Chapter Two

Literature Review and Methodology

2.1 Introduction

intro
Research is a systematic approach to find out new knowledge about a
given subject. It is important to conduct a thorough literature search in
order to gain sound evidence to support the question being asked. This
underpins the whole problem solving process, but is frequently overlooked
in the haste to discover an answer (Craig & Smyth 2012).
The process taken to answer the proposed question was a systematic
approach in the form of a literature review. This chapter shows how the
literature searches and retrieval of journals was conducted. A thorough
search of evidence will produce large amounts of data, so an in depth
examination by the author has to be conducted in order to discover the
most relevant to be critiqued. Therefore, it is crucial to have the
knowledge of the best way to navigate literature to guarantee no avenue
is missed.
The places favoured most to gather clinical information is textbooks and
personal contacts, directly followed by journal articles (Greenhalgh 2010).
Although in recent years online resources have increased in popularity,
particularly

via

PubMed/MEDLINE

which

consists

of

twenty

million

references. However, this resource is conservative and slow to add new

journals from health sciences and outside of the United States. To this
effect a multitude of databases must be explored and systematically
searched to gain a range of studies (Greenhalgh 2010).
This chapter sets out to illustrate the process by which the best evidence
available was selected for the critical analysis.
235

2.2 Search Strategy

strat
When searching for evidence, large amounts of data will clearly be
generated, when a thorough search of an extensive range of evidence is
carried out. A thorough examination of the studies in some depth will need
to be conducted to retrieve those relevant for critiquing.
A systematic search of multiple databases must be completed in order to
obtain a suitable quantity and range of studies (Greenhalgh 2010). The
most commonly used databases are MEDLINE, EMBASE, Cochrane Library
and Collective indexes of nursing and allied health literature (e.g. CINAHL)
(Greenhalgh 2010).
Initially the Cochrane library was searched, as it contains Cochrane
Collaboration reviews which are the "Gold standard" systematic reviews
within healthcare interventions (Craig 2012). Cochrane contains current up
to date literature and other systematic reviews and randomised controlled
trials (Greenhalgh 2010). This was utilised to ensure that this projects
question, formulated in chapter one, had not already been conducted and
answered. In this case it had not and this project could then move forward
to considering evidence to answer the question.
The initial search criteria were established using the PICO framework (See
Chapter One, Table 3). When forming the initial clinical question, key words
and phrases were acknowledged. Studies to be reviewed will be searched
for in relevant search engines, which require the need for systematic
searches term to be applied.
A systematic literature search will be conducted using thoughtful search
strategies ensuring no relevant studies are overlooked. Specific search
terms and strategies are used to ensure the searches are focused,
although can yield fewer relevant articles (Burns & Grove 2009). 244

2.3 Hierarchy of Evidence

hier
The best possible evidence must be applied, to appropriately finalise the
most accurate interpretation to the research question. The two main
sources of evidence are primary and secondary (Burns & Grove 2009).
Primary research is written by the person in charge of the study whereas
secondary is citations and notions sourced from primary research (Burns &
Grove 2009). Secondary resources can be biased, as opinions can
influence the findings, although a methodological, systematic approach is
taken to eliminate this. Furthermore, secondary resources can have
publication bias by not including unpublished studies (Craig & Smyth
2012).
There are many hierarchies for evidence; these differ depending on what
needs to be established (Aveyard & Sharp 2013). It is argued that some
methods and designs of research are more influential than others; this has
increased the need for hierarchies of evidence (Burns & Grove 2009).
Similarly, there are many varying forms of evidence and they vary in
quality (Pooler 2011). The effectiveness of evidence should be considered
within health research and the use of a recognised hierarchy of evidence
can be a beneficial guide for professionals (EBNP 2003). Effectiveness is
the extent to which interventions achieve their intended outcomes,
meaning, does the intervention work, the benefits and harm and who will
benefit from its use (Pooler 2011).
Aveyard & Sharp (2013) offer a traditional classification to evidence
resources putting it into eight categories and orders them in order of their
importance (See Table 5).
Table 5: Hierarchies of Evidence
1

Systematic reviews and meta-analysis

Randomised controlled trials [RCTs]

Cohort studies, case controlled studies

Surveys

Case reports
3

Qualitative studies

Expert opinion

Anecdotal opinion

(Aveyard & Sharp 2013)

Randomised Controlled Trial [RCT] are ranked second as they provide the
highest level of evidence after systematic reviews, however, it is important
to remember that RCTs are not the always the best source of good quality
evidence depending on the type of investigation (Aveyard & Sharp 2013).
There are limitations to this hierarchy (Aveyard & Sharp 2013). It is only
relevant

when

looking

for

evidence

that

determines

whether

an

intervention or treatment is effective or not. The best available evidence is

using an RCT or a review of RCTs to answer the question. However,
qualitative studies although lower down the hierarchy are not useless
(Pooler 2011), Aveyard & Sharp (2013) agree, suggesting some questions
are not best answerable with RCTs, in this case the above hierarchy is
inappropriate.
For the purpose of this project it is crucial that quantitative research
studies are used to determine whether patients pain due to dry mouth is
reduced by the use of acupuncture. RCTs will be used as they produce the
best possible evidence available. 372

2.4 Index and Database

databases
Online electronic databases have been constructed to incorporate citations
from around the world from many different subject areas, CINAHL
database offers a collective catalogue for nursing and allied health
literature (Craig & Smyth 2012). The search will incorporate the use of
AMED, CINAHL, Cochrane, EMBASE, MEDLINE, Web of Science and
PsycINFO online databases (See Table 6).
All the databases were relevant; however, due to limited amounts of
evidence found during some searches, every avenue had to be reviewed
systematically. Delphis is the local library's current search tool, which
simultaneously searches a huge range of resources to find information
needed, however it incorporates the above databases, so was utilised to
do a broad initial search.
Table 6: Databases Used
Database
AMED

CINAHL

Description
Covers a selection of journals in

Reason for inclusion

This study focuses on acupuncture,

complementary medicine, palliative

covered within complementary

care and several allied professions

Provides influential coverage of

medicines
This database is specific for nursing

literature associated to midwifery,

and health sciences.

nursing, health education and other

COCHRANE

related subject areas.

Home the Cochrane Reviews. "Gold

Check that a review of this studies

standard" systematic reviews in

question has not already been

healthcare interventions. Also

evaluated and has access to

contains information on other

randomised control trials.

systematic reviews and randomised

EMBASE

controlled trials.
Leading clinical medicine and

This resource has access to

biomedical database - similar

international journals.

coverage to MEDLINE (particularly

in drugs, toxicology, biotechnology,
health affairs and forensic
MEDLINE

medicine)
The world's best-known medicine

This resource has access to USA

and clinical science database (with

based journals.

world

literature

Incorporating

since
broad

1946).
set

of

measured

vocabulary

called

Medical Subject Headings (MeSH

terms). Also free on the web from
PubMed.

Table 6 continued
WEB OF

Previously known as Web of

This resource has access to health

SCIENCE

Knowledge. Also provides access to

science journals.

Web of Science Core Collection

(health, social science, humanities
and others), BIOSIS (biological &
biomedical science) and Inspec
(physics, computing, electrical &
PSYCH

electronic engineering, etc.).

A key database for psychology and

Incorporates relevant documents

INFO

related subjects. Containing

that may contain valuable research

references and abstracts for journal

articles, books, book chapters and
dissertations.

107

2.5 Search terms

term
The search terms used were identified from PICO (See Table 3, Chapter
One). Keywords are essential to determine the main ideas or variables of a
research topic (Burns & Grove 2009).
A variety of key terms were used in the search for this project (See Table
7). These terms reduced the search to convey a number publications in
the databases used.
Table 7: Search Terms Used
The identified search terms where used for the retrieval of literature:

Acupuncture

Cancer or oncology

Pain

Head and Neck

The databases used are all designed to use Boolean logic (Greenhalgh
2010) (See Appendix 3). When searching the Cochrane library and Delphis
key information was input differently into the search bar. The key
information entered was acupuncture pain, head, neck, cancer, resulting in
potential papers relevant to the project. However, after further scrutiny it
was found that three papers in Cochrane were regarding the same clinical
trial, one was the preliminary, the second was the published article and
the third was the same trail as the published article. The 26 searches that
were retrieved in Delphis, of which 5 were duplicates and many were not
subject related (See Table 8 below for the results of the search).

Table 8: Search Findings

Database

Search Terms

Number of hits
D 71464

S1 =

A 9088

C 10206

Acupuncture

E 66479

M 19320

W 60910

AMED,

S2 = Cancer OR

A 10789

C 184397

D 1224382

CINAHL,

Oncology

E 4274511

M 1362115

W 7433696

A 26115

C 155361

D 1973271

E 2026960

M 480658

W 1629608

DELPHIS,
EMBASE,

S3 = Pain

MEDLINE,
PSYCHINF

S4 = Head and

A 770

C 12839

D 258535

O AND

Neck

E 351373

M 116608

W 321012

WEB OF
SCIENCE

S5 = S1 S4

A3

C9

D 26

using AND

E 322

M6

W 14

There are alternative methods to search for research other than online
databases, such as snowballing (See Appendix 4), one study to be
critiqued was discovered using this technique. 176

2.6 Inclusion and Exclusion Criteria

Inc exc
Research studies must define an eligibility criteria to their sample to
provide control measures and guarantee representation (Polit & Beck
2012). Eligibility criteria will be applied for this project ensuring each study
critiqued is relevant to answer the question.
When an article was selected, it was subjected to a brief critical analysis
before it was deemed relevant; the use of inclusion and exclusion criteria
was adopted to narrow the search (See Tables 9 & 10).
Table 9: Inclusion criteria (in alphabetical order)
Inclusion
Acupuncture for pain
English Language
Head and Neck

Reasoning
This is the specific therapy being evaluated for
pain. Included in the title.
Has to written in English or information could
get lost in translation
Very specific area of cancer being researched
Some areas use oncology and others cancer so

Oncology and Cancer

including both gives a wider perspective on

research

Randomised Control
Trial
Research Only
Xerostomia (dry
mouth)

RCTs are the best form of evidence for

acupuncture and evidence based research
This type of procedure would need to be tested
via a Randomised Control Trial [RCT]
This is the specific area to be reviewed.

Table 10: Exclusion criteria (in alphabetical order)

Exclusion
Reasoning
All therapies except acupuncture excluded
Alternative therapy

Case Series Reports

Children studies
Complementary
therapy

Electro Acupuncture

from the search as it can be classed as an

alternative therapy.
Does not contain enough evidence to answer
the question.
It was deemed that childrens anatomy is very
different to adults
All therapies except acupuncture excluded
from the search as it can be classed as an
alternative therapy.
This is the use of electrodes placed on the
acupuncture points. Has a differing effect to
needle therapy.

Foreign Languages
Non-Research Articles
Transcutaneous
Electrical Nerve
Stimulation [TENS]

Information could get lost in translation

Acupuncture needs to be research based
articles
Anything that is along the lines of TENS as this
is nerve stimulation not needle acupuncture.
Although reviews are high on the hierarchy,

Systematic Reviews

this evidence is the same as the project being

undertaken

The inclusion and exclusion criteria (See Tables 9 & 10) were applied
during the initial searches. Initially the title was examined to deem
whether the study was relevant, then the abstracts were perused to
establish whether or not they would be beneficial to answer the research
enquiry. Any articles stating they were conducted using RCTs were
immediately included and non-research (qualitative) articles excluded. The
best available evidence for the project would be discovered by using
inclusion and exclusion criteria throughout.
The first inclusion criteria to be adopted was acupuncture for pain due to
xerostomia (dry mouth) or other symptoms of HN treatment, requiring
10

each study to have this as a focus. It was important the study was an RCT,
as this is the best evidence required for the focus of the question. However
after adopting the other criteria, it was found that many of the studies had
acupuncture for cancer pain but were not in reference to HN patients
although other areas of cancer.
Throughout the database searching many studies incorporating other
areas of cancer were found, some were quantitative and a few qualitative.
These studies were all produced valuable findings in relation to cancer
pain, but they unsuccessfully determined the effect of acupuncture to the
HN region. Although qualitative methods could be used to seek out the
human experience, the aim is narrative and subjective striving to gain an
understanding of feelings (Parahoo 2006), which has limitations of the
personal nature of the conclusions, that are not easily replicated or
necessarily generalizable (Polit & Beck 2012). Whereas quantitative
research generate predictions by using deductive reasoning, which are
tested in the real world, controls are put in place to minimize any situation
bias and validity and precision are maximized (Polit & Beck 2012). The aim
of this project is to determine if acupuncture can help pain and discomfort
alongside conventional analgesics, a quantitative design is essential in
order to gather deductive scientific evidence. A case series report was
excluded due to its nature of being a report and not having a control group
(Craig & Smyth 2012), there were not results or statistic to enable a review
of the work. Case reports are a description of a single patients medical
history in the form of a story, when they are run together they form a case
series, which are traditionally considered weak scientific evidence
(Greenhalgh 2010). However, they are valuable in understanding the
patients journey. 447

11

2.7 Outcomes of Literature Search

Out lit search

Once a systematic review of all the databases had been conducted,
literature was subjected to inclusion and exclusion criteria to narrow the
literature to be used for critiquing.
The articles selected and rejected were narrowed down using inclusion and
exclusion criteria (See Tables 11 & 12). The selected literature will be
reviewed and critiqued in chapter three. 53
Table 11: Rejected Literature
Article Title

Author/
s

The Role of
Acupuncture
in Cancer
Supportive
Care

Lin J &
Chen Y

Date and
published
American
Journal of
Chinese
Medicine
2012.40(2):
219-29

The Role and

Impact of
Acupuncture
After Head
and Neck
Treatments

Hart J

Alternative
and
Compliment
ary
Therapies
2011. 17(4):
210-213

Integration of
Acupuncture
into the
Oncology
Clinic

Johnston
e P;
Polston
G;
Niemtzo
wR&
Martin P

Palliative
Medicine
2002.
16:235-239

Acupuncture
for Dysphagia
after
Chemoradiati
on Therapy in
Head and
Neck Cancer:
A Case Series

Lu W;
Posner
M;
Wayne
P;
Rosenth
al D; &
Haddad

Integrated
Cancer
Therapies
2010.
9(3):284-290

Summary of
Research
Reviewing
what the role
of acupuncture
has in
supportive
care.
Reviewing
research a
sample of
literature
supporting the
use of
acupuncture
after Head and
Neck
treatments
This paper
describes the
physical
integration of
the discipline
into the
Oncology
Clinic, and
patient
perspectives
on its
availability and
efficacy.
The purpose of
this study is to
determine if
Acupuncture
can help
relieve
dysphagia,
although it

Rational for Rejection

This is a literature review
and not research. Good
source of background
knowledge.

This is a literature review

and not research. Good
source for background
information.

This paper is a study but

looks at many different
forms of cancer problems
and is looking at patients
perspectives.

This paper includes Head

and Neck patients and is
specific to dysphagia,
using acupuncture in
relieving pain for the
causes of, dry mouth being
one problems areas, could
still answer the question

12

Report

incorporates
Xerostomia as
one of the
causes.

set. However does not

have details of statistical
analysis, results just a case
summary and vignette

Table 12: Selected literature

Article title

Author/s

Acupuncture
for Pain and
Dysfunction
After Neck
Dissection:
Randomised
Control Trial.

Pfister D;
Cassileth
B; Deng
G; Yeung
K; Lee J;
Garrity D;
Cronin A;
Lee N;
Fraus D;
Shaha A;
Shah J &
Vickers A

Acupuncture
for
PilocarpineResistant
Xerostomia
following
Radiotherap
y for Head
and Neck
Malignancies

Acupuncture
for
Xerostomia

Date and
published

Summary of
Research

Rational for Inclusion

Journal
of
Clinical
Oncology
2010.
28(15):
2565-2570

Purpose to
determine
whether
acupuncture
reduces pain
and dysfunction
in patients with
cancer with a
history of neck
dissection

This study includes Head

and Neck patients and is
specific to neck dissection,
however it has a
secondary observation of
acupuncture in relieving
dry mouth, which still
answer the question set.

Johnstone
P; Peng
P;
May B;
Inouye W
&
Niemtzow
R

Internation
al Journal of
Radiation
Oncology
2001.
50(2): 353357

The purpose of
this study is to
test if
acupuncture
help
Xerostomia
after
radiotherapy, to
patients who
are resistant to
pilocarpine
mouth wash.

This study includes Head

and Neck patients and is
specific to Xerostomia,
using acupuncture in
relieving dry mouth, which
answers the question set.

Johnstone
P; Nietzow
R&
Riffenburg
hR

American
Cancer
Society
2002.
94(4):
1151-1156

The purpose of
this study is to
test if
acupuncture
help
Xerostomia.

This study includes Head

and Neck patients and is
specific to Xerostomia,
using acupuncture in
relieving dry mouth, which
answers the question set.

13

2.8 Critical Appraisal

Crit app
The word critical in critical appraisal is synonymous with the limitations of
a piece of work, although the strengths should also be addressed (Cutcliffe
& Ward 2007). Critiquing or critical appraisal is used to describe reading
research articles, manuscripts or papers in a critical manner (Cutcliffe &
Ward 2007). Whereas Craig & Smyth (2012) suggest critical reading is a
systematic way to evaluate studies and their applicability and validity. The
assessment of the strengths and weaknesses of a study are how the
meaning and significance is considered, subsequent to a methodical
analysis (Burns & Gove 2009). Thus critical appraisal permits nursing to
better understand all evidence available.
In practice nurses are expected to make evidence based clinical decisions
every day. Nursing is described as holistic and is more than the sum of its
parts, thus, requiring high level skills and understanding (DH 2006).
Healthcare requires intellectually and emotionally aware nurses, able to
use both practical clinical skills with profound understanding and aptitudes
for care (DH 2006).
Clinical effectiveness is a priority of the healthcare agenda and use
systematic

frameworks

to

appraise

research,

which

assists

the

development (DH 2007). In addition, clinical governance principles are at

the heart of quality assurance for health organisations, including clinical
auditing, quality assurance and enhancement, clinical effectiveness and
evidence-based practice, which all apply to practice to support high quality
of care (Peate 2012). 208

14

2.9 Critiquing Tools

Crit tool
When critiquing a paper reviewers must record factual information about
methodologic features and findings along with making judgements about
the quality of the evidence (Polit & Beck 2012). Judging the quality of
research and its applicability to a clinical area and patient group is crucial,
if using it to inform practice in a significant way, along with critiquing
research nurses must understand if the research could be beneficial in
updating their area of practice (Ellis 2010).
A systematic approach needs to be adopted when critiquing research, so
to efficiently critique the selected studies, a suitable tool is required
(Coughlan et al 2007; Cutcliffe & ward 2007). There is not a specific
approach that is the exact way when conducting a critique, however to
make the process simpler there are various strategies (Ellis 2010) (See
Table 13).
Table 13: Critiquing Strategy
1. Skim read the paper (gain a sense of the general methodology of the
research)
2. Read the paper in depth (comprehend each element of the paper)
3. Split the study up into its elements
4. Consider the study as a whole and consider its message
(Lobiondo-Wood & Haber 1998 cited in Ellis 2010)

Critiquing frameworks can be found on many websites and in various

books. Numerous tools were reviewed for appropriateness for this project.
Research frameworks can relate to a particular paradigm, so it is
imperative to determine what tool relates to which paradigm. Frameworks
are either generic or specific to either the qualitative or quantitative
research, while some relate to specific methodologies (Ellis 2010). Five
tools were considered for this project (See Table 14 below).

15

Table 14: Critiquing Tools (in alphabetical order)

Tool to be Evaluated

Aveyard et al (2011)
Six questions to trigger
critical thinking

Strengths

Limitations

Generic Questions

Generic Questions

Questions are simple and

Questions are too simple, which

easy to follow.

may mean important elements

of the research are overlooked

Easily available
CASP (2013)

Generic Questions

Critical Appraisal Skills

Generic well-defined

Programme

questions

Quantitative research

Easily available

Questions are too simple and

concise, which may mean
important elements of the
research are overlooked

Generic Questions
COUGHLAN et al (2007)
Step-by-step guide to
critiquing research.
Quantitative research

Well-defined structured

Generic Questions
Questions are simple and

questions particular to type

concise, however this may

of study

mean important elements of

Easily available

the research are overlooked

Structure is weak

PARAHOO (2006)

Generic Questions

A structure for evaluating

Questions are simple and

quantitative studies

easy to follow.

Generic Questions
Questions are too simple and
concise, however this may
mean important elements of
the research are overlooked

POLIT & BECK (2012)

Complex detailed questions

Generic Questions

Guide to an Overall

Well-defined and structured

Questions are concise, however

Critique of a Quantitative

questions particular to type

they are over complex in some

Research Report

of study

areas

The framework decided on was an adapted version of Guide to an Overall

Critique of a Quantitative Research Report (Polit and Beck 2012) (See
Appendix 4) due to the type of questions posed. The authors credentials
are not an essential part of whether a piece of research is credible or not
(Ellis 2010), as many journals do not publish authors qualifications, so it
was decided to remove the global issues from the framework for this
project, however the overall presentation would be reviewed along with
conducting a summary of the strengths and weaknesses of each paper.
271
2115 total
16

References
refs
Aveyard H & Sharp P (2013) A Beginners Guide to Evidence-Based
Practice in Health and Social Care (2nd Edition). Berkshire
Burns N & Grove S (2009) The Practice of Nursing Research: Appraisal
synthesis and generation of evidence (6th Edition). St Louis: Elsevier
Birch et al (2004) Clinical Research on Acupuncture: Part 1. What Have
Reviews of the Efficacy and Safety of Acupuncture Told Us So Far?....
Craig J & Smyth R (2012) The Evidence-Based Practice Manual for Nurses
(3rd Edition). London: Livingstone.
Greenhalgh T & Peacock R (2005) Effectiveness and efficiency of search
methods in systematic reviews of complex evidence: audit of primary
sources. British Medical Journal 331 1064-1065
Parahoo K (2006) Nursing research: principles, process and issues (2nd
Edition). Hampshire: Palgrave
Polit D & Beck C (2012) Nursing Research: Generating and Assessing
Evidence for Nursing Practice (9th Edition). Philadelphia: Lippincott Williams
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17