdone to further test the effectivenessand efficacy of a drug or therapy.and efficacy of a drug or therapy.

As you move up the pyramid theAs you move up the pyramid the

amount of available literatureamount of available literature

decreases, but increases in itsdecreases, but increases in its

relevance to the clinical setting.relevance to the clinical setting.

Type of StudyType of Study Meta-Meta-

AnalysisAnalysis

SystematicSystematic

ReviewReview

RandomizedRandomized

Controlled TrialControlled Trial

Cohort studiesCohort studies

Case Control studiesCase Control studies Case Series/Case ReportsCase Series/Case Reports

AnimalAnimal

research/Laboratoryresearch/Laboratory

studiesstudies
http://www.hsl.unc.edu/services/tutorials/EBM/Supplements/QuestionSupplement.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/Supplements/QuestionSupplement.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/Supplements/QuestionSupplement.htm


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Medical DatabasesMedical Databases

CINAHLCINAHL EBSCOEBSCOhosthost

http://http://

support.epnet.com/trsupport.epnet.com/tr

CINAHL.comCINAHL.com Online trainingOnline training

http://http://www.cinahl.com/liwww.cinahl.com/li

MedlineMedline EBSCOEBSCOhosthost

PubMedPubMed Online trainingOnline training

http://http://

www.nlm.nih.gov/www.nlm.nih.gov/
http://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.phphttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.php


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Evidence in MEDLINEEvidence in MEDLINE

Searching for evidence in MEDLINESearching for evidence in MEDLINE

includes several steps:includes several steps:

formulate a clinical questionformulate a clinical question run a subject searchrun a subject search

Ex. heart disease and aspirinEx. heart disease and aspirin

select a strategy to retrieveselect a strategy to retrieveliterature related toliterature related to therapy,therapy,diagnosis, prognosis,diagnosis, prognosis,

harm/etiology.harm/etiology.


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Evidence in CINAHLEvidence in CINAHL

formulate a clinicalformulate a clinical

questionquestion

run a subjectrun a subject

searchsearch use the Researchuse the Research

limit on the Mainlimit on the Main

Search Page.Search Page. This is a very effective way toThis is a very effective way to

limit retrieval to researchlimit retrieval to research

studies in CINAHL.studies in CINAHL.

Tutorial:Tutorial: http://http://www.hscl.ufl.edu/help/CINAwww.hscl.ufl.edu/help/CINA
http://www.hscl.ufl.edu/help/CINAHL/index.htmhttp://www.hscl.ufl.edu/help/CINAHL/index.htmhttp://www.hscl.ufl.edu/help/CINAHL/index.htmhttp://www.hscl.ufl.edu/help/CINAHL/index.htm


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Cochrane Database of SystemicCochrane Database of Systemic

ReviewsReviews

includes the full text of theincludes the full text of theregularly updatedregularly updated

systematic reviews of thesystematic reviews of the

effects of healthcareeffects of healthcare

prepared by The Cochraneprepared by The Cochrane

CollaborationCollaboration can be searched bycan be searched by

combing keywords orcombing keywords or

phrases.phrases.

TheThe Browse TopicsBrowse Topics iconicon

retrieves a list of Cochraneretrieves a list of CochraneGroups who prepare andGroups who prepare and

maintain the reviews inmaintain the reviews in

respective clinical areas,respective clinical areas,

such as nursing.such as nursing.

http://http://www.cochrane.org/index.htmwww.cochrane.org/index.htm
http://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htm


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Database of Reviews of Effectiveness (DAREDatabase of Reviews of Effectiveness (DARE

Database of Reviews of Effectiveness (DARE) a full textDatabase of Reviews of Effectiveness (DARE) a full text

database with critical structured abstracts of studiesdatabase with critical structured abstracts of studies

reported in various medical journals.reported in various medical journals.
http://www.york.ac.uk/inst/crd/crddatabases.htmhttp://www.york.ac.uk/inst/crd/crddatabases.htmhttp://www.york.ac.uk/inst/crd/crddatabases.htm


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What is SystemicWhat is Systemic

Review?Review?

Systematic reviews are known as theSystematic reviews are known as the

highest level of evidence in clinicalhighest level of evidence in clinical

research.research.

Developed countries are developing theirDeveloped countries are developing theirmedical guidelines based on the informationmedical guidelines based on the information

provided by systematic reviews ofprovided by systematic reviews of

effectiveness.effectiveness.

Therefore, it is mandatory for allTherefore, it is mandatory for all

professionals involved in the delivery ofprofessionals involved in the delivery of

healthcare, to reach to a goodhealthcare, to reach to a good

understanding about systematic reviews.understanding about systematic reviews.

This web site offers information about whatThis web site offers information about what

systematic reviews are, and how to conductsystematic reviews are, and how to conduct


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TheThe

National Guidelines ClearinghouseNational Guidelines Clearinghouse

includes evidence-based practice guidelines from variousincludes evidence-based practice guidelines from various

health centers and organizations. It can be searched byhealth centers and organizations. It can be searched by

disease, treatment or organization. The Clearinghousedisease, treatment or organization. The Clearinghouse

includes a feature comparing attributes of two or moreincludes a feature comparing attributes of two or more

guidelines.guidelines.
http://www.guidelines.gov/http://www.guidelines.gov/http://www.guidelines.gov/


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HealthWebHealthWeb

TheThe Evidence-Based Health CareEvidence-Based Health Care

section of HealthWeb includes asection of HealthWeb includes awealth of information about EBwealth of information about EB

organizations, databases andorganizations, databases and

publications.publications.

The Tools and Tutorials has manyThe Tools and Tutorials has many

helpful links including thehelpful links including the

EBM Tool KitEBM Tool Kit andand EBM ToolboxEBM Toolbox..
http://www.healthweb.org/http://www.healthweb.org/http://healthweb.org/browse.cfm?subjectid=39http://healthweb.org/browse.cfm?subjectid=39http://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.cebm.net/toolbox.asphttp://www.cebm.net/toolbox.asphttp://www.cebm.net/toolbox.asphttp://www.med.ualberta.ca/ebm/ebm.htmhttp://healthweb.org/browse.cfm?subjectid=39http://www.healthweb.org/


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OtherOther

Search EnginesSearch Engines

MedstoryMedstory

Google ScholarGoogle Scholar

MammaHealthMammaHealth MedlinePlusMedlinePlus

KosmixKosmix

ReleMedReleMed

DatabasesDatabases

DynaMedDynaMed

Up-to-DateUp-to-Date

MDConsultMDConsult NursingConsultNursingConsult

InfoPOEMSInfoPOEMS

St t i Cli i lSt t i Cli i l
http://www.medstory.com/http://www.medstory.com/http://scholar.google.com/http://scholar.google.com/http://www.mammahealth.com/http://www.mammahealth.com/http://www.medlineplus.com/http://www.medlineplus.com/http://www.kosmix.com/http://www.kosmix.com/http://www.relemed.com/http://www.relemed.com/http://www.uptodate.com/http://www.uptodate.com/http://eresourcesonline.com/resources/default.asp?what=MDCONSULThttp://eresourcesonline.com/resources/default.asp?what=MDCONSULThttp://eresourcesonline.com/resources/default.asp?what=NURSINGCONSULThttp://eresourcesonline.com/resources/default.asp?what=NURSINGCONSULThttp://www.infopoems.com/http://www.infopoems.com/http://www.infopoems.com/http://eresourcesonline.com/resources/default.asp?what=NURSINGCONSULThttp://eresourcesonline.com/resources/default.asp?what=MDCONSULThttp://www.uptodate.com/http://www.relemed.com/http://www.kosmix.com/http://www.medlineplus.com/http://www.mammahealth.com/http://scholar.google.com/http://www.medstory.com/


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Steps to answering ClinicalSteps to answering Clinical

Questions using the MedicalQuestions using the Medical

LiteratureLiterature

The Anatomy of the ClinicalThe Anatomy of the Clinical

Question:Question:

1. Formulate a clinical question1. Formulate a clinical question("PICO" approach):("PICO" approach):

PPatient characteristicsatient characteristics

IIntervention being consideredntervention being consideredCComparison intervention (if any)omparison intervention (if any)

OOutcome of clinical interestutcome of clinical interest


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Clinical Question cont.Clinical Question cont.

2. Run your subject search.2. Run your subject search.

3. Select the MEDLINE strategy to3. Select the MEDLINE strategy to

answer the question:answer the question:

Therapy, Diagnosis, Prognosis,Therapy, Diagnosis, Prognosis,Harm/Etiology.Harm/Etiology.

(including study design/article(including study design/article

type)type)


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For Quick SearchesFor Quick Searches

A question of...A question of...

TherapyTherapyLimit search to PublicationLimit search to Publication

Type -Type - Randomized ControlledRandomized Controlled

TrialTrial ptpt


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In-depth EBM Searches:In-depth EBM Searches:

TherapyTherapy

exp research design/ or exp clinical trials/ orexp research design/ or exp clinical trials/ or

comparative study/ or placebos/ orcomparative study/ or placebos/ or

multicenter study.pt. or clinical trial$1.pt. Ormulticenter study.pt. or clinical trial$1.pt. Or

random$.ti,ab. or (single blind$ or doublerandom$.ti,ab. or (single blind$ or double

blind$ or triple blind$3).ti,ab. orblind$ or triple blind$3).ti,ab. or

placebo$1.ti,ab. or (clinical adjtrial$1).ti,ab.placebo$1.ti,ab. or (clinical adjtrial$1).ti,ab.

or exp epidemiologic research design/ oror exp epidemiologic research design/ or(controlled clinical trial or randomized(controlled clinical trial or randomized

controlled trial).pt. or practice guideline.pt.controlled trial).pt. or practice guideline.pt.

Or feasibility studies/ or clinical protocols/ orOr feasibility studies/ or clinical protocols/ or

exp treatment outcome/ or double blindexp treatment outcome/ or double blind


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DiagnosisDiagnosisCombine subject search withCombine subject search with

search forsearch for exp "sensitivity andexp "sensitivity and

specificity"specificity"

I d h EBM S h


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DiagnosisDiagnosis

exp "sensitivity and specificity"/ or falseexp "sensitivity and specificity"/ or false

negative reactions/ or false positivenegative reactions/ or false positive

reactions/ or (sensitivity or specificity).ti,ab.reactions/ or (sensitivity or specificity).ti,ab.

or (predictive adj value$1).ti,ab. oror (predictive adj value$1).ti,ab. or

(likelihood adj ratio$1).ti,ab. or (false adj(likelihood adj ratio$1).ti,ab. or (false adj

(negative$1 or positive$1)).ti,ab. or(negative$1 or positive$1)).ti,ab. or

(randomized controlled trial or controlled(randomized controlled trial or controlled

clinical trial).pt. or double blind method/ orclinical trial).pt. or double blind method/ or

single blind method/ or practicesingle blind method/ or practiceguideline.pt. Or consensus developmentguideline.pt. Or consensus development

conference$.pt. or random$.ti,ab. or randomconference$.pt. or random$.ti,ab. or random

allocation/ or (single blind$3 or doubleallocation/ or (single blind$3 or double

blind$3 or triple blind$3).ti,ab.blind$3 or triple blind$3).ti,ab.


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PrognosisPrognosisCombine subject search withCombine subject search with

search forsearch for exp cohort studiesexp cohort studies

oror exp riskexp risk

d h S hI d th EBM S h


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PrognosisPrognosis

exp cohort studies/ or prognosis/ or expexp cohort studies/ or prognosis/ or exp

mortality/ or exp morbidity/ ormortality/ or exp morbidity/ or

(natural adj history).ti,ab. or(natural adj history).ti,ab. or

prognos$.ti,ab. or course.ti,AB orprognos$.ti,ab. or course.ti,AB orpredict$.ti,ab. or exp "outcomepredict$.ti,ab. or exp "outcome

assessment (health care)"/ orassessment (health care)"/ or

outcome$1.ti,ab. or (inception adjoutcome$1.ti,ab. or (inception adj

cohort$1).ti,ab. or diseasecohort$1).ti,ab. or diseaseprogression/ or exp survival analysis/progression/ or exp survival analysis/


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Harm/EtiologyHarm/EtiologyCombine subject search withCombine subject search with

search forsearch for exp cohort studiesexp cohort studies

OR exp riskOR exp risk

I d th EBM S hI d th EBM S h


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Harm/EtiologyHarm/Etiology

random$.ti,ab. or exp epidemiologicalrandom$.ti,ab. or exp epidemiological

studies/ or odds ratio/ orstudies/ or odds ratio/ or

cohort$.ti,ab. or (case$1 adjcohort$.ti,ab. or (case$1 adj

control$).ti,ab. or risk$.ti,ab. or (oddscontrol$).ti,ab. or risk$.ti,ab. or (oddsadj ratio$1).ti,ab. or causa$.ti,ab. oradj ratio$1).ti,ab. or causa$.ti,ab. or

(relative$1 adj risk$).ti,ab. or(relative$1 adj risk$).ti,ab. or

predispos$.ti,ab. or (randomizedpredispos$.ti,ab. or (randomized

controlled trial or controlled clinicalcontrolled trial or controlled clinicaltrial).pt. or exp risk/ or practicetrial).pt. or exp risk/ or practice

guideline.pt. or exp case-controlguideline.pt. or exp case-control

studies/ or exp cohort studies/studies/ or exp cohort studies/


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4. Locate other sources of4. Locate other sources of

evidence as necessary.evidence as necessary.

5. Examine the evidence, critically5. Examine the evidence, criticallyappraise/evaluate the literature.appraise/evaluate the literature.

6. Apply the evidence + clinical6. Apply the evidence + clinical

experience + the patient'sexperience + the patient's

preferences.preferences.

7. Evaluate patient outcomes.7. Evaluate patient outcomes.


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In-depth EBM SearchesIn-depth EBM Searches

4. Once copied, paste it into the4. Once copied, paste it into the

search box in MEDLINE.search box in MEDLINE.

5. Click "5. Click "Perform SearchPerform Search."."6. Combine this set with your6. Combine this set with your

original search usingoriginal search using ANDAND (i.e. 1(i.e. 1

AND 2).AND 2).

(EBM filters developed by the Miner(EBM filters developed by the Miner

Library at theLibrary at the

University of Rochester Medical CenteUniversity of Rochester Medical Cente
http://www.urmc.rochester.edu/hslt/miner/index.cfmhttp://www.urmc.rochester.edu/hslt/miner/index.cfmhttp://www.urmc.rochester.edu/hslt/miner/index.cfm


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NoteNote

You can save each of these EBM filters as a separateYou can save each of these EBM filters as a separatesearch in MEDLINE so that they can be run assearch in MEDLINE so that they can be run as

needed when searching MEDLINEneeded when searching MEDLINE

To do this:To do this:

Authenticate to a new MEDLINE session with aAuthenticate to a new MEDLINE session with a

blank search history.blank search history.

Copy and paste one EBM filter.Copy and paste one EBM filter.

Click "Click "Perform SearchPerform Search."."

After retrieving search results, click "After retrieving search results, click "Save SearchSave Search

HistoryHistory."."

Select "Select "PermanentPermanent," and name the search (ex.," and name the search (ex.

EBM Therapy or Therapy Filter).EBM Therapy or Therapy Filter).


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To use save searches:To use save searches:

Run your subject search.Run your subject search.

Click "Click "Run Saved SearchRun Saved Search."."

Select the EBM filter to run basedSelect the EBM filter to run basedon the type of question beingon the type of question being

asked (Therapy, Diagnosis,asked (Therapy, Diagnosis,

Prognosis, or Harm/Etiology).Prognosis, or Harm/Etiology).

Combine the two searches usingCombine the two searches using

ANDAND..


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EVIDENCE BASEDEVIDENCE BASEDMEDICINE TOOLKITS &MEDICINE TOOLKITS &

TUTORIALSTUTORIALS

For further clarification and practice check out more onlineFor further clarification and practice check out more online

training EBM Toolkit based on the series in JAMA:training EBM Toolkit based on the series in JAMA:

http://http://www.med.ualberta.ca/ebm/ebm.htmwww.med.ualberta.ca/ebm/ebm.htm

ORORFrom Duke University Medical Center:From Duke University Medical Center:

http://http://

www.hsl.unc.edu/services/tutorials/EBM/welcome.htmwww.hsl.unc.edu/services/tutorials/EBM/welcome.htm
http://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htm


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EBM JeopardyEBM Jeopardy
http://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmjeopardy.ppthttp://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmjeopardy.ppthttp://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmjeopardy.ppt


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Thank youThank youAnn Celestine,Ann Celestine, BA MLS AHIPBA MLS AHIP

Library DirectorLibrary Director

nursing research resources 72

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