Questions and Topics We Can Help You Answering; 

Literature Searches
An important step in the EBP process is reviewing the current body of literature to better understand the subject or topic in which you are interested. By conducting a review of the literature, you are building foundational knowledge about the topic; later, you can use this background to build new insights. Developing a strong grasp of a topic can only be garnered by taking the time to thoroughly search for relevant information and resources.
For this Discussion, you will practice searching the literature to find evidence on a specific topic.
To prepare:
•    Choose a simple search term(s) relating to a topic of your PICOT question.
•    Review the information on the evidence hierarchy discussed in Chapter 2 of the course text, in the article, “Facilitating Access to Pre-Processed Research Evidence in Public Health,” and in the multimedia presentation “Hierarchy of Evidence Pyramid,” found in this week’s Learning Resources.
•    Review the information on the Walden Library’s website, “Levels of evidence.” Take a few minutes to explore the different types of databases available for each level of evidence and focus on the meaning of filtered and non-filtered resources.
•    Conduct a literature search in the Walden Library on your selected topic using the databases that you reviewed. Use at least one database for each of the three levels of filtered information and at least one unfiltered database. Record the number of hits that you find at each level of the hierarchy of evidence.
•    Select one article from the results at each level of the hierarchy. Compare the articles based on the quality and depth of information. What would be the value of each resource if you were determining an evidence-based practice?
By Day 3
Post a summary of your search. Describe what topic you selected, the search term(s) that you used, and the number of results found at each level of the hierarchy. Compare the types of information found in the articles from different levels and the value of the information from each level. Highlight a useful tip that you could share with your colleagues about conducting an effective literature search.


Information

Finding Resources for EBP Program Transcript NARRATOR: In this video, Dr. Marianne Chulay discusses finding the right standards to apply to research evidence, such as national guidelines and consensus statements by experts. She also uses her expertise to highlight what might be done in cases of conflicting evidence. MARIANNE CHULAY: Now, where do you find this evidence to support your practice? My suggestion would be the very best place to find the evidence is to look at national guidelines or standards that are published in the literature to help guide you in making decisions about what is best practice. The other source that I would recommend is to look to the literature and find out if there's any consensus statements that have been written by the experts on a topical area. So, for example, recently a group of cardiovascular experts got together and established a consensus statement on the use of ST segment monitoring and care of the cardiovascular patient. They identified what patient populations it's most likely to be effective in and under what conditions should it be used. And then they also detailed some of the how-to's of ST segment monitoring. That's a wonderful source then to guide your practice because those experts put together that publication based on not only their area of expertise, but also the research that's out there. And so that's an easy way to get guidance on what is the best evidence that we have to date. I don't know, have any of you ever had the opportunity to go out and try and answer a clinical practice question by looking at the evidence that's out there? And if so, what did you look at? FEMALE SPEAKER: I had read in just a regular journal article about keeping the head of the bed up on patients that's been ventilated. So I wanted to research and see what actual research studies have been out there about how high the head of the bed should be. So I did a literature search in CINAHL and MEDLINE © 2013 Laureate Education, Inc. 1 Finding Resources for EBP to see what studies have been done. And then also, CDC has some recommendations on reducing ventilator-associated pneumonia. MARIANNE CHULAY: So that when you went out to look at the literature by yourself, if you will, looking at the individual studies, that was quite timeconsuming. FEMALE SPEAKER: Very time-consuming. MARIANNE CHULAY: But gave you, I'm sure, a lot of detail. But both the Center for Disease Control and also the American Association of Critical Care Nurses actually have guidelines on prevention of ventilator-associated pneumonia, and they detail that evidence about head of the bed elevation. So, yeah. FEMALE SPEAKER: So I've looked into the national guidelines, but what value is it to call around and find out what the community standards in the hospital setting is? MARIANNE CHULAY: It's a good question. To be honest, I wouldn't recommend that you do that. And the reason is, we have that community standard concern primarily for legal reasons. Oftentimes, in a court of law, what will be brought to bear as the practice that you, as a practitioner, should be doing is what the community standard is. And in the old days, when community was quite honestly your little town, that made some sense to call around to what the other hospitals in the area are doing. But today, our community is United States and how nursing's practiced in the United States. So it isn't going to be helpful to you to find out what the other hospitals in your area are doing. It doesn't necessarily mean you're in alignment with the community standard. So more often than not, you're better off looking to the national standard. Which in most cases, is to look to your professional nursing association for whatever their guidelines are, or their recommendations of what practice should be. Because that's the community standard in today's language. © 2013 Laureate Education, Inc. 2 Finding Resources for EBP All right, how do you figure out what's evidence and what's not? When you've read a good article that's directing your nursing practice you want to look at those references that are there and look to see, are the research studies there that are saying, what's the best thing to do? That means that the author is using the latest evidence to base their recommendations. Even as clinicians, when we're saying to each other, I think this is the way you should suction the patient, you should be prepared for someone to say, well, what do you base that on? It should be based on the research that shows that, for example, normal saline shouldn't be instilled when you're doing endotracheal sectioning because we have a lot of research now that shows that's not a good practice. The other thing I'm often asked is, how much evidence do you need in order to really change practice? If you just read one study on something that says, this is the new way to do things, should we all go out and change in practice? Well, it's a tough one. In general, I think the answer should be no, we shouldn't just base our changes in practice on one single study. The other thing that does happen sometimes, when you look at the literature, you come to find out there's two studies that show an intervention to be effective. There's two over here that show it's not effective. Now what do I do when you get this conflicting data situation? Well, the first step is proceed with caution. Don't go out and change practice quite yet. We need to investigate this. Don't just pick the studies you like. If you like the outcome of two studies, don't just pick those. We've got to look at them all. The first step is to step back, look at all the studies, first evaluate which of those research studies are valid studies. Did they have good research design, good © 2013 Laureate Education, Inc. 3 Finding Resources for EBP methods? Were they well done studies? If so, put all of those studies over in a pile by themselves and basically throw out the other studies. Just look at the good studies and now, look to see if you still have that conflicting data. The other suggestion I would have is sometimes it's helpful for you to call a national expert and talk to them and help them sort through, is it realistic for you to interpret some of the data that's out there as being beneficial, and therefore you want to change practice? Sometimes they can help guide you through that thinking. The last sort of recommendation on this problem area when we have conflicting data is, be sure and keep documentation in the workplace about why you made the decision you made to either accept or not accept the conflicting data.

Information 2

Finding Sources of Evidence Finding Sources of Evidence Program Transcript NARRATOR: Once a nurse researcher has identified a practice-related problem or question, the research process can begin. In this video, Dr. Kristen Mauk explains the process of selecting a research framework, and finding existing evidence for her DNP project, which focused on the impact of education on nursing staff in a rehabilitation unit. For this project, Dr. Mauk created resources and developed competency modules for new nurses entering into a rehabilitation unit. And then measured their knowledge using pre- and post-tests. Before she could begin, however, Dr. Mauk selected a theoretical framework and gathered information from existing research related to this topic. KRISTEN MAUK: I don't know if we would call it an evidence-based practice model, but I did use a model, a theoretical framework, and that was Rogers' Diffusion of Innovations. And the reason I chose that is because that models a lot about change, and introducing change in an organization. There had to be a lot of buy-in, a lot of approvals. Some of the barriers of implementation was getting approval from everyone to do this project. And once we got buy-in from everybody, oh, it just took off and they were all excited and very invested. ANGELA BOLAND: I was thrilled about the opportunity. She presented how she would go about this series of learning modules on my floor with my staff, and with me being an active participant. I was very excited about the opportunity to work with Kris. My biggest buy-in to the whole project being on the rehab unit is we were a relatively new program looking at being competitive within the rehabilitation market in the region. Felt that it was important of, what can we bring? How can we stand out as a rehab unit? And really, believing and understanding evidence-based practice in the quality outcomes that we could have for our patients. © 2013 Laureate Education, Inc. 1 Finding Sources of Evidence KRISTEN MAUK: So I looked at the methods that were in the 19 sources that I used for my project. There were lots of different effective ways to educate. There wasn't just one way to educate. So there were many ways that worked. So I kind of could just draw, pick and choose when I looked at my method that I wanted to use. And so the decision to change practice was that knowledge does increase performance and giving education does increase knowledge. So I wanted to also tailor the intervention to the needs of the staff and the organization. So I had two outcomes. The first one is that the staff would increase knowledge in basic rehab competencies. And we measured that by pre- and post-tests. And the second outcome was that they would report an increase in rehab nursing knowledge. Then when I went to implement, I had a staff of about 16 nurses who participated. And it was a new 11-bed inpatient rehab unit. I used Rogers' Diffusion of Innovation as my framework, and negotiated the method with the nurse manager, and had to go through getting buy-in from the administrators, and submitting our IRB for approval to them and to my university. And when I reviewed the literature, you can see some of the search engines I used-- CINAHL, PubMed, Medline, ProQuest, Cochrane and Joanna Briggs. And it's really nice when you report that review of literature that you say how many hits you got at first, and then show how you narrowed it down. If you look at the poster in that section under review of literature, you can see there were 4,892 hits from PubMed. But that only gave us 3 relevant resources. So you have to narrow, narrow down by your keywords and what you're really looking for. So you may come up with these huge amounts of literature to start with, but really only a few good sources that apply to your project that you're going to use. And then you always need to list your inclusion and exclusion criteria. For me, I looked at maybe 10 years, the past 10 years, and excluded poor or irrelevant evidence. © 2013 Laureate Education, Inc. 2 Finding Sources of Evidence And then, the next column is synthesizing the evidence. And it's customary to list how many articles under each level you have. For my project, there weren't any Level 1's, which was kind of disappointing. And I really had to go into looking at competencies was a keyword and certification. I got most of my good literature results by looking at certification. And so what I gathered from the evidence is that the evidence was pretty good. There wasn't much specific to rehabilitation, but it's a newer field so we kind of would expect that. And that, in general, the more knowledge that nurses had, the better staff outcomes. They had better retention, better job satisfaction, better personal growth. And that certification was a big key to better patient outcomes, like improved safety and fewer complications. A lot of your searching for evidence is based on your keywords. And you will narrow them down, narrow them down. I always think it's funny when students come and they're talking about when they're trying to search for evidence and they found 14,000 articles that they're going to look at. Well, obviously didn't narrow enough because you're not realistically going to look at 14,000 articles. So you need to have your keywords narrow enough that you get a smaller group of the best evidence. And when we collect evidence, I think typically new students who aren't as familiar with evidence-based, that whole process, will just take any articles. But remember, we're not looking for all articles, we're looking for the best evidence. So you're looking at the quality of the evidence. If the methods of the research aren't good, then just discard that article. You're looking for research that's good, that's sound, that's reliable, that's valid. So you need to have some mastery over analyzing those types of research articles. Do not be discouraged when it looks overwhelming looking at thousands of articles. Use your keywords to narrow down your searches if you're looking at one particular piece of evidence-based practice. And you can use the tools that are out there to keep track of your analyses. There's many things that already exist to help you analyze a quantitative article with certain questions you ask. © 2013 Laureate Education, Inc. 3 Finding Sources of Evidence Use all those tools. There are some for qualitative articles, there's some for clinical practice guidelines. I'd say certainly, if there's a clinical practice guideline on your topic, that is a big place to go. Because you've already had a whole bunch of experts look at the literature, and the research, and make some recommendations. So don't get overwhelmed by wading through the research. Because what you find is all these little nuggets then that you can go and use later. I think we assume when we read research that the author, or researcher, or EBP project manager is coming from an ethical basis. So has not changed their results, has not tweaked anything, is accurately and honestly reporting the data as it has come to them. I think that's the true ethical piece, is you need to have trust in what you're reading. And whoever is writing that up for publication, or presenting it at a conference, or putting it on a poster, has the burden of proof to demonstrate to the reader that they have engaged in scientific rigor and that we can trust your results. And if you're reading an article and you get that vibe that I'm not sure they've really explained this very well, then you should really question whether that's a study that you want to include, or to consider when you're looking at something like a DNP or EBP project.