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Research and diabetes nursing. Part 2: Process of critical review

This article is the second in a six-part series addressing research and the DSN. Critical review is a key aspect of research and evidence-based care and, therefore, of clinical and professional practice. Critical review is an analytical and reflective process that involves judging the quality of research publications and their relevance to practice. This article outlines key aspects of how to review publications and conference presentations, how critical review applies to clinical care, and how this process can help develop writing and critical thinking skills. Also addressed are the general aspects of critical review, and a list of further reading and useful websites is provided. Specific considerations for particular research methods such as quantitative, qualitative, evaluation studies and audits will be addressed in later articles in the series.

The ability to appraise research publications and presentations critically is a part of the research process. It is also essential to evidence-based care. Keeping up-to-date with current research is vital in all fields. The volume of publications in all formats makes it difficult to read every relevant publication, therefore it is important to develop the ability to determine rapidly the content and quality of a publication. Although many publications undergo editorial scrutiny and peer review before they are published, these processes are not foolproof. In addition, keeping up-to-date with research and having the ability to review publications critically enables DSNs improve their professional standing and writing skills. 

The first article in this series (Dunning, 2011) discussed how to make decisions about the quality of research publications and their application to practice. This article intends to introduce the key aspects of the process of critical review, rather than be a definitive guide. Processes for reviewing different types of articles – quantitative, qualitative, evaluation and case studies – will be addressed in subsequent articles in the series. 

Background
Critical review is an analytical, reflective process that involves searching and reading literature on a particular topic and discussing the information using logic, knowledge of the topic, and professional judgment. Table 1 lists some of the benefits to taking a critical approach when reading research publications to create and maintain the academic basis for evidence-based diabetes education and management, and advancement in the discipline.

Most day-to-day reading involves “skim reading” or flicking through journals, online information, articles selected for journal club discussions and conference presentations. This helps determine whether the publication is relevant to the particular area of practice or the reader’s interest at the time. If the publication is relevant, a structured approach is needed to determine the quality and trustworthiness of the material selected.

READER
One method of commencing a critical review is embodied in the acronym “READER” (MacAuley, 1994):

R: Is the article relevant to your practice?

E: Is it educational: will it change how you practice?

A: Are the findings applicable to your practice?

D: Discrimination. Are the findings valid?

E: Can you evaluate the quality of the article?

R: What is your reaction to the article?

The acronym does not address the depth of critical thinking or reflection needed to review objectively and judge the scientific merit of a publication. However, DSNs new to critical review might find it a useful starting point. Undertaking a critical review course and/or participating in journal club discussions and other relevant professional development processes help develop confidence and skills.

The process of critical review
Critical review involves two main processes: initial or “skim reading” the publication, and then detailed critical reading. 

Initial reading
Skim reading involves a quick first reading of the publication to gain an overall impression of the content, making a note of questions and/or issues you need to examine more carefully. “READER” can be useful in the initial reading to help formulate specific questions about information you do not understand or where you might need to seek further information. 

It can help to think of the publication as a story. Like all stories, research publications have a theme, a beginning, a middle and an end. The story should flow logically so the connections among the sections of the publication are clear and easy to follow. Subheadings are like signposts, they help the reader negotiate the story and make it easier to read. Below is a list of common subheadings, along with the purpose of each section. A selection of questions you might ask yourself when critically reading the publication is shown in Table 2

Title
Should reflect what the article is about.

Abstract
Abstracts summarise the main points in the article. Structured abstracts have an introductory background sentence, an aim, method, results and findings, and conclusion. Abstracts are usually short, between 100 and 300 words. 

Literature review
Sometimes the literature review incorporates an introductory paragraph or separate subheading that describes the origins of the study and defines the scope of the article. The literature review should encompass relevant existing literature relating to the topic. 

The literature review sets the context of the article. It should outline what is already known about the topic and identify the gaps in the literature it aims to address. That is, it shows how the study fits within the existing body of literature. The literature should be discussed by outlining the strengths and limitations of the work cited. Sometimes conceptual or theoretical frameworks are described as part of the literature review or as a separate subheading, especially for qualitative studies. The literature review should logically move the reader towards the next section of the article. 

Aim or purpose 
The aim is arguably the most important part of the article because it is the framework for the method, the results and the conclusion, as well as any implications for practice. 

Methods 
The method describes how the study was carried out. It usually has several subsections, for example sampling population. The sample selection process might include inclusion and exclusion criteria. The sample size is denoted as “n”. The methods section may also contain the following subheadings: data collection process (there may be more than one if there is more than one aim); data collection instruments; data analysis techniques; and ethical considerations. Many journals require ethics approval from an appropriately constituted ethics committee before they will publish an article and will require a statement to that effect in the manuscript.

Results or findings 
In the results section the authors should tell the reader what they found. In qualitative studies some discussion of the findings might also occur, consistent with the method. 

Discussion
In the discussion section the authors tell the reader what the results mean, how the study relates to the existing literature, and provide some explanations for similarities and differences. 

Strengths and limitations 
A good discussion of the strengths and limitations helps the reader interpret the findings. It also provides important information about the validity and reliability of the results, which helps the reader make conclusions about the generalisability and/or transferability to other populations and settings. 

Conclusion
The conclusion should not speculate too far beyond the study findings. It should address the aim of the study.  

Other subsections typically found within research articles are acknowledgements, references, and tables and figures. Sometimes, the implications of the findings and areas for further research are included. Likewise, definitions of terms and a conceptual or theoretical framework for the study might be included, especially in publications reporting qualitative research. Subheadings are very useful when undertaking a detailed critical review. They also help determine whether the author told the reader everything they need to know about each section of the publication, and overall.  

Detailed critical reading
Undertaking a detailed critical reading involves considering three main issues:

  • Structure of the article.
  • Scientific content.
  • Author’s ability to use clear, concise writing, i.e. their ability to communicate effectively.

Studies generally fall into the following broad categories:

  • Quantitative studies (empirical).
  • Review articles (which might include systematic reviews, structured reviews, meta-analysis or meta-synthesis).
  • Qualitative studies (human behaviour).
  • Evaluation studies.
  • Audits.
  • Case studies.

A number of tools are available that outline critical review processes for specific types of studies (Box 1). These tools are also helpful when developing clinical practice guidelines (which should be based on the best available evidence), when writing assignments, research protocols, and when making grant applications.

Plagiarism
Plagiarism and self-plagiarism can occur and are very serious offences. Plagiarism can bring the author/s and publisher into disrepute.

Plagiarism refers to intentionally or unintentionally omitting to acknowledge other people’s work, including online publications. It can be difficult to identify plagiarism. Reviewers and authors need to become familiar with copyright laws and understand what constitutes plagiarism. Importantly, ignorance of copyright law does not protect authors, if plagiarism charges are made. One indication that plagiarism might have occurred is a distinct change in the writing style and word usage that is not attributed to another author.

Self-plagiarism is a type of plagiarism in which the same author/s publish various very similar articles about the same piece of work. It is sometimes referred to as “salami slicing”. One reason for self-plagiarism is the increasing pressure on academics to publish and build a track record (“publish or perish”). 

There are a number of online tools that academics can use to detect similarities among texts and therefore root out plagiarism.

Conclusion
Critical review is a skill that can be learnt and developed over time. It is a logical process that involves reading a publication critically, asking relevant questions, reflecting on the publication in light of experience and knowledge, and making informed judgments about the content, scientific merit and clarity of the writing. Authors need to consider the reviewers’ comments when their article undergoes critical review as part of the publication process. Reviewers’ comments almost always improve the article and the chances of publication.

REFERENCES:

Dunning T (2011) Research engagement: a key aspect of diabetes management. J Diabetes Nursing 15: 9–14
MacAuley D (1994) READER: an acronym to aid critical reading by general practitioners. Br J General Practice 44: 83–5

Other resources
Blackwell Publishing. Author Services: http://authorservices.wiley.com (accessed 01.02.11)
Centre for Evidence Based Medicine: http://www.cebm.net (accessed 01.02.11)
Chalmers I, Altman D (eds) (1995) Systematic Reviews. BMJ Publishing, London
Cochrane Collaboration: http://www.cochrane.org (accessed 01.02.11)
Greenhalgh T, Taylor R (1997) How to read a paper: Papers that go beyond numbers (qualitative research). BMJ 315: 740–3
Greenhalgh T (2000) How to Read a Paper. BMJ Publishing Group, London
International Committee of Medical Journal Editors. Information about copyright and plagiarism. http://www.icmje.org/#over (accessed 01.02.11)
PubMed Single Citation Matcher: http://www.ncbi.nlm.nih.gov/entrez/query/static/citmatch.html (accessed 01.02.11)

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