critical appraisal literature review

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Critical appraisal literature review

Search this Guide Search. Literature Review: Evaluating sources and critical appraisal of literature This guide will define a literature review, describe the process of writing a literature review and examine where to search for literature. Home Introduction Types of literature reviews Toggle Dropdown Traditional or narrative literature reviews Systematic literature review Scoping Reviews Annotated bibliography Developing a search strategy Toggle Dropdown Keeping up to date with literature Where to search Toggle Dropdown Finding a thesis Evaluating sources and critical appraisal of literature Managing and analysing your literature Resources.

Evaluating literature While you are searching for relevant information about your topic you will need to think about the accuracy of the information, whether the information is from a reputable source, whether it is objective and current. Accuracy Is the information reliable? Is the information error-free? Is the information based on proven facts?

Can the information be verified against other reliable sources? Authority Who is the author? Is the author affiliated with a reputable university or organization in this subject field? Is the source peer reviewed or refereed?

Objectivity What is the intended purpose of the information? Is the information fact or opinion? Is the information biased? Currency When was the information published? Is the information current or out-dated? As such, the systematic review of qualitative literature is also gaining popularity in healthcare research [ 8 ]. The low use of services by members of minority ethnic groups is an issue which is gaining increasing attention from policy makers within end-of-life EoL care the term 'minority ethnic group' is used, in accordance with the official classification used by the UK Office for National Statistics, to describe groups other than 'white British'.

First highlighted by Rees [ 9 ], in a study of 'immigrant' use of one hospice, the issue did not, however, reach the policy agenda until a decade later, when Hill and Penso [ 10 ] drew attention to disparities between minority ethnic groups' estimated need of services and their actual service use. Further research has confirmed low use of EoL care services and identified a number of reasons for this, including: younger population age structure; lower rates of cancer; lower rates of referrals; low awareness of services; and, some culturally inappropriate services [ 10 — 18 ], This growing body of literature has given rise to a number of literature reviews, which have focused on various aspects of EoL care and minority ethnic groups [ 19 — 31 ].

Given the number of reviews and their range of foci it is essential to assess their quality and, therefore, their potential to represent the evidence base and inform policy. A similar approach has been used for the evaluation of literature reviews of palliative care services [ 32 ] and interventions to improve care [ 33 ]. Various policy initiatives have included commitments to ensure equal access for people from minority ethnic groups to EoL care services [ 27 , 34 — 37 ].

Some policy documents explicitly state the importance of sensitivity to cultural and religious differences and the need for services to provide 'culturally sensitive' care to reduce inequalities [ 27 , 35 — 37 ]. Cultural competency training is also identified as a priority for healthcare staff [ 27 , 35 — 37 ]. This article aims to evaluate the reviews of the literature concerning minority ethnic groups and EoL care in the UK. It is important to critically assess reviews in order to examine their quality, identify gaps in knowledge and assess their suitability as an evidence base for policy.

Specific objectives include: to identify all reviews systematic and non-systematic regarding minority ethnic groups and EoL care from the UK; to examine the methodological quality of the reviews; to carry out an interpretive synthesis of reviews' findings; and, to identify recommendations for service improvement. PRISMA is an integrated programme consisting of eight work packages which aim to co-ordinate research priorities and practice about end-of-life care across Europe and Africa [ 39 ].

Thirteen electronic databases were searched using the search terms in table 1. Publications by authors of included articles were searched via authors' web pages when available and the Web of Knowledge 'author search' facility. Experts recommended literature, including unpublished and grey literature. Only literature reviews were included; a systematic review of primary research has been undertaken as a second part of the project and published elsewhere [ 40 ]. No relevant foreign language reviews were identified.

Both traditional non-systematic and systematic reviews were included. Non-systematic reviews were included, despite difficulties in assessing both their methodological quality and their propensity for bias, because the use of systematic search procedures is a relatively recent development, especially for qualitative and mixed method research. To thoroughly appraise all reviews of the literature on minority ethnic groups, which have potentially influenced British policy, the inclusion of non-systematic reviews was necessary.

Articles were managed in Endnote X2. Titles and abstracts were initially assessed by one reviewer NE to eliminate those not related to EoL care. All remaining titles and abstracts were then assessed for relevance in regular team meetings minimum three participants.

When there was insufficient information to decide upon inclusion, the full text was retrieved and appraised. Data were extracted from full text copies of the reviews tables 2 and 3 by one reviewer NE and checked by another MG. Reviews that took a systematic approach were appraised for methodological quality table 3 using a grading scheme adapted from Russell, et al.

Five areas of reporting were graded: specifying the objectives; searching the literature; selecting relevant and valid studies; critical appraisal of studies; and, synthesis of data and presentation of findings more details in table 3.

Reviews were graded independently by two reviewers NE and MG and then compared. Differences were discussed in team meetings minimum 3 people and resolved by consensus. It was only possible to grade the methodological quality of reviews that had followed a systematic search procedure. No studies were excluded on the basis of quality, as it was not possible to grade non-systematic reviews.

In addition, there is no agreement on the role of quality criteria especially when reviews include qualitative and mixed methods studies. Instead, for transparency, it has been made explicit which reviews are systematic and which are non-systematic.

Furthermore, the difference in quality of systematic reviews is highlighted in the score breakdown table 3. An interpretative approach, following the principles of constant comparison was used to identify key themes from the reviews [ 45 , 46 ]. The findings from each review were coded, categorised and summarised. Codes and categories were iteratively compared and contrasted, cross-cutting themes were identified, which were reduced to a number of key themes [ 45 , 46 ].

Finally, a narrative synthesis of findings concerning the key themes was conducted, paying particular attention to commonalities and discordance between reviews. This article does not intend, however, that a review of reviews should be used as an evidence base for policy.

Such an approach would presuppose that those who conducted the original reviews were correct in both their approach and assessments of the evidence. In contrast, the purpose of this synthesis is to provide a representation of the findings of existing reviews of the literature. After removing duplicates, a total of citations were screened.

Of these, were discarded after reviewing the title and abstract as they did not fulfil the inclusion criteria. Thirty-six articles were not available for full text assessment none of these were reviews. The full text of articles was examined in more detail.

On closer examination, 13 articles were found not to meet inclusion criteria and a further were not reviews 45 original studies and 55 other articles. A total of 13 reviews met inclusion criteria Figure 1 , details of reviews [ 19 — 31 ] and related articles [ 47 ] can be seen in table 2.

A number of included reviews had a narrow focus; restricting the review by ethnic group [ 24 ], a particular aspect of EoL care [ 21 , 22 ], or EoL care setting [ 29 , 31 ]. In addition, broader reviews of cancer services and minority ethnic groups were included if they reported significant findings regarding EoL care [ 19 , 23 ]. All reviews were published between and table 2. Reviews' inclusion criteria differed in line with their varied focus.

In addition, five reviews only included primary research [ 19 , 21 , 23 , 24 , 31 ], whereas eight reviews [ 20 , 22 , 25 — 30 ] included overviews, opinion pieces, and even web-based resources to build a picture of minority ethnic groups' experience of EoL care.

The majority of the articles included in the reviews came from the UK; five reviews [ 19 , 23 , 27 , 29 , 30 ] included evidence from the UK only, whereas eight reviews included non-UK sources to a greater or lesser extent [ 20 — 22 , 24 — 26 , 28 , 31 ]. Where reviews included material from non-UK sources this has been highlighted in table 2. Due to the difference in reviews' aim, scope and inclusion criteria it is difficult to judge the success or the relevance of a review by the number of articles included alone.

Descriptions of the review process ranged from no information to thorough outlines of a systematic review procedure. Seven reviews followed a systematic search procedure [ 19 — 24 , 31 ]. These reviews were graded for methodological quality according to the criteria in table 3.

Quality scores ranged from four to nine out of ten. The mean score was six median seven , indicating that the 'systematic' reviews were, on average, of a reasonable methodological quality table 3. These reviews all included electronic database searches and most included reference list searches [ 19 — 24 , 31 ].

Three reviews included journal hand-searches [ 21 , 22 , 31 ], one searched grey literature [ 20 ], and one contacted experts in the field [ 19 ]. The number of reviewers was rarely explicit. Three reviews graded studies for quality [ 21 , 23 , 31 ]. Four 'systematic' reviews did not grade articles or explicitly rejected grading [ 19 , 20 , 22 , 24 ].

The synthesis of data and presentation of findings was found to be good in most reviews table 3. The remaining six reviews did not provide sufficient information to allow the grading of quality [ 25 — 30 ]. A lack of detail does not necessarily mean the review process was of poor quality or that results are less significant. It is not, however, possible to assess the rigour of the review process. An interpretative synthesis of review findings resulted in the following six themes: structural inequality; inequality by disease group; referrals; place of care and death; awareness and communication issues; and, cultural competency.

Structural inequalities which people from minority ethnic groups face due to socio-economic and geographic disadvantages was a reoccurring theme [ 21 , 24 , 28 , 48 ]. Services were acknowledged to be 'disproportionally needed in areas of social deprivation, and disproportionally present in areas of social affluence' [ 27 ]. Inequality in provision is partly due to the predominately charitable nature of service development; with more donations received in wealthier areas [ 28 , 48 ].

Minority ethnic groups, therefore, face 'double discrimination', as higher concentrations of such groups are found in areas of social deprivation, and even within these areas they have low service use in comparison to 'white British' service users [ 27 ].

Elderly members of minority ethnic groups were said to be particularly vulnerable due to the combined effects of low socio-economic status and discrimination [ 28 , 29 ]. Furthermore, carers reported additional problems, such as anxieties regarding housing and visas [ 23 , 30 ]. Differences in cancer incidence and mortality were highlighted in a number of reviews [ 19 , 20 , 23 , 25 — 28 ] and the focus on cancer in EoL care provision was cited as a major source of inequality due to the greater importance of non-malignant diseases among minority ethnic groups [ 20 , 21 , 25 , 30 ].

Limited service provision for non-malignant diseases was attributed to: uncertain disease trajectories; limited service capacity; different expectations of carers and patients; and, a lack of appropriate expertise [ 21 ]. The reviews that focused only on cancer services, however, highlighted that as age structures and lifestyles converge, cancer incidence and mortality among minority ethnic groups can be expected to increase [ 23 , 26 , 28 ]. Patients from minority ethnic groups were said to lack 'timely referrals' to specialist EoL care services [ 21 , 23 , 28 , 31 ].

Reasons included a limited knowledge of services and the referral process among physicians who are not EoL care or cancer specialists [ 21 ]. Physicians were said to resist sharing patients and to perceive institutional care as inappropriate for minority ethnic groups, who prefer to 'look after their own' [ 21 , 29 , 31 ]. General practitioners were also seen as 'gate-keeping' services through the referral process and poor communication with general practitioners could limit access [ 28 ].

Furthermore, some patients rejected referral due to negative perceptions of services [ 21 ]. Recent policy initiatives have promoted home deaths on the basis of a reported preference among patients to die at home [ 27 , 30 ]. A number of reviews highlighted the perceived preference among minority ethnic groups for home care [ 21 , 23 , 29 ]. Payne et al. In contrast, Walshe et al. Above all, the need for discussion and choice regarding place of death was identified as a priority by members of minority ethnic groups [ 30 ].

Lack of information in an appropriate format, negative perceptions and low awareness of services were identified as barriers to service use [ 19 , 25 , 28 ]. Problems persisted once services had been accessed; poor communication between patients and their families and healthcare professionals was an issue repeatedly emphasised [ 20 — 22 , 25 , 26 , 28 , 48 ].

Four reviews emphasised the importance of good communication above all other factors [ 19 , 22 , 26 ]. Specific problems included: a lack of information provided in appropriate languages and formats [ 19 , 25 , 28 ]; inadequate interpreting and advocacy provision [ 19 , 25 , 28 ]; differences in social taboos about death and illness [ 22 , 25 , 28 ]; and, difficulties in understanding and communicating both verbally and non-verbally [ 22 , 49 ].

Due to limited resources, family members were used to interpret information of a sensitive or unsuitable nature, increasing the risk of non-disclosure [ 25 ]. Jones [ 20 ], however, called for understanding in regard to disclosure and involvement of family members in decision-making. Furthermore, Payne et al. The communication of patients' wishes through advance care planning was discussed just twice in the reviews. Similarly, Cox et al.

Negative perceptions towards services were considered significant impediments to increased utilisation, and some services were identified as culturally insensitive [ 48 ]. A common recommendation was the need for training in care that is sensitive to cultural difference [ 23 — 25 , 28 , 29 , 48 ]. Only one review, however, explicitly defined the terms used for such care 'cultural competence' and 'cultural safety' [ 25 ].

In contrast to the frequent recognition that services need to provide culturally competent care, few reviews provided recommendations about how to achieve this. Only one review highlighted the large numbers of minority ethnic staff working in the healthcare services [ 29 ]. Cultural differences were said to lead to uncertainty, even when staff were trained in 'cultural competency' issues [ 29 ].

Concerns were raised about deterministic links between cultural, ethnic or religious factors and EoL preferences an approach referred to as the 'cookbook' approach [ 20 ] and the stereotyping of patients was warned against [ 19 , 20 ]. Jones [ 20 ] stated that the majority of literature regarding healthcare and minority ethnic groups merely presents information about religious rituals and beliefs.

Whereas, Payne et al. These concerns led authors to emphasize that meeting 'cultural' needs is only part of meeting patients' individual needs [ 19 , 20 , 24 , 28 , 30 ]. In contrast, Cox et al. The importance of monitoring service users' ethnicity was frequently stressed [ 20 , 23 , 25 , 29 — 31 ]. However, data was said to be inadequately collected and rarely used to influence service provision [ 25 , 29 ].

A number of recommendations were made in the reviews for improving EoL care services for minority ethnic groups table 4. The literature reviews concerning minority ethnic groups and EoL care in the UK described a range of social, institutional, epidemiological and cultural reasons for low service use and identified some distinct EoL preferences and needs.

In light of this evidence, in order to improve the use of, and satisfaction with, palliative care services by such groups, it is necessary to recognise the complexity of factors leading to low service use and sub-standard provision of care and implement a systematic, organisation wide, approach to tackling these multiple and inter-related factors.

The influence of these multiple and inter-related factors was reflected in the reviews' recommendations for service improvement table 4. Of the thirteen reviews identified, seven took a systematic approach [ 19 — 24 , 31 ], and four scored highly for methodological quality [ 19 , 21 , 23 , 50 ].

These reviews provide a good reflection of the evidence base and could be used to inform policy. Six reviews did not provide sufficient information for their quality to be graded, including the End-of-Life Care Strategy: Equality Impact Assessment [ 30 ]. The aim of this document was to ensure that the UK End-of-Life Care Strategy [ 37 ] 'does not inadvertently create inequality', but referenced just seven articles concerning 'race' and 'religion'.

Due to the relatively small number of articles included in the End-of-Life Care Strategy: Equality Impact Assessment [ 30 ], the themes and recommendations identified from the literature reviews were compared and contrasted with those of the End-of-Life Care Strategy [ 37 ]. The recommendations regarding minority ethnic groups made within the Strategy table 5 were more limited than those made within the reviews table 4 , and omitted a number of recommendations made in its own Equality Impact Assessment [ 30 ] table 4.

The recommendations focused on problems that arise during the physician-patient encounter such as issues regarding communication and awareness of different EoL preferences or raising awareness of services amongst minority ethnic groups table 5. Although inequalities in service provision due to geographical factors or disease group were addressed in the Strategy, their contribution to low service use by minority ethnic groups was not recognised. In addition, a lack of timely referrals for members of minority ethnic groups was not mentioned.

No mention was made to minority ethnic groups in the Strategy's sections on 'place of death', 'core principles and competencies', 'education, training and continued development', 'improving the environment', 'prisons and secure units' even though one third of prisoners come from minority ethnic groups [ 51 ] and 'future research'.

The need for 'spiritual, religious and cultural care competences' to be 'adopted within all core training' was highlighted, however, these needs were not repeated in the Strategy's sections regarding 'core principles and competencies' and 'education, training and continued development'.

In addition, the Strategy took an apparent 'cookbook' approach regarding organ donation, providing the link to a website on 'the perspectives on organ donation of the six major religions in the UK' [ 37 ], an approach criticised within the reviews. A case study which described an 'engagement project' referred to the establishment of a dialogue between the hospice and 'ethnic communities' [ 37 ].

Use of the term 'ethnic' to describe 'minority ethnic groups' implies that 'ethnicity' is something that only 'minority ethnic groups' have, rather than recognising that, in fact, 'ethnicity' is something that everyone has. Furthermore, the End-of-Life Care Strategy: Equality Impact Assessment [ 30 ] used the terms 'minority ethnic', 'black and minority ethnic' and 'race' interchangeably, implying equivalence.

The evidence base which informed the Strategy's recommendations on minority ethnic groups was found to be small. The bibliography includes just one review Cox et al. Moreover, just five studies and one report concerning minority ethnic groups were cited [ 18 , 22 , 28 , 52 — 55 ]. Its sections on 'race' and 'religion', however, highlighted a paucity of research looking at inequality due to 'racial' or 'religious' factors and referenced just seven articles [ 18 , 52 , 54 , 56 — 59 ], only five of which were original studies [ 30 ].

Thirteen reviews concerning minority ethnic groups and EoL care in the UK were identified, of which seven took a systematic approach [ 19 — 24 , 31 ]. However, the reviews identified either had a narrow focus, such as restricting the review by ethnic group [ 24 ] or a particular aspect of EoL care [ 21 , 22 , 31 ], or were broader reviews of cancer services and minority ethnic groups that reported significant findings regarding EoL care [ 19 , 23 ]. Only one systematic review specifically focused on minority ethnic groups and EoL care in the UK [ 20 ].

However, this review received a low quality score 4 and most articles included came from outside the UK. There remains a need for a thorough systematic review of EoL care and minority ethnic groups in the UK to improve the evidence base on which policy initiatives are ideally based. Thirteen reviews of the literature concerning minority ethnic groups and EoL care were identified.

The complexity of inter-related social, institutional, epidemiological and cultural factors leading to low service use were recognised and this complexity was reflected in the reviews' recommendations for service improvement. Recommendations made in the End-of-Life Care Strategy were limited in comparison. However, despite certain omissions, the recommendations made within the Strategy give the impression that minority ethnic groups had been taken into consideration.

The lack of integration, however, of these recommendations into key sections of the document brings their real impact into question. In addition, the evidence base, on which recommendations were made, was found to be narrow and some important issues addressed in the Equality Impact Assessment were not addressed.

Public healthcare policy is ideally based upon systematic reviews of the literature. All but three of the thirteen reviews of the literature identified [ 23 , 29 , 31 ] had been published prior to the publication of the End-of-Life Care Strategy. In response to the finding that these reviews had a minimal influence on the End-of-Life Care Strategy, it is recommended that future policy be based upon systematic reviews of the current literature, or at least upon existing systematic reviews, in order to reflect the current evidence and minimise bias.

Six non-systematic narrative reviews which are more at risk of selection bias were included. Furthermore, publication bias towards quantitative studies whose results are statistically significant, and towards qualitative studies which have striking or easily understandable findings, may introduce sources of bias into systematic reviews of the literature. The reviews which took a systematic approach were of varying quality, although on average they were of a reasonable standard.

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How to Use the Evidence-Ebook Assessment and application of scientific evidence. You Tube video about Critical Appraisal This session looks briefly at how and why we appraise literature. Required reading in many medical and healthcare institutions, How to Read a Paper is a clear and wide-ranging introduction to evidence-based medicine and healthcare, helping readers to understand its central principles, critically evaluate published data, and implement the results in practical settings.

Author Trisha Greenhalgh guides readers through each fundamental step of inquiry, from searching the literature to assessing methodological quality and appraising statistics. How to Read a Paper addresses the common criticisms of evidence-based healthcare, dispelling many of its myths and misconceptions, while providing a pragmatic framework for testing the validity of healthcare literature. Now in its sixth edition, this informative text includes new and expanded discussions of study bias, political interference in published reports, medical statistics, big data and more.

Offers user-friendly guidance on evidence-based healthcare that is applicable to both experienced and novice readers Authored by an internationally recognised practitioner and researcher in evidence-based healthcare and primary care Includes updated references, additional figures, improved checklists and more How to Read a Paper is an ideal resource for healthcare students, practitioners and anyone seeking an accessible introduction to evidence-based healthcare.

ROB 2. Choose the appropriate version. Individually randomized, parallel group trials traditional RCT 2. Cluster randomized, parallel group trials like traditional but randomized by groups 3. Animal Research:. Diagnostic Accuracy. SIGN checklist for diagnostic accuracy studies.

Public Health Ontario guide to appraising grey literature. Critical Appraisal of a Network Meta-Analysis. JBI Critical Appraisal tools. CASP Worksheets. Best Bets Critical Appraisal Worksheets. Evidence-Based Medicine Toolbox. ConQual approach Rating the confidence of qualitative systematic review findings. Report a problem. Tags: integrative review , living systematic review , meta-analysis , mixed methods review , network meta-analysis , overview of reviews , qualitative review , rapid review , scoping review , Systematic Review , systematic review service , umbrella review.

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Critical appraisal literature review Furthermore, Payne et al. Is the information based on proven facts? Nav Login. Critical appraisal literature review Who is the author? The total number of participants with the number of those excluded, dropped out or withdrawn from the study should be analysed. The need for 'spiritual, religious and cultural care competences' to be 'adopted within all core training' was highlighted, however, these needs were not repeated in the Strategy's sections regarding 'core principles and competencies' and 'education, training and continued development'.
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Critical appraisal is the process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. If you have been fortunate enough to find a recent systematic review of evidence from a reliable source to answer your clinical question you will not have to undertake the process of critical appraisal.

However, if you have found one or two individual studies you will need to assess the quality of the evidence to decide whether you wish to apply the evidence in practice. For urgent issues, please call the Statewide Service Desk on 28 55 33 and press 2 for clinical. If you are not a member of NSW Health and would like to get in touch, please submit your enquiries here.

Empirical literature in this context refers to knowledge derived from research. In other words, the knowledge is based on data from research data-based. Data-based literature consists of reports of research and includes published studies, usually in journals, on the Internet, or books, and unpublished studies, such as master theses and doctoral dissertations.

Most references cited in quality literature reviews are primary sources that are peer-reviewed. A primary source is written by the person who originated or is responsible for generating the ideas published. A research report written by the researchers who conducted the study is a primary source. A secondary source summarizes or quotes content from primary sources. Authors of secondary sources paraphrase the works of researchers and theorists and present their interpretation of what was written by the primary author.

Secondary sources are used only if primary sources cannot be located, or the secondary source provides creative ideas or a unique organization of information not found in a primary source. Peer-reviewed means that the author of the research report, clinical description, or theoretical explanation has submitted a manuscript to a journal editor, who identified scholars familiar with the topic to review the manuscript.

These scholars provide input to the editor about whether the manuscript in its current form is accurate, meets standards for quality, and is appropriate for the journal. A peer-reviewed paper has undergone significant scrutiny and is considered trustworthy. Quality literature reviews include relevant and current sources.

Relevant studies are those with a direct bearing on the problem of concern. Current sources are those published within 5 years before publication of the manuscript. Sources cited should be comprehensive as well as current. Some problems have been studied for decades, and the literature review often includes seminal and landmark studies that were conducted years ago.

Seminal studies are the first studies on a particular topic that signaled the beginning of a new way of thinking on the topic and sometimes are referred to as classical studies. Landmark studies are significant research projects that have generated knowledge that influences a discipline and sometimes society as a whole. Such studies frequently are replicated or serve as the basis for the generation of additional studies. Some authors may describe a landmark study as being a groundbreaking study.

Citing a few older studies significant to the development of knowledge on the topic being reviewed is appropriate. Most publications cited, however, should be current. Replication studies are reproductions or repetitions of a study that researchers conduct to determine whether the findings of the original study could be found consistently in different settings and with different subjects. Replication studies are important to build the evidence for practice.

A replication study that supports the findings of the original study increases the credibility of the findings and strengthens the evidence for practice. A replication that does not support the original study findings raises questions about the credibility of the findings. Syntheses of research studies, another type of data-based literature, may be cited in literature reviews.

A research synthesis may be a systematic review of the literature, meta-analysis of quantitative studies, meta-synthesis of qualitative studies, or a mixed-method systematic review. These publications are valued for their rigor and contributions to evidence-based practice see Chapters 1 and Appraising the literature review of a published study involves examining the quality of the content and sources presented.

A correctly prepared literature review includes what is known and not known about the study problem and identifies the focus of the present study. As a result, the review provides a basis for the study purpose and may be organized according to the variables quantitative or concepts qualitative in the purpose statement. The sources cited must be relevant and current for the problem and purpose of the study. The reviewer must locate and review the sources or respective abstracts to determine whether these sources are relevant.

To judge whether all the relevant sources are cited, the reviewer must search the literature to determine the relevant sources. This is very time-consuming and usually is not done for appraisal of an article. However, you can review the reference list and determine the focus of the sources, the number of data-based and theoretical sources cited, and where and when the sources were published.

Sources should be current, up to the date the paper was accepted for publication. Most articles indicate when they were accepted for publication on the first page of the study. Although the purpose of the literature review for a quantitative study is different from the purpose of the literature review for a qualitative study, the guidelines for critically appraising the literature review of quantitative and qualitative studies are the same.

However, because the purposes of literature reviews are different, the type of sources and the extent of the literature cited may vary. Critical Appraisal Guidelines. Synthesis of strengths and weaknesses of available evidence. The anxiety related to having a surgical or diagnostic procedure can have adverse effects. Brand, Munroe, and Gavin , p.

In addition to the references included in the review of the literature, these authors cited references throughout the research report. The reference list, previously formatted in the style of medical literature, is included in APA format in this chapter. All the cited references are considered in the critical appraisal.

Research Example. Because it is common, however, does not mean it should be ignored. The shift from inpatient hospital stays for surgery to same-day surgery has been monumental; most patients undergoing surgeries that once required an overnight hospital stay now go home within hours of surgery Mitchell, Unfortunately, nurses and physicians have a fraction of the time they once had to achieve all of the postoperative goals and outcomes, including, but not limited to, pain management and postoperative education Mitchell, Grieve described causes of anxiety in the preoperative patient.

These researchers also learned that when patients felt valued and attained a high level of comfort, these beliefs were strong predictors of patient satisfaction. There is a link between preoperative anxiety and postoperative pain. In their systematic review of predictors for postoperative pain, Ip et al. In their literature review, Vaughn et al. In her review of studies for strategies to decrease patient anxiety, Bailey found that perioperative education and music therapy were successful.

McRee et al. In their review, Cooke et al. Braden et al. However, the use of essential oils may pose challenges with infection control standards, which often specify the brand name i. Kim et al. Of all the alternative methods used to alleviate anxiety in preoperative patients, we identified hand massage as a strategy that was consistent with the time constraints in the perioperative setting.

We were curious to see whether hand massage would improve patient outcomes and overall patient satisfaction. Results of previous research have shown that significant psychological and physiological changes take place after a hand massage Kim et al. Hand massage is also a high-touch nursing care procedure that supports the concept of patients feeling valued and feeling the highest level of comfort during a time of stress and uncertainty.

Bailey, L. Strategies for decreasing patient anxiety in the perioperative setting. AORN Journal , 92 4 , — Braden, R. The use of the essential oil lavandin to reduce preoperative anxiety in surgical patients. Journal of Perianesthesia Nursing , 24 6 , — Chlan, L. Relationship between two anxiety instruments in patients receiving mechanical ventilatory support. Journal of Advanced Nursing , 48 5 , — Cline, M.

Standardization of the visual analog scale. Nursing Research , 41 6 , — Cooke, M. The effect of music on preoperative anxiety in day surgery. Journal of Advanced Nursing , 52 1 , 47— Creating the patient experience.

Controlling pain. New thinking about fibromyalgia pain. Nursing , 41 2 , 63— Forshee, B. Stress and disease. McCance, S. Huether, V. Rote Eds. Louis, MO: Mosby. Gilmartin, J. Day surgery: Patients felt abandoned during the preoperative wait. Journal of Clinical Nursing , 17 18 , — Grieve, R.

Day surgery preoperative anxiety reduction and coping strategies. British Journal of Nursing , 11 10 , — Ip, H. Predictors of postoperative pain and analgesic consumption. Anesthesiology , 3 , — Kim, M. Effects of hand massage on anxiety in cataract surgery using local anesthesia. Journal of Cataract and Refractive Surgery , 27 6 , — Leach, M.

How anxious are surgical patients? Lin, L. Abdominal surgery, pain and anxiety: Preoperative nursing intervention. Journal of Advanced Nursing , 51 3 , — McRee, L. Using massage and music therapy to improve postoperative outcomes. AORN Journal , 78 3 , — Mitchell, M.

Patient anxiety and modern elective surgery: A literature review. Journal of Clinical Nursing , 1 6 , — Nilsson, U. The anxiety- and pain-reducing effects of music interventions: A systematic review. AORN Journal , 87 4 , — Oshodi, T. The impact of preoperative education on postoperative pain. British Journal of Nursing , 16 3 , — Quattrin, R. Use of reflexology foot massage to reduce anxiety in hospitalized cancer patients in chemotherapy treatment: Methodology and outcomes.

Journal of Nursing Management , 14 2 , 96— Salmore, R. The effect of preprocedure teaching, relaxation instruction and music on anxiety as measured by blood pressures in an outpatient gastrointestinal endoscopy laboratory. Gastroenterology Nursing , 23 3 , — Statistical package for the social sciences.

Version Vaughn, F. Does preoperative anxiety level predict postoperative pain? AORN Journal , 85 3 , — Wang, S. The use of complementary and alternative medicines by surgical patients: A follow-up survey study. Anesthesia and Analgesia , 97 4 , — Wagner, D. Effects of comfort warming on perioperative patients. AORN Journal , 84 3 , — Watson, J. The philosophy and science of caring revised ed.

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Critical appraisal is the process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. If you have been fortunate enough to find a recent systematic review of evidence from a reliable source to answer your clinical question you will not have to undertake the process of critical appraisal. However, if you have found one or two individual studies you will need to assess the quality of the evidence to decide whether you wish to apply the evidence in practice.

For urgent issues, please call the Statewide Service Desk on 28 55 33 and press 2 for clinical. If you are not a member of NSW Health and would like to get in touch, please submit your enquiries here. Above all, the need for discussion and choice regarding place of death was identified as a priority by members of minority ethnic groups [ 30 ]. Lack of information in an appropriate format, negative perceptions and low awareness of services were identified as barriers to service use [ 19 , 25 , 28 ].

Problems persisted once services had been accessed; poor communication between patients and their families and healthcare professionals was an issue repeatedly emphasised [ 20 — 22 , 25 , 26 , 28 , 48 ]. Four reviews emphasised the importance of good communication above all other factors [ 19 , 22 , 26 ]. Specific problems included: a lack of information provided in appropriate languages and formats [ 19 , 25 , 28 ]; inadequate interpreting and advocacy provision [ 19 , 25 , 28 ]; differences in social taboos about death and illness [ 22 , 25 , 28 ]; and, difficulties in understanding and communicating both verbally and non-verbally [ 22 , 49 ].

Due to limited resources, family members were used to interpret information of a sensitive or unsuitable nature, increasing the risk of non-disclosure [ 25 ]. Jones [ 20 ], however, called for understanding in regard to disclosure and involvement of family members in decision-making. Furthermore, Payne et al. The communication of patients' wishes through advance care planning was discussed just twice in the reviews. Similarly, Cox et al. Negative perceptions towards services were considered significant impediments to increased utilisation, and some services were identified as culturally insensitive [ 48 ].

A common recommendation was the need for training in care that is sensitive to cultural difference [ 23 — 25 , 28 , 29 , 48 ]. Only one review, however, explicitly defined the terms used for such care 'cultural competence' and 'cultural safety' [ 25 ]. In contrast to the frequent recognition that services need to provide culturally competent care, few reviews provided recommendations about how to achieve this.

Only one review highlighted the large numbers of minority ethnic staff working in the healthcare services [ 29 ]. Cultural differences were said to lead to uncertainty, even when staff were trained in 'cultural competency' issues [ 29 ]. Concerns were raised about deterministic links between cultural, ethnic or religious factors and EoL preferences an approach referred to as the 'cookbook' approach [ 20 ] and the stereotyping of patients was warned against [ 19 , 20 ]. Jones [ 20 ] stated that the majority of literature regarding healthcare and minority ethnic groups merely presents information about religious rituals and beliefs.

Whereas, Payne et al. These concerns led authors to emphasize that meeting 'cultural' needs is only part of meeting patients' individual needs [ 19 , 20 , 24 , 28 , 30 ]. In contrast, Cox et al. The importance of monitoring service users' ethnicity was frequently stressed [ 20 , 23 , 25 , 29 — 31 ]. However, data was said to be inadequately collected and rarely used to influence service provision [ 25 , 29 ].

A number of recommendations were made in the reviews for improving EoL care services for minority ethnic groups table 4. The literature reviews concerning minority ethnic groups and EoL care in the UK described a range of social, institutional, epidemiological and cultural reasons for low service use and identified some distinct EoL preferences and needs.

In light of this evidence, in order to improve the use of, and satisfaction with, palliative care services by such groups, it is necessary to recognise the complexity of factors leading to low service use and sub-standard provision of care and implement a systematic, organisation wide, approach to tackling these multiple and inter-related factors. The influence of these multiple and inter-related factors was reflected in the reviews' recommendations for service improvement table 4.

Of the thirteen reviews identified, seven took a systematic approach [ 19 — 24 , 31 ], and four scored highly for methodological quality [ 19 , 21 , 23 , 50 ]. These reviews provide a good reflection of the evidence base and could be used to inform policy. Six reviews did not provide sufficient information for their quality to be graded, including the End-of-Life Care Strategy: Equality Impact Assessment [ 30 ].

The aim of this document was to ensure that the UK End-of-Life Care Strategy [ 37 ] 'does not inadvertently create inequality', but referenced just seven articles concerning 'race' and 'religion'. Due to the relatively small number of articles included in the End-of-Life Care Strategy: Equality Impact Assessment [ 30 ], the themes and recommendations identified from the literature reviews were compared and contrasted with those of the End-of-Life Care Strategy [ 37 ].

The recommendations regarding minority ethnic groups made within the Strategy table 5 were more limited than those made within the reviews table 4 , and omitted a number of recommendations made in its own Equality Impact Assessment [ 30 ] table 4. The recommendations focused on problems that arise during the physician-patient encounter such as issues regarding communication and awareness of different EoL preferences or raising awareness of services amongst minority ethnic groups table 5.

Although inequalities in service provision due to geographical factors or disease group were addressed in the Strategy, their contribution to low service use by minority ethnic groups was not recognised. In addition, a lack of timely referrals for members of minority ethnic groups was not mentioned. No mention was made to minority ethnic groups in the Strategy's sections on 'place of death', 'core principles and competencies', 'education, training and continued development', 'improving the environment', 'prisons and secure units' even though one third of prisoners come from minority ethnic groups [ 51 ] and 'future research'.

The need for 'spiritual, religious and cultural care competences' to be 'adopted within all core training' was highlighted, however, these needs were not repeated in the Strategy's sections regarding 'core principles and competencies' and 'education, training and continued development'. In addition, the Strategy took an apparent 'cookbook' approach regarding organ donation, providing the link to a website on 'the perspectives on organ donation of the six major religions in the UK' [ 37 ], an approach criticised within the reviews.

A case study which described an 'engagement project' referred to the establishment of a dialogue between the hospice and 'ethnic communities' [ 37 ]. Use of the term 'ethnic' to describe 'minority ethnic groups' implies that 'ethnicity' is something that only 'minority ethnic groups' have, rather than recognising that, in fact, 'ethnicity' is something that everyone has.

Furthermore, the End-of-Life Care Strategy: Equality Impact Assessment [ 30 ] used the terms 'minority ethnic', 'black and minority ethnic' and 'race' interchangeably, implying equivalence. The evidence base which informed the Strategy's recommendations on minority ethnic groups was found to be small.

The bibliography includes just one review Cox et al. Moreover, just five studies and one report concerning minority ethnic groups were cited [ 18 , 22 , 28 , 52 — 55 ]. Its sections on 'race' and 'religion', however, highlighted a paucity of research looking at inequality due to 'racial' or 'religious' factors and referenced just seven articles [ 18 , 52 , 54 , 56 — 59 ], only five of which were original studies [ 30 ].

Thirteen reviews concerning minority ethnic groups and EoL care in the UK were identified, of which seven took a systematic approach [ 19 — 24 , 31 ]. However, the reviews identified either had a narrow focus, such as restricting the review by ethnic group [ 24 ] or a particular aspect of EoL care [ 21 , 22 , 31 ], or were broader reviews of cancer services and minority ethnic groups that reported significant findings regarding EoL care [ 19 , 23 ].

Only one systematic review specifically focused on minority ethnic groups and EoL care in the UK [ 20 ]. However, this review received a low quality score 4 and most articles included came from outside the UK. There remains a need for a thorough systematic review of EoL care and minority ethnic groups in the UK to improve the evidence base on which policy initiatives are ideally based.

Thirteen reviews of the literature concerning minority ethnic groups and EoL care were identified. The complexity of inter-related social, institutional, epidemiological and cultural factors leading to low service use were recognised and this complexity was reflected in the reviews' recommendations for service improvement.

Recommendations made in the End-of-Life Care Strategy were limited in comparison. However, despite certain omissions, the recommendations made within the Strategy give the impression that minority ethnic groups had been taken into consideration. The lack of integration, however, of these recommendations into key sections of the document brings their real impact into question.

In addition, the evidence base, on which recommendations were made, was found to be narrow and some important issues addressed in the Equality Impact Assessment were not addressed. Public healthcare policy is ideally based upon systematic reviews of the literature.

All but three of the thirteen reviews of the literature identified [ 23 , 29 , 31 ] had been published prior to the publication of the End-of-Life Care Strategy. In response to the finding that these reviews had a minimal influence on the End-of-Life Care Strategy, it is recommended that future policy be based upon systematic reviews of the current literature, or at least upon existing systematic reviews, in order to reflect the current evidence and minimise bias. Six non-systematic narrative reviews which are more at risk of selection bias were included.

Furthermore, publication bias towards quantitative studies whose results are statistically significant, and towards qualitative studies which have striking or easily understandable findings, may introduce sources of bias into systematic reviews of the literature. The reviews which took a systematic approach were of varying quality, although on average they were of a reasonable standard. The narrow focus of some reviews may have biased results towards these topics.

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Journal of The Royal Society of Medicine. Download references. PRISMA aims to provide evidence and guidance on best practice to ensure that research can measure and improve outcomes for patients and families.

PRISMA activities aim to reflect the preferences and cultural diversities of citizens, the clinical priorities of clinicians, and appropriately measure multidimensional outcomes across settings where end-of-life care is delivered.

Principal Investigator: Richard Harding. Scientific Director: Irene J Higginson. In addition, the authors thank Yasmin Gunaratnam for comments regarding the terminology used in the End-of-Life Care Strategy. You can also search for this author in PubMed Google Scholar. Correspondence to Natalie Evans. NE designed the search strategy, screened articles, carried out data extraction, graded papers, participated in team meetings in which grading of papers was discussed, analysed results and drafted the manuscript.

AM participated in team meetings in which grading of papers was discussed and helped to draft the manuscript. EA participated in team meetings in which grading of papers was discussed and helped to draft the manuscript. JK provided help with the search strategy and helped to draft the manuscript.

RH participated in its design and coordination of the project and helped to draft the manuscript. IH participated in its design and coordination of the project and helped to draft the manuscript. RP participated in its design and coordination of the project and helped to draft the manuscript. MG screened articles, carried out data extraction, graded papers, analysed findings, participated in team meetings in which grading of papers was discussed, conceived the project and helped to draft the manuscript.

All authors read and approved the final manuscript. This article is published under license to BioMed Central Ltd. Reprints and Permissions. Evans, N. Appraisal of literature reviews on end-of-life care for minority ethnic groups in the UK and a critical comparison with policy recommendations from the UK end-of-life care strategy.

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How to read a systematic review and meta-analysis

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