Abstract
From time to time, I have heard clinicians talk about changing their practice based on the findings from one research study that they have read or seen summarized in the media. This is always disturbing—for many reasons, which I will discuss in this editorial. Many researchers share my discomfort, as we have discussed this topic often. To frame this discussion, a little background is needed about how knowledge, the accumulation of research findings necessary to make a decision, is developed.
In the age of almost instantaneous communication between people on opposite sides of the globe and Twitter feeds relaying news as it happens, one might think that knowledge development occurs at the same speed. It does not. Although it is true that research evidence (knowledge) in any field is being accumulated at greater speeds than ever before in history due largely in part to the efficiency of our communication systems, communicating knowledge is not the same as developing knowledge. Knowledge development occurs at a much slower pace. Knowledge is built through the accumulation of rigorous research studies on the same topic and follows a well-established trajectory starting with descriptive studies and progressing toward experimental studies. It is essential that the foundational studies on any particular topic be descriptive in nature. Only after a sufficient number of research studies have been conducted using descriptive designs is it appropriate for researchers to move on to conducting research using comparative and correlational designs. Once a substantial number of studies on the topic have been carried out that establish a body of knowledge, researchers can move on to experimental designs with the randomized controlled trial being the gold standard for providing evidence about predicting outcomes (Polit & Beck, 2017). This process takes time and multiple studies that build upon each other to create solid reproducible results.
Why is this progression necessary? Why not move right to randomized controlled trials if we know these types of studies produce the most compelling evidence? Although the process of developing a knowledge base for our practice may seem too slow and cumbersome, it provides greater certainty that there are sound empirical reasons for the way in which we provide care to breastfeeding families. Because our practices involve human beings in complex multidimensional situations, the greatest care must be taken to ensure that what we do is grounded in a body of evidence created through rigorous research with diverse groups of people (samples) in various locations (settings) and under different circumstances (study design). As discussed in our About Research column in this issue (Burke & Dodgson, 2017), most study results do not predict outcomes with certainty. One study, no matter how well designed and rigorously conducted, cannot provide enough evidence to change practice. Studies need to be replicated with different samples and settings, using research methods that test outcomes, before sufficient evidence has been amassed to consider practice changes.
In the health sciences, there have been a few examples of the evidence from one study being so overwhelmingly clear that practice must change (think penicillin and other drug studies). In our Lactation Newsmakers column in this issue (Marinelli, 2017), Dr. Kathryn Dewey discusses the work it took to change the growth standards for breastfed infants—a number of studies over many years.
However, it is rare in the lactation field that one study of sufficient quality and rigor with results that are compelling enough to change practice exists. One rigorously designed and conducted study might suggest a practice change; additional studies that substantiate the findings are necessary. In today’s world, where anyone and everyone often make grandiose claims about the quality and importance of their work, it is essential that researchers and clinicians look skeptically. Knowledge is about accumulating reproducible evidence.
A key component of the peer review and editing process at JHL is to critically examine the findings and implications of each submitted research manuscript to ensure that the authors do not overstate the significance of results or draw conclusions that are not congruent with the data. This is one of the beauties of the peer review process. Researchers anonymously review each other’s work to ensure scientific rigor and quality. However, research does get published that has not undergone this rigorous peer review process due to the exponential growth of predatory journals. It can often be difficult for clinicians and researchers to identify these unethical and low-quality journals.
How do we know when enough evidence has accumulated to change clinical practice? This is not an easy question; however, we do have some ways to analyze the body of evidence on any given topic. The Cochrane Review teams conduct a particularly rigorous evaluation of existing studies on a particular topic and provide summaries of these studies, which may be used to change practice. For example, Balogun and colleagues (2016) conducted an excellent review of interventions to promote breastfeeding.
Systematic literature reviews use a critical analysis methodology to provide important guidance for clinicians and researchers about the state of the science on a particular topic (Dodgson, 2017). Unlike the Cochrane Reviews, this type of literature is usually not sufficient evidence to change practice but is often used to determine where more evidence is needed. JHL published an excellent systematic review by Wouk, Tully, and Labbok (2017) about Baby-Friendly Hospital Initiative Step 3.
Another powerful way to determine the state of the science on a given topic, using quantitative methods, is to conduct a meta-analysis, which is a statistical reanalysis and integration of the results across several studies on the same topic. “Meta-analysis is a convenient, objective method of integrating a body of findings and of observing patterns that might otherwise have gone undetected” (Polit & Beck, 2017, p. 27). This type of study provides a summation of the current evidence and may be used to modify practice if results are compelling. An example of this type of analysis is Brockway, Benzies, and Hayden’s (2017) article about self-efficacy and breastfeeding duration in this issue.
A process similar to meta-analysis used to synthesize qualitative research findings is called meta-synthesis. At least 12 different methodological approaches and techniques have been identified in the literature as ways to conduct this type of research. This is a particularly interesting way to examine findings across qualitative studies, creating the possibility of increasing the trustworthiness of these studies and enhancing the usefulness of the findings for clinical practice.
The take-home message is that we need our evidence base to be as rigorously built as possible, so that we can provide the best care possible for the breastfeeding families we serve. This is not possible when shortcuts are taken. Building our knowledge base carefully, thoughtfully using a skeptical eye when results seem too good to be true, is a professional and ethical imperative.