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THE BULK of nursing research in the past has been concerned with the study of the people doing nursing and the bureaucratic systems within which nursing takes place. Gradually the realization has grown that what is needed is more study of the process of nursing itself. This includes a study of what individuals are like in health and illness and how they respond to the stress of illness, changes in their way of life, and modifications of family structure. It includes as well an appraisal of nursing action in its attempt to modify these stresses and help individuals move toward health.1 Clinical nursing research is the way in which nurse-researchers study these processes trying to build a theoretical framework on which to base nursing actions. There are many difficulties involved in identifying problems for study and in planning this research. In this paper a look will be taken at specific problems in carrying out clinical nursing research.
As clinical nursing research gains prominence in the profession, the need for, and advantages of, pilot studies are increasing. This article describes the purposes of pilot studies, the potential positive and negative outcomes of these studies, and three examples of pilot studies with different outcomes. The emphasis is on issues related to clinical nursing research, particularly research done in acute care settings.
The focus group interview is an exciting qualitative research design that is gaining popularity among nurse clinicians and researchers. This article provides a practical approach to designing and implementing focus groups. The authors' own research experience with post-coronary angioplasty patients is used as a model.
The literature review is a critical step in designing and conducting a credible study. It might seem tedious at first, but your own ideas will become better developed and thoughtful as you critique what other researchers have done. It will make your study stronger. Thus, don't skim over this part of the process. A good literature review will make the next steps easier. It will also assure that you are studying an important area, that the outcome has clinical importance to your patients, and that writing and reporting the results will be easier.
PURPOSE: To review the literature for best practices for engaging clinical nurses in nursing research. DESIGN: Review of the research and nonresearch papers published between 2005 and 2015 that answered the evidence-based practice (EBP) question: what are the best practices for engaging clinical nursing staff in nursing research? METHODS: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Joanna Briggs Institute, and Cochrane were searched using a combination of controlled vocabulary and key words. Nineteen papers that answered the EBP question were selected for review. RESULTS: It can be difficult to involve clinical nurses in research. There are multiple factors to consider when nursing leadership looks to engage clinical nurses in nursing research. CONCLUSIONS: Nurse leaders can take many approaches to engage clinical nurses in research. Each organization must perform its own assessment to identify areas of opportunity. Nursing leadership can take these areas of opportunity to structure a multifaceted approach to support clinical staff in the conduct and dissemination of nursing research. CLINICAL RELEVANCE: The evidence from this review offers EBP recommendations as well as reports on the gaps in the literature related to best practices for engaging clinical nurses in nursing research.
The purpose of this study was to determine the effect of participation in research on staff nurses' attitude towards, access to, perceived support of and reported use of research in practice. Six medical surgical units in a southeastern Ontario teaching hospital were randomly assigned to receive 3 different levels of exposure to research: high, low and usual. On the high participation units, a clinical research group consisting of the investigator and interested nurses (n = 18) critiqued research literature related to an important clinical issue (i.e., patterns of sleep) and designed and implemented a clinical research study. On the low participation units, a similar clinical research group (n = 10) met once and were involved, solely, in the design and implementation of the clinical research protocol. On the control units, there were no formalized research groups or activities. All registered nurses (n = 235), including the research group participants, on the 6 units were surveyed with a research utilization questionnaire (RUQ) pre and post participant intervention. The RUQ scores were higher on the high participation units at baseline and post intervention in comparison to the low and control units. Nurses who participated directly in the clinical research groups (high and low) reported similar RUQ scores post intervention and higher scores in comparison to all nurses. All RUQ scores were higher post intervention. Nurses with clinical expertise but minimal research expertise participated meaningfully in clinical research. While participation had an individual effect there was no unit effect, suggesting other factors, such as organizational support and culture, are important determinants of research use.
PART ONE: PHILOSOPHICAL, THEORETICAL AND METHODOLOGICAL PERSPECTIVES AND ISSUES Section Overview - Ada Sue Hinshaw Diversity in Philosophical Approaches - Ada Jacox et al Evolving Nursing Research Traditions - Ada Sue Hinshaw Influencing Factors What Is Known about Caring in Nursing Science - Kristen M Swanson A Literary Meta-Analysis Relationship of Research Perspectives to Methodology - Carolyn L Murdaugh PART TWO (A): CRITICAL HEALTH NEEDS OF COMMUNITIES AND VULNERABLE POPULATIONS: CLINICAL NURSING RESEARCH FOR VULNERABLE POPULATIONS Section Overview - Toni Tripp-Reimer The Sampler Quilt - Clarann Weinert and Mary E Burman A Metaphor of Rural Communities Research with Immigrants and Refugees - Juliene G Lipson and Afaf I Meleis Cultural Interventions for Ethnic Groups of Color - Toni Tripp-Reimer Community-Focused Interventions and Outcomes Strategies - Joan K Magilvy, Nancy J Brown and Patricia Moritz PART TWO (B): CLINICAL NURSING PRACTICE STRATEGIES AND NURSE SENSITIVE OUTCOMES Section Overview - Joan L F Shaver Promoting Physiological Stability - Pamela H Mitchell Therapeutic Actions and Outcomes for Preterm (Low Birth Weight) Infants - Barbara S Medoff-Cooper and Diane Holditch-Davis Therapeutic Outcomes Sensitive to Nursing - William L Holzemer and Suzanne Bakken Henry PART TWO (C): FAMILIES IN HEALTH, ILLNESS AND LIFE TRANSITIONS Section Overview - Suzanne L Feetham Normative Family Transitions and Health Outcomes - Marilyn McCubbin Nursing Care of Families in No-Normative Transitions - Catherine L Gilliss and Kathleen A Knafl The State of Science and Practice Nursing Research of Families - Suzanne L Feetham and Susan B Meister State of the Science and Correspondence with Policy PART TWO (D): HEALTH PROMOTION AND RISK REDUCTION Section Overview - Nola J Pender Interventions for Promoting Health in Adolescents - Carol J Loveland-Cherry Prevention and Treatment of Hypertension in Black Americans - Martha N Hill Lowering Risk for Cardiovascular Disease in Children and Adolescents - Joanne S Harrel and Barabara J Speck Health Promotion and Disease Prevention Intervention in Worksites - Sally Lechlitner Lusk PART TWO (E): BIOBEHAVIORAL MANIFESTATIONS OF HEALTH AND ILLNESS Section Overview - Ada M Lindsey and Joan L F Shaver Management of Mobility and Altered Physical Activity - Barbara Smith and Mary MacVicar Managing Dyspnea - Virginia Carrieri-Kohlman and Susan Janson Managing Pain - Betty R Ferrell Managing Urinary and Fecal Incontinence - Molly C Dougherty and Linda L Jensen Managing Nausea and Vomiting - Margaret Heitkemper Managing Sleep and Waking Behaviors and the Symtom of Fatigue - Joan L F Shaver PART TWO (F): WOMEN'S HEALTH Section Overview - Nancy Fugate Woods Women's Work, Women's Health - Marcia Gruis Killien From Menarche to Menopause - Nancy Fugate Woods, Ellen Sullivan Mitchell and Diana Taylor Contributions form Nursing Research and Recommendations for Practice Infertility - Ellen Olshansky Women and Sexuality - Catherine Ingram Fogel Contributions from Nursing Research and Practice Recommendations Clinical Nursing Research on Battered Women and Their Children - Jacquelyn Campbell and Barbara Parker A Review PART TWO (G): OLDER ADULTS: HEALTH AND ILLNESS ISSUES Section Overview - Patricia G Archbold Activities of Daily Living - Beverly L Roberts Factors Related to Independence Managing Cognitive Impairment and Depression in the Elderly - Cornelia K Beck et al Supportive and Non-Supportive Care Environments for the Elderly - Linda R Phillips and Martha Ayres PART TWO (H): ENVIRONMENTS FOR OPTIMIZING CLIENT OUTCOMES Section Overview - Joyce A Verran Acute Care Environments - Gail L Ingersoll and Pamela H Mitchell Transitional Environments - Dorothy Brooten and Mary Duffin Naylor Quality Outcomes and Contextual Variables in Nursing Homes - Meridean L Maas and Janet P Specht
BACKGROUND: The acquisition of quality clinical experience within a supportive and pedagogically adjusted clinical learning environment is a significant concern for educational institutions. The quality of clinical learning usually reflects the quality of the curriculum structure. The assessment of the clinical settings as learning environment is a significant concern within the contemporary nursing education. The nursing students' satisfaction is considered as an important factor of such assessment, contributing to any potential reforms in order to optimize the learning activities and achievements within clinical settings. The aim of the study was to investigate nursing students' satisfaction of the clinical settings as learning environments. METHOD: A quantitative descriptive, correlational design was used. A sample of 463 undergraduate nursing students from the three universities in Cyprus were participated. Data were collected using the Clinical Learning Environment, Supervision and Nurse Teacher (CLES + T). RESULTS: Nursing students were highly satisfied with the clinical learning environment and their satisfaction has been positively related to all clinical learning environment constructs namely the pedagogical atmosphere, the Ward Manager's leadership style, the premises of Nursing in the ward, the supervisory relationship (mentor) and the role of the Nurse Teacher (p < 0.001). Students who had a named mentor reported more satisfied with the supervisory relationship. The frequency of meetings among the students and the mentors increased the students' satisfaction with the clinical learning environment. It was also revealed that 1st year students were found to be more satisfied than the students in other years. CONCLUSION: The supervisory relationship was evaluated by the students as the most influential factor in their satisfaction with the clinical learning environment. Student's acceptance within the nursing team and a well-documented individual nursing care is also related with students' satisfaction. The pedagogical atmosphere is considered pivotal, with reference to students' learning activities and competent development within the clinical setting. Therefore, satisfaction could be used as an important contributing factor towards the development of clinical learning environments in order to satisfy the needs and expectations of students. The value of the development of an organized mentorship system is illustrated in the study.
Using the Delphi technique, a panel of 433 nurse and nonnurse experts was surveyed regarding priorities for clinical research in nursing. Of these, 341 completed all four Delphi survey rounds. Three questions were studied: 1) Is this an area in which nursing should assume primary research responsibility? 2) How important is research on this topic for the profession of nursing? 3) What is the likelihood of change in patient welfare because of research on the topic? Although the nature and amount of data produced prohibited interpretation of the data or delineation of succinct conclusions about priorities for clinical nursing research, responses to the three questions supported these statements: The majority of research areas identified in the questionnaire are areas in which nursing should take research leadership. Although there is some overlap, priorities for professional significance and social or patient welfare relevance are different. In terms of professional significance, highest priority was given to items regarding measuring the quality of care, role, nursing process, and the research process. In terms of patient welfare, several programs of research are discernible in the items ranked in the top ten percent; these include nursing interventions related to stress, care of the aged, pain, and patient education. The Delphi technique also is described.
AIMS AND OBJECTIVES: To describe the importance of, and methods for, successfully conducting and translating research into clinical practice. BACKGROUND: There is universal acknowledgement that the clinical care provided to individuals should be informed on the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice, decisions and change to improve the way we deliver care. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients, families and society. Despite its importance, translating research into clinical practice is challenging. There are more nurses in the frontline of health care than any other healthcare profession. As such, nurse-led research is increasingly recognised as a critical pathway to practical and effective ways of improving patient outcomes. However, there are well-established barriers to the conduct and translation of research evidence into practice. DESIGN: This clinical practice discussion paper interprets the knowledge translation literature for clinicians interested in translating research into practice. METHODS: This paper is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We provide practical, evidence-informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse-led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are presented in conjunction with supporting evidence. CONCLUSIONS: Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician/consumer behaviour change and it is critical that implementation strategy includes this. RELEVANCE TO PRACTICE: Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central.
AIMS: The aim of this paper is to report a study to identify themes and provide a 'snap-shot' of the scope and uses of photography in clinical nursing practice and research. BACKGROUND: Despite the dominance of vision as a way of understanding the world in Western societies, the applications of photography in clinical nursing practice and research have not been well synthesized or reported in the literature. METHODS: A computerized search of CINAHL database was performed using the terms photographs, photography, photographic, photovoice, videorecording and videotaping. Hand searching for additional citations was also undertaken. FINDINGS: The identified papers on photography were categorized into broad themes that reflected the different applications to which photography had been applied: documentation and surveillance; therapeutic intervention; teaching, learning and evaluating performance; research methods; and descriptive and instructional literature. Approaches to the use of photography, as recorded in the nursing literature, are broad and include: wound surveillance, covert patient surveillance, photo essay, art therapy, self-portraits, life albums, simulated recall, participant observation, photovoice, photo hermeneutics, production of research scenarios, and video modelling. CONCLUSIONS: The most common applications of photography in nursing and related journals include photo elicitation to promote understanding in research, videorecording as a method of teaching and learning, and as a method of observation, with more creative approaches tending to be employed in health professions other than nursing. Few reports gave explanations of how researchers negotiated ethical concerns when seeking approval for studies in clinical settings, and few gave details of the processes of data analysis.
This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.
Sparked by the Institute of Medicine's report titled Crossing the Quality Chasm, research-based decision making has been emphasized for improving care. Patients should receive care that is based on the best available scientific knowledge, and care should not vary from clinician to clinician or from place to place. Implementing research-based practices at the bedside is a complex endeavor. It is all too easy to discover that clinically important research findings are either not known by practitioners or not being used in actual practice. Efforts to instill and sustain research-based practices improve significantly when staff nurses are involved with the research from the start. Institutions that are effective in involving clinicians have built a foundation of infrastructures that enable processes for engaging clinicians to take place. What distinguishes effective from ineffective hospital nursing research and evidence-based practice programs is the presence of structures whereby processes can occur that (1) unleash the creativity of staff by securing their involvement early, (2) educate staff by involving them, (3) create internal expertise for research and evidence-based practice, and (4) ensure that patients experience principled implementation of research-based practices to improve their lives. This article describes infrastructures that can ensure and sustain research-based practices while unleashing the talent and creativity of clinicians as they question practice and ponder the merits of current research. Fostering participation in such clinical inquiry will summon professional growth, influence the lives of patients, and help each nurse develop a unique personal professional legacy.
The aims of this research project were to identify areas for research in Australian critical care nursing with potential for improvement in patient care, and to advise nursing research policy and priorities with relevance to areas of patients' needs. Research participants represented a national sample of clinical nurse specialists (CNSs) and clinical nurse consultants (CNCs). The Delphi method was used to obtain the most reliable consensus of the specialist nurses, and over 238 research priorities were identified initially. In the final phase of the research nine high priorities were identified. The findings of this study suggest directions for clinical nursing research in critical care.
Effectiveness research is undertaken to evaluate the effects of interventions in achieving desired outcomes when tested in the real-world conditions of everyday practice. Although the randomized clinical trial (RCT) is considered the gold standard for effectiveness research, its feasibility, generalizability, and the clinical utility of its results are being questioned. This state of the science prompted the call for a paradigm shift, characterized by alternative methods for clinical research. The alternative methods attempt to account for clinical realities when conducting research, with the goal of minimizing discrepancies in the perspective and assumptions underlying practice and research. In this article a theory-driven approach to intervention evaluation is presented as a viable alternative paradigm for clinical research. The application of this approach demands changes in four aspects of research: participant selection criteria, assignment to treatment options, delivery of the intervention, and selection of outcome measures. The changes are discussed at the conceptual level and illustrated with examples from an ongoing multisite study aimed at determining the usefulness of this theory-driven approach to intervention evaluation.
Clinical Research for the Doctor of Nursing Practice is a user-friendly guide that offers DNP students a step-by-step method to implement clinically-based research. Designed specifically for DNP courses, it introduces a new, streamlined approach to research. It guides graduate students through the steps needed to complete a clinical research project by emphasizing crucial information and eliminating extraneous material. The book includes: *Learning objectives at the beginning of each chapter to highlight critical information in each chapter *Learning enhancement tools that encourage readers to think critically about the information presented and draw connections to their own research *Resources for further study throughout the book to aid students with their research *Glossaries to define new terms for the reader
Using the delphi technique, a group of clinical nurse specialists was surveyed regarding delineation of clinical nursing research priorities. Upon completion of the four-round survey, the results suggested that the top priorities for nursing research are: (1) factors which influence longevity in clinical nursing practice, (2) patient care delivery systems as related to nurse satisfaction, and (3) indicators of quality nursing care.
Is qualitative research an end in itself or the beginning of a process? qualitative nursing research - a free-for-all, Janice M.Morse on bracketing the phenomenological perspective,Joan M.Anderson on developing theory inductively ethnography and epistemology - generating nursing theory, Agnes M.Aamodt on ethics and validity being a phenomenologicl researcher, Vangie Bergum on fieldwork in your own setting the use of self in ethnographic research, Julienne G.Lipson on nursing phenomena doing fieldwork in your own culture, Peggy Ann Field on the evolving nature of qualitative methods in nursing qualitative clinical nursing research when a community is the client, Judith A.Strasser on terminology strategies for sampling, Janice M.Morse on replicability are counting and coding acappella appropriate in qualitative research?, Phylis Noerager Stern on issues about reliability and validity issues of reliability and validity,Pamela J.Brink on interviewing interview techniques in qualitative research - concerns and challenges, Katharyn Antle May on the relationship between the researcher and the subject conducting qualitative studies with children and adolescents, Janet A.Deatrick and Sandra A.Faux on triangulation triangulation in qualitative research - issues in conceptual clarity and purpose, Kathleen A.Knalf and Bonnie J.Breitmayer,the granting game funding strategies for qualitative research, Toni Tripp-Reimer and Marlene Zichi Cohen on muddling methods institutional review of qualitative research proposals - a task of no small consequence, Patricia L.Munhall on the team approach feild research - a collaborative model for practice and research, Joyceen S.Boyle on teaching qualitative methods teaching qualitative research - perennial problems and possible solutions, Sally A.Hutchinson and Rodman B.Webb.
Academia and Clinic18 August 2009Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA StatementFREEDavid Moher, PhD, Alessandro Liberati, MD, DrPH, Jennifer Tetzlaff, BSc, and Douglas G. Altman, DSc, the PRISMA Group*David Moher, PhDFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, Alessandro Liberati, MD, DrPHFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, Jennifer Tetzlaff, BScFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, and Douglas G. Altman, DScFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, the PRISMA Group*Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-4-200908180-00135 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Editor's Note: In order to encourage dissemination of the PRISMA Statement, this article is freely accessible on the Annals of Internal Medicine Web site (www.annals.org) and will be also published in PLOS Medicine, BMJ, Journal of Clinical Epidemiology, and Open Medicine. The authors jointly hold the copyright of this article. For details on further use, see the PRISMA Web site (www.prisma-statement.org).Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field (1, 2), and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research (3), and some health care journals are moving in this direction (4). As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies (5). In 1987, Sacks and colleagues (6) evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement (7).In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized, controlled trials (8). In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).Box 1. Conceptual Issues in the Evolution From QUOROM to PRISMA Download figure Download PowerPoint TerminologyThe terminology used to describe a systematic review and meta-analysis has evolved over time. One reason for changing the name from QUOROM to PRISMA was the desire to encompass both systematic reviews and meta-analyses. We have adopted the definitions used by the Cochrane Collaboration (9). A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. Meta-analysis refers to the use of statistical techniques in a systematic review to integrate the results of included studies.Developing the PRISMA StatementA three-day meeting was held in Ottawa, Ontario, Canada, in June 2005 with 29 participants, including review authors, methodologists, clinicians, medical editors, and a consumer. The objective of the Ottawa meeting was to revise and expand the QUOROM checklist and flow diagram, as needed.The executive committee completed the following tasks, prior to the meeting: a systematic review of studies examining the quality of reporting of systematic reviews, and a comprehensive literature search to identify methodological and other articles that might inform the meeting, especially in relation to modifying checklist items. An international survey of review authors, consumers, and groups commissioning or using systematic reviews and meta-analyses was completed, including the International Network of Agencies for Health Technology Assessment (INAHTA) and the Guidelines International Network (GIN). The survey aimed to ascertain views of QUOROM, including the merits of the existing checklist items. The results of these activities were presented during the meeting and are summarized on the PRISMA Web site (www.prisma-statement.org).Only items deemed essential were retained or added to the checklist. Some additional items are nevertheless desirable, and review authors should include these, if relevant (10). For example, it is useful to indicate whether the systematic review is an update (11) of a previous review, and to describe any changes in procedures from those described in the original protocol.Shortly after the meeting a draft of the PRISMA checklist was circulated to the group, including those invited to the meeting but unable to attend. A disposition file was created containing comments and revisions from each respondent, and the checklist was subsequently revised 11 times. The group approved the checklist, flow diagram, and this summary paper.Although no direct evidence was found to support retaining or adding some items, evidence from other domains was believed to be relevant. For example, Item 5 asks authors to provide registration information about the systematic review, including a registration number, if available. Although systematic review registration is not yet widely available (12, 13), the participating journals of the International Committee of Medical Journal Editors (ICMJE) (14) now require all clinical trials to be registered in an effort to increase transparency and accountability (15). Those aspects are also likely to benefit systematic reviewers, possibly reducing the risk of an excessive number of reviews addressing the same question (16, 17) and providing greater transparency when updating systematic reviews.The PRISMA StatementThe PRISMA Statement consists of a 27-item checklist (Table 1; see also Table S1, for a downloadable Word template for researchers to re-use) and a four-phase flow diagram (Figure 1; see also Figure S1, for a downloadable Word template for researchers to re-use). The aim of the PRISMA Statement is to help authors improve the reporting of systematic reviews and meta-analyses. We have focused on randomized trials, but PRISMA can also be used as a basis for reporting systematic reviews of other types of research, particularly evaluations of interventions. PRISMA may also be useful for critical appraisal of published systematic reviews. However, the PRISMA checklist is not a quality assessment instrument to gauge the quality of a systematic review.Table 1. Checklist of Items to Include When Reporting a Systematic Review or Meta-AnalysisFigure 1. Flow of information through the different phases of a systematic review. Download figure Download PowerPoint From QUOROM to PRISMAThe new PRISMA checklist differs in several respects from the QUOROM checklist, and the substantive specific changes are highlighted in Table 2. Generally, the PRISMA checklist “decouples” several items present in the QUOROM checklist and, where applicable, several checklist items are linked to improve consistency across the systematic review report.Table 2. Substantive Specific Changes Between the QUOROM Checklist and the PRISMA ChecklistThe flow diagram has also been modified. Before including studies and providing reasons for excluding others, the review team must first search the literature. This search results in records. Once these records have been screened and eligibility criteria applied, a smaller number of articles will remain. The number of included articles might be smaller (or larger) than the number of studies, because articles may report on multiple studies and results from a particular study may be published in several articles. To capture this information, the PRISMA flow diagram now requests information on these phases of the review process.EndorsementThe PRISMA Statement should replace the QUOROM Statement for those journals that have endorsed QUOROM. We hope that other journals will support PRISMA; they can do so by registering on the PRISMA Web site. To underscore to authors, and others, the importance of transparent reporting of systematic reviews, we encourage supporting journals to reference the PRISMA Statement and include the PRISMA Web address in their instructions to authors. We also invite editorial organizations to consider endorsing PRISMA and encourage authors to adhere to its principles.The PRISMA Explanation and Elaboration PaperIn addition to the PRISMA Statement, a supporting Explanation and Elaboration document has been produced (18) following the style used for other reporting guidelines (19–21). The process of completing this document included developing a large database of exemplars to highlight how best to report each checklist item, and identifying a comprehensive evidence base to support the inclusion of each checklist item. The Explanation and Elaboration document was completed after several face-to-face meetings and numerous iterations among several meeting participants, after which it was shared with the whole group for additional revisions and final approval. Finally, the group formed a dissemination subcommittee to help disseminate and implement PRISMA.DiscussionThe quality of reporting of systematic reviews is still not optimal (22–27). In a recent review of 300 systematic reviews, few authors reported assessing possible publication bias (22), even though there is overwhelming evidence both for its existence (28) and its impact on the results of systematic reviews (29). Even when the possibility of publication bias is assessed, there is no guarantee that systematic reviewers have assessed or interpreted it appropriately (30). Although the absence of reporting such an assessment does not necessarily indicate that it was not done, reporting an assessment of possible publication bias is likely to be a marker of the thoroughness of the conduct of the systematic review.Several approaches have been developed to conduct systematic reviews on a broader array of questions. For example, systematic reviews are now conducted to investigate cost-effectiveness (31), diagnostic (32) or prognostic questions (33), genetic associations (34), and policy making (35). The general concepts and topics covered by PRISMA are all relevant to any systematic review, not just those whose objective is to summarize the benefits and harms of a health care intervention. However, some modifications of the checklist items or flow diagram will be necessary in particular circumstances. For example, assessing the risk of bias is a key concept, but the items used to assess this in a diagnostic review are likely to focus on issues such as the spectrum of patients and the verification of disease status, which differ from reviews of interventions. The flow diagram will also need adjustments when reporting individual patient data meta-analysis (36).We have developed an explanatory document (18) to increase the usefulness of PRISMA. For each checklist item, this document contains an example of good reporting, a rationale for its inclusion, and supporting evidence, including references, whenever possible. We believe this document will also serve as a useful resource for those teaching systematic review methodology. We encourage journals to include reference to the explanatory document in their Instructions to Authors.Like any evidence-based endeavor, PRISMA is a living document. To this end we invite readers to comment on the revised version, particularly the new checklist and flow diagram, through the PRISMA Web site. We will use such information to inform PRISMA's continued development.References1. Oxman AD, Cook DJ, Guyatt GH. Users' guides to the medical literature. VI. How to use an overview. Evidence-Based Medicine Working Group. JAMA. 1994;272:1367-71. [PMID: 7933399] CrossrefMedlineGoogle Scholar2. Swingler GH, Volmink J, Ioannidis JP. Number of published systematic reviews and global burden of disease: database analysis. BMJ. 2003;327:1083-4. [PMID: 14604930] CrossrefMedlineGoogle Scholar3. Canadian Institutes of Health Research. Randomized controlled trials registration/application checklist. December 2006. Accessed at www.cihr-irsc.gc.ca/e/documents/rct_reg_e.pdf on 19 May 2009. Google Scholar4. Young C, Horton R. Putting clinical trials into context. Lancet. 2005;366:107-8. [PMID: 16005318] CrossrefMedlineGoogle Scholar5. Mulrow CD. 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[PMID: CrossrefMedlineGoogle In to A Article, and Disclosure From Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United The following to the PRISMA Altman, DSc, Centre for Statistics in Medicine United PhD, University Hospital MD, Health Research & Health PLoS Medicine United PhD, Hospital of Ontario, A. & Research and PhD, PLoS Medicine the of United PhD, Cochrane Centre United and of and MD, of Medicine, Clinical Epidemiology and University Ontario, PhD, Università di Modena e Reggio and Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario J. PhD, University of United MD, PhD, of Medicine, Clinical Epidemiology and University Ontario, PhD, of Health MD, of and Medicine, University of MD, PhD, Medical United MD, The Cochrane Centre PhD, Ottawa Hospital Research Institute Ontario, MD, of Medicine, Clinical Epidemiology and University Ontario, PhD, United MD, University of MD, PhD, Systematic Reviews United and for Health and University of the and Alessandro Liberati, MD, Università di Modena e Reggio and Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario MD, Centre for the of the of Health PhD, The United MD, Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Moher, PhD, Ottawa Methods Centre, Ottawa Hospital Research Institute Ontario, MD, Annals of Internal Medicine for Medical MD, Health Research Centre Health and Technology Assessment Ontario, Canada; at the of the first meeting of the group, Ontario, MD, University of Hospital of Ontario, PhD, Health International G. MD, PhD, Evidence-Based Jennifer Tetzlaff, BSc, Ottawa Methods Centre, Ottawa Hospital Research Institute Ontario, The Cochrane Cochrane Collaboration United at the of the first meeting of the group, United and MD, Institute of University of Ottawa Ontario, PRISMA was by the Canadian Institutes of Health Università di Modena e Reggio Emilia, Italy; Research Clinical Evidence The Cochrane Collaboration; and Liberati is in through of the of University and Altman is by Research Moher is by a University of Ottawa Research of the any in the or of the PRISMA no a role in the Moher, PhD, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Ottawa, Canada; Moher and Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Ottawa, Università di Modena e Reggio and Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Centre for Statistics in Medicine, University of Oxford, United of the PRISMA is in the PRISMA Statement for Reporting Systematic Reviews and of Studies Health Explanation and Elaboration Alessandro Liberati Douglas G. Altman Jennifer