Topic 6

• Evidence-Based Nursing Practice


  A conscious process that involves exploration of thoughts, knowledge and practices in order to recognise inconsistencies, strengths, limitations…identify where change and adjustments are required within ourselves, the healthcare environment and clinical practice
• Critical thinking


  • A fundamental skill enabling nurses to deliver safe, quality healthcare
  • Involves process of: questioning, interpreting, analysing, determining relevance, making judgements about information, knowledge, professional practice and research
• Reflective practice


  • A conscious process that involves exploration of thoughts, knowledge and practices in order to recognise inconsistencies, strengths, limitations…identify where change and adjustments are required within ourselves, the healthcare environment and clinical practice
• Critical appraisal


  • Structured and systematic process
  • Strengths and limitations of research studies appraised
  • Relevance to clinical practice evaluated
  • Many appraisal tools available (e.g. CASP, JBI)
• Why is critical appraisal?

  Critical appraisal allows us to: reduce information overload, identify the most relevant papers, distinguish evidence from opinion, assumptions, misreporting, and belief, assess the validity of the study, assess the usefulness and clinical applicability of the study, recognise any potential for bias
• Types of critical appraisal checklists

  • JBI
  • CASP_RCT standard checklist
• How to select checklist?

  Clinical questions vs. Best evidence
• Types of research questions

  • Therapy/intervention
  • Prevention
  • Prognosis/prediction
  • Diagnosis
  • Etiology
  • Meaning
• What to appraise?


  • Are the results of the study valid? (validity)
  • What are the results? (reliability)
  • Will the results help me in caring for my patients ? (applicability)
• Preliminary appraisal_Main questions to ask


  • Why was the study undertaken?
  • What is the underlying question: is it relevant to my question or interests?
  • What type of evidence is provided?
  • Is there a clear statement of aims?
  • What was the overall design of the study?
  • Is the study design appropriate for the research question and study objectives?
  • Is the study population relevant to my question or clinical situation?
  • What were the outcomes of the study?
  • Are the results and conclusions relevant?
• Title


  • Is it concise but informative?
  • Does it indicate the research approach?
• Example study title: Effectiveness of conservative urinary incontinence management among female nursing home residents —A cluster RCT
• Detailed appraisal: methodology


  • Was the study methodologically sound?
  • Sample size and design, including sampling, data collection, data analysis and findings
  • Quality of study: internal validity and reliability in quantitative research, trustworthiness in qualitative research
• Questions to ask regarding methodology

  • Qualitative:
  • Are the participants appropriate to provide information sought?
  • How does researcher account for own presence in data collection/analysis?
  • Any outside factors that might have influenced data collection?
  • Any method changes accounted for?
  • Analysis appropriate for data collected?
  • In-depth description of analysis method?

  Quantitative:

  • Adequate sample size? Sufficient power?
  • Source of sample? Representative of broader population?
  • Sufficient information regarding inclusion/exclusion criteria?
  • Sampling method: how were participants recruited? Bias?
  • Are the groups for comparison identical?
  • Blinding? (experimental)
  • Follow-up/dropout
  • Data collection methods/tools valid & reliable? Instrument previously validated?
  • Any outside factors that might have influenced data collection?
  • Any method changes accounted for?
  • Analysis appropriate for data collected?
  • Tests used and findings appropriately reported?
• Example quantitative study: Effectiveness of conservative urinary incontinence management among female nursing home residents —A cluster RCT
• Example qualitative study:
• Detailed appraisal: Findings & conclusion

  • Data clearly presented?
  • Statistical significance reported?
  • Drop out/missing data accounted for?
  • Results credible/trustworthy?
  • Validity and reliability
  • Will the results help locally?
  • Can the results be applied to your local population/in your context?
  • Clear statements of findings made?
  • Conclusions drawn?
  • Ethical issues address and ethical approval obtained
• Document critical appraisal with a summary table of retrieved articles with headings such as: Author, year & country, Purpose, Study design & Data collection, Sample size & sites, Key findings, Results of quality appraisal
• Clinical significance vs statistical significance

  Statistical significance: a determination that a relationship between two or more variables is caused by something other than chance (p<0.05)

  Clinical significance: usually calculated in terms of effect size, confidence intervals (CI), risk ratios
• Levels of evidence


  • Level 1: Systematic review & meta-analysis of RCTs; clinical guidelines based on systematic reviews or meta-analyses

  Level 2: Randomized controlled trials

  Level 3: Controlled trials (no randomization)

  Level 4: Case-control or cohort studies

  Level 5: Systematic reviews of descriptive & qualitative studies

  Level 6: A single descriptive or qualitative study

  Level 7: Expert opinion
• Quantitative Evidence Pyramid
• Which level of evidence?