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Fostering Best Practice: Strategies for Writing Evidence-Based Practice Briefs

Section Editor(s): Gephart, Sheila M. PhD, RN

doi: 10.1097/ANC.0000000000000222
Guest Editorial
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College of Nursing, The University of Arizona, Tucson.

Correspondence: Sheila M. Gephart, PhD, RN, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721 (gepharts@email.arizona.edu).

Dr Gephart received training support from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program and the Agency for Healthcare Research and Quality (1K08HS022908-01A1). The content is solely the responsibility of the author and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Robert Wood Johnson Foundation.

The author declares no conflicts of interest.

Have you ever started a project reluctantly but did so by diving right in, intent to “figure it out” but without reading the directions? I certainly did last weekend when helping my 8-year-old daughter build a craft from Home Depot. In a rush, we left the store before she was finished. At home the responsibility to read the instructions was left to me, so together we could achieve the motto, “let's build something together.” First, we laid out the pieces and took a careful look at what the finished product was to look like. Next, we arranged the parts so that they lined up exactly with what the instruction pictures showed. Pretty soon, we had made a few comical errors but finished the project. A competing priority to the project on this holiday weekend was the knowledge that I needed to write a similar “how to” set of instructions to tell new writers the steps in constructing an evidence-based practice (EBP) brief. In this editorial, I will provide instructions to make the task of writing a brief manageable for even the newest of authors. From asking a compelling clinical question to telling the story of a critical appraisal of evidence to making recommendations, the overall goal of writing such a brief is to support best practice care in the neonatal intensive care unit.

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DEVELOPMENTAL HISTORY OF EBP BRIEFS

Over the last 5 years, authors have been writing briefs for Advances in Neonatal Care (ANC). Initially, editorial board members were solicited to author the manuscripts and peer review was completed by the section editor. In the early days, abstracts were not included and the structure of the brief was not specified. Still, authors were addressing clinically relevant topics including nonpharmacologic pain management,1 incubator humidity,2 the use of ultrasound to guide peripherally inserted central catheter (PICC) placement,3 and managing desaturations in preterm infants.4 Best practice for splinting intravenous cannulas5 and approaches to reduce gastroesophageal reflux were also explored.6 Progressively, author guidelines specifically for the brief have become more structured, and now we are moving to the manuscripts being reviewed through the routine peer-review process used by the journal. As such, authors have the opportunity to respond to reviewer's comments to strengthen and refine the manuscripts when resubmitting. Although papers have at times been longer, the intent is to still keep the briefs just that—brief. In a structured, consumable format, bedside clinicians will be able to quickly read through and comprehend the state of the evidence for the routine practices they deliver right at the bedside.

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EBP BRIEF TOPICS

Selecting a topic for the brief can arise from several sources. One approach is to look at what the practice trends are and another is to select a policy or procedure that is up for review in your particular clinical setting and focus the brief around 1 or the other. Another consideration is what briefs have explored recently (ie, <3-5 years). Table 1 includes topics covered recently and the associated clinical questions used to guide the searches. In my case, I selected topics on the basis of issues that bothered me so I could channel that negative energy to look into the caregiving area of concern deeply and critically. Beginning with best practice approaches to structure shift handoffs,7 to exploring the evidence about the use of colostrum as oral immune therapy,8 the questions I asked reflected my broader interests as a nurse scientist. Other authors have written about which tool to measure neonatal abstinence symptoms was best,9 or how to standardize practice when the best practice was not clear (eg, What is the best practice for securing the umbilical line?”).10 No matter the topic, at the core of any excellent EBP brief is a focused clinical question.

TABLE 1-a

TABLE 1-a

TABLE 1-b

TABLE 1-b

TABLE 1-c

TABLE 1-c

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PURPOSE STATEMENTS

What many authors may not realize is that there is a bit of formulaic work to writing a scientific manuscript—there is a recipe to it. One example of this is to clearly define your purpose of the manuscript and place it strategically as the last sentence of the introduction. Another important strategy for making sure that your work is found is to include key words that mimic the key words you used for your search strategy. Including the maximum amount of key words allowed will increase the possibility your article will be found by those interested. For example, key words for this editorial could include “evidence-based practice, neonate, nursing, critical appraisal, and neonatal intensive care unit.” Furthermore, while catchy, interesting titles engage one's interest—a scientific audience is also likely looking for a title that is descriptive and declarative, minimizing the use of question marks. That said, we have published titles with question marks and catchy titles, and 1 of their benefits is that they are easy to remember.

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FOCUSING THE CLINICAL QUESTION

Clinical questions explore topics that can be directly translated today to impact patient care, education, or best practice in the clinical environment. Four components of a great clinical question include specifying the 4 PICO components (1) the population (P); (2) the intervention or practice (I); (3) the comparison group (C); and (4) the outcome of interest (O).27 Successful focusing of the clinical question depends in part on how clearly you can define the outcome.

Historically, the focused briefs (and indeed the shorter ones) had very tightly defined outcomes and interventions. This is not to say 1 approach trumps another—it just speaks to the breadth of ways to ask clinical questions and structure briefs. Once you have defined the clinical question, each PICO component can be entered as search criteria when you conduct your literature search. According to the author guidelines, the clinical question is posed in both the abstract and within the body of the manuscript.

Over the history of the EBP briefs, the questions asked vacillated between broad questions exploring the state of the evidence in an area to focused questions like “do infants fed during blood transfusion get necrotizing enterocolitis more often than those who are not fed during transfusion?”13 Although topics covered in EBP briefs have been broad over the last 5 years, topics we are particularly interested in for the future include management strategies for critically ill infants who are not very low birth-weight, glucose management options, and issues of particular concern to the registered nurse at the bedside.

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SEARCH STRATEGY

Approaches to searching the literature are vast and well discussed elsewhere,28 yet there are a few key points to address when writing your brief. First, define your databases searched. A best practice is to search at least 2 databases, and most authors begin with PubMed and the Cochrane library. When looking at nursing or psychosocial interventions, CINAHL and Psych Info are very helpful and include nursing and psychological literature. Although broad Internet searches can occasionally identify good sources, it is important to focus them to look for guidelines or position statements from professional organizations (see Table 2 for EBP sources). Once you identify your databases, conduct your reviews using structured key terms. Keeping track of your search terms used, your inclusion criteria, exclusion criteria, and counts of articles retrieved will strengthen the methodology section of your brief. Although not required, if you choose to conduct a systematic review, following standards to report the systematic review will strengthen your brief and chances for a smooth review process (see www.prisma.org for more details about this type of review). More often EBP briefs are categorized as narrative or integrative reviews.

TABLE 2

TABLE 2

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CRITICAL APPRAISAL

Next steps include assessing how the studies you identified fall according to levels of evidence. Although many stratification schemes for levels of evidence exist, ones that incorporate the types of studies at high interest for nurses (ie, should categorize qualitative and descriptive studies) and/or adhere to disciplinary standards (eg, a scheme that is commonly used in the Neonatal Cochrane Reviews or the AHRQ sponsored Clinical Practice Guidelines) is efficient. In general, when discussing the levels of evidence, meta-analyses and systematic reviews are considered to be the highest quality, whereas expert opinion is considered the lowest. Other considerations include whether randomization was used, if the study was single or multisite, and how many participants were included. In neonatal care, it is also generally important to consider if they looked at groups by gestational age or birth weight. Finally, I always look to see where the studies were conducted, how they were funded, and where they were published. This information helps you to consider whether there are any biases in the results. Sample characteristics should always be reported to allow the critical appraiser to determine if the participants in the study had characteristics similar to the infants or units with which you want to compare and/or apply the results.

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WRITING RESULTS

Although there are different approaches to summarizing studies, 1 very nice one is to construct a table for the studies. The studies are listed as rows, and the columns are the different key aspects of the study. Common column titles include authors/year/country, study design/subjects, results, and implications. Good examples of evidence tables are available from past EBP briefs including by Hartley et al,26 Newnam,9 Allen,21,23 and Garcia and Gephart.19 Including outcome statistics in your tables will help you and your readers to understand how much of an impact the intervention of interest had or to see what the strength of the intervention effect was. When using abbreviations in this table, include a legend at the bottom that provides a key for spelling out any abbreviations you might use. Although you might construct your table with lots of detail, you may want to include a less detailed table in your final manuscript. Space is always an issue and remember you want your reader to look at the table and quickly understand it rather than be overwhelmed by a table that goes on for pages.

Now that you have the studies in a form where you can look across the studies for similarities and differences, this is a good time to identify where and how results were consistent across studies and where they were different. When different, you can hypothesize about why they were different. Consider the breadth of the study locations (eg, 2 were multisite; 3 were individual sites), rigor of research designs (eg, blinded randomized controlled trial vs descriptive study without a comparison group), and sample diversity. When writing the “Results” section of your brief, the reviewers are looking for synthesis of what the findings were versus a rehashing of individual studies or listing them 1 by 1. Describing results is a main section for the EBP brief. Ideally, if you present the results in sufficient detail, the reader can check your recommendations and determine whether they agree or disagree with them.

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MAKING RECOMMENDATIONS

There are 2 sets of recommendations we want in an EBP brief (1) for practice and (2) for research. We have even asked you to summarize this at the end of your article with a list of recommendations using the headings (1) What we know, (2) What needs to be studied, and (3) What we can do today. Recommendations for practice may be presented as a sample protocol like those published for feeding protocols,16 colostrum for oral care,8 or facilitated tucking.26 Reading the discussion sections for the studies you reviewed can help you to write recommendations for research. Examples of recommendations for research can include the use of more rigorous study designs, more diverse samples, or tailoring the intervention to fit local contexts. Available position statements from professional organizations like the National Association of Neonatal Nurses, American Academy of Pediatrics, or other reputable sources can support your ideas when writing this section as well.

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INCLUDING TABLES AND FIGURES

Tables and figures in your article should add detail where it is needed but also serve to engage your reader. Some busy readers will read the abstract, the last sentence of your introduction (to determine the article's purpose), and then focus their attention on the tables and figures. Although your paper should read well from start to finish and present a coherent train of thought and logical reasoning, it is a good approach to write also for the reader who does not read sequentially. Focusing on writing very clear purpose statements; adding a topic and concluding sentence for each paragraph; and refining your tables, figures, abstract, and conclusion will engage the reader who tends to jump from section to section to read for their interests or needs. Finally, if the brief is about a clinical practice that you can depict in a picture, including a picture will add interest to your paper.

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PREPARING TO SUBMIT

Preparing to submit your brief includes proofreading, assembling individual document files, and uploading the documents into the file submission system Editorial Manager. A checklist is provided in Table 3. An important first step is to ask a naive reader to review the brief to give you constructive feedback. Incorporate their revisions and read the revised brief out loud to yourself. This is a good way to catch typographical errors, issues with grammar, and mixed verb tenses. If you have any very long sentences (eg, >3 lines long), break into shorter sentences. Mixing more complex sentences structures with short ones is a good way to keep your reader's interest. Compose a cover letter telling the editorial office that the paper has not under consideration with another journal, and it is your original work. Gather copyright transfer forms from all of your coauthors. Finally, assemble your documents with each table, figure, cover letter, copyright transfer, and manuscript file ready to upload separately.

TABLE 3

TABLE 3

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RESPONDING TO REVIEW FOR RESUBMISSION

Once your article is received, reviewers are invited to read it and offer their opinion about its readiness for publication and to propose recommendations to improve the manuscript. It is common to have 3 to 5 reviews to respond to and ultimately the process is meant to refine the final product before publication. Tips for responding to reviewers comments are described elsewhere for this journal.29 Reviewers may disagree or offer suggestions that the authors disagree with at times. If this is the case, it will show your responsiveness if you can offer justification for why a change was not made that a reviewer recommended. Structuring response to reviewers in a table with 1 column for the reviewers comment and the second column for your response is a strong approach for showing your careful consideration as you refined the paper. Timelines for responding to critique are typically short. However, if this is a hardship, sending an e-mail to the editorial office is a good approach. Finally, it is extremely rare to have an article accepted without any revisions recommended. Similarly, the editors can choose to delay the acceptance of the paper until they can identify the authors' responsiveness to review. Although responding to review can be a new experience for developing authors, it serves to prepare the best possible article for readers and is well worth the work.

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CONCLUSION

Applying evidence in everyday nursing practice is fundamental to professionalism, but it takes time and energy. Just like I needed a set of instructions to build the project with my daughter, I am hopeful that this set of directions will help you invest your time, talent, and energy to publish an EBP brief. When you publish your work you cease the opportunity to impact practice beyond what you provide on your own. By doing the hard work of writing and committing to the process of revising and refining, you also commit to improving neonatal practice for other nurses. It is our desire in the editorial office that you accept the challenge so that we can build better neonatal practice together!

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EDITORS' NOTE

A Word of Thanks and Gratitude

As we are nearing the end of our second year as coeditors we are celebrating the continued success of the journal. Part of that success was our very first Impact Factor announced in July. Advances in Neonatal Care's Impact Factor of 1.12 reflects the high quality of our manuscripts and places it 40 out of 108 nursing journals. A journal's Impact Factor comes primarily from the citation of the work (manuscripts) by other authors. In evaluation of the cited articles that contributed to our Impact Factor, EBP briefs played a significant role. In addition, the most cited ANC article during the years reviewed for establishing the impact factor was “Necrotizing Enterocolitis Risk State of the Science” by Dr Gephart and colleagues.30 Join us in congratulating Dr Gephart and all our journal authors!

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References

1. Hardy W. Facilitating pain management. Adv Neonatal Care. 2011;11(4):279–281.
2. Fidler HL. Incubator humidity: more than just something to sweat about!! Adv Neonatal Care. 2011;11(3):197–199.
3. Fidler HL. The use of bedside ultrasonography for PICC placement and insertion. Adv Neonatal Care. 2011;11(1):52–53.
4. Fidler HL. What do we aim for? Oxygen saturation targets in extremely preterm infants. Adv Neonatal Care. 2011;11(6):404–405.
5. Fidler HL. To splint or not to splint: securing the peripheral intravenous cannula. Adv Neonatal Care. 2010;10(4):204–205.
6. Hardy W. Reducing gastroesophageal reflux in preterm infants. Adv Neonatal Care. 2010;10(3):157.
7. Gephart SM. The art of effective handoffs: what is the evidence? Adv Neonatal Care. 2012;12(1):37–39.
8. Gephart SM, Weller M. Colostrum as oral immune therapy to promote neonatal health. Adv Neonatal Care. 2014;14(1):44–51.
9. Newnam KM. The right tool at the right time: examining the evidence surrounding measurement of neonatal abstinence syndrome. Adv Neonatal Care. 2014;14(3):181–186.
10. Elser HE. Options for securing umbilical catheters. Adv Neonatal Care. 2013;13(6):426–429.
11. Allen KA. Premedication for neonatal intubation: which medications are recommended and why. Adv Neonatal Care. 2012;12(2):107–111.
12. Elser HE. Positioning after feedings: what is the evidence to reduce feeding intolerances? Adv Neonatal Care. 2012;12(3):172–175.
    13. Gephart SM. Transfusion-associated necrotizing enterocolitis: evidence and uncertainty. Adv Neonatal Care. 2012;12(4):232–236.
    14. Allen KA. Promoting and protecting infant sleep. Adv Neonatal Care. 2012;12(5):288–291.
    15. Elser HE. Is lasix after a blood transfusion necessary? Adv Neonatal Care. 2012;12(6):369–370.
      16. Gephart SM, Hanson CK. Preventing necrotizing enterocolitis with standardized feeding protocols: not only possible, but imperative. Adv Neonatal Care. 2013;13(1):48–54.
      17. Allen KA. Treatment of intraventricular hemorrhages in premature infants: where is the evidence? Adv Neonatal Care. 2013;13(2):127–130.
        18. Elser HE. Bathing basics: how clean should neonates be? Adv Neonatal Care. 2013;13(3):188–189.
          19. Garcia C, Gephart SM. The effectiveness of early intervention programs for NICU graduates. Adv Neonatal Care. 2013;13(4):272–278.
          20. Allen KA. Music therapy in the NICU: is there evidence to support integration for procedural support? Adv Neonatal Care. 2013;13(5):349–352.
            21. Allen KA. Moderate hypothermia: is selective head cooling or whole body cooling better? Adv Neonatal Care. 2014;14(2):113–118.
            22. Wagner J, Hanson C, Anderson-Berry A. Considerations in meeting protein needs of the human milk-fed preterm infant. Adv Neonatal Care. 2014;14(4):281–289.
            23. Allen KA. The neonatal nurse's role in preventing abusive head trauma. Adv Neonatal Care. 2014;14(5):336–342.
            24. Briere CE. Breastfed or bottle-fed: who goes home sooner? Adv Neonatal Care. 2015;15(1):65–69.
              25. Lucas RF, Smith RL. When is it safe to initiate breastfeeding for preterm infants? Adv Neonatal Care. 2015;15(2):134–141.
                26. Hartley KA, Miller CS, Gephart SM. Facilitated tucking to reduce pain in neonates: evidence for best practice. Adv Neonatal Care. 2015;15(3):201–208.
                27. Melnyk BM, Fineout-Overholt E. Key steps in implementing evidence-based practice: asking compelling, searchable questions and searching for the best evidence. Pediatr Nurs. 2002;28(3):262–263, 266.
                28. McGrath JM, Brandon D. Searching the literature is not for the faint of heart! Adv Neonatal Care. 2014;14:229–231.
                29. Brandon D, McGrath JM. Provision of and response to manuscript reviews. Adv Neonatal Care. 2014;14:137–138.
                30. Gephart SM, McGrath JM. Effken JA, Halpern MD. Necrotizing enterocolitis risk: state of the science. Adv Neonatal Care. 2012;12(2):77–87.
                © 2015 by The National Association of Neonatal Nurses