Category Archives: Evidence hierarchy

Dispelling the nice or naughty myth: retrospective observational study of Santa Claus.

Naughty NiceGo to full article


“OBJECTIVE:  To determine which factors influence whether Santa Claus will visit children in hospital on Christmas Day.

DESIGN:  Retrospective observational study.

SETTING:  Paediatric wards in England, Northern Ireland, Scotland, and Wales.

PARTICIPANTS:  186 members of staff who worked on the paediatric wards (n=186) during Christmas 2015.

MAIN OUTCOME MEASURES:  Presence or absence of Santa Claus on the paediatric ward GIFTSduring Christmas 2015. This was correlated with rates of absenteeism from primary school, conviction rates in young people (aged 10-17 years), distance from hospital to North Pole (closest city or town to the hospital in kilometres, as the reindeer flies), and contextual socioeconomic deprivation (index of multiple deprivation).

RESULTS:  Santa Claus visited most of the paediatric wards in all four countries: 89% in England, 100% in Northern Ireland, 93% in Scotland, and 92% in Wales. The odds of him not visiting, however, were significantly higher for paediatric wards in areas of higher socioeconomic deprivation in England (odds ratio 1.31 (95% confidence interval 1.04 to 1.71) in England, 1.23 (1.00 to 1.54) in the UK). In contrast, there was no correlation with school absenteeism, conviction rates, or distance to the North Pole.

CONCLUSION:  The results of this study dispel the traditional belief that Santa Claus rewards children based on how nice or naughty they have been in the previous year. Santa Claus is less likely to visit children in hospitals in the most deprived areas. Potential solutions include a review of Santa’s contract or employment of local Santas in poorly represented region.”  Park et al. (2016).BMJ. 2016 Dec 14;355:i6355. doi: 10.1136/bmj.i6355.

How would you translate this into practice?   Questions to help you with this endeavor:   Where does this retrospective, observational research fall on the evidence hierarchyEBNIs it quantitative or qualitative research?  Experimental or non-experimental research? How generalizable is this research? What are the risks,resources, and readiness of people in potentially using the findings (Stetler & Marram, 1996; Stetler, 2001)?   What might happen if you try to apply the abstract information to practice without reading the full article?  Do you think the project done in Europe is readily applicable to America?  What would be the next level of research that you might undertake to better confirm these findings?
Enjoy your holiday season! -Dr H

“Here Comes Santa Claus?” What IS the Evidence?

It’s that time of year again! Enjoy this illustration of how to use one model in applying best, available evidence to practice. Have fun and a merry and bright season.


How strong is the evidence regarding our holiday Santa Claus (SC) practices? And what are the opportunities on this SC topic for new descriptive, correlation, or experimental research?  Although existing evidence generally supports SC, in the end we may conclude, “the most real things in the world are those that neither children nor men can see” (Church, as cited in Newseum, n.d.).santa3

If you want to know the answers, check out: Highfield, M.E.F. (2011).  Here comes Santa Claus: What’s the evidence? Advanced Emergency Nursing Journal, 33(4), 354-6. doi:   Using bona fide published work, the article shows you how to evaluate the strength of evidence and how to apply it to practice.   You can request a full-text for your personal use from your library or from the author via .  

Critical thinking: Check out this related research study with fulltext available through PubMed: Black Pete…

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Missing in Action: The Pyramid foundation

Last post I commented on the potentially misleading terms of Filtered & Unfiltered Filtered Unfiltered jpgresearch.  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.

Ask an ExpertYou 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

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.