Review Chapter 5 Searching the Evidence, Chapter 6 Evidence Appraisal Research, and Chapter 7 Evidence Appraisal Nonresearch in the Johns Hopkins Evidence-based Practice for Nurses and Healthcare Prof

Information literacy is a set of abilities requiring individuals to “rec - ognize when information is needed and have the ability to locate, evaluate, and use effectively the needed information” (American Li - brary Association, 1989, para. 3). Developing information literacy skills requires knowledge of the nursing literature and an aptitude for locating and retrieving it. “Given the consistent need for curren\ t information in health care, frequently updated databases that hold the latest studies reported in journals are the best choices for finding r\ ele - vant evidence to answer compelling clinical questions” (Fineout-Over\ - holt et al., 2019, p. 60). Studies have shown that positive changes in \ a nurse’s information literacy skills and increased confidence in using those skills have a direct impact on appreciation and application of research, are vital for effective lifelong learning, and are a prerequis\ ite to evidence-based practice (McCulley & Jones, 2014).

EBP teams can collect evidence from a variety of sources, including the web and proprietary databases. The information explosion has 5 Searching for Evidence Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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100 made it difficult for healthcare workers, researchers, educators, admi\ nistrators, and policymakers to process all the relevant literature available to the\ m every day. Evidence-based clinical resources, however, have made searching for medical information much easier and faster than in years past. This chapter: ■ Describes key information formats ■ Identifies steps to find evidence to answer EBP questions ■ Suggests information and evidence resources ■ Provides tips for search strategies ■ Suggests methods for screening and evaluating search results Key Information Formats Nursing, and healthcare in general, is awash with research data and reso\ urces in support of evidence-based nursing, which itself is continually evolving \ (Johnson, 2015). Evidence-based literature comes from many sources, and healthcar\ e professionals need to keep them all in mind. The literature search is a \ vital component of the EBP process. If practitioners search only a single reso\ urce, database, or journal, they will likely miss important evidence. Likewise\ , target searching for a specific intervention or outcome may exclude important\ alternative perspectives. Through a thorough and unbiased search, healthcare profess\ ionals expand their experience in locating evidence important to the care they \ deliver.

Primary evidence is data generally collected from direct patient or subject contact, including hospital data and clinical trials. This evidence exis\ ts in peer- reviewed research journals, conference reports, abstracts, and monograph\ s, as well as summaries from data sets such as the Centers for Medicare & Medi\ caid Services (CMS) Minimum Data Set. Databases that include primary source\ evidence include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, library catalogs, other bibliographic literature databases, and institutional repositories. For hospital admin\ istrators, the Healthcare Cost and Utilization Project (HCUP) is a source for health \ statistics and information on hospital inpatient and emergency department use.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 101 Evidence summaries include systematic reviews, integrative reviews, meta- analysis, meta-synthesis, and evidence syntheses. The literature summari\ es that identify, select, and critically appraise relevant research use specific analy\ ses to summarize the results of the studies. Evidence-based summaries also resi\ de in library catalogs, online book collections, and online resources such as \ PubMed, CINAHL, the Cochrane Library, and JBI (formerly known as the Joanna Briggs Institute). For hospital administrators and case managers, Health Busin\ ess Full Text is a source for quality improvement and financial information.

Translation literature refers to evidence-based research findings that, after much investigation and analysis, professional organizations or multi-discipli\ nary panels of experts translate for use in the clinical practice settings. Translation literature formats include practice guidelines, protocols, standards, critical path\ ways, clini - cal innovations, and evidence-based care centers and are available throu\ gh peer- reviewed journals and bibliographic databases. JBI, CINAHL, and PubMed a\ lso provide this type of literature using Best Practice information sheets. \ The Answerable Question After identifying a practice problem and converting it into an answerabl\ e EBP question, the search for evidence begins with the following steps:

1. Identify the searchable keywords contained in the EBP question and list \ them on the Question Development Tool (see Appendix B). Include also any synonyms or related terms, and determine preliminary article inclu - sion criteria. 2. Identify the types of information needed to best answer the ques - tion, and list the sources where such information can be found. What database(s) will provide the best information to answer the question? 3. Develop a search strategy.

4. Evaluate search results for relevance to the EBP question.

5. Revise the search strategy as needed.

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5 Searching for Evidence 102 6. Record the search strategy specifics (terms used, limits placed, year\ s searched) on the Question Development Tool and save the results. 7. Screen results to systematically include or exclude relevant literature.\ EBP Search Examples The first step in finding evidence is selecting appropriate search t\ erms from the answerable EBP question. It may be useful to have a sense of the inc\ lusion and exclusion criteria, which will guide the study selection. The Questi\ on Development Tool (Appendix B) facilitates this process by directing the team to identify the practice problem and, using the PICO components, to deve\ lop a searchable question.

For example, consider the following background question: What are best p\ rac - tices to reduce the rates of medical device-related pressure injuries in\ hospital - ized adult patients? Some search terms to use may be hospital, pressure injuries, and devices. Table 5.1 illustrates how to use each part of an answerable PICO question to create an overall search strategy. Because the question addresses best practices that affect the outcomes, outcome search terms are not include\ d in the search to avoid bias. Table 5.1 PICO Example: Best Practices to Prevent Medical-Device Related Pressure Injuries PICO Elements Initial Search Terms Related Search Terms P: Adult hospitalized patients Inpatient* OR hospital* Ward OR unit OR floor OR nurs* I: Best practices to prevent medical-device- related pressure injuries Pressure injur* OR HAPI OR pressure ulcer* OR decubitis OR bedsore OR Braden scale device OR devices OR tube OR tubes OR tubing OR catheter OR catheters OR nasal cannula* OR restraint* OR tape Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 103 C: n/a O: Rates of medical device-related pressure injuries Table 5.2 displays another PICO question with each element mapped to pote\ ntial search terms to help answer the EBP foreground question: In patients wit\ h chest tubes, does petroleum impregnated gauze reduce catheter dwell time\ s as compared to a dry gauze dressing? In this case, the searcher may want\ to consider brand or product names to include in the search terms. Table 5.2 PICO Example: Chest Tube Dressing Comparison PICO Elements Initial Search Terms Related Search Terms P: Patients with chest tubes Chest tube* OR chest drain* Pleural catheter* OR pleura shunt* OR intercostal drain OR (vendor-specific catheter names) I: petroleum impregnated gauze Petroleum (vendor-specific name gauze) OR occlusive gauze C: dry gauze dressing Gauze dressing OR bandage* O: catheter dwell times dwell Time OR hour* OR day* Teams need to consider the full context surrounding the problem when thin\ king of search terms. As an example, intervention is a term used frequently in nursing; it encompasses the full range of activities a nurse undertakes in the ca\ re of patients. Searching the literature for nursing interventions, however, is far too general and requires a focus on specific interventions. Additionally, directional terms related to outcomes may bias the search. For example, including th\ e term “reduce” will exclude potentially valuable information that may sh\ ow alternative findings for the intervention in question.

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5 Searching for Evidence 104 Selecting Information and Evidence Resources After selecting search terms, EBP teams can identify quality databases c\ ontaining information on the topic. This section briefly reviews some of the uni\ que features of core EBP databases in nursing and medicine. CINAHL CINAHL covers nursing, biomedicine, alternative or complementary medicin\ e, and 17 allied health disciplines. CINAHL indexes more than 5,400 journal\ s, contains more than 6 million records dating back to 1976, and has comple\ te coverage of English-language nursing journals and publications from the \ National League for Nursing and the American Nurses Association (ANA).\ In addition, CINAHL contains healthcare books, nursing dissertations, selec\ ted conference proceedings, standards of practice, and book chapters. Full-t\ ext material within CINAHL includes more than 70 journals in addition to leg\ al cases, clinical innovations, critical paths, drug records, research inst\ ruments, and clinical trials.

CINAHL also contains a controlled vocabulary, CINAHL Subject Headings , which allows for more precise and accurate retrieval. Selected terms are\ searched using “MH” for Exact Subject Heading or “MM” for Exact Major\ Subject Heading. Additionally, CINAHL allows searching using detailed filters to nar - row results by publication type, age, gender, and language. The example PICO on pressure injuries could be searched using the CINAHL Headings. It may\ look like this: (MH “Pressure Ulcer”) AND (MH “Hospitalization” OR MH “Inpatients”) MEDLINE and PubMed MEDLINE and PubMed are often used interchangeably; however, teams need to keep in mind that they are not the same. PubMed is a free platform available through the National Library of Medicine’s interface that searches not only MEDLINE but also articles not yet indexed in MEDLINE and articles that a\ re included in PubMed Central.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 105 MEDLINE, a database that contains over 30 million references (as of May\ 2020), includes journal articles in the life sciences with a concentrat\ ion on bio - medical research. One of MEDLINE’s most notable features is an extensive, controlled vocabulary: Medical Subject Headings (MeSH). An indexer, who is a specialist in a biomedical field, reviews each record in MEDLINE. The \ indexer assigns 5–15 appropriate MeSH terms to every record, which allows for\ precise searching and discovery. MeSH terms can help the searcher account for ambigui - ty and variations in spelling and language. A common saying in the libra\ ry world is: “Garbage in, garbage out.” MeSH terms can eliminate “garbag\ e,” or irrel - evant articles. Searchers should be aware that not every record in PubMe\ d re - ceives MeSH indexing, so searching best practice involves including both\ MeSH terms and additional keywords for optimal evidence discovery.

To search in MEDLINE through PubMed using the PICO example for medical device-caused pressure injuries in hospitalized patients, one would use \ the MeSH term for “Pressure Ulcer” [MeSH] as the basis for the first concept. For the sec - ond concept, the searcher could select the MeSH terms “Hospitalization”[MeSH] and “Inpatients”[MeSH] to describe the concept of hospitalized patients, or al - ternatively, the MeSH term for “Equipment and Supplies”[MeSH]. There is no MeSH term for medical device, but “equipment and supplies” should capture some of that literature. A PubMed search strategy utilizing MeSH terms w\ ould look like this: (“Pressure Ulcer”[MeSH]) AND (“Hospitalization”[MeSH] OR \ “Inpatients”[MeSH]) PubMed also contains Clinical Queries , a feature that has prebuilt evidence- based filters. Clinical Queries uses these filters to find relevant information on topics relating to one of five clinical study categories: therapy, diagnosis, etiology, prognosis, and clinical prediction guides. Clinical Queries also includes a search filter for systematic reviews. This filter adds predetermined limits\ to narrow the results to systematic reviews. To use the Clinical Queries feature, access it through the PubMed homepage, and enter the search as normal. Clinical Queries are beneficial only if a search has already been built.

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5 Searching for Evidence 106 The Cochrane Library The Cochrane Library is a collection of databases that includes the Coch\ rane Database of Systematic Reviews. Internationally recognized as the gold s\ tandard in evidence-based healthcare, Cochrane Reviews investigate the effects o\ f interventions for prevention, treatment, and rehabilitation. Over 7,500 \ Cochrane Reviews are currently available. Published reviews include an abstract, \ plain language summary, summaries of findings, and a detailed account of the review process, analysis, and conclusions. Abstracts of reviews are available f\ ree of charge from the Cochrane website; full reviews require a subscription. A\ medical librarian can identify an organization’s access to this resource. JBI (formerly known as the Joanna Briggs Institute) JBI is an international, not-for-profit, membership-based research and development organization. Part of the Faculty of Health Sciences at the \ University of Adelaide, South Australia, JBI collaborates internationall\ y with over 70 entities. The Institute and its collaborating entities promote a\ nd support the synthesis, transfer, and utilization of evidence by identifying feasible, appropriate, meaningful, and effective practices to improve healthcare o\ utcomes globally. JBI includes evidence summaries and Best Practice information sheets produced specially for health professionals using evidence reported in s\ ystematic reviews. JBI resources and tools are available only by subscription thro\ ugh Ovid, and a medical librarian can identify an organization’s access to this resource. Selecting Resources Outside of the Nursing Literature At times, it may become necessary to expand searches beyond the core nur\ sing literature. Databases of a more general and multidisciplinary nature are\ presented in this section. PsycINFO PsycINFO is a database supported by the American Psychological Associati\ on that focuses on research in psychology and the behavioral and social sci\ ences.

PsycINFO contains more than 4.8 million records, including journal artic\ les, Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 107 book chapters, book reviews, editorials, clinical case reports, empirica\ l studies, and literature reviews. The controlled vocabulary for PsycINFO is availa\ ble through the Thesaurus feature. Users can search Thesaurus terms as major\ headings and explore terms to search for terms that are related and more\ specific.

Users can limit searches in PsycINFO by record type, methodology, language, and age to allow for a more targeted search. Health and Psychosocial Instruments (HaPI) The HaPI database contains over 200,000 records for scholarly journals, \ books, and technical reports. HaPI, produced by the Behavioral Measureme\ nt Database Services, provides behavioral measurement instruments for use i\ n the nursing, public health, psychology, social work, communication, sociology, and organizational behavior fields. Physiotherapy Evidence Database (PEDro) PEDro is a free resource that contains over 45,000 citations for randomi\ zed trials, systematic reviews, and clinical practice guidelines for physiotherapy. The Center for Evidence-Based Physiotherapy at the George Institute for Global Heal\ th produces this database and attempts to provide links to full text, when \ possible, for each citation in the database. Creating Search Strategies and Utilizing Free Resources In the following section, we will cover the necessary components used to\ create a robust search strategy. Databases are unique, so the components to select when creating a search strategy will vary; not every search strategy will uti\ lize every component. The end of this section includes a list of free, reliable res\ ources with descriptions explaining the content available in each resource. Remember\ to check with a local medical library to see what additional resources may be ava\ ilable. Key Components to Creating Search Strategies After identifying appropriate resources to answer the question, the EBP \ team can begin to create a search strategy. Keep in mind that this strategy may need Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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5 Searching for Evidence 108 adjustment for each database. Begin by breaking the question into concep\ ts, se - lecting keywords and phrases that describe the concepts, and identifying\ appro - priate controlled vocabulary, if available. Use Boolean operators (AND, OR , and NOT ) to combine or exclude concepts. Remember to include spelling variatio\ ns and limits where necessary. Note the search strategy examples’ search strategies for PubMed and CINAHL in the previous sections were created by combining\ the AND and OR Boolean operators.

Use OR to combine keywords and controlled vocabulary related to the same\ concept (example searches formatted for PubMed): (“Pressure Ulcer”[MeSH] OR “pressure ulcer*” OR “pressur\ e injur*” OR “decubitis”) Use AND to combine two separate concepts: (“Pressure Ulcer”[MeSH] OR “pressure ulcer*” OR “pressur\ e injur*” OR “decubitis”) AND (“Hospitalization”[MeSH] OR “Inpatients”[MeSH] OR “hospital*” OR “inpatient*”) Review the following steps to build a thorough search strategy:

1. Use a controlled vocabulary when possible.

Controlled vocabularies are specific subject headings used to index concepts within a database. They are essential tools because they ensure consistency and reduce ambiguity where the same concept may have different names. Additionally, they often improve the accuracy of keyword searching by reducing irrelevant items in the retrieval list.\ Some well-known vocabularies are MeSH in MEDLINE (PubMed) and CINAHL Subject Headings in CINAHL.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 109 2. Choose appropriate keywords for the search’s concepts.

Look at key articles to see how they use the terms that define the top\ - ics. Think of possible alternative spellings, acronyms, and synonyms.

Remember that even within the English language, spelling variations in American and British literature exist. In British literature, Ss often re - place Zs, and OU s often replace Os. Two examples of this are organisa - tion versus organization and behaviour versus behavior . 3. Use Boolean operators.

Boolean operators are AND, OR, and NOT. Use OR to combine key - words and phrases with controlled vocabulary. Use AND to combine each of the concepts within the search. Use NOT to exclude keywords and phrases; use this operator with discretion to avoid excluding terms \ that are relevant to the topic. (See Table 5.3.) 4. Use filters where appropriate.

Most databases have extensive filters. PubMed and CINAHL allow filtering by age, gender, species, date of publication, and language. The filter for publication types assists in selecting the highest levels o\ f evi - dence: systematic reviews, meta-analyses, practice guidelines, random - ized controlled trials, and controlled clinical trials. Apply filters \ carefully and with justification, because it is easy to exclude something import\ ant when too many filters are applied. 5. Revise the search.

As the team moves through Steps 1–4, they are likely to find new te\ rms, alternate spellings of keywords, and related concepts. Revise the search\ to incorporate these changes. The search is only complete when the team \ can answer the question. If given a previous search to update, the team \ may need to make revisions because terms may have changed over time, and new related areas of research may have developed.

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5 Searching for Evidence 110 Table 5.3 Using Boolean Operators Boolean Operator Venn Diagram Explanation Example AND Use AND to link ideas and concepts where you want to see both ideas or concepts in your search results. The area in yellow (in ebook) or gray (print book) on the diagram highlights the recall of the search when AND is used to combine words or concepts. As you can see, AND narrows the search. “pressure ulcer” AND “hospitalization” OR Use OR between similar keywords, like synonyms, acronyms, and variations in spelling within the same idea or concept. The area in yellow (in ebook) or gray (print book) on the diagram highlights the recall of the search when OR is used to combine words or concepts. As you can see, OR broadens the search. “pressure ulcer” OR “pressure injury” NOT NOT is used to exclude specific keywords from the search; however, you will want to use NOT with caution because you may end up missing something important. The area in yellow (in ebook) or gray (print book) on the diagram shows the search results you get when combining two concepts using NOT. As you can see, NOT is used to make broad exclusions. “pressure injury” NOT “crush injury” Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 111 Free Resources Most databases require a paid subscription, but some are freely searchab\ le online. Table 5.4 lists quality web resources available at no cost. Check the loc\ al medical or public library to see what is accessible. Many databases are \ available through multiple search platforms. For example, teams can search the MEDLINE database through PubMed, but it is also available through other \ vendors and their platforms, such as EBSCOhost, ProQuest, and Ovid.

Medical librarians, knowledgeable about available resources and how to u\ se their functions, can assist in the search for evidence and provide inval\ uable personalized instruction. Never be afraid to ask for help! The only fool\ ish question is the one unasked. Table 5.4 Free Online Resources Resource Focus Website PubMed Biomedical Research https://pubmed.ncbi.nlm.nih.gov PubMed Central Full-Text Biomedical Resources https://www.ncbi.nlm.nih.gov/pmc Sigma Repository Research, Dissertations, and Conference Abstracts https://www.sigmarepository.org The Cochrane Collaboration Systematic Reviews and Controlled Trials https://www.cochranelibrary.com TRIP Medical Database (Turning Research Into Practice) Clinical Practice https://www.tripdatabase.com US Preventive Services Task Force (USPSTF) Clinician and Consumer Information http://www.uspreventiveservicestaskforce.org ClinicalTrials.gov Clinical Trials https://clinicaltrials.gov continues Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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5 Searching for Evidence 112 Resource Focus Website NIH RePORTER:

Research Portfolio Online Reporting Tool Federally Funded Research Projects http://report.nih.gov Google Scholar Multidisciplinary Resources http://scholar.google.com The Sigma Repository (formerly the Virginia Henderson Global Nursing e-Repository) is a resource offered through the Honor Society of Nursing, Sigma Theta Tau International. It gives nurses online access to easily utilized and r\ eliable information. Primary investigator contact information is also available \ for requests of full-text versions of studies. The Sigma Repository also pro\ vides a list of tools, instruments, and measurements useful to nurses.

The TRIP Medical Database is a clinical search engine designed to allow health professionals to rapidly identify the highest-quality evidence for clini\ cal practice.

It searches hundreds of evidence-based medicine and nursing websites tha\ t contain synopses, clinical answers, textbook information, clinical calcu\ lators, systematic reviews, and guidelines.

The US Preventive Services Task Force (USPSTF), created in 1984, is an independent, volunteer panel of national experts in prevention and evide\ nce- based medicine. It works to improve health by making evidence-based recommendations on clinical preventive services such as screenings, coun\ seling services, and preventive medications, drawing from preventive medicine a\ nd primary care including family medicine, pediatrics, behavioral health, o\ bstetrics and gynecology, and nursing.

Clinical Trials.gov is a resource providing patients, healthcare professionals, researchers, and the public with access to publicly and privately suppor\ ted clinical Table 5.4 Free Online Resources (cont.) Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 113 studies for a variety of health conditions and diseases. The National Li\ brary of Medicine (NLM) and the National Institutes of Health (NIH) mainta\ in this resource. The principal investigator (PI) of the clinical study u\ pdates and provides information on the studies included. Currently, ClinicalTrials.gov contains data from studies conducted in all 50 states and over 216 count\ ries.

Searchers can look for studies that are currently recruiting as well as \ completed clinical studies.

NIH Research Portfolio Online Reporting Tool (RePORTER) is a federal gov - ernment database that lists biomedical research projects funded by the N\ IH as well as the Centers for Disease Control and Prevention (CDC), Agenc\ y for Healthcare Research and Quality (AHRQ), Health Resources and Services \ Ad - ministration (HRSA), Substance Abuse and Mental Health Services Admini\ s - tration (SAMHSA), and US Department of Veterans Affairs (VA). RePORTER allows extensive field searching, hit lists that can be sorted and dow\ nloaded in Microsoft Excel, NIH funding for each project (expenditures), and publ\ ications and patents that have acknowledged support from each project (results)\ .

Google Scholar is not associated with a hospital or academic library. It is a search aggregator that returns open and subscription results, including \ grey liter - ature, such as conference proceedings, white papers, unpublished trial d\ ata, gov - ernment publications and reports, and dissertations and theses. Google S\ cholar allows a broad search across many disciplines, searching academic publis\ hers, professional societies, online repositories, universities, and other web\ sites for articles, theses, books, abstracts, and court opinions. Searches can inc\ lude non - medical terms, and due to its multidisciplinary nature, content can be a\ ccessed related to non-nursing subject matter. Google Scholar ranks documents by weighting the full text, publisher, and author(s), as well as how recently and fre - quently they are cited in other scholarly literature.

Though Google Scholar can be simple to use because of its familiarity an\ d the wide use of Google as a search engine, the EBP team must be cautious. Se\ arch algorithms change daily, but journals are not indexed, making it impossible to Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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5 Searching for Evidence 114 replicate a search. As with a database, the EBP team must realize that s\ earch - ing using only Google Scholar will result in insufficient evidence (G\ usenbauer & Haddaway, 2020). With these caveats in mind, the EBP team can reap some ad - ditional benefits when using Google Scholar: ■ A helpful feature is the user’s ability to set up a Google Scholar profile, from which routine alerts for relevant search terms can be set up and sent via email notification. For example, if the EBP team is searching\ the literature using search terms fall risk and acute care , a recommendation rule can be set up so that any time Google adds a new document, an email can be sent directly to the EBP team, alerting them to this information.

■ Google Scholar has the ability to both generate citations as well as export citations to citation managers to help keep track of references. \ By clicking on the closed quotation icon (”) under a citation recor\ d, a pop-up will appear with a citation for the relevant document in a variet\ y of output styles. Teams can directly copy or export these citations into a citation manager.

■ Another benefit in Google Scholar is the “cited by” feature. By \ clicking on this option, Google Scholar will display publications that have cited\ the selected piece of literature. This can be helpful when trying to ide\ ntify recent literature or other articles that may have used similar methods. Additional Search Techniques It is important to note that not all literature is found through databas\ e searching, either due to indexing or because the results were presented as a confer\ ence paper or poster and therefore not found in most databases. Because of th\ is, the team can gain valuable information by: ■ Hand searching the table of contents of subject-related, peer-reviewed journals, and conference proceedings Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 115 ■ Evaluating the reference list of books and articles cited in the eligibl\ e articles ■ Searching for references citing relevant articles and evaluating the reference lists Screening, Evaluating, Revising, and Storing Search Results Whether EBP team members conduct a search independently or with the help\ of a medical librarian, it is the searchers’ responsibility to evalua\ te the results for relevance based on the practice question as well as inclusion and ex\ clusion criteria . Keep in mind that to answer the question thoroughly, a team’s search strategies may need several revisions, and they should allow adequate ti\ me for these alterations.

When revising a search, consider these questions: ■ When was the last search conducted? If the search is several years old, you need to consider changes that may have happened in the field that \ were missed by the previous search.

■ Have new terms been developed related to your search question? Terms often change. Even controlled vocabulary such as MeSH is updated annually. Make sure to search for new controlled vocabulary and new keywords.

■ Did the search include databases beyond the nursing literature? Are there databases outside of nursing that are relevant to your question? Does your question branch into psychology or physical therapy? Were those databases searched previously?

■ Are the limits used in the first search still appropriate? If an age range limit was used in the last search, is it still relevant? Were there restrictions on publication type or methodology that are no longer useful?

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5 Searching for Evidence 116 After creating a successful search strategy, teams or individuals should keep a record of the work. Often individuals research the same topic throughout\ their career, so saving search strategies assists in updating work without duplicati\ on of effort. Most databases have a feature that allows saving a search wit\ hin the database; however, it is always a good idea to keep multiple copies of searches.

Microsoft Word documents or emails are a great way to keep a record of work.

PubMed is an example of a database that allows users to save multiple se\ arches . My NCBI , a companion piece to PubMed, permits users to create an account, save searches, set alerts, and customize preferences. Users can save sea\ rch results by exporting them into a citation management software program such as En\ d - Note, RefWorks, Zotero, Mendeley, or Papers. Though some citation manage - ment programs are free, others need to be purchased; some may be provide\ d at no cost by an organization. The function and capabilities of the various\ pro - grams are similar.

Once the team downloads and stores search results, the next step is scre\ ening those results. Systematically and rigorously screening literature search\ results lends credence to the eventual recommendations from the project by ensur\ ing a comprehensive and unbiased picture of the state of the evidence on a giv\ en topic, as well as saving time and effort among team members (Lefebvre et al., \ 2019; Whittemore & Knafl, 2005).

In addition to the question of rigor, comprehensive literature reviews can be a large undertaking with hundreds, if not thousands, of results. Screening\ is a nec - essary step to narrow the results of a search to only the pertinent resu\ lts. It is im - portant to note that a very large number of articles may be a sign that \ the search strategy or the practice question needs to be revised. Employing a team-\ based literature screening protocol and tracking mechanism helps to establish \ clear documentation of the process and makes screening more efficient and re\ liable.

Following a step-wise approach of reviewing titles and abstracts, then f\ ull-text reading, conservatively allows a team to screen 500–1,000 articles ov\ er an eight- hour period (Lefebvre et al., 2019). Quickly culling superfluous res\ ults helps the team to home in on information truly relevant to the identified proble\ m. With Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 117 many competing priorities, EBP teams should avoid spending time consider\ ing articles that do not answer the EBP question through thoughtful approach\ es to the process.

The following steps outline how teams can create a well-documented liter\ ature screening process. These steps have been adapted from the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which were c\ re - ated to improve reporting of systematic reviews (Lefebvre et al., 2019;\ Moher et al., 2009). While systematic reviews and EBP integrative reviews are di\ fferent, they share the common goal of synthesizing the best evidence and are sub\ ject to similar risks. The EBP team meets to:

1. Establish inclusion and exclusion criteria for the literature screening.\ Commonly used exclusion criteria include population, language, date, intervention, outcomes, or setting. The team engages in critical thinkin\ g as they evaluate each article’s potential contribution to answering the EBP question. 2. Establish a system (or way) for the EBP team to track the process for \ literature screening. If the team plans to publish their results, they may consider using tool\ s such as Microsoft Excel to format search results and to function as a shared document for coding inclusion/exclusion. Including information related to the inclusion/exclusion criteria, duplicates removed, number \ of articles excluded at each stage, and any additional investigations outside of the systematic database search (e.g., hand searching) can strengthen the reporting of an EBP project. For systematic literature re\ - views, tools such as Covidence, Rayyan, and Abstrackr are available. 3. Decide how to complete the screening process.

The literature screening process can be divided among all members of the EBP team. Best practice is to have at least two people review and agree whether an article should be included or excluded (Lefebvre et al\ ., 2019; Polanin et al., 2019).

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5 Searching for Evidence 118 4. Begin by screening only the title and abstracts produced from the search. Performing a title screening and then returning to the remaining article\ s for an abstract screening can save time and distraction (Mateen et al.,\ 2013). A key to remember in this step is that the article is included u\ ntil proven otherwise. Exclude only those articles that concretely meet one of the exclusion criteria or do not answer the EBP question. 5. While screening, take notes.

As the team delves deeper into the literature, they will gain a greater \ understanding of the available knowledge on a topic and the relevant vocabulary related to the practice question. Communicate as needed with the team members to make further group decisions on what to include and exclude in the search. There is no right or wrong answer; it\ is important that all group members have a common understanding of the scope of the project and that any changes or updates are well docu - mented (de Souza et al., 2010). 6. After identifying citations, obtain full text.

If full text is not available, submit the citation information through an interlibrary loan request with a local library. Prices associated with interlibrary loan vary with each library and each request. Contact a librarian for pricing inquiries. Some sites, such as EndNote Click and Unpaywall, can provide free, legal access to full text. 7. Complete full-text screening for all articles that remain after screenin\ g the titles and abstracts. Assigned reviewers complete a full-text reading of the articles to con - tinue to determine whether they answer the EBP question and meet all inclusion criteria. This is an objective assessment and does not take in\ to account the quality of the evidence. It is normal to continue to exclude\ articles throughout this stage.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 119 Summary This chapter illustrates how to use the PICO framework as a guide for li\ terature searches. An essential component of evidence-based practice, the literat\ ure search is important to any research-and-publication activity because it enables\ the team to acquire a better understanding of the topic and an awareness of relev\ ant literature. Information specialists, such as medical librarians, can hel\ p with com - plex search strategies and information retrieval.

Ideally, an iterative search process is used and includes: examining literature\ databases, using appropriate search terms, studying the resulting articl\ es, and, fi - nally, refining the searches for optimal retrieval. The use of keywords, co\ ntrolled vocabulary, Boolean operators, and filters plays an important role in finding \ the most relevant material for the practice problem. Database alerting servi\ ces are effective in helping researchers keep up to date with a research topic. \ Exploring and selecting from the wide array of published information can be a time\ - consuming task, so plan carefully in order to carry out this work effect\ ively. References American Library Association. (1989). Presidential committee on information literacy: Final report . http://www.ala.org/acrl/publications/whitepapers/presidential de Souza, M. T., da Silva, M. D., & de Carvalho, R. (2010). Integrative review: What\ is it? How to do it? Einstein (São Paulo) , 8(1), 102–106. https://doi.org/10.1590/S1679-45082010RW1134 Fineout-Overholt, E., Berryman, D. R., Hofstetter, S., & Sollenberger, J. (2019). Finding relevant evidence to answer clinical questions. In B. Mazurek Melnyk, & E. Fineou\ t-Overholt (Eds.), Evidence-based practice in nursing & healthcare: A guide to best practic\ e (pp. 36–63). Wolters Kluwer Health. Gusenbauer, M., & Haddaway, N. R. (2020). Which academic search systems are suitable for systematic reviews or meta-analyses? Evaluating retrieval qualities of g\ oogle scholar, PubMed, and 26 other resources. Research Synthesis Methods , 11(2), 181–217. https://doi.org/10.1002/ jrsm.1378 Johnson, J. H. (2015). Evidence-based practice. In M. J. Smith, R. Car\ penter, & J. J. Fitzpatrick (Eds.), Encyclopedia of nursing education (1st ed.), (pp. 144–146). Springer Publishing Company, LLC. Lefebvre, C., Glanville, J., Briscoe, S., Littlewood, A., Marshall, C., \ Metzendorf, M. I., Noel-Storr, A., Rader, T., Shokraneh, F., Thomas, J., & Wieland, L. S. (2019). Searching for and selecting studies. In Cochrane handbook for systematic reviews of interventions (pp. 67–107). https:// training.cochrane.org/handbook/current/chapter-04#section-4-6-5 Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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5 Searching for Evidence 120 Mateen, F., Oh, J., Tergas, A., Bhayani, N., & Kamdar, B. (2013). Titles versus titles and abstracts for initial screening of articles for systematic reviews. Clinical Epidemiology , 5(1), 89–95. https:// doi.org/10.2147/CLEP.S43118 McCulley, C., & Jones, M. (2014). Fostering RN-to-BSN students’ confidenc\ e in searching online for scholarly information on evidence-based practice. The Journal of Continuing Education in Nursing , 45 (1), 22–27. http://dx.doi.org/10.3928/00220124-20131223-01 Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & the PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA sta\ tement. PLOS Medicine , 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097 Polanin, J. R., Pigott, T. D., Espelage, D. L., & Grotpeter, J. K. (2019). Best practice guidelines for abstract screening large-evidence systematic reviews and meta-analys\ es. Research Synthesis Methods , 10(3), 330–342. https://doi.org/10.1002/jrsm.1354 Whittemore, R., & Knafl, K. (2005). The integrative review: Updated \ methodology. Journal of Advanced Nursing , 52 (5), 546–553. https://doi.org/10.1111/j.1365-2648.2005.03621.x Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition