Practice based in evidence (EBP) means that you must critique/synthesize evidence and then apply it to particular setting and populations using your best judgement. This means that you must discriminate about when (and when NOT) to apply the research. Be sure to use best professional judgment to particularize your actions to the situation!
Add to your repertoire of EBP tools, the Number Needed to Treat (NNT). This is not mumbo -jumbo. NNT explained here–short & sweet: http://www.thennt.com/thennt-explained/
CRITICAL THINKING: Check out this or other analyses at the site. How does the info on antihypertensives for mild hypertension answer the question of whether more is better? Are there patients in whom you SHOULD treat mild HTN? (“We report, you decide.”) http://www.thennt.com/nnt/anti-hypertensives-for-cardiovascular-prevention-in-mild-hypertension/
MORE INFO: Check out what the data say about other risk/benefit treatments at http://www.thennt.com/
Want to know the standardized format for writing up your research study, QI report, case study, systematic review, or clinical practice guideline? Check out these standardized reporting guidelines: http://www.equator-network.org/reporting-guidelines/
Of course you should always give priority to the author instructions for the particular journal in which you want to publish, but most adhere generally or fully to these standardized guides.
Last post I commented on the potentially misleading terms of Filtered & Unfiltered research. My key point? Much so-called “unfiltered research” has been screened (filtered) carefully through peer-review before publication; while some “filtered research” may have been ‘filtered’ only by a single expert & be out of date. If we use the terms filtered and unfiltered we should not be naive about their meanings. (Pyramid source: Wikimedia Commons )
This week, I address what I see as a 2nd problem with this evidence based medicine pyramid. That is, missing in action from it are descriptive, correlation, & in-depth qualitative research are not mentioned. Where are they? This undercuts the EBM pyramid as a teaching tool and also (intentionally or not) denigrates the necessary basic type of research on which stronger levels of evidence are built. That foundation of the pyramid, called loosely “background information,” includes such basic, essential research.
You may have heard of Benner’s Novice to Expert theory. Benner used in-depth, qualitative interview descriptions as data to generate her theory. Yet that type of research evidence is missing from medicine’s pyramid! Without a clear foundation the pyramid will just topple over. Better be clear!
I recommend substituting (or at least adding to your repertoire) an Evidence Based NURSING (EBN) pyramid. Several versions exist & one is below that includes some of the previously missing research! This one includes EBP & QI projects, too! Notice the explicit addition of detail to the below pyramid as described at https://www.youtube.com/watch?v=MfRbuzzKjcM.
Critical thinking: #1List some EBM & EBN pyramid differences. #2 Figure out where on the hierarchy this project would go: Crowell, J., OʼNeil, K., & Drager, L. (2017). Project HANDS: A bundled approach to increase short peripheral catheter dwell time. Journal of Infusion Nursing, 40(5), 274-280. doi: 10.1097/NAN.0000000000000237. 1st use medicine’s EBM pyramid; & then 2nd use nursing’s EBN pyramid. #3 Label Crowell et al.’s study as filtered or unfiltered and explain what you mean by that.
For more info: Watch the YouTube video at the link above.
Are we talking cigarettes? water? coffee? other? Yes, other. In this case about what is sometimes called “filtered” or “unfiltered” literature in the evidence-based medicine pyramid of research evidence. (I have more than one issue with this particular pyramid as a representation of all evidence, but for right now let’s look at filtered information & unfiltered information. Pyramid source: Wikimedia Commons
Filtered is considered stronger–meaning that we can be more confident that literature from this category better supports cause and effect. I agree.
Unfiltered evidence (usually single studies etc) is considered weaker–meaning that we must be more cautious about its accuracy in representing reality. I agree.
But, “Is unfiltered information really unfiltered?” No filtering at all? My qualified answer is, “No.” Argue with me if you like.
My opinion: If the “unfiltered” article is a primary source, research study that has strong design and is published in a peer-review journal then it has been filtered by multiple, expert peer reviewers just to make it to publication.
Thus, when discussing filtered vs. unfiltered one should be very clear on what those terms mean and do not mean.
Critical Thinking: When filtered literature (systematic reviews & critically appraised topics & articles) has been filtered by one individual, is that superior to unfiltered literature in terms of introducing bias? What if the “filtered” evidence is 7 years old and a primary, “unfiltered” source(s) from this year has different findings? What is the relationship between “filtered” and “unfiltered”–after all the “unfiltered” is the pyramid base so what does that mean?
For more Info: For peer review, the lower level filtering of single studies, consider its 1) advantages (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975196/) and 2) its potential flaws (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1420798/)
For new graduate RNs (& those who help them) entering the workforce, Dr. Pat Benner PhD RN FAAN, who wrote Novice to Expert, has some great, very practical advice: https://www.youtube.com/watch?v=yxsBVPxS_zg (1:56) (hint: Remember the only behavior you can control is your own!)
And…it’s pretty good advice for any who assume a new job, too!
For More Information: If you want to know what it feels like sometimes to be a new grad RN, check out the 2 main themes and the subthemes voiced by new graduates in the free full-text: Hussein et al., (2017). New graduate nurses‘ experiences in a clinical specialty: a follow up study of newcomer perceptions of transitional support. BMC Nursing, 16(42). doi: 10.1186/s12912-017-0236-0. eCollection 2017.
Critical Thinking: Whether or not you are a new grad, did you have experiences similar to those in Hussein’s study? Can you use Benner’s suggestions to deal with the issues?
Want to know how to write an introduction/background section of a paper? Pay attention to STRUCTURE & evidence-based ARGUMENT in order to DIY (do-it-yourself) your own intro/background for a school paper or research report!
Let’s use this 2015 free full-text article by Marie Flem Sørbø et al. as a model! Past and recent abuse is associated with early cessation of breast feeding: results from a large prospective cohort in Norway . (Hint: Clicking on the article’s pdf tab may make it easier to read.)
Focus only on the INTRO/BACKGROUND section for now. Check out the STRUCTURE then the EVIDENCE-BASED ARGUMENT of the Intro/Background. This is how you should write your own.
STRUCTURE of INTRO/BACKGROUND in Sørbø et al. (2015):
- Where is the Intro/Background section located in the article?
- What heading is used for the section?
- Where are the research questions located in the Intro/Background? (HINT: this is the standard place in all papers & in this case the authors call them “aims.)
ARGUMENTS in INTRO/BACKGROUND in Sørbø et al. (2015):
- Look at the first (topic) sentence of each paragraph in INTRO/BACKGROUND & listen to the systematic argument the researchers are making for WHY their study is important.
- “Breast feeding has long been acknowledged as the optimal infant nutrition conferring beneficial short-term and long-term health effects for both infants and mothers.1–5 …
- Abuse of women is common worldwide, as one in three women during lifetime suffer partner or non-partner abuse.10 …Adverse effects [of abuse]… are barriers to breast feeding.*…
- Given the overwhelming evidence of the positive effects of breast feeding, knowledge about factors influencing breastfeeding behaviour is essential….
- We explored the impact of abuse of women on breastfeeding behaviour in a large prospective population in Norway where the expectations to breast feed are high, and breast feeding is facilitated in the work regulations….” (pp. 1-2)
- Now look at the research & other evidence written down AFTER each of above key sentences that SUPPORT each idea.
- Notice that the INTRO/BACKGROUND is NOT a series of abstracts of different studies!! Instead evidence is grouped into key arguments for the study: Breast feeding is best, Abuse is common, Abuse creates barriers to breastfeeding, & Therefore, knowing about factors affecting breastfeeding is important). [Note: Of course, if your particular professor or editor asks you to do a series of abstracts, then you must, but do group them in arguments like the topic sentences.]
All this leads naturally, logically to …(drum roll please!)…the research questions/hypotheses, which are the gaps in our knowledge that the research will fill. This sets up the rest of the research article!
Critical Thinking: Your turn! Write your own Intro/Background using
- Structure: Placement in article, heading, placement of research question/hypothesis
- Argument: Key idea topic sentences (make a list 1st) with supporting research & other evidence (your literature review).
For more info on Intro/Background: Review my blogpost Intro to Intro’s
*ok, yeh. I cheated and included one additional sentence to capture the authors’ flow of argument.