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UNDERSTANDING
RESEARCH METHODS
for evidence-based
practice in health
S ECO N D E D ITI O N
TR I S H A M . J OH N EL AINE AMANDA JA N E
G R E EN H ALGH BIDEWELL CRISP L AMBROS WA RL A N D
© John Wiley & Sons Australia, Ltd. Not for resale or distribution. Any unauthorised distribution or use will result in legal action.
Understanding
research methods
for evidence-based
practice in health
SECOND EDITION
Trisha M Greenhalgh
John Bidewell
Elaine Crisp
Amanda Lambros
Jane Warland
Pdf_Folio:i
Second edition published 2020 by
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© John Wiley & Sons Australia, Ltd 2017, 2020
Authorised adaptation of Trisha Greenhalgh, How to Read a Paper: The Basics of

Evidence-Based Medicine, 5th edition (ISBN 9781118800966), published by BMJ Books, used
under licence by John Wiley & Sons, Inc., Chichester, United Kingdom. © 2014 in the United
Kingdom by John Wiley & Sons Inc. All rights reserved.
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BRIEF CONTENTS
About the authors vii
1. Introduction to research, the research process and EBP 1

2. Asking questions and searching for evidence 11
3. Reviewing literature 21
4. Qualitative research 32
5. Quantitative research 43
6. Levels of evidence 55
7. Statistics for the non-statistician 73
8. Mixed methods research 88
9. Sampling 97
10. Ethics 106
11. Getting evidence into practice 114
12. Challenges to evidence-based practice 124
Index 133
Pdf_Folio:iii
CONTENTS
About the authors vii 3.2 Reviewing the methods of primary
research papers 25
CHAPTER 1 Sample and setting: who are the participants,
and where is the study being
Introduction to research, the carried out? 25
research process and EBP 1 What data-collection methods
1.1 The meaning of ‘evidence-based were used? 26
practice’ 2 How was the data analysed? 26
1.2 Apprehension towards evidence-based 3.3 Reviewing the methods of secondary
practice 5 (review) papers 26
Decision making by anecdote 6 Question 1. What is the focused clinical
Decision making by press cutting 6 question that the review addressed? 27
Decision making by expert opinion 6 Question 2. Was a thorough search of the
Decision making by cost minimisation 7 appropriate database(s) carried out, and
were other potentially important
1.3 Before you start: formulate the problem 8
sources explored? 27
CHAPTER 2 Question 3. Who evaluated the studies,
and how? 28
Asking questions and Question 4. How sensitive are the results
to the way the review has
searching for evidence 11 been performed? 28
2.1 Different types of searching Question 5. Have the results been interpreted
for evidence 12 sensibly, and are they relevant to the
Informal 12 broader aspects of the problem? 28
Focused looking for answers 13 Meta-analyses and meta-syntheses 28
Searching the literature 13
2.2 Differences between primary and CHAPTER 4
secondary research 13
2.3 Effective search strings 13
Qualitative research 32
Steps for effective searching 14 4.1 Qualitative research explained 33
One-stop shopping: federated 4.2 The difference between qualitative and
search engines 16 quantitative research 34
2.4 Other avenues for how to search 4.3 Qualitative methodologies and data
for evidence 17 collection strategies 35
Searching for information using Qualitative sampling 36
social media 19 Data collection 36
4.4 Evaluating papers that describe
CHAPTER 3 qualitative research 37
Question 1. Did the paper describe an
Reviewing literature 21 important clinical problem addressed via a
3.1 Is a paper worth reading at all? 23 clearly formulated question? 38
Question 1. Who wrote the paper? 23 Question 2. Was a qualitative approach
Question 2. Is the title appropriate appropriate? 38
and illustrative, and is the Question 3. How were (a) the setting and
abstract informative? 23 (b) the subjects selected? 38
Question 3. What was the research design, Question 4. What was the researcher’s
and was it appropriate to the perspective, and has this been taken
question? 24 into account? 38
Question 4. What was the research question, Question 5. What methods did the researcher
and why was the study needed? 24 use for collecting data, and are these
Question 5. Do the results or findings answer described in enough detail? 39
the question? 24
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Question 6. What methods did the researcher Have valid assumptions been made about the
use to analyse the data, and what quality nature and direction of causality? 78
control measures were implemented? 39 7.4 Probability and confidence 79
Question 7. Are the results credible and, if so, How are p values interpreted? 79
are they clinically important? 40 Confidence intervals 81
Question 8. What conclusions were drawn, 7.5 Clinical importance of treatment
and are they justified by the results? 40 effects 81
Question 9. Are the findings of the study Clinical importance 81
transferable to other settings? 40 7.6 Summarising treatment effects from
multiple studies of interventions in a
CHAPTER 5
systematic review 84
Quantitative research 43
CHAPTER 8
5.1 Why and how quantitative research
is done 44 Mixed methods research 88
5.2 Quantitative research designs 46 8.1 An overview of mixed methods
Intervention studies 46 research 89
Observational studies 47 Why use mixed methods in nursing and health
5.3 Measurement 48 sciences research? 89
Variables — independent 8.2 Different mixed methods designs 90
and dependent 49 Convergent study 90
Reliability and validity in measurement 50 Sequential study 91
Multiphase (multilevel) study 91
CHAPTER 6
Embedded study 92
Levels of evidence 55 8.3 Integration in mixed methods
6.1 Clinical questions in healthcare 56 research 93
Finding the best evidence 56 Integrating the research question 93
NHMRC and evidence-based practice 57 Research design 93
How researchers answer Sampling 93
clinical questions 57 Analysis 93
6.2 Matching clinical questions to NHMRC Interpretation 94
levels of evidence 58 8.4 Mixed method design considerations 94
NHMRC evidence levels for Weighting (dominance) 94
intervention studies 60 General challenges associated with mixed
6.3 How bias threatens the validity of research methods studies 94
evidence 63
CHAPTER 9
6.4 Evaluating the evidence – quality of
evidence and grades of recommendations Sampling 97
for practice guidelines 65
9.1 Understanding the terminology around
6.5 Levels within levels 66
sampling 98
Theoretical population (or target
CHAPTER 7
population) 98
Statistics for the Study population (or accessible
population) 98
non-statistician 73 Sampling 99
7.1 Storing quantitative data in a data set 74 Sample 99
7.2 Descriptive statistics for summarising Sampling frame 99
sample characteristics 75 9.2 Types of sampling 99
Descriptive statistics for Probability sampling 99
categorical variables 75
Non-probability sampling 100
Descriptive statistics for
Sampling methods 100
continuous variables 76
9.3 Sampling error 102
7.3 The researchers ‘setting the scene’ 77
9.4 Calculating sample size 102
Have the researchers tested the assumption
Quantitative research 102
that their groups are comparable? 77
Qualitative research 103
What assumptions apply to the shape
of the data? 77
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CONTENTS v
CHAPTER 10 11.3 Organisational support of evidence-
based practice 117
Ethics 106 Integrated care pathways 117
10.1 Ethical principles 107 Clinical practice guidelines 118
Autonomy: patients/clients are free to 11.4 The client perspective in evidence-
determine their own actions 107 based practice 119
Beneficence: acting to benefit Patient-reported outcome measures
human kind 108 (PROMs) 119
Justice: obligation to treat fairly 108 Shared decision-making 119
Non-maleficence: avoiding or minimising Option grids 120
harm 108
Respect for human dignity 108 CHAPTER 12
Confidentiality: maintenance of privileged
information, including the right to privacy Challenges to evidence-
and anonymity 109 based practice 124
Veracity: obligation to tell the truth 109 12.1 When evidence-based practice is
10.2 The role and function of human research done badly 126
ethics committees 109 12.2 When evidence-based practice is
10.3 Judging the ethical aspects of a done well 126
published journal article 111 Guidelines devalue
professional expertise 126
CHAPTER 11
The guidelines are too narrow (or
Getting evidence into too broad) 127
The guidelines are out of date 127
practice 114 The client’s perspective is ignored 127
11.1 Adoption of evidence-based There are too many guidelines 128
practice (EBP) 115 Practical and logistical problems 128
Individual barriers 115 The evidence is confusing 128
Organisational barriers 116 12.3 Achieving evidence-based practice 129
11.2 Encouraging individuals to implement
evidence-based practice 116 Index 133
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vi CONTENTS
ABOUT THE AUTHORS
Trisha M Greenhalgh
Dr Trisha Greenhalgh is a Professor of Primary Care Health Sciences at the University of Oxford and
a practising GP. She completed a BA in Social and Political Sciences at the University of Cambridge
in 1980 and a medical degree at the University of Oxford in 1983. Trisha’s research aims to apply the
traditional aspects of medicine while embracing the opportunities of contemporary science to improve
health outcomes for patients. She is the author of more than 240 peer-reviewed publications as well as
a number of scholarly textbooks. Trisha has received numerous accolades for her work, including twice
winning the Royal College of General Practitioners Research Paper of the Year Award, and receiving the
Baxter Award from the European Health Management Association. In 2001, she was awarded an OBE for
services to evidence-based medical care.
John Bidewell
Dr John Bidewell is a Lecturer in Research Methods at the School of Science and Health at Western
Sydney University. From an early career in school teaching, John moved into psychology, acquiring three
degrees while always maintaining an interest in education. Opportunities arose in applied social research
and data analysis, leading John in that direction. For many years, he provided technical and inspirational
support to academic and student researchers, covering every stage of the research process from concept to
publication, and especially data analysis and interpretation, at Western Sydney University’s nursing and
midwifery school. John has provided consultancy services in research and statistics to business, industry
and governments, and has taught research methods and statistics to nursing, business and allied health
students at undergraduate and postgraduate levels.
Elaine Crisp
Dr Elaine Crisp is a Registered Nurse (RN) and Lecturer at the School of Nursing at the University
of Tasmania, where she coordinates both the Bachelor of Nursing (BN) course and the Translational
Research unit within the BN. This dual role enables her to ensure the BN highlights the connection between
research and clinical practice. She has also taught research methods to nursing and allied health students
at the postgraduate level, encouraging clinicians to understand and use research evidence in their everyday
practice. Elaine worked as an RN in aged care and in the perioperative area before commencing her PhD,
which combined her love of history and nursing. Her major research interests are nursing and welfare
history, aged and dementia care, and nurse education.
Amanda Lambros
Amanda E Lambros is a Professional Speaker, Author and Clinical Counsellor as well as a past Clinical
Fellow. She has completed a Bachelor of Health Sciences at the University of Western Ontario (2001), a
Postgraduate Diploma of Ethics (2002), a Master of Forensic Sexology (2004) and a Master of Counselling
(2014). Amanda has developed, coordinated and taught evidence-informed health practice to thousands of
Interprofessional First Year Health Sciences students throughout her career. Amanda’s private practice
focuses on relationships, mental health, and grief and loss. Providing her clients with the most up-to-date
and evidence-based care is imperative to her, and she has a strong focus on EBP, ethics and communication.
Amanda has received numerous accolades for her work, including NifNex 100 Most Influential Business
Owners, a Telstra Business Award nomination and a Telstra Business Woman of the Year nomination.
Jane Warland
Dr Jane Warland is an Associate Professor at the School of Nursing and Midwifery at the University
of South Australia (UniSA). She worked as a midwife from 1988 to 2007, and gained her PhD from
the University of Adelaide in 2007. Jane was appointed as an academic staff member to the School of
Nursing and Midwifery in February 2008, and teaches a foundational research course in the undergraduate
midwifery program. Her own program of research is STELLAR (stillbirth, teaching, epidemiology, loss,
learning, awareness and risks). Jane has a track record in research using qualitative, quantitative and mixed
methods. She has a strong interest in research ethics and served two terms as a member of the UniSA
Human Research Ethics Committee. Jane has written numerous book chapters about research — she has
more than 90 publications, including books, chapters and peer-reviewed journal articles.
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ABOUT THE AUTHORS vii
Pdf_Folio:viii
CHAPTER 1
Introduction to research,
the research process
and EBP
LEARNING OBJECTIVES
1.1 What does ‘evidence-based practice’ mean?

1.2 Why are people apprehensive about evidence-based practice?
1.3 How do we get started with evidence-based practice?
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OPENING SCENARIO
Imagine you are taking the time to visit your grand-

father, Wilf, who has been living on his own for the
past two years, and recently began seeing a health
professional regarding his chronic hip and knee
pain. When you walk into his house, you see him in
the living room following along to a televised fitness
program — you ask: ‘Hey gramps, don’t you think
you should avoid exercise because of the pain from
your osteoarthritis?’. He sits you down and tells
you that, in short, he’s recently been exercising at
home and attending regular yoga classes alongside
his standard care to decrease the levels of pain
in his hips and knees. He continues to tell you
that he’s already feeling much better since he has
started exercising. At first, you are a bit sceptical of
this revelation, but it turns out that by doing these
activities, coupled with standard care, your grandfather will experience a reduction in his hip and knee
pain symptoms, while gaining confidence and decreasing depressive symptoms.1 In fact, this advice was
not given to your grandfather ‘on a whim’ or based on a simple research paper that guided the health
professional to advise your grandfather of this; it was a systematic review — the highest level of evidence.
(More on this in the chapter on levels of evidence.)
Now imagine that you are the health professional and Wilf is your client. Rather than just providing
‘standard’ practice, think about the ways in which you could provide evidence-based practice (EBP) —
a practice that is supported by scientific evidence, clinical expertise and client values — and how this
practice will have significantly better outcomes than ‘standard’ care for your clients. Isn’t this the care that
you would want to provide? I don’t know about you . . . but that’s the type of care that I would not only
prefer to provide as a health professional but also receive as a health consumer. This is just the start —
EBP becomes so much more exciting from here on in. The more you know, the more you want to know.
This is one of the most fascinating topics to learn about, because you can’t ‘undo’ your learning. If you
allow yourself the opportunity to become immersed in the topic, it will change your perception of nearly
everything you hear, read and do for the rest of your life!
............................................................................................................................................................................
DISCUSSION QUESTIONS
1. Have you visited a health professional in the past 12 months?
(a) If so, do you believe the health professional was an evidence-based practitioner?
(b) How can you be sure that you were receiving evidence-based care?
2. How would you distinguish evidence-based care from standard care?
1.1 The meaning of ‘evidence-based practice’

LEARNING OBJECTIVE 1.1 What does ‘evidence-based practice’ mean?
The aim of this chapter is for you to start to understand ‘research’, the ‘research process’ and ‘evidence-
based practice’ as fundamentally critical to you — not only as an individual, but also as a health consumer
and a health practitioner. This chapter will give you the opportunity to explore the importance of evidence-
based practice and open your mind to copious real-world examples that surround you on a daily basis,
which you might not even recognise as EBP.
EBP is much more than just reading papers. According to the most widely quoted definition, it is ‘the
conscientious, explicit and judicious use of current best evidence in making decisions about the care of
individual patients’.2 Professor Sackett continued to explain that EBP should be visualised as a three-
pronged and overlapping approach, also known as a triad approach: the best possible research evidence,
clinical expertise and patient values and preferences.3
Pdf_Folio:2
2 Understanding research methods for evidence-based practice in health
FIGURE 1.1 The triad approach
Best research
evidence
EBP
Clinical Patient
expertise values
Let’s take a moment to break down each of these areas so you fully grasp what is being considered when
explaining EBP.
1. The best possible research evidence. As you will learn in the chapter on levels of evidence, the higher
the level of evidence, the better the evidence is. Think of it this way: would you prefer implementing a
new exercise regime because your cousin told you it worked for her (Level 5 — anecdotal evidence), or
because a systematic review of over 450 000 people (Level 1 — systematic review) demonstrated that it
would have significant results? Therefore, when we are looking at ‘best possible research evidence’, it
is literally looking for the best options currently available (because you don’t want to use old evidence).
Typically, research evidence is updated at least every 3–5 years, depending on the topic, which means
you could continuously improve your practice.
2. Clinical expertise. This takes into consideration your experiences, both personal and professional, to
help guide you in how to best care for your clients. You might have previously attempted something
yourself — it could be as simple as using a saline rinse around allergy season to alleviate allergy
symptoms. You then have a client tell you how horrible their hayfever symptoms are each year when
the flowers start to bloom, but are not sure how to effectively manage this. In this situation, you might
explain to them that using a saline irrigation for allergic rhinitis works quite well because it thins the
mucus in the nasal cavity and removes some allergens,4 and that although the evidence is low, it’s cost-
effective, available without a prescription and a good alternative to steroid and antihistamine use. Later
on, that client might attempt this ‘remedy’ and then report the results back to you — you then begin to
build your ‘clinical expertise’ in this area.
3. Patient values and preferences. There are times when you might have researched the ‘best possible
treatment’ for your client. From clinical experience you are aware that it would work quite well, but
when you explain the treatment or procedure to the client, they might prefer an alternative treatment;
or their values or religious beliefs will not permit the treatment you have suggested. As you are treating
your clients, their values and preferences should be the first thing that you take into consideration, as
there is no point in continuously suggesting treatments they are not able or willing to engage with.
If you are a health practitioner working in rural or remote locations, you also need to consider whether
‘best practice’ is available — you might have to seek alternative treatments because the EBP is simply not
accessible in your location.
You might now be asking ‘What is research?’. Essentially, it is ‘focused, systematic enquiry aimed at
generating new knowledge’. Throughout this resource, it will be explained how this definition can help
you distinguish genuine research (which should inform your practice) from the poor-quality endeavours
of well-meaning amateurs (which you should politely ignore).
If you follow an evidence-based approach to clinical decision making, all sorts of issues relating to
your clients will prompt you to ask questions about scientific evidence (figure 1.2), seek answers to those
questions in a systematic way and alter your practice accordingly.
Pdf_Folio:3
CHAPTER 1 Introduction to research, the research process and EBP 3
FIGURE 1.2 Some things to consider when assessing clients
• Client preferences
• Symptoms
• Physical/diagnostic signs
• Age, sex and ethnic origin of the client
• Benefits versus risks
• Cost-effectiveness of the treatment
Sackett and Haynes summarised the five essential steps in the emerging science of EBP5 as:
1. to convert our information needs into answerable questions (i.e. to formulate the problem) (ASK)
2. to track down, with maximum efficiency, the best evidence with which to answer these questions —
which may come from the clinical examination, the diagnostic laboratory, the published literature or
other sources (ACQUIRE)
3. to appraise the evidence critically (i.e. weigh it up) to assess its validity (closeness to the truth) and
usefulness (clinical applicability) (APPRAISE)
4. to implement the results of this appraisal in our clinical practice (APPLY)
5. to assess our performance (EVALUATE).
Hence, EBP requires you not only to read papers but also to read the right papers at the right time, and
then to alter your behaviour accordingly (and, what is often more difficult, influence the behaviour of other
people) in the light of what you have found. At no time should one step be seen as more important than
another — all steps should hold equal importance. Yet if you have asked the wrong question or sought
answers from the wrong sources, you might as well not read any papers at all. Equally, all your training
in search techniques and critical appraisal will go to waste if you do not put at least as much effort into
implementing valid evidence and measuring progress towards your goals as you do into reading the paper.
Greenhalgh added to the steps above to create what she deemed a ‘context-sensitive checklist for
evidence-based practice’ to incorporate the client’s perspective, resulting in eight stages, as outlined in
figure 1.3.6
This resource has been strategically designed and written so that you can get the best possible overview
of evidence-based practice, especially for those who are new to the concept of EBP. Our goal is for you to
be able to have an understanding of EBP so that when you become a practitioner, you have the minimum
skills and knowledge to apply evidence and practice as an evidence-based practitioner.
FIGURE 1.3 Is my practice evidence-based? A context-sensitive checklist for individual clinical encounters
Have I identified and prioritised the clinical, psychological, social and other problem(s), taking into
account the patient’s perspective?
Have I performed a sufficiently competent and complete examination to establish the likelihood of
competing diagnoses?
Have I considered additional problems and risk factors that may need opportunistic attention?
Have I, where necessary, sought evidence (from systematic reviews, guidelines, clinical trials and
other sources) pertaining to the problems?
Have I assessed and taken into account the completeness, quality and strength of the evidence?
Have I applied valid and relevant evidence to this particular set of problems in a way that is both
scientifically justified and intuitively sensible?
Have I presented the pros and cons of different options to the patient in a way they can understand,
and incorporated the patient’s preferences into the final recommendation?
Have I arranged review, recall, referral or other further care as necessary?
Incidentally, if you want to explore the subject of EBP online, you will note that throughout this resource,
we provide you with a plethora of websites that can help guide you on the various topics. Please don’t feel
overwhelmed by the vast amount of literature available — most of the sites offer very similar material and
you certainly don’t need to visit them all . . . just visit them if you are interested in digging a little deeper
into each topic.
Pdf_Folio:4
1.2 Apprehension towards evidence-based practice
LEARNING OBJECTIVE 1.2 Why are people apprehensive about evidence-based practice?
Unfortunately, some people might be apprehensive or groan when mentioning evidence-based practice
because they have heard through the grapevine that it’s all about statistics and number crunching. Before
we go much further, let’s clarify something and pop that bubble! EBP is not ‘all about statistics’. Although
yes, statistics, numbers, equations, odds ratios, confidence intervals, etc. are all words you will hear in
EBP, understanding how to interpret and implement EBP is much more important at this point in time.
Numbers are great but, in reality, if you don’t understand what the numbers mean, then you are not really
able to implement EBP. Alternatively, if you don’t understand how the researchers completed the math
behind the numbers, you can’t double-check their work — which is sometimes equally as important. With
this in mind, Greenhalgh and Donald proposed an alternative definition of EBP, which demonstrates the
use of mathematics.
Evidence-based practice is the use of mathematical estimates of the risk of benefit and harm, derived
from high-quality research on population samples, to inform clinical decision making in the diagnosis,
investigation or management of individual patients.7
Students regularly allow the idea of ‘numbers’ and a ‘new language’ to blur their excitement for learning
about EBP — please don’t let this happen to you. Be open to learning about the topic, which will stick
with you for the rest of your life. The more open you are to learning about EBP, the better the practitioner
you will become!
The second reason that people often groan when you mention evidence-based practice is because there
are plenty of daunting new (and often long) words that look like a foreign language. While it is like a
new language, absolutely everything in EBP can be broken down into simple and manageable steps. For
example, students are often stumped by retrospective longitudinal cohort design (which you will learn
about in this resource), but once they break it down, it makes perfect sense:
• retrospective — in the past (think of the word ‘retro’)
• longitudinal — over a long period of time
• cohort — a group of people
• design — type of study.
Now that it’s broken down into manageable chunks, you instantly know that ‘retrospective longitudinal
cohort design’ means a type of study that was done over a long period, looking at a group of people in
the past. So, please don’t feel overwhelmed by the words — they all make sense, but some just need to be
broken down first.
Anyone who works face-to-face with clients knows that it is necessary to seek new information before
making a clinical decision. Health practitioners spend countless hours searching through libraries, books
and online to inform their practices. In general, we wouldn’t put a client on a new drug or through a
new treatment without evidence that it is likely to work — but, unfortunately, best practice is not always
followed. There have been a number of surveys on the behaviours of health professionals. In the United
States in the 1970s, only around 10–20 per cent of all health technologies then available (i.e. drugs,
procedures, operations, etc.) were evidence-based; in the 1990s, that figure improved to 21 per cent.8
Studies of the interventions offered to consecutive series of clients suggested that 60–90 per cent of clinical
decisions, depending on the specialty, were ‘evidence-based’.9 Unfortunately, due to various excuses and
limitations, we are still selling our clients short most of the time.
A large survey by an Australian team looked at 1000 clients treated for the 22 most commonly seen
conditions in a primary-care setting. The researchers found that while 90 per cent of clients received
evidence-based care for coronary heart disease, only 13 per cent did so for alcohol dependence.10
Furthermore, the extent to which any individual practitioner provided evidence-based care varied in the
sample from 32 per cent of the time to 86 per cent of the time. A more recent study found that one in
three hospitals are not meeting performance metrics. One of the leading reasons was failure to implement
EBP.11 Following this, a study suggested that medical error is now the third leading cause of death in the
United States.12 These findings suggest plenty of room for improvement; therefore, with a new wave of
practitioners, hopefully we can increase the application of EBP so that the majority of health consumers
are receiving evidence-based care.
Let’s look at the various approaches that many health professionals use to reach their decisions in
reality — all of which are examples of what EBP isn’t . . . therefore, please do not practise these!
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Decision making by anecdote
When Trisha Greenhalgh was a medical student, she was able to join a distinguished professor on his daily
ward rounds. On seeing a new client, he would ask about their symptoms, turn to the massed ranks of
juniors around the bed, and relate the story of a similar client encountered a few years previously. ‘Ah, yes.
I remember we gave her such-and-such and she was fine after that’. He was cynical, often rightly, about
new drugs and technologies, and his clinical acumen was second to none. Nevertheless, it had taken him
40 years to accumulate his expertise and the largest medical textbook of all — the collection of cases that
were outside his personal experience — was forever closed to him.
Anecdote (storytelling) has an important place in clinical practice.13 It is common practice for students
and practitioners to listen to professors, tutors and clients and memorise their stories or scripts in the
form of what was wrong with particular clients, and their outcomes to use later. Health professionals
glean crucial information from clients’ illness narratives — most crucially, perhaps, what being ill means
to the client. Experienced health professionals take account of the accumulated ‘illness scripts’ of all
their previous clients when managing subsequent clients — but that doesn’t mean simply doing the
same for client B as you did for client A if your treatment worked, and doing precisely the opposite if
it didn’t!
We would not be human if we ignored our personal clinical experiences, but we would be better to base
our decisions on the collective experience of thousands of health professionals treating millions of clients,
rather than on what we as individuals have seen and felt.
Decision making by press cutting

Imagine simply trawling the internet, magazines, newspapers and information presented throughout all
forms of media and simply ‘cutting and pasting’ then creating, for lack of a better analogy, a scrapbook
of treatments, cures, etc. — continuously altering your practice in line with the various conclusions. For
example, ‘probiotics improve your mood’,14 and advocating that all clients take probiotics. The advice was
in print, and it was recent, so it must surely replace what was previous practice.
This approach to clinical decision making is, unfortunately, still very common. How many doctors do
you know who justify their approach to a particular clinical problem by citing the results section of a single
published study, even though they might fail to tell you:
• the methods used to obtain those results
• whether the trial was randomised and controlled
• the number, age, sex and disease severity of the clients involved
• how many withdrew from (‘dropped out of’) the study and why
• by what criteria clients were judged ‘cured’
• if the findings of the study appeared to contradict those of other researchers; whether any attempt was
made to validate (confirm) and replicate (repeat) them
• whether the statistical tests that allegedly proved the authors’ point were appropriately chosen and
correctly performed (see the chapter on statistics for the non-statistician)
• whether the client’s perspective has been systematically sought and incorporated via a shared decision-
making tool.
Therefore, health practitioners who like to cite the results of medical research studies have a respon-
sibility to ensure that they first go through a checklist like this before simply making decisions by press
cutting.
Decision making by expert opinion

In extreme cases, an ‘expert opinion’ may consist simply of the lifelong bad habits and personal press
cuttings of an ageing health professional, which could simply multiply the misguided views of any one
of them. Table 1.1 gives examples of practices that were at one time widely accepted as good clinical
practice, but that have subsequently been discredited by high-quality clinical trials. Serious harm can be
done by applying guidelines that are not evidence-based. It is a major achievement of the EBP movement
that almost no guideline these days is produced solely by expert opinion!
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TABLE 1.1 Examples of harmful practices once strongly supported by ‘expert opinion’
Approximate Clinical practice accepted by Practice shown

time period experts of the day to be harmful in Impact on clinical practice
a
From 500 BC Bloodletting (for just about any 1830s Bloodletting ceased
acute illness) around 1910
Early 1900s Complete immobilisation in the 1930s Although very hot dressings
form of splints and braces on and physical therapy (what we
the affected limbs for infantile now know as physiotherapy)
paralysis (Polio) was deemed to be effective,
it was not fully implemented
for the treatment of polio until
the 1950s
1957 Thalidomide for ‘morning 1960 The teratogenic effects of

sickness’ in early pregnancy, this drug were so dramatic
which led to the birth of over that thalidomide was rapidly
8000 severely malformed withdrawn when the first case
babies worldwide report appeared
From at least 1900 Bed rest for acute low 1986 Many doctors still advise people
back pain with back pain to ‘rest up’
1960s Benzodiazepines (e.g. 1975 Benzodiazepine prescribing

diazepam) for mild anxiety for these indications fell in
and insomnia, initially the 1990s
marketed as ‘non-addictive’
but subsequently shown to
cause severe dependence and
withdrawal symptoms
1970s Intravenous lignocaine in acute 1974 Lignocaine continued to

myocardial infarction, with a be given routinely until the
view to preventing arrhythmias, mid-1980s
subsequently shown to have
no overall benefit and in some
cases to cause fatal arrhythmias
Late 1990s Cox-2 inhibitors (a new class of 2004 Cox-2 inhibitors for pain were
non-steroidal anti-inflammatory quickly withdrawn following
drug), introduced for the some high-profile legal cases
treatment of arthritis, were later in the United States, although
shown to increase the risk of new uses for cancer treatment
heart attack and stroke (where risks may be outweighed
by benefits) are now being
explored
a
Interestingly, bloodletting was probably the first practice for which a randomised controlled trial was suggested.
Decision making by cost minimisation

The popular press tends to be horrified when they learn that a treatment has been withheld from a client for
reasons of cost. Managers, politicians and, increasingly, health professionals can count on being pilloried
when a child with a rare cancer is not sent to a specialist unit in the United States or a frail elderly woman
is denied a drug to stop her visual loss from macular degeneration. Yet, in the real world, all healthcare
is provided from a limited budget, and it is increasingly recognised that clinical decisions must take into
account the economic costs of a given intervention. Clinical decision making purely on the grounds of cost
(‘cost minimisation’ — purchasing the cheapest option with no regard to how effective it is) is generally
ethically unjustified, and we are right to object vocally when this occurs.
Expensive interventions should not, however, be justified simply because they are new, or because they
ought to work in theory, or because the only alternative is to do nothing — but because they are very likely
to save life or significantly improve its quality.
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1.3 Before you start: formulate the problem
LEARNING OBJECTIVE 1.3 How do we get started with evidence-based practice?
If midwifery students are asked what they know about childbirth and pain management, they can talk at
length about the different pain management techniques, how they measure pain by having a conversation
with the woman in labour, what the textbooks define as pain — the list goes on. They are truly aware of
the concept of ‘pain’ and its management during the labouring process.
However, when the students are asked a practical question such as ‘Mrs Janes wants the most effective,
non-invasive and non-pharmacological pain management technique — what would you advise her as her
options?’, they appear startled. One student replies ‘Mrs Janes can have absolutely anything she wants
to manage her pain!’ — a great response, but it doesn’t provide the best possible evidence to Mrs Janes,
especially if she’s asking direct questions. The response could be relaxation techniques,15 massage and
reflexology,16 aromatherapy,17 and so on — but the student would need to revise the evidence. They may
sympathise with Mrs Janes’s predicament, but they often draw a blank as to where to draw on information
such as this, which could possibly be the one thing that Mrs Janes needs or wants to know.
Experienced health professionals might think they can answer Mrs Janes’s question from their own
personal experience, but few of them would be right. Even if they were right on this occasion, they would
still need an overall system for converting all of the information about a client (age, ethnicity, subjective
pain scale, etc.), the particular values and preferences (utilities) of the client, and other things that could be
relevant (a hunch, a half-remembered article, the opinion of a more experienced colleague or a paragraph
discovered by chance while flicking through a textbook) into a succinct summary. The summary would
need to cover what the problem is, and what specific additional items of information we need to solve that
problem and come up with a desired outcome.
Sackett et al., in a book subsequently revised by Straus,18 explained that the parts of a good clinical
question should include three components.
• First, define precisely whom the question is about (i.e. ask ‘How would I describe a group of clients
similar to this one?’).
• Next, define which manoeuvre (treatment, intervention, etc.) you are considering in this client, and, if
necessary, a comparison manoeuvre (e.g. placebo or current standard therapy).
• Finally, define the desired (or undesired) outcome (e.g. reduced mortality, better quality of life, and
overall cost savings to the health service).
Thus, in Mrs Janes’s case, we might ask, ‘In a thirty-year-old Caucasian woman with a high pain
threshold, two previous labouring/birthing experiences, no coexisting illness, and no significant past
medical history, whose blood pressure is currently X/Y, would the benefits of suggesting massage and
reflexology provide her with the desired outcome of an effective, non-invasive and non-pharmacological
pain management technique to decrease pain during labour?’ Note that in framing the specific question, we
have already established that Mrs Janes has previously experienced labour and birth twice. Knowing this,
we recognise that she may have also previously experienced invasive or pharmacological interventions and
is aware of the discomfort of labouring and birthing.
Remember that Mrs Janes’s alternative to an effective, non-invasive and non-pharmacological pain
management technique is potentially invasive and may have side effects — on not only Mrs Janes, but
also the birthing process and/or the baby about to be born. Not all of the alternative approaches would help
Mrs Janes or be acceptable to her, but it would be quite appropriate to seek evidence as to whether they
might help her — especially if she was asking to try one or more of these remedies.
Before you start, give one last thought to your client in labour. In order to determine her personal
priorities (how much does she value a 10 per cent reduction in her pain to still experience the labour and
birthing process compared to the inability to feel below her belly button?), you will need to approach Mrs
Janes, not anybody else in that labouring room, and start the dialogue towards providing evidence-based
care.
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SUMMARY
Evidence-based practice is much more than ‘reading an academic article’. It includes, at a very minimum,
the best possible research evidence available, clinical expertise as well as understanding the client’s values
and preferences. EBP is not about learning a technique, skill and treatment methodology once and applying
it for the rest of your career; it should be a continuous loop of learning and improvement by using the Ask,
Acquire, Appraise, Apply and Evaluate model. Although some students (and even health practitioners)
attempt to avoid learning about EBP because they believe that it’s all math-driven and hard to understand,
it’s much more than just numbers. Once you learn the techniques, you will begin to see evidence-based
information all around you and will continue to apply EBP throughout your life as both a health consumer
and eventually a health practitioner. When the best question is formulated, it becomes much easier to find
the best evidence to answer the question.
KEY TERMS
evidence-based care Care that is based on evidence-based practice (supported by scientific evidence,
clinical expertise and client values).
evidence-based practice (EBP) A practice that is supported by scientific evidence, clinical expertise
and client values.
knowledge An accepted body of facts or ideas that is acquired through the use of the senses, reasons
or through research methods.
retrospective longitudinal cohort design A type of study conducted over a long period, looking at a
group of people in the past.
WEBSITES
1 Centre for Research in Evidence-based Practice (CREBP): https://bond.edu.au/researchers/research-
strengths/university-research-centres/centre-research-evidence-based-practice
2 Centre for Evidence-based Medicine: www.cebm.net
3 ‘What is evidence-based medicine?’, British Medical Journal: www.bmj.com/content/312/7023/71
4 HPNA Position statements ‘Evidence-Based Practice’, Hospice and Palliative Nurses Association
(US): https://advancingexpertcare.org/position-statements
Joanna Briggs Institute: www.joannabriggs.org
5
Australasian Cochrane Centre: http://aus.cochrane.org
6
‘Evidence-based information’, QUT Library: www.library.qut.edu.au/search/howtofind/evidencebased
7
‘Answering Clinical Questions’, University of Western Australia: www.meddent.uwa.edu.au/
8
teaching/acq
9 ‘Evidence based practice’, University of Tasmania: https://utas.libguides.com/ebp
10 ‘Introduction to evidence-based practice’, Duke University Medical Center Library and the Health
Sciences Library at the University of North Carolina: https://guides.mclibrary.duke.edu/ebmtutorial
ENDNOTES
1. M. Hurley et al., ‘Hip and knee osteoarthritis: a mixed methods review,’ Cochrane Database of Systematic Reviews 4 (2018).
doi:10.1002/14651858.CD010842.pub2.
2. D. L. Sackett et al., ‘Evidence-based practice: what it is and what it isn’t,’ BMJ: British Medical Journal 312, no. 7023
(1996): 71.
3. Sackett, ‘Evidence-based practice,’ 71.
4. K. Head et al., ‘Saline irrigation for allergic rhinitis,’ Cochrane Database of Systematic Reviews 6 (2018).
doi:10.1002/14651858.CD012597.pub2.
5. D. L. Sackett and R. B. Haynes, ‘On the need for evidence-based practice,’ Evidence-based Practice 1, no. 1 (1995): 4–5.
6. T. Greenhalgh, ‘Is my practice evidence-based?,’ BMJ: British Medical Journal 313, no. 7063 (1996): 957.
7. T. Greenhalgh, How to read a paper: the basics of evidence-based medicine (Oxford: Blackwell-Wiley, 2006).
8. M. Dubinsky and J. H. Ferguson, ‘Analysis of the national institutes of health medicare coverage assessment,’ International
Journal of Technology Assessment in Health Care 6, no. 3 (1990): 480–8.
9. D. L. Sackett et al., ‘Inpatient general practice is evidence-based,’ The Lancet 346, no. 8972 (1995): 407–10.
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10. W. B. Runciman et al., ‘CareTrack: assessing the appropriateness of health care delivery in Australia,’ Medical Journal of
Australia 197, no. 10 (2012): 549.
11. B. Melnyk, ‘Are you getting the best health care? Evidence says: maybe not,’ The Conversation, June 9, 2016,
https://theconversation.com/are-you-getting-the-best-health-care-evidence-says-maybe-not-59206.
12. M. A. Makary and M. Daniel, ‘Medical error — the third leading cause of death in the US,’ BMJ: British Medical Journal 353
(2016): i2139.
13. J. Macnaughton, ‘Anecdote in clinical practice,’ in Narrative based practice: dialogue and discourse in clinical practice, ed.
T. Greenhalgh and B. Hurwitz (London: BMJ Publications, 1998).
14. L. Steenbergen et al., ‘A randomized controlled trial to test the effect of multispecies probiotics on cognitive reactivity to sad
mood,’ Brain, Behavior, and Immunity (2015): 258–64. doi:10.1016/j.bbi.2015.04.003.
15. C. A. Smith et al., ‘Relaxation techniques for pain management in labour,’ Cochrane Database of Systematic Reviews 3
(2018). doi:10.1002/14651858.CD009514.pub2.
16. C. A. Smith et al., ‘Massage, reflexology and other manual methods for pain management in labour,’ Cochrane Database of
Systematic Reviews 3 (2018). doi:10.1002/14651858.CD009290.pub3.
17. C. A. Smith, C. T. Collins, and C. A. Crowther, ‘Aromatherapy for pain management in labour,’ Cochrane Database of
Systematic Reviews 7 (2011). doi:10.1002/14651858.CD009215.
18. S. E. Straus et al., Evidence-based practice: how to practice and teach EBP, 4 ed. (Edinburgh: Churchill Livingstone, 2010).
ACKNOWLEDGEMENTS
Adapting author for this Australian edition: Amanda Lambros
Photo: © Halfpoint / Shutterstock.com
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CHAPTER 2
Asking questions and

searching for evidence
LEARNING OBJECTIVES
2.1 What are the different reasons we might search for evidence?
2.2 What are the differences between primary research and secondary literature?
2.3 How do you construct an effective search string?
2.4 What are some other avenues for how to search for evidence?
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OPENING SCENARIO
Imagine one of your clients asks you a question that

you don’t immediately know the answer to. How
do you go about finding the answer? One strategy
would be to conduct a Google search, but is that
likely to reveal an evidence-based answer to your
question? Let’s have a look at one example: An
older client asks you if they should spend money on
trying foot orthoses for their plantar heel pain.
You are not sure about the answer, so you go to
Google and search for ‘orthotic, heel pain, effec-
tive’ you get 880 000 results, many of which are
opinion-based articles or companies selling differ-
ent devices. If you go to Google Scholar and use
the same search terms you get 19 300 hits covering
a wide range of peer-reviewed articles, only some of which will be helpful for answering your question. If
you go to a database such as PubMed and enter the same search terms, you get less than 30 hits and find
a number of articles that suggest orthotics reduce pain and improve function in adults with acute plantar
fasciitis, with few risks or side effects.
This scenario should indicate that, while it may be tempting to answer clinical questions using a quick
Google search, this may not be the most effective means of finding evidence-based information. While
searching for evidence using a systematic search strategy may seem difficult and overwhelming, it is a skill
that can be learnt. Knowing how to access these navigational wonders will save you time and improve
your ability to find the best evidence. Consequently, the development of skills in searching electronic
databases is vital for the up-to-date clinician. The purpose of this chapter is not to teach you to become a
researcher or even an expert searcher. Instead, the aim is to give you the basics of searching the literature
to answer a clinical question, which will help you recognise:
• the kinds of search tools, databases and resources that are available
• how to choose intelligently among them
• how to utilise them to put them to work directly.
............................................................................................................................................................................
DISCUSSION QUESTIONS
1. How do you go about keeping up to date with current research in your area of practice?
2. How do you search for new information to answer clinical questions?
3. What skills do you already have in database searching?
2.1 Different types of searching for evidence

LEARNING OBJECTIVE 2.1 What are the different reasons we might search for evidence?
You may approach finding evidence for practice using three main methods.
1. Informally, almost recreationally, surfing the internet to keep current and/or to satisfy your own
curiosity.
2. Focused, looking for answers, perhaps related to questions that have occurred in a clinical setting or
that arise from your clients and their questions.
3. Surveying the existing literature, perhaps before embarking on a research project or clinical audit.
Each approach involves searching in a very different way.
Informal
There are a number of tools to help us keep current with an area of interest. One of these is to use an
‘alert’ service. You can set up an alert from a specific journal to let you know when a new issue has been
published and even to tell you if articles matching your interest profile are in that issue. A more general
‘Google alert’ can be set that picks up a broad range of information, including newspaper articles, news
reports and press releases. Twitter feeds are also useful for staying connected with colleagues who share
your interests and passions. It is also easy to share interesting articles and sites that you have found via
other forms of social media.
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Focused looking for answers
Focused looking for answers should take a much more detailed approach, especially if we can trust the
‘answer’ we find and apply it directly to the care of a client. When we find information, we need to know
how we can tell if it is trustworthy and, if so, that it is OK to stop looking — we don’t need to find
absolutely every study that may have addressed this topic. This kind of query is increasingly well served
by new synthesised information sources whose goal is to support evidence-based care and the transfer of
research findings into practice. This is discussed in more detail shortly.
Searching the literature

When writing an essay or an article for publication, searching the literature involves an entirely different
process. The purpose here is less to influence client care directly than to identify the existing body of
research that has already addressed a problem and clarify the gaps in knowledge that require further
research. For this kind of searching, you need knowledge about information resources and some basic skills
in searching. A simple search of one database can often be enough for this kind of searching. Although,
you should be aware that if you want to search systematically (for example, a systematic review of the
literature), then multiple relevant databases need to be searched systematically, and citation chaining needs
to be employed to ensure that you are being thorough enough. If this is your goal, you should consult with
an information professional, such as a health librarian.
2.2 Differences between primary and

secondary research
LEARNING OBJECTIVE 2.2 What are the differences between primary research and secondary literature?
Literature that reports primary research is from a single research study. Primary sources can be found
in a variety of ways. You could look at the reference lists and hyperlinks from secondary sources. You
could identify them direct from journal alerts — for example, via RSS feeds, table-of-contents services or
more focused topical information services. You could also search databases such as PubMed/Medline,
EMBASE, PASCAL, Cochrane Library, CINAHL (Cumulated Index of Nursing and Allied Health
Literature), Web of Science, Scopus or Google Scholar.
Secondary research reports ‘synthesised’ findings and usually takes the form of a literature review.
A literature review will typically:
• examine multiple primary research papers
• summarise the research papers.
A literature review of quantitative articles may also include a meta-analysis. A review of qualitative
literature will often include a meta-synthesis, meaning that this type of literature has combined findings to
provide strong evidence on which to base practice.
Secondary literature is also useful to assist you to quickly understand what is already known about a
topic; but, if you would like (or have been asked) to locate evidence from primary research, then the rest
of this chapter is for you.
2.3 Effective search strings

LEARNING OBJECTIVE 2.3 How do you construct an effective search string?
PubMed is a frequently accessed online resource for most physicians and health professionals worldwide,
probably because it is free and well known. When conducting a basic PubMed search, you can use
two or three search words — but taking this approach characteristically turns up hundreds or thousands
of references, and many of these may be irrelevant for your topic of interest. This is certainly not an
effective way to search, but it is the reality of how most people do search.1 It is surprisingly easy to
improve the efficiency of this kind of approach, which can enable you to become much more effective at
basic searching.
Simple tools that are part of most database search engines help to focus a basic search and produce
better results.
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CHAPTER 2 Asking questions and searching for evidence 13
Boolean operators are words (connectors) placed between search terms to narrow or expand a search.
The common Boolean operators are OR, AND and NOT.
• OR expands your search by finding studies containing either of the specific keywords.
• AND narrows your search by only finding studies containing all of the specific keywords.
• NOT narrows your search by excluding studies containing specific keywords.
Using Boolean operators results in more focused results. Therefore, using these saves time and effort
by eliminating many of the inappropriate hits.
Steps for effective searching

Say a pregnant client asks you if hypnosis is a useful form of pain relief in labour. You could answer from
your clinical or personal experience, or you could ask someone else if they knew — but, ideally, you would
go to the literature to find the answer there.
If you entered the words ‘hypnosis’, ‘pain relief’ and ‘labour’ into a search database such as Google
Scholar, it would generate more than 11 500 hits. It would be tempting to simply look at the first ten or so of
these, but if you did that, you may well miss important studies that answer your client’s clinical question.
Google Scholar can be an excellent place to start searching for a topic, as it will identify publications that
are listed on PubMed as well as those that aren’t. Unfortunately, the advanced search option does not
provide quality filters or limits, nor does Google Scholar accept Boolean operators; therefore, in order to
use these functions you would need to use another database. If you go to a publicly available database such
as PubMed and use the ‘advanced search’ option to add the Boolean operator AND between each of your
words ‘hypnosis AND pain relief AND labour’, you gain less than 45 hits!
FIGURE 2.1 Advanced Boolean operator search on PubMed
Source: PubMed 2019.
However, this may have limited your search too much. In order to have a good look at the literature to
answer your client’s question, you can construct a simple search.
Boolean operators
If you use the Boolean operator OR this will help you locate other articles that have used related terms that
your first search might not have captured. For example, you know that ‘pain relief’ may also be referred
to as ‘analgesia’, so to include these two terms in your search you would link them using OR.
When constructing a simple search, you need to enter all the related terms together using OR to link
them — you would need to do this with related terms for pain relief and any related terms for labour. This
process will initially result in a large number of hits. Don’t worry about this, as once you complete your
search using the AND function this number will be reduced again.
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Truncation
Another way to make your search more efficient is with the use of truncation. Truncation identifies
variations of a word without the need to enter each one individually. For example, ‘hypno*’ will retrieve
hypnosis as well as hypnotherapy. There are a couple of traps to note when using truncation however.
• Typing ‘hypno*’ will also give hypnoanalysis and hypnotic, which are probably not going to be useful
in this search. Two ways around this is to either remove the unwanted words from the search using the
Boolean operator NOT. So, you might add ‘NOT hypnoanalysis OR hypnotic’ to your search, especially
if it seemed you were getting a lot of extra hits by using these words. Alternatively, you could simply
link the two words you want in full by using the OR operator (i.e. hypnosis OR hypnotherapy).
• It is important not to truncate too much, as this process will give every word that starts with those same
letters. For example, a student that truncated ‘woman’ to ‘wom*’, because she wanted to capture articles
about both ‘woman’ and ‘women’ in her search, also got many completely irrelevant hits like ‘wombat’!
Frequently used truncation symbols are the asterisk (*), a question mark (?) or a dollar sign ($). Note
that some databases do not accept truncation.
Wildcards
The use of wildcards enables the entering of one search term to account for the many different ways a
word may be spelt. For example, using the question mark (?) wildcard symbol, ‘randomi?ation’ finds both
‘randomization’ and ‘randomisation’. This can be a very useful thing to add to a search string; however,
not all databases allow for wildcards, such as PubMed.
So far, your search for hypnosis and pain relief in labour using Boolean operators and truncation looks
like this.
FIGURE 2.2 Using truncation and Boolean operators in PubMed
Source: PubMed 2019.
If you enter this, you now get a little over one hundred hits. Unless you want to wade through all of
these articles, you now need to consider using filters.
Filters
Another useful way to focus a search is by using filters. Many librarians will tell you to avoid applying
filters to your initial search. For example, if you filter a search to ‘full text’ you may inadvertently miss
a gem. (Remember, librarians can help you find the full text of an article, such as through an interlibrary
loan). It is, however, useful to apply a filter for the languages that you can read and understand, as well
as ‘human’ studies to avoid the many about rats and mice. It may also be useful to apply a date filter to
reduce your hits to more recent research.
If you filter the article type to ‘clinical trial’, this will superimpose a filter based on optimum study
designs for best evidence, depending on the domain of the question and the degree to which you wish to
focus it. For example, if you wanted to tell your client only about the randomised clinical trials (RCT),
you could filter your search and find a handful of RCTs on the topic.
Please note that in PubMed you find the filters on the ‘front page’ of the search and you can see the
effect of the filter on your search as soon as you tick (or untick) the box. Figure 2.3 shows a screenshot of
search results using the filtering terms of ‘clinical trial’, ‘last five years’, and ‘human’ (seen by the ‘ticks’
in the left-hand column). As these are all in English, there is no point in adding an English language filter.
Pdf_Folio:15
CHAPTER 2 Asking questions and searching for evidence 15
Another random document with
no related content on Scribd:
BY HERBERT ADAMS
III
Someone promptly asks what are the rules of relief. But are rules
of much use here? Rules of relief are seldom mentioned by the
sculptor; never until after they have been patently transgressed. He
has of course his standards; he allows to his reliefs some of the
privileges of painting, such as perspective and distance, but he does
not presume too far with these borrowings, lest his work lose its
sculptural style. A relief is largely a matter of innate artistic feeling,
as well as of trained taste. And quite as much as a work in the round,
it tells the personality of its maker. A Saint-Gaudens relief, whether
the monumental bronze Shaw, or the marble portrait, slightly under
life-size, of Mrs. Stanford White, or the little reduction, “about as
large as the hand of a child of twelve years,” made from the bas-
relief of the baby Homer, reveals the artist’s temperament, shows his
principles and prejudices in art.
Many of this master’s pupils have made memorable reliefs in
various styles from medallic to monumental. The medals and
portrait-reliefs of Martiny, Flanagan, Fraser, and Weinman are well-
known. Less familiar to the general public because kept in private
collections are the admirable bronze or marble portrait-reliefs by
Frances Grimes. After the mechanical roughing-out of the pointing-
machine is over, Miss Grimes herself finishes all her marbles,
whether created in the round or in relief. She does this oftener in her
studio than in the Sunday picture papers; and because her designs
for marble are from their first rude beginnings in the clay imagined
with a full realization of their final possibilities in marble, they
naturally have an integrity not always attained in the work of
sculptors unfamiliar with the chisel.
IV
Most artists would probably agree with Saint-Gaudens that “the
great coins are the Greek, ... just as the great medals are those of
the fifteenth century by Pisanello and Sperandio.”
VICTORY MEDAL
BY JAMES EARL FRASER
But he who designs the modern American coin, however

enthusiastic he may be in his admiration of the Greek high relief
masterpieces of monetary beauty, must take serious and constant
thought of the curiously un-Greek conditions confronting him. His
coin must work harder than the Greek coin; it must “stack” properly;
it must be struck in numbers undreamed of in Hellas. Our difficult
modern ideal calls alike for quantity and for quality. Comparatively
limited as was the circulation of our recent Victory medal, four million
copies were considered necessary. One of the good precedents
introduced by Roosevelt, in consultation with Saint-Gaudens, was
that of entrusting the designing of our coins to our most talented
sculptors; the resulting improvement in our coinage, on the æsthetic
side, has been one of our twentieth-century triumphs. And the “great
medals” Saint-Gaudens loved are still influencing the medallic art of
the Western world.
The candor and warm simplicity of Pisanello and Sperandio were
perhaps lost sight of during those years while the earlier French
master-medalists of the nineteenth century, David d’Angers, Oudiné,
and Ponscarme, were paving the difficult way for a later and more
sympathetic flowering of the medallic art in the hands of Roty,
Chaplain, and Charpentier. But the delightful quality of the
Renaissance medal was never more deeply appreciated in France
than at the time when a goodly number of our American sculptors
were studying there, and shared in that appreciation; and now that
the modern reducing-machine allows the artist fully to develop his
design for a medal in a fairly large size before bringing it within the
final small circumference, it is certainly well for him to bear in mind
the admirable results obtained by the less sophisticated quattrocento
methods. Never before has the medalist had at hand as many
excellent mechanical aids as at present. Never before has he faced
a greater need of remembering the value of clarity in his vision, of
simplicity and sincerity in his touch.
Some of our purists maintain that every medal should be
modeled from first to last in its ultimate size, however trying and
meticulous this task may be. But does not such strictness denote a
rather rabid hostility to mechanical contrivances? There are medals
whose intricate yet logical design could hardly be carried out by the
human hand, no matter how skilful, within the narrow limits thus
prescribed. Of this type is the plaquette designed by Saint-Gaudens
as a token of gratitude to all who took part in the Masque of the
Golden Bowl, offered to him on a famous anniversary.
“Within its harmonious oblong are shown the columns and the
blazing altar and the Greek seat that figured in the scene, framed by
the proscenium arch of great New England pines, and by the stage-
curtains crowned with masks invented by the joyous fancy of
Maxfield Parrish; below is the triumphal chariot; and, as a symbol of
the love that prompted the pageant, there stands by the altar the
winged figure of Amor, who has borrowed the lyre of Apollo. The
names of the seventy figurants are beautifully inscribed, making a
decoration for certain spaces in the background; this feature,
naturally prized by those who received the medal, was made
possible by modeling the original on a large scale. Here is no hodge-
podge of unrelated symbols, but a beautiful and lovingly considered
arrangement of deeply significant things. We associate with it the
same sculptor’s Columbus medal-obverse, and many reductions, in
plaquette form, from his portrait reliefs. While delighting in the
conceptions of antiquity and of the Renaissance, Saint-Gaudens,
more than any other master of his day, made a faithful study of all
the conditions of the modern portrait relief.”
PLAQUETTE
BY AUGUSTUS SAINT-GAUDENS
The fact that this sculptor not only prized the bas-relief form, but
also achieved a beautiful originality in it has of course turned many
Americans to the same path of expression. It is one of the delightful
ways in which modeling can take an occasional half-holiday from the
facts of form.
CHAPTER VIII
OF GARDEN SCULPTURE AND ORNAMENTA
I
Visitors were standing by the fountain in the garden of a sculptor;
and some one was asking him what in his opinion was the most
beautiful material to model in. The questioner probably had in mind
clay, wax, stone, metal and other solid substances; but the sculptor
answered quickly: “Water. There is nothing in the whole world so
marvelous to manipulate as water.” A gleam of creative rapture lit his
face. “Shall I show you my ‘Veil of Mist?’ or would you rather see my
‘Jeweled Elm-Tree?’”
A
This chapter is largely a reprint, permitted
through the courtesy of the American Magazine
of Art.
There are few sculptors who have not been fascinated at one
time or another by the designing of fountains, with their primary
interest of sculpture and their secondary mystery and magic of
water; whether of still water, with its mirrored pictures of blue sky,
dark trees, many-colored flowers and sun-flecked walls; or of gently
dropping water, suggestive of leisure and repose; or of leaping,
flashing, dancing water, hypnotic even without copper or silver balls
tossed up and down; or of water brought from afar in grandiose
cascades or canals, as in the garden art of the Villa d’Este, the Villa
Lante, Versailles, and Saint Cloud; or even of water turned at great
cost to wondrous baroque inventions for drenching the unwary
bystander, as in the Villa Aldobrandini. Fortunately, at the present
hour, the practical joke in fountains is out of date; and there is a
growing use of fountains as memorials, either stately or intimate,
either in public squares or in private gardens.
Setting aside the innumerable pots, urns, sarcophagi and other
“containers” for trees, shrubs and flowering plants, the larger part of
our garden sculpture centres about water and its works. Besides the
more or less imposing figure fountain, with its bronze boys, dolphins,
fauns, nymphs, Nereids, Tritons, turtles and other hardy perennials
of the aquatic imagination, there are tanks, reservoirs, bathing pools,
all no less practical if touched with some suggestion of the sculptor’s
art; there is the basin of the well-known pozzo type, flowering out
into putti, corpulent or lean, bending under their swags of foliage and
fruit; there is the little wall-fountain, borrowed from the lavabo of
Renaissance churches, and dear to the careful gardener,
replenishing from it the green-painted, fine-snouted watering-pot
kept sacred to his tiny seedlings. Then there is the water-spout,
ready with its witty word of grotesque, and the rainwater pipe-head,
in which English lead-work of the sixteenth and seventeenth
centuries displayed a vigorous and interesting art. There is even the
bird-bath, that modern invention of the nature-lover, since today,
though we profit by many of the garden ideas of the Renaissance,
we do not imitate those Siennese gallants who tied blinded thrushes
to the dwarf ilex and cypress, to decoy winged creatures for
convenient garden shooting. The twentieth-century bird-bath lures
birds to life rather than to death, as is shown in a decorative bronze
by Annette Saint-Gaudens, who has represented upon it characters
in Percy MacKaye’s bird-masque, Sanctuary. The masquing spirit is
afoot these days with new opportunities for sculpture; the outdoor
stage, now no very uncommon feature in private gardens and
groves, shows a retaining wall and other boundaries ready for
suitable sculptural accent by means of statues, Hermæ, vases,
mascarons or garlands.
BACCHANTE
BY F. W. MacMONNIES
As not every day is fit for verse, so not every artist is gifted with
the happy hand for designing garden forms. It is a temperamental
matter; generally the note should be that of joy, or at least of serenity.
Mr. MacMonnies’s Bacchante and his Boy with Heron long ago set
the perfect pace of gayety for American gardens. And today, what
gladder creature this side of Arcady can you find than the
MacMonnies Duck Baby? Unless it is Edith Barretto Parsons’s
laughing Child with Turtle, or else one of Miss Scudder’s engaging
imps of Frogland. Some of our most accomplished sculptors have
delighted us with their garden art. How exquisite is the graciousness
of John Gregory’s kneeling Philomela, a statue lately designed for
the bird-garden of Mrs. Payne Whitney! No figure in recent years has
seemed more original and alluring than this “blithe spirit” considering
the wonder of her pinions.
FOUNTAIN FIGURE
BY JANET SCUDDER
The garden sculptor should have above all a true dramatic
instinct for the rôle his work is to play in the garden ensemble—a fine
relation-sense which will by no means clip the wings of his design.
You can not make pleasure-sculpture out of accurate letter-of-the-
law nature-copying alone. In a fountain figure, for example, with its
silhouette seen under varying conditions, today drenched with sun
and tomorrow dripping with water, all according to wind and weather,
surely the artist has much to consider aside from inch-by-inch
anatomical modeling. Sculptors know this, but sometimes forget it,
when once launched out on the simple joy of “copying a morceau.”
Here we touch a great difficulty in our art education. In spite of all
the chattered tomfoolishness of the hour, the fact remains that for
most artists, the school training is the beginning of wisdom. It is not a
goal, but a starting-point; it gives firm ground for future creative
flights. Yet no house can be well built of foundation-stuff alone. The
school provides a foundation, and something of a ground-floor
besides, but the artist himself must build his own upper stories. He
must create his own personal syntheses in art, with the help of the
repeated analyses practised by him in school. And now comes his
perilous moment; to survive, he needs time and opportunity. The
most advanced type of artistic training, that offered by our American
Academy in Rome, does not begin and end with Houdon’s “Copiez
toujours,” but allows for contemplation, for self-communion, for the
personal synthesis, and for the exchange of thought between
sculptor, painter and architect, so that each may understand the
other’s aims. American art today needs all the mellowing and
broadening influences that both the contemplative and the
communicative spirit can bestow. Mr. Manship’s figures and groups,
with their rich inventions of rainbow-winged fancy, are here to prove
that the Academy is not an ogre, whose chief delight is to crush
personal genius. But human frailty does not easily part with its
incurably romantic ideas of a fabulous monster; the public demands
a scape-goat; it would rather than not believe in the Evil Eye; and the
mood of the moment, with the injudicious, is to charge all untoward
influences in art to some Gryphon of an Academy, of which little is
known, and everything suspected.
II
Meanwhile, Mr. Manship from Rome and Mr. McCartan in New
York have both proved in their work that they not only know how to
model the nude and compose a statue, but, what is far more rare,
that they can “handle ornament.” Now ornament is often regarded as
beneath the notice of the new-fledged sculptor, while as a matter of
sad fact, it is more likely to be quite beyond his powers; and this is
partly because he lacks invention, and partly because he is without
knowledge of the rhythms of design; not hearing the music, his mind
cannot march. Garden sculpture as well as severe monumental form
calls constantly for the light touch or the strong arm of ornament.
Noting our American lack in this direction, the Society of Beaux Arts
Architects, in coöperation with the National Sculpture Society, has
been at pains to install in New York ateliers in which the ornament-
modeler, as distinct from the sculptor, may seriously study his art.
And when an artist like Mr. McCartan designs and models the
exquisite ornament seen upon his Barnett Prize Fountain, a new
hope is breathed into the efforts of those who would improve our
American standards in artistic craftsmanship, and break down the
stupid barrier between artist and artisan. Somewhere in the unknown
lies a vast continent of design-forms not yet touched by any
Columbus—a wealth of fauna and flora not of the Acropolis or the
Roman Forum or the Gothic cathedral, but akin to Greek and Gothic
in beauty and power; and the world is waiting for these new good
things.
III
Given our garden fountain, with or without its ornament, what
more natural than a coign of vantage from which to enjoy it? The
exedra, as introduced to us long ago by McKim, White and other
architects, has been eagerly adopted by garden lovers. A beloved
spot at Aspet, the Saint-Gaudens estate, holds in the far distance a
blue sky, a blue mountain and a lordly crest of purple pines; in the
middle distance is a magic stretch of simple grass, while near at
hand, and flanked by a rosy tracery of oleander blossoms, a golden
god Pan pipes to the seven golden fishes spouting water into a
green-veined white marble basin, rectangular in form. Facing this,
and shaded by pines, hemlocks and silver birches, is a great white
exedra, planned not on the usual curve but on the three sides of an
oblong, and showing in relief, on the end of each wing, an ivy-
crowned faun, by Louis Saint-Gaudens. Two giant terra-cotta vases,
made in this country from Italian originals, stand at the entrance to
the pergola that garlands the “old studio”; in an upper garden, a
bronze Narcissus leads the eye toward the house, with its white
balustrade accented by gracious heads of the Seasons.
Some years ago, I saw in the garden of a sculptor an exedra
with outlines pleasing to the eye, and comfortable to the anatomy.
The material was concrete, that first aid to the garden-mad and their
domestic sculpture. Inquiry brought out the fact that the contour had
been established by the sculptor’s actual sitting down, in propria
persona, in a roughly shaped mass of fresh concrete. To use the
human frame as a heroic modeling-tool, or templet, struck me at that
time as a delightfully unique idea in sculpture; today, with so many
artists keen for the queer, it would doubtless seem a mere
commonplace; one might even be glad that the human templet was
not used upside down, in the pursuit of novelty. But to speak justly,
our garden sculpture has not succumbed to the idea that queerness
is higher than beauty, and a shock to the spectator a richer artistic
achievement than his delight. Garden art in our country is no longer
in its infancy, and not yet in its decadence. Accepting the broad
principles of Italian garden design, (such as the treatment of the
garden as a place to live in, the harmonizing of the house with the
garden, and the adaptation of both to climate and landscape) it does
not today admit the baroque puerilities of the hydraulic practical joke,
or the grotto of mechanical toys and monsters. Fortunately, much of
our landscape gardening is in the hands of true artists, who employ
the best resources of other days, and the genius of modern
sculptors.
Among the oldest inhabitants of gardens are the Hermæ, or
boundary gods, once used, it is said, to define limits of land, but now
freed from that dull task, to be set up (singly, or in pairs, or in rows)
wherever found desirable, as to accent a terrace, or to flank a flight
of steps. The variety of type is infinite; male and female, these
terminal deities are the chorus in the grand opera of garden
sculpture, the only rule laid upon them being that they must play the
foursquare post below the waist, and look pleasant above. Marble is
their best dress, but they may with good effect wear terra-cotta in the
paler tones; a material well adapted also for the legion of great
decorative pots, round or square, that “help so” in gardens either
intimate or imposing. Many garden owners collect “antiques,”
delightful enough even though some of them, like women and music,
are perhaps better left undated. Renaissance sarcophagi are put to
the cheerful uses of pink geraniums; capitals and fonts and well-
heads bubble over with all sorts of blooming things. In the sun-dial,
little regarded by the Latin temperament, but dear as the lawn itself
to the Britannic imagination, the American sculptor has a subject that
cannot be accused of alien origin. Associated chiefly with English
landscape art, it nevertheless may “mark only happy hours” in more
formal surroundings. Harriet Frishmuth and Brenda Putnam are our
most lately laureled dialists; both have been successful in adapting
the well-modeled human figure to this form of garden sculpture.
Alas, that in every human effort shown out-of-doors, the climate
has always the last word! Good old Horace, grumbling impressively
about the hard winters of Tibur, would find his sandaled toes
shrewdly nipped in a Cornish garden on the Ides of December, with
Mercury’s winged heel quite capable of hitting well below the zero
mark. In Italy, the tooth of time is not a bad sort of modeling-tool; it
has carved a veil of illusion for triviality, and has given a new grace
to things already beautiful. But in our northern latitudes, the tooth of
time does not model; it ravages and corrodes, often with incredible
swiftness, and due winter precautions must enshroud our garden
sculpture. The question of material is ever with us. Bronze endures,
but turns dark; marble is fair, but frail. In the dooryard of many an
American artist, home-grown miracles have been wrought from
cement. I recall charming tennis benches, with ornamented ends; a
wall-fountain with reliefs of satyrs; some great vases enriched with
the owner’s coat-of-arms, and cast in a three-piece mold; and
numerous basins, posts, balustrades and steps. But trowel-sculpture
has its limitations, and the question of durability has not yet been
fully answered by the years. Perhaps, at some future day, science
will co-operate with art, and produce for the garden sculptor a
material as easily modeled as terra-cotta, as exquisite as marble, as
impressive as granite, and as durable as bronze. Until then, we must
manage as best we can with the materials the ancients had, though
under climatic conditions more favorable than ours; and we may at
least note with thankfulness that in garden art as in all things
annihilation has its uses.
CHAPTER IX
OF SMALL BRONZES AND GREAT CRAFTS
I
Akin to the faculty for creating garden sculpture is the gift for
designing those “small bronzes” in which American connoisseurs are
now taking a happy interest. The general public also is being made
familiar with the best of these pieces; a result reached through the
initiative of the National Sculpture Society and the enthusiasm of our
American Federation of Arts in sending out traveling exhibitions of
small bronzes to various cities. The small bronze may be either a
potentially perfect reduction from some full-sized masterpiece, as in
the well-known Saint-Gaudens reliefs reduced from larger originals;
or it may on the other hand be designed from the start in the ultimate
size. Both types are excellent. American sculpture today counts
scores of artists with a sure and delightful touch for the latter type.
Some of our women sculptors have created little masterpieces in this
intimate and friendly form.
Bessie Potter Vonnoh is an acknowledged leader here; one
might say that she is the originator of an American genre, in which
small size does not for a moment imply either a trifling imagination or
a petty rendering. I well remember Mr. Howells’s enthusiasm for
Bessie Potter’s figurines when they were first shown at a New York
exhibition. Their authentic American note captivated him. “These,” he
declared, “are real creations in sculpture.” The same may be said of
Miss Eberle’s vivid groups and figures from street and fireside and
doorstep; they have the charm and integrity of folk-lore tales told in a
plastic medium. Animal form, as in the days of Barye and Frémiet,
easily disports itself in this field. Miss Hyatt, Mr. Roth, Mr. Laessle
and others press all the imaginable joys of La Fontaine’s fables
within the contours of their bronze goats and bears, tigers, turkeys,
and elephants. Like the fables themselves, these bronzes are
classics, as in the stricter sense, the delightful groups of Manship
and Jennewein are classics.
Generally speaking, we do not like a look of toil and endeavor in
our small bronzes; we want something spontaneous, whether
graceful or humorous. Well and good. Yet here again is a real
danger; anyone who has had the sobering privilege, year by year, of
reviewing the rank and file of little plastic works presented for
exhibition knows very well that many of these pieces utterly lack the
solid qualities of construction, workmanship and an understanding of
nature’s detail.
II
One of the brighter possibilities of the small bronze designed in
its ultimate size is that it may well be cast by the cire perdue
process. That name is not altogether a happy one, because in truth
less of the sculptor’s personal touch is “lost” by this method than by
the sand process of bronze casting. By the lost wax method, it’s the
sculptor’s own fault if there’s anything wrong with the wax figure as it
leaves his hands. A mold made of a composition suitable for
enduring the subsequent impact of molten metal is then built up
directly on the wax figure, which has of course its insoluble core.
This stout mold or shell, closely enveloping every knob and crevice
of its wax kernel, is subjected to heat; the wax is thus melted out;
and, if all is well, an absolutely perfect space is left behind it,
between core and shell, ready to receive the red-hot bronze. The
cire perdue process theoretically avoids all unseemly seams, all ill-
joined joints. At its best, it approaches perfection; and such work is
as well done in our country as anywhere on earth.
CENTAUR AND DRYAD
BY PAUL MANSHIP
The small bronze has then its two separate manifestations. It
may present itself either as a reduction from some much larger work
worthy of wide recognition and ownership, or as a spontaneous first-
hand offering of a sculptural thought well-suited for expression within
modest confines. In either shape, its cost is not prohibitive for many
of our private citizens as well as for our museums. The cause of art
and the delights of possession are advanced side by side.
III
Whether we look at a little book-end bear in bronze, or at a
heroic equestrian statue in bronze and stone, or at a colossal
monument in granite or marble, the importance of fine craftsmanship
is evident. The artist is the last person in the world who can afford to
underrate the craftsman.
Not long ago in reading an essay on literary criticism, I was
confronted with this impressive query: What has the navel done for
modern life? Of course modern literature in its desire to be
impressive asks many curious questions of the reader, but this one
about the navel seemed unduly wide of the mark. I was disturbed
until I suddenly perceived that the printer had used an a for an o; the
luckless author had meant to ask about the novel, not the navel. But
the artist in words suffers less often at the hands of his helping
craftsman than does the artist in paint or clay. The sculptor in
particular runs grave risks. Even the forces of nature conspire
against him; the fair-faced marble hypocritically hides her blemishes
until weeks of carving lay them bare. Even chemistry betrays him;
the bronze that should be perfect everywhere has perhaps a spongy
place or a “tin spot” or a treacherous seam just where it does the
greatest possible damage to his statue.
One of the advantages of the ancient apprentice system was
that the beginner in art could learn all the tricks, and not only the
tricks but the very serious difficulties of the various trades that help
to bring the artist’s work to completion. Our American sculpture,

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1. Introduction to research, the research process and EBP 1

ABOUT THE AUTHORS vii

1.1 What does ‘evidence-based practice’ mean?

Imagine you are taking the time to visit your grand-

1.1 The meaning of ‘evidence-based practice’

2 Understanding research methods for evidence-based practice in health

CHAPTER 1 Introduction to research, the research process and EBP 3

4 Understanding research methods for evidence-based practice in health

CHAPTER 1 Introduction to research, the research process and EBP 5

Decision making by press cutting

Decision making by expert opinion

6 Understanding research methods for evidence-based practice in health

Approximate Clinical practice accepted by Practice shown

1957 Thalidomide for ‘morning 1960 The teratogenic effects of

1960s Benzodiazepines (e.g. 1975 Benzodiazepine prescribing

1970s Intravenous lignocaine in acute 1974 Lignocaine continued to

Decision making by cost minimisation

CHAPTER 1 Introduction to research, the research process and EBP 7

8 Understanding research methods for evidence-based practice in health

CHAPTER 1 Introduction to research, the research process and EBP 9

10 Understanding research methods for evidence-based practice in health

Asking questions and

Imagine one of your clients asks you a question that

2.1 Different types of searching for evidence

12 Understanding research methods for evidence-based practice in health

Searching the literature

2.2 Differences between primary and

2.3 Effective search strings

CHAPTER 2 Asking questions and searching for evidence 13

Steps for effective searching

FIGURE 2.1 Advanced Boolean operator search on PubMed

Source: PubMed 2019.

14 Understanding research methods for evidence-based practice in health

FIGURE 2.2 Using truncation and Boolean operators in PubMed

Source: PubMed 2019.

CHAPTER 2 Asking questions and searching for evidence 15

But he who designs the modern American coin, however

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