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 UNDERSTANDING
RESEARCH METHODS
for evidence-based
practice in health
S ECO N D E D ITI O N

TR I S H A M . J OH N EL AINE AMANDA JA N E
G R E EN H ALGH BIDEWELL CRISP L AMBROS WA RL A N D

© John Wiley & Sons Australia, Ltd. Not for resale or distribution. Any unauthorised distribution or use will result in legal action.
© John Wiley & Sons Australia, Ltd. Not for resale or distribution. Any unauthorised distribution or use will result in legal action.
 Understanding
research methods
for evidence-based
practice in health
SECOND EDITION

Trisha M Greenhalgh
John Bidewell
Elaine Crisp
Amanda Lambros
Jane Warland

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 Second edition published 2020 by
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 BRIEF CONTENTS
About the authors vii

1. Introduction to research, the research process and EBP 1

2. Asking questions and searching for evidence 11
3. Reviewing literature 21
4. Qualitative research 32
5. Quantitative research 43
6. Levels of evidence 55
7. Statistics for the non-statistician 73
8. Mixed methods research 88
9. Sampling 97
10. Ethics 106
11. Getting evidence into practice 114
12. Challenges to evidence-based practice 124

Index 133

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 CONTENTS
About the authors vii 3.2 Reviewing the methods of primary
research papers 25
CHAPTER 1 Sample and setting: who are the participants,
and where is the study being
Introduction to research, the carried out? 25
research process and EBP 1 What data-collection methods
1.1 The meaning of ‘evidence-based were used? 26
practice’ 2 How was the data analysed? 26
1.2 Apprehension towards evidence-based 3.3 Reviewing the methods of secondary
practice 5 (review) papers 26
Decision making by anecdote 6 Question 1. What is the focused clinical
Decision making by press cutting 6 question that the review addressed? 27
Decision making by expert opinion 6 Question 2. Was a thorough search of the
Decision making by cost minimisation 7 appropriate database(s) carried out, and
were other potentially important
1.3 Before you start: formulate the problem 8
sources explored? 27
CHAPTER 2 Question 3. Who evaluated the studies,
and how? 28
Asking questions and Question 4. How sensitive are the results
to the way the review has
searching for evidence 11 been performed? 28
2.1 Different types of searching Question 5. Have the results been interpreted
for evidence 12 sensibly, and are they relevant to the
Informal 12 broader aspects of the problem? 28
Focused looking for answers 13 Meta-analyses and meta-syntheses 28
Searching the literature 13
2.2 Differences between primary and CHAPTER 4
secondary research 13
2.3 Effective search strings 13
Qualitative research 32
Steps for effective searching 14 4.1 Qualitative research explained 33
One-stop shopping: federated 4.2 The difference between qualitative and
search engines 16 quantitative research 34
2.4 Other avenues for how to search 4.3 Qualitative methodologies and data
for evidence 17 collection strategies 35
Searching for information using Qualitative sampling 36
social media 19 Data collection 36
4.4 Evaluating papers that describe
CHAPTER 3 qualitative research 37
Question 1. Did the paper describe an
Reviewing literature 21 important clinical problem addressed via a
3.1 Is a paper worth reading at all? 23 clearly formulated question? 38
Question 1. Who wrote the paper? 23 Question 2. Was a qualitative approach
Question 2. Is the title appropriate appropriate? 38
and illustrative, and is the Question 3. How were (a) the setting and
abstract informative? 23 (b) the subjects selected? 38
Question 3. What was the research design, Question 4. What was the researcher’s
and was it appropriate to the perspective, and has this been taken
question? 24 into account? 38
Question 4. What was the research question, Question 5. What methods did the researcher
and why was the study needed? 24 use for collecting data, and are these
Question 5. Do the results or findings answer described in enough detail? 39
the question? 24

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 Question 6. What methods did the researcher Have valid assumptions been made about the
use to analyse the data, and what quality nature and direction of causality? 78
control measures were implemented? 39 7.4 Probability and confidence 79
Question 7. Are the results credible and, if so, How are p values interpreted? 79
are they clinically important? 40 Confidence intervals 81
Question 8. What conclusions were drawn, 7.5 Clinical importance of treatment
and are they justified by the results? 40 effects 81
Question 9. Are the findings of the study Clinical importance 81
transferable to other settings? 40 7.6 Summarising treatment effects from
multiple studies of interventions in a
CHAPTER 5
systematic review 84
Quantitative research 43
CHAPTER 8
5.1 Why and how quantitative research
is done 44 Mixed methods research 88
5.2 Quantitative research designs 46 8.1 An overview of mixed methods
Intervention studies 46 research 89
Observational studies 47 Why use mixed methods in nursing and health
5.3 Measurement 48 sciences research? 89
Variables — independent 8.2 Different mixed methods designs 90
and dependent 49 Convergent study 90
Reliability and validity in measurement 50 Sequential study 91
Multiphase (multilevel) study 91
CHAPTER 6
Embedded study 92
Levels of evidence 55 8.3 Integration in mixed methods
6.1 Clinical questions in healthcare 56 research 93
Finding the best evidence 56 Integrating the research question 93
NHMRC and evidence-based practice 57 Research design 93
How researchers answer Sampling 93
clinical questions 57 Analysis 93
6.2 Matching clinical questions to NHMRC Interpretation 94
levels of evidence 58 8.4 Mixed method design considerations 94
NHMRC evidence levels for Weighting (dominance) 94
intervention studies 60 General challenges associated with mixed
6.3 How bias threatens the validity of research methods studies 94
evidence 63
CHAPTER 9
6.4 Evaluating the evidence – quality of
evidence and grades of recommendations Sampling 97
for practice guidelines 65
9.1 Understanding the terminology around
6.5 Levels within levels 66
sampling 98
Theoretical population (or target
CHAPTER 7
population) 98
Statistics for the Study population (or accessible
population) 98
non-statistician 73 Sampling 99
7.1 Storing quantitative data in a data set 74 Sample 99
7.2 Descriptive statistics for summarising Sampling frame 99
sample characteristics 75 9.2 Types of sampling 99
Descriptive statistics for Probability sampling 99
categorical variables 75
Non-probability sampling 100
Descriptive statistics for
Sampling methods 100
continuous variables 76
9.3 Sampling error 102
7.3 The researchers ‘setting the scene’ 77
9.4 Calculating sample size 102
Have the researchers tested the assumption
Quantitative research 102
that their groups are comparable? 77
Qualitative research 103
What assumptions apply to the shape
of the data? 77
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 CHAPTER 10 11.3 Organisational support of evidence-
based practice 117
Ethics 106 Integrated care pathways 117
10.1 Ethical principles 107 Clinical practice guidelines 118
Autonomy: patients/clients are free to 11.4 The client perspective in evidence-
determine their own actions 107 based practice 119
Beneficence: acting to benefit Patient-reported outcome measures
human kind 108 (PROMs) 119
Justice: obligation to treat fairly 108 Shared decision-making 119
Non-maleficence: avoiding or minimising Option grids 120
harm 108
Respect for human dignity 108 CHAPTER 12
Confidentiality: maintenance of privileged
information, including the right to privacy Challenges to evidence-
and anonymity 109 based practice 124
Veracity: obligation to tell the truth 109 12.1 When evidence-based practice is
10.2 The role and function of human research done badly 126
ethics committees 109 12.2 When evidence-based practice is
10.3 Judging the ethical aspects of a done well 126
published journal article 111 Guidelines devalue
professional expertise 126
CHAPTER 11
The guidelines are too narrow (or
Getting evidence into too broad) 127
The guidelines are out of date 127
practice 114 The client’s perspective is ignored 127
11.1 Adoption of evidence-based There are too many guidelines 128
practice (EBP) 115 Practical and logistical problems 128
Individual barriers 115 The evidence is confusing 128
Organisational barriers 116 12.3 Achieving evidence-based practice 129
11.2 Encouraging individuals to implement
evidence-based practice 116 Index 133

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vi CONTENTS

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 ABOUT THE AUTHORS
Trisha M Greenhalgh
Dr Trisha Greenhalgh is a Professor of Primary Care Health Sciences at the University of Oxford and
a practising GP. She completed a BA in Social and Political Sciences at the University of Cambridge
in 1980 and a medical degree at the University of Oxford in 1983. Trisha’s research aims to apply the
traditional aspects of medicine while embracing the opportunities of contemporary science to improve
health outcomes for patients. She is the author of more than 240 peer-reviewed publications as well as
a number of scholarly textbooks. Trisha has received numerous accolades for her work, including twice
winning the Royal College of General Practitioners Research Paper of the Year Award, and receiving the
Baxter Award from the European Health Management Association. In 2001, she was awarded an OBE for
services to evidence-based medical care.
John Bidewell
Dr John Bidewell is a Lecturer in Research Methods at the School of Science and Health at Western
Sydney University. From an early career in school teaching, John moved into psychology, acquiring three
degrees while always maintaining an interest in education. Opportunities arose in applied social research
and data analysis, leading John in that direction. For many years, he provided technical and inspirational
support to academic and student researchers, covering every stage of the research process from concept to
publication, and especially data analysis and interpretation, at Western Sydney University’s nursing and
midwifery school. John has provided consultancy services in research and statistics to business, industry
and governments, and has taught research methods and statistics to nursing, business and allied health
students at undergraduate and postgraduate levels.
Elaine Crisp
Dr Elaine Crisp is a Registered Nurse (RN) and Lecturer at the School of Nursing at the University
of Tasmania, where she coordinates both the Bachelor of Nursing (BN) course and the Translational
Research unit within the BN. This dual role enables her to ensure the BN highlights the connection between
research and clinical practice. She has also taught research methods to nursing and allied health students
at the postgraduate level, encouraging clinicians to understand and use research evidence in their everyday
practice. Elaine worked as an RN in aged care and in the perioperative area before commencing her PhD,
which combined her love of history and nursing. Her major research interests are nursing and welfare
history, aged and dementia care, and nurse education.
Amanda Lambros
Amanda E Lambros is a Professional Speaker, Author and Clinical Counsellor as well as a past Clinical
Fellow. She has completed a Bachelor of Health Sciences at the University of Western Ontario (2001), a
Postgraduate Diploma of Ethics (2002), a Master of Forensic Sexology (2004) and a Master of Counselling
(2014). Amanda has developed, coordinated and taught evidence-informed health practice to thousands of
Interprofessional First Year Health Sciences students throughout her career. Amanda’s private practice
focuses on relationships, mental health, and grief and loss. Providing her clients with the most up-to-date
and evidence-based care is imperative to her, and she has a strong focus on EBP, ethics and communication.
Amanda has received numerous accolades for her work, including NifNex 100 Most Influential Business
Owners, a Telstra Business Award nomination and a Telstra Business Woman of the Year nomination.
Jane Warland
Dr Jane Warland is an Associate Professor at the School of Nursing and Midwifery at the University
of South Australia (UniSA). She worked as a midwife from 1988 to 2007, and gained her PhD from
the University of Adelaide in 2007. Jane was appointed as an academic staff member to the School of
Nursing and Midwifery in February 2008, and teaches a foundational research course in the undergraduate
midwifery program. Her own program of research is STELLAR (stillbirth, teaching, epidemiology, loss,
learning, awareness and risks). Jane has a track record in research using qualitative, quantitative and mixed
methods. She has a strong interest in research ethics and served two terms as a member of the UniSA
Human Research Ethics Committee. Jane has written numerous book chapters about research — she has
more than 90 publications, including books, chapters and peer-reviewed journal articles.

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ABOUT THE AUTHORS vii

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 CHAPTER 1

Introduction to research,
the research process
and EBP
LEARNING OBJECTIVES

1.1 What does ‘evidence-based practice’ mean?

1.2 Why are people apprehensive about evidence-based practice?
1.3 How do we get started with evidence-based practice?

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 OPENING SCENARIO

Imagine you are taking the time to visit your grand-

father, Wilf, who has been living on his own for the
past two years, and recently began seeing a health
professional regarding his chronic hip and knee
pain. When you walk into his house, you see him in
the living room following along to a televised fitness
program — you ask: ‘Hey gramps, don’t you think
you should avoid exercise because of the pain from
your osteoarthritis?’. He sits you down and tells
you that, in short, he’s recently been exercising at
home and attending regular yoga classes alongside
his standard care to decrease the levels of pain
in his hips and knees. He continues to tell you
that he’s already feeling much better since he has
started exercising. At first, you are a bit sceptical of
this revelation, but it turns out that by doing these
activities, coupled with standard care, your grandfather will experience a reduction in his hip and knee
pain symptoms, while gaining confidence and decreasing depressive symptoms.1 In fact, this advice was
not given to your grandfather ‘on a whim’ or based on a simple research paper that guided the health
professional to advise your grandfather of this; it was a systematic review — the highest level of evidence.
(More on this in the chapter on levels of evidence.)
Now imagine that you are the health professional and Wilf is your client. Rather than just providing
‘standard’ practice, think about the ways in which you could provide evidence-based practice (EBP) —
a practice that is supported by scientific evidence, clinical expertise and client values — and how this
practice will have significantly better outcomes than ‘standard’ care for your clients. Isn’t this the care that
you would want to provide? I don’t know about you . . . but that’s the type of care that I would not only
prefer to provide as a health professional but also receive as a health consumer. This is just the start —
EBP becomes so much more exciting from here on in. The more you know, the more you want to know.
This is one of the most fascinating topics to learn about, because you can’t ‘undo’ your learning. If you
allow yourself the opportunity to become immersed in the topic, it will change your perception of nearly
everything you hear, read and do for the rest of your life!
............................................................................................................................................................................
DISCUSSION QUESTIONS
1. Have you visited a health professional in the past 12 months?
(a) If so, do you believe the health professional was an evidence-based practitioner?
(b) How can you be sure that you were receiving evidence-based care?
2. How would you distinguish evidence-based care from standard care?

1.1 The meaning of ‘evidence-based practice’

LEARNING OBJECTIVE 1.1 What does ‘evidence-based practice’ mean?
The aim of this chapter is for you to start to understand ‘research’, the ‘research process’ and ‘evidence-
based practice’ as fundamentally critical to you — not only as an individual, but also as a health consumer
and a health practitioner. This chapter will give you the opportunity to explore the importance of evidence-
based practice and open your mind to copious real-world examples that surround you on a daily basis,
which you might not even recognise as EBP.
EBP is much more than just reading papers. According to the most widely quoted definition, it is ‘the
conscientious, explicit and judicious use of current best evidence in making decisions about the care of
individual patients’.2 Professor Sackett continued to explain that EBP should be visualised as a three-
pronged and overlapping approach, also known as a triad approach: the best possible research evidence,
clinical expertise and patient values and preferences.3

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 FIGURE 1.1 The triad approach

Best research
evidence

EBP

Clinical Patient
expertise values

Let’s take a moment to break down each of these areas so you fully grasp what is being considered when
explaining EBP.
1. The best possible research evidence. As you will learn in the chapter on levels of evidence, the higher
the level of evidence, the better the evidence is. Think of it this way: would you prefer implementing a
new exercise regime because your cousin told you it worked for her (Level 5 — anecdotal evidence), or
because a systematic review of over 450 000 people (Level 1 — systematic review) demonstrated that it
would have significant results? Therefore, when we are looking at ‘best possible research evidence’, it
is literally looking for the best options currently available (because you don’t want to use old evidence).
Typically, research evidence is updated at least every 3–5 years, depending on the topic, which means
you could continuously improve your practice.
2. Clinical expertise. This takes into consideration your experiences, both personal and professional, to
help guide you in how to best care for your clients. You might have previously attempted something
yourself — it could be as simple as using a saline rinse around allergy season to alleviate allergy
symptoms. You then have a client tell you how horrible their hayfever symptoms are each year when
the flowers start to bloom, but are not sure how to effectively manage this. In this situation, you might
explain to them that using a saline irrigation for allergic rhinitis works quite well because it thins the
mucus in the nasal cavity and removes some allergens,4 and that although the evidence is low, it’s cost-
effective, available without a prescription and a good alternative to steroid and antihistamine use. Later
on, that client might attempt this ‘remedy’ and then report the results back to you — you then begin to
build your ‘clinical expertise’ in this area.
3. Patient values and preferences. There are times when you might have researched the ‘best possible
treatment’ for your client. From clinical experience you are aware that it would work quite well, but
when you explain the treatment or procedure to the client, they might prefer an alternative treatment;
or their values or religious beliefs will not permit the treatment you have suggested. As you are treating
your clients, their values and preferences should be the first thing that you take into consideration, as
there is no point in continuously suggesting treatments they are not able or willing to engage with.
If you are a health practitioner working in rural or remote locations, you also need to consider whether
‘best practice’ is available — you might have to seek alternative treatments because the EBP is simply not
accessible in your location.
You might now be asking ‘What is research?’. Essentially, it is ‘focused, systematic enquiry aimed at
generating new knowledge’. Throughout this resource, it will be explained how this definition can help
you distinguish genuine research (which should inform your practice) from the poor-quality endeavours
of well-meaning amateurs (which you should politely ignore).
If you follow an evidence-based approach to clinical decision making, all sorts of issues relating to
your clients will prompt you to ask questions about scientific evidence (figure 1.2), seek answers to those
questions in a systematic way and alter your practice accordingly.

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CHAPTER 1 Introduction to research, the research process and EBP 3

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 FIGURE 1.2 Some things to consider when assessing clients

• Client preferences
• Symptoms
• Physical/diagnostic signs
• Age, sex and ethnic origin of the client
• Benefits versus risks
• Cost-effectiveness of the treatment

Sackett and Haynes summarised the five essential steps in the emerging science of EBP5 as:
1. to convert our information needs into answerable questions (i.e. to formulate the problem) (ASK)
2. to track down, with maximum efficiency, the best evidence with which to answer these questions —
which may come from the clinical examination, the diagnostic laboratory, the published literature or
other sources (ACQUIRE)
3. to appraise the evidence critically (i.e. weigh it up) to assess its validity (closeness to the truth) and
usefulness (clinical applicability) (APPRAISE)
4. to implement the results of this appraisal in our clinical practice (APPLY)
5. to assess our performance (EVALUATE).
Hence, EBP requires you not only to read papers but also to read the right papers at the right time, and
then to alter your behaviour accordingly (and, what is often more difficult, influence the behaviour of other
people) in the light of what you have found. At no time should one step be seen as more important than
another — all steps should hold equal importance. Yet if you have asked the wrong question or sought
answers from the wrong sources, you might as well not read any papers at all. Equally, all your training
in search techniques and critical appraisal will go to waste if you do not put at least as much effort into
implementing valid evidence and measuring progress towards your goals as you do into reading the paper.
Greenhalgh added to the steps above to create what she deemed a ‘context-sensitive checklist for
evidence-based practice’ to incorporate the client’s perspective, resulting in eight stages, as outlined in
figure 1.3.6
This resource has been strategically designed and written so that you can get the best possible overview
of evidence-based practice, especially for those who are new to the concept of EBP. Our goal is for you to
be able to have an understanding of EBP so that when you become a practitioner, you have the minimum
skills and knowledge to apply evidence and practice as an evidence-based practitioner.

FIGURE 1.3 Is my practice evidence-based? A context-sensitive checklist for individual clinical encounters

Have I identified and prioritised the clinical, psychological, social and other problem(s), taking into
account the patient’s perspective?
Have I performed a sufficiently competent and complete examination to establish the likelihood of
competing diagnoses?
Have I considered additional problems and risk factors that may need opportunistic attention?
Have I, where necessary, sought evidence (from systematic reviews, guidelines, clinical trials and
other sources) pertaining to the problems?
Have I assessed and taken into account the completeness, quality and strength of the evidence?
Have I applied valid and relevant evidence to this particular set of problems in a way that is both
scientifically justified and intuitively sensible?
Have I presented the pros and cons of different options to the patient in a way they can understand,
and incorporated the patient’s preferences into the final recommendation?
Have I arranged review, recall, referral or other further care as necessary?

Incidentally, if you want to explore the subject of EBP online, you will note that throughout this resource,
we provide you with a plethora of websites that can help guide you on the various topics. Please don’t feel
overwhelmed by the vast amount of literature available — most of the sites offer very similar material and
you certainly don’t need to visit them all . . . just visit them if you are interested in digging a little deeper
into each topic.
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 1.2 Apprehension towards evidence-based practice
LEARNING OBJECTIVE 1.2 Why are people apprehensive about evidence-based practice?
Unfortunately, some people might be apprehensive or groan when mentioning evidence-based practice
because they have heard through the grapevine that it’s all about statistics and number crunching. Before
we go much further, let’s clarify something and pop that bubble! EBP is not ‘all about statistics’. Although
yes, statistics, numbers, equations, odds ratios, confidence intervals, etc. are all words you will hear in
EBP, understanding how to interpret and implement EBP is much more important at this point in time.
Numbers are great but, in reality, if you don’t understand what the numbers mean, then you are not really
able to implement EBP. Alternatively, if you don’t understand how the researchers completed the math
behind the numbers, you can’t double-check their work — which is sometimes equally as important. With
this in mind, Greenhalgh and Donald proposed an alternative definition of EBP, which demonstrates the
use of mathematics.
Evidence-based practice is the use of mathematical estimates of the risk of benefit and harm, derived
from high-quality research on population samples, to inform clinical decision making in the diagnosis,
investigation or management of individual patients.7

Students regularly allow the idea of ‘numbers’ and a ‘new language’ to blur their excitement for learning
about EBP — please don’t let this happen to you. Be open to learning about the topic, which will stick
with you for the rest of your life. The more open you are to learning about EBP, the better the practitioner
you will become!
The second reason that people often groan when you mention evidence-based practice is because there
are plenty of daunting new (and often long) words that look like a foreign language. While it is like a
new language, absolutely everything in EBP can be broken down into simple and manageable steps. For
example, students are often stumped by retrospective longitudinal cohort design (which you will learn
about in this resource), but once they break it down, it makes perfect sense:
• retrospective — in the past (think of the word ‘retro’)
• longitudinal — over a long period of time
• cohort — a group of people
• design — type of study.
Now that it’s broken down into manageable chunks, you instantly know that ‘retrospective longitudinal
cohort design’ means a type of study that was done over a long period, looking at a group of people in
the past. So, please don’t feel overwhelmed by the words — they all make sense, but some just need to be
broken down first.
Anyone who works face-to-face with clients knows that it is necessary to seek new information before
making a clinical decision. Health practitioners spend countless hours searching through libraries, books
and online to inform their practices. In general, we wouldn’t put a client on a new drug or through a
new treatment without evidence that it is likely to work — but, unfortunately, best practice is not always
followed. There have been a number of surveys on the behaviours of health professionals. In the United
States in the 1970s, only around 10–20 per cent of all health technologies then available (i.e. drugs,
procedures, operations, etc.) were evidence-based; in the 1990s, that figure improved to 21 per cent.8
Studies of the interventions offered to consecutive series of clients suggested that 60–90 per cent of clinical
decisions, depending on the specialty, were ‘evidence-based’.9 Unfortunately, due to various excuses and
limitations, we are still selling our clients short most of the time.
A large survey by an Australian team looked at 1000 clients treated for the 22 most commonly seen
conditions in a primary-care setting. The researchers found that while 90 per cent of clients received
evidence-based care for coronary heart disease, only 13 per cent did so for alcohol dependence.10
Furthermore, the extent to which any individual practitioner provided evidence-based care varied in the
sample from 32 per cent of the time to 86 per cent of the time. A more recent study found that one in
three hospitals are not meeting performance metrics. One of the leading reasons was failure to implement
EBP.11 Following this, a study suggested that medical error is now the third leading cause of death in the
United States.12 These findings suggest plenty of room for improvement; therefore, with a new wave of
practitioners, hopefully we can increase the application of EBP so that the majority of health consumers
are receiving evidence-based care.
Let’s look at the various approaches that many health professionals use to reach their decisions in
reality — all of which are examples of what EBP isn’t . . . therefore, please do not practise these!
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 Decision making by anecdote
When Trisha Greenhalgh was a medical student, she was able to join a distinguished professor on his daily
ward rounds. On seeing a new client, he would ask about their symptoms, turn to the massed ranks of
juniors around the bed, and relate the story of a similar client encountered a few years previously. ‘Ah, yes.
I remember we gave her such-and-such and she was fine after that’. He was cynical, often rightly, about
new drugs and technologies, and his clinical acumen was second to none. Nevertheless, it had taken him
40 years to accumulate his expertise and the largest medical textbook of all — the collection of cases that
were outside his personal experience — was forever closed to him.
Anecdote (storytelling) has an important place in clinical practice.13 It is common practice for students
and practitioners to listen to professors, tutors and clients and memorise their stories or scripts in the
form of what was wrong with particular clients, and their outcomes to use later. Health professionals
glean crucial information from clients’ illness narratives — most crucially, perhaps, what being ill means
to the client. Experienced health professionals take account of the accumulated ‘illness scripts’ of all
their previous clients when managing subsequent clients — but that doesn’t mean simply doing the
same for client B as you did for client A if your treatment worked, and doing precisely the opposite if
it didn’t!
We would not be human if we ignored our personal clinical experiences, but we would be better to base
our decisions on the collective experience of thousands of health professionals treating millions of clients,
rather than on what we as individuals have seen and felt.

Decision making by press cutting

Imagine simply trawling the internet, magazines, newspapers and information presented throughout all
forms of media and simply ‘cutting and pasting’ then creating, for lack of a better analogy, a scrapbook
of treatments, cures, etc. — continuously altering your practice in line with the various conclusions. For
example, ‘probiotics improve your mood’,14 and advocating that all clients take probiotics. The advice was
in print, and it was recent, so it must surely replace what was previous practice.
This approach to clinical decision making is, unfortunately, still very common. How many doctors do
you know who justify their approach to a particular clinical problem by citing the results section of a single
published study, even though they might fail to tell you:
• the methods used to obtain those results
• whether the trial was randomised and controlled
• the number, age, sex and disease severity of the clients involved
• how many withdrew from (‘dropped out of’) the study and why
• by what criteria clients were judged ‘cured’
• if the findings of the study appeared to contradict those of other researchers; whether any attempt was
made to validate (confirm) and replicate (repeat) them
• whether the statistical tests that allegedly proved the authors’ point were appropriately chosen and
correctly performed (see the chapter on statistics for the non-statistician)
• whether the client’s perspective has been systematically sought and incorporated via a shared decision-
making tool.
Therefore, health practitioners who like to cite the results of medical research studies have a respon-
sibility to ensure that they first go through a checklist like this before simply making decisions by press
cutting.

Decision making by expert opinion

In extreme cases, an ‘expert opinion’ may consist simply of the lifelong bad habits and personal press
cuttings of an ageing health professional, which could simply multiply the misguided views of any one
of them. Table 1.1 gives examples of practices that were at one time widely accepted as good clinical
practice, but that have subsequently been discredited by high-quality clinical trials. Serious harm can be
done by applying guidelines that are not evidence-based. It is a major achievement of the EBP movement
that almost no guideline these days is produced solely by expert opinion!

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 TABLE 1.1 Examples of harmful practices once strongly supported by ‘expert opinion’

Approximate Clinical practice accepted by Practice shown

time period experts of the day to be harmful in Impact on clinical practice
a
From 500 BC Bloodletting (for just about any 1830s Bloodletting ceased
acute illness) around 1910

Early 1900s Complete immobilisation in the 1930s Although very hot dressings
form of splints and braces on and physical therapy (what we
the affected limbs for infantile now know as physiotherapy)
paralysis (Polio) was deemed to be effective,
it was not fully implemented
for the treatment of polio until
the 1950s

1957 Thalidomide for ‘morning 1960 The teratogenic effects of

sickness’ in early pregnancy, this drug were so dramatic
which led to the birth of over that thalidomide was rapidly
8000 severely malformed withdrawn when the first case
babies worldwide report appeared

From at least 1900 Bed rest for acute low 1986 Many doctors still advise people
back pain with back pain to ‘rest up’

1960s Benzodiazepines (e.g. 1975 Benzodiazepine prescribing

diazepam) for mild anxiety for these indications fell in
and insomnia, initially the 1990s
marketed as ‘non-addictive’
but subsequently shown to
cause severe dependence and
withdrawal symptoms

1970s Intravenous lignocaine in acute 1974 Lignocaine continued to

myocardial infarction, with a be given routinely until the
view to preventing arrhythmias, mid-1980s
subsequently shown to have
no overall benefit and in some
cases to cause fatal arrhythmias

Late 1990s Cox-2 inhibitors (a new class of 2004 Cox-2 inhibitors for pain were
non-steroidal anti-inflammatory quickly withdrawn following
drug), introduced for the some high-profile legal cases
treatment of arthritis, were later in the United States, although
shown to increase the risk of new uses for cancer treatment
heart attack and stroke (where risks may be outweighed
by benefits) are now being
explored
a
Interestingly, bloodletting was probably the first practice for which a randomised controlled trial was suggested.

Decision making by cost minimisation

The popular press tends to be horrified when they learn that a treatment has been withheld from a client for
reasons of cost. Managers, politicians and, increasingly, health professionals can count on being pilloried
when a child with a rare cancer is not sent to a specialist unit in the United States or a frail elderly woman
is denied a drug to stop her visual loss from macular degeneration. Yet, in the real world, all healthcare
is provided from a limited budget, and it is increasingly recognised that clinical decisions must take into
account the economic costs of a given intervention. Clinical decision making purely on the grounds of cost
(‘cost minimisation’ — purchasing the cheapest option with no regard to how effective it is) is generally
ethically unjustified, and we are right to object vocally when this occurs.
Expensive interventions should not, however, be justified simply because they are new, or because they
ought to work in theory, or because the only alternative is to do nothing — but because they are very likely
to save life or significantly improve its quality.

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 1.3 Before you start: formulate the problem
LEARNING OBJECTIVE 1.3 How do we get started with evidence-based practice?
If midwifery students are asked what they know about childbirth and pain management, they can talk at
length about the different pain management techniques, how they measure pain by having a conversation
with the woman in labour, what the textbooks define as pain — the list goes on. They are truly aware of
the concept of ‘pain’ and its management during the labouring process.
However, when the students are asked a practical question such as ‘Mrs Janes wants the most effective,
non-invasive and non-pharmacological pain management technique — what would you advise her as her
options?’, they appear startled. One student replies ‘Mrs Janes can have absolutely anything she wants
to manage her pain!’ — a great response, but it doesn’t provide the best possible evidence to Mrs Janes,
especially if she’s asking direct questions. The response could be relaxation techniques,15 massage and
reflexology,16 aromatherapy,17 and so on — but the student would need to revise the evidence. They may
sympathise with Mrs Janes’s predicament, but they often draw a blank as to where to draw on information
such as this, which could possibly be the one thing that Mrs Janes needs or wants to know.
Experienced health professionals might think they can answer Mrs Janes’s question from their own
personal experience, but few of them would be right. Even if they were right on this occasion, they would
still need an overall system for converting all of the information about a client (age, ethnicity, subjective
pain scale, etc.), the particular values and preferences (utilities) of the client, and other things that could be
relevant (a hunch, a half-remembered article, the opinion of a more experienced colleague or a paragraph
discovered by chance while flicking through a textbook) into a succinct summary. The summary would
need to cover what the problem is, and what specific additional items of information we need to solve that
problem and come up with a desired outcome.
Sackett et al., in a book subsequently revised by Straus,18 explained that the parts of a good clinical
question should include three components.
• First, define precisely whom the question is about (i.e. ask ‘How would I describe a group of clients
similar to this one?’).
• Next, define which manoeuvre (treatment, intervention, etc.) you are considering in this client, and, if
necessary, a comparison manoeuvre (e.g. placebo or current standard therapy).
• Finally, define the desired (or undesired) outcome (e.g. reduced mortality, better quality of life, and
overall cost savings to the health service).
Thus, in Mrs Janes’s case, we might ask, ‘In a thirty-year-old Caucasian woman with a high pain
threshold, two previous labouring/birthing experiences, no coexisting illness, and no significant past
medical history, whose blood pressure is currently X/Y, would the benefits of suggesting massage and
reflexology provide her with the desired outcome of an effective, non-invasive and non-pharmacological
pain management technique to decrease pain during labour?’ Note that in framing the specific question, we
have already established that Mrs Janes has previously experienced labour and birth twice. Knowing this,
we recognise that she may have also previously experienced invasive or pharmacological interventions and
is aware of the discomfort of labouring and birthing.
Remember that Mrs Janes’s alternative to an effective, non-invasive and non-pharmacological pain
management technique is potentially invasive and may have side effects — on not only Mrs Janes, but
also the birthing process and/or the baby about to be born. Not all of the alternative approaches would help
Mrs Janes or be acceptable to her, but it would be quite appropriate to seek evidence as to whether they
might help her — especially if she was asking to try one or more of these remedies.
Before you start, give one last thought to your client in labour. In order to determine her personal
priorities (how much does she value a 10 per cent reduction in her pain to still experience the labour and
birthing process compared to the inability to feel below her belly button?), you will need to approach Mrs
Janes, not anybody else in that labouring room, and start the dialogue towards providing evidence-based
care.

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 SUMMARY
Evidence-based practice is much more than ‘reading an academic article’. It includes, at a very minimum,
the best possible research evidence available, clinical expertise as well as understanding the client’s values
and preferences. EBP is not about learning a technique, skill and treatment methodology once and applying
it for the rest of your career; it should be a continuous loop of learning and improvement by using the Ask,
Acquire, Appraise, Apply and Evaluate model. Although some students (and even health practitioners)
attempt to avoid learning about EBP because they believe that it’s all math-driven and hard to understand,
it’s much more than just numbers. Once you learn the techniques, you will begin to see evidence-based
information all around you and will continue to apply EBP throughout your life as both a health consumer
and eventually a health practitioner. When the best question is formulated, it becomes much easier to find
the best evidence to answer the question.

KEY TERMS
evidence-based care Care that is based on evidence-based practice (supported by scientific evidence,
clinical expertise and client values).
evidence-based practice (EBP) A practice that is supported by scientific evidence, clinical expertise
and client values.
knowledge An accepted body of facts or ideas that is acquired through the use of the senses, reasons
or through research methods.
retrospective longitudinal cohort design A type of study conducted over a long period, looking at a
group of people in the past.

WEBSITES
1 Centre for Research in Evidence-based Practice (CREBP): https://bond.edu.au/researchers/research-
strengths/university-research-centres/centre-research-evidence-based-practice
2 Centre for Evidence-based Medicine: www.cebm.net
3 ‘What is evidence-based medicine?’, British Medical Journal: www.bmj.com/content/312/7023/71
4 HPNA Position statements ‘Evidence-Based Practice’, Hospice and Palliative Nurses Association
(US): https://advancingexpertcare.org/position-statements
Joanna Briggs Institute: www.joannabriggs.org
5
Australasian Cochrane Centre: http://aus.cochrane.org
6
‘Evidence-based information’, QUT Library: www.library.qut.edu.au/search/howtofind/evidencebased
7
‘Answering Clinical Questions’, University of Western Australia: www.meddent.uwa.edu.au/
8
teaching/acq
9 ‘Evidence based practice’, University of Tasmania: https://utas.libguides.com/ebp
10 ‘Introduction to evidence-based practice’, Duke University Medical Center Library and the Health
Sciences Library at the University of North Carolina: https://guides.mclibrary.duke.edu/ebmtutorial

ENDNOTES
1. M. Hurley et al., ‘Hip and knee osteoarthritis: a mixed methods review,’ Cochrane Database of Systematic Reviews 4 (2018).
doi:10.1002/14651858.CD010842.pub2.
2. D. L. Sackett et al., ‘Evidence-based practice: what it is and what it isn’t,’ BMJ: British Medical Journal 312, no. 7023
(1996): 71.
3. Sackett, ‘Evidence-based practice,’ 71.
4. K. Head et al., ‘Saline irrigation for allergic rhinitis,’ Cochrane Database of Systematic Reviews 6 (2018).
doi:10.1002/14651858.CD012597.pub2.
5. D. L. Sackett and R. B. Haynes, ‘On the need for evidence-based practice,’ Evidence-based Practice 1, no. 1 (1995): 4–5.
6. T. Greenhalgh, ‘Is my practice evidence-based?,’ BMJ: British Medical Journal 313, no. 7063 (1996): 957.
7. T. Greenhalgh, How to read a paper: the basics of evidence-based medicine (Oxford: Blackwell-Wiley, 2006).
8. M. Dubinsky and J. H. Ferguson, ‘Analysis of the national institutes of health medicare coverage assessment,’ International
Journal of Technology Assessment in Health Care 6, no. 3 (1990): 480–8.
9. D. L. Sackett et al., ‘Inpatient general practice is evidence-based,’ The Lancet 346, no. 8972 (1995): 407–10.
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 10. W. B. Runciman et al., ‘CareTrack: assessing the appropriateness of health care delivery in Australia,’ Medical Journal of
Australia 197, no. 10 (2012): 549.
11. B. Melnyk, ‘Are you getting the best health care? Evidence says: maybe not,’ The Conversation, June 9, 2016,
https://theconversation.com/are-you-getting-the-best-health-care-evidence-says-maybe-not-59206.
12. M. A. Makary and M. Daniel, ‘Medical error — the third leading cause of death in the US,’ BMJ: British Medical Journal 353
(2016): i2139.
13. J. Macnaughton, ‘Anecdote in clinical practice,’ in Narrative based practice: dialogue and discourse in clinical practice, ed.
T. Greenhalgh and B. Hurwitz (London: BMJ Publications, 1998).
14. L. Steenbergen et al., ‘A randomized controlled trial to test the effect of multispecies probiotics on cognitive reactivity to sad
mood,’ Brain, Behavior, and Immunity (2015): 258–64. doi:10.1016/j.bbi.2015.04.003.
15. C. A. Smith et al., ‘Relaxation techniques for pain management in labour,’ Cochrane Database of Systematic Reviews 3
(2018). doi:10.1002/14651858.CD009514.pub2.
16. C. A. Smith et al., ‘Massage, reflexology and other manual methods for pain management in labour,’ Cochrane Database of
Systematic Reviews 3 (2018). doi:10.1002/14651858.CD009290.pub3.
17. C. A. Smith, C. T. Collins, and C. A. Crowther, ‘Aromatherapy for pain management in labour,’ Cochrane Database of
Systematic Reviews 7 (2011). doi:10.1002/14651858.CD009215.
18. S. E. Straus et al., Evidence-based practice: how to practice and teach EBP, 4 ed. (Edinburgh: Churchill Livingstone, 2010).

ACKNOWLEDGEMENTS
Adapting author for this Australian edition: Amanda Lambros
Photo: © Halfpoint / Shutterstock.com

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 CHAPTER 2

Asking questions and

searching for evidence
LEARNING OBJECTIVES

2.1 What are the different reasons we might search for evidence?
2.2 What are the differences between primary research and secondary literature?
2.3 How do you construct an effective search string?
2.4 What are some other avenues for how to search for evidence?

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 OPENING SCENARIO

Imagine one of your clients asks you a question that

you don’t immediately know the answer to. How
do you go about finding the answer? One strategy
would be to conduct a Google search, but is that
likely to reveal an evidence-based answer to your
question? Let’s have a look at one example: An
older client asks you if they should spend money on
trying foot orthoses for their plantar heel pain.
You are not sure about the answer, so you go to
Google and search for ‘orthotic, heel pain, effec-
tive’ you get 880 000 results, many of which are
opinion-based articles or companies selling differ-
ent devices. If you go to Google Scholar and use
the same search terms you get 19 300 hits covering
a wide range of peer-reviewed articles, only some of which will be helpful for answering your question. If
you go to a database such as PubMed and enter the same search terms, you get less than 30 hits and find
a number of articles that suggest orthotics reduce pain and improve function in adults with acute plantar
fasciitis, with few risks or side effects.
This scenario should indicate that, while it may be tempting to answer clinical questions using a quick
Google search, this may not be the most effective means of finding evidence-based information. While
searching for evidence using a systematic search strategy may seem difficult and overwhelming, it is a skill
that can be learnt. Knowing how to access these navigational wonders will save you time and improve
your ability to find the best evidence. Consequently, the development of skills in searching electronic
databases is vital for the up-to-date clinician. The purpose of this chapter is not to teach you to become a
researcher or even an expert searcher. Instead, the aim is to give you the basics of searching the literature
to answer a clinical question, which will help you recognise:
• the kinds of search tools, databases and resources that are available
• how to choose intelligently among them
• how to utilise them to put them to work directly.
............................................................................................................................................................................
DISCUSSION QUESTIONS
1. How do you go about keeping up to date with current research in your area of practice?
2. How do you search for new information to answer clinical questions?
3. What skills do you already have in database searching?

2.1 Different types of searching for evidence

LEARNING OBJECTIVE 2.1 What are the different reasons we might search for evidence?
You may approach finding evidence for practice using three main methods.
1. Informally, almost recreationally, surfing the internet to keep current and/or to satisfy your own
curiosity.
2. Focused, looking for answers, perhaps related to questions that have occurred in a clinical setting or
that arise from your clients and their questions.
3. Surveying the existing literature, perhaps before embarking on a research project or clinical audit.
Each approach involves searching in a very different way.

Informal
There are a number of tools to help us keep current with an area of interest. One of these is to use an
‘alert’ service. You can set up an alert from a specific journal to let you know when a new issue has been
published and even to tell you if articles matching your interest profile are in that issue. A more general
‘Google alert’ can be set that picks up a broad range of information, including newspaper articles, news
reports and press releases. Twitter feeds are also useful for staying connected with colleagues who share
your interests and passions. It is also easy to share interesting articles and sites that you have found via
other forms of social media.
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 Focused looking for answers
Focused looking for answers should take a much more detailed approach, especially if we can trust the
‘answer’ we find and apply it directly to the care of a client. When we find information, we need to know
how we can tell if it is trustworthy and, if so, that it is OK to stop looking — we don’t need to find
absolutely every study that may have addressed this topic. This kind of query is increasingly well served
by new synthesised information sources whose goal is to support evidence-based care and the transfer of
research findings into practice. This is discussed in more detail shortly.

Searching the literature

When writing an essay or an article for publication, searching the literature involves an entirely different
process. The purpose here is less to influence client care directly than to identify the existing body of
research that has already addressed a problem and clarify the gaps in knowledge that require further
research. For this kind of searching, you need knowledge about information resources and some basic skills
in searching. A simple search of one database can often be enough for this kind of searching. Although,
you should be aware that if you want to search systematically (for example, a systematic review of the
literature), then multiple relevant databases need to be searched systematically, and citation chaining needs
to be employed to ensure that you are being thorough enough. If this is your goal, you should consult with
an information professional, such as a health librarian.

2.2 Differences between primary and

secondary research
LEARNING OBJECTIVE 2.2 What are the differences between primary research and secondary literature?
Literature that reports primary research is from a single research study. Primary sources can be found
in a variety of ways. You could look at the reference lists and hyperlinks from secondary sources. You
could identify them direct from journal alerts — for example, via RSS feeds, table-of-contents services or
more focused topical information services. You could also search databases such as PubMed/Medline,
EMBASE, PASCAL, Cochrane Library, CINAHL (Cumulated Index of Nursing and Allied Health
Literature), Web of Science, Scopus or Google Scholar.
Secondary research reports ‘synthesised’ findings and usually takes the form of a literature review.
A literature review will typically:
• examine multiple primary research papers
• summarise the research papers.
A literature review of quantitative articles may also include a meta-analysis. A review of qualitative
literature will often include a meta-synthesis, meaning that this type of literature has combined findings to
provide strong evidence on which to base practice.
Secondary literature is also useful to assist you to quickly understand what is already known about a
topic; but, if you would like (or have been asked) to locate evidence from primary research, then the rest
of this chapter is for you.

2.3 Effective search strings

LEARNING OBJECTIVE 2.3 How do you construct an effective search string?
PubMed is a frequently accessed online resource for most physicians and health professionals worldwide,
probably because it is free and well known. When conducting a basic PubMed search, you can use
two or three search words — but taking this approach characteristically turns up hundreds or thousands
of references, and many of these may be irrelevant for your topic of interest. This is certainly not an
effective way to search, but it is the reality of how most people do search.1 It is surprisingly easy to
improve the efficiency of this kind of approach, which can enable you to become much more effective at
basic searching.
Simple tools that are part of most database search engines help to focus a basic search and produce
better results.
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 Boolean operators are words (connectors) placed between search terms to narrow or expand a search.
The common Boolean operators are OR, AND and NOT.
• OR expands your search by finding studies containing either of the specific keywords.
• AND narrows your search by only finding studies containing all of the specific keywords.
• NOT narrows your search by excluding studies containing specific keywords.
Using Boolean operators results in more focused results. Therefore, using these saves time and effort
by eliminating many of the inappropriate hits.

Steps for effective searching

Say a pregnant client asks you if hypnosis is a useful form of pain relief in labour. You could answer from
your clinical or personal experience, or you could ask someone else if they knew — but, ideally, you would
go to the literature to find the answer there.
If you entered the words ‘hypnosis’, ‘pain relief’ and ‘labour’ into a search database such as Google
Scholar, it would generate more than 11 500 hits. It would be tempting to simply look at the first ten or so of
these, but if you did that, you may well miss important studies that answer your client’s clinical question.
Google Scholar can be an excellent place to start searching for a topic, as it will identify publications that
are listed on PubMed as well as those that aren’t. Unfortunately, the advanced search option does not
provide quality filters or limits, nor does Google Scholar accept Boolean operators; therefore, in order to
use these functions you would need to use another database. If you go to a publicly available database such
as PubMed and use the ‘advanced search’ option to add the Boolean operator AND between each of your
words ‘hypnosis AND pain relief AND labour’, you gain less than 45 hits!

FIGURE 2.1 Advanced Boolean operator search on PubMed

Source: PubMed 2019.

However, this may have limited your search too much. In order to have a good look at the literature to
answer your client’s question, you can construct a simple search.

Boolean operators
If you use the Boolean operator OR this will help you locate other articles that have used related terms that
your first search might not have captured. For example, you know that ‘pain relief’ may also be referred
to as ‘analgesia’, so to include these two terms in your search you would link them using OR.
When constructing a simple search, you need to enter all the related terms together using OR to link
them — you would need to do this with related terms for pain relief and any related terms for labour. This
process will initially result in a large number of hits. Don’t worry about this, as once you complete your
search using the AND function this number will be reduced again.

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 Truncation
Another way to make your search more efficient is with the use of truncation. Truncation identifies
variations of a word without the need to enter each one individually. For example, ‘hypno*’ will retrieve
hypnosis as well as hypnotherapy. There are a couple of traps to note when using truncation however.
• Typing ‘hypno*’ will also give hypnoanalysis and hypnotic, which are probably not going to be useful
in this search. Two ways around this is to either remove the unwanted words from the search using the
Boolean operator NOT. So, you might add ‘NOT hypnoanalysis OR hypnotic’ to your search, especially
if it seemed you were getting a lot of extra hits by using these words. Alternatively, you could simply
link the two words you want in full by using the OR operator (i.e. hypnosis OR hypnotherapy).
• It is important not to truncate too much, as this process will give every word that starts with those same
letters. For example, a student that truncated ‘woman’ to ‘wom*’, because she wanted to capture articles
about both ‘woman’ and ‘women’ in her search, also got many completely irrelevant hits like ‘wombat’!
Frequently used truncation symbols are the asterisk (*), a question mark (?) or a dollar sign ($). Note
that some databases do not accept truncation.

Wildcards
The use of wildcards enables the entering of one search term to account for the many different ways a
word may be spelt. For example, using the question mark (?) wildcard symbol, ‘randomi?ation’ finds both
‘randomization’ and ‘randomisation’. This can be a very useful thing to add to a search string; however,
not all databases allow for wildcards, such as PubMed.
So far, your search for hypnosis and pain relief in labour using Boolean operators and truncation looks
like this.

FIGURE 2.2 Using truncation and Boolean operators in PubMed

Source: PubMed 2019.

If you enter this, you now get a little over one hundred hits. Unless you want to wade through all of
these articles, you now need to consider using filters.

Filters
Another useful way to focus a search is by using filters. Many librarians will tell you to avoid applying
filters to your initial search. For example, if you filter a search to ‘full text’ you may inadvertently miss
a gem. (Remember, librarians can help you find the full text of an article, such as through an interlibrary
loan). It is, however, useful to apply a filter for the languages that you can read and understand, as well
as ‘human’ studies to avoid the many about rats and mice. It may also be useful to apply a date filter to
reduce your hits to more recent research.
If you filter the article type to ‘clinical trial’, this will superimpose a filter based on optimum study
designs for best evidence, depending on the domain of the question and the degree to which you wish to
focus it. For example, if you wanted to tell your client only about the randomised clinical trials (RCT),
you could filter your search and find a handful of RCTs on the topic.
Please note that in PubMed you find the filters on the ‘front page’ of the search and you can see the
effect of the filter on your search as soon as you tick (or untick) the box. Figure 2.3 shows a screenshot of
search results using the filtering terms of ‘clinical trial’, ‘last five years’, and ‘human’ (seen by the ‘ticks’
in the left-hand column). As these are all in English, there is no point in adding an English language filter.
Pdf_Folio:15

CHAPTER 2 Asking questions and searching for evidence 15

© John Wiley & Sons Australia, Ltd. Not for resale or distribution. Any unauthorised distribution or use will result in legal action.
Another Random Scribd Document
with Unrelated Content
 POET TO HIS LOVE
An old silver church in a forest
Is my love for you.
The trees around it
Are words that I have stolen from your heart.
An old silver bell, the last smile you gave,
Hangs at the top of my church.
It rings only when you come through the forest
And stand beside it.
And then, it has no need for ringing,
For your voice takes its place.
 OLD AGE
In me is a little painted square
Bordered by old shops with gaudy awnings.
And before the shops sit smoking, open-bloused old men,
Drinking sunlight.
The old men are my thoughts;
And I come to them each evening, in a creaking cart,
And quietly unload supplies.
We fill slim pipes and chat
And inhale scents from pale flowers in the centre of the square....
Strong men, tinkling women, and dripping, squealing children
Stroll past us, or into the shops.
They greet the shopkeepers and touch their hats or foreheads to
me....
Some evening I shall not return to my people.
 DEATH
I shall walk down the road;
I shall turn and feel upon my feet
The kisses of Death, like scented rain.
For Death is a black slave with little silver birds
Perched in a sleeping wreath upon his head.
He will tell me, his voice like jewels
Dropped into a satin bag,
How he has tip-toed after me down the road,
His heart made a dark whirlpool with longing for me.
Then he will graze me with his hands,
And I shall be one of the sleeping, silver birds
Between the cold waves of his hair, as he tip-toes on.
 Edwin Curran

Edwin Curran was born at Zanesville, Ohio, May 10, 1892, and was educated at
St. Thomas’ School in the city of his birth. After working as an unskilled laborer in
various trades, he learned telegraphy in 1914 and has been employed ever since as
an operator for the Pennsylvania Railroad Company.
In 1917 he printed a little paper-bound pamphlet of thirty pages (First Poems)
with this naïve note: “Price of this book is 35 cents postpaid. Author is 25,
unmarried, a beginner and needs publisher. If this volume meets expenses,
another, possibly better, will be issued.” Expecting to find poetry of an absurd
simplicity, one is startled to find striking images, strange pictures and (in such
poems as “Soldier’s Epitaph” and “Sailing of Columbus”) lines like:

We climbed the slippery alleys of the sea

and many a lyric flash like:

The stars, like bells, flash down the silver sky ...
Ringing like chimes on frozen trees, or cry
Along the marble ground.

Second Poems (1920) has a similar beauty mixed with banality. Both booklets
are a jumble of passion, platitude, bad grammar and exaltation. Curran has
absolutely no critical perceptions; he has little control over his music. For better or
for worse, his mood controls him.
 AUTUMN
The music of the autumn winds sings low,
Down by the ruins of the painted hills,
Where death lies flaming with a marvelous glow,
Upon the ash of rose and daffodils.
But I can find no melancholy here
To see the naked rocks and thinning trees;
Earth strips to grapple with the winter year—
I see her gnarled hills plan for victories!

I love the earth who goes to battle now,

To struggle with the wintry whipping storm
And bring the glorious spring out from the night.
I see earth’s muscles bared, her battle brow,
And am not sad, but feel her marvelous charm
As splendidly she plunges in the fight.
THE PAINTED HILLS OF ARIZONA
The rainbows all lie crumpled on these hills,
The red dawns scattered on their colored sills.
These hills have caught the lightning in its flight,
Caught colors from the skies of day and night
And shine with shattered stars and suns; they hold
Dyed yellow, red and purple, blue and gold.
Red roses seem within their marble blown,
A painted garden chiseled in the stone;
The rose and violet trickling through their veins,
Where they drop brilliant curtains to the plains—
A ramp of rock and granite, jeweled and brightening,
Like some great colored wall of lightning!
 Edna St. Vincent Millay

Edna St. Vincent Millay, possibly the most gifted of the younger lyricists, was
born February 22, 1892, at Rockland, Maine. After a childhood spent almost
entirely in New England, she attended Vassar College, from which she was
graduated in 1917. Since that time she has lived in New York City. Besides her
keenly individual lyrics, Miss Millay has written a quantity of short stories under
various pseudonyms, has translated several songs, and has been connected with
the Provincetown Players both as playwright and performer.
Although the bulk of her poetry is not large, the quality of it approaches and
sometimes attains greatness. Her first long poem, “Renascence,” was the
outstanding feature of The Lyric Year (1912), an anthology which revealed many
new names. “Renascence” was written when Miss Millay was scarcely nineteen; it
remains today one of the most remarkable poems of this generation. Beginning like
a child’s aimless verse it proceeds, with a calm lucidity, to an amazing climax. It is
as if a child had, in the midst of its ingenuousness, uttered some terrific truth. The
sheer cumulative power of this poem is surpassed only by its beauty.
Renascence, the name of Miss Millay’s first volume, was published in 1917. It is
full of the same passion as its title-poem; here is a hunger for beauty so intense
that no delight is great enough to give the soul peace. Such poems as “God’s World”
and the unnamed sonnets vibrate with this rapture. Magic burns from the simplest
of her lines. Figs from Thistles (1920) is a far more sophisticated booklet. Sharp
and cynically brilliant, Miss Millay’s craftsmanship no less than her intuition saves
these poems from mere cleverness.
Second April (1921) is an intensification of her lyrical gift tinctured with an
increasing sadness and disillusion. Her poignant poetic play, Aria da Capo, first
performed by the Provincetown Players in New York, was published in The
Monthly Chapbook (Harold Monro, England); the issue of July, 1920, being
devoted to it.
 GOD’S WORLD
O world, I cannot hold thee close enough!
Thy winds, thy wide grey skies!
Thy mists that roll and rise!
Thy woods, this autumn day, that ache and sag
And all but cry with colour! That gaunt crag
To crush! To lift the lean of that black bluff!
World, World, I cannot get thee close enough!

Long have I known a glory in it all,

But never knew I this;
Here such a passion is
As stretcheth me apart. Lord, I do fear
Thou’st made the world too beautiful this year.
My soul is all but out of me,—let fall
No burning leaf; prithee, let no bird call.
RENASCENCE{See Transcriber’s Note 1.}
All I could see from where I stood
Was three long mountains and a wood;
I turned and looked another way,
And saw three islands in a bay.
So with my eyes I traced the line
Of the horizon, thin and fine,
Straight around till I was come
Back to where I’d started from;
And all I saw from where I stood
Was three long mountains and a wood.
Over these things I could not see;
These were the things that bounded me;
And I could touch them with my hand,
Almost, I thought, from where I stand.
And all at once things seemed so small
My breath came short, and scarce at all.
But, sure, the sky is big, I said;
Miles and miles above my head;
So here upon my back I’ll lie
And look my fill into the sky.
And so I looked, and, after all,
The sky was not so very tall.
The sky, I said, must somewhere stop,
And—sure enough!—I see the top!
The sky, I thought, is not so grand;
I ’most could touch it with my hand!
And, reaching up my hand to try,
I screamed to feel it touch the sky.

I screamed, and—lo!—Infinity
Came down and settled over me;
And, pressing of the Undefined
The definition on my mind,
Held up before my eyes a glass
Through which my shrinking sight did pass
Until it seemed I must behold
Immensity made manifold;
Whispered to me a word whose sound
Deafened the air for worlds around,
A db ht ffl d t
And brought unmuffled to my ears
The gossiping of friendly spheres,
The creaking of the tented sky,
The ticking of Eternity.

I saw and heard, and knew at last

The How and Why of all things, past,
And present, and forevermore.
The universe, cleft to the core,
Lay open to my probing sense
That, sick’ning, I would fain pluck thence
But could not,—nay! But needs must suck
At the great wound, and could not pluck
My lips away till I had drawn
All venom out.—Ah, fearful pawn!
For my omniscience paid I toll
In infinite remorse of soul.
All sin was of my sinning, all
Atoning mine, and mine the gall
Of all regret. Mine was the weight
Of every brooded wrong, the hate
That stood behind each envious thrust,
Mine every greed, mine every lust.
And all the while for every grief,
Each suffering, I craved relief
With individual desire,—
Craved all in vain! And felt fierce fire
About a thousand people crawl;
Perished with each,—then mourned for all!
A man was starving in Capri;
He moved his eyes and looked at me;
I felt his gaze, I heard his moan,
And knew his hunger as my own.
I saw at sea a great fog-bank
Between two ships that struck and sank;
A thousand screams the heavens smote;
And every scream tore through my throat.
No hurt I did not feel, no death
That was not mine; mine each last breath
That, crying, met an answering cry
That, crying, met an answering cry
From the compassion that was I.
All suffering mine, and mine its rod;
Mine, pity like the pity of God.
Ah, awful weight! Infinity
Pressed down upon the finite Me!
My anguished spirit, like a bird,
Beating against my lips I heard;
Yet lay the weight so close about
There was no room for it without.
And so beneath the weight lay I
And suffered death, but could not die.

Deep in the earth I rested now;

Cool is its hand upon the brow
And soft its breast beneath the head
Of one who is so gladly dead.
And all at once, and over all,
The pitying rain began to fall;
I lay and heard each pattering hoof
Upon my lowly, thatchèd roof,
And seemed to love the sound far more
Than ever I had done before.
For rain it hath a friendly sound
To one who’s six feet underground;
And scarce the friendly voice or face;
A grave is such a quiet place.

The rain, I said, is kind to come

And speak to me in my new home.
I would I were alive again
To kiss the fingers of the rain,
To drink into my eyes the shine
Of every slanting silver line,
To catch the freshened, fragrant breeze
From drenched and dripping apple-trees.
For soon the shower will be done,
And then the broad face of the sun
Will laugh above the rain-soaked earth
Until the world with answering mirth
Sh k j l d h dd
Shakes joyously, and each round drop
Rolls, twinkling, from its grass-blade top.
How can I bear it; buried here,
While overhead the sky grows clear
And blue again after the storm?
O, multi-colored, multiform,
Beloved beauty over me,
That I shall never, never see
Again! Spring-silver, autumn-gold,
That I shall never more behold!
Sleeping your myriad magics through,
Close-sepulchred away from you!
O God, I cried, give me new birth,
And put me back upon the earth!
Upset each cloud’s gigantic gourd
And let the heavy rain, down-poured
In one big torrent, set me free,
Washing my grave away from me!

I ceased; and, through the breathless hush

That answered me, the far-off rush
Of herald wings came whispering
Like music down the vibrant string
Of my ascending prayer, and—crash!
Before the wild wind’s whistling lash
The startled storm-clouds reared on high
And plunged in terror down the sky,
And the big rain in one black wave
Fell from the sky and struck my grave.

I know not how such things can be

I only know there came to me
A fragrance such as never clings
To aught save happy living things;
A sound as of some joyous elf
Singing sweet songs to please himself,
And, through and over everything,
A sense of glad awakening.
The grass, a tip-toe at my ear,
Whispering to me I could hear;
Whispering to me I could hear;
I felt the rain’s cool finger-tips
Brushed tenderly across my lips,
Laid gently on my sealèd sight,
And all at once the heavy night
Fell from my eyes and I could see,—
A drenched and dripping apple-tree,
A last long line of silver rain,
A sky grown clear and blue again.
And as I looked a quickening gust
Of wind blew up to me and thrust
Into my face a miracle
Of orchard-breath, and with the smell,—
I know not how such things can be!—
I breathed my soul back into me.
Ah! Up then from the ground sprang I
And hailed the earth with such a cry
As is not heard save from a man
Who has been dead, and lives again.
About the trees my arms I wound;
Like one gone mad I hugged the ground;
I raised my quivering arms on high;
I laughed and laughed into the sky,
Till at my throat a strangling sob
Caught fiercely, and a great heart-throb
Sent instant tears into my eyes;
O God, I cried, no dark disguise
Can e’er hereafter hide from me
Thy radiant identity!
Thou canst not move across the grass
But my quick eyes will see Thee pass,
Nor speak, however silently,
But my hushed voice will answer Thee.
I know the path that tells Thy way
Through the cool eve of every day;
God, I can push the grass apart
And lay my finger on Thy heart!

The world stands out on either side

No wider than the heart is wide;
Above the world is stretched the sky,—
No higher than the soul is high.
The heart can push the sea and land
Farther away on either hand;
The soul can split the sky in two,
And let the face of God shine through.
But East and West will pinch the heart
That cannot keep them pushed apart;
And he whose soul is flat—the sky
Will cave in on him by and by.
 PITY ME NOT
Pity me not because the light of day
At close of day no longer walks the sky;
Pity me not for beauties passed away
From field and thicket as the year goes by;
Pity me not the waning of the moon,
Nor that the ebbing tide goes out to sea,
Nor that a man’s desire is hushed so soon,
And you no longer look with love on me.

This have I known always: love is no more

Than the wide blossom which the wind assails;
Than the great tide that treads the shifting shore,
Strewing fresh wreckage gathered in the gales.
Pity me that the heart is slow to learn
What the swift mind beholds at every turn.