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Nursing and Health Research

What Is It & Purpose

"The integration of the best research evidence with our clinical expertise and our patient's unique values and circumstances" (Albarqouni et al, 2018). 

The 5 A's of Evidence based practice

 

See definition of the five steps of evidence based practice in the text below this image

Image source: https://www.library.ucdavis.edu/guide/ebp-resources/

ASK: 

  1. Identify knowledge gaps
  2. Differentiate between background & foreground questions (General vs. clinically specific)
  3. Develop an answerable & searchable question structured with the PICO format
  4. Determine PICO question domain (therapy/treatment, prevention, diagnosis, prognosis, etiology, meaning)

ACQUIRE:

  1. Understand the levels of evidence provided from various types of research.
  2. Differentiate between the sources of information (primary research/unfiltered vs. pre-appraised/filtered).
  3. Understand the difference between databases and how to navigate databases in the search for evidence. 
  4. Develop search strategies utilizing search terms/key words/controlled vocabularies, Boolean operators and search limiters. 

APPRAISE: 

  1. Understand the anatomy of a scientific paper and identify the key components
  2. Critically appraise the validity, reliability & value of the evidence in relation to the clinical question (CASP)

APPLY: 

  1. Synthesize the best available evidence with your clinical expertise and the patient's values

ASSESS: 

  1. Self-evaluation of the EBP process

Source: A.T. Still University. (n.d.). Evidence-Based Practice: Home. A.T. Still University Library. https://guides.atsu.edu/Evidencebasedpractice/home

ASK

Background vs. Foreground Questions

Background questions: 

Are there elements of the question which require basic (background) research? Is there a gap in the clinician's/researcher's knowledge about specific elements of the question? 

  • What additional information does the clinician/researcher require to better understand the patient/population or problem? 
  • What additional information does the clinician/researcher require to better understand the intervention proposed? 
  • What additional information does the clinician/researcher require to better understand the control variable proposed? 
  • What additional information does the clinician/researcher require to better understand the desired outcome? 

Background questions are typically answered with textbooks, reference texts, summary/review articles, and point-of-care tools.

Background question example: 

Asian-American adult female with type 2 diabetes mellitus requests alternatives to insulin treatment. 

  • What is type 2 diabetes mellitus?
  • Is type 2 diabetes mellitus prevalent in the Asian-American community? 
  • What is the standard of treatment for adult women with type 2 diabetes?
  • What should be known about insulin treatments? 
  • What are the effects of untreated type 2 diabetes mellitus?

Foreground question: 

Foreground questions combine predetermined elements of the clinical problem to acquire specific knowledge. They are more complex and specific than background questions. 

Foreground questions combine the Patient/Population/Problem and the Intervention and the Control treatment and the desired Outcome into a PICO format. 

PICO format

PICO Elements Considerations
P Patient/Population/Problem Demographics, Problem type, Diagnosis
I Intervention/Exposure Therapeutic, preventative, diagnostic, time, exposure
C  Control/Comparison Placebo, Standard of care, Preventative measure, Not applicable
O  Outcome Measure Mortality rate, Measure of test, Rate of disease progression, Resolution

 

When forming your questions using PICO, consider: 

  • Demographic variables can include: age, gender, ethnicity, socioeconomic status in addition to health issue.
  • Comparison is not required
  • Outcomes measure a positive impact on the patient/population's wellbeing and should be measurable. Use validated instruments and assessments when possible.
  • Using the PICO format to develop a searchable & answerable question will provide the elements needed to obtain the best evidence from rigorous studies with statistically relevant findings. 

PICO Format Worksheet

Source: A.T. Still University. (n.d.). Asking the Clinical Question. A.T. Still University Library. https://guides.atsu.edu/Evidencebasedpractice/ask

Acquire

Question Domain/Type of Evidence

Question Domain

Patient/Population/

Problem

 Intervention Control Outcome Measure Level of Evidence

Therapeutic/

Treatment

 Disease or condition Therapeutic measures: Exercise, medication, surgical, life style change Standard of care, additional intervention, placebo, no control Measurable improvement in impairment/disease factors Randomized Control Trial (RCT)
Prevention Risk factors, Medical history Preventative measures Alternative preventative measures or no control Measurable improvement in impairment/disease factors RCT or Prospective study
Diagnosis Specific disease or condition Diagnostic test or procedure Standard of care  Measurable results of test/procedure utility/sensitivity/odds ratio RCT or Cohort Study
Prognosis Duration & sensitivity of main prognostic factor or clinical problem Typically time related Typically not applicable Mortality rates or rates of disease progression Cohort Study and/or Case-Control Series
Etiology Risk factors, health disorders, medical history Strength/dose/duration of intervention or exposure (risk factor) of interest Typically not applicable Mortality rates or rates of disease progression Cohort Study

Source: https://canberra.libguides.com/c.php?g=599346&p=4149722

the structure of the evidence based pyramid is described in the text below this image

Study designs at the top of the evidence pyramid are considered to have more rigorous methodologies and are more likely to minimize the effect of bias on the results of the study. 

"Evidence Pyramid" by Dartmouth Biomedical Libraries is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Synthesized Evidence combines data from multiple studies critically appraised for validity and reliability. It is helpful for clinical decision-making at the point of care. Common sources include systematic reviews, meta-analyses, and evidence-based guidelines. Benefits include summarization of multiple studies, reduced bias, and a larger data pool. However, limitations include potential delays in availability and the possibility that a high-quality Randomized Control Trial (RCT) may surpass the quality of a systematic review.

Primary Evidence, which includes original, individual studies like RCTs, cohort studies, and case-control studies, offers more recent and specific findings. However, it is more susceptible to bias and confounding factors. Given that it has not been compared with similar studies, careful interpretation and critical appraisal are crucial. While well-conducted primary evidence can provide robust data, it generally lacks the aggregated rigor of synthesized research.

Examples:

  • Synthesized Evidence: Systematic reviews and meta-analyses
  • Primary Evidence: RCTs, cohort studies, and clinical trials.

"Evidence-based research is the use of prior research in a systematic and transparent way to inform a new study so that it is answering questions that matter in a valid, efficient, and accessible manner."

Robinson, K. A., Brunnhuber, K., Ciliska, D., Juhl, C. B., Christensen, R., & Lund, H. (2021). Evidence-Based Research Series-Paper 1: What Evidence-Based Research is and why is it important? Journal of Clinical Epidemiology, 129, 151–157. https://doi.org/10.1016/j.jclinepi.2020.07.020

Below is an edited version of the "Evidence Level & Quality Guide" of evidence-based medicine hierarchy from the Johns Hopkins Nursing Evidence Based Practice Model:

Level I Experimental studies, systematic reviews of randomized controlled trials
Level II Quasi-experimental studies, mixed methods, systematic reviews of randomized controlled trials and quasi-experimental studies
Level III

Non-experimental studies, systematic reviews of randomized, quasi-, and non-experimental studies, mixed methods,

qualitative meta-analysis
Level IV Expert opinions, clinical practice guidelines, position statements
Level V Traditional narrative literature reviews, quality improvement, case reports, opinions based on anecdotal evidence

Dang, D., Sigma Theta Tau International, Dearholt, S., & Johns Hopkins University. (2018). Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines: Vol. Third edition. Sigma Theta Tau International.

Appraise

Critical Appraisal Process

Critical appraisal is a systematic process of analyzing research to determine the strength of the validity, reliability and relevance. 

  1. What is the focus of the study?
    • The focus will address the population, intervention and outcome 
  2. What type of study was completed? 
    • Is the study design matched with the domain of the research question? 
  3. What are the study characteristics?
    • Use the PICO question format to determine the study characteristics:
      • What are/is the Patient/Population/Problem? How were the participants selected? 
      • What intervention/treatment/test is being studied?
      • Does the study compare the intervention to a control group? 
      • What outcomes are being assessed? Are the outcomes objective, subjective, surrogate? 
  4. How did the researchers address bias within the study?
    • Were the study participants randomly assigned to study groups? 
    • Was the randomization process double or triple blind? 
    • Were the study groups similar at the beginning of the study? 
    • What was the percentage of participant attrition? How many left the study prior to completion? 
    • Apart from the tested intervention, were the groups of the study treated equally? 
  5. What are the study results? Are the results valid?
    • Were the effects of the study provided comprehensively? 
    • What outcomes were measured? Were they clearly specified? 
    • Would the drop out rate effect the study results? 
    • Is there any missing or incomplete data? 
    • Are the potential sources of bias identified? 
    • How large was the treatment/intervention effect? 
    • Do the authors provide access to the raw data? 
  6. Is this study relevant to your population, intervention and outcome? 
    • Are the results generalizable? 
    • Compare study participants to your population of study. Are the outcome measures relevant? 
    • Is this intervention applicable to your patient/population? (Including patient values)
    • Would this intervention provide greater value to the your patient/population? 
    • Would participant differences alter the outcomes? 
    • Are there limitations in this study that would impact the outcomes desired? 

University of Canberra library. (2021). Module 3: Appraisal. Evidence-based practice in health. https://canberra.libguides.com/c.php?g=599346&p=4149244

Critical Appraisal Checklists

Apply

the 4 aspects of clinical decision making are the synthesis of patient values, research evidence, clinical experience and practice context
 
  1. Considerations for the application of evidence: 
  2. Critical appraisal of the evidence: is it relevant to the clinical context and patient values?
  3. Is it optimal for patient treatment?
  4. Does this conform with the patient's values and preferences? 
  5. Have the potential benefits, harms, costs, and inconveniences been considered?

Source: A.T. Still University. (n.d.). Applying the Evidence. A.T. Still University Library. https://guides.atsu.edu/Evidencebasedpractice/apply

Freely Available Resources for Evidence Based Practice

Agency for Healthcare Research and Quality, a Federal agency. Its mission is to improve the quality of healthcare and promote evidence-based decision making. Includes a collection of Evidence Reports.