Evidence-based practice and research Along with gaining comfort while reading and critiquing studies, there is one final step: deciding how, when, and if to apply the studies to your practice so that your practice is evidence based. Evidence-based practice allows you to systematically use the best available evidence with the integration of individual clinical expertise, as well as the patient’s values and preferences, in making clinical decisions (Sackett et al., 2000). Evidence-based practice involves processes and steps, as does the research process. These steps are presented throughout the text. Chapter 19 provides an overview of evidence-based practice steps and strategies.
When using evidence-based practice strategies, the first step is to be able to read a study and understand how each section is linked to the steps of the research process. The following section introduces you to the research process as presented in published articles. Once you read a study, you must decide which level of evidence the study provides and how well the study was designed and executed. Fig. 1.1 illustrates a model for determining the levels of evidence associated with a study’s design, ranging from systematic reviews of randomized clinical trials (RCTs) (see Chapters 9 and 10) to expert opinions. The rating system, or evidence hierarchy model, presented here is just one of many. Many hierarchies for assessing the relative worth of both qualitative and quantitative designs are available. Early in the development of evidence-based practice, evidence hierarchies were thought to be very inflexible, with systematic reviews or meta-analyses at the top and qualitative research at the bottom. When assessing a clinical question that measures cause and effect, this may be true; however, nursing and health care research are involved in a broader base of problem solving, and thus assessing the worth of a study within a broader context of applying evidence into practice requires a broader view.
FIG 1.1 Levels of evidence: Evidence hierarchy for rating levels of evidence associated with a study’s
design. Evidence is assessed at a level according to its source.
The meaningfulness of an evidence rating system will become clearer as you read Chapters 8 through 11. ➤ Example: The Nyamathi et al. (2015) study is Level II because of its experimental, randomized control trial design, whereas the vanDijk et al. (2016) study is Level VI because it is a qualitative study. The level itself does not tell a study’s worth; rather it is another tool that helps you think about a study’s strengths and weaknesses and the nature of the evidence provided in the findings and conclusions. Chapters 7 and 18 will provide an understanding of how studies can be
assessed for use in practice. You will use the evidence hierarchy presented in Fig. 1.1 throughout the book as you develop your research consumer skills, so become familiar with its content.
This rating system represents levels of evidence for judging the strength of a study’s design, which is just one level of assessment that influences the confidence one has in the conclusions the researcher has drawn. Assessing the strength of scientific evidence or potential research bias provides a vehicle to guide evaluation of research studies for their applicability in clinical decision making. In addition to identifying the level of evidence, one needs to grade the strength of a body of evidence, incorporating the domains of quality, quantity, and consistency (Agency for Healthcare Research and Quality, 2002).
• Quality: Extent to which a study’s design, implementation, and analysis minimize bias.
• Quantity: Number of studies that have evaluated the research question, including overall sample size across studies, as well as the strength of the findings from data analyses.
• Consistency: Degree to which studies with similar and different designs investigating the same research question report similar findings.
The evidence-based practice process steps are: ask, gather, assess and appraise, act, and evaluate (Fig. 1.2). These steps of asking clinical questions; identifying and gathering the evidence; critically appraising and synthesizing the evidence or literature; acting to change practice by coupling the best available evidence with your clinical expertise and patient preferences (e.g., values, setting, and resources); and evaluating if the use of the best available research evidence is applicable to your patient or organization will be discussed throughout the text.
FIG 1.2 Evidence-based practice steps.
To maintain an evidence-based practice, studies are evaluated using specific criteria. Completed studies are evaluated for strength, quality, and consistency of evidence. Before one can proceed with an evidence-based project, it is necessary to understand the steps of the research process found in research studies.
Research articles: Format and style Before you begin reading research articles, it is important to understand their organization and format. Many journals publish research, either as the sole type of article or in addition to clinical or theoretical articles. Many journals have some common features but also unique characteristics. All journals have guidelines for manuscript preparation and submission. A review of these guidelines, which are found on a journal’s website, will give you an idea of the format of articles that appear in specific journals.
Remember that even though each step of the research process is discussed at length in this text, you may find only a short paragraph or a sentence in an article that provides the details of the step. A publication is a shortened version of the researcher(s) completed work. You will also find that some researchers devote more space in an article to the results, whereas others present a longer discussion of the methods and procedures. Most authors give more emphasis to the method, results, and discussion of implications than to details of assumptions, hypotheses, or definitions of terms. Decisions about the amount of material presented for each step of the research process are bound by the following:
• A journal’s space limitations
• A journal’s author guidelines
• The type or nature of the study
• The researcher’s decision regarding which component of the study is the most important
The following discussion provides a brief overview of each step of the research process and how it might appear in an article. It is important to remember that a quantitative research article will differ from a qualitative research article. The components of qualitative research are discussed in Chapters 5 and 6, and are summarized in Chapter 7.
Abstract An abstract is a short, comprehensive synopsis or summary of a study at the beginning of an article. An abstract quickly focuses the reader on the main points of a study. A well-presented abstract is accurate, self-contained, concise, specific, nonevaluative, coherent, and readable. Abstracts vary in word length. The length and format of an abstract are dictated by the journal’s style. Both quantitative and qualitative research studies have abstracts that provide a succinct overview of the study. An example of an abstract can be found at the beginning of the study by Nyamathi et al. (2015) (see Appendix A). Their abstract follows an outline format that highlights the major steps of the study. It partially reads as follows:
Purpose/Objective: “The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of the three levels of peer counseling (PC) and nurse delivered intervention was compared at 12 month follow up.”
In this example, the authors provide a view of the study variables. The remainder of the abstract provides a synopsis of the background of the study and the methods, results, and conclusions. The studies in Appendices A through D all have abstracts.
H E L P F U L H I N T An abstract is a concise short overview that provides a reference to the research purpose, research questions, and/or hypotheses, methodology, and results, as well as the implications for practice or future research.
Introduction Early in a research article, in a section that may or may not be labeled “Introduction,” the researcher presents a background picture of the area researched and its significance to practice (see Chapter 2).
Definition of the purpose The purpose of the study is defined either at the end of the researcher’s initial introduction or at the end of the “Literature Review” or “Conceptual Framework” section. The study’s purpose may or may not be labeled (see Chapters 2 and 3), or it may be referred to as the study’s aim or objective. The studies in Appendices A through D present specific purposes for each study in untitled sections that appear in the beginning of each article, as well as in the article’s abstract.
Literature review and theoretical framework Authors of studies present the literature review and theoretical framework in different ways. Many research articles merge the “Literature Review” and the “Theoretical Framework.” This section includes the main concepts investigated and may be called “Review of the Literature,” “Literature Review,” “Theoretical Framework,” “Related Literature,” “Background,” “Conceptual Framework,” or it may not be labeled at all (see Chapters 2 and 3). By reviewing Appendices A through D, you will find differences in the headings used. Nyamathi et al. (2015) (see Appendix A) use no labels and present the literature review but do have a section labeled theoretical framework, while the study in Appendix B has a literature review and a conceptual framework integrated in the beginning of the article. One style is not better than another; the studies in the appendices contain all the critical elements but present the elements differently.
H E L P F U L H I N T Not all research articles include headings for each step or component of the research process, but
each step is presented at some point in the article.
Hypothesis/research question A study’s research questions or hypotheses can also be presented in different ways (see Chapter 2). Research articles often do not have separate headings for reporting the “Hypotheses” or “Research Question.” They are often embedded in the “Introduction” or “Background” section or not labeled at all (e.g., as in the studies in the appendices). If a study uses hypotheses, the researcher may report whether the hypotheses were or were not supported toward the end of the article in the “Results” or “Findings” section. Quantitative research studies have hypotheses or research questions. Qualitative research studies do not have hypotheses, but have research questions and purposes. The studies in Appendices A, B, and D have hypotheses. The study in Appendix C does not, since it is a qualitative study; rather it has a purpose statement.
Research design The type of research design can be found in the abstract, within the purpose statement, or in the introduction to the “Procedures” or “Methods” section, or not stated at all (see Chapters 6, 9, and 10). For example, the studies in Appendices A, B, and D identify the design in the abstract.
One of your first objectives is to determine whether the study is qualitative (see Chapters 5 and 6) or quantitative (see Chapters 8, 9, and 10). Although the rigor of the critical appraisal criteria addressed do not substantially change, some of the terminology of the questions differs for qualitative versus quantitative studies. Do not get discouraged if you cannot easily determine the design. One of the best strategies is to review the chapters that address designs. The following tips will help you determine whether the study you are reading employs a quantitative design:
• Hypotheses are stated or implied (see Chapter 2).
• The terms control and treatment group appear (see Chapter 9).
• The terms survey, correlational, case control, or cohort are used (see Chapter 10).
• The terms random or convenience are mentioned in relation to the sample (see Chapter 12).
• Variables are measured by instruments or scales (see Chapter 14).
• Reliability and validity of instruments are discussed (see Chapter 15).
• Statistical analyses are used (see Chapter 16).
In contrast, qualitative studies generally do not focus on “numbers.” Some qualitative studies may use standard quantitative terms (e.g., subjects) rather than qualitative terms (e.g., informants). Deciding on the type of qualitative design can be confusing; one of the best strategies is to review the qualitative chapters (see Chapters 5 through 7). Begin trying to link the study’s design with the level of evidence associated with that design as illustrated in Fig. 1.1. This will give you a context for evaluating the strength and consistency of the findings and applicability to practice. Chapters 8 through 11 will help you understand how to link the levels of evidence with quantitative designs. A study may not indicate the specific design used; however, all studies inform the reader of the methodology used, which can help you decide the type of design the authors used to guide the study.
Sampling The population from which the sample was drawn is discussed in the section “Methods” or “Methodology” under the subheadings of “Subjects” or “Sample” (see Chapter 12). Researchers should tell you both the population from which the sample was chosen and the number of subjects that participated in the study, as well as if they had subjects who dropped out of the study. The authors of the studies in the appendices discuss their samples in enough detail so that the reader is clear about who the subjects are and how they were selected.
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