Cumulative Index to Nursing and Allied Health Literature.
TABLE 3.3 Databases for Nursing
Database Source CINAHAL PLUS with FULL TEXT (EBSCO)
Full text database for nursing and allied health widely used by nursing and health care—a useful starting point (Source: https://health.ebsco.com/products/cinahl-plus- with-full-text)
Provides free access to MEDLINE, NLM’s database of citations and abstracts in medicine, nursing, dentistry, veterinary medicine, health care systems, and preclinical sciences, including full text (Source: https://www.nlm.nih.gov/bsd/pmresources.html)
PsycINFO Centered on psychology, behavioral, and social sciences; interdisciplinary content, one of the most widely used databases (Source: http://www.apa.org/pubs/databases/psycinfo/)
Education Source with ERIC (EBSCO)
The largest and most complete collection of full-text education journals. This database provides research and information to meet needs of students, professionals, and policy makers, covers all levels of education—from early childhood to higher education—as well as all educational specialties such as multilingual education, health education, and testing. (Source: https://www.ebscohost.com/academic/education-source)
CINAHL, Cumulative Index to Nursing and Allied Health Literature.
Sources of literature
Preappraised literature Preappraised literature is a secondary source of evidence, sometimes referred to as preappraised synopses, or simply synopses. Reading an expert’s comment about another author’s research can help develop your critical appraisal and synthesis skills. Some synopses include a commentary about the strength and applicability of the evidence to a patient population. It is important to keep in mind that there are limitations to using preappraised sources. These sources are useful for giving you a preview about the potential relevance of the publication to your clinical question and the strength of the evidence. You can then make a decision about whether to search for and critically appraise the primary source. Preappraised synopses can be found in journals such as Evidence-Based Nursing (http://ebn.bmj.com) and Evidence-Based Medicine (http://ebm.bmj.com) or the Joanna Briggs Institute (JBI) EBP Database (http://joannabriggs.org).
E V I D E N C E – B A S E D P R A C T I C E T I P If you find a preappraised commentary on an individual study related to your PICO question, read the preappraised commentary first. As a beginner, this strategy will make it easier for you to pick out the strengths and weaknesses in the primary source study.
Primary sources When searching the literature, primary sources should be a search strategy priority. Review Table 3.1 to identify the differences between primary and secondary sources. Then, as noted in Step VIII of Table 3.2, strategies to conduct a literature search, you need to apply your critiquing skills to determine the quality of the primary source publications. Review Chapters 7, 11, and 18 so you can apply the critical appraisal criteria outlined in these chapters to your retrieved studies. Example: ➤ For your PICO question, you searched for and found two types of primary source publications. One primary source was a rigorous systematic review related to your clinical question that provided strong evidence to support your PICO comparison intervention, the current standard of care; you also found two poorly designed RCTs that provided weak evidence supporting your proposed intervention. Which primary source would you recommend? You would need to make an evidence- based decision about the applicability of the primary source evidence supporting or not supporting the proposed or comparison intervention. The well-designed systematic review provided the highest level of evidence (Level I on the Fig. 1.1 evidence hierarchy). It also provided strong evidence that supported continuation of the current standard of care in comparison to the weak evidence supporting the proposed intervention provided by two poorly designed RCTs (Level II on the Fig. 1.1 evidence hierarchy). Your team would conclude that the primary source systematic review provided the strongest evidence supporting that the current standard of care be retained and recommended, and that there was insufficient evidence to recommend a practice change.
H E L P F U L H I N T • If possible, consult a librarian before conducting your searches to determine which databases and
keywords to use for your PICO question. Save your search history electronically.
• Learn how to use an online search management tool such as RefWorks, EndNote, or Zotero.
E V I D E N C E – B A S E D P R A C T I C E T I P • If you do not retrieve any studies from your search, review your PICO question and search
strategies with a librarian.
• Every meta-analysis begins with a systematic review; however, not every systematic review results in a meta-analysis. Read Chapter 11 and find out why.
Performing an electronic search
Why use an electronic database?
Perhaps you still are not convinced that electronic database searches are the best way to acquire information for a review of the literature. Maybe you have searched using Google or Yahoo! and found relevant information. This is an understandable temptation. Try to think about it from another perspective and ask yourself, “Is this the most appropriate and efficient way to find the latest and strongest research on a topic that affects patient care?” Yes, Google Scholar might retrieve some studies, but from an EBP perspective, you need to retrieve all the studies available on your topic/clinical question. The “I” and “C” of your PICO question require that you retrieve from your search all types of interventions, not just what you have proposed. To understand the literature in a specific area requires a review of all relevant studies. A way to decrease your frustration is to take the time to learn how to conduct an efficient database search by reviewing the steps presented in Table 3.2. Following these strategies and reviewing the Helpful Hints and EBP Tips provided in this chapter will help you gain the essential competencies needed for you to be successful in your search. The Critical Thinking Decision Path provides a means for locating evidence to support your clinical question (Kendall, 2008). Path shows a way to locate evidence to support your research or clinical question.
C R I T I C A L T H I N K I N G D E C I S I O N PAT H
Types of resources Print and electronic indexes: Books and journals Most college/university libraries have management retrieval systems or databases to retrieve both print and online books, journals, videos, and other media items, scripts, monographs, conference proceedings, masters’ theses, doctoral dissertations, archival materials, and Grey literature (e.g., information produced by government, industry, health care organizations, and professional organizations in the form of committee reports and policy documents; dissertations are included in the Grey literature). Print indexes are useful for finding sources that have not been entered into online databases. Print resources such as the Grey literature are still necessary if a search requires materials not entered into a database before a certain year. Also, another source is the citations/reference lists from the articles you retrieved; often they contain studies not captured with your search.
Refereed journals A major portion of most literature reviews consist of journal articles. Journals are published in print and online. In contrast to textbooks, which take much longer to publish, journals are a ready source of the latest information on almost any subject. Therefore, journals are the preferred mode of communicating the latest theory or study results. You should use refereed or peer-reviewed journals as your first choice when looking for primary sources of theoretical, clinical, or research articles. A refereed or peer-reviewed journal has a panel of internal and external reviewers who review submitted manuscripts for possible publication. The external reviewers are drawn from a pool of nurse scholars and scholars from related disciplines who are experts in various specialties. In most cases, the reviews are “blind”; that is, the manuscript to be reviewed does not include the name of the author(s). The reviewers use a set of criteria to judge whether a manuscript meets the publication journal’s standards. These criteria are similar to what you will use to critically appraise the evidence you obtained in order to determine the strengths and weaknesses of a study (see Chapters 7 and 18). The credibility of a published research or theoretical/conceptual article is strengthened by the peer-review process.
Electronic: Bibliographic and abstract databases Electronic databases are used to find research and theoretical/conceptual articles on a variety of topics, including doctoral dissertations. Electronic databases contain bibliographic citation information such as the author name, title, journal, and indexed terms for each record. Libraries have lists of electronic databases, including the ones indicated in Table 3.3 and Table 3.4. Usually these include the abstract, and some have the full text of the article or links to the full text. If the full text is not available, look for other options such as the abstract to learn more about the article before requesting an interlibrary loan of the article. Reading the abstract (see Chapter 1) is a critical step of the process to determine if you need to retrieve the full text article through another mechanism. Use both CINAHL and MEDLINE electronic databases as well as a third database; this will facilitate all steps of critically reviewing the literature, especially identifying the gaps. Your college/university most likely enables you to access such databases electronically whether on campus or not.
TABLE 3.4 Selected Examples of Websites for Evidence-Based Practice
Website Scope Notes Virginia Henderson International Nursing Library (www.nursinglibrary.org)
Access to the Registry of Nursing Research database contains abstracts and the full text of research studies and conference papers
Offered without charge. Supported by Sigma Theta Tau International, Honor Society of Nursing.
National Guideline Clearinghouse (www.guidelines.gov)
Public resource for evidence-based CP guidelines Offers a useful online feature of side-by-side comparison of guidelines and the ability to browse by disease/condition and treatment/intervention.
JBI is an international not-for-profit research and development center Membership required for access. Recommended links worth reviewing, as well as descriptions on their levels of evidence and grading scale is provided.
Content from free online resources, including synopses, guidelines, medical images, e-textbooks, and systematic reviews, organized under the TRIP search engine.
Site offers a wide sampling of available evidence and ability to filter by publication type—that is, evidence based synopses, systematic reviews, guidelines, textbooks, and research.
Agency for Health Research and Quality (www.ahrq.gov)
Evidence-based reports, statistical briefs, research findings and reports, and policy reports.
Free source of government documents, searchable via PubMed.
Cochrane Collaboration Access to abstracts from Cochrane Database of Systematic Reviews. Full text Abstracts are free and can be browsed or searched; uses many databases in its
(www. cochrane.org) of reviews and access to databases that are part of the Cochrane Library. Information is high quality and useful for health care decision making. It is a powerful tool for enhancing health care knowledge and decision making.
reviews, including CINAHL via EBSCO and MEDLINE; some are primary sources (e.g., systematic reviews/meta-analyses); others (if commentaries of single studies) are a secondary source; important source for clinical evidence.
CP, Clinical practice; CINAHL, Cumulative Index to Nursing and Allied Health Literature; JBI, Joanna Briggs Institute; TRIP, Turning Research into Practice.
Electronic: Secondary or summary databases Some databases contain more than journal article information. These resources contain either summaries or synopses of studies, overviews of diseases or conditions, or a summary of the latest evidence to support a particular treatment. Table 3.4 provides a few examples.
Internet: Search engines You are probably familiar with accessing a web browser (e.g., Internet Explorer, Mozilla Firefox, Chrome, Safari) to conduct searches, and with using search engines such as Google or Google Scholar to find information. However, “surfing” the web is not a good use of your time when searching for scholarly literature. Table 3.4 indicates sources of online information; all are free except JBI. Most websites are not a primary source for research studies.
H E L P F U L H I N T S Be sure to discuss with your instructor regarding the use of theoretical/conceptual articles and other Grey literature in your EBP/QI project or a review of the literature paper.
Less common and less used sources of scholarly material are audio, video, personal communications (e.g., letters, telephone or in-person interviews), unpublished doctoral dissertations, masters’ theses, and conference proceedings.
E V I D E N C E – B A S E D P R A C T I C E T I P Reading systematic reviews, if available, on your clinical question/topic will enhance your ability to implement evidence-based nursing practice because they generally offer the strongest and most consistent level of evidence and can provide helpful search terms. A good first step for any question is to search the Cochrane Database of Systematic Reviews to see if someone has already completed a systematic review addressing your clinical question.
How far back must the search go? Students often ask questions such as, “How many articles do I need?”; “How much is enough?”; “How far back in the literature do I need to go?” When conducting a search, you should use a rigorous focused process or you may end up with hundreds or thousands of citations. Retrieving too many citations is usually a sign that there was something wrong with your search technique, or you may not have sufficiently narrowed your clinical question.
Each electronic database offers an explanation of its features; take the time and click on each icon and explore the explanations offered, because this will increase your confidence. Also, take advantages of tutorials offered to improve your search techniques. Keep in mind the types of articles you are retrieving. Many electronic resources allow you to limit your search to the article type (e.g., systematic reviews/meta-analyses, RCTs). Box 3.2 provides a number of features through which CINAHL Plus with Full Test allows you to choose and/or insert information so that your search can be targeted. BOX 3.2
T i p s : U s i n g C u m u l a t i ve I n d e x t o N u r s i n g a n d A l l i e d H e a l t h L i t e r a t u r e v i a E B S C O • Locate CINAHL from your library’s home page. It may be located under databases, online
resources, or nursing resources.
• In the Advanced Search, type in your keyword, subject heading, or phrase (e.g., maternal-fetal attachment, health behavior). Do not use complete sentences. (Ask your librarian for any tip sheets, or online tutorials or use the HELP feature in the database.)
• Before choosing “Search,” make sure you mark “Research Articles” to ensure that you have retrieved articles that are actually research.
• In the “Limit Your Results” section, you can limit by year, age group, clinical queries, and so on.
• Using the Boolean connector “AND” between each of the words of your PICO variables narrows your search—that is, it will exclude an article that doesn’t use both terms; using “OR” broadens your search.
• Once the search results appear, save them, review titles and abstracts online, export to your management system (e.g., RefWorks), and/or e-mail the results to yourself.
CINAHL, Cumulative Index to Nursing and Allied Health Literature.
When conducting a literature review for any purpose, there is always a question of how far back one should search. There is no general time period. But if in your search you find a well-done meta- analysis that was published 6 years ago, you could continue your search, moving forward from that time period. Some research and EBP projects may warrant going back 10 or more years. Extensive literature reviews on particular topics or a concept clarification helps you limit the length of your search.
As you scroll through and mark the citations you wish to include in your downloaded or printed search, make sure you include all relevant fields when you save or print. In addition to indicating which citations you want and choosing which fields, there is an opportunity to indicate if you want the “search history” included. It is always a good idea to include this information. It is especially helpful if you feel that some citations were missed; then you can replicate your search and determine which variable(s) you missed. This is also your opportunity to indicate if you want to e- mail the search to yourself. If you are writing a paper and need to develop a reference list, you can export your citations to citation management software, which formats and stores your citations so that they are available for electronic retrieval when they are needed for a paper. Quite a few of these software programs are available; some are free, such as Zotero, and others your institution has most likely purchased, including EndNote and RefWorks.
H E L P F U L H I N T Ask your faculty for guidance if you are uncertain how far back you need to conduct your search. If you come across a systematic review/meta-analysis on your specific topic, review it to see what years the review covers; then begin your search from the last year of the studies included in the review and conduct your search from that year forward to the present to fill in the gap.
E V I D E N C E – B A S E D P R A C T I C E T I P You will be tempted to use Google, Google Scholar, or even Wikipedia instead of going through Steps I through III of Table 3.2 and using the databases suggested, but this will most likely result in thousands of citations that aren’t classified as research and are not specific to your PICO question. Instead, use the specific parameters of your electronic database.
What do I need to know? Each database usually has a specific search guide that provides information on the organization of the entries and the terminology used. Academic and health science libraries continually update their websites in order to provide tutorials, guides, and tips for those who are using their databases. The strategies in Table 3.2 incorporate general search strategies, as well as those related to CINAHL and MEDLINE. Finding the right terms to “plug in” as keywords for a computer search is important for conducting an efficient search. In many electronic databases you can browse the controlled vocabulary terms and see how the terms of your question match up and then add them before you search. If you encounter a problem, ask your librarian for assistance.
H E L P F U L H I N T One way to discover new terms for searching is to find a systematic review that includes the search strategy. Match your PICO words with the controlled vocabulary terms of each database.
In CINAHL the Full Text via EBSCO host provides you with the option of conducting a basic or advanced search using the controlled vocabulary of CINAHL headings. This user-friendly feature has a built-in tutorial that reviews how to use this option. You also can click on the “Help” feature at any time during your search. It is recommended that you conduct an Advanced Search with a Guided Style tutorial that outlines the steps for conducing your search. If you wanted to locate articles about maternal-fetal attachment as they relate to the health practices or health behaviors of low-income mothers, you would first want to construct your PICO:
P Maternal-fetal attachment in low-income mothers (specifically defined group)
I Health behaviors or health practices (event to be studied)
C None (comparison of intervention)
O Neonatal outcomes (outcome)
In this example, the two main concepts are maternal-fetal attachment and health practices and how these impact neonatal outcomes. Many times when conducting a search, you only enter in keywords or controlled vocabulary for the first two elements of your PICO—in this case, maternal- fetal attachment and health practices or behaviors. The other elements can be added if your list of results is overwhelming (review the Critical Thinking Decision Path).
Maternal-fetal attachment should be part of your keyword search; however, when you click the CINAHL heading, it indicates that you should use “prenatal bonding.” To be comprehensive, you should use the Boolean operator of “OR” to link these terms together. The second concept, of health practices OR health behavior, is accomplished in a similar manner. The subject heading or controlled vocabulary assigned by the indexers could be added in for completeness. Boolean operators are “AND,” “OR,” and “NOT,” and they dictate the relationship between words and concepts. Note that if you use “AND,” then this would require that both concepts be located within the same article, while “OR” allows you to group together like terms or synonyms, and “NOT” eliminates terms from your search. It is suggested that you limit your search to “peer-reviewed” and “research” articles. Refine the publication range date to 10 years, or whatever the requirement is for your search, and save your search. Once these limits were chosen for the PICO search related to maternal-fetal attachment described previously, the search results decreased from an unmanageable 294 articles to 6 research articles. The key to understanding how to use this process is to try the search yourself using the terms just described. Developing search skills takes time, even if you complete the library tutorials and meet with a librarian to refine your PICO question, search terms, and limits. You should search several databases. Library database websites are continually being updated, so it is important to get to know your library database site.
H E L P F U L H I N T When combining synonyms for a concept, use the Boolean operator “OR”—OR is more!
Review your library’s tutorials on conducting a search for each type database (e.g., CINAHL and MEDLINE).
Use features in your database such as “limit search to” and choose peer review journal, research article, date range, age group, and country (e.g., United States).
How do I complete the search? Once you are confident about your search strategies for identifying key articles, it is time to critically read what you have found. Critically reading research articles requires several readings and the use of critical appraisal criteria (see Chapters 1, 7, and 18). Do not be discouraged if all of the retrieved articles are not as useful as you first thought, even though you limited your search to “research.” This happens to even the most experienced searcher. If most of the articles you retrieved were not useful, be prepared to do another search, but before you do, discuss the search terms with your librarian and faculty. You may also want to add a fourth database. It is a good practice to always save your search history when conducting a search. It is very helpful if you provide a printout of the search you have completed when consulting with your librarian or faculty. Most likely your library will have the feature that allows you to save your search, and it can be retrieved during your meeting. In the example of maternal-fetal bonding and health behaviors in low-income
women, the third database of choice may be PsycINFO (see Table 3.3).
H E L P F U L H I N T Read the abstract carefully to determine if it is a research article; you will usually see the use of headings such as “Methodology” and “Results” in research articles. It is also a good idea to review the reference list of the research articles you retrieved, as this strategy might uncover additional related articles you missed in your database search, and then you can retrieve them.
Literature review format: What to expect Becoming familiar with the format of a literature review in the various types of review articles and the literature review section of a research article will help you use critical appraisal criteria to evaluate the review. To decide which style you will use so that your review is presented in a logical and organized manner, you must consider:
• The research or clinical question/topic
• The number of retrieved sources reviewed
• The number and type of research versus theoretical/conceptual materials and/or Grey literature
Some reviews are written according to the variables or concepts being studied and presented chronologically under each variable. Others present the material chronologically with subcategories or variables discussed within each time period. Still others present the variables and include subcategories related to the study’s type or designs or related variables.
Hawthorne and colleagues (2016) (see Appendix B) stated that the purpose of their “longitudinal study was to test the relationships between spirituality/religious coping strategies and grief, mental health (depression and post-traumatic stress disorder), and mothers and fathers” at selected time periods after experiencing the death of an infant in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU). At the beginning of their article, after some basic overall facts on infant deaths and parents’ grieving, they logically presented the concepts they addressed in their quantitative study (see Appendix B). The researchers did not title the beginning of their article with a section labeled Literature Review. However, it is clear that the beginning of their article is a literature review. Example: ➤ After presenting general facts on infant deaths and parents grieving and related research, the authors title a section Use of Spirituality/Religion as a Coping Strategy and the next section Parent Mental Health and Personal Growth. In these sections they discuss studies related to each topic. Then, they present a section labeled Conceptual Framework, indicating that will use a specific grief framework to guide their study.
H I G H L I G H T Each member of your QI committee should be responsible for searching for one research study, using the agreed upon search terms and reviewing the abstract to determine its relevance to your QI project’s clinical question.
H E L P F U L H I N T The literature review for an EBP/QI project or another type of scholarly paper is different than one found in a research article.
Make an outline that will later become the level headings in your paper (i.e., title the concepts of your literature review). This is a good way to focus your writing and will let the reader know what to expect to read and demonstrate your logic and organization.
Include your search strategies so that a reader can re-create your search and come up with the same results. Include information on databases searched, time frame of studies chosen, search terms used, and any limits used to narrow the search.
Include any standardized tools used to critically appraise the retrieved literature.
Appraisal for evidence-based practice When writing a literature review for an EBP/QI project, you need to critically appraise all research
reports using appropriate criteria. Once you have conducted your search and obtained all your references, you need to evaluate the articles using standardized critical appraisal criteria (see Chapters 7, 11, and 18). Using the criteria, you will be able to identify the strengths and weaknesses of each study.
Critiquing research or theoretical/conceptual reports is a challenging task for seasoned consumers of research, so do not be surprised if you feel a little intimidated by the prospect of critiquing and synthesizing research. The important issue is to determine the overall value of the literature review, including both research and theoretical/conceptual materials. The purposes of a literature review (see Box 3.1) and the characteristics of a well-written literature review (Box 3.3) provide the framework for evaluating the literature. BOX 3.3
C h a r a c t e r i s t i c s o f a We l l – W r i t t e n R e v i e w o f t h e L i t e r a t u r e — A n E B P Pe r s p e c t i ve Each reviewed source reflects critical thinking and writing and is relevant to the study/topic/project, and the content meets the following criteria:
• Uses mainly primary sources—that is, a sufficient number of research articles for answering a clinical question with a justification of the literature search dates and search terms used
• Organizes the literature review using a systematic approach
• Uses established critical appraisal criteria for specific study designs to evaluate strengths, weaknesses, conflicts, or gaps related to the PICO question
• Provides a synthesis and critique of the references indicating similarities, differences, strengths, and weaknesses between and among the studies
• Concludes with a summary that provides recommendations for practice and research
• In a table format, summarizes each article succinctly with references
The literature review should be presented in an organized manner. Theoretical/conceptual and research literature can be presented chronologically from earliest work of the theorist or first studies on a topic to most recent; sometimes the theoretical/conceptual literature that provided the foundation for the existing research will be presented first, followed by the research studies that were derived from this theoretical/conceptual base. Other times, the literature can be clustered by concepts, pro or con positions, or evidence that highlights differences in the theoretical/conceptual and/or research findings. The overall question to be answered from an EBP perspective is, “Does the review of the literature develop and present a knowledge base to provide sufficient evidence for an EBP/QI project?” Objectives 1 to 3, 5, 8, 10, and 11 in Box 3.1 specifically reflect the purposes of a literature review for EBP/QI project. Objectives 1 to 8 and 11 reflect the purposes of a literature review when conducting a research study.
Regardless of how the literature review is organized, it should provide a strong knowledge base for a CP or a research project. When a literature review ends with insufficient evidence, this provides a gap in knowledge and requires further research. The more you read published systematic and integrative reviews, as well as studies, the more competent you become at differentiating a well-organized literature review from one that has a limited organizing framework.
Another key to developing your competency in this area is to read both quantitative (meta- analyses) and qualitative (meta-syntheses) systematic reviews. A well-done meta-analysis adheres to the rigorous search, appraisal, and synthesis process for a group of like studies to answer a question and to meet the required guidelines, which include that it should be conducted by a team.
The systematic review on how nurses who lead clinics for patients with cardiovascular disease found in Appendix E is an example of a well-done quantitative systematic review that critically appraises and synthesizes the evidence from research studies related to the effect of the mortality and morbidity rates of patients with cardiovascular disease who are followed in nurse-led clinics.
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