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December 2014, Supplement to Volume 18, Number 6
Putting Evidence Into Practice: The Process for Evidence-Based Research
Lee Ann Johnson, MSN, RN
The Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP®) resources provide easily accessible evidence-based resources on 20 cancer-related topics. Using a team-based approach, the ONS PEP teams search for relevant literature, create comprehensive summaries of empirically tested intervention research, and rank each intervention according to its effectiveness. PEP resources are available to nurses and other clinicians caring for people with cancer and their caregivers online and through multiple print sources. The purpose of this article is to explain the PEP process.
Nursing societies can maximize the impact of evidence-based practice (EBP) on clinical patient outcomes by publishing resources and guidelines for nurses and other healthcare providers (Mallory, 2010). The Oncology Nursing Society (ONS) is committed to improving nurse-sensitive patient outcomes (NSPOs) by providing resources such as the evidence-based Putting Evidence Into Practice (PEP®) resources. NSPOs are the result of nursing actions, must fall within the scope of nursing practice, and are an integral part of nurse-managed care (Given & Sherwood, 2005). However, PEP extends beyond the scope of nursing to include additional knowledge pertinent to oncology nursing care, such as yoga, decongestive therapy, and surgical techniques. The primary goal of PEP is to identify and disseminate the best available scientific evidence to help nurses improve NSPOs. Although the primary audience for PEP is nurses, the intervention recommendations can be beneficial for and implemented by healthcare professionals from other disciplines who care for patients with cancer.
Each PEP resource provides comprehensive evidence summaries and a synthesis of available published literature that is organized and classified according to the effectiveness of individual interventions in specific patient outcomes. The PEP topics are anorexia, anxiety, caregiver strain and burden, chemotherapy-induced nausea and vomiting, cognitive impairment, constipation, depression, diarrhea, dyspnea, fatigue, hot flashes, lymphedema, mucositis, pain, peripheral neuropathy, prevention of bleeding, prevention of infection, radiodermatitis, skin reactions, and sleep-wake disturbances.
PEP resources are available to clinicians in a variety of formats, including online resources, books, monographs, a pocket guide, and peer-reviewed articles. The purpose of this article is to explain the PEP process, including the selection and training of topic teams, the search process, the summarization of evidence, and the review and classification of evidence.
The PEP program is a multifaceted project that involves the coordination of ONS staff as well as volunteer team contributors. Several checkpoints exist during the PEP process to ensure quality and consistency of the final products. The PEP process follows the EBP model of identifying a problem, searching for evidence, critiquing the literature, synthesizing the research, and summarizing the strength of evidence (Eaton & Tipton, 2009) (see Figure 1).
PEP topic teams are comprised of volunteer nurse researchers, advanced practice nurses, and staff nurses who have demonstrated experience and interest in a PEP topic. Topic leaders are nurse scientists or advanced practice nurses with demonstrated expertise in the topic through research and/or publications. All volunteers complete the standardized ONS conflict of interest and confidentiality forms. PEP teams are comprised of members from across the United States as well as Canada, Spain, South Korea, Israel, Pakistan, Saudi Arabia, and United Arab Emirates.
The Search Process
PEP topic leaders determine topic-specific inclusion and exclusion criteria and search terms in consultation with the ONS library staff. The ONS medical librarian uses medical subject heading (MeSH) search terms to conduct monthly automated literature searches. MeSH terms are a controlled and comprehensive list of vocabulary terms used to index published articles and books in scientific fields. Detailed search results, specific inclusion and exclusion criteria, and search terms can be found in topic articles.
ONS research staff review abstracts against inclusion and exclusion criteria and obtain articles that meet the criteria. Standard databases and sources used include PubMed, CINAHL®, the Cochrane Collaboration, and the National Comprehensive Cancer Network guidelines. Standard inclusion criteria are (a) studies, guidelines, systematic reviews, and meta-analyses involving the use of any intervention in patients with cancer for the outcome or PEP topic of interest; (b) a study sample that includes either adult or pediatric patients with cancer; and (c) measurement and results for the outcome of interest. Exclusion criteria are (a) grey literature or literature that has not formally been published, (b) case studies or case series only, (c) studies not involving patients with cancer, and (d) descriptive studies that do not examine effects of an intervention on the patient outcome of interest. Additional topic-specific inclusion and exclusion criteria are established and identified by the PEP teams.
Summarizing the Studies
Studies that meet inclusion criteria are summarized by pairs of contributors on a standardized form. The structured form includes information about the purpose of the study, a brief description of the intervention, sample size and characteristics, design, measurement instruments, conclusions, limitations that show risk of bias and threats to validity in design, and implications for nursing practice. Two contributors review each summary to ensure quality. Complete summaries for each study are available to the nurses and general public via the ONS website (www.ons.org/practice-resources/pep).
Classification of Evidence
Web conferences are held with the project team members to categorize the evidence based on summaries completed. Classification considers all previous as well as new evidence for each intervention. Conferences are facilitated by ONS research staff and classification of individual interventions is determined by team consensus.
Teams categorize interventions based on the ONS PEP weight-of-evidence classification schema (Mitchell & Friese, n.d.) (see Figure 2). The schema is intended to be used with existing research-based knowledge on health interventions and is based on previous research (Ciliska, Cullum, & Marks, 2001; Hadorn, Baker, Hodges, & Hicks, 1996; Ropka & Spencer-Cisek, 2001; Rutledge, DePalma, & Cunningham, 2004). PEP teams consider the entire body of evidence rather than a single study for classification, and more weight is given to studies that rank higher in ONS’s priority symptom management project categorization. The highest level of evidence, level I, includes quantitative and qualitative systematic reviews; appropriately sized randomized, controlled trials; and well-designed trials with no randomization (Ropka & Spencer-Cisek, 2001). Team members also consider the magnitude of the outcome and the concurrence of the evidence for an intervention prior to assigning a classification. Interventions are classified by team consensus after application of the schema.
The ONS intervention classifications are color coded (green, yellow, and red) to help nurses quickly determine the level of evidence for each intervention. Green color-coded interventions are the highest level of evidence and are labeled recommended for practice or likely to be effective. Yellow color-coded interventions do not have sufficient evidence to support use in the clinical setting and are labeled benefits balanced with harms or effectiveness not established. Red color-coded interventions do not have evidence to support use and are labeled effectiveness unlikely or have been found to be harmful or ineffective and are labeled not recommended for practice. Intervention classifications are updated twice per year.
Nursing societies are uniquely positioned to promote EBP in a variety of ways, including the summary and synthesis of research (Mallory, 2010). Through the rigorous and transparent process outlined in the current article, ONS and PEP generate a sizeable knowledge base to help guide EBP in an oncology setting. PEP is easily accessible to organizations and to individual oncology nurses and can be used to improve the quality of cancer care. This detailed description of the PEP process provides nurses with assurance of the rigor used to develop the resources.
Implications for Practice
Ø Become involved in the Putting Evidence Into Practice (PEP®) process to play a role in the identification and classification of evidence-based interventions.
Ø Use online and print PEP materials to become better aware of scientific advances in cancer care.
Ø Choose PEP resources to select beneficial interventions that are appropriate for and acceptable to patients.
Ciliska, D., Cullum, N., & Marks, N. (2001). Evaluation of systematic reviews of treatment or prevention interventions. Evidence-Based Nursing, 4, 100–104.
Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Putting Evidence Into Practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
Given, B.A., & Sherwood, P.R. (2005). Nursing-sensitive patient outcomes—A white paper. Oncology Nursing Forum, 32, 773–784.
Hadorn, D.C., Baker, D., Hodges, J.S., & Hicks, N. (1996). Rating the quality of evidence for clinical practice guidelines. Journal of Clinical Epidemiology, 49, 749–754.
Mallory, G. (2010). Professional nursing societies and evidence-based practice: Strategies to cross the quality chasm. Nursing Outlook, 58, 279–286. http://dx.doi.org/10.1016/j.outlook.2010.06.005
Mitchell, S.A., & Friese, C.R. (n.d.). ONS PEP (Putting Evidence Into Practice) weight of evidence classification schema. Retrieved from http://bit.ly/1ucnHHm
Ropka, M.E., & Spencer-Cisek, P. (2001). PRISM: Priority Symptom Management Project phase I—Assessment. Oncology Nursing Forum, 28, 1585–1594.
Rutledge, D., DePalma, J., & Cunningham, M. (2004). A process model for evidence-based literature syntheses. Oncology Nursing Forum, 31, 543–550. http://dx.doi.org/10.1188/04.ONF.543-550
Lee Ann Johnson, MSN, RN, is a research associate at the Oncology Nursing Society in Pittsburgh, PA. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the author, planners, independent peer reviewers, or editorial staff. Johnson can be reached at email@example.com, with copy to editor at CJONEditor@ons.org. (Submitted May 2014. Revision submitted July 2014. Accepted for publication July 11, 2014.)
Key words: methodology; cancer nursing; evidence-based nursing