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Evidence-Based Practice: N-CARE

Information and resources on EBP including PICO

What is N-CARE

The Nursing Career Advancement and Recognition of Excellence (N-CARE©) Program encompasses the mission and vision of the Department of Nursing at Memorial Sloan Kettering Cancer Center (MSKCC). Our four-tiered clinical career ladder (clinical nurse I-IV), based on Patricia Benner’s theory “From Novice to Expert”, successfully supports the professional development and retention of clinical nurses and advanced degree nurses. The N-CARE© Program ensures that MSKCC’s Department of Nursing recruits and retains top professional nursing talent.

Purpose​

The N-CARE© Program provides consistency and standardization for nursing professional development. Consistent with the tenets of our professional practice model, Relationship-Based Care (RBC), N-CARE© acknowledges the evolving role of the nurse and supports lifelong professional development. This program requires organizational citizenship, which empowers the professional nurse to reach beyond the individual unit and contribute to MSKCC’s greater organizational goals. It inspires staff to utilize evidence-based decision-making that impacts their nursing practice and improves patient care outcomes. Within this program, the N-CARE© Review Board utilizes peer review that ensures the application process is equitable for all.

 
Complete applications for promotion are due on June 30 and December 31 for CNIII and CNIV Applications
Promotional Process

Nurses should schedule the meeting at least three months before submission of application. ​​​​​​​This meeting will help establish a general timeline for your application requirements and facilitate discussion between the Nurse Leader/Immediate Supervisor and applicant. 

Components of the Promotional Process

  • Role of the Nurse Leader
  • Promotional Development Plan (PDP) Form
  • Application for Promotion Form
  • Organizational Citizenship
  • Exemplars
  • Letters of Recommendation
  • Certifications
  • Evidence-Based Presentation Requirements
  • Shadow Day (for CN IV Applicants - to be completed within the previous 18 months)
  • Interview (for CN IV Applicants) 
     
Evidence-Based Presentation Requirements

CNIII and CNIV applications are required to demonstrate the use of CTEP methodology through an evidence-based presentation. Presentations submitted for promotional consideration need to be original content created by the applicant(s) in response to a specific clinical need or practice concern that is relevant to the applicant’s unit/practice. Please refer to the  N-CARE© PROGRAM Description for complete details regarding EBP Presentation Requirements.

Annual Maintenance Requirements

At the time of their performance appraisal, the nurse will submit the Maintenance Criteria Form to their Nurse Leader for review. This is to ensure that the annual requirements to maintain their level within the N-CARE© Program have been met. A copy of this form will be submitted with the Annual Performance Appraisal to the Nursing Staffing Office. 

Evidence Based Presentations are no longer required for CNII and CNIV annual maintenance

 

N-CARE Resources

N-CARE: EBP Presentation

PICO(T) is a mnemonic that stands for:

P - Patient/Population/Problem
Who is your patient? (Disease or Health status, age, race, sex) / What is the problem?

I - Intervention
What do you plan to do for the patient? (Specific tests, therapies, medications)

C - Comparison
What is the alternative to your plan? (ie. No treatment, different type of treatment, etc.)

O - Outcome
What outcome do you seek? (Less symptoms, no symptoms, full health, etc.)

(T) - Time Frame (Optional)
What is the time frame? (This element is not always included)

PICO(T) Question Type Definitions
  • Intervention/Therapy: When you need to know what is the best approach to this situation?
  • Issue: When you need to know what is the best approach to a situation?
  • Meaning: When you need to know about the experience of this situation.
  • Prognosis/Prediction: Do you need to know what is the most likely progression for a patient? 
  • Diagnosis: When you need to know about tests related to a patient’s diagnosis.
  • Etiology: When you need to know about risk factors contributing to a patient’s diagnosis. 
A PICO(T) question must always…
  • Follow one of the designated templates
  • Be non-directional (i.e. unbiased)
  • Have a comparison
  • Guide your search
  • Have a P that matches the O
  • Only include Time when it is relevant
Identify all the possible synonyms for each aspect of the PICO(T) question

Example: In critically ill patients, how does a preventative dressing compared to repositioning affect pressure injury development?

Synonyms for each PICO(T) component:

P: critical care, ICU, immobile
I: preventative dressing, foam dressing, sacral dressing
C: repositioning, standard of care, skin bundle
O: pressure injury, pressure ulcers, skin injury, deep tissue injury
T: ---

Boolean Operators

Combine search terms effectively using Boolean operators and logic to create a search strategy.

“AND” logic -- Using AND narrows a search by combining terms

  • AND IS LESS - narrow search, less results
  • PICO(T) components are separated by AND

“OR” logic -- Using OR broadens a search to include results that contain either of the words

  • OR IS MORE - broadens search, more results
  • Synonyms are grouped together within a parenthesis ( )

 

(critical care OR ICU) AND (preventative dressing OR foam dressing) AND (pressure injury OR pressure ulcers)

Other Search Strategy Tips

Below are some additional searching tips that can help broaden or narrow the results retrieved. These are more advanced searching techniquies and should be used if your initial search strategies are not identifying what you want or need.

Phrase Searching - May be done with double quotes (“ “)

  • “critical care”
  • “pressure injury”

Truncation - Add an * to the end of a root word to look for variations of the word

  • nurs*  will search for:  nurse, nurses, nursing
  • child*  will search for:  child, children, childhood, childs, childrens
  • genetic*  will search for:  genetic, genetics, genetically

Subject Headings -  Controlled vocabulary can be used in certain databases

Complete Search Strategy

(“Critical Care” OR ICU OR Immobile OR “Critically ill”) AND (“foam dressing” OR “sacral dressing” OR “Wound care”) AND (reposition* OR “skin bundle”) AND (injury OR ulcer* OR “pressure ulcer”)

This search strategy can be copied and pasted directly into the databases you chose to search.

Select Appropriate Databases

Identify three (3) databases that are appropriate for searching on your topic/question. Below are many of the popular databases available through the MSK Library.

Focus & Scope

Know what the database is best for and chose those matched to the topic you are searching.

Database Primary Focus
PubMed Biomedical/nursing literature
CINAHL Nursing/allied health literature
Embase Biomedical literature; international; drug, disease, device focus
Joanna Briggs (JBI) Systematic Reviews and EB practice recommendations and summaries
Cochrane Library Systematic Reviews and clinical trials
Web of Science Multidisciplinary; good for searching for similar citations; identify references and cited bys of citations
HAPI Validated Health and Psychosocial Instruments/Tools/Surveys
PsycINFO Behavioral health/psych literature
ERIC Education literature
TRIP Clinical search tool designed to rapidly identify the highest quality clinical evidence
Popular EBP Databases

Below are some of the most popular MSK databases to use for N-CARE EBP presentations.

PubMed: PubMed comprises more than 29 million citations for biomedical literature from MEDLINE, life science journals, and online books. Links are available from PubMed to full text articles (Fulltext@MSK) provided by the MSK Library.

  • PubMed is the go-to database to start your search
  • Simply copy/paste your complete search strategy into the search bar on the main page
  • Use filters on the left to limit by publication date and language, as well as study type and publication type
  • PubMed also includes publication types such as letters, editorials, comments, etc that are not peer-reviewed journal articles

CINAHL (Cumulative Index for Nursing & Allied Health Literature): Covers nursing, biomedicine, alternative/complementary medicine, consumer health, and the allied health fields. It offers access to health care articles, books, nursing dissertations, selected conference proceedings, standards of practice, educational software, and audiovisual materials.

  • CINAHL is a nursing/allied health focused database
  • It is considerably smaller (fewer results) than PubMed, and has significant overlap with PubMed
  • Simply copy/paste your complete search strategy into the search bar
  • Be sure to limit to English language and select a publication date range under advanced search
  • CINAHL also includes non-peer reviewed material such as trade journals (magazines), dissertations, and conference abstracts -- use the Peer Reviewed box in advanced search to limit to only peer-reviewed journal articles

Embase: A comprehensive international bibliographic resource with millions of records from journals, conferences, and non-English publications in the biomedical and pharmaceutical fields.

  • Embase is a massive database that includes all of MEDLINE (PubMed) as well as unique content, including specialized content in pharmaceuticals and medical devices, international onferences, and non-English language
  • Use the Quick Search and simply copy/paste your complete search strategy into the bar
  • Use the special PICO search and simply plug your terms into each section and select a publication date range
  • Be sure to limit to English language and publication date range
  • Embase also includes conference abstracts, so be aware not everything has full-text -- you can limit publication types to Articles, in the filters on the left side of the results

Joanna Briggs Institute (JBI): JBI EBP Database allows you to simultaneously search a wide range of summarized and appraised health care evidence across seven publication types including Evidence Based Recommended Practices, Evidence Summaries, Best Practice Information Sheets, Systematic Reviews, Consumer Information Sheets, Systematic Review Protocols, and Technical Reports.

  • Use the Basic Search and simply copy/paste your complete search strategy into the bar
  • Be sure to limit to English language and select a publication date range
Assess if the search strategy is too narrow or too broad

Considerations:

  • Are there too many or too few PICOT elements included in the search strategy?
  • Are the keywords specific enough or too broad? Are too many or too few keywords used?
  • Are abbreviations used appropriately? Do they capture irrelevant material? Are the full terms also included not just the abbreviations?
Keep track of the search strategy

It should be able to be replicated by someone else.

  • What databases were searched?
  • How many results (references) were initially found?
  • How many references were kept after screening the titles/abstracts?
  • How many papers were kept after reading the full text articles?
Keeper Articles

Requirements for keeper articles:

  • A minimum of three (3) databases must be searched
  • You must have a minimum of five (5) keeper articles in your presentation
  • Articles should be within the last 5 years
    • If article is older than that, please specify reason in Current Evidence slide(s)
EBP Presentation

In your presentation you must summarize each keeper article by including the following:

  •  Purpose of the study
  •  Method use
  •  Results
  •  Conclusion/Recommendation
  •  If article is older than 5 years, please specify reason for keeping article
  • Use 1-2 slides for each keeper article summary
  • Use APA citation format for your references
Nurse Mentor

When to seek assistance from your nurse mentor/educator:

  • Identifying a clinical question
  • Phrasing your question in PICO(T) format
  • Broadening your PICO(T) question if you are retrieving too few results
  • Narrowing your PICO(T) question if you are retrieving too many results
MSK Library

When to see assistance from the library/librarian:

  • Not sure what database to use for your topic
  • Identifying additional databases to search
  • Troubleshooting database searching (e.g. getting error messages, no results, full-text, etc.)
  • Identifying synonyms for your terms (may need to use controlled vocabulary/subject headers)
  • Combining terms with Boolean operators/logic (AND, OR, NOT)
  • Search is still retrieving too few results, even after modification with your mentor
  • Search is still retrieving too many results, even after modification with your mentor
  • Your mentor has approved escalating to a librarian for assistance