Open the attach files …

By Ellen Fineout-Overholt, PhD, RN,
FNAP, FAAN, Bernadette Mazurek
Melnyk, PhD, RN, CPNP/PMHNP,

FNAP, FAAN, Susan B. Stillwell,
DNP, RN, CNE, and Kathleen M.

Williamson, PhD, RN

In May’s evidence-based prac-tice (EBP) article, Rebecca R., our hypothetical staff nurse,
and Carlos A., her hospital’s ex-
pert EBP mentor, learned how to
search for the evidence to answer
their clinical question (shown
here in PICOT format): “In hos­
pitalized adults (P), how does a
rapid response team (I) compared
with no rapid response team (C)
affect the number of cardiac ar­
rests (O) and unplanned admis­
sions to the ICU (O) during a
three­month period (T)?” With
the help of Lynne Z., the hospi-
tal librarian, Rebecca and Car-
los searched three databases,
PubMed, the Cumulative Index
of Nursing and Allied Health
Literature (CINAHL), and the
Cochrane Database of Systematic
Reviews. They used keywords
from their clinical question, in-
cluding ICU, rapid response
team, cardiac arrest, and un­
planned ICU admissions, as
well as the following synonyms:
failure to rescue, never events,
medical emergency teams, rapid
response systems, and code
blue. Whenever terms from a

database’s own indexing lan-
guage, or controlled vocabulary,
matched the keywords or syn-
onyms, those terms were also
searched. At the end of the data-
base searches, Rebecca and Car-
los chose to retain 18 of the 18
studies found in PubMed; six of
the 79 studies found in CINAHL;
and the one study found in the
Cochrane Database of System-
atic Reviews, because they best
answered the clinical question.

As a final step, at Lynne’s rec-
ommendation, Rebecca and Car-
los conducted a hand search of
the reference lists of each study
they retained looking for any rele-
vant studies they hadn’t found in
their original search; this process
is also called the ancestry method.
The hand search yielded one ad-
ditional study, for a total of 26.

The next time Rebecca and Car-
los meet, they discuss the next
step in the EBP process—critically
appraising the 26 studies. They
obtain copies of the studies by
printing those that are immedi-
ately available as full text through

library subscription or those
flagged as “free full text” by a
database or journal’s Web site.
Others are available through in-
terlibrary loan, when another
hos pital library shares its articles
with Rebecca and Carlos’s hospi-
tal library.

Carlos explains to Rebecca that
the purpose of critical appraisal
isn’t solely to find the flaws in a
study, but to determine its worth
to practice. In this rapid critical
appraisal (RCA), they will review
each study to determine
• its level of evidence.
• how well it was conducted.
• how useful it is to practice.

Once they determine which
studies are “keepers,” Rebecca
and Carlos will move on to the
final steps

By Ellen Fineout-Overholt, PhD, RN,
FNAP, FAAN, Bernadette Mazurek
Melnyk, PhD, RN, CPNP/PMHNP,

FNAP, FAAN, Susan B. Stillwell,
DNP, RN, CNE, and Kathleen M.

Williamson, PhD, RN

In September’s evidence- based practice (EBP) article, Rebecca R., our hypotheti cal
staff nurse, Carlos A., her hospi-
tal’s expert EBP mentor, and Chen
M., Rebecca’s nurse colleague, ra-
pidly critically appraised the 15
articles they found to answer their
clinical question—“In hospital-
ized adults (P), how does a rapid
response team (I) compared with
no rapid response team (C) affect
the number of cardiac arrests (O)
and unplanned admissions to the
ICU (O) during a three-month
period (T)?”—and determined
that they were all “keepers.” The
team now begins the process of
evaluation and syn thesis of the
articles to see what the evidence
says about initiating a rapid re-
sponse team (RRT) in their hos-
pital. Carlos reminds them that
evaluation and synthesis are syn-
ergistic processes and don’t neces-
sarily happen one after the other.
Nevertheless, to help them learn,
he will guide them through the
EBP process one step at a time.

Rebecca, Carlos, and Chen begin
to work with the evaluation table

they created earlier in this process
when they found and filled in the
essential elements of the 15 stud-
ies and projects (see “Critical Ap –
praisal of the Evidence: Part I,”
July). Now each takes a stack of
the “keeper” studies and system-
atically begins adding to the table
any remaining data that best re –
flect the study elements pertain-
ing to the group’s clinical question
(see Table 1; for the entire table
with all 15 articles, go to http:// They
had agreed that a “Notes” sec-
tion within the “Appraisal: Worth
to Practice” column would be a
good place to record the nuances

of an article, their impressions
of it, as well as any tips—such as
what worked in calling an RRT—
that could be used later when
they write up their ideas for ini-
tiating an RRT at their hospital, if
the evidence points in that direc-
tion. Chen remarks that al though
she thought their ini tial table con-
tained a lot of information, this
final version is more thorough by
far. She appreciates the opportu-
nity to go back and confirm her
original understanding of the
study essentials.

The team members discuss the
evolving patterns as they complete
the table. The three systematic

Critical Appraisal of the Evidence: Part III
The process of synthesis: seeing similarities and differences
across the body of evidence.

This is the seventh article in a series from the Arizona State University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach
to the delivery of health care that integrates

Clinical Issue of interest

Name of student:



Date of submission:

Topic is the clinical issue of interest.



The clinical issue of interest is the high speed response team to patients.

This employed especially to patients that are suffering from mental illness.

Patients that are admitted to the Intensive Care Unit without proper arrangements also needs the attention of this team.

The team serves in times of crises and in case complexes develop in certain patients.

This team plays a critical role in any health centre.

They work hand in hand with the nurses.

The take care of emergencies from patients in all wards.

They particularly work in the ICU.



Key words are very critical in the search engines as they reduce traffic in the media.

The use of key words in the Google search engine was employed.

All the essential key words regarding the subject matter, namely the clinical issue of interest were noted down.

The key words were then search in a special manner using the search engines such as Google and other journals as directed.

The correct choosing of key words is very critical in any search engine.

The Google is the dominant search engine employed in this modern days.

The correct choice of the keywords reduces the traffic in the media.

A list of the correct key words is first developed before the exercise starts.



The following articles were used

1. American journal clinical medicine

2. European journal of clinical issues of interest.

International journal on nursing code of conduct.

The universal journal on the patient population.

The articles are all peer reviewed.

They are in line with the subject matter.



Lundh, A., Boutron, I., Stewart, L., & Hróbjartsson, A. (2019). What to do with a clinical trial with conflicts of interest. BMJ evidence-based medicine, bmjebm-2019.

Klek, S., Forbes, A., Gabe, S., Holst, M., Wanten, G., Irtun, Ø., … & Blaser, A. R. (2016). Management of acute intestinal failure: A position paper from the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Group. Clinical Nutrition, 35(6), 1209-1218.

Ozkan, S., Ceylan, Y., Ozkan, O. V., & Yildirim, S. (2015). Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy. World Journal of Gastroenterology: WJG, 21(23), 7134.


All the references have been acquired with a custom range of 5 years.

The format of c

Student’s Name
Institution Affiliation

Evidence based practice (EBP)

Clinical Issue

There are multiple of the mental illness which are common such Generalized Anxiety Disorder, Bipolar, Dementia, Schizophrenia and list continues.

There are various models of the treatment such Cognitive behavioral therapy, exposure therapy and medication such as use of antidepressants.

Globally, mental illnesses account for 33% of the disability that adult get due to health problems.

Therefore, narrowing down to Generalized anxiety disorder, my concern is to establish effectiveness of the psychotherapy method of treatment used and specifically cognitive behavioral therapy.

Mental disorder has been global problem that which affects over 900 million people in the world.

Global burden cuts across high income countries to low income countries.

Correct method of treatment of mental illness is important and can be helpful to persons.

Treatment of the mental disorders is put into two categories which are; psychotherapy- behavioral therapy, cognitive therapy, interpersonal therapy, Psychodynamic therapy, Group therapy and Family therapy.

Second category is medication-Antidepressants, Antipsychotics, Mood stabilisers and Sleeping pills and minor tranquillisers.

Choice of the method of treatment is determined by its effictiveness.


Development of PICOT

Picot is method of developing of clinical question which was introduced in 1995 (Davies, 2011).

In was developed to help in carrying out the research where relevant information ought to be collected depending on the components of the clinical question that was formulated.

In view of this, PICOT has been basis of formulation of the clinical questions that guides in coming up with evidence based practice which is used in making in making clinical decisions.

Clinicians deal with human life and it is critically important they make decision on the medication that they should give based on the level of the evidence that is available which influence delivery of quality healthcare.

In conducting the research in clinical setting, clinical questions must be formulated.

To ensure that relevant data is corrected, clinical questions is collected using the format of the question known as PICOT.

PICOT has been used since 1995 and has confirmed as an effective way to formulate clinical questions that help to collect data that is analyzed, tested and later inform desion making for better delivery of the quality care.



Considering the clinical issue discussed in the second slide, Picot clinical question will be, for generalized anxiety disorder patient, how does cognitive behavioral therapy against antidepressants affects anxiety