I read with interest the article on developing and using a clinical practice council and evidenced-based literature to update, revise, and inform clinical policies.1 It is absolutely essential that clinical nurse specialists (CNSs) use evidence-based practice approaches to care, and the authors correctly assert the policy and procedure manual as a strategic place to start. They identify useful criteria for selecting staff champions of the practice council. I applaud the authors in providing an easily adoptable strategy to use in other organizations. (And I hope their health system now considers the 4 hours spent on the practice council to be PRODUCTIVE hours!)

I do have a few comments I hope will enhance information-seeking strategies used in revising nursing policies and procedures. The first illustrates what may be an unrecognized strength of the strategy used by Dr Becker and colleagues. The second encourages the CNS to use additional strategies to search for evidence. A third is included to encourage continued critical appraisal of research findings.

Most clinicians remember the triangular schematic representing the commonly portrayed hierarchy of evidence. At the pinnacle is the meta-analysis considered to be the "highest level" of evidence. As the triangle broadens, it moves downward including nonexperimental research to sources considered "less credible," such as expert opinion, at the base. This is considered by many to be the criterion standard in evaluating the quality of research, and this view appears to be supported by the authors as indicated in Table 3 (page 79). However, I note and applaud their use of qualitative research in the Clinical Practice Alert-Psychosocial Care of the Family on page 84. Their first research citation addresses the experience of frontline ICU nurses in caring for patients who have family present at the bedside. What a valuable resource to have in developing this particular practice guideline!

Qualitative research is underrecognized as a method of scientific inquiry that provides evidence to inform clinical practice.2 Students are taught the importance of fit between the research question and the research design. It is essential they also be taught the importance of fit between the clinical question or clinical topic and the evidence needed to fully inform practice. Dr Becker and colleagues demonstrate the necessity of using such scientific evidence to inform practice by including qualitative research findings.

However, I do believe further searching may have produced additional relevant information. It appears they may have only searched the nursing literature-that is, publications listed within CINAHL. There is 1 citation from Critical Care Medicine, but that journal is indexed within CINAHL. Exclusively using CINAHL is a problem I have with my graduate CNS students who have been indoctrinated to believe they should use only nursing literature to answer nursing questions. But consider the topic of this particular practice guideline-Psychosocial Care of the Family. This phenomenon transcends disciplinary boundaries. Our colleagues in psychology (and other health-related disciplines) are certain to have useful material to inform psychosocial care of the family-material that the CNS and members of a clinical practice council would want to be aware of.

It may be the authors searched multiple databases in their quest for material; however, this is not reported in the published article. My point is this: CNSs need to be proficient in thoroughly searching for scientific evidence to inform clinical practice.3 This evidence can exist outside CINAHL. Certainly, the issues needing to be considered will be addressed in a variety of sources from a variety of health professionals. I expect my CNS graduates to be aware of relevant scientific evidence they can bring back to inform their nursing practice. In addition to CINAHL, particularly useful and easily accessible databases include Cochrane Library Online, MEDLINE, PsychINFO, and PubMed. The Joanna Briggs Institute also provides extremely useful information for CNSs.

One final note concerning scientific evidence concerns implications from published research, and there really are 2 issues here. First, CNSs need to be aware that methodological errors adversely impact research findings. And it is the research findings we use in our evidence-based practice! Statistical errors have been reported in health-related publications in medicine,2,4 behavioral health,5 communication,6 and even nursing.7,8 The other issue is overstated conclusions. Researchers/authors may overstate their findings in their enthusiasm to communicate with readers. Consider this a gentle reminder to look at the research questions posed in the article with what the authors determine are findings and conclusions. Evaluate the connection of each conclusion/recommendation with the research purpose or question. If the study wasn't designed to uncover a finding, chances are, you won't want to use that information in your practice.

Tracy A. Riley, PhD, RN, CNS

Associate Professor, Nursing

University of Akron

Akron, Ohio

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