Use the 6A’s to Remember the Evidence-Based Practice Process

In recent weeks, I presented an overview of what the three components of evidence-based practice (best evidence, clinical expertise, and patient preferences) really mean to the evidence-based practitioner.  In this post, I’m going to present an overview of the evidence-based practice process, also known as the “A’s” – this post will outline the 6A’s of the EBP process.

In case you haven’t downloaded my freebie on What is Evidence-Based Practice? – do it now and follow along!

picture of 6A's of evidence-based practice process

The 6A’s of the Evidence-Based Practice Process

The 6A’s of the EBP process provide the clinician with a structured approach to being an evidence-based practitioner.  You’ll see that the 6A’s are easily remembered and are similar to the nursing process. 

Mnemonics are memory aids to prompt recall of a series of related concepts, such as remembering signs and symptoms of a specific disease process (e.g., MUDPILES for high-anion gap metabolic acidosis) or steps of an improvement process (e.g., DMAIC for Six Sigma projects).  The use of all “A” words does the same for the EBP process – they outline the sequence of events needed to implement EBP (coupled with your knowledge and skills, of course).

There are a variety of evidence-based practice process steps in the literature; some reflect the authors’ specific theory (e.g., Kitson., Harvey, & McCormack, 1998; Rosswurm & Larrabee, 1999).  Some authors note only 5A’s, combining Assessment and Ask into one step by assuming that assessment has been done as preparation for the Ask step (Straus et al., 2005).  I have called out the Assess step to bring awareness of that important first step in every problem-solving situation.

The 6A’s of the EBP process denote the 6 steps: Assess, Ask, Acquire, Appraise, Apply, and Audit. 



The first step for the EBP practitioner is to do an assessment of the patient or of the problem situation. The assessment step is all about collecting data — information about a patient for clinical decision-making or about the issue of interest for organizational decision-making, for example (e.g., staffing models). 

When making decisions with individual patients, the clinical questions that are of interest to nurses and other healthcare providers come up during the normal assessment and care of the patient, every day.  Straus et al. (2005) noted that inpatient encounters usually triggered at least 5 questions, for which the provider may not have answers.  Questions may have come directly from the patient or be related to the patient’s disease process or clinical condition, diagnosis, prognosis, treatment plans, etc. The point is that healthcare providers need “valid information” every day to provide quality care for patients. 

Included in the assessment process is reflecting upon or analyzing the data you’ve collected to then determine the clinical problem(s) to be addressed.  Many times I’ve had a tendency to want to solve a problem before really understanding the root cause of the problem – maybe you can relate?  For example, deciding that more patient education is needed for a particular patient when in fact the patient just needed his glasses to be able to read the patient education material!  

So one of my nursing colleagues taught me to ask, “What is the real problem?” before I got ahead of myself coming up with solutions.  Assessing the patient or the situation helps you answer that question and saves you from coming up with solutions for a problem that may not really exist!

The first steps in the nursing process are Assessment and Diagnosis – you are gathering physical, psychological, sociocultural, and spiritual data in order to identify actual and potential problems.

The purpose of the Assess step of EBP is to gather data to identify and clarify the problem for which you need additional evidence, so you can formulate a clear and specific question to narrow your subsequent literature search. 


Now that you have an idea about the problem, you need more information and evidence. 

The purpose of the Ask step is to formulate a focused clinical question that will help you efficiently and effectively search the research literature. Some authors talk about formulating an “answerable” question.  Melnyk and Fineout-Overholt (2015) refer to this step as “Ask the burning clinical question” (p. 10). 

Questions may be patient-centered (i.e., the patient’s needs) or learner-centered (i..e, your learning needs). Clinical questions may focus on causal factors of disease, treatment, prevention, diagnosis/differential diagnosis, prognosis/clinical predictions, patient experience and meaning of illness, or economic factors.  

EBP practitioners differentiate between questions that provide general information about a topic (AKA Background questions) and questions that are specific to the issue at hand (AKA Foreground questions). Straus et al. (2005) outlined the characteristics of Background and Foreground questions. 

Background and Foreground Questions

Background questions are primarily inquiry types of questions.  Background questions usually center around understanding the basis of the problem of interest — for example, What is normal physiology and the pathophysiology of the patient’s problem; How does a particular drug or a diagnostic test work?, What type of treatments are used for a certain disease process? Novices tend to ask a lot of background-type questions, as do experienced practitioners when they encounter a condition for which they have little or no experience.  

Background questions consist of a stem and a verb.  Stems include who, what, where, when, how, and why.  The second part of the question is related to a disease process, diagnostic test, treatment, or for example, Who is at risk for heart failure? What causes Ebola? Which diagnostic test is best for diagnosing strep? How does deep vein thrombosis cause a pulmonary embolism? What are the signs and symptoms of a myocardial infarction? 

Where do you find the answers to Background Questions?  Current textbooks or the Internet are good informational sources (be sure to verify the site first!) to answer background questions. 

Foreground questions, in contrast, are formulated to find out specific information needed to make clinical decisions.  Experienced EBP practitioners use foreground questions to search the literature more efficiently for those specific answers that will answer their clinical questions about individual patients. 

Foreground questions are more efficient because they include targeted components that are more likely to find research findings relevant to their patient’s problem. EBP is geared toward answering foreground questions (Agoritsas et al., 2015). Foreground questions are not haphazard, but well thought-out and contain the essential elements needed to mount a successful search. Posing the question in a structured format will assist you in finding the answers you need to manage the patient safely and according to the best evidence. 

The components included in a foreground question are captured in the mnemonic PICO(TS):

  • Patient population of interest or Problem of interest
  • Intervention (i.e., a test, drug, treatment or exposure) or issue of interest 
  • Comparison of interest (i.e., counter-intervention, placebo, standard care)
  • Outcome of interest
  • Time frame (usually linked to the outcome; not always appropriate for every type of question)
  • Search strategy (i.e., the type of search strategy that would limit your results to a specific study design in which you are likely to find the answers to your PICO question; not always used, but would be very helpful to limit search results)

You would enter the main concepts of the components in your database search box and/or use these components as search limiters.  

Where do you find the answers to Foreground Questions? Research and literature databases are the best sources for answers to foreground questions. 

For example, let’s say you have an adult patient with type 2 diabetes and high blood pressure.  

Background questions: What is the relationship between type 2 diabetes and high blood pressure?  How does type 2 diabetes cause high blood pressure? What are the benefits of tight blood pressure control in patients with type 2 diabetes? Which medications are recommended to lower blood pressure in type 2 diabetics?

Foreground question: In patients with type 2 diabetes, does tight blood pressure control compared to standard care decrease the risk of coronary heart disease and stroke?:

  • P: adult patients with type 2 diabetes
  • I: tight blood pressure control
  • C: standard of care (SOC)
  • O: prevention of coronary heart disease and stroke
  • S: Therapy (can use to limit the search to Therapy articles only)

It’s easier to start with the PICO components and then translate these into a coherent PICO question. You don’t always have to note a comparison in the full question if it is the standard of care – because the SOC is then assumed: In patients with type 2 diabetes, does tight blood pressure control decrease the risk of coronary heart disease and stroke? 

Search Strategy suggestions: Type 2 Diabetes AND blood pressure control AND coronary heart disease OR stroke  Search limiters: Adults, Therapy-Best Balance, English  Note: adding search limiters will decrease the number of “hits” you get — and that’s the point of them, of course; but sometimes you might need less to get an idea of the scope of the literature you are dealing with.  I got 2 hits in CINAHL with this search string when using all three limiters; 24 hits (mostly relevant citations) when I took off the Therapy limiter. 

Can you see how the answers you’ll get from a background question will be more general than those from a targeted foreground question? Can you see how the foreground question will be more likely to give you an answer to make a decision about the treatment of this patient because it’ll find research concerning treatment using tight or intensive blood pressure control specific to type 2 diabetics?

Remember, the point of forming a PICO question is to make your search strategy as efficient as possible – that is, among the many databases and thousands of studies, you increase the likelihood of finding the evidence you need (if it’s out there) to answer your clinical question.


Once you’ve done the literature search, you’ll need to select the articles that are relevant to your PICO question.  Searching the literature using the PICO components does not always produce 100% relevant results! So you will have to identify a list of the research studies and literature that look like they will help you answer your question.  

Look for the highest level of evidence first! The top levels of the 6S hierarchy of evidence are preappraised sources — the appraisal work has been done already. Summaries, Synopses of Syntheses, Syntheses (i.e., systematic reviews), Synopses of Studies, and original Studies are the levels (DiCenso, Bayley, & Haynes, 2009). (Systems is the highest level actually, but this is a computerized decision support information system that is integrated with best evidence and the patient’s electronic medical record — so access is limited to those clinical institutions who have implemented this technology [Dicenso et al., 2009]). 

For convenience, as you determine which articles you’ll review, you can search for online formats.  You can read the studies online or download/print the pdfs. Regardless, print or copy your citation list for your reference. 

During this stage, you also want to search for other evidence that may be helpful to you, such as benchmarking data, national standards, or clinical guidelines. 


Once you have the literature collected, you’ll need to critically appraise the original studies (reports of single randomized controlled trials or observational studies for example) for reliability and validity.  Yes, this will take some time, but there are tools you can use to accomplish this task.  The point is simple, if the research methods of the studies are not strong, the results won’t be either. 

The best case scenario is that you find pre-appraised, credible sources that will have already done the hard work for you!  

Finding the highest level of evidence possible will make your job easier. Using the 6S hierarchy of evidence sources (DiCenso et al., 2009), the highest level of evidence for treatment studies would be regularly updated summaries of clinical practice guidelines or textbooks. Synopses of syntheses would be summaries of systematic reviews and are the next highest evidence source. We’ll talk about how to find pre-appraised sources in a future post. Hint: The Cochrane Collaboration is one credible source of systematic reviews (i.e., syntheses). 


Once you’ve determined that the results from the evidence are valid and meaningful, then you want to see if you can apply them to your patient.  At this point, you want to integrate the study results with your clinical expertise and knowledge of the patient’s clinical circumstances, with the patient’s values and preferences.  

You want to make sure that your patient is similar to the patients in the study if you want to predict that your patient will have similar outcomes as the study patients.  Look at the study sample’s demographics and description of the clinical characteristics or pathobiology of the study sample. Will your patient be exactly like the patients in the study? No, probably not. But you are looking for similarities — is your patient similar enough to the study patients for you to be reasonably sure that the intervention will work as indicated?

You will also need to assess whether the intervention is available in your setting and is feasible — what’s the cost? patient burden? etc. What are the potential benefits and harms? 

And, of course, what are your patient’s expectations, values, and preferences? 

There’s a lot to think about when making a recommendation for practice.  This step is analogous to the implementation stage of the nursing process. 


Finally, once a clinical decision has been made and implemented, you need to evaluate the outcomes of that decision (just like the evaluation phase of the nursing process). The outcomes for the patient should be evaluated so that revisions or changes in treatment, etc. can be accomplished. 

You should also evaluate how well the process worked for you! What did you learn? How can you do things better the next time? There are many questions that can be asked to improve your own process, and that of the team if applicable. 

Bottom Line

As evidence-based practitioners, we need to be constantly questioning our practice and our assumptions. Questions arise from uncertainties in our clinical practice and may be patient-related, clinician-related, managerial, or economic in nature. In practice, it is estimated that a clinician comes up with multiple questions per patient encounter depending on the practice specialty (Straus et al., 2005).

Understanding the 6A’s of the evidence-based practice process will help you be systematic in your search for answers.  And as an added benefit, it may help you graduate from graduate school.  🙂 When I teach EBP, I always tell my students to memorize the 6A’s because this mnemonic will come in handy for the comprehensive exams (AKA comps)!

I know the EBP process sounds complicated, but I think it’s important that you understand the process, so that when I teach you the process shortcuts – you’ll have an appreciation for the process as a whole.  Hang in there! We’ll get through it together!

Just another reminder, that you might find my freebie on What is Evidence-Based Practice? helpful in your practice. 

What kind of questions do you have about the 6A’s of the EBP process? Let me know in the comments!