Nurse Education in Practice (2009) 9, 190–198

Nurse

www.elsevier.com/nepr

Educationin Practice

The feasibility of introducing an evidence basedpractice cycle into a clinical area: An evaluationof process and outcome

Jenny Morris a,*, Veronica Maynard b

a Faculty of Health and Social Work, University of Plymouth, Knowledge Spa, Truro TR1 3HD,United Kingdomb Faculty of Health and Social Work, University of Plymouth, Drake Circus, Plymouth, United Kingdom

Accepted 23 June 2008

14do

*

18

KEYWORDSEvidence basedpractice;Clinical teaching;Undergraduatenursing programmes

71-5953/$ - see front mattei:10.1016/j.nepr.2008.06.0

Corresponding author. Tel.72 256451.E-mail address: jmmorris@

r �c 20002

: +44 (0)

plymout

Summary The aim was to examine the feasibility of introducing an evidence basedpractice (EBP) cycle into a practice area within an undergraduate pre-registrationprogramme.

The cycle involved four meetings over five weeks on a cardiac intensive care unit.Three 3rd year adult branch nursing students participated with their mentors. A webpage for the project was developed to support the process.

Evaluation focused on changes in EBP knowledge and skills and issues aroundimplementation and perceived value of the EBP cycle. The findings showed thatthe EBP cycle was straight forward to set up and was recognised as being of valueby both students and mentors. The students demonstrated modest improvementsin EBP knowledge and skills. The main problems were lack of time and difficultiesin accessing on-line resources.

�c 2008 Elsevier Ltd. All rights reserved.

Introduction

Evidence based practice is embedded in mostundergraduate health care pre-registration andpost-qualifying programmes, and is also taught atpostgraduate level. To become skilled in evidence

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based practice, students are taught how to developfocused questions using frameworks such as PICO(Nollan et al., 2005), how to search efficientlyusing search terms, how to select appropriateinformation both in terms of the topic and in termsof the nature of the evidence likely to be yielded,how to critically appraise primary and secondarysources of research, and how to apply appraisedevidence to practice. The importance of evidencebased practice to health care curricula is reflected

ved.

The feasibility of introducing an evidence based practice cycle into a clinical area 191

in the Sicily statement developed following thethird international conference of evidence basedhealth care for teachers and developers. Thisstatement recommended ‘. . .that all practitionersunderstand the principles of EBP, implement evi-dence based policies, and have a critical attitudeto their own practice and to evidence’. . . (Daweset al., 2005, p. 3).

The journal club format used traditionally inmedical education is now recognised as a usefultool for developing critical appraisal skills in othergroups of health care students (e.g. Owen et al.,2001; Goodfellow, 2004; Dobrzanska and Cromack,2005; McQueen et al., 2006). However, journalclubs also have their limitations in that many sufferfrom non-attendance and lack of preparation or ac-tive participation by those attending (e.g. Cramerand Mahoney, 2001; Dobrzanska and Cromack,2005) and have been criticised for not encouragingdeep learning in participants (Khan and Gee, 1999).

Changing a journal club focus from critical ap-praisal to evidence based medicine has demon-strated increased knowledge and satisfactionamongst the participants (Cramer and Mahoney,2001). Indeed Phillips and Glasziou (2004) haveshown journal clubs that are driven by a questionrelating to the practice situation that learners findthemselves in, and that focus on appraising the evi-dence and generating written output, are consid-ered to be more successful than others.

It is evident, however, that teaching the widerskills associated with evidence based practice willnot necessarily bring about a change in behaviour.Several studies of different professional groupshave shown that evidence based practice educa-tional interventions may well improve knowledgebut not necessarily lead to more evidence basedpractice in the clinical setting (Forsetlund et al.,2003; McCluskey and Lovarini, 2005; Stevenson etal., 2004). A recent study supporting this findingcomes from a study conducted in the United Statesby Pravikoff et al. (2005) who looked at the readi-ness of nurses to use evidence in their practice.They found that although practitioners recognisedthat they needed information to inform their prac-tice, they were more inclined to ask their col-leagues or search the Internet rather than usepeer-reviewed research based information. Upton(1999) in a survey of nurses also reported thatrespondents would most often act on informationreceived from experienced colleagues. In addition,the results highlighted that many of the respon-dents were not skilled in locating and appraising re-search based evidence.

A recent study by Gerrish and Clayton (2004)examined the factors influencing the achievement

of EBP in the clinical situation. They undertook asurvey of clinical nurses to examine the extent towhich they use different sources of knowledge toinform their practice, to explore potential barriersto using evidence based information and imple-menting evidence into practice. The findings fromthis study indicated that respondents tended torely on experiential knowledge rather than re-search knowledge to inform their practice and thatthe biggest barriers to utilisation of research evi-dence were a lack of time, resources and authorityto change practice.

These findings suggest that despite theoreticalinput around EBP, EBP skills are not being utilisedor developed in practice. This highlights the needto integrate the teaching of EBP into the practicesituation, the importance of which has been thesubject of a systematic review by Coomarasamyand Khan (2004). They showed that integratedcourses led to a greater improvement in critical ap-praisal skills, attitudes to evidence based medicineand behaviour change reflected in reading habitsand how information resources were used.

The benefit of integrated approaches to theteaching of EBP is the opportunity for students toutilise the skills developed through relevant mod-ules in relation to real cases, thereby ensuring rel-evance to patient care. Most of the research,however, has been undertaken in the context ofmedical education. Our aim was to extend thisintegrated approach into other health care profes-sional B.Sc. pre-registration programmes to inves-tigate whether it was feasible, and also resultedin an improvement in EBP knowledge and skills.The specific focus of our study was on developingevidence based practice knowledge and skillsamong pre-registration nursing and allied healthprofessional students using an evidence basedpractice cycle consisting of a case study supportedby a student-led journal club.

Methods

Design

A pre- and post-test evaluation to examine the pro-cess and outcome of the evidence based practicecycle.

Evidence based practice cycle

There were two main components to the cycle: theidentification of a patient-related issue, and an evi-dence based, student-led journal club. The cycleconsisted of four meetings between the students,

192 J. Morris, V. Maynard

their mentors and the academic team. The purposeof these four meetings was: (i) to outline the nat-ure of the project, and to collect baseline informa-tion; (ii) to identify and confirm the suitability ofthe issue identified by the students; to formulatea searchable question using the PICO framework(Nollan et al., 2005); and to decide on the searchstrategy that the students would follow; (iii) forthe students to present critical appraisals of the re-search identified, and to discuss the application ofthe evidence appraised to practice; and (iv) for thestudents to discuss the outcome of the process withtheir mentors and the academic team, and to agreea method of dissemination within the placementarea and wider Trust as appropriate; and to collectfinal evaluation data from the students and thementors. The entire cycle was completed within afive week period.

A web page for the project was designed by theacademic team to enable students to access docu-mentation and resources on searching and retriev-ing research based evidence, critical appraisal andformulating clinical questions (http://www.ebp-case-study.org.uk). The site was designed usingMacromedia Dreamweaver 8 to build the webpages, and Adobe Photoshop CS2 to design thegraphics.

This project was seen as an educational initia-tive and designed as such with the inclusion of anevaluation component. Whilst formal ethical com-mittee approval was not required for the study,care was taken to ensure the process was integralto the students’ practical experience requirementsand did not place undue demands on either the stu-dents, their mentors or the practice area. The sup-port of the head of school and relevant programmeleads, along with the unit manager in the place-ment area where the study was to be undertaken,was obtained prior to approaching the students.The unit manager and the clinical team wereenthusiastic about the nature of the study and allgave their full support. Following this approvalwe wrote to the students and their mentors toask if they would be willing to take part in thestudy.

Student year group and programme

The study was undertaken in England. Third yearstudents were selected as these students had com-pleted a first year EBP theoretical module and asecond year research methods module. B.Sc. adultbranch nursing, physiotherapy, occupational ther-apy and dietetics students were considered asthese programmes had placements of sufficientduration to enable the implementation of our EBPcycle.

Placement areas

Possible placement areas were those where therewas more than one third year student placed be-tween 06.11.06 and 24.12.06 (the timeframe ofthe EBP cycle for this project). Cardiac intensivecare (ITU) and cardiac high dependency (HDU) unitsat a local NHS Trust hospital were the only suitableareas.

Evaluation

The focus of the evaluation was on:

(1) Changes in EBP knowledge and skills as a con-sequence of taking part in the project mea-sured using a modified version of the Fresnotest of competence in evidence based medi-cine (Ramos et al., 2003). This questionnairewas adapted and validated for use with occu-pational therapists (McCluskey and Lovarini,2005) and was the version used for this study,with clinical scenarios developed for our stu-dent group (Appendix). The Fresno test ofcompetence is used to test EBP knowledgeand skills in the following areas: writingfocused questions, identifying appropriatesources of information, identifying suitablestudy designs, developing effective searchstrategies, validity and significance ofresearch findings.

(2) Issues around implementation and the per-ceived value of the EBP cycle. A questionnairewas designed for the project to capture thestudents’ views about taking part in the pro-ject as well as their perceptions about howtaking part had contributed to any develop-ment of EBP knowledge and skills, theirknowledge about the management of the typeof case identified, and whether taking part inthe project aided their integration into theunit.

Results

Sample

Four students from the adult branch nursing pro-gramme were in placement at the time of thestudy. One of the four students changed her shiftin advance of the first meeting and only attendedthe second meeting and did not complete any ofthe evaluation documents. The results are basedon information collected from the remaining threestudents. Data were collected from the two men-tors who were able to attend more than one ofthe meetings.

The feasibility of introducing an evidence based practice cycle into a clinical area 193

Changes in EBP knowledge and skills

All three students completed a pre- and post-testadapted Fresno questionnaire where the maximumscore possible was 156. All students showed modestimprovements in their scores on post-testing withpercentage increases ranging from 6% to 19% asshown in Table 1. The median scores pre- andpost-test according to each question are outlinedin Table 2. At pre-test, the students did not haveany difficulty creating a focused clinical question(question 1 – see Appendix) in order to assist withthe organisation of a search of the clinical litera-ture; and in each case scored 9 out of a possible12 marks. However, at the end of the case studythere was no improvement in these scores for anyof the students. There were modest increases inpost-test scores for all remaining questions. Thequestions that students appeared to have thegreatest difficulty in answering at pre-test werequestions 5 and 7 which focused on issues of valid-ity and statistical significance (see Appendix); twoof the students scored zero for both questions.There were, however, improvements in post-testscores for both of these questions.

Implementation and perceived value of theEBP cycle

The greatest difficulty from the perspective of theproject team was identifying those placementareas where there was more than one student fromany programme at the time of the project period

Table 1 Modified Fresno total scores at pre-test and post

Student Pre-test

1 (01S) 50 (32)2 (02S) 57 (37)3 (04S) 78 (50)

Table 2 Modified Fresno test illustrating median scores a

Question (see Appendix) Pre-t

1 – Writing a focused question 92 – Sources of information 83 – Type of study design 124 – Search strategy to retrieve evidence 125 – Relevance of study characteristics 06 – Internal validity of study 107 – Magnitude and significance of findings 0

NB Each question had a maximum score of 24, except for question

and where the placement period allowed the fiveweek cycle to take place. The EBP cycle was timedto avoid clashing with any module assessments orexaminations. Only one placement area met thesecriteria but the four students were from the sameprogramme. Each student had at least one mentorand one or two co-mentors whilst on the unit.Although there was initial interest in the web pagedesigned for the project to enable quick access tokey EBP resources, the students and mentors didnot use this partly because of the difficulties theyhad in accessing the computer in the placementarea, but also because of the lack of evidencearound the topic they had selected.

The three students believed the cycle had been‘of some value’ in developing their knowledgeabout the EBP process, in searching and retrievingevidence, and in critically appraising research evi-dence. One student felt the cycle was ‘of great va-lue’ and two ‘of some value’ in developing afocused clinical question. All three students felttaking part had enhanced their understanding ofthe relevance of EBP to the clinical situation: ‘Ithas shown me how difficult it can be to find infor-mation. . .which influences/changes practice’ (ID2); ‘. . .has made me more aware of EBP andencouraged me to be a little more analytical of re-search and protocols’ (ID 4).

The students’ opinion was that taking part in theEBP cycle provided them with an opportunity toexperience the EBP process in practice which theybelieved enhanced their EBP skills, and also pro-vided them with a valuable insight into how someclinical decisions were made. In addition, the EBP

-test (%)

Post-test % Change

68 (44) › 1288 (56) › 1987 (56) › 6

nd median difference in scores by question

est Post-test Median difference

9 014 615 316 45 5

18 810 10

1 which had a maximum score of 12.

194 J. Morris, V. Maynard

cycle helped the students to identify an area in prac-ticewhere there were gaps in research evidence andthus highlighted those areas where further researchwas needed. All three students believed that takingpart in the cycle improved their knowledge aboutthe management of the case they had identifiedwhich they perceived to be a consequence ofreviewing the research evidence upon which thechange was made and assessing the relevance topractice (ID 1). They also felt that working in thisway helped to increase their confidence in question-ing staff about unit protocols (ID 2 and 4).

The three students believed that taking part inthe EBP cycle influenced how they approachedthe care of patients on the unit ‘to a great extent’.The comments made by all the students suggestedthat this was due to learning to question the way inwhich decisions were made and implemented; andappreciating that changes in protocols were not al-ways understood by the staff involved in theirimplementation.

All three students believed that participation inthe cycle assisted with their integration on to theunit: ‘Ward staff seemed interested in what wewere doing and it sparked some debate’ (ID 4);‘. . .built relationships with members of staff thatI may not have necessarily had communicationwith’ (ID 1); ‘. . .helped me to learn peoples’roles/names and gave me some reason to approachthem to ask for their knowledge/views’ (ID 2). Thiswas supported by a comment from one of the men-tors who indicated that the cycle approach was avaluable exercise for the integration of studentson to the unit in that it ‘. . .encourages professionalrelationships between the mentor and student’ andthat it ‘. . .provides them with lifelong skills and in-creases their competency (in this area) on qualify-ing’ (ID 4M).

A further benefit identified by the students wasthat they would be able to use the material gainedfrom the study in their practice portfolio. Addition-ally, two of the students identified two theoreticalmodules that could be informed by the informationcollected as part of the EBP cycle.

Two of the students felt it was ‘difficult’ to takepart in the cycle and one ‘very difficult’. The twofelt it was ‘difficult’ due to other academic com-mitments (ID 4), not being able to get together,and inconsistent support from ward staff (ID 1and 4). The student who thought it was ‘very diffi-cult’ cited the fact that research evidence was notreadily available, the difficulty in accessing the rel-evant practice protocols, and the lack of knowl-edge from the clinical staff about the protocolchange. The amount of time associated with facil-itation of the cycle was perceived ‘not to be an is-

sue’ by the mentors. However, one mentor feltthat there was ‘not enough time’ to provide the ex-tent of input required throughout the cycle as awhole. The second mentor, however, felt therewere no time issues. When it came to considerationof incorporating this kind of placement activityinto the mentorship role, it was felt that therewould be time issues. Comments included‘. . .requires a lot of time inside of work’ and‘. . .management issues for unit’ (ID 4M); ‘in thisparticular environment (critical care) this extraactivity is too much for the student’ (ID 08M). Addi-tionally one mentor perceived that there was ‘littlesupport from colleagues’, and that ‘not everyone isinterested in giving effort to improve aspects ofnursing’ (ID 4M). In terms of access to resourcessuch as library and journals, these were not feltto be a barrier to facilitating such a placementactivity on the unit.

The issue of timing was raised in the third meet-ing and following discussion all of the studentsagreed that the timing was probably best in thethird year as they had more confidence clinically.The two mentors felt that such a cycle should takeplace in the second year as their view was that stu-dents were already under pressure in the third yearwith the completion of coursework, etc.

All of the students felt the five week period ofthe cycle was ‘just right’ and provided sufficienttime for them to gather the required information.One student highlighted the importance of thisbeing undertaken as part of the placement, andthereby counting towards practice hours. One ofthe mentors felt that the duration of the cyclewas ‘too short’; as the time required to review re-search was limited due to the pressures of work ona busy unit; however the second mentor felt thatthe duration was ‘just right’.

The three students felt ‘quite well’ supported bytheir mentor although one student added that hermentor was interested but had been unable to at-tend meetings. If the EBP cycle was introduced for-mally into the curriculum, the three students feltthat University academic staff rather than practicementors should be the lead facilitators. This wasdue to perceived pressure of time on mentors andsometimes a lack of interest.

Discussion and conclusions

The results of this feasibility study have demon-strated how an evidence based cycle and student-led evidence based journal club can be includedin a clinical area within a pre-registration health

The feasibility of introducing an evidence based practice cycle into a clinical area 195

care professional programme; and have shown thevalue of such an approach to the development ofevidence based practice skills and knowledge. Inparticular, the use of a journal club that focusedon questions identified from clinical practice hasbeen valued by both students and mentors in thisstudy which is consistent with the results fromother studies (e.g. Phillips and Glasziou, 2004).However, there were also several difficulties iden-tified in setting up the EBP cycle. The first was notbeing able to include students from more than oneprogramme. Second, only two of the ten mentorswere able to attend all the meetings and fully en-gage with the process due to time constraintswhich will need to be considered if this kind of ap-proach is implemented. This general issue of men-tors not having sufficient time to work withstudents has been widely discussed (e.g. Dolan,2003). Third and perhaps most importantly giventhe focus of the EBP cycle, the students and theirmentors had difficulty accessing electronic re-sources in the clinical setting. This was due tothe fact that the students and some of their men-tors did not have access to the computers in theclinical area, which was clearly a limiting factorand a source of frustration.

The findings of this study provide support to oth-ers who have highlighted the importance of inte-grating evidence based practice teaching withpractice (e.g. Mangrulkar et al., 2002; Coomaras-amy and Khan, 2004; Portney, 2004). Informationfrom the students showed that taking part in theEBP cycle helped them understand the relevanceof evidence based practice to the clinical situation;and influenced their understanding of the issuesaround protocol development in practice. In rela-tion to a more objective measure of knowledgeand skills using the adapted Fresno questionnaire,there were modest improvements in pre- andpost-test scores.

Students who were in the 3rd year of their pro-grammes were selected for this study as it was feltthat they needed the clinical experience and con-sequently confidence, as well as the evidencebased practice theoretical knowledge, in order tosuccessfully participate in the process. We wouldargue that in order to link the evidence based prac-tice process with the clinical situation it is neces-sary to have this level of knowledge andconfidence. It does, however require mentors withsufficient evidence based practice skills to helpfacilitate the process. We were surprised by thelack of EBP knowledge of some of the mentors par-ticularly as the Nursing and Midwifery Councilemphasise the importance of EBP as a key compe-tency in terms of supporting learning and assess-

ment in practice (Nursing and Midwifery Council,2004).

The mentors also found the process useful butwere unable to fully participate due to a lack oftime. One additional benefit noted by both stu-dents and mentors was how the process aidedthe integration of the students into the unit. Itshould be noted, however, that only two mentorsparticipated fully in the process despite therebeing approximately ten mentors allocated tothe students overall. This highlights the need tohave such a process fully integrated into theplacement schedule and to ensure that it is partof the learning contract agreed at the outset be-tween the students and their mentors. This wouldensure that the evidence based process wasrecognised as an integral part of the curriculumas acknowledged by Dawes et al. (2005) and Port-ney (2004).

From an academic perspective, this type ofintervention was relatively easy to implement inthe clinical situation although this was helpedby the fact that the initiative was well supportedby senior clinical staff. This was reflected in thefact that the clinical manager, students and theirmentors worked together to identify meetingdates when all could attend. The clinical man-ager attended one of the meetings and it wasclear from the discussions that the educationalinitiative was perceived to be of value to theclinical team as well as the students. This is con-sistent with the work of others who have recogni-sed that such initiatives were more likely to workif supported by senior staff and when attendeesare given protected time (Alguire, 1998 and Leeet al., 2005). The value of the intervention froman academic perspective was to enable the stu-dents to work with the concepts of evidencebased practice in the clinical situation and there-by contribute directly to patient management, aswell as developing their knowledge and skills.Others have also reported that integrated teach-ing of evidence based practice was preferred(e.g. McGinn et al., 2002; Nicholson and Shieh,2005).

In conclusion, the findings from this small feasi-bility study illustrate that it is possible to introducethis kind of learning initiative into practice andthat it can provide added value to the curriculumin terms of students’ experience as well as address-ing the theory-practice gap in terms of evidencebased practice. We feel there is merit in continuingthis line of study to build upon the findings thathave so far emerged and to develop the work fur-ther with students from a variety of programmes.At the outset we had envisaged that this kind of

196 J. Morris, V. Maynard

EBP cycle could be implemented by clinical staff aspart of their mentoring role. However, issuesaround the time to work with students and a possi-ble lack of EBP knowledge and skills at the appro-priate level would need to be addressed. It is alsoclear from this study that the access to electronicresources in the practice setting is a limiting fac-tor; and, therefore, further research is requiredto find alternative and sustainable ways of support-ing students in practice in terms of accessing rele-vant research based evidence in order to continueto develop their EBP skills in practice.

Conflict of interest statement

None.

Acknowledgements

We would like to thank the Centre for Excellence inProfessional Placement Learning for funding thisproject; the students and their mentors for takingpart in the project; and Alex Ledbrooke, postgrad-uate research associate from the Cornwall CollegeAir Quality Unit based at Cornwall College fordesigning our web site.

Appendix. Modified Fresno questionnaire

The practice of evidence based practice (EBP) in-volves some basic knowledge and skills related tosearching and evaluating health care literature.This modified version of the UCSF-Fresno MedicalEducation tool is designed to assess the level atwhich you are already utilizing EBP skills. Pleasecomplete the entire test in one sitting. There areseven short answer questions, and you should allowyourself at least 30 min to complete the test.

Please read the three clinical scenarios below,select one scenario and answer the following ques-tions to the best of your ability. Do not worry if youare unfamiliar with the diagnoses mentioned; thisshould not affect your answers.

Pre-test scenarios

Clinical scenario 1

A 45 year old man comes to his GP with persis-tent lower back pain (LBP). He has been sufferingfrom LBP for the last 12 months for which hetakes anti-inflammatories and goes for regularphysiotherapy. However, his pain does not seem

to be getting any better. On examination hehas paraspinal muscle tenderness but no neuro-logical signs. You suggest he tries an alternativeanalgesia and considers acupuncture to help withpain relief, though you are not sure of the evi-dence to support this (adapted from Gidwani(2004) BestBETs).

Clinical scenario 2

A 40 year old woman attends an outpatient cliniccomplaining of bilateral painful wrists and a tin-gling sensation in both hands. The pain has beengetting progressively worse over the last 6 months.The woman is employed as a word processor andhas been diagnosed with occupational overuse syn-drome. In addition to conducting a workplaceassessment, you have recommended she immedi-ately starts regular stretching and exercises. How-ever, her workplace supervisor is reluctant tofollow your advice and wants the worker to rest in-stead (McCluskey and Bishop, 2006).

Clinical scenario 3

A 25 year old male comes into the EmergencyDepartment with a laceration to his right forearm.The wound will need cleaning before closing butthere appear to be many different cleaning solu-tions available in the department and you are un-sure which would be the best at reducinginfection and further complications. You haveheard that sterile saline or iodine solution wouldbe better than tap water, but are unsure of this(adapted from Thompson (2000) BestBETs).

Post-test scenarios

Clinical scenario 1

You have received a referral for a 38 year old malewith chronic low back pain. He sustained his injuryat work and is employed as a plumber. You are try-ing to decide if this man would benefit from using aTENS machine in addition to attending a series ofgroup education sessions on chronic pain manage-ment (Bishop and McCluskey, 2006).

Clinical scenario 2

An 18 year old girl with traumatic brain injury hasbeen referred to the occupational therapy depart-ment for advice on memory rehabilitation. She iscurrently completing the final year of her A-levelexams. You are trying to decide if teaching her touse a diary as a compensatory memory strategywould help her function better at school, inaddition to her usual strategies (Bishop and McClus-key, 2006).

The feasibility of introducing an evidence based practice cycle into a clinical area 197

Clinical scenario 3

A 30 year old woman presented to her GP with anexacerbation of her usual pattern of migraine.She asked specifically about whether riboflavinmight help as she had heard from a friend that itmight help prevent migraine (Glasziou, CEBM,2004).

Question 1: Write a focused clinical question forONE of the above scenarios that will help you orga-nise a search of the clinical literature.

Question 2: Where might you find answers tothese and other similar clinical questions? Nameas many possible sources of information as youcan – not just the ones you think are ‘good’sources. Describe the advantages and disadvan-tages of each type of information source you havelisted.

Sources Advantages Disadvantages

Question 3: What type of study (study design)would best answer your clinical question outlinedin Q1 and why?

Study design Rationale

Question 4: If you were to search Medline, CI-NAHL or any other database for original researchto answer your clinical question related to the sce-nario you selected for Question 1, describe thesearch strategy you might use. Be as specific asyou can about the search terms and search fieldsyou would use. Explain your rationale for takingthis approach. Describe how you might limit yoursearch if necessary and explain your reasoning.

Search terms Search fields and rationale Limits

Question 5: When you find a report of originalresearch on this question or any others, whatcharacteristics of the study will you consider todetermine if it is relevant? Include examples.Questions 6 and 7 will ask you how to determineif the study is valid, and how important the find-ings are. For this question, please focus on howto determine if it is really relevant to yourpractice.

Question 6: When you find a report of originalresearch related to your clinical question or any

others, what characteristics of the study will youconsider to determine if its findings are valid?(You’ve already addressed relevance, and question7 will ask how to determine the importance of thefindings. For this question, please focus on thevalidity of the study.)

Question 7: When you find a report of originalresearch which relates to your clinical question orany others, what characteristics of the findings willyou consider to determine their magnitude and sig-nificance (clinical and statistical)?

Magnitude Significance

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