Nursing

This stage is where you search for information to answer your question. You can use your PICO elements to plan how to search.

When answering clinical questions, you need to use the highest level of evidence possible. In the diagram below, evidence that is higher up the pyramid is of higher quality i.e., systematic reviews (secondary research).

Secondary research appraises the quality of original research studies, summarises the findings, and often makes recommendations for practice. However, secondary research is not always available, and searching for primary research such as randomised control trials may be required.

To learn more about levels of evidence, click on the links below:

JBI Levels of Evidence 

JBI Grades of Recommendation 

Use the arrows at the right and left of the box below to click through and see the characteristics of a number of different study types from the levels of evidence pyramid.

Use your PICO elements to create search terms. You might not include every element in your search, for example an outcome can sometimes be difficult to define.

The next step is to consider alternative terms that authors might use, for example synonyms, or medical terms. A table can be a useful way of recording these. 

Now you can use Boolean operators to group the terms together, and use search tips such as phrase searching and truncation:

(elderly OR aged OR geriatric) AND ("physical activit*" OR "aerobic training" OR "exercise*") AND ("cardiac arrest*" OR "heart attack*" OR "myocardial infarction*")

The library has many databases you can search in, depending on what level of evidence you need. Some of these databases allow you to filter results according to evidence type.

• Secondary research:
  • Trip Database: Useful for finding evidence based material, including clinical guideline, systematic reviews, and evidence based synopses
  • The Cochrane Database of Systematic Reviews: Detailed, structured reviews of articles written by teams of experts who evaluate the literature and summarise the findings
  • Joanna Briggs EBP Database: Contains evidence summaries and systematic reviews, as well as best practice recommendations
• Primary research:
  • CINAHL: Useful for finding primary, peer reviewed studies. There are extensive filters that allow you to select which study type you are interested in.
  • MEDLINE: Also useful for finding primary research, and using the Clinical Queries filter allows you to select from study categories such as therapy, diagnosis, etiology, and prognosis, and indicate whether you want a more sensitive or specific search

When you have found the articles and information, you will need to evaluate it for validity, and risk of bias. How you do this will depend on whether you are appraising primary or secondary research, and the study type, but there are common elements to consider. The CRAAP test is a good way to evaluate articles. A lot of what you need to appraise articles will be in the Methods section. Keep in mind evaluating articles is a skill that can take a while to learn, so if you need guidance, contact the library.

If you are interested in finding out more, the following article is old, but has some great questions to ask yourself when reading primary research, and is easy to read.

Greenhalgh, T. (1997). How to read a paper: Assessing the methodological quality of published papers. BMJ, 315(7103), 305–349. https://doi.org/10.1136/bmj.315.7103.305

This is another older paper by the same author that describes in more detail how to appraise secondary research.

Greenhalgh, T. (1997). How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses). BMJ, 315(7109), 672–675. https://doi.org/10.1136/bmj.315.7109.672

The article below has been annotated using the CRAAP test from above. Scroll through and hover the mouse over the highlights to see the types of things to consider when evaluating an article.

There are a number of tools and checklists researchers use to appraise studies that you can look at for a more detailed way of evaluation.. 

• Critical Appraisal Skills Programme (CASP)
• JBI (formerly Joanna Briggs Institute)
• Centre for Evidence-Based Medicine (CEBM)
• SIGN
• PEDro scale

 ebook:

Riegelman, R. K. (2005). Studying a study and testing a test: How to read the medical evidence (5th ed.).

Appraising qualitative research articles:

Côté, L. (2005). Appraising qualitative research articles in medicine and medical education.

Critical appraisal of Indigenous research:

Harfield, S., Pearson, O., Morey, K., Kite, E., Canuto, K., Glover, K., Gomersall, J. S., Carter, D., Davy, C., Aromataris, E., & Braunack-Mayer, A. (2020). Assessing the quality of health research from an Indigenous perspective: the Aboriginal and Torres Strait Islander quality appraisal tool. BMC Medical Research Methodology, 20(1), 1-9. https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-020-00959-3

Lock, M. J., Walker, T., & Browne, J. (2021). Promoting cultural rigour through critical appraisal tools in First Nations peoples’ research. Australian and New Zealand Journal of Public Health, 45(3), 210–211. https://doi.org/10.1111/1753-6405.13097

In this stage, you decide if the evidence you have collected is suitable for your clinical situation.

You also need to consider the other two areas of evidence based practice: clinical expertise and patient values.

• Clinical expertise: Is the intervention suitable for your setting? Will the benefits outweigh harm?
• Patient values: What are the patient's circumstances, views, beliefs, and values? Are they concerned or worried about anything? What is their preference for treatment?

Sometimes you are not certain of the right thing to do even after looking at the evidence. To help you decide, you can:

• Ask a more experienced colleague
• Take a quick break to reflect
• Consider the standards, codes of practice and legal requirements

The final step is to reflect on your practice and consider strengths, weakness and where you need to improve.

Consider how you applied the evidence, whether what you implemented was effective, and was the outcome satisfactory for the patient.

Evidence-Based Medicine Information Sites

Centre for Evidence-Based Medicine (Oxford University)

The Centre promotes evidence-based health care and provide support and resources to anyone who wants to make use of them. Includes the EBM Toolbox, an assortment of materials which are very useful for practitioners of EBM, and EBM Teaching Materials, including PowerPoint presentations.

Centre for Evidence-Based Medicine (Canada based)

Includes many resources for practicing and teaching EBM

Alberta Research Centre for Health Evidence

Contains links to recent publications published by the ARCHE team.

Introduction to Evidence-Based Medicine

From Duke University Medical Center Library and University of North Carolina at Chapel Hill Health Sciences Library.