Review your problem or issue (Pressure Ulcer Prevention) and the study materials (Attached) to formulate a PICOT question for your capstone project change proposal. A PICOT question starts with a desi

Figure 1. Hierarchy of Research Designs and Levels of Scientific Evidence s e c o n d a r y p r e a p p r a t s e d o r f i l t e r e d s t u d i e s p r i m a r y , e x p e r i m e n t a l s t u d i e s p r o s p e c t i v e , t e s t s t r e a t m e n t p r i m a r y , n o n - e x p e r i m e n t a l / o b s e r v a t i o n a l s t u d i e s p r o s p e c tiv e : h a v e b e e n e x p o s e d t o a risk; o b s e r v e f o r c p r i m a r y , n o n - e x p e r i m e n t a l / o b s e r v a t i o n a l s t u d i e s r e t r o s p e c t i v e : s u b j e c t s h a v e o u t c o m e o f I n t e r e s t ; I n o d e s ig n n a r r a t i v e r e v ie w s , e x p e r t o p i n i o n s , e d i t o r i a l s d o e s n o t in v o lv e h u m a n s Reprinted fr o m Forrest JL, M ille r SA. EBDM in A c tio n : D eveloping com p e te n ce in EB practice, © 2 0 1 6 . Used by perm ission o f th e author.

10 J a n u a ry 2017 SPECIALFC IL TPAUE IRE rBLyECC LD eBAIAyniis M..BnACAFo wECEnByR First, consider where the article is published. For scientific evidence, the source needs to be peer-reviewed (or “refereed”). Peer-reviewed means the m anuscripts have been reviewed by experts who have evaluated the study design and th e strength o f the conclu­ sions.5 Typically, there are at least two reviewers. I f the study inform ation is reported clearly and accurately, the m anuscript can be accepted w ith o u t additional work. W h en the inform a­ tion is incom plete o r confusing, the reviewers’ critiques are sent to the au­ thors for consideration and im plem en­ tation. The m anuscript is revised to address the issues raised, to strengthen and improve its quality before publi­ cation. After revision, the m anuscript may be accepted w ith o u t further review, o r sent back to the reviewers for an o th er review. In this case, there is no guarantee that the m anuscript will be accepted. W hen a m anuscript is extensively flawed o r no t appropriate for a particular publication, it will be rejected upon initial review.

W hen evaluating research articles, determine if the source is peer-reviewed, o r if it is a practice-based publication th a t publishes expert opinions, product overviews and continuing education.

Both types o f publications have value to dental hygiene practitioners, but the most credible scientific information is generally found in peer-reviewed journals. W hile considering the type o f publication, also review the references cited to see if they represent higher levels o f evidence (research studies) or if they represent personal interviews, expert or layman opinions, commercial websites, magazine articles and online materials from less credible popular sources. H igh-quality scientific articles cite other high-quality evidence like clinical practice guidelines; systematic reviews; meta-analysis; randomized con­ trolled trials (RCTs); controlled clinical trials; o r governmental reports, laws and regulations.Forrest and Miller have succinct­ ly outlined questions from evi­ dence-based sources th a t health care providers can use to evaluate, or crit­ ically appraise, scientific literature.6' 8 These questions provide the basis for the critical evaluation process discussed in this article. A prelim inary assess­ m en t helps to determ ine w hat the article actually is abo u t.7 For example, • W h y was the study conducted, and w hat question did the a u th o r examine? Is there a clear statem ent o f purpose, a specific P IC O question, or a list o f precise objectives stated at the beginning o f the article? A P IC O question identifies the patient problem or population (P), intervention (I), comparison (C) and outcome(s) ( O ) .

• W h a t type o f research was conducted? W here does this type o f research fall on the Hierarchy o f Research Designs and Levels o f Evidence (Figure 1)?

- In general, secondary research is the highest level o f research because it follows a distinct, systematic process to synthesize prim ary research studies that address the same question.

Secondary research includes systematic reviews and meta-analyses, representing a body o f knowledge versus an individual study (Figure 2). It provides the basis for clinical practice guidelines (CPG ) (Box 1).

• Was the appropriate research design used based on the purpose o f the study? For example, an R C T w ith experimental and control groups is the m ost appropriate design for answering questions related to a therapy or preventive procedure/technique, whereas a controlled clinical trial would be used for answering questions related to a diagnostic test/ in stru m en t as there would be no control group. Both typesA SURVEY OF DENTAL HYGIENISTS' PREFERENCES, ATTITUDES 01* PRACTICES W O U LD NOT ANSWER QUESTIONS ABO U T THE EFFECTIVENESS OF CLINICAL PROTOCOLS.

o f research use experimental research designs.6 A survey o f dental hygienists’ preferences, attitudes or practices would no t answer questions ab o u t the effectiveness o f clinical protocols or be able to assess the outcomes o f an intervention o n a patient or comm unity.

Assuming this initial screening using the prelim inary questions indicates good quality thus far, th e process continues by asking three specific questions.8 1. Is the study valid?

2. W h a t are the results?

3. D o the results apply to my patient?

1. Is the study valid?

In o th er words, was the question or objective clearly focused, and did the investigators use the correct study design to answer the question? I f the answer is no, it will be difficult to have confidence in the findings, so why bother continuing to read the study?

To begin assessing validity, identify w hether the authors directly address the stated purpose a n d /o r the research questions or hypothesis. Then consider w hether rigorous m ethods were used.

M ethods to assure objectivity and rig­ or, depending on the design, include following strict pre-established criteria, selecting and recruiting subjects A c c e s s 11 S PEC I A E LPFTU PRrBAyPRD TALenrET ECFE insinTnRE ECn FEEiPLAEnT EI Ln TEA y M PnyU iFRyI. Bo FTTPDRPRD sFiEPrPsFRET Ii EinFE. nRET EI DiIAsTU LBPRyPRD sFiEPrPsFRET F R y wI i n,F.PRniT EI DiIAs Ii PREniHnREPIR FTTPDR.nREU PRrBAyPRD F rIREiIB Ii rI.sFiPTIR DiIAs Ii ATPRD F TEFRyFiy inaninRrnU FR y ATPRD inTnFirC PRTEiA. nRET S PEC yIrA. nREny nTEFLBPTCny HFBPyPEo FRy inBPFLPBPEo dHniM TAT ECn FAECIiTJ TP.sBo rinFEPRD IRn ECno EC I A D C E S IABy FTTnTT ECn ynTPiny IAErI.nTtg vCn TEAyo FBTI TCIABy Ln rIRyArEny S PEC F BFiDn nRIADC TF.sBn EI EnTE ECn TEFEny CosIECnTPT Ii FRTSni ECn inTnFirC lAnTEPIRTg hnBBuynTPDRny T.FBB TEAyPnT Fin FrrnsEFLBnm ECn inTABET eATE Rnny EI Ln PREnisinEny rFinaABBog h CPBn T.FBB TEAyPnT rFR siIHPyn inTABET lAPr1BoU ECno yI RI E RIi. FBBo oPnBy ynaPRPEPHn inTABETg vCATU ECn FAECIiT TCIABy R I E .F1n TEiIRD rIRrBATPIRT FLIAE F iPT1 aFrEIi Ii EiPFB PREniHnREPIRU inDFiyBnTT I a EC n inTABETg 0RTEnFyU T.FBBTEAyPnT TCIABy Ln ATny EI ynTPDR BFiDni TEAyPnT Ii rIRaPi. sinBP. PRFio inTABETg 0 a TEAyoJT FP. PT EI siIHPyn HFBPy FRy inBPFLBn nHPynRrn IR F iPT1 aFrEIi Ii RnS PREniHnREPIRU ECn TEAyo TCIABy Ln BFiDn nRIADC EI yI TIg )nTT iPDIiIAT . nECIyT RnDFEPHnBo P. sFrE EC n HFBPyPEo I a F TEAyoJT inTABETg *Ii n,F.sBnU TEAyoPRD IiFB CoDPnRn S PEC IRn DiIAs I a ynREFB CoDPnRn TEAynRET EI ynEni. PRn naanrEPHnRnTT I a F sinHnREPHn EnrCRPlAn I i FssiIFrC CFT FBSFoT Tnn.ny IyyU FT PE S IABy Ln FTTA.ny ECno . PDCE HFBAn IiFB CoDPnRn Ii IiFB CnFBEC yPaaninREBo ECFR ECn FHniM FDn sFEPnREg + nFTAiPRD sBFlAnU DPRDPHFB LBnnyPRD FRy PRaBF. . FEPIR L A E RI E siILPRD yns EC FRy rBPRPrFB FEEFrC. nRE BnHnB d,-)t S IABy RI E Ln HFBPy PR F TEAyo I a F sniPIyIREPEPT PREniHnREPIR LA E S IABy Ln HFBPy IAErI. nT EI FTTnTT PR F TEAyo I a DPRDPHPEPTg 0R nyArFEPIRFB inTnFirCU ynEni. PRPRD Pa FR nyArFEPIRFB siIDiF. P. siIHny 1RISBnyDn aiI.

sinEnTE EI sITEEnTE S PEC RI rI.sFiPTIRIi rIREiIB DiIAs .Fo R I E Ln HFBPy LnrFATn 1RISBnyDn S IABy Ln n,snrEny EI PRrinFTn aIBBISPRD nyArFEPIRg 2. W hat are the results?

A fter d e term in in g if the study is valid, review the results. Are the findings statistically a n d /o r clinically significant? C linical significance can be in te rp re te d as im p o rta n c e .11 Sta­ tistical significance estim ates the like­ lihood or p robability th a t the results truly are related to the variable being stu d ied versus due to chance. Some results can be statistically significant w ith o u t being clinically significant.

For example, w hen com p arin g two treatm ents for p erio d o n titis, a statis­ tical difference in favor o f treatm en t X m ig h t be found. I f treatm en t X resulted in a gain o f CAL o f 0.25 mm and tre a tm e n t Y resulted in a CAL P r im a r y vs. S e c o n d a r y R esearch Primary Research Individual Research Studies A ll a n s w e r in g t h e s a m e q u e s t i o nSecondary Research Reviews o f A lread y C onducted Research 1 t ----------------------------- ----------------------------- 1 Systematic Review & Meta-Analysis S t a t is t ic a l S y n t h e s i z e d . A n a l y s i s o f R e s u l t s S y n t h e s i z e d R e s u lt s B o d y o f E v i d e n c e TJ Reprinted fr o m Forrest JL, M ille r SA. EBDM in A c tio n : D eveloping co m p e te n ce in EB practice, © 2 0 1 6 . Used by permission o f t h e author.

12 J a n u a r y 2 0 1 7 SPECI AL FTIURCrByB PDe nyPDePieB sM i .oPCwPyrD, HIBIPiUT aryIiPywiI R esource W e b s ite Type o f T o o l(s ) P rovid ed Critical Appraisal Skills Programme (CASP)h ttp ://w w w .c a s p - u k.n e t/ca sp-tools- checklistsCritical appraisal checklists for:

1. system atic reviews 2. randomized controlled trial 3. diagnostic 4. economic evaluation 5. q u a litative 6. case control 7. cohort study 8. clinical prediction rules Consolidated S tan­ dards o f Reporting Trials (CONSORT)h ttp ://w w w .c o n - s o rt-s ta te m e n t.o rg /S tatem ent regarding m inim um recom mendations fo r RCTs and a checklist and flow diagram fo r c r it i­ cal appraisal o f RCTs Preferred Reporting Ite m s fo r System atic Reviews and Me­ ta-Analyses (PRISMA)h ttp ^ / p r i s ­ m a -s ta te m e n t.o rg / K •• - I #S tatem ent regarding m inim um recom mendations fo r system atic reviews and m eta-analyses and a checklist and flow diagram fo r c r it­ ical appraisal of system atic reviews and m eta-analyses Standards fo r Re­ porting Studies of Diagnostic Accuracy (STARD)h ttp ://w w w .e q u a - to r-n e tw o rk .o rg / w p -c o n te n t/u p - lo a d s /2 0 1 5 /0 3 / STARD-2015-check- lis t.p d fA checklist fo r evaluating studies of diagnostic tests and devices S trengthening the reporting of observa­ tional studies in epi­ dem iology (STROBE)h t t p : / / w w w .

stro b e-statem ent.

o rg /? id = a v a il- able-checklistsChecklists (combined and in d ivid u ­ al) fo r evaluating 1. Cohort studies 2. Case study 3. Cross-sectional studies 4. Conference abstracts Wiley Critical apprais­ al checklistsh ttp ://o n lin e lib ra ry.

w ile y.co m /d o i/ 10.100 2/ 9780470987407.

a p p 2 /p d fChecklists fo r various study designs 1. Experimental (random ized and non-randomized controlled tria l) designs.

2. Q uasi-experim ental ( in te r ru p t­ ed tim e series) designs 3. A ttrib u tio n studies 4. Questionnaire surveys 5. Q ualitative studies 6. M ixed-m ethodology case stu d ­ ies 7. Real world and action research Access 13 S PE CI A LFT FU R L r BR U yFU D e n Fi D LFT D s MAre s.

o S RsDi P T y w D w F, w D s y LD H D Ls P a D H Fi D T U D y P d B P H Fi D , n Fi FT , d B FT U Fd LD s a P B s d D U FaFU s F y n R J y FP T s P B U P T i FyFP T s I o t E R g d LD s B D LR yD i y P i D T yR L w v , FD T D d B R U yFU D FT U Ln i D d Fy l R T i a Fs s n B D s D R LR T ys h R T i T P T l s n B , FU R L y B D R y g D T y P a U w B P T FU d D B F P i P T y F y F s I Cu gain o f 0.10 m m , th e dental hygienist has to determ ine w hether th e differ­ ence in gain in CAL between the two approaches (0.15 mm ) is clinically significant. Is it im p o rta n t enough to change protocols, purchase a device or revise p atien t self-care practices? Also, consider how m any additional visits were required to o b tain the 0.15 m m gain and at w h at cost? Remember, statistical significance does n o t d eter­ m ine clinical significance. Conversely, findings can be clinically significant w ith o u t being statistically significant, especially w hen they make a tangible difference to th e p a tie n t.12 3. "W ill the results help in caring fo r my patients?" O n ce the study’s validity is estab­ lished, and the results are determ ined, consider this final question in the critical appraisal process.6 Com pare your patient(s) or com m unities o f in ­ terest to those studied in terms o f age, education or socioeconomic level, and disease parameters and assess w hether they are similar o r different. In other words, w ould they have qualified to be in the study? I f they are different, the results w ould no t apply. C onsider how your experiences and your p atien t’s preferences will influence the decisions ab o u t incorporating these results into th a t patient’s care. Also, be careful how you apply results o f population-based research to an individual patient. At times, research examines the char­ acteristics o f a group o f patients or a selected com m unity to estimate population-based risks. Results from these studies can indicate incidence o f a given disease or risk factors. Findings can be used to generate hypotheses for studies to assess individual’s risks.

However, conclusions from such p o p u ­ lation-based research cannot be applied to individual patients.5After you have evaluated the strength o f the evidence and d eter­ m ined its relevance, decide w hether it should be incorporated into your treatm ent plan. I f so, take action by actually planning its im plem entation d uring patient care when similar circumstances arise. Share th e findings with others in your practice setting who m ight have patients w ith similar conditions. This EB D M process not only is likely to improve treatm ent outcomes, b u t also has the potential to make your w ork more interesting. H D en ise B ow en, R D H , M S , professor em eritus in d e n ta l hygiene a t I d a ­ ho S ta te University, has served as a co n su lta n t to d e n ta l industry, as w ell as governm ent, universities a n d p r iv a te organizations. S h e has p re se n ted a t m eetings o f the A D H A , C a n a d ia n D e n ta l H ygienists’ Association, A m e r ­ ican A ssociation o f D e n ta l Schools, A m e rica n P u b lic H e a lth Association, N o r th A m e r ic a n Conference on D e n ta l H ygiene Research, a n d In te r n a tio n a l S ym posium s on D e n ta l H ygiene in C a n ­ ada, Russia, C h in a a n d Costa Rica. Shehas c o n tr ib u te d to several d e n ta l hygiene texts a n d is w id ely k n o w n through her n um erous p u b lis h e d articles in d e n ta l hygiene a n d h er d y n a m ic c o n tin u in g education program s related to nonsurgi- c a lp e r io d o n ta l therapy, p re v e n tiv e oral care, research a n d education.

Jane L. Forrest, R D H , E d D is professor o f C lin ica l D entistry; section chair, Behavioral Science, Ostrow School o f Dentistry, University o f Southern Cali­ fo r n ia ; a n d director, N a tio n a l Center f o r D e n ta l H ygiene Research & Practice. She is a n internationally recognized aitthor a n d presenter on evidence-based decision m a k in g (E B D M ). Projects have in clu d ed p re p a rin g the A D H A w h ite p a p e r on E B D M in d e n ta l hygiene, serving on the p la n n in g com m ittee a n d p a rticip a tin g in the A m erica n D e n ta l Association's C ham pions Conference on E BD . H er p u b lic a tio n s include book chapters on E B D M f o r C lin ica l Periodontology a n d f o r D e n ta l Hygiene: Theory a n d Practice. She is the lead co-author o f tw o textbooks, the m ost recent being Evidence-Based Decision M a k in g : D evel­ oping Competence in E B Practice.

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3. M iller SA, F orrest JL. Translating evidence based decision m aking into practice: appraising a n d applying the evidence. J Evid Base D en t Pract. 200 9 ; 9(4): 164-82.

4. Forresr JL. Evidence-based decision making:

intro d u ctio n an d fo rm ulating good clinical questions. Available at: w ww .dentalcare.com /en- us/professional-education/ce-courses/ce311 5. H ollister C . Reading dental literature: ju st rhe basics. Nashville Area D ental S upport C e n te r U nited S outh a n d Eastern Tribes. Inc.

n.d. Available at: www.nappr.org/files/dental- resource-gu ide/C l i n ical% 20Resources/ Reading% 20D ental% 20L.iterature-Basics.pdl.

Accessed O c to b e r 2 4 ,2 0 1 6 .

6. F orrest JL , Miller SA. E B D M in action:developing com petence in eb practice.

ebdLibrary: C olbe rt, Wash., 2016.

7. G reenhalgh T. G e ttin g your bearings (deciding w h at the paper is ab o u t). BMJ 1997; 315(7 1 0 2 ): 243-6.

8. Critical Appraisal Skills Program m e (GASP).

A ppraising th e evidence. Available at: www.

casp-uk.net. Accessed O c to b e r 30, 2016.

9. W rig h t JT, Crall JJ, F ontana M , e t al.

Evidence-based clinical practice guid eline for the use o f pit-and-fissure sealants. J A m D en t Assoc. 2016; 147(8): 6 7 2 - 8 2 . e l 2.

10. Smiley C J, Tracy SL, Evidence-based clinical practice guid eline on the nonsurgical tre atm en t o f chronic p eriodontitis by means o f scaling a n d ro o t p la n in g w ith o r w ith o u t adjuncts. J Am D e n t Assoc. 201 5 ; l4 6 ( 7 ):5 2 5 -3 5 .

11. University o f O rtow a. Statistical Significance an d C linical Im portance. Available at h ttps://w w w .m ed.uottaw a.ca/sim /data/ StatisticaLsign i fic ance_im portance_e.htm .

Accessed Nov. 5, 2016.

12. H ujoel P. Levels o f clinical significance, j Evid Base D e n t Pract 2004; 4:32-6.

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