Introduction to Evidence-Based Practice
Learning Objectives
Explain the meaning of 'evidence-based practice'.
Understand the origins of evidence-based practice.
Explain the importance of evidence-based practice.
Describe the scope of evidence-based health care.
List and explain the five steps of the evidence-based practice process.
What is Evidence-Based Practice?
Definition: Evidence-based practice involves explicit and conscientious efforts to find the best available research evidence to assist health professionals in making informed decisions for their patients.
Origin: The definition originated in evidence-based medicine but has expanded to all health professions and services.
Problem-Based Approach: Evidence-based practice is a problem-based approach where research evidence is used to assist in clinical decision-making.
Integration of Information: Informed clinical decisions require integrating information from patients, families, clinical settings, and research.
Focus on Research Evidence: Evidence-based practice emphasizes the role of research in informing clinical decisions.
Process:
Turn clinical information needs into questions.
Search for evidence from research.
Assess the quality of the evidence.
Decide whether and how to use the evidence to answer the question.
Enhancing Clinical Decision Making: Evidence from research enhances clinical decision-making and differs from information from testing theories and background clinical knowledge.
Importance of Basic Sciences: Knowledge of anatomy, pathology, psychology, and social structures is essential and refined through research.
Models for Clinical Management: Science-based training provides models for clinical management.
Understanding Mechanisms of Illnesses: Understanding the mechanisms of illnesses and conditions is important (e.g., heart failure, diabetes).
Pitfalls of Focusing Only on Mechanisms: Focusing solely on illness mechanisms can be misleading.
Direct Testing of Information: Evidence-based practice encourages focusing on research that directly tests the information (e.g., the effectiveness of a treatment).
Examples of Misleading Mechanism-Based Approaches (Table 1.1)
Putting babies on their fronts when they go to sleep
Previous recommendation: If babies vomit in their sleep, they might swallow the vomit into their lungs and develop pneumonia (Dr. Spock in the 1950s).
Empirical research that showed it was wrong: Observational data have shown that babies are more likely to die of sudden infant death syndrome (SIDS) if they lie on their fronts, rather than on their backs, when sleeping.
Bed rest after a heart attack (myocardial infarct)
Previous recommendation: The heart needs resting after an insult in which some of the heart muscle dies
Empirical research that showed it was wrong: Randomised controlled trials showed that bed rest makes thromboembolism (a dangerous condition in which a clot blocks the flow of blood through a blood vessel) much more likely.
Covering skin wounds after removal of skin cancer
Previous recommendation: To prevent bacteria gaining access and therefore causing infection
Empirical research that showed it was wrong: A randomised controlled trial showed that leaving skin wounds open does not increase the infection rate.
Best Available Evidence from Research:
Suitability of Study Design: The 'best type' of study design depends on the question being asked (Chapter 2).
Understanding Study Designs: It is important to understand the main types of study designs and their pros and cons.
Locating Appropriate Study Designs: Part of evidence-based practice is locating the type of study design best suited to provide the most appropriate type of information for a particular clinical decision.
Quality of Research: Studies must be well-designed and conducted to ensure confidence in their conclusions.
Integrating Clinical Expertise with Research Evidence
Importance of Integration: Evidence-based medicine involves integrating individual clinical expertise with the best available external clinical evidence from systematic research.
Definition of Clinical Expertise: Clinical expertise refers to the proficiency and judgment clinicians acquire through clinical experiences and practice.
Reflection of Expertise: Increased expertise is reflected in more effective diagnosis and thoughtful, compassionate use of patients’ predicaments, rights, and preferences.
Explicit and Conscientious Attempts: The definition deliberately states that attempts to find evidence should be ‘explicit’ and ‘conscientious’.
Reasons for Emphasis: Prior to evidence-based practice, research access was haphazard, and understanding of research results was superficial.
Addressing Clinical Information Needs: Simply using readily available evidence from journals is insufficient for clinical information needs.
Encouragement for Explicit and Conscientious Efforts: The definition encourages being ‘explicit’ and ‘conscientious’ in locating the ‘best available evidence from research’.
Evolution of the Definition of Evidence-Based Practice
Current Definition: Involves integrating the best research evidence with clinical expertise and the patient’s values and circumstances.
Consideration of Context: Requires considering characteristics of the local and broader practice context (Figure 1.1).
Valuing Education, Skills, and Experience: Emphasizes valuing and using the education, skills, and experience of health professionals.
Patient Preferences and Values: Focuses on considering patient preferences and values in decision-making.
Practice Context: Takes into account available resources, policies, and socio-cultural and geographical factors.
Clinical Reasoning: Integrating all elements involves clinical (or professional) reasoning (Chapter 15).
Engaging in Evidence-Based Practice: Combining research evidence, clinical expertise, patient values, and practice context enables informed decisions about patient care.
Terminology: Uses the word ‘patient’ while acknowledging other terms like ‘client’ or ‘consumer’ are used in different disciplines.
Evidence-Informed practice: Some disciplines use the phrase ‘evidence-informed practice.
Clinical Expertise: Includes thoughtfulness and consideration of the patient and their preferences and situations.
Importance of Patient Preferences: Exploring patient preferences and incorporating them into the decision-making process is addressed in Chapter 14.
Clinical Expertise Coverage: The concept of clinical expertise is covered in more depth in Chapter 15.
Origins of Evidence-Based Practice
McMaster University: Originated from a new medical school started in the 1970s at McMaster University in Canada.
Short Program: The medical program was only three years long, emphasizing the need to teach students how to find information.
Focus on Information Retrieval: Teachers aimed to teach students how to find what they needed to know, leading to the birth of evidence-based medicine.
What Preceded Evidence-Based Practice?
Reliance on Experience: Previously, reliance was on experience, expertise of older colleagues, and teachings from student days.
Flaws in Traditional Sources: These sources can be flawed.
Bias in Experience: Experience is subject to bias.
Outdated Knowledge: What was taught as students is often outdated.
Conservatism in Health Professions: Relying on older colleagues risks outdated, biased, and incorrect information.
Importance of Clinical Experience: Clinical experience is still a key feature in the definition of evidence-based practice (Chapter 15).
Clinical Reasoning: Clinical reasoning processes help make sense of information from research, clinical settings, patients, and clinical experience.
Clarifying Misconceptions
Not Just Randomized Controlled Trials: Randomized controlled trials are one study design (Chapter 4).
Effectiveness of Interventions: They are the cornerstone of research investigating whether interventions (treatments) work.
Questions Beyond Intervention Effectiveness: Health professionals need information about:
Aetiology (causes of disease)
Frequency (how common it is)
Diagnosis (how to know if a patient has the disease)
Prognosis (what happens over time)
Patients’ experiences and concerns
Focus of the Book: The book focuses on answering questions about interventions, diagnosis, prognosis, and patients’ experiences.
Variety of Research Designs: Each question type requires a different research design.
Examples of other research designs:
Case-control studies
Cross-sectional studies
Cohort studies
Qualitative research designs
Not Just Following Guidelines: Clinical guidelines are one route to evidence-based practice (Chapters 12 & 13).
Limitations of Guidelines: Some guidelines are not evidence-based and may be derived from expert opinion.
Not Practice-Based Evidence: ‘Practice-based evidence’ involves systematically collecting data about local clinical practices.
Complementing Evidence-Based Practice: Such data can complement evidence-based practice.
Accessibility of Evidence-Based Practice
Competency: With training, practice, and experience, anyone can learn evidence-based practice.
Resources: Access to the internet and databases (PubMed, Cochrane Library) is important.
Collaboration: Trustworthy colleagues can help check findings.
Core Competencies: Core competencies in evidence-based practice have been developed.
Skill Development: Some competencies require practice (critical appraisal, shared decision-making).
Time Constraints and Integration
Barriers and Enablers: Address barriers to evidence-based practice.
Responsibility: Evidence-based practice is a standard expectation for health professionals.
Integration: Integrate evidence-based decision-making into everyday practice.
Learning Activities: Choose continuing professional development activities carefully.
Traditional Learning Methods: Traditional methods (reading journals, attending conferences) may not be as helpful.
Journal clubs can be part of evidence-based practice(Chapter 17)
Importance of Evidence-Based Practice
Goal: Helps health professionals and patients make evidence-informed decisions.
Improved Outcomes: Achieves optimal patient outcomes and care.
Patient Information: Assesses the accuracy of patient-provided information and suitability of intervention.
Promotes Inquiry: Encourages questions about current practices.
Professional Accountability: Reinforces professional responsibility to provide care informed by the best available evidence.
Wise Use of Resources: Ensures health resources are used wisely.
Funding Decisions: Relevant evidence is considered when funding health services.
Harmful Interventions: Prevents wasting resources on harmful or ineffective interventions.
Absence vs. Ineffectiveness: Absence of evidence differs from evidence of ineffectiveness or harm.
Impact of COVID-19 Pandemic
Importance highlighted: The importance of rapidly generating, appraising, and disseminating quality evidence for decision-making became evident during the COVID-19 pandemic.
Consequences of not using evidence: policies and clinical decisions not based on evidence led to the use of ineffective or harmful treatments.
Power of coordinated trials: Coordinated international randomized trials provided convincing evidence about the effectiveness of various treatments.
Challenges of keeping up with research: Researchers and clinicians faced challenges in keeping up with and synthesizing the extensive COVID-19 research.
Scope of Evidence-Based Health Care
Expansion Beyond Medicine: Concepts now permeate all of health care and beyond.
Evidence-Based Purchasing: Purchasers use research to make informed decisions about health- and social-care services and resources.
Evidence-Based Policy: Policy makers integrate research evidence into policy formation.
Evidence-Based Management: Managers integrate research findings into management tasks.
Significant Impact: Evidence-based practice has influenced major health systems and government policies worldwide.
Broader Applications: Principles are applied in social care, criminology, education, conservation, engineering, and sport.
Common Criticisms of Evidence-Based Practice (Table 1.2)
Relies too heavily on quantitative research.
Qualitative research is very important in helping us to understand moreabout how individuals and communities perceive and manage theirhealth and make decisions related to health service usage. Appreciation of the value of qualitative research to evidence-based practice isgrowing. This is partially reflected in the growth of mixed-methodsresearch papers (that use a combination of qualitative and quantitativeapproaches) in both primary studies and systematic reviews.
Limitations of relying on research to provide the evidence upon which to base practice, particularly in areas where there is limited research available.
While we acknowledge that there is little research and/or inconsistencies in evidence for some clinical questions, evidence-based practice emphasizes using the best research evidence available. The othercomponents of evidence-based practice (clinical experience andreasoning, patient preferences) must be relied on even more where there is a lack of evidence or uncertainty between the various options.
The amount of evidence available is overwhelming.
This is more of a problem for some disciplines and topics than others. There certainly are areas where there is much research, overlap and a huge amount of synthesised evidence (such as systematic reviews andguidelines, which sometimes are conflicting). For areas such as this, being an efficient searcher of evidence, being guided by the pyramid ofevidence-based information (see Chapter 3) and having critical appraisal skills (even for synthesised evidence) are very important
Contemporary large, randomised trials over-focus on achieving small gains in health.
Proper practice of evidence-based practice should include careful consideration of the size of the effect (both benefits and harms). Hence, clinical significance from the patient’s perspective, not juststatistical significance (see Chapters 2 and 4), should be considered, as well as that the trials measured outcomes that matter to the patient.
Clinicians (particularly inexperienced ones) may slavishly follow ‘the evidence’ (and associated rules and algorithms) without considering patient factors (including preferences and multimorbidity).
Proper practice of evidence-based practice is not about following rules. Clinical judgment and reasoning are crucial to it and should includecareful consideration of the patient’s ‘whole-person’ best interestsand their preferences. This is sometimes called ‘individualizingevidence decisions’ . In Chapter 14, you will learn about how shareddesicion making is a crucial component of evidence-based practice.
The process of evidence-based practice
Convert your information needs into an answerable clinical question.
Find the best evidence to answer your clinical question.
Critically appraise the evidence for its validity (risk of bias), impact and applicability.
Integrate the evidence with clinical expertise; the patient’s values, preferences and circumstances; and information from the practice context.
Evaluate the effectiveness and efficiency with which steps 1–4 were carried out, and think about ways to improve your performance of them next time.
Some people may prefer to remember these steps as thefive As:
Ask a question.
Access the information.
Appraise the articles found.
Apply the information.
Audit.
It has been wisely suggested that even prior to beginning the first step of asking a question, health professionals should undertake Step 0, which is recognising our uncertainties.22 This can include acknowledging that we often have basic uncertainties about common tests and treatments. Uncertainty is an inherent part of health care. And it often makes health professionals uncomfortable. Acknowledging the uncertainties is important. It is also important to recognise the uncertainties in evidence for aclinical question and to incorporate this into your discussions with patients. This issue is covered in other chapters of this book.
Step 1: Convert your information needs into an answerable clinical question
The process of evidence-based practice begins with the recognition that you, as a health professional, have a clinical information need. Some types of clinical information needs can be answered with the assistance of research evidence. Chapter 2 describes the different types of clinical information needs and which of these research evidence can help to answer. An important step in the evidence-based practice process is turning this informa tion need into an answerable clinical question. There are some easy ways to do this, which are demonstrated in Chapter 2. You may have a question about the following:
Intervention (that is, treatment)—for example, in adults with rheumatoid arthritis, is education about joint protection techniques effective in reducing hand pain and improving function?
Diagnosis—for example, in adults admitted to a chestpain unit, which elements of serial diagnostic testingare the most sensitive and specific predictors of cardiacinvolvement?
Prognosis—for example, in people undergoing total knee replacement for osteoarthritis, what improvementin walking ability is expected after six weeks?
Patients’ experiences and concerns—for example, what does the lived experience of older adults transitioning to residential aged care facilities mean for theirability to integrate and find a sense of identity?
The type of question will determine the type of researchthat you need to look for to answer your question. Thisprocess is explained further in Chapter 2.
Step 2: Find the best evidence to answer your clinical question
Once you have structured your clinical question appropriately and know what type of question you are asking and,therefore, what sort of research you need to look for, thenext step is to find the research evidence to answer yourquestion. It is important that you are aware of the manyonline evidence-based resources and which of these will bemost appropriate for you to use to search for the evidenceto answer your question. Being able to efficiently searchonline evidence-based resources is a crucial skill for anyoneengaged in evidence-based practice. Chapter 3 containsinformation about the key online evidence-based resourcesand how to efficiently search for evidence.
Step 3: Critically appraise the evidence for its validity (risk of bias), impact and applicability
Upon finding the evidence, you will need to criticallyappraise it. That is, you need to examine the evidenceclosely to determine whether it is worthy of being used toinform your clinical practice.
Why do I need to critically appraise the evidence?Surely all published research is good quality?
Unfortunately, it is not. A number of studies suggest thatmuch published research is of poor quality, poorly reported orwrong.23–29 Sadly, much clinical research is not useful, as it isoften not sufficiently pragmatic, or it is not built upon infor-mation gained from systematic reviews of existing research, oris not patient-centred (that is, it does not reflect patients’ toppriorities or use outcomes that are meaningful to them), or isnot sufficiently transparent or feasible.24 These deficiencieslead to waste in research.25–28 How is it that poor-qualityresearch can pass through peer review? Unfortunately, peerreview is a flawed process, with peer reviewers sometimes nomore informed about appropriate study design, analysis andreporting than the researchers who conducted the studies; asa result, flawed studies are published.30–33
There is now a growing awareness, by researchers, peerreviewers and journal editors, of the importance of strongstudy design (thanks, in part, to the proliferation of evidence-based practice). As you will see in various chapters throughoutthe book, guides have been developed for how certain types ofstudies should be reported. (For example, in Chapter 4, you willlearn about the CONSORT statement for randomised con-trolled trials.) A list of the reporting guidelines for various studytypes is available at the website of the EQUATOR Network(www.equator-network.org). A growing number of journalsnow require authors of studies to follow these guides closely ifthey wish their article to be considered for publication. All ofthis is good news for us (as health professionals using evidenceto inform our clinical decisions), as it has the potential to makeit easier to appraise and interpret research reports.Because of this, before you can use the results of a researchstudy to assist you in making a clinical decision, you need todetermine whether the study methods are sound enough toprovide you with potentially useful information or, alterna-tively, whether the methods are so flawed that they mightpotentially provide misleading results. Studies that are poorlydesigned may produce results that are distorted by bias (andoften more than one type of bias). Some of the commontypes of bias are introduced in Chapter 2. The main types ofbias that are relevant to each of the question types areexplained in detail in the corresponding chapter that dis-cusses how to appraise the evidence for each question type.
What is involved in critically appraising evidence?
There are three main aspects of the evidence (that is, eachstudy) that you need to appraise (in the following order):
Internal validity (or risk of bias).
This refers to whether the evidence is trustworthy. That is, can you believe the results of the study? You evaluate the validity of the study by determining whether the study wascarried out in a way that was methodologically sound.In this step, we are concerned with the study’s internalvalidity—this is explained more fully in Chapter 2.This term can be interchanged with ‘risk of bias’, andour focus is on appraising the extent to which thedesign and conduct of a study are likely to have mini-mised its bias. In qualitative research, the concept ofinternal validity is not used; as Chapter 10 explains, the concepts of trustworthiness and credibility of astudy are used instead.
Impact.
If you decide that the validity of the study issufficient that you can believe the results, you thenneed to look closely at those results. The main thingyou need to determine is the impact (that is, the clinicalimportance) of the evidence. For example, in astudy that compared the effectiveness of a new inter-vention with an existing intervention, did the newintervention have a large enough effect on the clinicaloutcome(s) of interest that you would consider alteringyour practice and using the new intervention with yourpatient?
Applicability.
If you have decided that the validity of the study is adequate and that the results are clinically important, the final step in critical appraisal is toevaluate whether you can apply the results of the studyto your patient. Essentially, you need to assess whetheryour patient is so different from the participants in thestudy that you cannot apply the results of the study tothat individual. This step is concerned with assessingthe external validity (or the ‘generalisability’ or ‘appli-cability’) of the study, as explained more fully inChapter 2. In qualitative research, the concept of trans-ferability may be used, rather than generalisability, andthis is discussed in Chapter 10.
Many of the chapters of this book (Chapters 4–12) aredevoted to helping you learn how to critically appraisevarious types of evidence. There are plenty of appraisalchecklists that you can use to help you to criticallyappraise the evidence. Many of the checklists are freelyavailable on the internet. Most of them contain more-or-less the same key items. The checklists that we haveused in this book as a general guide for the appraisal ofquantitative research are mostly based on those that weredeveloped by the UK National Health Service PublicHealth Resource Unit as part of the Critical AppraisalSkills Programme (CASP). In turn, these checklists werelargely derived from the well-known Journal of the Amer-ican Medical Association (JAMA) Users’ Guides.34 TheCASP checklists are freely available at www.casp-uk.net.For the appraisal of qualitative research, we have used
the Qualitative Assessment and Review Instrument(QARI), which was developed by the Joanna Briggs Insti-tute and can be accessed through https://jbi.global. TheCASP checklist for appraising qualitative studies has alsobeen described, and the two approaches are compared inChapter 10.
Each of the CASP checklists begins by asking a screen-ing question about whether the study addressed a clearlyfocused question (such as in terms of the population,intervention and outcomes studied). This question is tohelp you not waste your time proceeding to appraise thevalidity, impact and applicability of a study that is goingto be of too poor quality for you to use in clinical decision making. In the worked examples in Chapters 5, 7, 9 and11, you will notice that this screening question is not included in the examples. This is because, prior toappraising their chosen article, the authors of each of theworked examples had already conducted a screening pro-cess to decide which article was the best available evidenceto use to answer their clinical question; as part of this, theyalso checked that it addressed a clearly focused question.When you are critically appraising research articles, keepin mind that no research is perfect and that it is importantnot to be overly critical of research articles. An article justneeds to be good enough to assist you to make a clinicaldecision.
Ideally, the evidence for all clinical questions wouldalready be pre-appraised and synthesised in a resourcesuch as a guideline. Unfortunately, this is not yet the situa-tion for many, many clinical questions and far less so forhealth professions other than medicine. The reality is thatthere will be times when you will need to use primary stud-ies as the best available evidence to answer your clinicalquestion. And you will need the skills to critically appraisethese studies. Skills in critical appraisal need to go beyondjust knowing how to assess risk of bias. Knowing how tointerpret other aspects such as the quality and certainty ofa body of evidence, magnitude of an effect and the appli-cability of evidence are also important. We follow thisbroader approach to critical appraisal skills throughoutthis book.
Step 4: Integrate the evidence with clinical expertise; the patient’s values, preferencesand circumstances; and information from the practice context
The fourth step in the evidence-based practice processinvolves integrating the findings from the criticalappraisal step with your clinical expertise; your patient’svalues, preferences and circumstances; and the practice(clinical) context. As discussed earlier in this chapter andillustrated in Figure 1.1, these four elements form thedefinition of evidence-based practice. ‘Clinical expertise’refers to a health professional’s accumulated experience,education and disciplinary and clinical skills.Asevidence-based practice is a problem-solving approachthat initially stems from a patient’s needs, any clinicaldecision that is made in relation to that individualshould involve consideration of the unique needs, values,preferences, concerns and experiences that each patientbrings to the situation. Evidence alone is never sufficientto guide clinical decisions. Many decisions are preferencesensitive and what is the ‘best choice’ for one person willnot be the best choice for another, even though the clinicalquestion may be the same. Many of the chapters of thisbook discuss the need for and process of integratingresearch evidence with clinical expertise and the patient’spreferences, with appropriate consideration also given tothe practice context. When thinking about the practicecontext, it is not only the local context that should beconsidered (such as the nature of the setting, resourcesavailable, roles of various disciplines, local servicedelivery priorities and policies) but sometimes also theimpact of the broader context in which the care is beingdelivered (such as relevant state or federal policies,funding mechanisms and socio-cultural and geographical factors).
Step 5: Evaluate the effectivenessand efficiency with which steps 1–4 werecarried out, and think about ways to improveyour performance of them next time
As evidence-based practice is a process intended for healthprofessionals to incorporate into their routine clinicalpractice, it is important that you learn to do it as efficientlyas possible so that it does not become a time-consumingor onerous task. Asking yourself self-reflection questionsafter you have completed the previous four steps of theevidence-based practice process can be a useful way toidentify which steps you are doing well and areas whereyou could improve. Box 1.1 contains some examples ofself-reflection questions that you could ask when evaluat-ing how well you performed steps 1–4 of the evidence-based practice process.
How this book is structured
The process of evidence-based practice that was justdescribed is used as the main structure for this book. Inaddition to the key steps in the process, there are othertopics that health professionals who wish to do evidence-based practice should know about. Hence, these topics(such as sharing decisions with patients and how to im-plement evidence into practice) also have their own chap-ters in the book.
Chapter 1: Introduction to evidence-based practice
Addresses some of the background information about evi-dence-based practice, such as what it is, why it was developed,why it is important, and the five key steps that underlie theprocess of evidence-based practice.
Chapter 2: Information needs, asking questions,and some basics of research studies
Provides details about clinical information needs, how toconvert them into an answerable question, and how thetype of research that you look for differs according to thetype of question that you are asking.
Contains some of the background statistical informa-tion that you need to understand before being able tocritically appraise research evidence.
Chapter 3: Finding the evidence
Contains information about how to undertake the secondstep of the evidence-based practice process: searching forevidence to answer your clinical question.
Chapter 4: Evidence about effects of interventions
Explains what to do when you have a clinical question aboutthe effects of an intervention, with a focus on how to performthe third and fourth steps of the evidence-based practiceprocess. Provides details about how to assess the risk of bias ofthe evidence, understand the results and use the evidenceto inform practice.
Chapter 5: Questions about the effects
of interventions: examples of appraisalsfrom different health professions
As the steps of evidence-based practice become easier withpractice, this chapter provides you with multiple workedexamples of questions about interventions so that you cansee, step-by-step, for various clinical scenarios how ques-tions are formulated and evidence is found, appraised andapplied. In keeping with the multidisciplinary nature ofthis book, examples from a range of health professions areprovided.
Chapter 6: Evidence about diagnosis
Uses the same structure as Chapter 4, but the content isfocused on how to appraise the evidence when your clini-cal question is about diagnosis (or assessment).
Chapter 7: Questions about diagnosis: examplesof appraisals from different health professions
Contains multiple worked examples of questions aboutdiagnosis from a range of health professions that com-monly have diagnostic or assessment informational needs.
Chapter 8: Evidence about prognosis
Follows the same structure as Chapters 4 and 6, but thecontent is focused on how to appraise evidence when yourclinical question is about prognosis.
Chapter 9: Questions about prognosis: examplesof appraisals from different health professions
Contains multiple worked examples of questions aboutprognosis from a range of health professions that com-monly consider prognostic issues.
Box 1.1 Examples of self-reflection questions when evaluating your performance of steps 1–4 of the evidence-based practice process
Am I asking well-formulated clinical questions? (SeeChapter 2.)
Am I aware of the best sources of evidence for the dif-ferent types of clinical questions? (See Chapter 3.)
Am I searching the databases efficiently? (See Chapter 3.)
Am I using the hierarchy of evidence for each type of clinical question as my guide for the type of evidencethat I should be searching for? (See Chapter 2.)
Where possible, am I searching for and using informa-tion that is higher up in the pyramid of levels of organ-isation of evidence (e.g. synthesised summaries,systematically derived recommendations, systematicreviews)? (See Chapter 3.)
Am I integrating the ‘findings’ from critically appraising relevant studies into my clinical practice? (SeeChapters 4–12.)