ANE 609 Literature Review-2010-Hogan-Audio

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The Literature Review:

The Literature Review ANE: 609 Research Methods University of New England Lisa J. Hogan CRNA, DNP

Learning Objectives:

Learning Objectives Demonstrate essential steps to search the literature. Compare and contrast available databases for various research designs. Discuss general considerations for an evidence based literature search. Describe several purposes of a literature review. Explain the difference between a primary and secondary source. Describe the key steps of evidence-based practice. Discuss how to rate the evidence. Identify obstacles and opportunities to evidence-based practice.

Evidence-Based Practice: Background:

Evidence-Based Practice: Background The term EBP : Is relatively new. The term began floating around in the mid 1990s, but was formally defined by Sackett et al. in 1996. EBP means integrating individual clinical expertise with the best available external clinical evidence from systematic research to meet the needs of the individual patient.

Evidence-Based Practice: Barriers:

Evidence-Based Practice: Barriers Investing in EBP can assist in: Lifelong learning and clinical performance of health care professionals. Some of the barriers encountered by nurses may include: Lack skills to evaluate research Lack of organizational support Accessibility of research findings

Evidence-Based Practice: Process:

Evidence-Based Practice: Process Five (5) step process: Formulating a searchable question Searching the literature efficiently Appraising the literature critically Applying the result to clinical practice or patient Evaluating the outcomes of the applied evidence in your practice or patient

Literature Review: Purpose:

Literature Review: Purpose Two (2) Purposes Identifies what is known about a problem area Helps clarify and establish the significance Points out gaps in current knowledge Illustrates how a problem can be best studied. Provide ideas on how variables can be measured. Provides specific procedures of studies in past.

Literature Review:

Literature Review Process Product Gather information Organize & Write Lit. Review Synthesize information Both a process and product Comprehensive & critical analysis of the knowledge of a topic. Compiling, reviewing and summarizing references.

Search Strategies for Identifying Studies.:

Search Strategies for Identifying Studies.

Developing a Search Strategy:

Developing a Search Strategy Strike a balance between comprehensiveness and precision. Comprehensiveness involves reducing precision and retrieving more non-relevant articles. It is a process which calculates a desired result by repeated cycle of operations. There is diminished returns after a certain stage and there comes a time when further search is not worth the time and effort.

Literature Search:

Literature Search Searching for research does not have to be a time consuming process. The results of your search will only be as good as the initial question you ask and what resource you are trying to use to answer that question. The first step is to reflect upon the type of information required before going to the resources.

Steps in the Literature Review:

Steps in the Literature Review Develop a clinically relevant question Read background Information Gather necessary tools List key words Check primary and secondary sources (databases) Refine or expand search as needed Determine what to read Determine the level of evidence.

Clinically Relevant Questions:

Clinically Relevant Questions The practice of EBP medicine begins with formulating a clinical question. Defining the question forces you to think about what you really want to know. A well defined question is a good start for finding relevant literature

Clinically Relevant Questions:

Clinically Relevant Questions They may arise from: Patients asking questions or looking for information Colleagues seeking advice Asking yourself what to do in a clinical situation Often the question will be open ended and ill defined EBP approach requires a well defined question.

Search Strategies: PICO:

Search Strategies: PICO Search strategies : Need to identify terminology that captures the question you are trying to answer. One of the benefits of thoughtful question development is that the search for evidence is easier. A formula to help guide this process is called PICO: Patient, Population, and/or Problem Intervention Comparison (optional) Outcome

PICO Question:

PICO Question Patient, Population, and/or Problem: Important characteristics of the patient. Description of a group of patients. Disorder and condition of interest. Intervention: Intervention, prognostic factor, diagnostic tool, or exposure. Comparison (optional): Alternative compared with the intervention? Outcome : What outcome you hope to accomplish or measure?

PICO Question:

PICO Question Patient, population and/or problem Intervention Comparison intervention Outcome Description of the patient, population and/or the target disorder of interest Examples: diagnostic test, prognostic factor, therapy, exposure Examples: standard of care, reference standard, Placebo Clinical outcome of interest to you and your patient

Example PICO Question:

Example PICO Question PICO Example: Scenario: A woman reports she experiences episodes of clammy hands, excessive sweating, and rapid heartbeat. You have determined that your patient is experiencing Post-Traumatic Stress Disorder (PTSD) as a result of the life-threatening car accident she experienced six months ago. You suggest she try psychotherapy first. Before making a referral you want to know whether or not psychotherapy provides greater benefit for treating PTSD than drug therapy or no treatment.

Example PICO Question:

Example PICO Question Patient, population and/or problem Intervention Comparison intervention Outcome Female with PTSD Psychotherapy Drug therapy or no treatment Alleviation of PTSD symptoms

Background and Foreground Information:

Background and Foreground Information Background information : Need introduction or baseline information on your topic. Handbooks, internet and textbooks often provide a foundation or introduction to an area of study and including generalized information. Background information is a convenient summary but not always the most current..

Background and Foreground Information:

Background and Foreground Information Foreground information : "Patient centered" or "Patient focused" questions are considered foreground information. These questions guide the information search for more specific and current research. These questions take into consideration specific characteristics of your patient such as age, sex, or comorbidities . Your search for foreground information will likely be guided by clinical questions: etiology, diagnosis, therapy, prevention, and harm.

Gathering Necessary Tools:

Gathering Necessary Tools Systematic gathering data will keep you organized and will prevent having to redo what you have already done. Need to keep records to include: Authors Title of reference Complete source listing Save in format (APA) Level of evidence Filing system

List Key words:

List Key words After background information, idea of the topic and should be able to generate key words. Use of a thesaurus can be invaluable. Consult the key word listings in each database Key words and phases are necessary because most databases are indexed and organized by subject PICO Question will give you key words and a focused search

Publication Types:

Publication Types Different types of publications have different characteristics: Primary Literature Secondary Literature Tertiary Literature Popular media Scholarly journals can contain all 4 types of literature (original research to opinion pieces). A core principle of EBP, is to look at the primary and secondary literature (scholarly literature) for the best evidence to inform clinical practice.

Primary Literature:

Primary Literature Primary Literature : is authored by the researchers, contains original research data, and is usually published in a peer-reviewed journal. Primary literature may also include conference papers, pre-prints, or preliminary reports. The intended audience of primary literature includes researchers and specialists, not the general public.

Secondary Literature:

Secondary Literature Secondary Literature : consists of organized works and compilations that are derived from or refer to the primary source literature. Examples of secondary literature include review articles (specifically meta-analysis and systematic reviews) and reference works. Professionals within a discipline take the primary literature synthesize, generalize, and integrate new research. Intended for colleagues with in a discipline or other fields.

Tertiary Literature:

Tertiary Literature Tertiary Literature : consists of textbooks, encyclopedia articles, and guidebooks or handbooks. The purpose is to provide an overview of key research findings and is an introduction to principles and practices within the discipline. This type of publication is an excellent resource for students.

Popular Media:

Popular Media Popular Media : The purpose of health sciences popular literature is to inform the general public about new research findings, prevention, and treatment. Popular media is often found in popular magazines, radio, newspapers, television, and web sites. The author need not be an expert in the discipline, and the aim is to summarize key concepts for the general public.

Comparison: Journal Types:

Comparison: Journal Types Scholarly Journals Popular Media Purpose Report original research in a specific field or discipline Inform readers about general topics Summarize key research findings Authors Researchers and scholars of the field or discipline Often more than one author Usually one author who is employed by the media outlet; for example, a magazine. Author not necessarily an expert in the field References References cited as footnotes or as a bibliography Usually do not have any cited references Access Library or institutional subscription Professional association membership Personal subscription Individual purchase Audience Researchers and scholars in the field or discipline General public, non-expert readers

Expanding the Search:

Expanding the Search Not enough search results or none at all? One problem is adding too many search terms. Each term decreases the number of results you retrieve. Remove search terms that are not the most important concepts of your search. Example : Do parents’ beliefs factor in how they manage their teenager’s chronic disease ? Solution: Do parents’ beliefs factor in how they manage their teenager’s chronic disease ?

Expanding the Search:

Expanding the Search Still not getting the articles you want, try different search terms. Use the same terminology as research author. Many ways to describe a concept or term: Search term 1 Parents Search term 2 Beliefs Search term 3 Teenager Search term 4 Chronic disease OR Family OR Culture OR Adolescent OR Chronic Disease OR Caregiver OR Customs OR Child OR Disability OR Religion

Refining the Search:

Refining the Search Too many search results? Finding current research is an important factor in Evidence-Based Nursing. Limit your results to the most current research (within 5 years). May be a more manageable list of references.

Refining the Search:

Refining the Search Another way to narrow, or focus, the search results is adding additional search terms related to your concern, such as: Example Add Search Term I am looking for the long term effects of X. Prognosis How to diagnosis X. Diagnosis How to stop the spread of X. Prevention

Refining the Search:

Refining the Search Consider limiting to the best study design for your question: Clinical Question Suggested Research Design Therapy RCT preferred otherwise: cohort study, case-control study, case series Diagnosis Prospective, blind comparison to a reference standard Etiology or Harm RCT preferred otherwise: cohort study, case-control study, case series Prognosis Cohort study preferred otherwise: case-control study, case series

Components of Research Articles:

Components of Research Articles Title & Author(s) Abstract Introduction Methods Results Discussion Conclusions Acknowledgements

Components of Research Articles:

Components of Research Articles Title & Author(s) : should be descriptive of the research, and generally the individual responsible for the majority of the research is the primary or first author. Abstract : The abstract should accurately represent the content of the article. Introduction : lays the foundation for the paper by stating the research problem, the rationale for the study, the research question, the hypothesis and contains a literature review.

Components of Research Articles:

Components of Research Articles Methods : The method’s section details how the study was done, including: Participants : demographic information, relevant characteristics, informed consent, and Institutional Review Board (IRB) approval Equipment (if applicable): for example, diagnostic tools Research Design : research methodology, protocol, and timeline for interventions and measurements Data Analysis : describes data collection methods and procedures for statistical analysis Results : should simply state the findings, without bias or interpretation. Research results confirm or reject a hypothesis.

Components of Research Articles:

Components of Research Articles Discussion : describes major findings, including whether the results are statistically significant. Compares the results to the current literature and describes how these results can be generalized to other situations. Limitations of the study are discussed. Conclusions : summarizes the research study. May also bring up other unanswered questions or next steps for further research. Acknowledgements : acknowledgement of grant or private funding, as well as individuals who made contributions.

Structured Abstract:

Structured Abstract Introduction and objective Research problem Rationale for the study Research question Hypothesis Methods *Participants * Setting * Research design Characteristics and number of the participants involved in the study Study location How the study was conducted Results Study results without interpretation Conclusion Summary of key research findings that includes authors ’ interpretation

Reading Abstracts:

Reading Abstracts Potential questions to ask when reading an abstract: Why is the research important? What is already known about this topic? What question is the researcher trying to answer? Can the results from this particular study be generalized to your population? What is the research methodology? How well matched is the methodology to the research question? Are the outcomes clinically important? What was discovered?


Abstracts Abstracts are only a brief introduction to the research article and do not contain all research results, conclusions, or potential faults or strengths of the study design. It is important not to base health care decisions solely on the abstract.

Levels of Evidence:

Levels of Evidence The ability to incorporate EBP into clinical care requires a basic understanding of research designs. Some research designs provide stronger levels of evidence than others based on their characteristics.

Systematic Reviews:

Systematic Reviews Systematic Review : S ummary of the medical literature. Uses strict methods to perform a comprehensive literature search and critical appraisal of individual studies. P rovide the strongest type of evidence A uthors then combine the research into a single analysis C onducted to answer a specific clinical foreground question Review articles : provide a broad overview on a topic to answer background questions unlike Systematic reviews which answer specific clinical question.

Meta- Analysis:

Meta- Analysis Meta-analysis : Particular type of systematic review Attempts to combine and summarize quantitative data from multiple studies using sophisticated statistical methodology. This strategy strengthens evidence by taking a sample size of individual studies much larger, giving the results more statistical power and more credibility. Meta-analyses are not comprehensive, as only compatible data may be combined into a larger data set.

Randomized Control Trials (RCT):

Randomized Control Trials (RCT) Randomized controlled trial : Experimental, Prospective study Participants are randomly assigned to ensure that each participant has an equal chance of being assigned to an experimental or control group, thereby reducing potential bias. Outcomes of interest may be death (mortality), a specific disease state (morbidity), or even a numerical measurement such as blood chemistry level.

Randomized Control Trials (RCT):

Randomized Control Trials (RCT) Typical RCT: Represents the flow of participants from the start of the study through the study outcome. The study starts and progresses from left to right represent prospective studies, “collecting data about a population whose outcome lies in the future.”

Example of RCT:

Example of RCT RCTs are used to measure the effectiveness of a particular therapy, especially drug therapy. Example: The intervention was behavioral. Participants were asked to adhere either to a low carb , low fiber diet or to a high carbohydrate, high fiber diet. The outcome of interest was the amount of weight loss.

Cohort Studies:

Cohort Studies Cohort study : An observational, prospective or retrospective study. Involves identification of two groups (cohorts) of patients, one that received the exposure of interest, and one that did not. These cohorts are studied forward for the outcome of interest.

Cohort Studies:

Cohort Studies Cohort studies may be prospective or retrospective. Retrospective studies : Begin and end in the present but involve a major backward glance to collect information about events that occurred in the past. Conducted on data that have already been collected, such as hospital records. Prospective studies : Framingham study Prospective studies can be time-consuming. (follow a cohort for years or decades). Participants may be lost to follow up, potentially biasing the results.

Cohort Study:

Cohort Study While at first glance a cohort study looks similar to a RCT, it differs in a very significant way: The researchers do not assign the exposure or randomize the groups in any way. RCTs are experimental, while cohort studies are observational.

Example of Cohort Study:

Example of Cohort Study Example: Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. The researchers determined how obesity was defined for this study, and then assigned participants to each group accordingly. The researchers did not manipulate the participants’ body weight.

Case Control Studies:

Case Control Studies Case-control study : Observational, retrospective study Involves identifying patients who have the outcome of interest (cases) and control patients without the same outcome. Involves looking back to see if they had the exposure of interest. Retrospective case-control studies rely on people’s memories, making them prone to error. It may be difficult to measure the exact amount of an exposure in the past.

Case Control Studies:

Case Control Studies Identify patients who have the outcome of interest (cases). Control patients without the same outcome. Look back to see if they had the exposure of interest

Example of Case Control Study:

Example of Case Control Study Example: Among people with bladder cancer, how might researchers determine the amount of artificial sweeteners used? Researchers might ask patients to self-report their estimated consumption. This method is inexact at best.

Case Series:

Case Series Case series: Descriptive report on a series of patients with an outcome of interest. No control group is involved. W eak evidence R elatively small number of patients and no experimental manipulation is involved O ften used to introduce practitioners to unusual and rare conditions, or to point out “exceptions to the rule.” Often the basis for future research using strong evidence study designs

Case Series:

Case Series

Editorials and Expert Opinions:

Editorials and Expert Opinions Editorials and Expert Opinions : The clinical experience, expertise, and judgment of a respected healthcare professional do play important roles in EBP. Sometimes no methodologically sound research to answer clinical question, and expert opinion will be important in your decision-making process. Both expert opinion and scientific research should be evaluated for selective use of evidence and other biases.

Editorials and Expert Opinions:

Editorials and Expert Opinions

Diagnostic Studies:

Diagnostic Studies Diagnosis study: Prospective study with independent, blind comparison. Diagnosis research design is different from the other types of research design discussed and is not represented in the levels of evidence pyramid. I nvolves the comparison of two or more diagnostic tests that are both applied to the same study population.

Diagnostic Studies:

Diagnostic Studies The reference standard, or “gold” standard and acts as the standard to test sensitivity and specificity against which the other test is compared. Sensitivity and specificity are two measures that describe the efficacy of a diagnostic tool in comparison to the reference standard. Sensitivity is the proportion of people with the target disorder who have a positive test result. Specificity is the proportion of people without the target disorder who have a negative test result.

Diagnostic Studies:

Diagnostic Studies To alleviate bias, the reference standard and test in question are applied independently The researchers interpreting the results are blinded to the results of the other diagnostic test. Used as an evaluation screening tools.

Clinical Questions and Research designs:

Clinical Questions and Research designs The type of question you are trying to answer often determines the best research design to seek. Example: a RCT would not be feasible for a prognosis study, so the highest level of evidence you could seek for prognosis is a cohort study. The 4 most common types of questions in EBP are: Therapy D iagnosis Etiology Prognosis.

Clinical Questions and Research designs:

Clinical Questions and Research designs Clinical Question Suggested Research Design Therapy RCT preferred otherwise: cohort study, case-control study, case series Diagnosis Prospective, blind comparison to a reference standard Etiology or Harm Cohort study, case-control study, case series Prognosis Cohort study preferred otherwise: case-control study, case series Quality Improvement RCT and qualitative studies Cost Economic evaluation

Qualitative Research:

Qualitative Research The primarily focus has been on quantitative research designs, but qualitative research does play an important role in EBP. Qualitative research focuses on how individuals (or groups) view and understand their world and experiences. Methods aimed to: Make sense of, or interpret phenomena in terms of the meanings people bring them Research that defines preliminary questions which can then be addressed in quantitative studies. In nursing, qualitative research is best for understanding the meaning of illness or patient experiences, attitudes, and beliefs

Generating a Reference List:

Generating a Reference List Translate content areas into key words or subjects. Use key words to identify relevant references. Major sources for identifying references: Computer Databases Indexes Abstracts Bibliographies


Databases Common Data Bases : Cochrane Library Medline (Pubmed) Google Scholar CINAHL psycINFO ERIC

Medline (PubMed):

Medline (PubMed) PubMed is the National Library of Medicine's search interface for MEDLINE. MEDLINE is the National Library of Medicine’s (NLM) premier reference database. 16 million citations and abstracts dating back to 1950s in the fields of medicine and allied health professions including veterinary medicine. MEDLINE is the primary component of PubMed , one of many databases provided by the National Center for Biotechnology Information (NCBI) at the NLM.

Medline (PubMed):

Medline (PubMed) MEDLINE citations, PubMed also contains: Records to articles before the are indexed and added to MEDLINE Citations to articles that are out of MEDLINE’s scope, primarily general science and general chemistry journals PubMed Central Some health sciences journals that submit open access full-text

Medline (PubMed):

Medline (PubMed) PubMed special features : Limits (e.g., language, gender, age) Spell Checker Citation links to related articles Clinical Queries Medical Subject Headings ( MeSH ) MyNCBI (customization tools for saving searching, search alerts, etc.)

PubMed :

PubMed Practical Tips for using PubMed PubMed’s search interface provides easy navigation for beginners Largely due to PubMed ability to automatically mapping your keywords to Medical Subject Headings (MeSH) Loaded with extra features to help you search more effectively and manage your results. Guides and tutorials are available through PubMed

Pub Med:

Pub Med PubMed Clinical Queries and EBP: The PubMed Clinical Queries page provides three specialized searches: Search by Clinical Study Category Finding Systematic Reviews Medical Genetics Searches Designed for busy health professionals, offers a user-friendly approach to EBP searching. Search in Clinical Studies will only work if you select the appropriate search category.

PubMed : Clinical Queries:

PubMed : Clinical Queries Not intended as a comprehensive literature search Provide a few articles, helps to make informed health-related decisions. Clinical Queries are divided into three sections: Clinical Studies : quickly locate relevant literature on etiology, diagnosis, therapy, prognosis, and clinical prevention guides. Systematic Reviews : finds citations for systematic reviews, meta-analyses, reviews of clinical trials, EBM consensus development conferences, and guidelines. Medical Genetics : quickly locate relevant literature on various topics in medical genetics.

The Cochrane Collaboration:

The Cochrane Collaboration The Cochrane Collaboration: An international non-profit organization committed to preparing, maintaining, and disseminating information about effects of health care. Established in 1993, named after the epidemiologist Archie Cochrane. Consists of several EBM databases, including the Cochrane Database of Systematic Reviews.

Cochrane Systematic Reviews:

Cochrane Systematic Reviews Cochrane Systematic Reviews: Based on the best available information about interventions in health care. Provide a single source of reliable evidence for health professionals, patients, and policy makers. Each systematic review addresses a clearly formulated question; for example: Can antibiotics help alleviate the symptoms of a sore throat? The Cochrane reviews are also indexed in PubMed , and will automatically be included in your search results. UNE Faculty and Students have access to full text.

PowerPoint Presentation:

Google Scholar: Very similar to the standard Google search engine Search results drawn from scholarly sources such as: Academic publishers Government supported research databases ( MEDLINE) University websites and Professional association websites. Google does not state its exact access to scholarly sources; this lack of transparency limits Google’s usefulness in conducting a thorough literature search.

PowerPoint Presentation:

Searches literature across many disciplines, making it useful for discovering research one might not find if only searching in a specialized database. Google Scholar orders search results by: # of times publication has been cited in other scholarly literature. "Weighing" of full text. Determine how often search term appears in text "Weighing" author and publication. Determine how often author and publication are linked in other web pages.

PowerPoint Presentation:

Should be wary of depending on Google Scholar for most up-to-date literature. A comparison search in Google Scholar and PubMed can provide very different results. Google will rank results according to their "weight". Google does not always crawl the web looking for information as swiftly as PubMed updates article citations .

PowerPoint Presentation:

Google Scholar strengths: Easy to use, familiar search interface. Filters out the extensive popular, non-scholarly sources. Searches full text of available resources. Easy cross-disciplinary searching. Provides access to full text via Library Links, for users associated with an academic library. "Cited by" allows for forward citation searching (tracks other citations within Google Scholar).

PowerPoint Presentation:

Google Scholar weaknesses: No controlled vocabulary . Indexing errors. Fewer ways to limit and filter results than other databases. Unknown coverage of research literature, possible gaps in coverage. No clear criteria of "scholarly" literature stated. Frequency of updates unclear, citations are not as current as specialized databases such as PubMed .

Other EBP Sources:

Other EBP Sources CINHAL : Cumulative Index to Nursing and Allied Health (CINAHL) database provides authoritative coverage of the literature related to nursing and allied health. PsycINFO : contains citations in the field of psychology and the psychological aspects of related disciplines, such as medicine, nursing, education. ERIC : Education Resources Information Center is a national education database sponsored by the U.S. Department of Education. Contains over one million citations in the field of education.

Other EBP Sources:

Other EBP Sources Current Opinion in An ae sthesiology : Full text Journal Up-to-Dat e: Evidence-based, synthesized medical information quickly at the point of care. It is comprised of original topics that are written, reviewed and continually updated by a faculty of physician experts. National Guideline Clearinghous e: Comprehensive database of EBP guidelines and related documents.

Other EBP Sources:

Other EBP Sources Evidence Based Medicine Reviews EBMR is a definitive resource for electronic information in the evidence based medicine (EBM) movement that combines 7 trusted EBM resources into a single, fully-searchable database. Includes Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, ACP Journal Club, Cochrane Central Register of Controlled Trials, and more. Evidence-Based Resources from the Joanna Briggs Institute : Systematic Reviews, Evidence Summaries, and Best Practice Information Sheets for nursing and the allied health professions.

Strategies for Success:

Strategies for Success Literature review is critical to ensure thoroughness, quality and usefulness of the written literature review. Don’t stop too soon Keep track of where you are. Allow plenty of time. Ask for help. Be efficient.

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