Appraisal for evidence based practice

Appraisal for evidence-based practice the research question and hypothesis When you begin to critically appraise a research study, consider the care the researcher takes when developing the research question or hypothesis; it is often representative of the overall conceptualization and design of the study. In a quantitative research study, the remainder of a study revolves around answering the research question or testing the hypothesis. In a qualitative research study, the objective is to answer the research question. Because this text focuses on you as a research consumer, the following sections will primarily pertain to the evaluation of research questions and hypotheses in published research reports.

Critiquing the research question and hypothesis The following Critical Appraisal Criteria box provides several criteria for evaluating the initial phase of the research process—the research question or hypothesis. Because the research question or hypothesis guides the study, it is usually introduced at the beginning of the research report to indicate the focus and direction of the study. You can then evaluate whether the rest of the study logically flows from its foundation—the research question or hypothesis. The author will often begin by identifying the background and significance of the issue that led to crystallizing development of the research question or hypothesis. The clinical and scientific background and/or significance will be summarized, and the purpose, aim, or objective of the study is then identified.

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Often the research question or hypothesis will be proposed before or after the literature review.


Sometimes you will find that the research question or hypothesis is not specifically stated. In some cases, it is only hinted at or is embedded in the purpose statement, and you are challenged to identify the research question or hypothesis. In other cases, the research question is embedded in the findings toward the end of the article. To some extent, this depends on the style of the journal.

Although a hypothesis can legitimately be nondirectional, it is preferable, and more common, for the researcher to indicate the direction of the relationship between the variables in the hypothesis. Quantifiable words such as “greater than,” “less than,” “decrease,” “increase,” and “positively,” “negatively,” or “related” convey the idea of objectivity and testability. You should immediately be suspicious of hypotheses or research questions that are not stated objectively. You will find that when there is a lack of data available for the literature review (i.e., the researcher has chosen to study a relatively undefined area of interest), a nondirectional hypothesis or research question may be appropriate.

You should recognize that how the proposed relationship of the hypothesis or research question is phrased suggests the type of research design that will be appropriate for the study, as well as the level of evidence to be derived from the findings. Example: ➤ If a hypothesis proposes that treatment X1 will have a greater effect on Y than treatment X2, an experimental (Level II evidence) or quasi-experimental design (Level III evidence) is suggested (see Chapter 9). If a research question asks if there will be a positive relationship between variables X and Y, a nonexperimental design (Level IV evidence) is suggested (see Chapter10).

Hypotheses and research questions are never proven beyond the shadow of a doubt. Researchers who claim that their data have “proven” the validity of their hypothesis or research question should be regarded with grave reservation. You should realize that, at best, findings that support a hypothesis or research question are considered tentative. If repeated replication of a study yields the same results, more confidence can be placed in the conclusions advanced by the researchers.

When critically appraising clinical questions, think about the fact that the clinical question should be focused and specify the patient population or clinical problem being addressed, the intervention, and the outcome for a particular patient population. There should be evidence that the clinical question guided the literature search and that appropriate types of research studies are retrieved in terms of the study design and level of evidence needed to answer the clinical question.

C R I T I C A L A P P R A I S A L C R I T E R I A Developing Research Questions and Hypotheses The research question

1. Does the research question express a relationship between two or more variables, or at least between an independent and a dependent variable, implying empirical testability?

2. How does the research question specify the nature of the population being studied?

3. How has the research question been supported with adequate experiential and scientific background material?

4. How has the research question been placed within the context of an appropriate theoretical framework?

5. How has the significance of the research question been identified?

6. Have pragmatic issues, such as feasibility, been addressed?

7. How have the purpose, aims, or goals of the study been identified?

The hypothesis

1. Is the hypothesis concisely stated in a declarative form?

2. Are the independent and dependent variables identified in the statement of the hypothesis?

3. Is each hypothesis specific to one relationship so that each hypothesis can be either supported or


not supported?

4. Is the hypothesis stated in such a way that it is testable?

5. Is the hypothesis stated objectively, without value-laden words?

6. Is the direction of the relationship in each hypothesis clearly stated?

7. How is each hypothesis consistent with the literature review?

8. How is the theoretical rationale for the hypothesis made explicit?

9. Given the level of evidence suggested by the research question, hypothesis, and design, what is the potential applicability to practice?

The clinical question

1. Does the clinical question specify the patient population, intervention, comparison intervention, and outcome?

2. Does the clinical question address an outcome applicable to practice?

Key points • Developing the research question and stating the hypothesis are key preliminary steps in the

research process.

• The research question is refined through a process that proceeds from the identification of a general idea of interest to the definition of a more specific and circumscribed topic.

• A preliminary literature review reveals related factors that appear critical to the research topic of interest and helps further define the research question.

• The significance of the research question must be identified in terms of its potential contribution to patients, nurses, the medical community in general, and society. Applicability of the question for nursing practice, as well as its theoretical relevance, must be established. The findings should also have the potential for formulating or altering nursing practices or policies.

• The final research question is a statement about the relationship of two or more variables. It clearly identifies the relationship between the independent and dependent variables, specifies the nature of the population being studied, and implies the possibility of empirical testing.

• Research questions that are nondirectional may be used in exploratory, descriptive, or qualitative research studies.

• Research questions can be directional, depending on the type of study design being used.

• Focused clinical questions arise from clinical practice and guide the literature search for the best available evidence to answer the clinical question.

• A hypothesis is a declarative statement about the relationship between two or more variables that predicts an expected outcome. Characteristics of a hypothesis include a relationship statement, implications regarding testability, and consistency with a defined theory base.

• Hypotheses can be formulated in a directional or a nondirectional manner and be further categorized as either research or statistical hypotheses.

• The purpose, research question, or hypothesis provides information about the intent of the research question and hypothesis and suggests the level of evidence to be obtained from the study findings.


• The interrelatedness of the research question or hypothesis and the literature review and the theoretical framework should be apparent.

• The appropriateness of the research design suggested by the research question or hypothesis is also evaluated.

Critical thinking challenges • Discuss how the wording of a research question or hypothesis suggests the type of research

design and level of evidence that will be provided.

• Using the study by Hawthorne, Youngblut, and Brooten (2016) (see Appendix B), describe how the background, significance, and purpose of the study are linked to the research questions.

•  The prevalence of catheter acquired urinary infections (CAUTIs) has increased on your hospital unit by 10% in the last two quarters. As a member of the Quality Improvement (QI) Committee on your unit, collaborate with your committee colleagues from other professions to develop an interprofessional action plan. Deliberate to develop a clinical question to guide the QI project.

• A nurse is in charge of discharge planning for frail older adults with congestive heart failure. The goal of the program is to promote self-care and prevent rehospitalizations. Using the PICO approach, the nurse wants to develop a clinical question for an evidence-based practice project to evaluate the effectiveness of discharge planning for this patient population. How can the nurse accomplish that objective?

Go to Evolve at for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.


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3. Bandura A. Self-efficacy The Exercise of Control. New York: Freeman;1997. 4. Cullum N. User’s guides to the nursing literature An introduction. Evidence-Based Nursing

2000;3(2):71-72. 5. Hawthorne D.M, Youngblut J.M, Brooten D. Patient spirituality, grief, and mental health at 1

and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80.

6. Johnson M, Sanchez P, Zheng C. Reducing patient clinical management errors using structured content and electronic nursing handover. Journal of Nursing Care Quality 2016;31(3):245-253.

7. Lazarus R.L, Folkman S. Stress, appraisal and coping. New York, NY: Springer;1984. 8. Lee S.C, Knobf M.T. Primary breast cancer decision-making among Chinese American women.

Nursing Research 2015;64(5):391-401. 9. Lewis H.S, Cunningham C.J.L. Linking nurse leadership and work characteristics to nurse

burnout and engagement. Nursing Research 2016;65(1):13-23. 10. Meehan A, Loose C, Bell J, et al. Impact of prompt nutrition care on patient outcomes and health

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transitional care. Journal of Nursing Scholarship 2016;48(3):322-329. 12. Nyamathi A, Salem B.E, Zhang S, et al. Nursing case management, peer coaching, and hepatitis

A and B vaccine completion among homeless men recently released on parole Randomized clinical trial. Nursing Research 2015;64(3):177-189.

13. NYU Langone Medical Center. New York, NY: Personal Communication;2016. 14. Parry M, Nielson C.A, Muckle F, et al. A novel noninvasive device to assess sympathetic nervous

system function in patients with heart failure. Nursing Research 2015;64(5):351-360. 15. Rahn D. Transformational teamwork Exploring the impact of nursing teamwork on nurse-

sensitive quality indicators. Journal of Nursing Care Quality 2016;31(3):262-268. 16. Rattanawiboon C, Chaweewannakorn C, Saisakphong T, et al. Effective fluoride mouthwash

delivery methods as an alternative to rinsing. Nursing Research 2016;65(1):68-75. 17. Richards E.A, Ogata N, Cheng C. Evaluation of the dogs, physical activity, and walking dogs

(Dogs PAW) intervention. Nursing Research 2016;65(3):191-201. 18. Sackett D, Straus S.E, Richardson W.S, et al. Evidence-based medicine How to practice and

teach EBM. London: Churchill Livingstone;2000. 19. Schlotfeldt R. Nursing in the future. Nursing Outlook 1981;29:295-301. 20. Shermont H, Pignataro S, Humphrey K, Bukoye B. Reducing pediatric readmissions Using a

discharge bundle combined with teach-back methodology. Journal of Nursing Care Quality 2016;31(3):224-232.

21. Silkworth A.I, Baker J, Ferrara J, et al. Nursing staff develop a video to prevent falls. A quality improvement project. Journal of Nursing Care Quality 2016;31(1):217-223.

22. Stoddard S.A, Varela J.J, Zimmerman M. Future expectations, attitude toward violence, and bullying perpetration during adolescence A mediation evaluation. Nursing Research 2015;64(6):422-433.

23. Thabault P.J, Burke P.J, Ades P.A. Intensive behavioral treatment weight loss program in an adult primary care practice. Journal of the American Association of Nurse Practitioners 2015;28:249-257.

24. Thompson C, Cullum N, McCaughan D, et al. Nurses, information use, and clinical decision- making The real world potential for evidence-based decisions in nursing. Evidence-Based Nursing 2004;7(3):68-72.

25. Traeger L, McDonnell T.M, McCarty C.E, et al. Nursing intervention to enhance outpatient chemotherapy symptom management Patient-reported outcomes of a randomized controlled trial. Cancer Nursing 2015;121(21):3905-3913.


26. Turner-Sack A.M, Menna R, Setchell S.R, et al. Psychological functioning, post-traumatic growth, and coping in parents and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43(1):48-56.

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C H A P T E R 3


Gathering and appraising the literature Barbara Krainovich-Miller

Learning outcomes

After reading this chapter, you should be able to do the following: • Discuss the purpose of a literature review in a research study. • Discuss the purpose of reviewing the literature for an evidence-based and quality improvement (QI) project. • Differentiate the purposes of a literature review from the evidence-based practice and the research perspective. • Differentiate between primary and secondary sources. • Differentiate between systematic reviews/meta-analyses and preappraised synopses. • Discuss the purpose of reviewing the literature for developing evidence-based practice and QI projects. • Use the PICO format to guide a search of the literature. • Conduct an effective search of the literature. • Apply critical appraisal criteria for the evaluation of literature reviews in research studies.


Boolean operator

citation management software controlled vocabulary

electronic databases electronic search

Grey literature literature review

preappraised synopses primary source

refereed, or peer-reviewed, journals secondary source

web browser

Go to Evolve at for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

You may wonder why an entire chapter of a research text is devoted to gathering and appraising the literature. The main reason is because searching for, retrieving, and critically appraising the literature is a key step for researchers and for practitioners who are basing their practice on evidence. Searching for, retrieving, critically appraising, and synthesizing research evidence is


essential to support an evidence-based practice (EBP). A question you might ask is, “Will knowing more about how to search efficiently and critically appraise research really help me as a student and as a practicing nurse?” The answer is, “Yes, it most certainly will!” Your ability to locate, retrieve, critically appraise, and synthesize research articles will enable you to determine whether or not you have the best available evidence to inform your clinical practice (CP).

The critical appraisal of research studies is an organized, systematic approach to evaluating a research study or group of studies using a set of standardized critical appraisal criteria. The criteria are used to objectively determine the strength, quality, quantity, and consistency of evidence provided by the available literature to determine its applicability to practice, policy, and education (see Chapters 7, 11, and 18).

The purpose of this chapter is to introduce you to how to evaluate the literature review in a research study and how to critically appraise a group of studies for EBP and quality improvement (QI) projects. This chapter provides you with the tools to (1) locate, search, and retrieve individual research studies, systematic reviews/meta-analyses, and meta-syntheses (see Chapters 6, 9, 10, and 11), and other documents (e.g., CP guidelines); (2) differentiate between a research article and a theoretical/conceptual article or book; (3) critically appraise a research study or group of research studies; and (4) differentiate between a research article and a conceptual article or book. These tools will help you develop your competencies to develop EBP and develop QI projects.

Review of the literature The literature review: The researcher’s perspective The overall purpose of the literature review in a study is to present a systematic state of the science (i.e., what research exists) on a topic. In Box 3.1, Objectives 1 to 8 and 11 present the main purposes of a literature review found in a research article. In a published study, the literature review generally appears near the beginning of the report and may or may not be labeled. It provides an abbreviated version of the literature review conducted by a researcher and represents the building blocks, or framework, of the study. Keep in mind that researchers are constrained by page limitations and so do not expect to see a comprehensive literature review in an article. The researcher must present in a succinct manner an overview and critical appraisal of the literature on a topic in order to generate research questions or hypotheses. A literature review is essential to all steps of the quantitative and qualitative research process, and is a broad, systematic critical review and evaluation of the literature in an area. BOX 3.1

O ve r a l l P u r p o s e s o f a L i t e r a t u r e R e v i e w Major goal To develop a strong knowledge base to conduct a research study or implement an evidence-based practice/QI project (1–3, 8–11) and carry out research (1–6, 11).

Objectives A review of the literature supports the following:

1. Determine what is known and unknown about a subject, concept, or problem.

2. Determine gaps, consistencies, and inconsistencies in the literature about a subject, concept, or problem.

3. Synthesize the strengths and weaknesses of available studies to determine the state of the science on a topic/problem.

4. Describe the theoretical/conceptual frameworks that guide a study.

5. Determine the need for replication or refinement of a study.

6. Generate research questions and hypotheses.


7. Determine an appropriate research design, methodology, and analysis for a study.

8. Provide information to discuss the findings of a study, draw conclusions, and make recommendations for future research, practice, education, and/or policy changes.

9. Uncover a new practice intervention(s) or gain supporting evidence for revising, maintaining current intervention(s), protocols, and policies, or developing new ones.

10. Generate clinical questions that guide development of EBP/QI projects, policies, and protocols.

11. Identify recommendations from the conclusion for future research, practice, education, and/or policy actions.

QI, Quality improvement.

The following overview about use of the literature review in relation to the steps of the quantitative and qualitative research process will help you understand the researcher’s focus. In quantitative studies, the literature review is at the beginning of the published research articles, and may or may not be titled literature review (see Appendix A, B, C, and D). As you read the selected research articles found in the appendices, you will see that none of these reports have a section titled Literature Review. But each has a literature review at the beginning of the article. Example: ➤ van Dijk and colleagues (2016) labeled this beginning section with the title Introduction (see Appendix C). Hawthorne and colleagues (2016), after a brief introduction about their topic, used sublevel headings for two major concepts of their review and then provided a sublevel heading to introduce their Conceptual Framework (see Appendix B). Appendix A’s study by Nyamathi and colleagues (2015), after presenting their nonlabeled literature review, also provided a sublevel heading labeled “Theoretical Framework.”

A review of the relevant literature found in a quantitative study (Fig. 3.1) is valuable, as it provides the following:

• Theoretical or conceptual framework

• Identifies concepts/theories used as a guide or map for developing research questions or hypotheses

• Suggests the presumed relationship between the independent and dependent variables

• Provides a rationale and definition for the variable(s) and concepts studied (see Chapters 1 and 2)

• Primary and secondary sources

• Provides the researcher with a road map for designing the study

• Includes primary sources, which are research articles, theoretical documents, or other documents used by the author(s) who is conducting the study, developing a theory, or writing an autobiography

• Includes secondary sources, which are published articles or books written by persons other than the individual who conducted the


research study or developed the theory. Table 3.1 provides definitions and examples of primary and secondary sources.

• Research question and hypothesis

• Helps the researcher identify completed studies about the research topic of interest, including gaps or inconsistencies that suggest potential research questions or hypotheses about a subject, theory, or problem

• Design and method

• Helps the researcher choose the appropriate design, sampling strategy, data collection methods, setting, measurement instruments, and data analysis method. Journal space guidelines limit researchers to include only abbreviated information about these areas

• Data analysis, discussion, conclusions, implications, recommendations

• Helps the researcher interpret, discuss, and explain the study results/findings

• Provides an opportunity for the researcher to return to the literature review and selects relevant studies to inform the discussion of the findings, conclusions, limitations, and recommendations. Example: ➤ Turner-Sack and colleagues’ (2016) discussion section noted several times how their findings were similar to previous studies (Appendix D)

• Useful when considering implications of research findings and making practice, education, and recommendations for practice, education, and research


FIG 3.1 Relationship of the review of the literature to the steps of the quantitative research process.

TABLE 3.1 Examples of Primary and Secondary Sources

Primary: Essential Secondary: Useful Publications written by the person(s) who conducted the study or developed the theory/conceptual model.

Publications written by a person(s) other than the person who conducted the study or developed the theory or model. It usually appears as a summary/critique of another author’s original work (research study, theory, or model); may appear in a study as the theoretical/conceptual framework, or paraphrased theory of the theorist.

Eyewitness accounts of historic events, autobiographies, oral histories, diaries, films, letters, artifacts, periodicals, and Internet communications on e-mail, Listservs, interviews, e-photographs, and audio/video recordings.

A biography or clinical article that cites original author’s work.

Can be published or unpublished. Can be published or unpublished. A published research study (e.g., research articles in ). An edited textbook (e.g., LoBiondo-Wood, G., & Haber, J. [2018]. Nursing research: Methods and critical appraisal for

evidence-based practice [9th ed.], Elsevier). Theory example: Dr. Jeffries in collaboration with the National League for Nursing developed and published a monograph entitled, The NLN Jeffries Simulation Theory (2015).

Theoretical framework example: Nyamathi and colleague’s 2015 study used “comprehensive health seeking and coping paradigm” theoretical framework by Nyamathi (1989), which Nyamathi adopted from Lazarus and Folkman’s (1984) “coping model” and Schlotfeldt’s (1981) “health seeking and coping paradigm” (see study presented in Appendix A).

HINT: Critical appraisal of primary sources is essential to a thorough and relevant literature review.

HINT: Use secondary sources sparingly; however, secondary sources, especially a study’s literature review that presents a critique of studies, are a valuable learning tool from an EBP perspective.

In contrast to the styles of quantitative studies, literature reviews of qualitative studies are usually handled differently (see Chapters 5 to 7). In qualitative studies, often little is known about the topic under study, and thus the literature review may appear more abbreviated than in a quantitative study. However, qualitative researchers use the literature review in the same manner as quantitative researchers to interpret and discuss the study findings, draw conclusions, identify limitations, and suggest recommendations for future study.

Conducting a literature review: The EBP perspective The purpose of the literature review, from an EBP perspective, focuses on the critical appraisal of research studies, systematic reviews, CP guidelines, and other relevant documents. The literature review informs the development and/or refinement of the clinical question that will guide an EBP or QI project. When a clinical problem is identified, nurses and other team members collaborate to identify a clinical question using the PICO format (Yensen, 2013; see Chapter 2).

Once your clinical question is formulated, you will need to conduct a search in electronic database(s) (you may seek the help of a librarian) to gather and critically appraise relevant studies, and synthesize the strengths and weaknesses of the studies to determine if this is the “best available” evidence to answer your clinical question. Objectives 1 to 3 and 7 to 10 in Box 3.1 specifically reflect the purposes of a literature review for these projects.

A clear and precise articulation of a clinical question is critical to finding the best evidence. Clinical questions may sound like research questions, but they are questions used to search the literature for evidence-based answers, not to test research questions or hypotheses (see Chapter 2). The PICO format is as follows:

P Problem/patient population—What is the specifically defined group?

I Intervention—What intervention or event will be used to address the problem or population?


C Comparison—How does the intervention compare to current standards of care or another intervention?

O Outcome—What is the effect of the proposed or comparison intervention?

One group of students was interested in whether regular exercise prevented osteoporosis for postmenopausal women who had osteopenia. The PICO format for the clinical question that guided their search was as follows:

P Postmenopausal women with osteopenia (Age is part of the definition for this population.)

I Regular exercise program (How often is regular? Weekly? Twice a week?)

C No regular exercise program (comparing outcomes of regular exercise [I] and no regular exercise [C])

O Prevention of osteoporosis (How and when was this measured?)

These students’ assignment to answer the PICO question requires the following:

• Search the literature using electronic databases (e.g., Cumulative Index to Nursing and Allied Health Literature [CINAHL via EBSCO], MEDLINE, and Cochrane Database of Systematic Reviews) for the information to identify the significance of osteopenia and osteoporosis as a women’s health problem.

• Identify systematic reviews, practice guidelines, and research studies that provide the “best available evidence” related to the effectiveness of regular exercise programs for prevention of osteoporosis.

• Critically appraise information gathered using standardized critical appraisal criteria and tools (see Chapters 7, 11, 18, 19, and 20).

• Synthesize the overall strengths and weaknesses of the evidence provided by the literature.

• Draw a conclusion about the strength, quality, and consistency of the evidence.

• Make recommendations about applicability of evidence to CP to guide development of a health promotion project about osteoporosis risk reduction for postmenopausal women with osteopenia.

As a practicing nurse, you may be asked to work with colleagues to develop or create an EBP/QI project and/or to update current EBP protocols, CP standards/guidelines, or policies in your health care organization using the best available evidence. This will require that you know how to retrieve and critically appraise individual research articles, practice guidelines, and systematic reviews to determine each study’s overall quality and then to determine if there is sufficient support (evidence) to change a current practice and/or policy or guideline.

H E L P F U L H I N T Hunting for a quantitative study’s literature review? Don’t expect to find it labeled as Literature Review—many are not. Assume that the beginning paragraphs of the article comprise the literature review; the length and style will vary.

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