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The Canadian Nurses Association believes: "Evidence-informed  decision-making  is a continuous  interactive process involving the explicit, conscientious and judicious consideration of the best available evidence to provide care."  However, the Association concludes: "It is imperative  to acknowledge that no level of evidence eliminates the need for professional clinical judgment or for the consideration of client preferences.


According to the Canadian Nurses Associaiton, Patients depend on nurses to do the best on their behalf. As part of their professional accountability, nurses must continually examine the best way to deliver care...When delivered in a context of caring and an organizational culture that promotes best practices, EBP is associated with higher quality care and better patient outcomes than care that is steeped in tradition."   Further "EBP also reduces practice variations, promoting greater consistency of care and contributing greatly to quality and patient safety agendas... EBP leads to improved health care provider satisfaction... including increased nurse autonomy...Work stress is reduced for nurses when evidence-based guidelines are enacted.... At a system level, “nursing and health-care services based on the best currently available evidence have been shown to decrease costs” and improve cost-effectiveness."

Types of Evidence

Canadian Nurses Association believes that a variety of sources are being used by nurses to facilitate their use of evidence. These sources include systematic reviews, research studies and abstraction journals that summarize valid, clinically useful published studies, and clinical practice guidelines. Guidelines are based on the most rigorous research available, and when research is not available, they are grounded in expert opinion and consensus." 

The 6S Pyramid: Resources for Evidence-Based Practice

The 6S pyramid is arranged in a hierarchy, with the different levels outlined and colour-coded to the right of this page

To begin your search for relevant evidence, use the concepts identified in your focussed question , remembering:

  • A piece of evidence's ability to guide clinical action increases as you move up the pyramid.

  • The breadth of knowledge is largest at the base of the triangle.

N.B.  This and the following panel of this Guide has been adapted from one developed at McMaster University.  It has been modified for local use.

Three Key References

Here are three articles, the first which will puts the 6S system in context and the second two which explain how it can be searched:

DiCenso, A., Bayley, L., & Haynes, R. B. (2009). Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evidence based nursing, 12(4), 99-101.

Robeson, P., Dobbins, M., DeCorby, K., & Tirilis, D. (2010). Facilitating access to pre-processed research evidence in public health. BMC public health, 10(1), 95.

Windish, D. (2013). Searching for the right evidence: how to answer your clinical questions using the 6S hierarchy. Evidence Based Medicine, 18(3), 93-97.


The 6S Pyramid in Action


Integrating information from the lower levels of the hierarchy with individual patient records, systems represent the ideal source of evidence for clinical decision-making. 



Summaries are regularly updated clinical guidelines or textbooks that integrate evidence-based information about specific clinical problems.

Clinical Practice Guidelines


Evidence-Based Texts


Synopses of syntheses, summarize the information found in systematic reviews.  By drawing conclusions from evidence at lower levels of the pyramid, these synopses often provide sufficient information to support clinical action.


Commonly referred to as a systematic review, a synthesis is a comprehensive summary of all the evidence surrounding a specific research question.    


Synopses of single studies summarize evidence from high-quality studies.   The following evidence-based abstract journals are the best place to find this type of information:


Studies represent unique research conducted to answer specific clincial questions.

Article Databases

The CINAHL, OVID (Medline, PsycINFO), and Pubmed databases can be searched using the Clinical Queries filter, limiting your results to specific clinical research areas: Therapy, Prognosis, Review, Qualitative, and Causation (Etiology)

For further information and tips on using the Clinical Queries filter, please visit the following links:


Meta-Searches search for evidence across multiple resources.  These tools return information from all levels of the pyramid: