Ilo-Katryn Maimets ilo@yorku.ca
416-736-2100 x33927
Steacie Library room 102K

“The integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making”
(Sackett et al., 2000)

A. Sources of Information – Library website a. Databases & More
B. Study Design – Hierarchy of Evidence
C. Conducting a Literature Search a. Search tips and Boolean Logic b. Keyword searching c. Subject heading searching
D. Steps in Evidence-based practice
E. Levels of Pre-Appraised Evidence

• Select Sources that will most likely answer the question:
– If the information is most likely found in Medical or
Nursing research journals then start your search in a database that indexes that kind of research:
• Cinahl (Nursing and Allied Health)
• Medline(OVID) and PubMed
• SCOPUS (interdisciplinary - indexes part of Embase)
• Web of Science (very interdisciplinary)
– Note that sometimes relevant research is indexed in:
• PsychINFO (psychology)
• Eric (education)

• Use the Research Guides to locate:
– General/Getting Started: Dictionaries,
Encyclopaedias and e-books
– Articles/Finding articles:
• Links to Databases
• Systematic Reviews and Evidence-based Practice
Resources
– Advanced/Advanced Research:
• Association and organizations
• Webguides and other resources
– Other Related Research Guides and Resources

http://researchguides.library.yorku.ca/nursing

Centre for Evidence Based Medicine, University of Oxford http://www.cebm.net/index.aspx?o=1039

http://guides.mclibrary.duke.edu/content.php?pid=274373&sid=2289252
Connie Schardt, Medical Centre Library, Duke University
Meta
Analyses
Systematic
Reviews
Randomized Controlled
Trials
Secondary studies which review original research
Experimental designs
Cohort Studies
Case Control Studies
Case reports / case series
Observational reports and studies

• Reports of observations of diseases, adverse reactions or unexpected events
– E.g. observations in the 1980s of a rare cancer combined with pneumonia led to the discovery of
HIV-AIDS
• However, there are no controls and so there is no statistical validity, and you cannot draw conclusions or make statistical comparisons.

• These are used to examine Harm questions
– Begin with an outcome or issue
– Look backwards in time to identify a possible exposure, or risk factor
– E.g. observations of lung cancer incidence in the
1950s led to an examination of patient records that uncovered links to cigarette smoking
Peto R. Darby S. Deo H. Silcocks P. Whitley E. Doll R. (2000) Smoking, smoking cessation, and lung cancer in the
UK since 1950: combination of national statistics with two case-control studies. BMJ. 321(7257):323-9.

• Are quick, inexpensive, convenient and ethical because the patient already has the condition.
• However, evidence is based on recall which may be biased, or on past records which may not be complete because they were created before knowing what the questions were.
• There may be confounders that are common to both groups
• It is difficult to choose appropriate controls.

• Involve 2 or more populations:
– Exposed: having a specific condition or receiving a particular treatment over time
– Non-Exposed: group that has not been affected by the condition or treatment being studied
• Follow the populations forward in time – sometimes for many years to determine the effect of the exposure.
• E.g. long-term effectiveness of influenza vaccines in community dwelling elderly people
Nichol KL, Nordin JD, Nelson DB, Mullooly JP, & Hak E. (2007). Effectiveness of influenza vaccine in the community-dwelling elderly. New England Journal of Medicine, 357(14):1373-1381.

• Observations are of people in their natural settings
• Evidence is strengthened by natural time sequence – exposure occurs before the outcome
• Ethical in that patients self-select (this may also be a source of bias)
• Possible confounders
• Long follow-up – often many years even decades.

• True experimental design that introduces a therapeutic randomized/control-placebo intervention
• Follows subjects forward in time to determine the effects of interventions
• Randomization is key and involves randomly assigning individuals to groups
• Less prone to bias, best for establishing efficacy
• May present ethical dilemmas
• Is very expensive and time-consuming
Müller O, Traoré C, Kouyaté B, Yé Y, Frey C, Coulibaly B, et al. (2006). Effects of insecticide-treated bednets during early infancy in an African area of intense malaria transmission: A randomized controlled trial. Bulletin
of the World Health Organization, 84(2):120-126.

• Secondary research that:
– Focusses on a clinical topic
– Involves a thorough review of the literature, published and unpublished
– Studies are subject to detailed scrutiny of their quality for inclusion
– Summarizes data for drawing conclusions that inform practice.
Pittler MH, Guo R, Ernst E. Hawthorn extract for treating chronic heart failure. Cochrane
Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005312.

• Mathematically/statistically pools the data from individual studies
– Sources of data can be the articles included in a systematic review or from otherwise selected primary studies, both peer-reviewed and grey literature
• Present results as if it were from a large study
Bahekar AA, Singh S, Saha S, Molnar J, Arora R. (2007). The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: A meta-analysis. American Heart Journal,
154(5): 830-7.

• Exhaustively reviews the current literature
• Articles are critically evaluated for inclusion
• Pooled data allows validation of findings in small studies
• Publication bias may be a problem as negative results are less often published than positive results
• Conducting them is very time consuming and so also expensive
• Data parameters and collection methods are not always the same from study to study, and so studies cannot be easily combined.

http://guides.mclibrary.duke.edu/content.php?pid=274373&sid=2289252
Connie Schardt, Medical Centre Library, Duke University
Meta
Analyses
Systematic
Reviews
Randomized Controlled
Trials
Secondary studies which review original research
Experimental designs
Cohort Studies
Case Control Studies
Case reports / case series
Observational reports and studies

• EBP started as part of medicine to determine best practices in quantitatively measurable procedures, effects, etc. However, in nursing, many questions are asked that cannot be answered by quantitative data.
– For example: what is the lived experience of women identified as carriers of the BRCA gene?
• In most EBP rating scales, qualitative evidence is deemed to be low on the scale for quality and validity

based on question type
DiCenzo, Guyatt, Ciliska, 2005, pg 28
1. Healthcare interventions: treatment, prevention, therapy
2. Harm: causation or etiology
3. Prognosis: future course of the condition
4. Diagnosis/assessment
5. Economics: economic efficiency of healthcare programs or interventions

DiCenzo, Guyatt, Ciliska, 2005, pg 32
• Case studies: involves studying a number of related cases in depth to inquire into an observed phenomenon. The belief is that understanding them will lead to a deeper understanding of a larger collection of cases.
• Ethnography: involves studying people within a culture in an intensive, ongoing, participatory way. The researcher is immersed in the culture for the duration of the study.

DiCenzo, Guyatt, Ciliska, 2005, pg 32
• Grounded Theory: involves discovering meanings that people assign to people and objects or situations that they interact with.
The purpose is to develop a theory to account for individual differences. Interviews and observation are used to collect data
• Phenomenology: examines the daily lived experience of people. Data are collected through in-depth interviews.

• Do not use statistical methods to combine findings and data
• Adhere to a systematic process for retrieving sources, selecting sources, and critiquing sources
• Their purpose is to synthesize the findings from multiple studies, and this process is called Meta-synthesis.
Levine and Feldman, 2006, pg 178

• Uses data from different qualitative studies that are linked because they are about the same or a related by topic. The methodologies used can be different.
• Is neither an integrated review nor a secondary analysis of primary data.
• Rather it is an analysis of the findings of these studies

• Are similar to qualitative systematic reviews, however, they use broader, often less rigorous methods to systematically combine the results of a body of studies.
Stevens, 2002, pg 530
• “The integrative review method is an approach that allows for the inclusion of diverse methodologies
(i.e. experimental and non-experimental research) and has the potential to play a greater role in evidence-based practice for nursing”
Whittemore, 2005, pg 547 http://users.phhp.ufl.edu/rbauer/ebpp/whittemore_knafl_05.pdf

• Focus is on understanding and analyzing the mechanisms by which an intervention works or fails to work
• Provides an explanation rather than a judgement about implementation and success of an intervention
• Accounts for not just outcomes but also context of the intervention
• By nature, RSs are well suited to complex implementation interventions

• Implementation interventions are by nature complex and multi-faceted.
• When developing and implementing an intervention, there is an underlying theory about how it should work.
• Deterministic theories cannot always explain or predict implementation outcomes in every context. http://www.ccsr.ac.uk/methods/publications/RMPmethods2.pdf

• Method to synthesize research in the context of systematic reviews that uses a narrative approach to summarize findings.
• Does not exclude numerical analyses and can occur alongside Meta-analyses
• Combines heterogeneous studies, and has not (yet) been developed according to consensual structurally and thematically coherent framework to describe a complex body of evidence

Good place to start – not exhaustive
Health Sciences Library, McMaster University.
Tips for Searching for the Evidence [Internet] [cited
2012 1/8/2012]. Available from: http://hsl.mcmaster.ca/education/nursing/ebn/search.htm

• Booleans, Brackets, Truncation, Quotation marks
– These features apply to most but not all Health and Science Databases
– If you are not sure, always check the Help Menu to see the syntax for the database you are searching

Use Boolean Logic to put together your search terms:
AND
OR
NOT

AND: Finds those citations that contain both search terms joined by AND
AND is used to find the intersection of different concepts
AND

i i i i i
i i i i i i i i id i id i id i id i id d d d d d d
d d d d d
AND

and brackets:
()
OR: Finds citations with ANY search terms joined by OR
OR is used to join synonyms and related terms of the same concept: isolation OR quarantine read: either isolation OR quarantine OR both
N.B. use brackets if you have more than one term for a concept: (isolation OR quarantine)

i i i i
i i i i i i i i i i iq i iq i iq i iq q q q q q q
q q q q q
OR

NOT: Finds citations that DO NOT contain these search terms
(check the database syntax to see what is used for the exclusion term e.g. some use BUTNOT)
NOT is used to exclude a set of results when you find that you are too many false hits on an unrelated topic
(Isolation OR quarantine) NOT seclusion

i q q i i q q i
Isolation i i i i is i i i iq i q is
Quarantine q q q q q q q sq
(isolation OR quarantine) s
Seclusion s s s s

• Truncation symbol: * To use truncation, enter the root of a search term and replace the endings with an *.
– Example: typing nurs* will find the words nursing, nurse, or
nurses as well as nursery, nurseries etc.
• Wildcard symbol: ? To use the wildcard, replace each unknown character with a ?.
– For example, type wom?n to find all citations containing woman or women.
– NB: the wildcard replaces a single character, so behavio?r will only retrieve behaviour and not behavior because the number of characters do not match
• Note that different databases may have different symbols and techniques for
Wildcard and Truncation

• MEDLINE and CINAHL- the search: well being will find
well and being anywhere in the text fields
In Medline, to find the phrase well being search: well being
Searching well adjN being will find articles where well and being are within N words from each other in any order
In CINAHL, to find the exact phrase well being search: ”well being”
Different databases may have additional operators such as
Adjacency Operators – check the Help Files for these

Which phrases would you find with the search:
Isolat* AND depress*
1. Isolation is associated with falls
2. Quarantine is required for SARS
3. Isolation can trigger depression
4. Isolation is associated with adverse effects
5. Is depression an outcome of isolation?

Which article(s) would you find with the search
Isolat* OR quarantin*
1. Patients with MRSA are isolated
2. In vitro protein isolation
3. Quarantine prevents the spread of rabies
4. DNA purification is a complex process
5. Both isolation and quarantine can have detrimental effects on emotional well-being

Which phrases would you find with the search:
(isolat* OR quarantin*) AND (depress*) NOT seclu*
• Isolation can lead to depression
• Quarantining patients with MRIs can trigger depressive symptoms
• Rabies was isolated from quarantined raccoons
• Does severe depression warrant seclusion?

1. Identify a problem for investigation
2. Develop a structured research question
3. Identify key concepts in the question
4. Develop a Keyword search strategy by identifying searchable terms: a) Find keywords: synonyms & related terms for each concept b) Combine with Boolean Logic
5. Subject Heading Search – using MeSH or equivalent
6. Select sources of evidence e.g. databases
7. Test search with vocabulary suitable to the database
8. Modify your search strategy if necessary
9. Run the search
10. Retrieve articles and appraise them for suitability

• Determine a Problem that you want to investigate:
• Example Problem:
Current practice requires that patients with multidrug-resistant infections be place in isolation. However, isolation has recently been associated with adverse effects on patients’ mental well-being.

• Develop a Question that will focus the information you will be gathering
• Example Structured Question:
Does patient isolation increase the incidence of depression?

• What are the main concepts in your question?
Does patient isolation increase the incidence of depression?
Concept 1: patient
Concept 2: isolation
Concept 3: depression

a. Identify keywords from the concepts
Q: Does patient isolation increase the incidence of depression ?
Concept 1:
Patient
Concept 2: Concept 3:
Isolation Depression
Quarantine Mental health
Mental wellbeing
Mental well being
Mental well-being
Psychological impact

• Combine synonyms within each concept with
OR:
Concept 1: patient
Concept 2: isolation OR quarantine
Concept 3: depression
Concept 3a: mental OR psychological
Concept 3b: health OR wellbeing OR wellbeing OR well being OR impact

• Identify alternate endings for each word:
Concept 1: patient[s]
Concept 2: isolat[ion, ed] OR quarantin[e, ed]
Concept 3: depress[ion, ed]
Concept 3a: mental[ly] OR psycholog[y, ical, ically]
Concept 3b: health[y] OR health[y] OR wellbeing
OR well-being OR well being OR impact

• Replace different endings with truncation symbol * and insert quotation marks to search for phrases:
Concept 1: patient*
Concept 2: isolat* OR quarantin*
Concept 3: depressi*
Concept 3a: mental* OR psychologic*
Concept 3b: health* OR wellbeing OR wellbeing OR “well being” OR impact*

Patient* AND (Isolat* OR quarantin*) AND
(depressi* OR ( (mental* OR psychologic*) AND
(wellbeing OR “well being” OR well-being OR health* OR impact*) ) )
N.B. Make sure all of your brackets “add up”
Run this search in all the databases you have selected
N.B. Some databases don’t support nested Booleans

• If you find you get very many results, chances are that a systematic review has already been conducted to synthesize the evidence.
• Limit your search to the available limits
OR select Additional
Limits to focus your search

• Make searching in MEDLINE so powerful.
• MeSH are specific terms that are used to index articles in MEDLINE.
– They are hierarchically organized and linked to express the specificity of topics so that narrower terms are more granular, and broader terms are more general.
– They provide a consistent way to find articles that are
about the same topic but use different terminology.
• CINAHL also features MeSH headings as well as CINAHL subject headings

Keyword search:
Cancer
Neoplasms cancer
Tumor
Tumour
Tumours
GERD
Abstract mentions esophageal cancer

Keyword search:
Cancer
Neoplasms cancer
Tumor
Map to SH
Tumour
Tumours
GERD
Abstract mentions esophageal cancer

Keyword search:
Cancer
Neoplasms cancer
Tumor neoplasms
Tumour
Map to SH
Tumours
GERD
Abstract mentions esophageal cancer

– Identify each concept in the topic and its synonyms
– Search one term (KW) at a time to find Subject
Headings that match the concepts
• combine subject headings for one concept with OR
• combine Different concepts with AND
– Initially try to keep your search broad to ensure that you find enough relevant articles.
– Once you have determined how many results you have and assessed their quality, you can refine your search with
• subheadings AND/OR limits

• Reviews
• Therapy
• Diagnosis
• Prognosis
• Causation-Etiology
• Economics
• Clinical Prediction
Guides
• Qualitative
• Costs
• Maximizes sensitivity
• Maximizes specificity
• Best balance of sensitivity and
Specificity

• Clinical Queries: http://www.ncbi.nlm.nih.gov/pubmed/clinical
– Results of searches are limited to specific clinical research areas:
• Clinical Study Categories:
– Therapy
– Diagnosis
– Etiology
– Prognosis
– Clinical Prediction guides
• Two types of retrieval emphasis:
– specific
– sensitivity

• Clinical Queries include:
– Therapy
– Prognosis
– Review
– Qualitative
– Causation (Etiology)
• Emphasis – strategies
– High sensitivity
– High specificity
– Best Balance

• Includes six databases:
– Cochrane Database of Systematic Reviews;
– Cochrane Central Register of Controlled Trials;
– Cochrane Methodology Register;
– Database of Abstracts of Reviews of Effects;
– Health Technology Assessment Database;
– NHS Economic Evaluation Database
• Search with keywords

(Medline)
Step 1: Select a reference by clicking in the checkbox
Step 2: click Export in the toolbar
Step 3: This opens a window for exporting directly to
RefWorks
Step 4: Click Save
The RefWorks Login window will open
Step 5: Log into RefWorks to complete the export
See RefWorks handout for more details

(CINAHL)
Step 1: Select a reference by clicking Add to Folder
Step 2: Go to Folder View
Step 3: Export opens a window for exporting directly to
RefWorks
Step 4: Click Save
The RefWorks Login window will open
Step 5: Log into RefWorks to complete the export
See RefWorks handout for more details

1. Observe and analyse the situation
2. Ask a focused question from a clinical observation that can be answered through research and other evidence sources. based on PICO: OR based on PS:
– P atient or Problem
– I ntervention or treatment
– C omparator or Control
– O utcome
– Patient
– Situation based on PCD:
Levine and Feldman, 2006, pg 232
– Patient
– Cues
– Differential diagnosis

3. Search for the best evidence available from the Hierarchy of Pre-processed Evidence
4. Appraise it for validity and suitability to answer the questions by asking:
– What is the validity of the evidence I have uncovered?
– Are the results of the studies clinically, (educationally OR administratively depending on your question) significant or important?
– Is the evidence usable with my population of patients, (students
OR nurses) in the setting in which I practice?
Levine and Feldman, 2006

5. Integrate the evidence with clinical expertise and patient’s perspectives in the care of the patient
– Clinical expertise refers to our assessment of the patient’s condition through subjective history-taking combined with the objective findings of lab results and physical examination results.
– Patients’ perspectives include their belief and value systems combined with their life choices and treatment choices.
6. Evaluate effectiveness of the care/treatment and whole process
– This includes self-evaluation as an integral part of reviewing the process we have just gone through to answer the question.
Levine and Feldman, 2006

including Quantitative and Qualitative Studies modified from Levine and Feldman, 2006, pg 179
1.
Evidence from a quantitative systematic review or meta-analysis of all relevant Randomized Controlled Trials or Evidence-Based Clinical
Practice Guidelines based on systematic reviews of RCTs
2.
Evidence from at least one well-designed Randomized Controlled Trial
3.
Evidence from well-designed controlled trials without randomization
4.
Evidence from well-designed case-control and cohort studies
5.
Evidence from Meta-synthesis i.e. systematic reviews of descriptive and qualitative studies
6.
Evidence from integrative reviews
7.
Evidence from a single descriptive or qualitative study
8.
Evidence from opinion of authorities or expert committees

Therapy
Cost
Diagnosis
Prognosis
Etiology/Harm
Prevention
Randomized controlled trial (RCT), cohort, case control, case series
Cohort studies with comparison to gold standard test
Cohort studies, case control, case series
RCT, cohort studies, case control, case series
RCT, cohort studies, case control, case series
Economic analysis http://www.ebbp.org/course_outlines/searching_for_evidence/#AA

Quantitative Studies http://libguides.ucalgary.ca/nurs385 http://www.library.ualberta.ca/uploads/HealthSciences/200717155.pdf
Systems
1. Computerized Decision Support Systems
Links best evidence with electronic patient records
Summaries 2. Recommended Practice Guidelines
Synopses of Syntheses
Synthesis
3. Summarizes findings in a high-quality systematic review to answer a focused clinical question
4. Systematic Review consolidates literature on a specific topic
Synopses of Single Studies
5. Synopsis of single high-quality study that can inform practice
Studies 6. Single Peer-reviewed articles

• Primary studies are the least critically appraised of all the levels of evidence, and so are the last resource to use if there are no higher levels of evidence available.
• They include Quantitative and Qualitative Research articles with Randomized Control Trials (RCT) considered to be the highest level
• Can be accessed through databases such as:
– CINAHL
– MEDLINE(Ovid and PubMed)
– Proquest Nursing and Allied Health
– Embase (accessed from SCOPUS)

• Synposes of Single Studies provide a brief, sufficiently detailed summary of a high-quality study that can inform clinical practice.
– Evidence-based nursing (open access journal)
– Evidence-based midwifery
– Bandolier (UK)
– Health Services/Technology Assessment Texts
(HSTAT) (NLM-US)
– ACP Journal Club

• Systematic Reviews summarize and analyze the primary literature on a specific topic.
• Identify all relevant studies
• Review study relevance and Evaluate methodologies
• Extract and analyze data
• Draw conclusions based on common findings, themes
• Examples:
• Nursing+ (McMaster University)
• Evidence Based Medicine Reviews : Cochrane DSR, ACP Journal
Club, DARE and CCTR
• Joanna Briggs Institute – Systematic Reviews
• The Cochrane Library (public) access from YorkU: EBM Reviews
• CINAHL and MELDINE

• “Systematic reviews provide a summary of the literature on a particular topic.
• They summarize …, appraise and communicate the results and implications of otherwise unmanageable quantities of research.
• Systematic reviews bring together separately conducted studies (sometimes with conflicting findings) and synthesize the results.
• In this way they contribute to the evaluation of both existing and new technologies and practices.”
Canadian Best Practices Portal

Short summaries of high-quality systematic reviews including commentary on the methodology and clinical applications of the review
• They are short but often offer enough information to support clinical decisions
– Canadian Best Practices Portal
– Worldviews on Evidence-Based Nursing (journal)
– Centre for Reviews and Dissemination
– Database of Abstracts of Reviews of Effects (DARE)
– www.health-evidence.ca
(DiCenso A, Bayley L, & Haynes RB. 2009)

“Summaries integrate best available evidence from the lower layers (drawing on syntheses as much as possible) to provide a full range of evidence concerning management options for a given health problem.”
(Haynes, 2006 p 162)

• Recommended Practice Guidelines integrate evidence-based information about specific nursing issues and provide regular updates:
– CNO Compendium of Standards of Practice for
Nurses in Ontario
– RNAO Nursing Best Practice Guidelines
– The Canadian Best Practices Portal
– National Guideline Clearinghouse
– Joanna Briggs Best Practice Information Sheets

• Computerized Decision Support Systems
– Evidence-based clinical information systems integrate and summarize all relevant and important research evidence about a clinical problem.
– Are updated as new evidence becomes available
– Link best evidence with electronic patient records
– E.g. UpToDate and MedWeaver

http://libguides.ucalgary.ca/nurs385 www.oahpp.ca
Systems
Computerized Decision Support Systems
Links best evidence with electronic patient records
Summaries Recommended Practice Guidelines
Synopses of Syntheses
Synthesis
Summarizes findings in a high-quality systematic review to answer a focused clinical question
Systematic Review consolidates literature on a specific topic
Synopses of Single Studies
Synopsis of a single high-quality study that can inform practice
Studies Single peer-reviewed articles

• Evidence based nursing : A guide to clinical practice (c2005).
In DiCenso A., (Ed.), . St. Louis, MO ;: Mosby.
• Evidence-based medicine: Mini manual. (2007). Retrieved
5/31/2013, 2013, from http://www.library.ualberta.ca/uploads/HealthSciences/2007
17155.pdf
• Teaching evidence-based practice in nursing : A guide for
academic and clinical settings (c2006). In Levin R. F., Feldman
H. R.(Eds.), . New York: Springer Pub. Co.
• Whittemore, R., & Knafl, K. (2005). The integrative review:
Updated methodology. Journal of Advanced Nursing, 52(5),
546-553. doi: 10.1111/j.1365-2648.2005.03621.x

Ilo-Katryn Maimets ilo@yorku.ca
416-736-2100 x33927