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Primary Sources are written by the person(s) who developed the theory or conducted the research. An appropriate literature review mainly reflect the use of primary sources.

Secondary Sources are usually a brief description of a study,written by person(s) other than the original researcher. Often, a secondary source represents a response to, or a summary and critique of, the original researchers' work.

Source: Fain, J. A. (2009). Reading, understanding, and applying nursing research (3rd ed.). Philadelphia: F.A. Davis Co..

It is helpful to begin by identifying the type of information you seek. For example, EBP questions are typically classified as background or foreground questions.  Ask a Librarian for assistance as you begin your research process. 

Background questions help you identify and understand what is known about an area of interest when it is unfamiliar. These questions address general knowledge of disease processes or clinical contexts and are often broad in scope. Example: Is Obesity a Disease? (Britannica ProCon.org).

Locating background information on a given topic can be critical for understanding the scope, context and foundation for a research area of interest. Background questions tend to be broader than specific clinical questions, and may include information such as:

• overviews of a particular disease or condition
• summaries of the key features of a given patient population
• explanations of a type of intervention (e.g., drug information)
• patient-facing educational materials related to a condition or an intervention
• summary statistics regarding a given disease or condition

When selecting a background source, consider:

• currency - how recently was the resource published? Is the topic an emerging technology or within a field of inquiry where information changes rapidly? (If so, consider searching for a very recent review article or evidence summary)
• authorship - who is the author? (a person? an organization?) What are their qualifications or expertise within the field?

Foreground questions ask for specific knowledge to inform decisions or actions and generally compare one or more options (intervention/comparison to the gold standard of care).

Foreground questions are more granular and refer to a particular feature of the condition in question, such as how best to make the right diagnosis, how to treat it, or what to expect based on factors the patient possesses. Therefore, foreground questions require primary sources that synthesize a wide range of knowledge, requiring a comprehensive literature search. Ask a Librarian for assistance. 

In order to most appropriately choose an information resource and craft a search strategy, it is necessary to consider what kind of question you are asking: a specific, narrow "foreground" question, or a broader background question that will help give context to your research (e.g. prevention, etiology, diagnostic, therapy). 

Tools: Cochrane Reviews (PICOs) | PICO Resource Center (Ovid)

Developing an effective and well-structured EBP question is very important because it directs the strategies you and your team will use to search for evidence. The PICO(TS) format is used to create questions that are as specific as possible, making your search more productive and efficient. Ask a Librarian for assistance. 

PICO(TS) defines and describes the elements of an answerable EBP question:

P = Patient/Population/Problem: Describes the patient, population, or problem succinctly. Includes the type of patient or population and the setting, considering attributes such as age, gender, symptoms, and diagnosis.

I = Intervention or Issue of Interest: The intervention can be a clinical treatment, an educational or administrative intervention, or a structure or process.

C = Comparison:  Foreground questions compare one intervention to another. Background questions do not include a comparison.

O = Outcome: This component describes the desired change or improvement.

T = Timing: Define the duration of treatment and the follow-up schedule that matter to patients. Consider both long- and short-term outcomes.

S = Setting: Define the setting (primary, specialty, inpatient, nursing homes, or other long-term care setting) where the study is implemented and the relevance of the study setting to real world use.

Source: Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. 

PICO is a widely used acronym to assist in remembering the key components of a clinical question. There are additional letters and frameworks to help you formulate a question fitting your research. Not all parts of PICO are required! PICO is a framework to help you narrow your topic, not a rule. PICO is the most common framework for developing a clinical research question, but multiple question frameworks exist.

When should you use PICO?

• In academia, when you are looking for evidence to support best practice
• In practice, when you have a question about patient care

Why should you use PICO?

• Helps you form a focused question that will return relevant results
• Helps you retrieve a manageable amount of results
• Assists you in brainstorming keywords for your research
• Saves time!

When should you use PPCO (Problem, Population, Change, Outcome)?

• Evidence based practice quality initiatives.
• Example: “Because the county’s one OB-GYN clinic no longer offers perinatal care services (P) to childbearing people (P), what clinic alternatives exist (C) for the delivery of safe perinatal care (O)?"

 Across most frameworks, you will often be considering:

• who (who was studied - a population or sample)
• what (what was done or examined - an intervention, an exposure, a policy, a program, a phenomenon)
• how ([how] did the [what] affect the [who] - an outcome, an effect)

Branum, Candise MLS; Schiavenato, Martin PhD, RN. Can ChatGPT Accurately Answer a PICOT Question?: Assessing AI Response to a Clinical Question. Nurse Educator: 10.1097/NNE.NNE.0000000000001436, April 28, 2023. DOI: 10.1097/NNE.0000000000001436.

Waldrop, J., & Jennings-Dunlap, J. (2024). CE: Beyond PICO-A New Question Simplifies the Search for Evidence. The American journal of nursing, 124(3), 34–37. https://doi.org/10.1097/01.NAJ.0001007676.91191.dd  

Waldrop, Julee DNP, PNP-BC, EBP-C, FAANP, FAAN; Jennings-Dunlap, Jayne DNP, FNP, CNE, EBP-C. CE: The Mountain Model for Evidence-Based Practice Quality Improvement Initiatives. AJN, American Journal of Nursing ():10.1097/01.NAJ.0001014540.57079.72, April 10, 2024. | DOI: 10.1097/01.NAJ.0001014540.57079.72 

Searching databases in a consistent, structured manner will save you time. As your searching progresses and your searches are refined, your search history can be extremely useful. It can also improve the relevancy of results obtained, as you reflect on your keywords and synonyms and how these influence your search results.

To develop a search strategy you will need to:

• define and write down your research question - what is it that you are going to research?
• identify, and keep a record of PICO question key words, MeSH terms and phrases
  • brainstorming your main discussion points to create concept/mind maps can help tease out themes and keywords
  • identify keyword synonyms, use a database Thesauri or Subject Headings;
• determine a time frame for your research, if needed
• consider what type of material you will include and why
• identify where you will search for the information
• look for pros and cons in your research - example: Do Video Games Contribute to Youth Violence?
• DO NOT only look for studies that support your hypothesis, rather follow where the evidence leads you
• know the science: how to make sense of a scientific journal article [NCCIH]
• Ask a Librarian for assistance! 

Searching is an iterative process and often requires re-evaluation and testing by adding or changing keywords and the ways they relate to each other. To guide your search development, follow the search steps below.

PICOT Example:

• P: Hospitalized adult patients
• I: Implementation of a nurse-led patient education program
• C: Standard care without a specific education program
• O: Reduction in hospital readmission rates
• T: Within 30 days post-discharge

Example PICOT Question: In hospitalized adult patients (P), how does the implementation of a nurse-led patient education program (I) compared to standard care affect hospital readmission rates (O) within 30 days post-discharge (T)?

Example Search Strategy:

1. Keywords and Phrases:
   • Hospitalized adult patients
   • Nurse-led patient education program
   • Standard care
   • Hospital readmission rates
   • 30 days post-discharge
2. Databases to Search:
   • Agency for Healthcare Research & Quality
   • ERIC
   • PubMed @ SMU
   • CINAHL (Cumulative Index to Nursing and Allied Health Literature)
   • Cochrane Library
   • Ovid | MEDLINE
   • Nursing & Allied Health Premium
   • Google Scholar
   • Trip Database Pro

Hand Search Journals: Health Affairs, Nursing, American Journal of Nursing

1. Medical Subject Headings [MeSH] Search Terms and Keyword Search Strategy:
   • ("Patient Readmission"[Mesh]) AND "Patient Education as Topic"[Mesh]
   • Combine keywords using Boolean operators (AND, OR, NOT)
   • Example: (“hospitalized adult patients” AND “nurse-led patient education program” AND “hospital readmission rates” AND “30 days post-discharge”)
2. Filters and Limits:
   • Limit to peer-reviewed articles, Adult: 19+ years), English
   • Set publication date range (e.g., last 5 years)
   • Filter by study type (e.g., randomized controlled trials, systematic reviews)
3. Review and Refine:
   • Review abstracts and titles for relevance
   • Refine search terms based on initial results
   • Use citation tracking to find additional relevant studies

Good search practice could involve keeping a search "research" log or document detailing your search activities so that you can keep track of effective search terms, or to help others to reproduce your steps and get the same results. 

This record could be a document, table, or spreadsheet with:

• The names of the sources you search and which provider you accessed them through - eg Medline (Ovid). You should also include any other literature sources you used.
• The search strategies that you applied when searching different sources (eg Medline) can be added as an appendix to your document. This provides additional detail on:
  • how you searched (keyword and/or subject headings)
  • which search terms you used (which words and phrases)
  • any search techniques you employed (truncation, adjacency, etc)
  • how you combined your search terms (AND/OR). 
• The number of search results from each source and each strategy used. This can be the evidence you need to prove a gap in the literature and confirms the importance of your research question.
• Gather your sources and organize with our writing and citing resource guides. 

A search planner may help you to organize your thoughts prior to conducting your search. If you have any problems with organizing your thoughts prior, during, and after searching please Ask a Librarian for individual help.