PBC Library

ASK:

Before you start, try following along with the Guide to Forming a PICO Question.

Construct a concise clinical question.

The first step in EBP is to write a focused clinical question. That question will be translated into a database query in step two. Best practice is to define your research question and identify which types of studies or publications would be best suited to that question before searching the literature. You should also be aware of the patient, if you are seeing one, and how their needs are informing your research.

Once you've considered the foundational components of your research, the next step involves constructing a question relevant to your needs and your patient's needs. It should be framed using the PICOT acronym:

Patient / Population:

What kind of person is the patient? What is their diagnosis? What is their particular situational need?

Example: pre-adolescent children with cerebral palsy

Intervention:

How would you describe the specific intervention you are considering?

Example: whole body vibration

Comparison / Control:

Is there a control group? Is there are an alternative intervention? (Keep in mind: not all questions have a "comparison" component)

Example: conventional physical therapy

Outcome:

What is the desired outcome? Does it involve reduction, relief, or elimination of symptoms? Can it be measured with a test?

Example: increased balance

(OPTIONAL) Time / Type:

What time periods should be considered?  What study types are most likely to have the information you seek?  What clinical domain does your question fall under?

Example: randomized controlled trials

Now, we string our PICO components together:

Does whole body vibration increase balance in comparison to standard physical therapy in children with cerebral palsy?

Clinical Domains

It can be helpful to classify your question based on the clinical domain it falls under. A clinical domain refers to the type of study you wish to locate. For instance, a question involving therapy (such as whole body vibration) falls under the the clinical domain, therapy. Knowing this, you can filter your search results to return randomized controlled trials, which are the "gold standard" for studies involving therapeutic interventions.

See the examples below for more clinical domains and corresponding PICO templates:

Further reading

Levels of Evidence Pyramid | Click Here

Types of Study Design:

Question Type & Study Design

Some study designs are better suited to answer certain types of questions. Identifying the clinical domain your question falls under can help determine what study designs to look for in order to find the best, most suitable evidence. Systematic Reviews and Meta-Analyses are always preferred.

For example:

Clinical question: In adults with total hip replacements, how effective is pain medication compared to aerobic stretching in controlling post operative pain during the perioperative and recovery time?

Clinical domain: Therapy

Preferred study designs: Systematic Reviews/Meta-analysis | Randomized Controlled Trials | Conrolled Trials

Background information

Foreground vs. Background information

Before proceeding, open the Step 3: Aqcuire worksheet by clicking here.

Foreground information is the complex, precise information often needed in order to answer a PICO question.  Before searching for foreground information, however, make sure you have a good understanding of each of the PICO concepts.  

Sometimes, you will find that you need background information before you ever even begin putting together your PICO question. That's okay! This entire process is iterative, which means repeating steps is sometimes necessary. 

Put simply, background information is the general health information typically available to the public. That doesn't mean it's easy to follow, but it should be less robust, and more summative than your average peer-reviewed study.

Practice guidelines provide one useful source for background information. For the most part, they are short, designed to be understood, and closely reviewed by professionals. To get an idea what a practice guideline looks like, check out your professional organization's website or look through this sample for working with transgender patients from the World Professional Association for Transgender Health: WPATH Standards of Care.

Test your knowledge!

Before moving on, answer the following questions on your Google Form:

• How might you assess whether you need background information or not?
• What are some important components of good background information?
• In what situations is having background information especially vital to patient care?

Public resources for background information:

• Centers for Disease Control and Prevention
• Choose PT (public health information from APTA)
• Google / Google Scholar (always vet information for credibility)
• Healthfinder.gov
• Medlineplus.gov (best bet for patient education)
• National Institutes of Health
• Pillbox
• Professional associations
• ToxTown
• Wikipedia.org (always use in a supplementary context)

A note about appraised resources

For practitioners who need immediate, credible information, appraised resources are highly preferred. BMJ Best Practices and UpToDate are two specific resources that can be leveraged at or around point-of-care. Keep in mind that PubMed also indexes appraised information; however, it is more difficult to parse due to PubMed's scope.

From a point-of-care perspective, we can place evidence into five categories:

When searching for best evidence in clinical decision making, start at the the top of the hierarchy with systems and work your way down to synopses, syntheses, and studies. Opt for databases like UpToDate, which present information quickly, clearly, and efficiently. 

Remember that point-of-care tools are meant to save time in a fast-paced clinical environment. Even so, it is important to maintain proficiency in larger databases such as MEDLINE, in order to locate new research studies as they are published.

Mobile Applications can also be very helpful at the point-of-care, however, use caution since nearly anyone can develop an app! You must carefully evaluate the information & source. STAT!Ref is a library resource with a mobile app that is recommended to NAU students, as it provides access to ACP Smart Medicine, 5 Minute Clinical Consult, Red Book, and more.

6S Levels of Evidence Pyramid | Click Here

Acquiring evidence

Finding foreground information

Following from the levels of evidence pyramid (see above), information resources can be collapsed into three broad categories (with corresponding sub-categories): 1) summaries and guidelines; 2) synopses of syntheses and syntheses; 3) synopses of studies and individual studies.

When we commit to a research question and literature search, we want to get as near to the top of the pyramid as we possibly can. Depending upon the research available, we work down from there.

Looking at the pyramid, answer the following questions in your Google Form:

• Why do we want to start at the top, and work our way down?
• Why do we use a pyramid rather than a square? Why is the top smaller than the bottom?
• What does it mean if you don't find any research published for your clinical question?

(NOTE: Don't worry about picking a resource just yet. You might want to look through summaries, but otherwise, move on to the next step.)

Click here to review NAU's complete journal listings.

Complete list of NAU health science databases

Conducting a search

After constructing your PICO question and finding the resource that best suits your needs, it's time to build and conduct a search. Listed below are strategies and tools that will make it easier to find information that is most applicable to you and your patients.

Primary concepts

Your PICO question should help you identify specific search terms that you can use to search the databases. This, combined with what you learned while searching background information, will help you form the "backbone" of your search question.

Take a few moments to list your PICO "primary" terms following the table below:

MyNCBI

More than likely, PubMed is the most common place you'll go for your research. It's an an enormous platform, and houses the MEDLINE, PMC, MeSH, and NCBI Bookshelf databases. It also has its own citation management tool, which you should access before using any other part of the service. 

This tool can be accessed as soon as you've set up a MyNCBI account. Doing so is fairly simple. Simply click Sign in to NCBI from the top right corner of the PubMed homepage. From there, you need only create a new account.

For more help, check out this walkthrough video from VCU Libraries on setting up an account: 

MeSH

It can be challenging to find exactly what you're looking for when searching databases. For that reason, it's valuable to adhere to the controlled vocabulary in the different databases you search. One of the most well-regarded is MeSH, which stands for "Medical Subject Headings". MeSH terms are an important part of the search experience in PubMed, one of the largest research platforms in the world. 

MeSH terms are created by the National Library of Medicine. Using them will help you formulate keywords for your search. Follow this link to go to the MeSH database: https://www.ncbi.nlm.nih.gov/mesh. 

Consider the following questions in your Google Form (Step 3: Acquire):

• Why is it important to at least browse MeSH terms before conducting a full-on search?
• Do you think that MeSH terms are valuable in databases outside PubMed? Why or why not?
• At what point would you want to consider a MeSH search?

For help with MeSH, see this short tutorial:

PubMed Clinical Queries

Now that you've put together your primary search concepts using MeSH, let's conduct a search in PubMed's Clinical Queries tool.

The clinical queries tool is designed to provide more efficient access to studies and systematic reviews which correlate with a specific clinical domain. It is not exhaustive! Rather, it is designed to give you more immediate insight into the amount of studies available in your field of study.

As you think about your clinical queries search keep in mind the following:

• When you begin formulating a search strategy, aim for a search with high recall rather than precision. In many cases, this will generate a larger number of results than is necessary; however, it is sometimes easier to narrow your search over time instead of doing so from the outset.
• Avoid using too many search concepts; concepts are the primary terms that align with your search needs. At the same time, a variety of synonymous search terms should be combined in conjunction with each concept.
  • IE: Intervention (concept) = hip strengthening | "hip flexor" OR "hip extension" OR "hip exercise" OR "hip stretch" OR ""hip stretches" OR hip stretching" OR "foam roll" OR "foam roller" OR "foam rolling" (search terms)
• Familiarize yourself with Boolean operators AND, OR & NOT, and apply them within your search string, both between concepts and between search terms.
  • AND separates concepts | "cerebral palsy" AND "whole body vibration" narrows your search, such that you receive papers about both cerebral palsy and vibration.
  • OR separates search terms | "children" OR "pediatrics" broadens your search to include both of these key words.
  • NOT excludes unwanted concepts | "stroke" NOT ("heat stroke" OR "breast stroke") makes it more likely your search results will be limited to cerebrovascular accidents.
• Two other rules to keep in mind involve parentheses and quotation marks:
  • Parentheses include phrases in your search, but will not limit to exact phrasing.
    • IE: (disorders of sexual development) will return any combination of those keywords.
  • Quotation marks limit search results to exact phrasing.
    • IE: "disorders of sexual development" will return this exact phrase.

For more help building these strategies into a search string, check out the University of Arizona search strategy builder.

Advanced Search Strategies

Read through this entire section before answering the questions in your Google Form (Step 3: Acquire)

Creating a Zotero account

Once you have compiled at least one promising study or review, you should consider a citation management platform like Zotero. This will help you keep your research organized, which is particularly helpful if you're writing a literature review or annotated bibliography!

Getting started with Zoteroo is easy (although it does require a NAU login ID). Simply navigate to: https://www.zotero.org and create an account from there. 

If you need help with Zotero, visit the Library's Research Support Services page, and click on Citation Management Apps.

Journals in NCBI Databases

Sometimes, it is helpful to initiate a journal search to find information. This is particularly useful when you:

• know which journals are most likely to publish studies similar to your topic;
• want to identify the type of studies being published in a specific journal;
• want to explore the "impact" of a specific journal within the discipline.

Journals can be searched by:

• topic (ie: developmental disabilities)
• journal title or abbreviation (ie: title = Transgender Health | abbreviation = Transgend Health)
• ISSN (ie: 2380-193X)

If planning to publish a study, it is very important to identify a journal that focuses on the type of research you want to present. In these instances, authors should also check out a journal's home page, which can be found from the journal listing in PubMed.

See this link to view the complete listing for Transgender Health.

​PubMed Central (PMC)

PubMed Central is the NLM's open-access archive of biomedical literature. PMC indexes published papers, manuscripts, retractions, and other forms of gray literature (conference proceedings, dissertations, etc.). It is an enormous resource, and particularly useful when performing systematic analyses of research, which often require scouring gray literature as well as published studies.

See this link to access PMC: https://www.ncbi.nlm.nih.gov/pmc/

Document Delivery Services

When you find studies that you can't access through NAU, that doesn't mean you can't read them! Instead, you'll need to use the library's Document Delivery Services tool to secure the paper from another source.

DDS is easy to use once you've set it up. Typically, it only takes 1 - 2 days to receive a requested study, which will be sent as a .PDF for you to save and use later.

To learn more about DDS, see this link: nau.edu/library/document-delivery-services/

Additional health science databases

Aside from PubMed, NAU provides access to a range of health science databases. See the table below (replicated from Step 3a) for specific databases that align with various study types.

In order to further narrow and refine your search, remember to:

• Use search filters to limit results, particularly when delineating between reviews, clinical trials, and/or other paper types
• Look for information that is timely when assessing for current trends
• Do not limit your search to Full Text, as you can request articles not owned by NAU through Document Delivery Services
• Be prepared to look in more than one database, and never expect that one database is a one-stop shop for information

See below for a list of select NAU Health Science databases:

Evaluating your findings

Once you have collected your findings, they must be properly assessed. This page will assist you as you go through that process.

Before you begin, you may use the following form to help you annotate and synthesize your research findings: bit.ly/pbc-journal-appraisal

Alternatively, a shorter fillable form can be accessed from this link: bit.ly/ebpstep4

Grading scales

You may find it necessary to use a grading scale when assessing a study. Try using one of the following:

Assessing an abstract

Before you ever get into a paper, it is possible to obtain some quality assessment data from an abstract.

While not all abstracts present with the same information, they are increasingly more uniform, and you should at least be able to do the following:

• Ensure that the paper was not published in a predatory journal
  • FYI: one easy way to do this is check and see if the paper has been indexed in MEDLINE using PubMed!
• Look for any notifications that the paper has been retracted
• For systematic reviews: look for evidence of registration in PROSPERO and adherence to PRISMA standards
  • NOTE: you may find that neither of these qualities are present in older systematic reviews
• Check the date of publication to ensure that the research is still applicable
• Ensure that the research can be generalized to other research, including your own

Validity and reliability

To find out if a finding is valid, ask:

• What was the study design, and is it appropriate for this clinical domain?
• Did experimental and control groups begin the study with a similar prognosis?
• Did experimental and control groups retain a similar prognosis after the study started?
• What are the results? Specifically, how large and precise was the treatment effect?
• How prevalent was bias? (NOTE: see below for more information regarding bias)
• Are results clinically significant in addition to being statistically significant?
  • See this paper for an explanation as to the differences between statistical and clinical significance

To find out if a finding is applicable, ask:

• Were study patients similar to my patient?
• Were all patient-important outcomes considered?
• Are the likely benefits worth the potential harms and costs?
• Does the intervention impose upon my patient's values and circumstances?
• Does this resource help me answer a PICO(T) question well enough to analyze and write about it myself?
• Does this study have wider significance to my field?
• Can this study be improved upon by further study?

Assessing for bias

Particularly for those conducting reviews (literature, scoping, systematic, etc.), it is important to assess for risk of bias. The following bullets, attributed to the Cochrane Handbook for Systematic Reviews, can help you ascertain the prevalence of bias in a given study:

Bias

• A bias is a systematic error, or deviation from the truth, in results or inferences. Biases can operate in either direction: different biases can lead to underestimation or overestimation of the true intervention effect. Biases can vary in magnitude: some are small (and trivial compared with the observed effect) and some are substantial (so that an apparent finding may be entirely due to bias). Even a particular source of bias may vary in direction: bias due to a particular design flaw (e.g. lack of allocation concealment) may lead to underestimation of an effect in one study but overestimation in another study. It is usually impossible to know to what extent biases have affected the results of a particular study, although there is good empirical evidence that particular flaws in the design, conduct and analysis of randomized clinical trials lead to bias.
• Bias should not be confused with imprecision. Bias refers to systematic error, meaning that multiple replications of the same study would reach the wrong answer on average. Imprecision refers to random error, meaning that multiple replications of the same study will produce different effect estimates because of sampling variation even if they would give the right answer on average. The results of smaller studies are subject to greater sampling variation and hence are less precise. Imprecision is reflected in the confidence interval around the intervention effect estimate from each study and in the weight given to the results of each study in a meta-analysis. More precise results are given more weight.
• A study may be performed to the highest possible standards yet still have an important risk of bias. For example, in many situations it is impractical or impossible to blind participants or study personnel to intervention group. It is inappropriately judgmental to describe all such studies as of ‘low quality’, but that does not mean they are free of bias resulting from knowledge of intervention status.

Types of bias

Using GRADE

The GRADE handbook breaks down the official grading rating scaled used for Cochrane reviews. The Handbook itself is lengthy, but it's easy to navigate across sections according to your needs. For appraisal, focus specifically on sections 4 and 5, Summarizing the evidence and Quality of evidence. 

See the image below for a typical journey using the GRADE approach. Note that it begins with framing the PICO question, and from there, goes through the literature search into appraisal, grading, and recommendations for guidelines.

Access the GRADE Handbook available through Cochrane. 

Cochrane's GRADE Framework for describing the certainty of evidence and justifying downgrading or upgrading:

Additional evaluation resources

EBP/EBM databases

eBooks from the collection