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Pico Question Health And Social Care Essay
Chapter 2
The Method
CHAPTER 2: THE METHOD
2.1 Introduction
The scope of this chapter is to describe as clearly as possible the systematic approach used to identify and retrieve reliable data.
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Write My Essay For MeIn order to produce a comprehensive literature review it is important to utilise a systemic approach and clearly document the steps involved in the literature review process (Aveyard, 2010). A systemic search strategy identifies the type of data needed to answer a research question beforehand. in this way logical search terms can be identified and through this relevant data may be acquired (Aveyard, 2010). By utilizing such a strategy Aveyard suggests that the chances of the researcher finding the greatest possible amount of relevant literature is increased.
2.2 Refining of the PICO question
When asking a clinical question in the first step of the EBP process the Population Intervention Comparison Outcome [PICO] format is utilized (Overholt, 2005). Formulating an answerable and searchable question is essential. Such a question will need answers from research and clinical judgement. If such a question is not formulated the whole EBP process will become flawed states Overholt. The issue of what approach should be taken to treat RDS led to focusing on the main types of interventions these being invasive and non invasive forms of ventilation. Originally the PICO question focused on invasive and non-invasive ventilation for the treatment of RDS. The initial searches performed on the University of Malta meta-search using the same selection of databases as will be mentioned later in this chapter provided vast amounts of results which lacked focus and clarity. Due to the vast amount of literature addressing numerous different types of interventions it was necessary to focus the question further narrowing down specifically on particular interventions. Since Nasal Continuous Positive Airway Pressure [NCPAP]; and Mechanical Ventilation [MV] provided the most relevant results including numerous randomized controlled trials it was decided that the PICO question had to be refined in order to produce an answerable and searchable research question as recommended by Overholt (2005). The refined PICO framework can be found in Table 2.1
Refined PICO Framework
PICO Question:
Is nasal Continuous Positive Airway Pressure safer than Mechanical Ventilation when treating neonatal Respiratory Distress Syndrome
Population:
Preterm neonates that are defined as of less than 37 weeks in gestational age.
Intervention
Nasal Continuous Positive Airway Pressure and Mechanical Ventilation for treating neonatal RDS.
Comparison:
Nasal Continuous Positive Airway Pressure versus Mechanical Ventilation
Outcome:
Improved survival rates and reduced incidence bronchopulmonary dysplasia [BPD].
Table 2.1: Refined PICO question and framework
2.3 Gathering of Data
After formulating the research question the second step of the EBP process involves searching for the best available evidence in order to generate an answer the PICO question (Overholt, 2005). This stage of the process according to Overholt provides the reader which databases are most appropriate, which keywords should be used, and which study designs are most reliable in order to answer the question.
It is important for a literature search to focus on high quality evidence which addresses the PICO question (SIGN, 2011). This search should cover studies which are located at the top of the hierarchy of study types (SIGN, 2011). The preferred form of literature for giving evidence based statements and recommendations include meta-analyses, systematic reviews of randomized controlled trials [RCT’s] or the RCT’s themselves (Scottish Intercollegiate Guidelines Network [SIGN], 2011). The sources which were used in order to gather data in order to answer to research question include a variety of databases. was one of the sources of databases which was used.
2.3.1 Keyword generation
The keywords chosen to search for literature are of great importance and need to be selected wisely. In order to access the widest variety of literature possible abbreviations also had to be utilized. The keywords used were different combinations of continuous positive airway pressure, mechanical ventilation, respiratory distress syndrome, CPAP, NCPAP, MV, RDS, surfactant, intubation, preterm, neonatal. In order to broaden or narrow the number of hits for each search the Boolean term ‘and’ or ‘or’ were utilised automatically through the functions available on the University of Malta MetaSearch engine to merge different keywords.
2.3.2 Databases used
The University of Malta MetaSearch engine was used, it was categorised to health sciences and nursing in order to display only relevant databases to nursing. From here on the following set of databases were selected with regards to the description of their content; these included; Academic Search Complete (EBSCO), CINAHL Plus with Full Text (EBSCO), Cochrane Central Register of Controlled Trials (EBSCO), Cochrane Database of Systematic Reviews (EBSCO), MEDLINE (ProQuest), JAMA & Archives, Directory of Open Access Journals and PubMed. The choice of which databases were to be used took place after analysis of the description provided for each one within the with regards to what type of data each database individually covered.
Apart from the databases provided by the University of Malta, the Google scholar search engine was also utilized in order to retrieve relevant data which was not available in full text within The University of Malta e-Library. If this also failed an email was sent to the author requesting a copy of the article without payment but this approach proved to be unsuccessful.
2.3.3 The searching process
In order to portray the search process a number of tables were compiled. These table include the keywords, the databases used, the number of hits for each database, and the number of articles retrieved from each database.
2.4 Inclusion and Exclusion Criteria
When handling relatively large amounts of data in order to address a research question it is important to “filter” through this data in order to discard irrelevant or inappropriate data while retaining important and relevant data. This process involves compiling a set of criteria which will focus the question even more while going into further detail with regards to the review’s relevance and scope.
the inclusion and exclusion criteria included amongst others English articles excluding all articles in other languages. Inclusion criteria focused only on articles from the year 2000 and onwards excluding any articles published before the year 2000. Articles to be included in the data retrieval process were those which focused on either NCPAP, MV, Intubation and surfactant administration or all of the above as interventions within the article. The form of literature which was to be included in the data retrieval process comprised of meta-analyses, systematic reviews of randomized controlled trials [RCT’s] and Randomized controlled trials themselves; any other literature to be used as evidence in order to answer the research question was excluded.
Inclusion Criteria
Exclusion Criteria
Articles published from the year 2000 to 2012
Articles published before the year 2000
Articles in English
Articles not in English
Neonatal Respiratory Distress Syndrome.
Respiratory Distress Syndrome in any age group above 37 weeks of gestational age.
Nasal Continuous Positive Airway Pressure, Surfactant, Intubation, Mechanical Ventilation as interventions.
Any other interventions.
Systematic reviews, Meta-Analysis, Randomized controlled trials and cohort studies
Other forms of literature lower in the hierarchy of evidence.
Ethical consideration.
No ethical consideration
Table 2.9: Inclusion and exclusion criteria applied
2.5 Critical Appraisal
The third stage in the EBP process involves critically appraising the evidence (Overholt, 2005). When carrying out a literature search the relevant studies and data retrieved need to be appraised in order to produce the best recommendations and also answer clinical questions based on evidence (National Institute for Clinical Excellence [NICE], 2005). Critical appraisal of evidence may be achieved by an efficient process; which focuses mainly on three questions argues Overholt. These questions address the validity of any studies or systematic reviews, their results and whether or not they are reliable and lastly if the results can or cannot be applied to the group of patients (Overholt, 2005). In this way the value of the available research with both its flaws and worth may be determined with relevance to practice (Overholt, 2005).
In order to produce a consistent approach to critically appraise research a critical appraisal tool is recommended (Aveyard, 2010). Since the review process is a complex one using a critical appraisal tool will help in developing a systemic approach to the review process and ensure than all literature is reviewed equally.
The tools which will be usedin order to critically appraise literature consist of Critical Appraisal Skills Programme [CASP] tools. Since meta-analyses, systematic reviews of RCT’s and RCT’s are the preferred form of literature for acquiring evidence; based on statements and recommendations (SIGN, 2011) the critical appraisal tool for each different type of literature was located and retrieved from the CASP website.
2.6 Conclusion
This chapter serves as a clear guide of the systematic approach utilized to retrieve the necessary relevant data essential for answering the research question. The refining of the PICO question, systematic search strategy, use of selected keywords, the selection of databases, and also the inclusion and exclusion criteria which were applied were all discussed throuought. The final part of the chapter addressed the critical appraisal tools which will be used to evaluate the methodology of the studies. In the next chapter the methodology of the literature retrieved will be critically appraised and discussed.
Chapter 3
Critical Appraisal of the Literature
Chapter 3: Critical Appraisal of the Literature
3.1 Introduction
This chapter of the dissertation will focus on the result of the literature search discussing the key papers. These key papers will then receive an in depth critical appraisal critically discussing the methodology used along with the approaches and methods with the use of a thematic and integrated approach. This literature will then be identified according to its credibility within a hierarchy of evidence. The chapter will then conclude by taking into account any ethical considerations involved with the studies.
3.2 The results of the search activity
The entire literature search process ended in a total of 48 articles being retrieved. When the duplicates and the Randomized controlled trials which were studies within the systematic review were removed a total of 6 articles remained. These 6 articles consisted of a systematic review Stevens, Blennow, Myers & Soll (2008); 3 Randomized controlled trails by Sandri, Plavka, Ancora, Simeoni, Stranak, Martinelli, Mosca, Nona, Thompson, Verder, Fabbri, Halliday (2010); Morley, Davis, Doyle, Brion, Hascoet, Carlin (2008) and SUPPORT (2010); and 2 cohort studies by Saxena, Thapar, Sondhi & Chandra (2012) and Tsakalidis, Kourti, Karagianni, Rallis, Porpodi & Nikolaidis (2010).
These studies addressed the interventions mentioned within the PICO framework including NCPAP and MV but also included other associated interventions namely intubation and surfactant administration. Further information with regards to the studies is found later on throughout this chapter utilizing the applicable CASP tools for appraisal.
3.3 Selection of key papers and the hierarchy of evidence
By utilizing the previously mentioned inclusion and exclusion criteria it was possible to narrow down to these 6 articles. According to SIGN (2011) the most reliable studies which provided the highest levels of evidence included Systematic reviews followed by Randomised controlled trials and Observational studies. The level of evidence also depends on the risk of bias for each study.
Utilizing the NHMRC (2009) evidence hierarchy it was made possible to clearly identify the types of studies the dimensions of evidence which include the strength of evidence, size of effect and the relevance of evidence. Using this approach in combination with using relevant CASP tools for each study it was possible to critically appraise them in a systematic and efficient manner. Later on throughout the chapter the level of evidence will be graded according to the adaptation of the NHMRC (2009) level of evidence table found in table 1.
