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Education and Teaching
Teaching EBP: “Getting from Zero to One.”
Moving from Recognizing and Admitting
Uncertainties to Asking Searchable,
Answerable Questions
Linda Johnston, RN, PhD, Ellen Fineout-Overholt, RN, PhD
Ourfirstcolumnintroducedreaderstotheemergenceof whoattendedthe2003conference“Signpostingthefuture
new research-related content in nursing and medical of EBHC (evidence-based health care).” The statement pro- curricula: the teaching of skills necessary for health care poses a curriculum that is based on the steps above, and professionals to practice from an evidential base. We in- outlines the minimum standard educational requirements tend to address in upcoming columns the ongoing dialogue for training health professionals in EBP.
among educators and researchers about how best to teach Anecdotally, the most difficult step in the EBP process evidence-based practice (EBP). Each column will focus on is what is known as “Step 0”—getting students/clinicians one of the steps in the five-step model of EBP (Cook et al.
to recognize and admit uncertainties. We know that uncer- 1992). We will present evidence from the literature that tainties exist in health care; however, the challenge is in supports identified teaching approaches for each of the clinicians achieving a comfort level so that they can em- steps and complement the evidence with descriptions of brace uncertainties as opportunities for change. At a min- our experiences as well as the experiences of others, along imum, practitioners should have a critical attitude toward with practical tips for developing your methods of teaching their own practice. This heightened awareness of what can be done to resolve recognizing uncertainty better provides The five-step model of EBP is comprised of: opportunity for clinical questions to arise continuously in 1 Translation of uncertainty to an answerable question, the course of providing routine care. Step 1 of the EBP pro- 2 Systematic retrieval of best evidence available, cess, focusing the question so that it is answerable, clarifies 3 Critical appraisal of evidence for validity, clinical rel- the objective of the literature search and guides the use of the appropriate tools for appraisal (Cook et al. 1992). Most 4 Application of results in practice, and questions arising from practice can be formulated in terms of a relationship among the patient, some “intervention,”and one or more specific outcomes of interest.
Students require skills in each of the steps listed above Dawes and colleagues (2005) have identified an edu- in order to move from the question arising from clinical cational outcome for the process of translating uncertainty practice through to outcome evaluation of evidence appli- into an answerable question. That outcome is that students cation. Curricular frameworks should take into account identify gaps in their knowledge as a result of reflecting on the importance of all the steps. The recently released Sicily their practice, and frame questions sufficiently focused to Statement on EBP (Dawes et al. 2005) is based on cur- lead to effective search and appraisal strategies. The Sicily rent literature and incorporates the experiences of delegates Statement on EBP provides examples of teaching methods,such as presenting a clinical scenario or asking students Linda Johnston, Chair of Neonatal Nursing Research and Deputy Head of School, Asso-
to present a problem they have encountered in their clini- ciate Head, Research, The University of Melbourne, School of Nursing, Australia. Ellen
cal practice, to assist students to frame a focused question Fineout-Overholt, Director, Center for the Advancement of Evidence-Based Practice,
Arizona State University, Tempe, Arizona.
within a structured format (Dawes et al. 2005).
An “evidence-based medicine learning prescription” Address correspondence to Linda Johnston, RN, PhD, Chair of Neonatal NursingResearch and Deputy Head of School, Associate Head, Research, The University of was first reported by Sackett and colleagues (1997) as an Melbourne, School of Nursing, Level 1, 723 Swanston Street, Carlton, Victoria 3010, approach to applying evidence to the real life clinical situ- Australia; [email protected] ation. This approach has been subsequently adapted with Copyright 2005 Sigma Theta Tau International “EBM Rx”—a pressure-sensitive pad, much like a prescrip- tion pad, that is used by clinicians at the bedside to identify Second Quarter 2005 r Worldviews on Evidence-Based Nursing areas of uncertainty in relation to patient care (Rucker & with attitude, knowledge, skill, behavior, and clinical out- Morrison 2000). The teacher helps learners frame a fo- comes as the outcomes measured. According to the frame- cused question arising from practice before handing the work replicators, doers and users will all recognize the learner a copy of the prescription form with an assigned importance of identifying gaps in their knowledge base, due date. The teacher retains a copy to ensure comple- understand that it is important to generate a focused clin- tion of the assignment. The learner performs the literature ical question, and be open to new knowledge. All three search, retrieves relevant literature, and completes a critical groups will be able to list and understand the components appraisal. A pilot study evaluating this approach to teach- of a structured, searchable question. With respect to behav- ing EBP indicated the technique was useful in bringing EBP ior outcomes, however, replicators will only occasionally from academic exercise to the clinical care context (Rucker ask colleagues focused clinical questions, while users and doers will frequently use appropriate questions to seek new Mangrulkar and colleagues (2002) advocate the amal- knowledge and/or record the questions that arose and those gam of two teaching approaches—the clinical “pearl” and questions that have been answered, respectively. One could EBP—at the bedside to aid in getting past Step 0 (Man- ask if the users and doers are more comfortable with un- grulkar et al. 2002). The clinical pearl is a short, pithy, certainty than the replicators. It is hoped all three groups instructive, and often anecdotal saying that may be used move on through the EBP process and use those questions by the senior clinician as a teaching point. The pearl can generated to identify gaps in practice and change practices be used to draw attention to a disorder that should be con- where appropriate (Straus et al. 2004).
sidered in a patient, to highlight treatment options, or to The Johns Hopkins Faculty Development Program in alter the proposed likelihood of a disease currently under Teaching Skills (Cole et al. 2004) was initiated in 1987 as a consideration. While the attitude of many clinicians may longitudinal model for faculty development of clinical ed- be that the process of EBP is rigid and impractical, the ucators to promote reflective learning. The overall learning pearl may be considered anecdotal and lacking in scien- goals of this program are for participants to improve their tific rigor. However, the approaches are complementary in skills in facilitating self-directed learning and create a col- terms of generating reflection and, together, have been used laborative and supportive learning environment. A recent as a teaching exercise that capitalizes on the advantages of pre- and post-study was designed to evaluate the outcomes both. This type of exercise brings evidence to the clinical of the structured model including teaching effectiveness, setting. As the pearl is always delivered within a clinical professional effectiveness other than teaching, teaching en- context, the search for evidence in relation to the pearl joyment, and learning effectiveness. Results suggested the also will be clinically relevant. Learners engage in higher- experiential learning methods with reflection were highly order thinking as they seek and synthesize literature that valued and promoted change in participants’ knowledge, may support or refute the pearl. The principles of EBP are attitudes, and skills with successful application to the real- therefore used to lend validity to the pearl (Mangrulkar world setting of clinical practice (Cole et al. 2004).
Since early 2004, Professor Linda Johnston has con- The Society of Internal Medicine Evidence-Based ducted a “Reflective Round” in the Neonatal Unit of The Medicine Task Force recognized that there is currently lit- Royal Children’s Hospital, Melbourne, Australia. The de- tle evidence on the most effective means of teaching EBP velopment of this approach to clinical inquiry was, in part, (Straus et al. 2004). The authors suggested health care pro- driven by the perceived irrelevance by unit nursing staff fessionals would generally fall into one of three groups with of a traditional journal club approach to investigating ev- respect to their incorporation of evidence into practice. For idence for practice. Held every month at the change over frequently encountered conditions and with no time con- time between day and evening shift and lasting a total of straints the “doer” will complete at least the first four steps 45 minutes, the round is designed to identify areas of un- of the EBP process. The “using” mode is adopted in the certainty in the management of a particular baby who is a rushed clinical situation and where less common condi- patient on the unit at the time. The unit clinical educators tions are encountered. The critical appraisal step is skipped, and academic research staff identify a baby of clinical com- with acceptance of pre-appraised resources such as Best Ev- plexity where issues regarding management may have been idenceC . “Replicators” abandon most of the steps and trust debated earlier by clinicians caring for the baby. Round at- the recommendations of respected leaders such as clinical tendees and unit nursing staff, usually between four and practice guideline developers and consensus groups. The eight in number, enter the unit and position themselves authors have developed and tested a conceptual framework at the baby’s bedside. A discussion on the baby’s clinical for evaluating methods of teaching EBM. The framework condition, within the context of family-centered care, is fa- has been applied to the formulation of clinical questions cilitated by the academic research staff, and uncertainties Worldviews on Evidence-Based Nursing r Second Quarter 2005 99 relating to management are identified. In a seminar signed to improve clinical question formulation. First-time room, questions arising from the round are framed us- users of an evidence center were randomized to receive the ing the PICOT framework: Patient-Intervention/exposure-
standard request form or the form with additional instruc- Comparator-Outcome-Time. A nursing staff member vol-
tions for proper question formulation and a diagrammatic unteers to undertake a search with the assistance of hospital example of how the components of an answerable question library staff and research staff to retrieve relevant research may be arranged. The primary outcome of interest was the papers. The following month the staff member reports to change in the proportion of reformulated questions that the group on the types and quality of studies retrieved, and included all components. Results suggested a significant if the evidence is deemed sufficient, strategies for imple- impact of specific instructions on the proportion of prop- menting changes to practice are developed. The latter half erly formulated clinical questions (Villanueva et al. 2001).
of the meeting is used for the conduct of another round.
Changes in health care delivery in the last decade have The clinical question generated, search strategy, and ap- required changes in nursing education to produce compe- praisal process are imported into the software developed tent graduates who can practice in an environment where by the Centre for Evidence Based Medicine in the United treatment-effectiveness data drives care decisions (NLN Kingdom, CATMaker . Thus a permanent, Web-based ver- 2002). Many of the teaching methods used in nursing edu- sion of the exercise is available for unit staff to review. The cation to enhance critical thinking skills focus on teaching Reflective Round process has led to: (1) reaffirmation that students how to directly apply knowledge. This approach best practice is occurring in the unit, (2) an understanding utilizes structured learning situations to teach how to apply that changes in practice need to be considered, and in some knowledge in a logical way that will result in the desired cases, (3) the development of research projects to provide outcomes. However, as Schon (1983) contends, thinking in practice presents a complexity as problems in the clinical Clearly, valid approaches to assessing methods in the world do not generally present themselves with an identi- teaching of EBP are required. Dawes and colleagues (2005) provided an example of the type of assessment that may The “new” paradigm of EBP advocates the formulated be undertaken to evaluate the effectiveness of a teaching clinical question as the starting point from which to identify approach to Step 0. They suggest a clinical scenario be pre- research evidence that can be integrated with expertise and sented to the student, and the student be asked to form a fo- the desires of the consumer. EBP has evolved from the ap- cused, answerable question. Ramos and colleagues (2003) plication of clinical epidemiology and critical appraisal of have developed the Fresno test—a reliable and valid test evidence to the process of explicit decision making within for determining the effect of teaching in evidence-based the context of daily clinical practice. It is clear that the medicine. The test begins with the presentation of two types of learners and the context in which they make de- clinical scenarios and requires the student to formulate cisions have influenced the uptake of this process. Simi- a focused, searchable question. The Sicily Statement sug- larly, educators in the academic and clinical settings need gests the Fresno test as a way to assess students’ ability to to identify approaches to teaching the necessary skills that achieve Step 0 (Dawes et al. 2005). To date, the test has take these differences into account. Uncertainty exists in only been validated in medicine, and further investigation health care; our comfort with this opportunity for problem on the utility of the test needs to be done with other clinical solving and clinical decision making begins with educators disciplines. The developers also suggest educators should who carefully and thoughtfully apply to their teaching the be challenged to design tests that reliably assess the use of best available evidence to assist learners in achieving such evidence in real clinical circumstances rather than simula- tions or vignettes (Ramos et al. 2003).
Knowing is not enough; we must apply. Willing is not enough, we must Villanueva and colleagues (2001) have conducted a ran- domized controlled trial that tested an intervention de- Framing YOUR Question
PICOT is designed to help turn not only a clinical problem, but also a research idea, into an answerable research question. If you have
had the experience of interrogating a database for information and spending hours finding nothing or thousands of “hits” of no relevance,
then the PICOT approach is for you:
P opulation:
Demographic data describing your patient population of interest, that is, who should be in the study?
I ntervention:
The treatment, diagnostic test, or predictor you are interested in.
100 Second Quarter 2005 r Worldviews on Evidence-Based Nursing C omparator:
The gold standard against which the intervention is tested, or the control comparison.
O utcome:
What outcome measurements are of interest to you?
T ime:
Over what time period are you interested?
Population
Population refers to the particular group of people or patients of the problem under study. This could include a particular patient or group
of patients with a similar condition. It may include health care providers of a particular professional group or an organization. Examples of
situations are: persons with dementia attending a day care center (an aspect of health care delivery), or independently living women over
the age of 65 years with urinary incontinence (a group of patients sharing similar demographic characteristics and a group of patients with
a particular condition).
Intervention
The intervention refers to the dimension of health care under question. Interventions can be: diagnostic, therapeutic, preventive, managerial,
or a matter of health economics. Examples of interventions are: newborn hearing screening (preventive), lung function testing (diagnostic),
timed voiding for management or urinary incontinence (therapeutic), nurse-led telephone triage (managerial), and home monitoring of
warfarin levels by point-of-care testing (health economics).
Comparator
In some, but not all, cases there may be a comparator of interest, such as a counter-intervention or gold standard. This includes standard
treatment or no treatment at all. In the timed voiding example, the counter-intervention could be the use of drug treatment as an alternative.
A gold standard for an instrument to measure warfarin levels at home would be collection and analysis in a laboratory.
Outcome
The outcome is the result that is of interest from the consumers’ perspective. Examples of outcomes could include: faster referral to
specialist services, reduction in number of incontinent episodes, or reduced cost of warfarin monitoring.
Time
The time period of interest will, to some extent, depend on the outcome of interest and its means of measurement. Sometimes time will not
be a relevant component of your question.
Use a table format to ensure all components of the searchable question are included. This question then contains the search terms to usewhen interrogating databases.
Participants
Intervention
Comparator
What is the effectiveness of timed voiding training for a period of 12 months in reducing thenumber of incontinent episodes in independently living women over the age of 65 years? evidence-based practice. BMC Medical Education, 5(1), Cole K., Barker L.R., Kolodner K., Williamson P., Wright S. & Kern D. (2004). Faculty development in teach- Mangrulkar R., Saint S., Chu S. & Tierney L. (2002). What ing skills: An intensive longitudinal model. Academic is the role of the clinical “pearl”? The American Journal Medicine, 79(5), 469–480.
of Medicine, 113(7), 617–624.
Cook D., Jaeschke R. & Guyatt G. (1992). Critical app- NLN. (2002). A vision for nursing education. New York: raisal of therapeutic interventions in the intensive care unit: Human monoclonal antibody treatment in sepsis.
Ramos K., Schafer S. & Tracz S. (2003). Validation Journal of Intensive Care Medicine, 7(6), 275–282.
of the Fresno test of competence in evidence based Dawes M., Summerskill W., Glasziou P., Cartabellotta A., medicine. British Medical Journal, 326(7384), 319– Martin J., Hopayian K., et al. (2005). Sicily statement on Worldviews on Evidence-Based Nursing r Second Quarter 2005 101 Rucker L. & Morrison E. (2000). The “EBM Rx”: An initial M., et al. (2004). Evaluating the teaching of evidence experience with an evidence-based learning prescrip- based medicine: Conceptual framework. British Medical tion. Academic Medicine, 75(5), 527–528.
Journal, 329(7473), 1029–1032.
Sackett D., Richardson W., Rosenberg W. & Haynes R.
Villanueva E., Burrows E., Fennessy P., Rajendran M. & (1997). Evidence-based medicine: How to practice and Anderson J. (2001). Improving question formulation teach EBM. New York: Churchill Livingstone.
for use in evidence appraisal in a tertiary care set- Schon D. (1983). Educating the reflective practitioner. San ting: A randomised controlled trial [ISRCTN66375463].
BMC Medical Informatics and Decision Making, 1(1), Straus S., Green M., Bell D., Badgett R., Davis D., Gerrity 102 Second Quarter 2005 r Worldviews on Evidence-Based Nursing

Source: http://www.pflege-forschung.de/downloads/zero_one.pdf