Using evidence to guide and inform clinical decision making is fundamental in nursing and health care. The Code of Ethics of the International Council of Nurses (2021) states that evidence-informed care is an essential component of nursing practice. In nursing, we use the best evidence available to inform practice and to guide clinical decisions. However, as a discipline concerned with the whole, nursing also considers the values and preferences of the individual, family, community, or population as well as the context and setting of where an intervention will be implemented (Nevo & Slonim-Nevo, 2011; Woodbury & Kuhnke, 2011).
At the highest level of the evidence pyramid are systematic reviews and meta-analysis of randomized controlled trials and clinical guidelines based on systematic reviews or meta-analyses (Melnyk & Fineout-Overholt, 2015). Unfortunately, much of nursing practice is not based on a systematic review of randomized clinical trials or even a randomized or controlled clinical trial. Instead, we may have a single descriptive or qualitative study (Level 6 evidence) or a systematic review of descriptive studies (Level 5 evidence) available to help inform and guide our practice.
At JANAC, we have five core values-inquiry, innovation, involvement, integrity, and inclusion (Relf et al., 2020). Two of these core values-inquiry and integrity-directly relate to evidence-informed practice. In support of inquiry, JANAC publishes numerous types of articles including original research of all designs and various types of reviews including systematic, scoping, and metasynthesis of qualitative literature. By publishing systematic reviews with and without meta-analyses, JANAC is able to disseminate evidence to inform practice and clinical decision making related to HIV prevention, care, and treatment.
In support of JANAC's core value of integrity, we strive to publish articles of the highest quality. As such, we promote the use of reporting guidelines in developing manuscripts. "The Enhancing the QUality And Transparency Of health Research (EQUATOR) Network is an 'umbrella' organisation that brings together researchers, medical journal editors, peer reviewers, developers of reporting guidelines, research funding bodies and other collaborators with mutual interest in improving the quality of research publications and of research itself" (EQUATOR network., n.d., About Us. What we do and how we are organized?, first paragraph). The reporting guidelines of the EQUATOR Network are simple, structured tools that researchers should follow when developing manuscripts. In total, there are 555 different guidelines (please see https://www.equator-network.org/reporting-guidelines/ for more information).
For systematic reviews, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines are considered the "gold standard." In 2021, Page et al. published an updated guideline for reporting systematic reviews; this is known as the PRISMA 2020 statement.
To help ensure the integrity of systematic reviews with or without a meta-analysis published in JANAC, the Instructions for Authors ask authors to consult and adhere to the 2020 PRISMA statement. One of the hallmarks associated with quality and rigor in a systematic review is the formal publication and/or registration of a systematic review protocol. On January 1, 2021, JANAC established the requirement that any systematic review submission be registered with the Prospective Register of Systematic Reviews (PROSPERO), the international database for registering systematic reviews related to health and social care. If a systematic review submitted to JANAC was not registered with PROSPERO, the authors will be asked to submit a full systematic review protocol using the PROSPERO registration requirements as supplemental digital content (SDC). If accepted for publication, the systematic review protocol will be published as SDC and the authors will be asked to include a statement in the manuscript, indicating that the systematic review was not prospectively registered.
To enhance the integrity, rigor, and quality of a systematic review, there are several domains of the PRISMA 2020 statement that should be carefully considered beyond registration. First, the introduction and background section of a systematic review should explicitly describe the current state of knowledge and its uncertainties (Page et al., 2021). Further, an explicit statement of the objectives or questions the review addresses should be included. In most situations, the use of the Population, Intervention, Control, and Outcome (PICO) should guide the research question.
Second, how the information sources associated with a systematic review were identified is another domain requiring attention (Page et al., 2021). To ensure clarity to the reader, authors of a systematic review manuscript should be certain to clearly specify all databases, registers, websites, and organizations searched. Furthermore, it is important for authors to also document procedures for identifying the "gray literature" associated with the research question. Regarding databases, authors are also asked to not only document the database searched but also the exact date of the search (month, date, and year) and the platform used to conduct the database search. For example, the database Medline can be searched by various platforms including PubMed and OVID. The Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews can be searched by both platforms from two different publishing houses including http://cochranelibrary.com by Wiley and Ovid by Wolters Kluwer. Similarly, the APA PsychInfo database can be searched on the platforms EBSCOhost (EBSCO) and Ovid (Wolters Kluwer). In identifying the information sources associated with a systematic review, study teams have to make decisions about geography, languages, years of dissemination, study setting, and report status as well as the exact outcomes of interest of the systematic review. For all these reasons, the inclusion of a librarian as a consultant, and possibly as a co-author, to a systematic review is invaluable in helping to develop the formal search strategy and conducting and documenting the actual search.
Third, the full line-by-line search strategy and the specific outcomes (number of articles for each search) for all databases and platforms should be provided as SDC. By providing this information, it allows the reader to replicate the search and to evaluate the rigor and quality of the information sources from which manuscripts were included in the final systematic review.
Fourth, during the selection process, best practice is for two independent reviewers to screen title and abstracts using the Population, Intervention, Control, and Outcome informed study questions and the inclusion and exclusion criteria. After title and abstract, two independent reviewers then screen full text. During full-text screening, it is also important to document the reason the study was not included in the systematic review. Examples of why a study may be excluded during full-text screening might include wrong period of data collection, results not stratified by population of interest (e.g., results may be specific to Black men who have sex with men but not be specific to young Black men who have sex with men), or wrong outcome. As part of the selection process, when the two independent reviewers do not agree, best practice recommends that a third independent reviewer resolve the disagreement. If this is not possible, the two independent reviewers should come together to discuss the area of disagreement and come to consensus. When this approach is used, the position and related rank of the reviewers (research supervisor vs. doctoral student; principal investigator vs. junior scientist/team member) should be carefully considered to reduce the risk of influence due to positional power. Another consideration associated with the selection process relates to procedures the authors used to obtain or confirm data from study investigators (Page et al., 2021).
Finally, another domain associated with a systematic review is the evaluation of the included evidence for quality and bias (Page et al., 2021). In this domain, the specification of the tool(s) and version used to assess risk of bias and/or quality is essential. Examples of tools include the Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I); the Newcastle-Ottawa scale; the Agency for Health care Research and Quality methodological checklist for cross-sectional/prevalence studies; and the Mixed Methods Appraisal Tool. As with title and abstract and full-text screening, two independent reviewers should evaluate each study for bias and/or quality using the tool described in the systematic review protocol. When there is disagreement, an independent third reviewer should resolve the disagreement. If this is not possible, the two independent evaluators of bias/quality should meet and come to consensus.
In closing, JANAC remains committed to integrity. As such, we use industry standards and best practices in our decision-making processes. Specific to systematic reviews, we require systematic review registration with PROSPERO, or similar registry, and use of the PRISMA 2020 statement as a basis for evaluating submitted manuscripts.
Disclosures
The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.
Author Contributions
Michael V. Relf was involved with the conceptualization, writing the original draft, and review and editing.
References