EBP Literature Searching Skills - Part 1

8th Annual Nursing Research Conference

Christiana Hospital, Newark, DE
November 1, 2013

Patricia Wynne, BSN, MS - Medical Librarian

Thomas Jefferson University - Scott Memorial Library
11/1/2013 8th Annual Nursing Research Conference

Agenda – Part 1

 Path to an evidence-based practice

 Formulating a research question
 Using the PICO format
 Type of clinical questions
 Study types
 Simple search and database record review
 Practice clinical query and search strategy
development
 Tips for creating a search strategy
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The Desire

 Consistently deliver high quality healthcare

 Achieve the best patient outcomes

 Maintain a professional commitment to an

evidence-based practice
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The Challenge
 Two million articles published in the biomedical literature
annually (year: 1978)1

 Publication growth rate is increasing geometrically

 If practitioners were to attempt to keep up with the

literature by reading two articles per day, in 1 year they
would fall 55 centuries behind1

 If physicians were to read everything of possible

biomedical relevance, they would need to read 5500
articles per day (year: 1986)2

1Cogent Communication: Overcoming Information Overload. Bernier, & Yerkey 1979

2How to keep up with the medical literature: I. Why try to keep up and how to get started. Annals of Internal Medicine,
1986
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What is needed?
 First requirement: a spirit of inquiry1

 Second requirement: critical thinking2

o Be aware (beware) of assumptions (pervasive in our thinking
patterns)
 Cloud our thinking
 Check their accuracy and validity
o Begin reasoning toward inferences (thoughts we form as we
reason toward conclusions)
o Find evidence to support our inferences
o Draw conclusions from developed observations & facts

1Adapted from Evidence-based practice, step by step: Asking the clinical question: A key step in evidence-based practice,
American Journal of Nursing, 2010
2Adapted from Teaching Evidence-Based Practice in Nursing, Levin & Feldman 2013
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What is needed?
 Third requirement: asking the clinical question
o Well-built clinical questions help us search for the most
current literature

o Use PICO(T) as a guide to systematically identify

components of a clinical issue
 Increases likelihood of quickly and efficiently finding the best
evidence to inform your practice

Adapted from Evidence-based practice, step by step: Asking the clinical question: A key step in
evidence-based practice, American Journal of Nursing, 2010
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What is needed?

 Fourth requirement: tenacity when doing

library research
o Searching is a complex process
o Give yourself time to get to know a tool
 Basic online tutorials
 Trial and error
 Ask your librarian
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Begin to formulate question

 Is it a Background question?
o General information on an issue
o Answer can usually be found in a textbook
o Necessary before you can answer a foreground question
 e.g. What is eczema?

 Is it a Foreground question?
o Focus on a specific clinical issue
o Can be answered from scientific literature
 e.g. Will acupressure help my patient with eczema?
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PICO (T)
P (population, patient, or problem)
I (intervention)
C (comparison)*
O (outcome)
(T) (time)*
*not always required
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PICO*

• P (age, gender, specific disease)

• I (therapy or issue of interest)
• C (alternative treatment, placebo, no
intervention)
• O (expected outcome (positive) or
outcome to avoid)

*Your query may not always fit neatly into the PICO format
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Types of clinical questions

 Intervention/Therapy

 Diagnosis (or diagnostic test)

 Prognosis

 Etiology/Harm

 Meaning
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Intervention/Therapy

• In _____________________________ (P)
• How does_______________________ ( I )
• Compared to ____________________ (C)
• Affect __________________________ (O)
• Within _________________________ (T)

Evidence-Based Practice in Nursing and Healthcare. Melnyk &Fineout-Overholt 2011

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Diagnosis

• In ______________________________ (P)
• Are/is ___________________________ ( I )
• Compared with ____________________ (C)
• More accurate in diagnosing _________ (O)

Evidence-Based Practice in Nursing and Healthcare. Melnyk &Fineout-Overholt 2011

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Prognosis

• In ________________________________ (P)
• How does _________________________ ( I )
• Compared to _______________________ (C)
• Influence or predict __________________ (O)
• Over _____________________________ (T)

Evidence-Based Practice in Nursing and Healthcare. Melnyk &Fineout-Overholt 2011

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Etiology

• Are ____________________________ (P)

• Who have _______________________ ( I )
• Compared with those without ________ (C)
• At ________ risk for _______________ (O)
• Over ____________________________ (T)

Evidence-Based Practice in Nursing and Healthcare. Melnyk &Fineout-Overholt 2011

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EBM Levels of Evidence Pyramid

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Let’s try a simple search first

Field searching (free-text)

You heard about an article that has chocolate and

happiness in the title but you have no other details about it

• Concept 1: chocolate AND Concept 2: happiness

• Search in Medline
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Result:
A clinical trial gone awry: the Chocolate Happiness
Undergoing More Pleasantness (CHUMP) study.

Chan, K. (2007). A clinical trial gone awry: The chocolate happiness undergoing
more pleasantness (CHUMP) study. Canadian Medical Association Journal,
177(12), 1539-1541.
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Let’s take a look at the record

MeSH Subject Headings
Adult
*Cacao (this is the preferred term for chocolate; the asterisk
means that it is a major focus of the article)
*Candy
Double-Blind Method
Feeding Behavior
Female
*Happiness
Humans
Male
*Wit and Humor as Topic (clicking on any hyperlinked subject heading
will take you to articles in the database that are indexed with it; this
heading has 2,829 papers that are indexed in Medline, that is, out of over
22 million biomedical articles in Medline, only 2,829 are humorous )
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Before we go any further…

Let’s talk about the process of creating a search

strategy along with some search tips
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Create a search strategy

 Select a database(s) (e.g. Medline, CINAHL)

 Use keywords (main concepts) from your PICO

question to formulate your search strategy
o It helps to put them in the format of a chart
 Columns for each main concept (these concepts will be
combined in the strategy using ‘AND’) but first…
 Add additional similar or related terms for each main concept
(these similar terms can be searched together using ‘OR’ in the
strategy)
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Create a search strategy

 Use database’s controlled vocabulary to find the
preferred subject headings for that database that
closely match the terms in your chart
o “MeSH” (Medline) - Medical Subject Headings
o “CINAHL Headings”

 Use free-text (e.g. as you would enter terms in

a Google search box) when your term is not
indexed in the database’s controlled vocabulary
o newer terms or concepts often don’t make it into the
database’s controlled vocabulary right away
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Searching tips

 Major focus: your term must be the main point of

the article

 Truncation: use asterisk in many databases to

obtain various forms of a term (useful if term is
not in database’s controlled vocabulary)
o E.g. impermeab* will retrieve articles that contain
impermeable or impermeability
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Searching tips
 Explode function: database will search for
related terms under a subject heading

 Boolean searching: AND, OR, NOT

 Combining search statements

o E.g. CINAHL: S1 AND S2 (tick box next to set 1 and set
2 then click on ‘Search with AND’ button to combine
them)
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More searching tips

 Limits & Filters: date, language, review articles,
systematic reviews, clinical queries, etc.
 Utilize subheadings in MeSH and CINAHL: help
to refine your topic. E.g. heart failure/th
o The subheading/th signifies therapy (in both Medline
and CINAHL) and by adding it to your term ‘heart failure’
it will retrieve records with the focus of heart failure and
therapy)
 Related citations
 Utilize database tutorials
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Clinical Scenario

A nurse in a pain clinic works with patients with chronic

back pain and wonders if evidence supports the use of
yoga as a treatment option.

Worksheet: http://bit.ly/12IFiH6
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Create PICO Question

What type of question is it?

Intervention/Therapy or Etiology or Diagnosis?

In ____”patients with chronic back pain ” __________________ (P)

How does ___”yoga” __________________________________ ( I )
Compared to ________________________________________ (C)
Affect ____ ”pain management” _________________________ (O)

“Do patients with chronic back pain who practice yoga experience less
pain?”
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MEDLINE OR CINAHL
Concept 1 AND Concept 2 AND Concept
3
Chronic back pain Yoga/ After combining concept 1 and
concept 2, you may want to
(use preferred MeSH look at your results before
term: Back Pain/) adding other terms. These
results will provide a broad
Use subheadings for view of the topic but if you’d
‘therapy’ and like to further narrow or focus
‘prevention and your results you can add the
control’ – following term(s) or other
Back Pain/th, pc measures you are interested in:

OR OR
Low Back Pain/th, pc Pain measurement/

OR
Quality of Life/
OR
Treatment Outcomes/
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Suggested Search Strategy* in

OVID Medline

1. exp Low Back Pain/th, pc

2. exp Back Pain/th, pc
3. 1 or 2
4. exp Yoga/
5. 3 and 4
6. limit 5 to (english language and clinical trial, all)

*One size does not fit all! Search strategies will vary for each research question.
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Suggested Search Strategy* in

CINAHL
1. (MH "Back Pain+/PC/TH") OR (MH "Low Back
Pain/PC/TH")
2. (MH "Yoga+")
3. S1 AND S2
4. Apply Limiters - English Language; Research Article

*One size does not fit all! Search strategies will vary for each research question.
 EBP Literature Searching Skills - Part 2

8th Annual Nursing Research Conference

Christiana Hospital, Newark, DE
November 1, 2013

Patricia Wynne, BSN, MS - Medical Librarian

Thomas Jefferson University - Scott Memorial Library
11/1/2013 8th Annual Nursing Research Conference

Agenda – Part 2

 Study types (continued)

 Practice clinical query and search strategy

development
o using your own clinical scenario or one from
the instructor

 Professional practice
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Study types
Can be found in biomedical literature databases
• Systematic Reviews
• Meta-analysis
• Randomized controlled clinical trials
• Cohort studies
• Case control studies
• Case series and Case reports
• Cross-sectional studies

See description of studies at:

http://guides.mclibrary.duke.edu/content.php?pid=431451&
sid=3530453
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EBM Levels of Evidence Pyramid

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Source: http://researchguides.dml.georgetown.edu/content.php?pid=129563&sid=1111394
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Source:
http://www.hsl.unc.edu/Services/Tutorials/EBM/Supplements/QuestionSupplement.htm
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Cochrane Database of Systematic

Reviews
 Systematic reviews of research in healthcare and health
policy
 Type of reviews include
o Intervention
o Diagnostic
o Methodology
 Findings based on the results of trials which meet certain
quality criteria
 Can search for reviews in Medline but must subscribe to
Cochrane to view full reviews
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Cochrane Database Search

A Protocol is an outline of a
review in preparation
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Clinical Scenario
A nurse working with asthmatic patients in a hospital
setting is occasionally asked by patients being discharged
if they should use impermeable bed covers to decrease
exposure to dust mites.

Worksheet: http://bit.ly/12IFiH6
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Create PICO Question

What type of question is it?
Intervention/Therapy or Etiology or Diagnosis?

In _______”asthmatic patients”__________________ (P)

How does _”the use of impermeable bed covers”____ ( I )
Compared to ________________________________ (C)
Affect ______”peak expiratory flow”_______________ (O)

In patients with asthma does the use of impermeable bed

covers improve peak expiratory flow?
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Medline
Concept 1 AND Concept AND Concept AND Concept
2 3 4

Asthma/ Bedding Impermeable peak expiratory flow

(use preferred (not a preferred term; use (use preferred MeSH

MeSH term: impermeab* to retrieve term: peak expiratory flow
Bedding and impermeable and rate/
Linens/) impermeability)

OR OR
Linens Barrier To broaden your topic you
may consider other terms
(use preferred (not a preferred term; use to ‘OR’ with “peak
MeSH term: barrier* to retrieve barrier expiratory flow”, e.g.
Bedding and or barriers) “symptoms”
Linens/)

OR
Covers

(not a preferred
MeSH term; use
cover* to retrieve
cover, covers, etc.)
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Suggested Search Strategy* in OVID Medline

1. exp Asthma/
2. exp "Bedding and Linens"/
3. cover*.mp.
4. 2 or 3
5. impermeab*.mp. [mp=title, abstract, original title, name of substance word,
subject heading word, keyword heading word, protocol supplementary concept,
rare disease supplementary concept, unique identifier]
6. barrier*.mp. [mp=title, abstract, original title, name of substance word,
subject heading word, keyword heading word, protocol supplementary concept,
rare disease supplementary concept, unique identifier]
7. 5 or 6
8. exp Peak Expiratory Flow Rate/
9. 1 and 4 and 7 and 8
10. limit 9 to (english language and clinical trial, all)

*One size does not fit all! Search strategies will vary for each research question.
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Your legacy!

 Commitment to a professional practice

 Career vs job
 Share your knowledge beyond your
institution
 Publish your results
o NAHRS 2012 Selected List of Nursing Journals
http://nahrs.mlanet.org/home/
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Resources
• AGREE II (international tool for the assessment of practice guidelines)
http://www.agreetrust.org/
• CINAHL (Cumulative Index for Nursing and Allied Health Literature);
subscription-based via EBSCOHost; check your library resources
• Cochrane Database (for systematic reviews); subscription-based; can
retrieve titles/abstracts from Medline but full records only through
subscription (check your library resources)
• DARE (Database of Abstracts of Review of Effects); a database of
abstracts of quality assessed systematic reviews produced by the Centre
for Reviews and Dissemination; available at
http://www.crd.york.ac.uk/crdweb/ and its content is also available via the
Cochrane Library, TRIP Database, OVID’s Evidence-Based Medicine
Reviews.
• InterTASC Information Specialists' Sub-Group Search Filter Resource
(search filters designed to retrieve research by study design or focus)
https://sites.google.com/a/york.ac.uk/issg-search-filters-resource/home
• Joanna Briggs Institute EBP Database (includes systematic reviews);
subscription based http://joannabriggs.org/ (check your library
resources)
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Resources
• KT Clearinghouse (formulating answerable clinical questions)
http://ktclearinghouse.ca/cebm/practise/formulate
• Medical Library Association: Nursing and Allied Health Resources
Section: NAHRS 2012 Selected List of Nursing Journals
http://nahrs.mlanet.org/home/
• Medline (biomedical literature database); free access at PubMed
www.pubmed.gov/ but full-text might not be freely available; or via
OvidSP (subscription-based), check your library resources
• National Guideline Clearinghouse (public resource for evidence-based
clinical practice guidelines) http://www.guideline.gov/
• Natural Standard (evidence-based information about complementary and
alternative medicine); subscription based
http://www.naturalstandard.com/ (check your library resources)
• PubMed Health (clinical effectiveness research)
http://www.ncbi.nlm.nih.gov/pubmedhealth/
• Trip Database (searches multiple sources for evidence-based
information); free access at http://www.tripdatabase.com/
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References
• Bernier, C.L., & Yerkey, A.N. (c1979). Cogent Communication: Overcoming Information
Overload. Westport, CT: Greenwood Press.

• Haynes, R. B., McKibbon, K. A., Fitzgerald, D., Guyatt, G. H., Walker, C. J., & Sackett,
D. L. (1986). How to keep up with the medical literature: I. why try to keep up and how
to get started. Annals of Internal Medicine, 105(1), 149-153.

• Howlett, B., Rogo, E., & Gabiola Shelton, T. (c2014). Evidence-Based Practice for
Health Professionals: An Interprofessional Approach. Burlington, MA: Jones & Bartlett
Learning.

• Levin, F., & Feldman, H. (Eds.). (c2013). Teaching evidence-based practice in nursing
(2nd ed.). New York, NY: Springer Pub.

• Melnyk, B. M., Fineout-Overholt, E. (c2011). Evidence-based practice in nursing &

healthcare: A guide to best practice (2nd ed.). Philadelphia: Wolters Kluwer/Lippincott
Williams & Wilkins Health.

• Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010).

Evidence-based practice, step by step: Asking the clinical question: A key step in
evidence-based practice. American Journal of Nursing, 110(3), 58-61.
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Thank you!
Contact Information:

Patricia Wynne, BSN, MS

Thomas Jefferson University
Scott Memorial Library
1020 Walnut St.
Philadelphia, PA 19107

Phone: 215-503-7815
Email: [email protected]
Link to slides http://jdc.jefferson.edu/aisrpubs/33/