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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
CONTENTS
About the authors vii
CHAPTER 1
Introduction to research, the
research process and EBP 1
1.1 The meaning of ‘evidence-based
practice’ 2
1.2 Apprehension towards evidence-based
practice 5
Decision making by anecdote 6
Decision making by press cutting 6
Decision making by expert opinion 6
Decision making by cost minimisation 7
1.3 Before you start: formulate the problem 8
CHAPTER 2
Asking questions and
searching for evidence 11
2.1 Different types of searching
for evidence 12
Informal 12
Focused looking for answers 13
Searching the literature 13
2.2 Differences between primary and
secondary research 13
2.3 Effective search strings 13
Steps for effective searching 14
One-stop shopping: federated
search engines 16
2.4 Other avenues for how to search
for evidence 17
Searching for information using
social media 19
CHAPTER 3
Reviewing literature 21
3.1 Is a paper worth reading at all? 23
Question 1. Who wrote the paper? 23
Question 2. Is the title appropriate
and illustrative, and is the
abstract informative? 23
Question 3. What was the research design,
and was it appropriate to the
question? 24
Question 4. What was the research question,
and why was the study needed? 24
Question 5. Do the results or findings answer
the question? 24
3.2 Reviewing the methods of primary
research papers 25
Sample and setting: who are the participants,
and where is the study being
carried out? 25
What data-collection methods
were used? 26
How was the data analysed? 26
3.3 Reviewing the methods of secondary
(review) papers 26
Question 1. What is the focused clinical
question that the review addressed? 27
Question 2. Was a thorough search of the
appropriate database(s) carried out, and
were other potentially important
sources explored? 27
Question 3. Who evaluated the studies,
and how? 28
Question 4. How sensitive are the results
to the way the review has
been performed? 28
Question 5. Have the results been interpreted
sensibly, and are they relevant to the
broader aspects of the problem? 28
Meta-analyses and meta-syntheses 28
CHAPTER 4
Qualitative research 32
4.1 Qualitative research explained 33
4.2 The difference between qualitative and
quantitative research 34
4.3 Qualitative methodologies and data
collection strategies 35
Qualitative sampling 36
Data collection 36
4.4 Evaluating papers that describe
qualitative research 37
Question 1. Did the paper describe an
important clinical problem addressed via a
clearly formulated question? 38
Question 2. Was a qualitative approach
appropriate? 38
Question 3. How were (a) the setting and
(b) the subjects selected? 38
Question 4. What was the researcher’s
perspective, and has this been taken
into account? 38
Question 5. What methods did the researcher
use for collecting data, and are these
described in enough detail? 39
 Question 6. What methods did the researcher
use to analyse the data, and what quality
control measures were implemented? 39
Question 7. Are the results credible and, if so,
are they clinically important? 40
Question 8. What conclusions were drawn,
and are they justified by the results? 40
Question 9. Are the findings of the study
transferable to other settings? 40
CHAPTER 5
Quantitative research 43
5.1 Why and how quantitative research
is done 44
5.2 Quantitative research designs 46
Intervention studies 46
Observational studies 47
5.3 Measurement 48
Variables — independent
and dependent 49
Reliability and validity in measurement
CHAPTER 6
Levels of evidence 55
6.1 Clinical questions in healthcare 56
Finding the best evidence 56
NHMRC and evidence-based practice 57
How researchers answer
clinical questions 57
6.2 Matching clinical questions to NHMRC
levels of evidence 58
NHMRC evidence levels for
intervention studies 60
6.3 How bias threatens the validity of research
evidence 63
6.4 Evaluating the evidence – quality of
evidence and grades of recommendations
for practice guidelines 65
6.5 Levels within levels 66
CHAPTER 7
Statistics for the
non-statistician 73
7.1 Storing quantitative data in a data set 74
7.2 Descriptive statistics for summarising
sample characteristics 75
Descriptive statistics for
categorical variables 75
Descriptive statistics for
continuous variables 76
7.3 The researchers ‘setting the scene’ 77
Have the researchers tested the assumption
that their groups are comparable? 77
What assumptions apply to the shape
of the data? 77
Have valid assumptions been made about the
nature and direction of causality? 78
7.4 Probability and confidence 79
How are p values interpreted? 79
Confidence intervals 81
7.5 Clinical importance of treatment
effects 81
Clinical importance 81
7.6 Summarising treatment effects from
multiple studies of interventions in a
systematic review 84
CHAPTER 8
Mixed methods research 88
8.1 An overview of mixed methods
research 89
Why use mixed methods in nursing and health
sciences research? 89
8.2 Different mixed methods designs 90
Convergent study 90
50 Sequential study 91
Multiphase (multilevel) study 91
Embedded study 92
8.3 Integration in mixed methods
research 93
Integrating the research question 93
Research design 93
Sampling 93
Analysis 93
Interpretation 94
8.4 Mixed method design considerations 94
Weighting (dominance) 94
General challenges associated with mixed
methods studies 94
CHAPTER 9
Sampling 97
9.1 Understanding the terminology around
sampling 98
Theoretical population (or target
population) 98
Study population (or accessible
population) 98
Sampling 99
Sample 99
Sampling frame 99
9.2 Types of sampling 99
Probability sampling 99
Non-probability sampling 100
Sampling methods 100
9.3 Sampling error 102
9.4 Calculating sample size 102
Quantitative research 102
Qualitative research 103
CONTENTS v
 CHAPTER 10
Ethics 106
10.1 Ethical principles 107
Autonomy: patients/clients are free to
determine their own actions 107
Beneficence: acting to benefit
human kind 108
Justice: obligation to treat fairly 108
Non-maleficence: avoiding or minimising
harm 108
Respect for human dignity 108
Confidentiality: maintenance of privileged
information, including the right to privacy
and anonymity 109
Veracity: obligation to tell the truth 109
10.2 The role and function of human research
ethics committees 109
10.3 Judging the ethical aspects of a
published journal article 111
CHAPTER 11
Getting evidence into
practice 114
11.1 Adoption of evidence-based
practice (EBP) 115
Individual barriers 115
Organisational barriers 116
11.2 Encouraging individuals to implement
evidence-based practice 116
vi CONTENTS
11.3 Organisational support of evidence-
based practice 117
Integrated care pathways 117
Clinical practice guidelines 118
11.4 The client perspective in evidence-
based practice 119
Patient-reported outcome measures
(PROMs) 119
Shared decision-making 119
Option grids 120
CHAPTER 12
Challenges to evidence-
based practice 124
12.1 When evidence-based practice is
done badly 126
12.2 When evidence-based practice is
done well 126
Guidelines devalue
professional expertise 126
The guidelines are too narrow (or
too broad) 127
The guidelines are out of date 127
The client’s perspective is ignored 127
There are too many guidelines 128
Practical and logistical problems 128
The evidence is confusing 128
12.3 Achieving evidence-based practice 129
Index 133
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.
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?
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!

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

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!

6 Understanding research methods for evidence-based practice in health

 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
form of splints and braces on
the affected limbs for infantile
paralysis (Polio)
1930s Although very hot dressings
and physical therapy (what we
now know as physiotherapy)
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
non-steroidal anti-inflammatory
drug), introduced for the
treatment of arthritis, were later
shown to increase the risk of
heart attack and stroke
a
Interestingly, bloodletting was probably the first practice for which a randomised controlled trial was suggested.
2004 Cox-2 inhibitors for pain were
quickly withdrawn following
some high-profile legal cases
in the United States, although
new uses for cancer treatment
(where risks may be outweighed
by benefits) are now being
explored

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.

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

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.

8 Understanding research methods for evidence-based practice in health

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
5 Joanna Briggs Institute: www.joannabriggs.org
6 Australasian Cochrane Centre: http://aus.cochrane.org
7 ‘Evidence-based information’, QUT Library: www.library.qut.edu.au/search/howtofind/evidencebased
8 ‘Answering Clinical Questions’, University of Western Australia: www.meddent.uwa.edu.au/
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.

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

 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

10 Understanding research methods for evidence-based practice in health

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?
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.

CHAPTER 2 Asking questions and searching for evidence 13

TABLE 2.1 (continued)

Information
retrieval, Data
Professional Collaboration filtering collection Dissemination
Example profile and and project and and and
Activity tools networking management management storage translation

Project and Basecamp, ✓ ✓

document Evernote,
management GoodReader,
Papers

Cloud Google ✓ ✓ ✓
services Docs
(software)

Cloud Dropbox, ✓ ✓
storage Google Drive,
MS Office 365

Information RSS feeds, ✓

retrieval Google Alerts

Reference Mendeley, ✓ ✓ ✓
managers Zotero,
Endnote web,
CiteULike

Video Skype, Zoom, ✓ ✓

conferencing Google
Hangouts
Meet,
MS Lync

Clinical ✓ ✓
databases
and
registries

Survey SurveyMonkey, ✓ ✓
tools Qualtrics,
Poll Daddy,
Google Forms

Mobile Text ✓ ✓
devices messaging,
apps

Social Facebook, ✓ ✓ ✓
networking Twitter,
Yammer

Blogging WordPress, ✓ ✓ ✓
Blogger

Microblogging Twitter, ✓ ✓ ✓ ✓
Instagram,
TweetDeck,
Tumblr

Curation Scoop.it, ✓ ✓
Pinterest

Video YouTube, ✓ ✓ ✓
hosting Vimeo

Altmetrics Impactstory.org, ✓ ✓
altmetrics.com

18 Understanding research methods for evidence-based practice in health

SUMMARY
There are three main types of searching for evidence: informal, focused looking for answers and searching
the literature. Primary research is from a single research study; whereas secondary literature usually
examines multiple primary research papers and summarises them. There are many tools, databases and
search engines that can help in effective searching (such as PubMed, Google Scholar and Trip). Other ways
of searching for and gathering evidence include consulting librarians and making use of social media.

KEY TERMS
advanced search Allows you to set specific parameters for your results, such as year, author, title or
study type. This option usually means you have less hits that are more relevant than results from a
basic search.
Boolean operators The use of AND, OR and NOT to expand or exclude keywords in a search, which
then results in more focused or productive search results.
primary research An original piece of research from a single study.
search string A list of words or phrases, which when combined are used to search for a specific piece of
information contained in a database.
secondary research Research that has examined multiple primary research papers and summarised
them.
truncation A searching technique used when searching databases in which a word ending is replaced by
a symbol — an asterisk (*), a question mark (?) or a dollar sign ($) — to enable the search to include
all possible endings of the word.
wildcards A searching technique used when searching databases in which a letter in a word is replaced
by a symbol — an asterisk (*), a question mark (?) or a dollar sign ($) — to enable the search to
include alternate spellings of the word.

WEBSITES
1 ‘Finding the evidence’ from the University of Oxford’s Centre for Evidence-Based Medicine includes
a series of helpful resources, including videos on searching databases: www.cebm.net/category/ebm-
resources/tools/finding-the-evidence
2 ‘PubMed tutorial’ from PubMed offers an overview of what PubMed does and doesn’t do, as well as
some exercises to help you get used to how to use it: www.nlm.nih.gov/bsd/disted/pubmedtutorial/cover.html

ENDNOTE
1. A. Hoogendam et al., ‘Answers to questions posed during daily patient care are more likely to be answered by UpToDate than
PubMed,’ Journal of Medical Internet Research 10, no. 4 (2008): e29.

ACKNOWLEDGEMENTS
Adapting author for this Australian edition: Jane Warland
Photo: © Twin Design / Shutterstock.com
Photo: © nopporn / Shutterstock.com
Figures 2.1, 2.2 and 2.3: © PubMed / Public Domain
Figure 2.4: © Trip Database
Table 2.1: Reprinted with permission of John Wiley & Sons, Inc.

20 Understanding research methods for evidence-based practice in health

CHAPTER 3

Reviewing literature
LEARNING OBJECTIVES

3.1 Is a paper worth reading at all?

3.2 How do we appraise the methods of primary research papers?
3.3 How do we appraise the methods of secondary (review) papers?
3.1 Is a paper worth reading at all?
LEARNING OBJECTIVE 3.1 Is a paper worth reading at all?
There are multitudes of health claims published in advertisements, websites, newspapers and magazines
that profess to be based on research, but which are, in fact, unsubstantiated, ineffective, and may even
have the potential to cause real damage. (Several websites are mentioned at the end of this chapter that
explore and expose a great number of these.7) Most clinicians can spot the flaws in these quite easily
and rarely waste time reading them. Nevertheless, when it comes to articles in scholarly journals, many
of us assume that these must be completely dependable, as we are told they have been subject to peer
review. That is, other experts in the field have determined their validity, originality and importance before
publication. However, this is no assurance that a published paper is completely trustworthy or worthwhile.
Not all journals are high quality; there has been an explosion of health-related journals produced in recent
years, many of which exist only online, and although these usually claim to be peer reviewed, they do not
always follow the rigorous standards necessary to ensure scholarly worth. Even within reputable journals,
published papers show flaws such as lack of originality, wrong design choices, inadequate sample sizes,
unjustified conclusions, conflicts of interest and poor writing. However, even if a paper is not perfect, there
may be good, practical reasons for this and it doesn’t mean you can’t read it and learn from it in some way
after considering the flaws.
Before you can use a research paper to inform your own practice, you need to assess both the quality of
the study and how useful it is to you. You are looking for three main things:
1. results (what did the study find?)
2. validity (do the results match the conclusions?)
3. applicability (will they help you with your own clients?).8
Most research papers appearing in journals are presented more or less in standard introduction, methods,
results and discussion (IMRaD) format:
• Introduction (why the authors decided to do this particular piece of research)
• Methods (how they did it and how they chose to analyse their results)
• Results (what they found)
• Discussion (what they think the results mean).
The introduction may include background and a short literature review, and the discussion will usually
include conclusions, although these sections may all have their own separate headings. Your evaluation
should rest mainly on the design of the methods section, which will be covered in more detail later in this
chapter. Here are five general questions to ask for all papers.

Question 1. Who wrote the paper?

As you become more knowledgeable in your field or specialty, you will also become familiar with the key
researchers in that area. In the meantime, you can make some judgements on an author’s expertise from
their qualifications and affiliations. Are these in an area that relates to the topic they are writing about?
In particular, you should look to see if there may be a conflict of interest or possible grounds for bias
in the paper; for example, is the researcher funded by the company that manufactures the intervention
that is being tested? Are they investigating an intervention they have designed themselves and have a
vested interest in proving it successful? This does not necessarily invalidate the research, but it will let you
know there may be an underlying agenda and that you should examine the results carefully to see how the
researcher avoided bias.

Question 2. Is the title appropriate and illustrative, and is the

abstract informative?
A good title will tell you the phenomenon being studied, the population and the methodology used by
the researcher in their study. For example, ‘Young people’s experience living with Crohn’s disease: a
phenomenological study’ tells you the topic (Crohn’s disease), the population (young people) and the
design (phenomenology). The abstract should summarise the entire paper briefly, but with enough detail
to help you decide whether to read the whole article. Some are structured, following the same IMRaD
pattern as the extended paper, while others are narrative. However, all should let you know what the study
is about, how it was carried out, and the findings made. These aspects will not tell you the quality of the
study itself, but they will give you a good idea of how well organised or well written the paper will be.

CHAPTER 3 Reviewing literature 23

Another random document with
no related content on Scribd:
 At three o’clock another collection of eggs is made, and at five
o’clock eggs are again collected, and at this last collection all the
corners of the litter under the dropping boards are carefully searched
for eggs laid by the wayward Biddy, who prefers her own scooped
out corner to a good nest.
The Houses are closed for the night, according to the condition of
the weather, and at this time still another collection of eggs is made.
At seven-thirty the Houses are again visited, and all birds not
roosting as they should be are removed from the nest boxes or
windows and placed upon the perches.

Mash Fed in Afternoon

During the Summer months, when the birds are on Range, they
are fed their mash and grain ration between the hours of two and
three in the afternoon.
Throughout the year nothing whatever is allowed to interfere with
the Schedule, and, if one would succeed with poultry a rigid
adherence to regularity is most necessary.
 CHAPTER XVIII
Incubation on the Corning Egg Farm
We find, in studying Artificial Incubation, it has been in vogue, one
might almost say, for centuries. The Chinese practiced artificial
incubation by the use of hot sand and ovens, for it must be
remembered that the Pekin Duck, which comes from China, is a non-
setter. Therefore, ages ago, the Chinese were driven to the
necessity of artificial incubation in order to maintain their large flocks
of ducks. In studying the art one cannot help wondering that the
progress in its development has been so slow, and the advance,
year by year, has been almost nothing.

Hen Reigns Supreme

The Owners of The Corning Egg Farm were somewhat taken
aback one day by the statement of a young man that he must evolve
a theory of incubation for himself, and carefully carry it out. In
incubation one does not want theory, but the knowledge which
comes from long practice and the most scientific study of the art.
After all these years, the hen, as a hatcher, reigns supreme. There is
nothing which approximates her ability to turn out strong, vigorous
chicks, and yet it is unfortunately necessary to abandon the hen
when large numbers of chicks are to be produced. So Man has
struggled in his vain efforts to reach something which will, at least in
a measure, become a competitor of the hen.

Livable Chicks—Not Numbers

In 1911, the readers of advertisements in the Poultry Magazines
were confronted with the statement that a certain incubator was the
only competitor the hen had. But, it is sad to state, there must have
been some mistake, for this incubator could not live up to the claim
in the advertisement, nor, so far as it is known, is there any incubator
which approximates that claim. Some marvelous hatches are written
of, but the question is not one of marvelous hatches, so far as it
means the number of chicks which manage to come through the
strenuous act of exclusion, but the real question of incubation is as
to the number of strong chicks, capable of living and growing into an
animal which will become a money maker for the man who hatched
and raised it.
Many people stand in great awe of an incubator, no matter what its
make, and have the feeling that to hatch a fair number of chicks in a
machine is almost a miracle. The fact is, however, if the purchaser of
any incubator will realize that the manufacturer knows more about
the proper way to run it than Tom Jones, or Bill Smith, who may be
neighbors, and will follow the instructions as given by the
manufacturer, with good fertile eggs, it will be almost a miracle if he
does not get at least a fair hatch.
There are so many different makes of machines it is quite
impossible to write a chapter on incubation which will cover the
needs of all phases of it. The above advice, however, if followed, will
certainly be more apt to bring about successful hatches than
anything else that can be done.
On The Corning Egg Farm the problem of incubation has been
most carefully studied from the inception of the Farm.

Uniform Temperature Most Important

A thermostat and regulator which will absolutely insure an even
temperature in the egg chamber, and a thermostat so sensitive, with
an adjustment of the regulator to such a nicety, that it will insure the
maintaining of an equal temperature in the egg chamber even if
there is a variation of atmosphere in the Cellar of from 10 to 20
degrees, is perhaps, the first great essential in incubation.

Ventilation and Moisture Next

 Ventilation and the retention of moisture undoubtedly come next.
The growing embryo must be fed a large quantity of oxygen, and
there must be a sufficient amount of moisture to prevent a too rapid
drying out of the egg, under the temperature which, if a chick is to
result, must be maintained. So far as moisture goes, it is not a
question of moisture at the time of hatching. If the proper amount of
moisture has been always present during the period of incubation
there will be no difficulty at the time of exclusion.
Where a large amount of incubation is going on, and the ordinary
style of lamp heated machine is being used, oxygen is of necessity
constantly absorbed from the atmosphere, by the fire. While it is
quite possible, nay, even probable, that any of the mammoth
machines of the day are far from what might be desired, still, they do
solve the difficulty of a great number of individual fires sucking the
vital oxygen.
Of the mammoth machines now on the market there are two which
produce better chicks than any of the others, so far as we can see.
There are features in the one which we finally decided upon, which,
from our point of view, made it more desirable than the other. We
feel, however, that in the construction of these machines there is
much to be desired, and we suggest to any would-be purchasers to
make most thorough and complete stipulations with any company
from whom they purchase, as to the workmanship and finish of the
machine, and also the proper fitting of one part to another, especially
the proper working of doors and egg trays through all the different
periods of incubation. All trays should be absolutely interchangeable,
and there should be a sufficient amount of play in the runs, so that,
with the swelling of the wood from the moisture, there would never
be a possibility of their binding. While the doors should shut air-tight,
their dove-tailed joints should so fit as to allow their coming away
without a particle of stick, or jar, to the machine.

Hot Water Machines Best

When it had been fully determined by The Corning Egg Farm to
put in Hot Water Heated Incubators, the capacity desired being
about sixteen thousand eggs, it was concluded to divide this capacity
between two machines.
It was also decided to build an entirely new Incubator Cellar, and
the dimensions were 146 feet long by 22 feet wide, 7 feet from the
concrete floor to the bottom of the floor joists, these latter being 12
inches in width, making a full height to the floor of the Brooder House
overhead, 8 feet. The floor joists on the under side of the floor of the
Brooder House are planed and painted white. The Cellar is
constructed of concrete blocks, made rock faced, and showing in the
interior of the Cellar. The two incubators are also painted white
enamel.
So as to eliminate any question of the consumption of oxygen by
fire in the Cellar the heaters are placed with a concrete block
partition between them and the incubators, the hot water pipes
passing through this concrete wall, and connecting with the
incubators.
In this separate part of the Cellar, where the heaters for the
incubators stand, are also the two heaters for the Brooding System,
upstairs, and also the large auxiliary heater which cares for the hot-
water system which allows the Brooder House to be carried at an
even temperature, day and night.
In the heater part of the Cellar there are three large windows, and
an entrance is made into this Cellar through a vestibule which is ten
by nine feet. The doors leading into this are large, double, glass
doors, and from the landing just inside there is a staircase leading to
the Brooder House, above. Entrance is made into the Heater Cellar
through another pair of glass doors, five feet wide. The Incubator
Cellar itself is reached directly in the center by a four foot door, also
of glass. The two side alleys between the incubators and the outer
walls, are also reached from the Heater Cellar by narrow, glass
doors.

Corning Incubator Cellar Unequaled

It is believed this Cellar, with its plan of equipment, is unequaled,
anywhere, as to the convenience of its general arrangement. Ample
light and ventilation are supplied in the Incubation Cellar proper, by
twelve windows on the north and east sides, the south wall being
blank, as the chick runs from the Brooder House go out on that side.
It is impossible, owing to the necessity of the narrow alleys
between the incubators and the walls, to use the V-shaped window
drops, which have been so successful on the Farm for the
prevention of draughts. The windows work on sash-weights, both top
and bottom. A Spring Roller Shade device, covered with sheer
muslin, with a screw eye on the window sill, is so placed that the
cord may be passed through it, holding the shade rigid. Thus, when
the prevailing wind creates a draught, the window may be opened to
any desired width, and the draught prevented by the shade.
In operating the incubators they are run empty for a sufficient
number of hours to adjust the regulator, and to know they will
maintain a temperature of 103 degrees exactly.

Eggs Turned from Third to Eighteenth Day

After eggs are placed in the incubators the process of turning does
not begin until the third day, after which they are turned regularly
twice a day until the completion of the 18th day, when they are left
undisturbed.

103 Degrees Maintained

The temperature at which the incubators are carried for the first
week is a matter of wide difference of opinion. In many cases 102
degrees is the maximum temperature for the first seven days, after
which 103 is maintained as closely as possible during the remaining
period of incubation. In operating the incubators on The Corning Egg
Farm it has been found (and this is particularly true of early hatches)
that, if the eggs are not brought up to 103 degrees for the first week,
a retarded hatch is the result. A hatch which drags over its time
usually means a lot of weaklings. It is our practice, therefore, to bring
the eggs up to 103 degrees as soon as possible after setting them,
and to continue this temperature as nearly as possible.
 Cool But Never Cold
Cooling the eggs is of course practiced on The Corning Egg Farm.
For the first week, five or six minutes will usually be found a sufficient
time, but as the embryo grows the length of time should be
increased.
It is quite impossible to give any exact length of period for cooling,
and it must be determined by the feel of the egg to the hand. They
should never reach a point where they can be termed perfectly cold,
but should feel slightly warm as the palm of the hand is laid upon
them. In cooling, the egg tray should be placed on top of an
incubator or table so that the bottom is completely protected,
otherwise the eggs will cool too rapidly. In other words they should
lie as they do in the nest of the hen. According to atmospheric
conditions, cooling, during the latter part of incubation, will
sometimes reach from forty to sixty minutes. It is a practice with us to
give the eggs a very long period of cooling on the 18th day, before
they are placed in the incubator for the last time.
After closing the incubator on the 18th day it is not opened again
until the chicks are removed on the 22d day.
To open the door and reach in to assist some chick out of difficulty
means allowing the moisture to escape, and, while the one individual
which was seen to be in trouble might be rescued, by the lack of
moisture in the egg chamber, many others would be held fast in the
shell.

Cover Glass Doors

When the chicks begin to hatch we make it a practice to throw a
cloth over the glass door, so as to prevent the youngsters crowding
toward the light, and piling up on top of each other, either in the egg
trays or in the nurseries below.

All Good Chicks Hatch in 20 Days

Many people have an erroneous idea in regard to the time
required for hatching. If the temperature has been carried at a
correct point during the entire period the eggs will begin to pip on the
afternoon of the 19th day, and the morning of the 20th day should
find the youngsters coming out of the shells like Pop Corn over a hot
fire if the eggs have been of proper strength, but on the morning of
the 21st day the hatch should be completed. Generally speaking,
chicks which hatch later than the 21st day are weak, and while they
may come along for a time, when placed in the Brooder House they
generally snuff out, and add to the list of mortalities.

Set Incubators Toward Evening

It is our belief that there is a best time in the twenty-four hours in
which to set an incubator. As a rule, it requires about eight hours
after the eggs have been placed in the machine for it to come up to
temperature. Therefore, if the eggs go into the chamber late in the
afternoon, and anything goes wrong with the regulator, the eggs
cannot have been in a detrimental temperature for any great length
of time before the operator is making his first morning round. We
observe the temperature in the egg chamber three times a day as a
rule, the first thing in the morning before the eggs are turned; at
noon, or a sufficient number of hours after turning and cooling the
eggs, allowing a sufficient time to elapse for coming up to
temperature; and again late in the afternoon, before the final turning
for the day. At these hours of observation any slight alteration of
regulator, to meet changes noted in the temperature, is, of course
made.
The Hot Water, Coal-Heated, Incubator is a great step in advance,
and these machines are now built in sizes from twelve hundred eggs
up.
With the old style lamp machine, people who were running a small
plant did not need an Incubator Cellar, but the Insurance Companies
would not allow the placing of an incubator in the cellar of a house
without a special permit, and in many cases would not issue such a
permit at all. The hot water machine will, of course, go into any cellar
without vitiating the insurance, and, what is more, the machine itself
is insurable, just as is any hot water plant in a house.
 Tested Only on Eighteenth Day
Until this season, on The Corning Egg Farm, we had made it a
rule to test the eggs on the 14th day. Many operators believe in
testing the eggs from the 5th to the 7th day, again on the 14th, with
the final test on the 18th day. In operating one of the old style
machines, with the large trays, it was expedient to remove the clear
eggs and those with dead germs to facilitate the turning of the eggs
in the trays, but all this arduous labor is done away with in the hot
water machine. The trays hold seventy-five eggs, and are so
constructed that one tray fits on top of another, and then the trays
are simply reversed and the turning is accomplished. This makes it
necessary to have a full tray to prevent the eggs rolling and breaking
when they are turned in the manner described. Testing the eggs is,
therefore, deferred until the 18th day.
When one sees the tremendous saving of time which the coal-
heated, hot water machine accomplishes for the operator, it
produces a feeling bordering on mirth in the man who has labored
with the old style machine and big tray, when thousands of eggs
were turned by hand twice a day. Ten thousand eggs in one of the
modern machines are handled with less effort and in less time than
three thousand could possibly be cared for in one of the other styles
of incubator.

Moisture
On The Corning Egg Farm moisture is provided in the Cellar by
thoroughly wetting the floor with a hose twice a day, the floor sloping
gently to a drain in one corner. Large earthen-ware vessels, of about
three inches in depth and eighteen inches in diameter, are stood at
different points throughout the Cellar, and are constantly kept filled
with fresh water. This is done, not so much for the purpose of
increasing the humidity of the air, as it is to take up the impurities. As
an illustration, if you stand vessels filled with water in a freshly
painted room, the odor of paint is almost entirely absorbed by the
water.
 As even a temperature as possible is carried in the Cellar, and at
all times there is a constant flow of fresh air, but it is so controlled
that it does not produce a draught. It should be remembered that
while a moist cellar is desirable, unless it is well ventilated, it is
utterly unfit for the purpose of incubation.

Chicks Handled Only Once

The chicks, at the end of the 22d day, are counted out of the
incubator into large baskets lined with Canton Flannel, and in these
they are carried upstairs to the Brooder House.
The last act of the chicken, before pipping the shell, is to absorb
into its system the yolk of the egg, which supplies it with a sufficient
amount of nourishment to last at least forty-eight hours. This supply
of nourishment is what really makes possible the tremendous
business carried on in “baby chicks.” But, as The Corning Egg Farm
views it, the Society for Prevention of Cruelty to Animals should step
in and stop this business. After exclusion is accomplished the chick
is thoroughly exhausted, and for a number of hours, if left to its own
devices, it lies in a deep sleep.

Baby Chick Business Cruel

Consider then the torture that this small animal is put through
when it is taken out of the warm egg chamber, or nursery, as soon as
it is dry enough, packed like a sardine in a box, and then hustled to
an express office, placed on a train, and, by the swaying of the train,
kept in constant motion.
The sellers of day old chicks in many cases guarantee the arrival
of the small “puff ball” alive. Unless the distance is extreme this is
not such a difficult feat. They are alive on arrival, and perhaps
continue to live in apparently fair strength for some days, but
somewhere between the 7th and 10th days the mortality usually runs
into such numbers that the purchaser finds the remaining number of
youngsters has cost him about a dollar apiece. As the season
advances many more of them drop off, one by one, from causes
which, to the unsophisticated, are unknown.
 A short time ago a gentleman who has been engaged in the Baby
Chick business for a number of years was making a call at The
Corning Egg Farm, and expressed his regret at having placed an
order with a breeder of White Rocks for eggs at too late a date to
insure their delivery before the first day of May. The breeder,
however, had offered him some day old chicks. Our amusement was
considerable when he remarked that he would not accept a day old
chick as a gift if he was expected to pay the expressage.
The man who expects to procure strong, healthy youngsters would
much better place his money in eggs for hatching, from reliable
breeders, than to make himself a party to the suffering of these
helpless mites.
If the humane side of the argument does not appeal to him,
certainly the money expended will.
Correct records, on cards designed by us for the purpose, are kept
on The Corning Egg Farm, showing the results from the incubators.
These are filed, giving the Farm a record which, as the years go by,
becomes invaluable, when planning for a year’s work in incubation.

INCUBATOR NO. HOVER NO.

Set P. M. 191 191

Eggs Chicks
Clear
Dead on 191
——— ———
Hatchable Moved to
Colony House No.
Chicks
Turn P. M.

14th day

18th day

21st day

BROODER HOUSE SHOWING CHICK RUNS

Extension of Building Nearing Completion
 CHAPTER XIX
Rearing Chicks in Brooder House—The
Following Two Years’ Results Depend Upon
Success in Brooding
The Brooder House is built over the Sprouted Oats Cellar and the
Incubator Cellar. Its total length is 264 feet. 118 feet of this is 16 feet
wide, and the balance is 22 feet wide.
Incubation might be termed a mechanical operation, and, as
outlined in the previous chapter, a very fair hatch is usually obtained.
But after all is said and done artificial rearing of young chicks is the
most difficult problem which a poultryman has to solve.
Chicks running with a hen will stand climatic conditions, and in fact
thrive under conditions, which, if they were being handled in a
Brooder House, would mean a tremendous mortality. The hen will
feed her brood on substances which would mean the annihilation of
ones’ entire flock of youngsters, should one attempt it, and, perhaps,
the most curious feature of the feeding part is the fact that one may
give the brood, running with the hen, food Nature never intended a
small chick to eat, and many of the brood will thrive on it, and the
mortality will, in most cases, be confined to the weak ones.

Corn Not Proper Chick Food

In past decades, wet corn meal seemed to be about the standard
ration which the chicks were fed on by the farmer’s wife, and in fact
this practice has not yet entirely gone out. Naturally, it brought about
a large mortality which everyone deplored but could not understand.
Corn in any form was never intended for a chick to eat, but when you
place it before them in the form of meal, and this made into a sloppy
mass, the wonder is, not at the largeness of the mortality, but rather
that any of them live at all.
But the advance in Poultry Culture has brought about feeding of
whole grains, to a large extent. For years the proper feeding of
chicks, even on farms with modern brooding equipment, has been a
stumbling block, causing serious loss, and, in many instances,
failure, to those attempting to raise chickens either in large or small
numbers.

Follow Nature’s Teaching

In Poultry Culture, in order to succeed it is essential to study
Nature, to find out how the hen in a wild state cares for her brood,
and then bring the artificial conditions as near to Nature as possible.
In almost every chick food put on the market the main ingredient,
namely corn, was never intended for a young chick to eat. Consider
for a moment, and you will realize that the hen in a wild state could
not possibly feed corn to her young. For the sake of argument,
however, suppose that corn did ripen at a time when it would be
possible for the hen to procure it for her brood, the size of the kernel
is so great that the small chick could not possibly swallow it. Thus
Nature plainly points out that corn, for young chicks, is not the proper
food.

A Balanced Food
On The Corning Egg Farm the question of chick food that could
properly be called “chick food” has been a study for years, the
problem being to procure a balanced ration containing, as closely as
possible, the ingredients intended by Nature for a young chick to eat
and thrive on. Many experiments were made with different mixtures,
both with chicks running with natural mothers and with those being
reared in the Brooder House, and it was found that in all cases
where corn was fed in the mixture the results were bad. The
youngsters running with the hen did not show the large mortality
which those did in the Brooder House, but even the broods running
with the hen did not do nearly so well where the corn was fed, as did
those not having this ingredient in their food.
The great mortality in young chicks is produced by the upsetting of
their digestive organs. Corn is very heating, and as soon as the
chick’s blood is over-heated its digestive organs fail to work properly,
and what is now known as “White Diarrhœa” almost invariably
develops. It is claimed by some authorities that this difficulty comes
from a germ which is in the egg before incubation. This may be the
case, but it is certainly true that wrong feeding will bring this germ
into active life, and snuff out the existence of the chick.
Another phase, which has been a special study on The Corning
Egg Farm in the brooding of chicks, is an abundant supply of fresh
air, not only in the room itself, but also to have the oxygen fed to the
chicks properly when they are under the hovers. The use of gas for
heating the hovers was found a decided improvement over the lamp,
so far as the freshness of the air went, but, for procuring the purest
hot air, to flow up into the hovers, we are now installing a system of
hot water pipes.

OLD ARRANGEMENT OF BROODER HOUSE

New House not Completed in Time for Photographing
 In a dwelling house, properly constructed, the entire heating
apparatus is a hot air furnace, with a cold air box connected with
outdoors constantly bringing in a fresh supply of pure air to be
heated. If it were possible this would be the ideal way of supplying
the heat to the hover, but of course in a long Brooder House it is
impossible to do this. The nearest approach to this system of heating
is a trunk line of hot water pipes, extending beneath the hover floor,
with the pipes enclosed in a long box, standing some two inches
from the floor, and with orifices of proper size to allow the fresh air to
circulate around the pipes, and then, through the radiating devices,
to flow out underneath the hover, and thus to be diffused over the
backs of the chicks. On The Corning Egg Farm this box is
constructed of galvanized iron, and covered on the top and sides
with asbestos board, with an air space between the asbestos board
and the hover floor. Through this floor comes a thimble which
connects with the radiator above. The top of this radiator is a spiral
screw, which works like a piano stool reversed, and with a tripod
device which carries the thread but allows the hover itself to be
removed without changing its position on the screw. As the chicks
grow the hover can be slowly raised away from them, until it is finally
removed entirely, and the chicks learn to do without it for a
considerable time before they are moved to the Colony Range. The
thimble is most thoroughly insulated with asbestos, so that there is
no possibility of the much dreaded heat on the hover floor, which,
when it does exist, tends to dry up the chicks’ legs.
From the hover floor there is an inclined runway down to the main
floor of the Brooder House, which is covered with a fine litter,
preferably short cut wheat straw, to a depth of about two inches.
The inclined runway is hinged to the hover floor and works with a
cord passing through a pulley on the ceiling, enabling the operator to
raise it and retain the chicks directly around the hover. The trough
surrounding the trunk line of hot water pipes is closed by a partition
corresponding to the width of the hover run, which prevents the heat
from flowing by the radiator in each section, and in this way
equalizing the heat in every hover.

Never Build a Double House

 The Corning Egg Farm is much opposed to what is known as the
Double Brooder House, which is advocated by many builders of
Brooder House equipments, and, in which, in the majority of cases,
the use of concrete floors is also practiced. The advantages in the
supposed economy of this construction are more than off-set by the
disadvantages. The proper place for the windows of the Brooder
House is on the south front, and likewise the south side of the
building is the proper place for the chick runs. The roof should be a
shed roof sloping to the north, thus carrying all the water to the back
and allowing none of it to drip down into the runs. The north side of
the Brooder House should be absolutely tight, for, from this quarter,
comes the great majority of cold storms, and the tight wall means an
economy in fuel. And every item of expense must be carefully
watched on a poultry farm.
In these different respects let us look at the double house. First, it
must run north and south; second, it must have windows on the east
and west, and the chick runs must go the same way; third, it must be
built with a peaked roof, the drippings from storms thus falling
directly into the yards.

Must Drain Chick Runs

In the Corning plan of Brooder House the yards are sloped toward
the south, and, as there is no possibility of dripping from the roof, in
a few moments after a hard storm the slope and the sun combined
put the yards at once into a usable condition, so that the youngsters
can be let out. All day long in this style Brooder House the yellow
babies enjoy the sunshine. In the double constructed Brooder House
the yards are bathed on the east side with sunshine for a short time,
and the west side receives the Sun for a few hours before sunset.

Concrete Floors Mean Dampness

An added menace in this double style of construction is the
concrete floor generally used. It is almost impossible, with the
greatest care and forethought, to produce a piece of concrete which
does not constantly take up and give off moisture, and one thing to
be absolutely avoided in poultry houses, little or big, is dampness.
The dollars saved in the construction of double houses are usually
dollars which would have been made ten times over by the
expenditure necessary to build a proper house.
The chick yards on The Corning Egg Farm are sloping, and are
twenty feet long, and correspond in width with the hover runs inside
the house, which vary from three to four feet in width. The diameter
of the hover varies with the size of the run, from 26 to 30 inches. The
sloping runs of the Brooder yards are covered with Anthracite Coal
ashes, which have been found to entirely eliminate the much talked
of danger of contamination of soil, the surface being constantly
renewed as the ashes are consumed by the chicks.
Each hover is numbered, and directly back, on the north wall of
the Brooder House, is a corresponding number, and a nail, on which
is hung the record card. When the chicks are carried up in baskets
from the Incubator Cellar, they are carefully examined, all weaklings
being excluded, and counted into the hover compartments. Careful
selection and the “survival of the fittest” begin at this point with the
stock on The Corning Egg Farm.
Before speaking of the number of chicks carried in the hover
compartments, it must be understood that running along the north
wall of the Brooder House is a coil of hot water pipes, capable of
maintaining a temperature of 85 degrees, three feet from the floor,
and in zero weather.

Corning Heated Brooder House

The Corning Egg Farm believes absolutely in Brooder Houses
heated beyond what is supplied by the hovers, and this is the reason
it is possible to carry such a large number of youngsters in each
hover compartment. In large hatches, when we have been crowded
for room, two hundred chicks have frequently been carried in one
compartment of four feet in width.
 CHICKS SIX WEEKS OLD IN BROODER HOUSE RUNS

Corning Feeds Dry Food Only

When the chicks are first placed in the hover compartment the
inclined plane is drawn up and they find two drinking cups ready—
the style that feeds itself into a small cup, into which it is not possible
for the youngsters to get. They also find waiting for them their first
meal of Corning Chick Food. For the first twenty-four hours the
inclined plane remains up, and the hovers are visited every two
hours. If the amount of Chick Food has been well cleaned up,
another feeding is evenly distributed over the boards. It must be
understood that litter is never placed on the hover floor, though it is
kept two inches deep on the floor of the pen.

Three Feeds Daily

The following morning the inclined plane is let down, about five
handfuls of Corning Chick Food to every hundred chicks is thrown
into the litter, and a little is scattered just at the top of the inclined
plane to entice the youngsters down. No more food is given until the
noon hour, when, into the litter is thrown two handfuls to every
hundred chicks, and again a small quantity is placed at the top. No
more feeding is done until four o’clock when five handfuls of Corning
Chick Food are again thrown into the litter.
For the first two or three nights, or more if necessary, the chicks
are quietly driven up to the hover, and the inclined plane pulled up
after them, it being let down the first thing in the morning.
Fresh water is supplied in the drinking cups each day, morning,
noon, and night, and, with the night filling, a brush on the plan of
those made for the cleansing of milk bottles, is used to give the cups
a proper cleaning.
On the back of the record cards, hung behind each hover, the
mortality is kept.
The hovers are raised every morning to learn the exact condition
of the entire brood after the night.

Green Food Third Day

On the third day green food is added to the ration, in the form of
the tops of Sprouted Oats. Never feed the rooty mass to the
youngsters for it is almost sure to upset them. The smallest chick
has no difficulty breaking up and getting away with Oat Sprouts from
one and a half to two inches long, and there is nothing they like so
well.

Animal Food Tenth Day

The regular ration is continued with judgment, for in feeding it is to
be remembered that judgment must be exercised at all times. After
the tenth day animal food is added to the ration, commencing with a
small handful of The Corning Egg Farm Mash, thrown on top of the
litter. Where beef scraps are used to supply the animal food they
may be fed alone, and this was done at first on The Corning Egg
Farm, but for the last three years we have fed the green bone in the
mash mixture. It, however, must be fed with great care, and the bone
used for this purpose must be most carefully selected, and must be
absolutely fresh.