systematic reviews in nursing

PERGAMON International Journal of Nursing Studies 35 (1998) 13-22

NURSING STUDIES

Systematic reviews in nursing Jacqueline Droogan”T* , Nicky Cullumb

j’ Research F&w. NHS Centrefor Rerie+vs and Dissemination, University qf York

h Retrder irz Health Studies und Director of the Centrefor Evidence-Based Nursing, Department qf Health Studies. Uniwrsity qf York

Keword.~: Systematic reviews; Cochrane collaboration; Nursing interviews

1. Introduction

The problem of how to keep abreast of literature, both old and new, confronts all health professionals, including nurses. There are over 400 nursing journals listed in Ulrich’s Periodicals Directory and most of these publish at least some research. It is clear that most nurses engaged in clinical practice get little or no time for reading during their working day, and nurses often feel a lack of con- fidence in their ability to critically appraise research (Pearcey, 1995). Because the volume ofinformation available to health care professionals is so large, it is likely that most rely on reviews to deliver synopses of current knowledge in accessible and manageable formats. Reviews might take the form of textbooks, or articles published in journals, and they vary enormously in quality and reliability.

It is self-evident that if we are to learn from information collated and appraised by others, then we need to be confident that their methods are rigorous and their conclusions valid. All of us, from students who use textbooks to learn the basics, to those who want to develop detailed knowledge of a specific aspect of nursing, assume that the authors of reviews, particularly if they are ‘experts’, are giving us the best available information. But is this a reasonable assumption? Important work undertaken in the 1980s demonstrated that the quality of information presented in reviews published in some of the most respected U.S. medical journals left a lot to be desired.

*Corresponding author

Mulrow (1987) identified 50 reviews published between June 1985 and June 1986 in four major medical journals (Annals of’ Internal Medicine, Archives of Internal Medi- cine, Journal of the American Medical Associution and The New England Journal qf Medicine) and used eight explicit quality criteria to assess the reviews. The eight criteria were:

1. 2.

3.

4.

5.

6.

I. 8.

Was the specific purpose of the review stated? Were sources and methods of the citation search identified? Were explicit guidelines provided that determined the material included in and excluded from the review? Was a methodologic validity assessment of material in the review performed? Was the information systematically integrated with explication of data limitations and inconsistencies’? Was the information integrated and weighted or pooled metrically? Was a summary of pertinent findings provided? Were specific directives for new research initiatives proposed?

Mulrow found no review met all eight of the quality criteria; one met six criteria; 32 met four or five and 17 met three. Only one review published a clear description of the literature search, and one the criteria by which reports were selected for review. The analogy in primary research would be publishing work without describing the methods used-it seems unimaginable. Mulrow con- cluded that ‘current medical reviews do not routinely use (such) scientific methods to identify, assess and synthesise information’. This is extremely worrying if reviews are relied upon to the extent that we believe.

0020@7489:98 $19.00 (’ 1998 Elsevier Science Ltd. All rights reserved PII: SOO2Om 7489(98)00007F8

14 J. Droogun, N. Cullutni’Int. J. Nurs. Stud. 35 (1998) 13-22

Reviews are pieces of research themselves which use primary research as their data; in other words they are research on research. As such they must be as rigorous as any piece of primary research. Reviews that uphold Mulrow’s criteria are differentiated from the mass by being termed ‘systematic reviews’; in short they

l Answer a well-defined question. l Use scientific methods which aim to avoid the intro-

duction of bias to the review. l Use a systematic approach to appraise the quality of

each piece of research they review.

A systematic review is therefore a major undertaking which needs to be adequately budgeted for just like primary research, but does this attention to detail really make any difference to the conclusions one draws? Some of the best evidence that it does comes from medicine, where Elliott Antman and colleagues (1992) compared the recommendations of ‘experts’ (writing in textbooks and reviews) regarding treatments for myocardial infarc- tion, with the evidence from the randomised controlled trials which existed at the time the reviews were written. They found that thrombolytic drugs for example were not recommended by more than half the ‘experts’ until 13 years after trials had shown them to reduce mortality! The message from this work (which we would urge read- ers to explore for themselves) is that it is dangerous to base one’s practice on unsystematic reviews.

Systematic reviews reduce large quantities of research into key findings in a reliable way and offer a means of enabling health care professionals to keep abreast of research; as such they are an essential step in the identification of evidence-based health care. The systematic approach to reviewing research evidence can be applied to reviews of any type of research, however this paper explores the extent to which there are systematic reviews available which evaluate the effectiveness of nursing prac- tices.

The NHS Research and Development Programme currently places great emphasis on the production of systematic reviews of the effects of health care through its funding of the U.K. Cochrane Centre in Oxford, and the NHS Centre for Reviews and Dissemination at York, U.K.

In 1979, Archie Cochrane wrote: “It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials” (Cochrane, 1979). He made particular reference to the randomised controlled trial (RCT) because he was particularly concerned with the evidence for the effectiveness of interventions, and the RCT, when rigorously conduc- ted, is likely to provide the least-biased evidence of effectiveness. Since then a number of groups have compiled registers of trials of specific treatments or for particular

health problems. Most notably, obstetricians and midwives compiled the Oxford Database of Perinatal Trials and produced systematic reviews of RCTs pertaining to the care of women during pregnancy and childbirth (Chalmbers et al., 1989). This group then became the inaugural review group of the Cochrane Collaboration- an international collaboration of people committed to preparing, maintaining and disseminating systematic reviews of the effects of health care. People from a variety of backgrounds (health care professionals, statisticians, users of health services) with an interest in a particular topic have come together to form review groups, covering areas such as stroke, pregrzancy und childbirth, tropicul di,ireases, peripherul casculur disease and wounds. Each group is co-ordinated by a small editorial team and the group seeks funding to support its activities, the fruits of which are systematic reviews published in the Cochrnne Library. The Cochrane Lihrq~ is available on CD-rom and floppy disk and includes the Cochrane Database of Systematic Reviews as well as the Cochrane Controlled Trials Register (a register of the RCTs identified through exhaustive searching by those involved with the Col- laboration), the Cochrane Review Methodology Dat- abase (a bibliography of articles about how to do systematic reviews), and the Database of Abstracts of Reviews of Effectiveness, or DARE.

DARE contains review articles that have been identified as being of a good quality by the reviews team at the NHS Centre for Reviews and Dissemination (CRD), at the University of York in the U.K. Weekly and mon- thly searches of a number of electronic databases such as Current Contents, MEDLINE, CINAHL and AMED are undertaken by members of the Information Service Staff of CRD using a comprehensive search strategy which has been developed in collaboration with the U.K. Cochrane Centre. References and abstracts identified by this search strategy are then sifted by members of the CRD reviews team to identify published systematic reviews of effectiveness. Reliability is ensured by having a second reviewer, blind to the first, sift references and abstracts in the same way.

The reviews of effectiveness which have been identified are then put through a second sifting process and examined for quality, by two more reviewers. That is, each reviewer, blind to the other, applies a set of standard quality criteria to each of the identified reviews. Reviews upon which the reviewers fail to agree are discussed until agreement is reached.

Reviews that meet the quality criteria are abstracted for DARE. A detailed abstract is written which includes comments on such things as: the specific interventions examined in the review; the characteristics of participants in the primary research; the quality of primary studies; inclusion criteria; the sources searched to identify studies and implications for practice.

DARE is concerned with systematic reviews of effec-

Nurs. Srud. 35 11998) 13-22 15

tiveness across health care not just medicine, and these reviews are made available to the whole health community. The work reported here is part of a larger project exploring the extent to which there is evidence underpinning the effectiveness of nursing interventions. Preliminary work examining the prevalence of systematic reviews of effectiveness in nursing is presented here.

2. Objectives

The objectives of this research were to:

l Develop a MEDLINE search strategy for identifying systematic reviews relevant to nursing.

. Use a combination of electronic and handsearching to identify systematic reviews of effectiveness in areas of nursing practice.

. Describe the identified systematic reviews in terms of the aspects of nursing covered and the quality of the reviews.

. Make the most recent systematic reviews in nursing accessible by including them in DARE.

3. Methods

This project proceeded in parallel with a project concerned with the identification of randomised controlled trials. A sensitive MEDLINE search strategy was developed to identify randomised controlled trials and systematic reviews pertaining to nursing (BOX I). MED- LINE was chosen as a starting point for this search as it incorporates the International Nursing Index, and has a more sophisticated methodological indexing system than other nursing bibliographies and has RANDOMISED CONTROLLED TRIAL as both a MeSH term and a publication type, and META ANALYSIS as a MeSH term. MEDLlNE was searched from 1987-1994 inclus- ive. Systematic, page-by-page handsearching was then undertaken of those nursing journals shown by the MED- LINE search to be rich in RCTs and/or systematic reviews since it has been shown that MEDLINE searching alone misses a high proportion of eligible papers (Dickersin et al.. 1995). The journals handsearched are listed in Table 1. Careful instructions were prepared for three volunteer handsearchers, who were instructed to search every page of a journal for reference to RCTs and systematic reviews in articles, abstracts, letters. short reports or any other format. The randomised controlled trials identified have been described elsewhere (Cullum, 1997).

The reviews identified were critically appraised using

Box 1 MEDLINE (Silver Platter) search strategy for the identification of randomised controlled trials and systematic reviews in nursing

#I

#2 #3 #4 #5 Ml #7 #8 #9

#lO #II #I2 #I3 #I4

#I5 #I6

#17 #18 #19 #20 #21 I#22 #23 #24

#25

NURSE-PATIENT-RELATIONS (Allows no subheadings) explode NURSING-CARE/all subheadings PSYCHIATRIC-NURSING/all subheadings explode NURSING/all subheadings explode NURSING-RESEARCH/all subheadings explode NURSES/all subheadings SKILLED-NURSING-FACILITIES:all subheadings COMMUNITY-HEALTH-NURSING/all subheadings SCHOOL-NURSING;all subheadings health visit* midwi* nurs* SB = NURSING #lor#2or#3or#4or#5or#6or#7or#Xor#9or #lOor#ll or#12or#l3 RANDOM-ALLOCATION (Allows no subheadings) RANDOMISED-CONTROLLED TRIALS!all subheadings DOUBLE-BLIND METHOD (Allows no subheadings) META-ANALYSIS (Allows no subheadings) randomly or randomised or controlled meta-analysis systematic review RANDOMISED-CONTROLLED-TRIAL in PT’ CONTROLLED-TRIAL in PT #15or#l6or#17or#18or#l9or#2Oor#21 or#22 or #23 #14 and #24

- ’ PT = Publication Type

the CRD quality criteria’ which are themselves a con- densed version of Mulrow’s original criteria. vi:.:

Does the review have a clear question? The sine qua non of any systematic review is that it sets out to answer a specific question or set of questions, and that the questions should be well-defined and ideally include reference to the target population, the health care intervention and the outcomes of interest. The prerequisite is analogous to the research question or hypothesis of a piece of primary research and enables users of reviews to decide quickly whether a review is likely to have implications for their practice. Does the review demonstrate a systematic, comprehensive search strategy in order to identify as large

‘The quality criteria used in this piece of work were those used by the NHS CRD up to the end of March 1996. These criteria have subsequently been made more specific and expanded from three to six criteria (see Appendix I).

16 J. Droogan, N. CullumlInt. J. Nurs. Stud. 35 (1998) 13-22

Table 1 Nursing journals handsearched from inception to end of 1994 for systematic reviews

Journal title Country of publication

Advances in Nursing Science Applied Nursing Research Clinical Nursing Research Research in Nursing and Health Nursing Research Journal qf Clinical Nursing Nursing Science Quarterl). Journal of’ Advanced Nursing International Journal qf Nursing Studies Nurse Anaesthesia Semrnars in Perioperatire Nursing

U.S.A. U.S.A. U.S.A. U.S.A. U.S.A. U.K. U.S.A. U.K. U.K. U.S.A. U.S.A.

a proportion as possible of all the primary studies? A review which does not take strenuous efforts to identify all relevant studies runs a great risk of introducing bias. Confining studies included to those which are published is likely to favour the inclusion of studies which demonstrate a ‘significant’, positive effect and therefore over-estimate any treatment effect (Eas- terbrook, 1991). Limiting oneself to a review of Engl- ish language articles only may mean missing the gre- ater part of the published research. Restricting the search strategy to electronic databases such as MED- LINE and neglecting handsearching will also mean running the risk of missing important research.

3. Does the review demonstrate an appropriate synthesis of data? Where there is more than one study sufficiently similar in terms of the intervention studied and the outcome(s) measured then statistical tech- niques may be used to synthesise (or pool) data from the primary studies (a process known as meta-analysis). It is important to emphasise that pooling is not always appropriate, and if studies are not sufficiently similar in either a clinical or design sense, then a critical narrative review which focuses on the quality of existing studies and the strength of the evidence they provide, will be more appropriate.

4. Main findings

The combination of MEDLINE searching (1987- 1994), handsearching of nursing journals from inception to 1994, and informal contact with nurse-researchers in the U.K. and abroad, identified 81 papers for further scrutiny. On examination of the full papers, 36 of the 81 were reviews which purported to answer a question of

effectiveness (Table 2), e.g. Patient controlled analgesia: can client education improve outcomes? (Shade, 1992); Effect of preoperative instruction on postoperative outcomes: a meta-analysis (Hathaway, 1985); Effects of psychoeducational care for adult surgical patients: a meta- analysis of 191 studies (Devine, 1992) and Effects of educational interventions in diabetes care: a meta-analysis of findings (Brown, 1988). Thirty-one of the 8 1 reviews were not principally concerned with issues of effectiveness, for example: An analysis of theory-research linkages in published gerontologic nursing studies, 1983-1989 (Mur- phy et al., 1991), and Meta-analysis of correlates of diabetes patients’ compliance with prescribed medications (Nagasawa, 1990) and so were not considered further. Fourteen of the 81 papers were not systematic reviews; nine were papers concerned with the methodology of undertaking systematic reviews or meta-analysis; and five were background papers to subsequent systematic reviews.

5. Quality of the systematic reviews identified

Nineteen of the 36 (53%) reviews of effectiveness met all three CRD quality criteria; namely they had a clear question, a comprehensive search strategy and appropriate data synthesis. Four reviews met two of the quality criteria and eight reviews met one (see Table 3). Only one review out of the 36 reviews of effectiveness failed to identify a clear question, tk. Platzer (I 989).

The earliest systematic reviews of effectiveness published in a nursing journal identified in this study are two meta-analyses published in 1986, one on the effectiveness of preoperative instruction published by Hathaway and the other on clinical and cost-saving effects of psychoeducational interventions with surgical patients by Devine. Of the 19 high quality systematic reviews of effectiveness, 12 were published since 1990, suggesting a possible increase in the number and quality of systematic reviews relevant to nursing.

Topic areas covered by the high quality systematic reviews can be seen in Table 4. It is worth noting that seven (37%) of the 19 papers covered patient education interventions.

6. Discussion

Systematic reviews are the most reliable and valid means of summarising the available research findings in any given topic, and are therefore the foundation stones of evidence-based health care. As part of an ongoing programme of work which explores the evidence for the effectiveness of interventions pertaining to nursing, we sought to identify and appraise existing systematic reviews in nursing.

Table 2

J. Drooyarz, N. C‘ullun~,‘lnt. J. Nurs. Stud 35 i 1998) 13-22 17

Thirty-six reviews of effectiveness relevant to nursing

Author Year Country Journal Title

Waisbren. S. E.. Schnell. R. R. and Levy. H. L.

Hathaway. D.

1980 U.S.A. Diet termination in children with phenylketonuria : a review of psychological assessments used to determine outcome

1985 U.S.A. Nur.sing Rcsearclz

Devine, E. C. and Cook, T. D.

1986 U.S.A. Rcsrarclt in Nursing and

HfYlllh

Burckhardt. C. S. 1987 U.S.A.

Effect of preoperative instruction on postoperative outcomes : a meta-analysis

Clinical and cost-saving effects of psychoeducational interventions with surgical patients : a meta-analysis

The effect of therapy on the mental health of the elderly

Burgencr. S. 19x7 U.S.A.

Rcwarch in Nursing and

H6Yilih Journal of Atkancrd

~Vurving

Justification of closed intermittent urinary catheter irrigation:installation : a revieu of current research and practice

Schwartz. R.. Moody. L.. Yardndi, H. and Anderson. G. C.

Sims. S. E. R.

19x7 U.S.A. Nursing Re.wtr~~h A meta-analysis of critical outcome variables in non-nutritive sucking in preterm infants

1987 U.K. Journal of Adwwd

Nursing

Brown, S. 1988 U.S.A. Nursing Rexarch

Heater. B. S., Becker. A. M. and Olson. R. K.

Metheny. N.

1988 U.S.A. Nursiny Re.srarch

Relaxation training as a technique for helping patients cope with the experience of cancer: a selective review of the literature

Effects of educational interventions in diabetes care : a meta-analysis of findings

Nursing interventions and patient outcomes : a meta-analysis of studies

1988 U.S.A.

Broome. M.E., Lillis. P.-P. and Smith, M. C

Hyman. R. B.. Feldman, H. R.. Harris. R. B.. Lcvin~ R. F. and Malloy, ‘3 B.

Platter. H.

1989

1989

19x9

1990

1990

I990

1990

1990

1991

1991

U.S.A.

Measures to test placement of nasogastric and naso-intestinal feeding tubes : a review

Pain interventions with children : a meta-analysis of research

U.S.A. The effects of relaxation training on clinical symptoms : a meta-analysis

U.K. Postoperative confusion in the elderly--a literature review

Brooker. C. U.K. Expressed emotion and psychosocial intervention : a review

Brown. S. A. U.S.A.

McCain. N. L. and Lynn, M. R.

Olds. D. L. and Kitrman. H.

Olson. R. K.. Heater. B. S. and Becker. A. M.

U.S.A.

U.S.A.

Internafionrrl Journal of

Nursing Studilies

Inrernational Journal of

/Nursing Sludies

Patienr Educuliorl and

Counsrlling

Westwn Journal qf Nursing Rrwarclt

Pediatrics

U.S.A. MCN : Tk American Journal of Maternal~Child

Nursing

Nursing Reswrch

Studies of educational interventions and outcomes in diabetic adults : a meta-analysis revisited

Meta-analysis of a narrative review : Studies evaluating patient teaching

Can home visitation improve the health of women and children at environmental risk?

A meta-analysis of the effects of nursing interventions on children and parents

Goode. C. J.. Titler. M., Rakel, B.. Ones. D.S.. Kleiber. C.. Small, S. and Triolo. P. K.

Goodman. M.

U.S.A. A meta-analysis of effects of heparin flush and saline flush : quality and cost implications

U.S.A. Seminars it2 Oncologj~ Adjuvant systemic therapy of stage one and two NursNI,q breast cancer

18 J. Droogan, N. CuNum~Int. J. Nurs. Stud. 35 11998) 13-22

Table 2-Continued

Author Year Country Journal Title

Haeuber, D. 1991 U.S.A. Oncolog~~ Nursing

FO/W?l Future strategies in the control of

myelosuppression : the use of coloni-stimulating factors

Hughes. C. P. 1991 U.K.

Kuhlman, G. J., Wilson, H. S., Hutchinson, S. A. and Wallhagen, M.

Lipman, T. 0.

1991 U.S.A.

Journal of Adtlanced

Nursing

Nursing Research

Community psychiatric nursing and the depressed elderly : a case for using cognitive therapy

Alzheimer’s disease and family care giving : critical synthesis of the literature and research agenda

1991 U.S.A. Clinical trials of nutritional support in cancer : parenteral and enteral therapy

Waddell, D. L. 1991 U.S.A.

Haemato/ogj’/OncologJ~

Clinics of North

America

Journal of Continuin,y

Education in

Nursing

Research in Nursing and

Health

The effects of continuing education on nursing practice : a meta-analysis

Brown, S. A. 1992 U.S.A. Meta-analysis of diabetes patient education research : variations in intervention effects across studies

Carr. E. K. and Kenney, F. D.

Devine, E. C.

1992 U.K.

1992 U.S.A.

International Journal qf

Nursing Studies

Patient Education and Counselling

Positioning of the stroke patient : a review of the literature

Effects of pscychoeducational care for adult surgical patients : a meta-analysis of 19 1 studies

Mullen, P. D., Mains, D. A. and Veiez, R.

Richardson, A.

1992 U.S.A.

1992

U.K.

Australia

Patient Education and

Counselling

International Journal of

Nursing Studies

Journal of Advanced

Nursing

Journal qf Adt>anwd

Nursing

A meta-analysis of controlled trials of cardiac patient education

1992

Shade, P.

Studies exploring self-care for the person copying with cancer treatment : a review

Patient controlled analgesia : can client education improve outcomes?

Barriball, A. L. and MacKenzie, A.

1993

1994

1994

1994

1994

U.K. Measuring the impact of nursing interventions in the community : a selective review of the literature

Ciliska, D.. Hayward, S., Thomas, H., ef ul.

Canada Quality of Nursing

Worklife Research

Unit

Report.fbr Department

of Health

Nursing Research

A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions

Cullum, N. U.K.

Krywanio. M. L. U.S.A.

Ling Tang, J., Law, M. and Wald, N.

U.K. British Medical Journal

The nursing management of leg ulcers in the community : a critical review of research

Meta-analysis of physiological outcomes of hospital-based infant intervention programs

How effective is nicotine replacement therapy in helping people to stop smoking?

It appears that nurses have a long history of undertaking systematic reviews. Systematic reviews of nursing issues were identified as far back as 1967 (Basson), though not all were reviews of effectiveness. There is also clearly a large number of reviews, published in nursing journals and elsewhere, which try to answer questions of effectiveness without using methods to minimise bias or synthesise data appropriately. This type of unsystematic review runs a high risk of drawing misleading conclusions and giving the wrong directions for practice. It is as important therefore for health care professionals to learn how to appraise reviews as it is for them to know how to

critique original research. It takes moments (and ulti- mately saves time) for a reader to decide whether a reviewer describes a thorough and comprehensive search strategy; if the answer is no then someone looking for directions for practice should read no further.

One can see from Table 4 that the reviews identified cover key clinical topics for nurses including palliative care, patient education and leg ulcer management. There are however many important topics noteworthy by their absence, with a paucity of reviews relating to the organ- isation of care and particularly innovations such as primary nursing ‘the named nurse’ which have been

J. Droogun, N. C‘ullw/Inr. J. Nurs. Stud. 35 (1998~ 13-22 19

Table 3 Quality appraisal of the thirty-six reviews of effectiveness

~-

Author:year ~- ~-

Systematic reviews which met all three criteria Brown S. (1988) Brown. S. A. (1990

Clear question

Brown, S. A. (1992) Burckhardt, C. S. (1987) Ciliska. D.. Hayward. S., Thomas. H.. et ul. (1994) Cullum. N. (1994) Devine. E. C. (1992) Devine. E. C. and Cook. T. D. (1986) Goode. C. J.. Titler. M.. Rakel. B.. Ones. D. S.. Kleiber, C., Small, S. and Triolo. P. K. (19Yl) Hathaway. D. (1986) Heater. B. S.. Becker. A. M. and Olson, R. K. (1988) Hyman, R. B.. Feldman. H. R., Harris, R. B., Levin. R. F. and Malloy.

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes

G. B. (1989) Krywanio. M. L. (1994) Yes Ling Tang. J.. Law. M. and Wald. N. (1994) Yes Lipman, T. 0. (1991) Yes Mullen. P. D.. Mains, D. A. and Velez, R. (1992) Yes Olson. R. K.. Heater. B. S. and Becker, A. M. (1990) Yes Schwartz. R.. Mood!. L.. Yarandi, H. and Anderson, G. C. (1987) Yes Waddell. D. L. (1991) Yes

Reviews which met two criteria Broome, M. E.. Lillis, P. P. and Smith, M. C. (1989) Hughes, C. P. (1991) Olds. D. L. and Kitrman. H. (1990) Platter. H. (lY8Y)

Yes Yes Yes No

Reviews which met one criterion Burgener, S. (1987) Carr. E. K. and Kenney. F. D. (1992) Goodman. M. ( I99 I ) McCain. N. L. and Lynn. M. R. (1990) Metheny. N. (1988) Shade, P. ( 1992) Sims. S. E. R. (1987) Waisbren. S. E.. Schnell, R. R. and Levy, H. L. (1980)

Yes Yes Yes Yes Yes Yes Yes Yes

Reviews which met none of the criteria Barriball. K. L. and MacKenzie, A. (1993) Brooker. C. (1990) Haeuber. D. (1991) Kuhlman. G. J.. Wilson. H. S.. Huchinson, S. A. and Wallhagen,M. (1991) Richardson. A. (I 992)

No No No NO

No

Search strategy


Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes

Yes Yes No Yes

NO No No No NO No No No

No No No No No

Data synthesis


Yes Yes Yes

Yes Yea Yes Yes Yes Yes Yes

No No Yes Yes

No No No No No No No No

No No No No No

implemented. This paper however reports only details of those reviews identified up to and including 1994.

It is clear that whilst there are some relevant, good quality systematic reviews available to nurses, more are urgently needed. Fortunately due to the endeavours of those who form the Cochrane Collaboration, and Centres

such as CRD, the number of systematic reviews useful to nurses should dramatically increase. For example, a systematic review of the evidence relating to pressure sore prevention was published in 1995 by CRD, (l?ff&tice Health Care, 1995), who are currently reviewing many other aspects of wound care including leg ulcer man-

20 J. Droogan, N. Cullum/Int. J. Nurs. Stud. 35 (1998) 13-22

Table 4 Topic areas covered by the 19 systematic reviews which met the three quality criteria

Topic Number of reviews

Patient education 7 Psychological interventions 2 Care of the neonate 2 Miscellaneous 1 Continuing nurse education I Management of intravenous therapy I Palliative care I Home visiting I Leg ulcer management 1 Paediatric Nursing 1 Smoking cessation I

agement. There are also reviews on the Cochrane Dat- abase of great relevance to nursing, for example: Sys- tematic review of randomised control trials on patient adherence and outcomes of interventions to assist patients to follow prescriptions for medications (Haynes et al., 1996) and Effectiveness of training health professionals to provide smoking cessation interventions: systematic review of randomised control trials (Silagy et al., 1996). However, it has been disappointing that comparatively few nurses have stepped forward to be reviewers in the Collaboration. In the real world health care is delivered by multiprofessional and mul- tidisciplinary collaboration, and systematic reviews should where appropriate, reflect this. For example, it would be unnatural to review only nursing research when one is conducting a review of leg ulcer management as so much important and relevant work has been undertaken by surgeons, physicians, etc. Thus the review groups of the Collaboration produce multiprofessional reviews wherein individuals from the professions and disciplines of relevance to a particular topic work together, often with users of the health service, to review the research in that area. Such joint endeavour helps to ensure that reviews address all the relevant research and perspectives and draw appropriate conclusions.

CRD continues to search MEDLINE, CINAHL, AMED and is handsearchingjournals to identify nursing, midwifery and health visiting reviews for inclusion on DARE (from 1994 to date)-important work if nurses, midwives and health visitors are to be able to access reliable synopses of their own research, but also make their research more available to the other health professions. Finally, the current trend to produce clinical practice guidelines must be underpinned by systematic reviews in order to ensure that guidelines are valid.

Acknowledgements

The authors acknowledge the Department of Health and North West Region NHS Executive for the initial funding of this work. Thanks are particularly due to the volunteer handsearchers, Drs Joyce Prince and Kate Seers and MS Beverley French; to Mrs Lesley Ronald for the administration of searching and development of the database, and to colleagues in the Cochrane Col- laboration and the NHS Centre for Reviews and Dis- semination for support and assistance with all aspects of the work.

Appendix 1

Quality criteria for inclusion on DARE

Since March 1996 the NHS Centre for Reviews and Dissemination has further developed the three quality assessment criteria for published reviews. A review can be included on DARE only if four or more of the following criteria are rated as Fair or Good.

(NA, Poor, Fair, Good).

1. 2.

3.

4. 5. 6.

Does the review answer a well defined question? Was a substantial effort to search for all the relevant literature made? Are the inclusion/exclusion criteria reported and appropriate? Is the validity of included studies adequately assessed? Is sufficient detail of the individual studies presented? Have the primary studies been combined or sum- marised appropriately?

(Song, 1996).

Appendix 2

Systematic reviews qf <flecticeness relevant to nursing

Barriball, K.L., MacKenzie, A., 1993. Measuring the impact of nursing interventions in the community: a selective review of the literature. Journal of Advanced Nursing 18, 401407.

Brooker, C., 1990. Expressed emotion and psychosocial intervention: a review. The International Journal of Nursing Studies 27(3), 2677276.

Broome, M.E., Lillis, P.P., Smith, M.C., 1989. Pain interventions with children: a meta-analysis of research. Nursing Research 38(3), 154-l 58.

Brown, S., 1988. Effects of educational interventions in diabetes care: a meta-analysis of studies. Nursing Research 37(4), 223-230.

Brown, S.A., 1990. Studies of educational interventions

J. Drqpn, N. Cullum~lnt. J. Nurs. Stud. 35 ilYY8) 13--22 21

and outcomes in diabetic adults: a meta-analysis revisited. Patient Education and Counseling 16, 1899 215.

Brown, S.A., 1992. Meta-analysis ofdiabetes patient education research: variations in intervention effects across studies, Research in Nursing and Health 15, 409419.

Burckhardt, C.S., 1987. The effect of therapy on the mental health of the elderly. Research in Nursing and Health 10, 277-285.

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