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DEPARTMENT Research Methods

Critiquing Research Evidence

for Use in Practice: Revisited

Juanita Conkin Dale, PhD, RN, CPNP-PC, Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, & Regena Spratling, PhD, RN, APRN, CPNP

There are numerous ways to appraise research and practice guidelines that are designed to

Nurse practitioners need to critically appraise the abundance of research evidence and clinical practice guidelines to make astute decisions about the implementation of the best available evidence to clinical practice. There are numerous ways to appraise research and practice guidelines that are designed to inform clinical prac- tice with the overall goals of improving patient outcomes. This article presents existing tools to appraise the research evidence in addition to a guide for providers on critical appraisal of a research study. J Pediatr Health Care. (2019) 33, 342−346

KEY WORDS Clinical decision-making, evidence-based practice, nurse practi- tioners, nursing research

The explosion of clinical research evidence has placed new demands on nurse practitioners (NPs) to critically appraise the abundance of research evidence and clinical practice guidelines to make astute decisions on the implementation of the best available evidence to clinical practice. There are

ita Conkin Dale, Pediatric Nurse Practitioner (retired), dren’s Health−Children’s Medical Center, Dallas, TX.

na Hallas, Clinical Professor and Director, Pediatric Nurse titioner Program, Rory Meyers College of Nursing, New York ersity, New York City, NY.

ena Spratling, Associate Professor and Associate Dean and f Academic Officer for Nursing, School of Nursing, Byrdine F. is College of Nursing and Health Professions, Georgia State ersity, Atlanta, GA.

flicts of interest: None to report.

espondence: Regena Spratling, PhD, RN, APRN, CPNP, rgia State University, School of Nursing, Byrdine F. Lewis ege of Nursing and Health Professions, 140 Decatur St., n Life Building Room 950, Atlanta, GA 30303; e-mail: [email protected]. diatr Health Care. (2019) 33, 342-346

1-5245/$36.00

yright © 2019 by the National Association of Pediatric Nurse titioners. Published by Elsevier Inc. All rights reserved.

lished online March 12, 2019.

s://doi.org/10.1016/j.pedhc.2019.01.005

Volume 33 � Number 3

numerous ways to appraise research and practice guidelines that are designed to inform clinical practice, with the overall goal of improving patient outcomes. Several authors have provided appraisal tools to critique the evidence (Buccheri & Sharifi, 2017; Gray & Grove, 2017; National Library of Medicine, 2015), and major centers, such as the Cochrane Collaboration and Cochrane Library, have extensive data- bases for systematic reviews of the literature, as well as the Joanna Briggs Institute, which provides a repository of evi- dence-based practice databases. Stevens (2019) suggested

inform clinical practice, with the overall goal of improving patient outcomes.

that critical appraisal of evidence is one of the most valuable skills that a clinician can have in today’s health care environment. This arti- cle is an update to an original and popular article published in the Journal of Pediatric Health Care entitled “Critiqu- ing Research for Use in Practice” (Dale, 2005), and it will present ways to critique an article for relevance to an individ-

ual’s or group’s clinical practice, as well as ways to critically appraise the best available evidence.

APPRAISING THE RESEARCH EVIDENCE Some aspects of appraising a research article are the same whether the study is quantitative, qualitative, or mixed methods (Dale, 2005; Gray & Grove, 2017). Caldwell, Henshaw, and Taylor (2011) described the development of a framework for critiquing health research, addressing both quantitative and qualitative research with one list of questions. This framework was created by educators for use by novice learners, in particu- lar baccalaureate students, to help them understand the research process. Early in their program of study, NP students may benefit from a basic framework to appraise a research

Journal of Pediatric Health Care

BOX. Questions for critical appraisal of a research study

Abstract Does the abstract discuss the purpose, methods, sample, results, and conclusions with implications for practice? Background � Is the purpose justified by the literature? � Are only the most relevant, primary, and up-to-date sources included? � Does the review address all the concepts proposed in the study?

Theoretical framework � Does the theoretical or conceptual framework or philosophical background relate to the concepts or phenomena of study and the methods used in the study?

Statement of problem and purpose � Are the problem and purpose clearly stated? � Are the key variables or concepts identified and defined, if applicable? � Is the problem significant to improve outcomes for children and their families? � Are the definitions clear? � Is (are) the hypothesis(es) and/or the research question(s) clearly stated?

Methodology � Is the design appropriate for the study’s purpose? � Is the sampling method appropriate and the sample size adequate? Does it include a description of the sample inclusion and exclusion criteria? For qualitative studies, are the selection of participants described and the sampling method iden- tified?

� Is the study approved by an institutional review board (i.e., IRB)? � Is the mechanism for obtaining assent from any child over 7 years of age described? � Is the setting clearly described? � Is there a rationale for selection of the instrument(s)? � Has the validity and reliability for the instrument(s) been established? If not, are the methods for doing so described? � Are the limitations for the instrument(s) given? Has (have) the instrument(s) been piloted? � Is the process for administration of the instrument(s) given? � Are the data collection methods appropriate for the study? For quantitative studies, is the data collection method valid and reliable? For qualitative studies, is the data collection method auditable?

� Are data analysis methods described and appropriate? Are the statistical methods used consistent with the study design? For quantitative studies, is the data analysis method valid and reliable? For qualitative studies, is the data analysis method credible and confirmable?

Results � Are the data presented objectively and factually?

Discussion/conclusions � Are the findings explained with regard to their significance? � Is the relationship between the findings and the conceptual or theoretical framework or philosophical background dis- cussed?

� Is the relationship between the findings and previous relevant research explained? � For quantitative studies, are the results generalizable? For qualitative studies, are the results transferable? � Are the conclusions linked to the study objectives? � Do the conclusions flow from the data and the analysis? � Are the limitations of the study presented?

Adapted from Caldwell, Henshaw, and Taylor (2011) and Dale (2005).

Since the mid- 2000s, there has been a proliferation of evidence-based practice interventions and clinical practice guidelines in all disciplines.

study before they attempt a more advanced critical appraisal of research studies and practice guidelines to determine the fitness of the study for implementation in their clinical decision mak- ing and clinical practice (see the Box). For both novice and experienced NPs, the skill of critiquing research studies, sys- tematic reviews, and clinical practice guidelines is a driving force in the delivery of quality of health care.

CRITICAL APPRAISAL TOOLS Since the mid-2000s, there has been a proliferation of evi- dence-based practice interventions and clinical practice guidelines in all disciplines. Readers must understand the

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value of using critical appraisal tools in the decision-making pro- cess for the implemen- tation of either an evidence-based study or a clinical practice guide- line into their own clinical practice. Readers and/or teams of clinicians should critically appraise using one of the

May/June 2019 343

standardized critical appraisal tools to determine whether the evidence-based practice or clinical practice guidelines are appropriate for implementation in their own clinical practice.

It is imperative to select the most appropriate critical appraisal tool to analyze research before implementing it in clinical practice (Buccheri & Sharifi, 2017). The AGREE II tool is used to appraise clinical practice guidelines and is available online (https://www.agreetrust.org/agree-ii/; Brouwers et al., 2010). The AGREE II is used as a quality assessment tool and covers six quality domains, with each domain containing between two and six questions for read- ers to answer in the critique (Buccheri & Sharifi).

Critical appraisal skills program (CASP) checklists are tools that can be used to critically appraise eight types of published research studies. Each tool is unique to the type of research that the article presents, such as randomized controlled trials and systematic reviews, and the tools are available online (https://casp-uk.net/; Critical Appraisal Skills Programme, 2018). Readers are encouraged to use the CASP tools for research studies and the AGREE II tool for clinical practice guidelines, to determine whether the study or guidelines are appropriate for implementation in their clinical practice.

THE IMPORTANCE OF THE ABSTRACT The abstract helps readers decide whether the study is of interest and relevant to practice and whether the entire arti- cle should be read (Dale, 2005). The abstract provides a suc- cinct summary of the study and should address the following items, based on journal guidelines: background and purpose; methods, including details about the study sample; and results that highlight key findings with implica- tions for practice (Caldwell, Henshaw, & Taylor, 2011; Gray & Grove, 2017).

REVIEW OF LITERATURE The review of literature should be comprehensive but con- cise, and should address the key health concerns and con- cepts of interest for the study. Only the most relevant, primary, and current references should be cited in the article (Caldwell, Henshaw, & Taylor, 2011; Gray, 2017; Gray & Grove, 2017). The cited literature should be less than 5 years old, unless the articles are considered classic or seminal works, or if the topic has limited literature. Articles should be cited from a wide range of scientific literature that includes nursing and other disciplines. The background or review of literature section should justify the purpose of the study and provide a sound theoretical framework for the research study (Dale, 2005). It should include a summary of what is known and not known about the research problem (Gray & Grove, 2017).

THEORETICAL FRAMEWORK The presentation of a theoretical or conceptual framework, or a philosophical background in a qualitative study, should relate to the concepts or phenomena of study and the meth- ods used in the, whether the study is qualitative or

344 Volume 33 � Number 3

quantitative (Bradbury-Jones, Taylor, & Herber, 2014; Cald- well, Henshaw, & Taylor, 2011). Researchers are encouraged to use a theoretical framework from nursing or other disci- plines to guide their research and offer an explanation of the relationship of the variables in the theoretical framework to the variables addressed in the research design and outcomes (Dale, 2005; Gray & Grove, 2017).

The utilization of nursing theory as a framework in research is essential to knowledge development and promotes theory-based nursing practice. Grounding nursing research in a theoretical framework facilitates a better understanding of human experiences with health and illness within the healthcare system. (Jennings, 2017, p. 370)

Readers who are not familiar with the application of nursing theoretical frameworks within research investiga- tions are encouraged to read two recent publications that use a quantitative methodology (Jennings, 2017) or a qualita- tive methodology (da Maia Lima et al., 2016) to guide research.

STATEMENT OF PROBLEM OR PURPOSE The researcher should clearly state the problem and purpose of the study. The purpose statement defines the project, the overall goal of the study, and specific aims or objectives (Caldwell, Henshaw, & Taylor, 2011; Polit & Beck, 2017). The variables of interest should be stated, if applicable. Terms should be defined, and the hypothesis(es) or research questions clearly stated (Caldwell, Henshaw, & Taylor; Gray & Grove, 2017). This section helps readers determine whether the problem is significant and related to the popula- tion of children they serve and whether there is the potential to improve the health care outcomes for children and their families (Dale, 2005).

RESEARCH DESIGN The research design presents the strategies that the researcher used to answer the research questions or test the hypothesis(es). The research design should be clearly stated and include a description of the sample inclusion and exclu- sion criteria (Caldwell, Henshaw, & Taylor, 2011; Gray & Grove, 2017). Data collection and data analysis methods should also be clearly described by the author. In addition, the author should specify why the design and methods were used in the study and how the researcher implemented con- trols to enhance the interpretability of the results (Caldwell, Henshaw, & Taylor, 2011; Dale, 2005; Gray & Grove, 2017; Polit & Beck, 2017).

SAMPLE AND SETTING The sample and setting should be described in enough detail for readers to determine if the participants and setting are similar to the population, and even the typical patient and practice setting (Caldwell, Henshaw, & Taylor, 2011). For qualitative studies, the selection of participants and the sam- pling method should be described (Caldwell, Henshaw, &

Journal of Pediatric Health Care

To make practice changes, NPs have a responsibility to review current research articles and apply the findings of the research to their practice.

Taylor). Consideration of the rights of human subjects should be discussed in addition to a statement on institu- tional review board or other approvals (Caldwell, Henshaw, & Taylor; Dale, 2005; Gray & Grove, 2017).

INSTRUMENTS, MEASURES, AND TOOLS The instruments used should be fully described, including reliability and validity and whether the tool was developed by the researcher and/or previously tested. The instruments should match the variables being studied, and the variables should be reflected in the concepts presented in the theoreti- cal framework (Jennings, 2017). The instruments, measures, or tools play an important role in helping readers determine the validity of the study findings with the use of valid and reliable measures that equate with the study design.

DATA COLLECTION Data collection is an important component for all research methodologies. The methods for data collection should clearly identify data collection strategies, which must be con- sistent with the study design. The researcher must identify the specific methods used by the data collectors and the blinding method used by the data collectors to ensure research rigor and study integrity. Novice and experienced researchers reviewing an article should ask what research design was used and what methods are most often used for data collection for the specific study design (Gray & Grove, 2017). Consulting a research textbook may be beneficial, because there are numerous methods for conducting quanti- tative, qualitative, and mixed methods studies.

DATA ANALYSIS This may be the most difficult section for readers to evalu- ate. The main question is whether the statistical methods used are consistent with the study design. For survey, descriptive statistics should be used. When the relationship between two variables was evaluated, correlational statistics should be used. However, if a comparison between two groups was made, inferential statistics such as the t test or analysis of variance (i.e., ANOVA) would be used. For stud- ies attempting to predict the effect of two or more variables on a dependent variable, multivariate statistical methods such as multiple regression or multiple correlation should be used. In most cases, the level of significance should be identified. Later in the results and discussion section, the sig- nificance or lack thereof should be described in relation to its importance to the study findings or clinical relevance.

For qualitative studies, the researcher should specify which qualitative methodology was used to analyze the data collected (Dale, 2005). The method of data analysis should be credible and confirmable (Caldwell, Henshaw, & Taylor, 2011). Powers (2019) recommended several additional questions specific to data analysis for qualitative studies. The data analysis should guide the direction of sampling and indicate when the data collection ended. The data management processes should be described. A description of the results should be reported, including interpretation of the results.

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RESULTS The goal of the results section of an article is to objectively report the findings of the study (Cherry, 2018). Figures and tables may be used to illustrate and present the results. The results should lead readers toward the researcher’s conclusions and justify the study conclusions (Cherry, 2018). The results section is reserved for factual information, whereas data inter- pretation is reserved for the discussion section (Dale, 2005).

DISCUSSION AND CONCLUSIONS The interpretation and meaning of the findings should be explained with regard to their significance to the sample and population of study. The researcher should describe the rela- tionship of the findings to the theoretical framework, if applicable, and to previous relevant study findings in the lit- erature. The conclusions should be linked to the objectives of the study and flow from the data and analysis. Limitations of the study are included in this section (Dale, 2005; Gray & Grove, 2017).

IMPLICATIONS AND RECOMMENDATIONS Implications for practice and future research should be pre- sented. At this point, readers can ask questions regarding whether the findings advance knowledge in the discipline and identify additional questions to answer related to the topic. This section also describes what else needs to be done before the findings can be generalized to other situations (Dale, 2005; Fosbinder & Loveridge, 1996; Gray & Grove, 2017; O’Mathuna & Fineout-Overholt, 2019).

SUMMARY Promoting and engaging in evidence-based practice is an important role for NPs. To make practice changes, NPs have a responsibility to review current research articles and

apply the findings of the research to their practice. The first step is to critique and appraise the research evidence. Through critiquing and appraising the research evidence, dialog with colleagues, and changing practice based on evi- dence, NPs can improve patient outcomes (Dale, 2005) and successfully translate research into

evidence-based practice in today’s ever-changing health care environment.

REFERENCES Bradbury-Jones, C., Taylor, J., & Herber, O. (2014). How theory is

used and articulated in qualitative research: Development of a new typology. Social Science & Medicine, 120, 135–141.

Brouwers, M., Kho, M., Browman, G., Burgers, J., Cluzeau, F., Feder, G., . . ., Zitzelsberger, L. (2010). AGREE II: Advancing

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guideline development, reporting, and evaluation in health care. CMAJ: Canadian Medical Association Journal, 182 (18), E839–E842.

Buccheri, R. K., & Sharifi, C. (2017). Critical appraisal tools and reporting guidelines for evidence-based practice. Worldviews on Evidence-Based Nursing, 14, 463–471.

Caldwell, K., Henshaw, L., & Taylor, G. (2011). Developing a frame- work for critiquing health research: An early evaluation. Nurse Education Today, 31(8), e1–e7.

Cherry, K. (2018). How to write an APA results section. New York, NY: About, Inc. Retrieved from https://www.verywellmind.com/ how-to-write-a-results-section-2795727

Critical Appraisal Skills Programme. (2018). [CASP]. Oxford, UK: Author. Retrieved from https://casp-uk.net/

da Maia Lima, C. F., Guedes dos Santos, J. L., Lima Pestana Magalh~aes, A., Pereira Caldas, C., Lorenzini Erdmann, A., & dos Santos, I. (2016). Integrating tran- sitions theory and grounded theory for nursing research and care. Revista Enfermagem UERJ, 24(5), 1–5.

Dale, J. C. (2005). Critiquing research for use in practice. Journal of Pediatric Health Care, 19, 183–186.

Fosbinder, D., & Loveridge, C. (1996). How to critique a research study. Advances in Nursing Practice Quarterly, 2(3), 68–71.

Gray, J. R. (2017). Review of relevant literature. In J. R. Gray, S. K. Grove, S. Sutherland (Eds.), Burns and Grove’s the practice of nursing research. (8th ed.). Philadelphia, PA: Saunders.

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Gray, J. R., & Grove, S. K. (2017). Critical appraisal of nursing stud- ies. In J. R. Gray, S. K. Grove, S. Sutherland (Eds.), Burns and Grove’s the practice of nursing research. (8th ed.). Philadel- phia, PA: Saunders.

Jennings, K. M. (2017). The Roy adaptation model: A theoretical framework for nurses providing care to individuals with anorexia nervosa. Advances in Nursing Science, 40, 370–382.

National Library of Medicine. (2015). https://www.nlm.nih.gov/serv ices/research_report_guide.html

O’Mathuna, D. O., & Fineout-Overholt, E. (2019). Critically appraising quantitative evidence for clinical decision making. In B. M. Melnyk, & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: A guide to best practice. (4th ed.). Philadelphia, PA: Wolters Kluwer.

Polit, D. F., & Beck, C. T. (2017). Essentials of nursing research: Appraising evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Powers, B. A. (2019). Critically appraising qualitative evidence for clinical decision making. In B. M. Melnyk, & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: A guide to best practice. (4th ed.). Philadelphia, PA: Wolters Kluwer.

Stevens, K. R. (2019). Critically appraising knowledge for clinical decision making. In B. M. Melnyk, & E. Fineout-Overholt (Eds.), Evidence-based practice in nurs- ing and healthcare: A guide to best practice. (4th ed.). Phila- delphia, PA: Wolters Kluwer.

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