Systematic and integrative reviews; synthesising evidence for clinical nursing practice Professor Catriona Kennedy Galway April 2013

Aims What are systematic/integrative reviews? Why do we need them? How do we do them? What do they contribute to the evidence base of practice?

Research synthesis…… Health care practice demands decision making based on robust evidence. The knowledge base which underpins nursing practice is drawn from an amalgam of art and science. Research synthesis in the format of the systematic review is currently regarded as the ‘gold standard’. Emergence of methods to test theory and hypothesis so moving beyond synthesis of existing findings

What is it? The systematic review is now widely regarded as the least biased and most rationale way to summarise the research evidence that evaluates health care interventions meant to prevent and treat illness Cochrane collaboration 20 years old in 2013

The integrative review..... Includes diverse forms of evidence to facilitate the synthesis of experimental and non experimental research to provide breadth of perspectives

Some issues Cochrane reviews (the ‘Gold standard’) focussed on RCTs criticised as not addressing many of the key issues in nursing practice Preponderance of small unrelated qualitative studies providing limited evidence for practice Emerging rigorous standards for conduct and reporting of reviews e.g. PRISMA (Quantitative) RAMESES (Qualitative)

What’s in a name and what type of review do you need to do? Systematic review Meta analysis Meta narrative Integrative review Narrative reviews……..

What do these two types of review have in common? Formulation of a review/research question Development of a robust search strategy to include key words, databases, search limits and results Data evaluation and analysis – exclusion and inclusion criteria Presentation/synthesis of results

Systematic reviews involve rigorous efforts to ensuring validity Researcher makes decisions and choices along the way – possibility of error Explicit inclusion/exclusion criteria Selection and analysis of data by two people Presentation of results in tables Reasons for exclusion documented Assessment of strength of evidence

Some examples and discussion

Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults Aim; To investigate the correct positioning (or mobilisation) and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC. Types of studies; randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning or mobilisation and bracing. Types of interventions; spinal bracing and guidance for patients on positioning (or mobilisation), for example lying flat, sitting up, standing or mobilised, or both, versus patients who receive no therapy or no positioning guidance, or neither. Types of outcome measures Primary outcomes Radiologically confirmed effects of bracing on vertebral collapse.Patient reported measures of pain relief, quality of life and satisfaction. Reported adverse events. Primary outcome measures should be measured using valid and reliable assessment tools (visual analogue scores (VAS) and quality of life (QoL) scales e.g. European Organisation for Research and Treatment of Cancer (EORTC)).

Findings Cochrane Review No RCTs met the inclusion criteria There is lack of evidence based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area. NICE (2008) guidelines make recommendations based on no/limited evidence

Integrative literature review, Nursing in the community……….. What is the context of nursing in the community? What do nurses in the community do? Are there core values that are evident? What is needed to meet Delivering Health in terms of improving effectiveness and outcomes? Is there enough evidence to indicate what developments are required? If not, what evidence is needed? SEHD, 2006d Nursing in the Community: a literature review. (KENNEDY et al.). Edinburgh: The Scottish Executive Health Department. ( /NHSScotland/nursing/communitynursing/r eviewprocedure/review) /NHSScotland/nursing/communitynursing/r eviewprocedure/review KENNEDY C, CHRISTIE J, HARBISON J, MAXTON F, RUTHERFORD I & MOSS D. (2008) Establishing the contribution of nursing in the community to the health of the people of Scotland: integrative literature review. Journal of Advanced Nursing doi: /j x

Findings from an integrative review Synthesis of findings from 73 papers under 5 policy areas Identification of core values and some limited evidence around early interventions and anticipatory care Overall limited evidence base for CHN practice

Conclusions Continuous growth in research knowledge and demands for evidence based practice will require HCPs and academics to understand, undertake and use the evidence which arises from systematic literature reviews rather than individual studies. Post graduate students are increasingly expected to conduct a systematic/integrative review as part of their dissertation/thesis Using systematic, transparent approaches to research synthesis can highlight gaps in the evidence base and strengthen decision making where evidence does exist. The Cochrane review provides rigorous evidence but may not answer all questions of relevance to nursing The integrative / meta narrative techniques currently being used and developed offer potential for theory development and testing.

Resources…… WONG G., GREENHALGH T., WESTHORP G., BUCKINGHAM J. & PAWSON R. ( ) RAMESES publication standards: meta-narrative reviews. Journal of Advanced Nursing 69(5), 987–1004. doi: WONG G., GREENHALGH T., WESTHORP G., BUCKINGHAM J. & PAWSON R. ( ) RAMESES publication standards: realist syntheses. Journal of Advanced Nursing 69(5), 1005–1022. doi: /jan Lee SH, Cox KM, Grant R, Kennedy C, Kilbride L. Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD DOI: / CD pub2. Cochrane library and resources at