The Second Step: Access

In this module, we will delve into accessing the evidence/searching for literature to help answer your clinical question. A treasure hunt for evidence!

Content includes:

1. Introduction to accessing/searching evidence in databases
2. Peer-reviewed articles
3. Primary and Secondary sources
4. Evidence hierarchy
5. Research versus Practice/Theory Articles
6. Literature Searches
   • Databases
   • Keywords and Search Terms

Objectives:

1. Explain what constitutes a peer-reviewed source
2. Differentiate research articles, practice articles/theory articles or informational articles.
3. Understand the steps in doing a literature search.
4. Explain the evidence hierarchy
5. Identify search strategies for finding evidence.

Peer-Reviewed Sources

An evidence/literature search is a very organized search in which keywords and phrases are used to find peer-reviewed sources on a specific topic and/or to answer a clinical question. A well-thought-out search will reveal articles that are current, reliable, valid, accurate, and pertinent.

Evidence-based practice should be based on the best evidence that comes from peer-reviewed articles. A peer-reviewed source means that the content has been reviewed by an expert in that field before it is published. The peer review process is blinded, which means the article author does not know who is reviewing their work and vice versa. When an article is submitted to a journal for publication, the journal will send the de-identified manuscript (to remove the author’s name) to expert peer reviewers (usually multiple reviewers). The potential article is reviewed, edits and revisions are suggested (if applicable) and sent back to the author, the author makes the revisions, and only then the article is published. Sometimes, submissions are rejected entirely if the content does not match the goal of the journal or if the article is deemed to have lack of rigor, validity, or accuracy. This laborious process results in a well-written and accurate source of information.

Peer-reviewed articles include the author’s title and credentials, a reference page, research data, and research analysis as a minimum. Peer-reviewed sources are considered to be of a higher quality, although the consumer/reader should still critically appraise when reading the published content.

Hot Tip! Remember this important point: Editorials, book reviews, opinions, and informational content are not peer-reviewed, even when found in a peer-reviewed journal. Keen eyes with the knowledge of how to critically appraise evidence will spot these.

Research Articles, Practice/Theory Articles, and Informational Articles

Pertinent to the last statement in the above section, let’s discuss the different types of articles you may stumble upon when performing your search for evidence.

Primary sources:

Primary sources are articles that are written by the researcher that actually performed the study. 

Knowledge to application link.

Here is an example of a primary study/source.

Secondary sources:

Secondary sources are descriptions of someone else’s study. They are pre-appraised evidence. They are not written by the researcher that performed the study. Literature reviews, therefore, are secondary sources. The EBP poster that you are creating is indeed considered a “secondary source”, because you did not conduct the research that you are summarizing.

Types of secondary sources in research include:

• Systematic Reviews: These merge and synthesize findings from various studies.
• Meta-Analyses: A technique for integrating multiple research findings statistically.
• Metasyntheses: Less about reducing information from multiple (qualitative) studies and more about interpreting it.

It is important to note that systematic reviews are essential in EBP. They are rich in information that multiple experts have reviewed. Considered to be the top database for systematic reviews is the Cochrane Library (contains systematic reviews, clinical answers, and is a central registry of controlled trials). This portal allows users to search several databases containing evidence-based medical resources: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessments, and Cochrane Central Register of Controlled Trials. Another top database is the Joanna Briggs Institute Evidence-Based Practice Database (evidence summaries, systematic reviews, recommended practices, and best practice information sheets). These are wealthy in information to begin your evidence search. See what articles they reviewed, as those are most likely primary sources and perfect for your EBP project.

Now that we know the difference between primary and secondary sources, let’s look at some types of articles that you may find when doing your search for evidence.

Knowledge to application link.

Here is an example of a secondary source. Now, this one could be tricky. Even though it says “An Integrative Review” in the title, the abstract states “this study…” in the conclusion, which could trick the unknowing eye.

 

Research versus practice/theory and informational articles:

For any evidence-based practice, and especially for your EBP project for this course, it is imperative to use actual research articles. As you are beginning to seek evidence to help answer your clinical question, there needs to be a focus on determining which type of article you are reading. Utilizing a non-research article can result in an invalidated review of evidence, as it would not be evidence but instead just anecdotal information or opinion. While the information contained in non-research articles may provide a breadth of information, they do not have utility in a review of evidence because they do not address the central question: “What is the current state of evidence on this research problem?” (Polit & Beck, 2021).

Here are some guidelines to look for when determining a research article from non-research:

A research study must:

• Ask a research question (or allude to the question)
• Identify a research population or sample
• Describe a research methodology
• Test or measure something
• Summarize the results

Examples of article types that are not research studies:

• Literature reviews (these are reviews of multiple, independent studies)
• Meta-analyses (these are analyses of multiple, independent study findings)
• Editorials
• Case studies
• Comments or letters relating to previously published studies
• General informative articles without a research methodology or research question

Steps of a Literature Search

A literature search is an organized and systematic process of finding relevant information on a specific topic or research question. It is a critical step in the research process, helping you to understand what has already been studied, identify gaps in the literature, and develop a theoretical framework.

Here are the key steps involved in conducting a literature search:

1. Define the Research Question or Topic
Clarify your objectives: Clearly define what you are looking to explore or investigate.
Develop research questions: Formulate specific, focused questions or hypotheses that guide your search.

2. Identify Key Concepts and Keywords
Break down your topic into main concepts and related terms.
Generate keywords: Use synonyms, related terms, and variations of your key concepts.
Consider Boolean operators: Use operators like AND, OR, and NOT to refine your search.

3. Select Appropriate Databases and Resources
Choose databases: Depending on your field, select relevant databases (e.g., PubMed for medical research, JSTOR for humanities, CINAHL for nursing, etc.).
Explore other resources: Consider books, conference proceedings, government reports, and reputable websites.

4. Conduct the Search
Enter keywords: Use your keywords in the selected databases.
Use filters: Apply filters like publication date, language, type of source (e.g., peer-reviewed), and subject area.
Adjust your search strategy: Refine your keywords and filters based on initial results to improve relevance.

5. Review and Refine Search Results
Screen titles and abstracts: Quickly assess which results are most relevant to your research question.
Evaluate the sources: Consider the credibility, relevance, and quality of each source.
Modify search terms if needed: Based on the initial findings, refine your keywords or search strategy to capture more relevant results.

6. Collect and Organize the Literature
Save relevant articles: Use citation management tools like EndNote, Zotero, or Mendeley to save and organize your sources.
Download full texts: Ensure you have access to the full articles, not just abstracts.

7. Analyze and Synthesize the Information
Identify key themes: Look for common findings, trends, gaps, and contradictions in the literature.
Evaluate methodologies: Assess the methods used in the studies to understand their strengths and limitations.
Synthesize information: Integrate findings from multiple sources to provide a comprehensive view of the topic.

8. Document the Search Process
Record search strategies: Keep a detailed record of databases used, search terms, filters applied, and dates of the searches.
Track references: Ensure you have complete citation information for each source for proper referencing in your work.

9. Review and Update Regularly
Stay current: Research is continually evolving, so periodically update your literature search to include the most recent findings.
Adjust scope as needed: As your understanding deepens, you may refine your search parameters or explore new avenues of inquiry.

10. Prepare the Literature Review
Organize the findings: Group the literature into themes or categories.
Write the review: Summarize and critically analyze the existing research, highlighting key insights, gaps, and the relevance to your research question.

Following these steps systematically will help ensure that your literature search is thorough, focused, and aligned with your research objectives.

The Evidence Hierarchy

Alright, let’s chat about how strong any piece of literature may be. Most EBP and research textbooks talk about the “evidence hierarchy” as it relates to bias and strength of rigor. There is some debate as to if “rigor” and “best evidence” is synonymous. The answer? No. Rigor and “best evidence” do not go hand-in-hand. If I could, I would remove the phrase “evidence hierarchy” and change it to “category of evidence”.

Here is why. When textbooks talk about the evidence hierarchy, they are referring to the potential for bias behind the study, with little regard to the actual clinical question the study was asking.

Let’s back up and think about this.

At the pinnacle (top) of most evidence hierarchy diagrams is the systematic review. Systematic reviews are a careful synthesis of multiple primary studies related to each other by using strategies that reduce biases and random errors. At the bottom of the diagram are expert opinions and case reports. When the hierarchy model was made, it reflected the Cochrane Collaboration’s initial focus on evidence as it related to the effectiveness of therapies rather than about broader health care questions (Polit & Beck, 2021). Indeed, as we look near the top of the diagram, we can see that randomized controlled trials (RCTs) are a high level of evidence. RCTs are well suited for medical therapies (think double-blinded pharmaceutical trials).

Randomized controlled trials (RCTs) are often hailed as “the gold standard” for quantitative research studies in health care because they allow the researcher to control the experiment and isolate the effect of an intervention by comparing it to a control group. This minimizes bias. However, the inclusion and exclusion criteria for participation can be quite strict and the high level of control is not consistent with real-world conditions, which can reduce the generalizability of findings to the population of interest (Applied Statistics in Healthcare Research).

However, if we look at the strength of evidence as it relates to medical therapies, we are placing the evidence from non-RCT and qualitative research “lower”. Let’s think about this. If our clinical question is qualitative in nature and we are trying to find out about the lived meaning of, for example, living with cancer, our highest level of evidence would not need to be at the top of the pyramid as it would not be applicable to have an RCT to measure a lived experience.

Here’s another diagram with various levels of evidence:

This is a summary of yet another hierarchy:

Thankfully, nurses spoke up and resisted a standardized hierarchy of evidence for EBP. You will now find various diagrams showing the rank of evidence as it pertains to the clinical question. Level 1 remains systematic reviews, but level II includes some categories that would be amenable to focused clinical questions related to descriptive questions and meaning questions.

Here is a modified evidence hierarchy for various types of EBP questions:

Finally, this diagram developed by Polit and Beck (2021) seems to be the easiest and most descript. This next diagram is what should be used for your Synthesis of Evidence Worksheet.

With all of this said, what are your best evidence sources for your EBP project? Well, it depends! But, mostly, you will not need to worry about finding Level I studies as we will be focusing on just primary sources. You will most likely find a wealth of Level II and III, and sometimes Level V articles for your therapy/intervention questions.

Here is a helpful table that differentiates the appropriate research methodologies for various research questions.

Let’s watch a helpful video about evidence hierarchies: Understanding Levels of Evidence – What are Levels of Evidence?

BCPhysio. (2012). Understanding ‘levels of evidence’ – what are levels of evidence?

. https://www.youtube.com/watch?v=5H8w68sr0u8

Search Strategies for Finding Evidence

Scholarly databases are updated frequently to hold the latest evidence, and these are the best choices for finding relevant evidence to answer compelling research/clinical questions. For an EBP venture, one of the best places to begin finding evidence are systematic reviews, clinical practice guidelines, or meta-analyses. Why? Well, preprocessed evidence is often appraised by an entire team, which means that the research conclusions are usually cross-checked, fairly objective, and accurate. This takes some guesswork out of finding the best evidence. However, be sure it is current. Is it within the last few years? If so, chances are good that you are on the right track.

However, for our EBP project, as it is a rapid literature review, we need to stick with primary articles. You may indeed look at secondary articles as a starting point, as they offer great overviews and have rich and valuable bibliographies (take a look at the primary articles that they are reviewing).

Novices to searching through databases for evidence are encouraged to contact the healthcare librarian who may be able to assist you with finding the most appropriate databases, search terms, and search phrases, and help to refine your search.

Literature Searches in Databases:

The first step in finding literature is to determine which databases you will search within. There are many options to choose from. Bibliographic databases are available to you from within the university library through EBSCO host.

First, navigate to the university library: library.utahtech.edu

Second, click on “Article Databases”:

Third, click on “Subject List”:

Fourth: Select subject of “Medicine and Health”:

Fifth: This will take you to the databases. They are already in order of most helpful for nurses! That’s wonderful! CINAHL is specific to the nursing field and has a wealth of articles specific to evidence-based practice. ProQuest Nursing and Allied Health Source is also wonderful and very nursing specific.

Once you select the database, this will take you to some advanced options. Before we watch a couple tutorials on that (for CINAHL and PubMed), let’s chat about some search terms and phrases to begin you search.

Hot Tip! While Google Scholar is an enticing option in searching for your articles, it also contains information that is not completely vetted. It is a great place to start to get an idea of what may be out there on a topic and identify some potential useful articles. It is always best to use a discipline-specific database like CINHAL, PubMed, etc.

Literature Search Terms/Phrases:

This textbook has included an Appendix A2, titled “The Evidence-Based Practice Question Development & Search Tips Checklist” for your assistance in developing your clinical question and starting your literature search. This would be an excellent time to pull that up. You are expected to use this document to guide you as you work on your project.

There are three major strategies to use when searching for applicable evidence to help answer a clinical question: Keywords, subject headings, and title searching. They each have their strengths and weaknesses. There is no perfect search! It takes various methodologies to find the articles that are most pertinent for your clinical question.

Keywords: The keywords used to generate a search are directly from the PICO clinical question. Well, that makes it easy to start! The PICO does the work for you in a sense. You will use the PICO to plug in keywords to help start your search.

The biggest challenge with keyword searching is that most words have various synonyms, alternate spellings, plurals, and similar words that might not be identical to your own PICO words. “Behavior” might be spelled “behaviour” in English journals, “mouse” might be “mice” in pertinent articles, etc. Keywords can absolutely be jargon-laden or even ambiguous. Think outside of the box and come up with as many various word choices, plural/singular versions, and spelling options as possible.

For example, if your population is “postoperative heart surgery inpatients”, you might utilize various keywords for heart such as “cardiovascular”, “cardiac”, “heart disease”, and so on. For “inpatients”, you might utilize various keywords such as “admitted”, “inpatient” [singular], “hospitalized”, etc.

Another weakness of keyword strategies is that even though your keywords might appear in the article, it does not mean that the article has these concepts as major topics. Remember – titles can be misleading! Similarly, keywords can be misleading. Also, the author of the article may not have actually used the keywords that you are using, so you might even be missing critical articles that would be helpful for you. Yikes!

If you use only keyword searches, you might wind up with huge result fields. At this point in knowledge acquisition, you might not have the ability to quickly target the articles that are most meaningful and have the most validity for your clinical question. This can wind up wasting a huge chunk of time! So, don’t depend on just keyword search strategies.

Subject Headings: Next up is subject heading searches. All articles in a database are coded in some way so that they can be retrieved, and they do this by categorizing entries. The indexing systems have specific subject headings so that all you need to do is start by entering the subject of which you are interested. The software within the database simply translates your keywords into the most plausible subject heading and then retrieves records that have already been coded with that subject heading. Much like doing an internet browser search, sometimes results will be pertinent and sometimes you may have to continue to refine your search. You also may need to search in multiple databases, as not all databases code their subject headings the same. All that is to say: Keep searching! You definitely want to do as an exhaustive search as possible.

Title Searching: Whew! Okay, one more search strategy to discuss and that is “Title Searching”. This type of strategy utilizes your P, I, and O terms in the title and increases the chance of finding relevant articles. However, you should not attempt this strategy lightly as you need to know the keywords that are most frequently used. As we are just beginning nursing students at this point, this strategy may be beyond our skill level. The weakness of this method of searching is that if authors do not use your terms in their title, you could miss the very best evidence.

Here is a handy table that shows the strengths and weaknesses of the three types of search strategies:

Melnyk & Fineout-Overholt, 2015

Now, when you enter a keyword into a search field in any database, the search will be launched into both a subject search and a textword search. A textword search looks for the keyword that you entered within the text fields of its records. In other words, it will look for that keyword in the title and the abstract. Now, remember above where it was mentioned that databases use coding systems? If you search for lung cancer, the search would retrieve citations coded for the subject code of lung neoplasms. Additionally, it would also retrieve any entries in which the phrase lung cancer appeared even if it had not been coded as lung neoplasm in subject heading (Polit & Beck, 2021).

Truncation: Truncation or wildcard symbols help to eliminate the need to search for plurals or a variant ending to a word. It greatly enhances your chance to find relevant studies. To truncate a word, part of a word is followed by an asterisk (*). For example, to find all versions of the word “nurse”, one would enter “nurs*” and then would result in: nurse, nurses, nursing. If one entered “foli*”, results would include “folic”, “foliage”, “folies”, etc. Some databases utilize truncation just a little differently, so be sure to know how to use truncation in whatever database you are searching. Sometimes a question mark (?) is used instead of an asterisk.

Boolean Operators: We have the option to enter multiple concepts into the search system when we utilize the PICO format. However, the disadvantage of doing so is that there is no way to determine which concept has the most evidence available.

Let’s look at an example of this.

Perhaps our PICO clinical question is: Does adjunctive music therapy in addition to pharmaceutical pain management alone, decrease reported pain levels in postoperative patients?

When “music therapy” and “pain management” were entered separately, it yielded 98 and 432,181 hits, respectively. There is clearly more written about pain management than music therapy. However, my question wants to see how music therapy and pain management interact, yes? Therefore, I am interested in seeing articles that researched this adjunctive method of music.

This is where the Boolean operator comes in. When a search of “music therapy” AND “pain management” was entered, the search yielded 62 studies. Remember, it is important to consider that out of a possible 98 studies, only 62 were found to contain both terms. Thus, it may not be possible to enter each PICO term individually with every search due to competing clinical priorities. However, it is really the best method to fully understanding what evidence exists to answer the clinical question.

Let’s look at the various Boolean operator options:

“AND”: The Boolean operator “AND” is used to combine subject headings or keywords. It limits the search, because it forces the database to search only for articles that have both entries combine.

“OR”: This is also used to combine subject headings or keywords. However, it expands the search. This Boolean operator is great to use when using synonyms or concepts.

“NOT”: This is used less frequently. It limits your search by eliminating terms from the results.

Limiting Searches: Finally, databases have various options to limit searches. Limiting searches helps to pare down the results to be more specific in helping to answer your clinical question. Some items you can checkmark in which to narrow your results include:

• Year of publication
• Age
• Gender
• Full-text (where the full article is available; but, use with caution as it eliminates potential wonderful evidence in non-full-text articles.)
• Peer-reviewed
• Academic journals
• And, so on.

Time is one such limiter. All EBP projects should be based on current information. Most scholars use five to seven years as the time frame for what is considered current. Some scholars use five years, and some use ten years. For the sake of the EBP project for this course, 10 years is the extreme limit. Five years is a much safer timeframe to use.

Lastly, as noted above, be wary when limiting searches to full-text. If you have a result in which the article seems helpful in answering your question, there is the option of interlibrary loan. Watch the tutorial for help in gaining access to articles. Never pay money for an article access. We have the university library at your fingertips to assist you in obtaining the full article!

Now that we have formulated our PICO and we know how to search for articles, start searching on your own and find 10-12 articles to start with and keep track of these on your Synthesis of Evidence Worksheet.

You will also need to keep a record of your methodologies (search strategies) in finding the most relevant articles. Remember, your instructor should be able to duplicate your search strategy and find the same articles (or very close to it). Your methodology should be able to be duplicated by others.

Keep track of the following search strategy methodologies as a minimum:

• Databases
• Keywords
• Limiters
• Boolean operators
• Result numbers

Here is a very helpful website that may help you to visualize how to insert your search terms in a database (in their example, CINAHL):

https://simmons.libguides.com/c.php?g=1033284&p=7490077

Here is a tutorial about searching in CINAHL: Searching CINAHL (Academic)

EBSCO. (2020). Searching CINAHL (Academic) 

. https://vimeo.com/403791714

Here is another tutorial about searching in PubMed: Searching PubMed,  https://libguides.ohsu.edu/ebptoolkit/levelsofevidence

Citing and Referencing Sources

This bring us to “APA formatting”. As you already know, when utilizing information from a source (internet, book, article, etc.) you must cite and reference the source in order to give credit to the original author. “APA” stands for the American Psychological Association who have established the standard of procedure with regard to the process of signifying original authors’ content as well as providing procedures for academic and profession writing. The APA Style is a set of guidelines for clear and precise scholarly communication that helps authors achieve excellence in writing.

The American Psychological Association (APA) formatting style serves several important purposes in academic and professional writing:

1. Clarity and Consistency: APA formatting provides a standardized structure for academic papers, ensuring a consistent and clear presentation of ideas. This uniformity makes it easier for readers to navigate and understand the content.
2. Credibility and Academic Integrity: Following APA guidelines demonstrates a commitment to academic integrity and professionalism. It shows that the writer has taken the time to present their work in a standardized, recognized format widely accepted in the academic community.
3. Communication of Ideas: APA formatting includes specific elements like in-text citations and a reference list, which help in properly crediting and acknowledging sources. This promotes transparency and allows readers to trace the origins of ideas and information presented in the paper.
4. Facilitation of Review and Replication: For scholarly research, APA formatting aids in the review and replication of studies. By providing clear and organized information about research methods, results, and references, researchers can more effectively evaluate and build upon existing work.
5. Publication Standards: Many academic journals and publications require submissions to adhere to APA formatting. Understanding and applying APA guidelines increase the likelihood of acceptance for publication, as it aligns the manuscript with the expectations of editors and peer reviewers.
6. Cross-disciplinary Communication: APA formatting is widely used not only in psychology but also in various other social sciences and disciplines. Using a common format facilitates communication and understanding across different fields of study.
7. Prevention of Plagiarism: The inclusion of proper citations and references in APA formatting helps to prevent plagiarism. It ensures that authors give credit to the original sources of information, ideas, or data, maintaining academic honesty.
8. Professional Presentation: APA formatting includes guidelines for font size, margins, and other layout elements, contributing to a polished and professional appearance of the document. This enhances the overall impression of the writer’s work.

You will find resources in the Appendices of this textbook to assist you with how to format in-text citations and full reference citations (for a reference list) in Appendix D2 and Appendix E2. We will focus on how to format in-text citations and references for scholarly journal articles in this course. Your other upcoming courses may require that you also know how to cite and reference other types of published works. You will for sure be required to know APA formatting during your 4th semester, so spend the time to learn it now. If do recommend buying the spiral-bound APA Style Manual as a resource. Here is a link for you: https://apastyle.apa.org/products/publication-manual-7th-edition

If you proceed with a graduate degree, you will need to be near-expect level at APA as most graduate schools assume that you have learned this type of formatting at the undergraduate level.

We will work on formatting styles in class. However, there is one major key element that you need to memorize now: If you have an in-text citation, you must list the source as a full reference as well. And, vice versa. This is standard and must be utilized for any writing, assignments, projects, and any other type of work that you produce.

A few other tenants of APA formatting include:

• References should be in alphabetical order according to last name of the first author of a published work
• Difference sources (books, articles, websites, etc.) have different formats
• For in-text citations, APA utilized the author-date citation system (Author, Year)
• In-text citations that utilize direct quotations must include page numbers

In summary, APA formatting serves as a set of guidelines designed to improve the clarity, consistency, and professionalism of academic and professional writing. It promotes ethical conduct, aids in effective communication, and aligns with the standards of scholarly publishing.

Finally, as you start compiling articles to help answer your clinical question, you will need to keep track of these on a Synthesis of Evidence Table (see Appendix H), for which you will need to turn in. Use the Search Strategy Table to assist with your search. Be sure to check the format of the full references on the synthesis table as you proceed. This will help save some time when it gets closer to submitting the assignment.

EBP Poster Application! You should have a good selection of articles by now. Start a Google Drive Folder with your group – add more articles to it as you go. You can weed out articles that you deem not helpful later. For now, just collect pertinent articles and list the information on the Synthesis of Evidence Table. As you go, you will see that table morph.

References & Attribution

“Green check mark” by rawpixel licensed CC0.

“Light bulb doodle” by rawpixel licensed CC0.

“Orange flame” by rawpixel licensed CC0.

Hamazaki, N., Koike, T., Kariya, H., Kobayashi, S., Miida, K., & Fukuda, M. (2022). Adverse events during early mobility are not associated with poor prognosis in COVID-19-related acute respiratory failure. Respiratory Care, 67(10).

Melnyk, B., Fineout-Overhold, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Igniting a spirit of inquiry. American Journal of Nursing, 109(11), 49-52.

Okusaga, O. (2022). Effectiveness of early mobilisation versus laxative use in reducing opioid induced constipation in post-operative orthopaedic patients: An integrative review. Australian Journal of Advanced Nursing, 39(2), 23–35.

Polit, D. & Beck, C. (2021). Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research (10th ed.). Wolters Kluwer Health.