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2.1 Introduction
intro
Research is a systematic approach to find out new knowledge about a
given subject. It is important to conduct a thorough literature search in
order to gain sound evidence to support the question being asked. This
underpins the whole problem solving process, but is frequently overlooked
in the haste to discover an answer (Craig & Smyth 2012).
The process taken to answer the proposed question was a systematic
approach in the form of a literature review. This chapter shows how the
literature searches and retrieval of journals was conducted. A thorough
search of evidence will produce large amounts of data, so an in depth
examination by the author has to be conducted in order to discover the
most relevant to be critiqued. Therefore, it is crucial to have the
knowledge of the best way to navigate literature to guarantee no avenue
is missed.
The places favoured most to gather clinical information is textbooks and
personal contacts, directly followed by journal articles (Greenhalgh 2010).
Although in recent years online resources have increased in popularity,
particularly
via
PubMed/MEDLINE
which
consists
of
twenty
million
strat
When searching for evidence, large amounts of data will clearly be
generated, when a thorough search of an extensive range of evidence is
carried out. A thorough examination of the studies in some depth will need
to be conducted to retrieve those relevant for critiquing.
A systematic search of multiple databases must be completed in order to
obtain a suitable quantity and range of studies (Greenhalgh 2010). The
most commonly used databases are MEDLINE, EMBASE, Cochrane Library
and Collective indexes of nursing and allied health literature (e.g. CINAHL)
(Greenhalgh 2010).
Initially the Cochrane library was searched, as it contains Cochrane
Collaboration reviews which are the "Gold standard" systematic reviews
within healthcare interventions (Craig 2012). Cochrane contains current up
to date literature and other systematic reviews and randomised controlled
trials (Greenhalgh 2010). This was utilised to ensure that this projects
question, formulated in chapter one, had not already been conducted and
answered. In this case it had not and this project could then move forward
to considering evidence to answer the question.
The initial search criteria were established using the PICO framework (See
Chapter One, Table 3). When forming the initial clinical question, key words
and phrases were acknowledged. Studies to be reviewed will be searched
for in relevant search engines, which require the need for systematic
searches term to be applied.
A systematic literature search will be conducted using thoughtful search
strategies ensuring no relevant studies are overlooked. Specific search
terms and strategies are used to ensure the searches are focused,
although can yield fewer relevant articles (Burns & Grove 2009). 244
hier
The best possible evidence must be applied, to appropriately finalise the
most accurate interpretation to the research question. The two main
sources of evidence are primary and secondary (Burns & Grove 2009).
Primary research is written by the person in charge of the study whereas
secondary is citations and notions sourced from primary research (Burns &
Grove 2009). Secondary resources can be biased, as opinions can
influence the findings, although a methodological, systematic approach is
taken to eliminate this. Furthermore, secondary resources can have
publication bias by not including unpublished studies (Craig & Smyth
2012).
There are many hierarchies for evidence; these differ depending on what
needs to be established (Aveyard & Sharp 2013). It is argued that some
methods and designs of research are more influential than others; this has
increased the need for hierarchies of evidence (Burns & Grove 2009).
Similarly, there are many varying forms of evidence and they vary in
quality (Pooler 2011). The effectiveness of evidence should be considered
within health research and the use of a recognised hierarchy of evidence
can be a beneficial guide for professionals (EBNP 2003). Effectiveness is
the extent to which interventions achieve their intended outcomes,
meaning, does the intervention work, the benefits and harm and who will
benefit from its use (Pooler 2011).
Aveyard & Sharp (2013) offer a traditional classification to evidence
resources putting it into eight categories and orders them in order of their
importance (See Table 5).
Table 5: Hierarchies of Evidence
1
Surveys
Case reports
3
Qualitative studies
Expert opinion
Anecdotal opinion
Randomised Controlled Trial [RCT] are ranked second as they provide the
highest level of evidence after systematic reviews, however, it is important
to remember that RCTs are not the always the best source of good quality
evidence depending on the type of investigation (Aveyard & Sharp 2013).
There are limitations to this hierarchy (Aveyard & Sharp 2013). It is only
relevant
when
looking
for
evidence
that
determines
whether
an
databases
Online electronic databases have been constructed to incorporate citations
from around the world from many different subject areas, CINAHL
database offers a collective catalogue for nursing and allied health
literature (Craig & Smyth 2012). The search will incorporate the use of
AMED, CINAHL, Cochrane, EMBASE, MEDLINE, Web of Science and
PsycINFO online databases (See Table 6).
All the databases were relevant; however, due to limited amounts of
evidence found during some searches, every avenue had to be reviewed
systematically. Delphis is the local library's current search tool, which
simultaneously searches a huge range of resources to find information
needed, however it incorporates the above databases, so was utilised to
do a broad initial search.
Table 6: Databases Used
Database
AMED
CINAHL
Description
Covers a selection of journals in
medicines
This database is specific for nursing
controlled trials.
Leading clinical medicine and
international journals.
medicine)
The world's best-known medicine
based journals.
world
literature
Incorporating
since
broad
1946).
set
of
measured
vocabulary
called
Table 6 continued
WEB OF
SCIENCE
science journals.
INFO
107
term
The search terms used were identified from PICO (See Table 3, Chapter
One). Keywords are essential to determine the main ideas or variables of a
research topic (Burns & Grove 2009).
A variety of key terms were used in the search for this project (See Table
7). These terms reduced the search to convey a number publications in
the databases used.
Table 7: Search Terms Used
The identified search terms where used for the retrieval of literature:
Acupuncture
Cancer or oncology
Pain
The databases used are all designed to use Boolean logic (Greenhalgh
2010) (See Appendix 3). When searching the Cochrane library and Delphis
key information was input differently into the search bar. The key
information entered was acupuncture pain, head, neck, cancer, resulting in
potential papers relevant to the project. However, after further scrutiny it
was found that three papers in Cochrane were regarding the same clinical
trial, one was the preliminary, the second was the published article and
the third was the same trail as the published article. The 26 searches that
were retrieved in Delphis, of which 5 were duplicates and many were not
subject related (See Table 8 below for the results of the search).
Search Terms
Number of hits
D 71464
S1 =
A 9088
C 10206
Acupuncture
E 66479
M 19320
W 60910
AMED,
S2 = Cancer OR
A 10789
C 184397
D 1224382
CINAHL,
Oncology
E 4274511
M 1362115
W 7433696
A 26115
C 155361
D 1973271
E 2026960
M 480658
W 1629608
DELPHIS,
EMBASE,
S3 = Pain
MEDLINE,
PSYCHINF
S4 = Head and
A 770
C 12839
D 258535
O AND
Neck
E 351373
M 116608
W 321012
WEB OF
SCIENCE
S5 = S1 S4
A3
C9
D 26
using AND
E 322
M6
W 14
There are alternative methods to search for research other than online
databases, such as snowballing (See Appendix 4), one study to be
critiqued was discovered using this technique. 176
Inc exc
Research studies must define an eligibility criteria to their sample to
provide control measures and guarantee representation (Polit & Beck
2012). Eligibility criteria will be applied for this project ensuring each study
critiqued is relevant to answer the question.
When an article was selected, it was subjected to a brief critical analysis
before it was deemed relevant; the use of inclusion and exclusion criteria
was adopted to narrow the search (See Tables 9 & 10).
Table 9: Inclusion criteria (in alphabetical order)
Inclusion
Acupuncture for pain
English Language
Head and Neck
Reasoning
This is the specific therapy being evaluated for
pain. Included in the title.
Has to written in English or information could
get lost in translation
Very specific area of cancer being researched
Some areas use oncology and others cancer so
Randomised Control
Trial
Research Only
Xerostomia (dry
mouth)
Electro Acupuncture
Foreign Languages
Non-Research Articles
Transcutaneous
Electrical Nerve
Stimulation [TENS]
Systematic Reviews
The inclusion and exclusion criteria (See Tables 9 & 10) were applied
during the initial searches. Initially the title was examined to deem
whether the study was relevant, then the abstracts were perused to
establish whether or not they would be beneficial to answer the research
enquiry. Any articles stating they were conducted using RCTs were
immediately included and non-research (qualitative) articles excluded. The
best available evidence for the project would be discovered by using
inclusion and exclusion criteria throughout.
The first inclusion criteria to be adopted was acupuncture for pain due to
xerostomia (dry mouth) or other symptoms of HN treatment, requiring
10
each study to have this as a focus. It was important the study was an RCT,
as this is the best evidence required for the focus of the question. However
after adopting the other criteria, it was found that many of the studies had
acupuncture for cancer pain but were not in reference to HN patients
although other areas of cancer.
Throughout the database searching many studies incorporating other
areas of cancer were found, some were quantitative and a few qualitative.
These studies were all produced valuable findings in relation to cancer
pain, but they unsuccessfully determined the effect of acupuncture to the
HN region. Although qualitative methods could be used to seek out the
human experience, the aim is narrative and subjective striving to gain an
understanding of feelings (Parahoo 2006), which has limitations of the
personal nature of the conclusions, that are not easily replicated or
necessarily generalizable (Polit & Beck 2012). Whereas quantitative
research generate predictions by using deductive reasoning, which are
tested in the real world, controls are put in place to minimize any situation
bias and validity and precision are maximized (Polit & Beck 2012). The aim
of this project is to determine if acupuncture can help pain and discomfort
alongside conventional analgesics, a quantitative design is essential in
order to gather deductive scientific evidence. A case series report was
excluded due to its nature of being a report and not having a control group
(Craig & Smyth 2012), there were not results or statistic to enable a review
of the work. Case reports are a description of a single patients medical
history in the form of a story, when they are run together they form a case
series, which are traditionally considered weak scientific evidence
(Greenhalgh 2010). However, they are valuable in understanding the
patients journey. 447
11
Author/
s
The Role of
Acupuncture
in Cancer
Supportive
Care
Lin J &
Chen Y
Date and
published
American
Journal of
Chinese
Medicine
2012.40(2):
219-29
Hart J
Alternative
and
Compliment
ary
Therapies
2011. 17(4):
210-213
Integration of
Acupuncture
into the
Oncology
Clinic
Johnston
e P;
Polston
G;
Niemtzo
wR&
Martin P
Palliative
Medicine
2002.
16:235-239
Acupuncture
for Dysphagia
after
Chemoradiati
on Therapy in
Head and
Neck Cancer:
A Case Series
Lu W;
Posner
M;
Wayne
P;
Rosenth
al D; &
Haddad
Integrated
Cancer
Therapies
2010.
9(3):284-290
Summary of
Research
Reviewing
what the role
of acupuncture
has in
supportive
care.
Reviewing
research a
sample of
literature
supporting the
use of
acupuncture
after Head and
Neck
treatments
This paper
describes the
physical
integration of
the discipline
into the
Oncology
Clinic, and
patient
perspectives
on its
availability and
efficacy.
The purpose of
this study is to
determine if
Acupuncture
can help
relieve
dysphagia,
although it
12
Report
incorporates
Xerostomia as
one of the
causes.
Author/s
Acupuncture
for Pain and
Dysfunction
After Neck
Dissection:
Randomised
Control Trial.
Pfister D;
Cassileth
B; Deng
G; Yeung
K; Lee J;
Garrity D;
Cronin A;
Lee N;
Fraus D;
Shaha A;
Shah J &
Vickers A
Acupuncture
for
PilocarpineResistant
Xerostomia
following
Radiotherap
y for Head
and Neck
Malignancies
Acupuncture
for
Xerostomia
Date and
published
Summary of
Research
Journal
of
Clinical
Oncology
2010.
28(15):
2565-2570
Purpose to
determine
whether
acupuncture
reduces pain
and dysfunction
in patients with
cancer with a
history of neck
dissection
Johnstone
P; Peng
P;
May B;
Inouye W
&
Niemtzow
R
Internation
al Journal of
Radiation
Oncology
2001.
50(2): 353357
The purpose of
this study is to
test if
acupuncture
help
Xerostomia
after
radiotherapy, to
patients who
are resistant to
pilocarpine
mouth wash.
Johnstone
P; Nietzow
R&
Riffenburg
hR
American
Cancer
Society
2002.
94(4):
1151-1156
The purpose of
this study is to
test if
acupuncture
help
Xerostomia.
13
Crit app
The word critical in critical appraisal is synonymous with the limitations of
a piece of work, although the strengths should also be addressed (Cutcliffe
& Ward 2007). Critiquing or critical appraisal is used to describe reading
research articles, manuscripts or papers in a critical manner (Cutcliffe &
Ward 2007). Whereas Craig & Smyth (2012) suggest critical reading is a
systematic way to evaluate studies and their applicability and validity. The
assessment of the strengths and weaknesses of a study are how the
meaning and significance is considered, subsequent to a methodical
analysis (Burns & Gove 2009). Thus critical appraisal permits nursing to
better understand all evidence available.
In practice nurses are expected to make evidence based clinical decisions
every day. Nursing is described as holistic and is more than the sum of its
parts, thus, requiring high level skills and understanding (DH 2006).
Healthcare requires intellectually and emotionally aware nurses, able to
use both practical clinical skills with profound understanding and aptitudes
for care (DH 2006).
Clinical effectiveness is a priority of the healthcare agenda and use
systematic
frameworks
to
appraise
research,
which
assists
the
14
Crit tool
When critiquing a paper reviewers must record factual information about
methodologic features and findings along with making judgements about
the quality of the evidence (Polit & Beck 2012). Judging the quality of
research and its applicability to a clinical area and patient group is crucial,
if using it to inform practice in a significant way, along with critiquing
research nurses must understand if the research could be beneficial in
updating their area of practice (Ellis 2010).
A systematic approach needs to be adopted when critiquing research, so
to efficiently critique the selected studies, a suitable tool is required
(Coughlan et al 2007; Cutcliffe & ward 2007). There is not a specific
approach that is the exact way when conducting a critique, however to
make the process simpler there are various strategies (Ellis 2010) (See
Table 13).
Table 13: Critiquing Strategy
1. Skim read the paper (gain a sense of the general methodology of the
research)
2. Read the paper in depth (comprehend each element of the paper)
3. Split the study up into its elements
4. Consider the study as a whole and consider its message
(Lobiondo-Wood & Haber 1998 cited in Ellis 2010)
15
Aveyard et al (2011)
Six questions to trigger
critical thinking
Strengths
Limitations
Generic Questions
Generic Questions
easy to follow.
Easily available
CASP (2013)
Generic Questions
Generic well-defined
Programme
questions
Quantitative research
Easily available
Generic Questions
COUGHLAN et al (2007)
Step-by-step guide to
critiquing research.
Quantitative research
Well-defined structured
Generic Questions
Questions are simple and
of study
Easily available
PARAHOO (2006)
Generic Questions
quantitative studies
easy to follow.
Generic Questions
Questions are too simple and
concise, however this may
mean important elements of
the research are overlooked
Generic Questions
Guide to an Overall
Critique of a Quantitative
Research Report
of study
areas
References
refs
Aveyard H & Sharp P (2013) A Beginners Guide to Evidence-Based
Practice in Health and Social Care (2nd Edition). Berkshire
Burns N & Grove S (2009) The Practice of Nursing Research: Appraisal
synthesis and generation of evidence (6th Edition). St Louis: Elsevier
Birch et al (2004) Clinical Research on Acupuncture: Part 1. What Have
Reviews of the Efficacy and Safety of Acupuncture Told Us So Far?....
Craig J & Smyth R (2012) The Evidence-Based Practice Manual for Nurses
(3rd Edition). London: Livingstone.
Greenhalgh T & Peacock R (2005) Effectiveness and efficiency of search
methods in systematic reviews of complex evidence: audit of primary
sources. British Medical Journal 331 1064-1065
Parahoo K (2006) Nursing research: principles, process and issues (2nd
Edition). Hampshire: Palgrave
Polit D & Beck C (2012) Nursing Research: Generating and Assessing
Evidence for Nursing Practice (9th Edition). Philadelphia: Lippincott Williams
& Wilkins
Pooler A (2011) An Introduction to evidence-based Practice in Nursing and
Healthcare. Harlow: Pearson
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