***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Systematic Review Series Series Editors : Cynthia Mulrow , MD , MSc Deborah Cook , MD , MSc The last article in this series outlined methods with which to search the literature for studies on the clinical question that generates a systematic review [ 1 ] . Herein , we discuss the subsequent steps of selecting and appraising  studies  for a review . Both of these steps involve important judgments that can influence the results of a review . In selecting studies , review ers judge the relevance of the studies to the review question . In appraising studies , review ers judge numerous features of design and analysis . Some of these judgments are easy to make ; others are more difficult and prone to error . To be confident in their decisions , review ers should use methods that are reliable ( the results do not change if the procedure is repeated ) , impartial ( not influenced by the study results ) , and explicit ( unambiguous ) [ 2 ] . These strategies for selection and appraisal are sensible , and they distinguish most systematic review s from most narrative review s. However , evidence to support the importance of some of the methods we suggest is either scant or conflicting ; readers are referred to the original research on these approaches for more details . Selecting Studies for Systematic Review s If review ers perform a comprehensive search of the literature using the methods described previously in this series [ 1 ] , they will probably have assembled a large sample of articles . This sample will include most ( ideally , all ) studies that are relevant to the review question ( that is , the sensitivity of the search will be high ) . Inevitably , because such a wide net is cast , articles not pertinent to the clinical question will be retrieved ( that is , the specificity of the search will be modest ) . Thus , the review ers ' next task is to sort through all of the potentially relevant articles and select those that will be included in the review . To do so , review ers adopt several of the tactics listed in Table 1 and Table 2 for planning and executing the selection process ( in effect , improving the specificity of the search ) ; these tactics are described below . Table 1 . Planning Study Selection Table 2 . Strategies for Selecting and Appraising Studies Begin with a Well-Built Clinical Question Review ers should ensure that the question for review includes the four elements of a well-built clinical question [ 3 , 4 ] : the patients of interest , the main interventions under investigation , the comparison interventions , and the clinical outcomes of interest . By including these four elements , review ers can better focus the selection process . Choose Selection Criteria That Fit the Clinical Question Consider a systematic review of the effectiveness of a drug treatment ( for example , a proton-pump inhibitor ) for patients with a particular disorder ( such as esophageal reflux ) . Review ers need to decide whether to include studies of patients with any symptoms of reflux , only those with classic symptoms , or only those in whom definitive diagnostic tests have confirmed the presence of reflux . In addition , review ers might choose to include studies of patients with different comorbid conditions ; patients from different demographic or geographic or cultural background s ; or patients from different health systems , such as inpatient or community population s. Similarly , review ers should use selection criteria that reflect the main and comparison interventions of interest . In our esophageal reflux example , review ers would need to decide whether to include studies of a particular drug or studies of all agents in that drug 's class and whether to include studies of any dose and regimen or only studies with a specific regimen . For the comparison interventions , the review ers would decide whether to include studies that compare the experimental drug with alternate treatments ( such as antacids or histamine-2-receptor antagonists ) , with placebo , or with both . For the clinical outcomes , review ers have analogous tasks of defining the outcomes and translating them into criteria . In our example , the review ers would start by listing each clinical outcome ( for example , whether the outcome was endoscopic or clinical and whether it focused on cure or persistence ) and then decide whether to include studies that reported any outcome or only those with certain clinical ly important outcomes ( such as improvement in symptoms at 1 year ) . After thoroughly considering each element of the review question , review ers compile a set of explicit selection criteria . When these criteria are not explicit , the results of the review are more prone to error [ 5 , 6 ] . Reporting the selection criteria used in a review is extremely important to readers because the criteria indicate the relevance of the review to the readers ' clinical practice . Specify the Types of Study Design To Be Included After creating selection criteria that appropriately reflect the review question , review ers should consider which study design s to include . Ideally , review ers choose study design s that are most likely to produce valid results . For example , to answer questions about therapy or harm , review ers may want to include r and omized trials [ 7 ] because they provide more accurate estimates of benefit or harm than do cohort studies , casecontrol studies , and case series [ 8 ] . In reality , however , r and omized trials may not be conducted to address questions of harm [ 9 ] . Therefore , review ers need to consider which study design s are likely to be available to answer their question ; this information may necessitate modification of originally conceptualized selection criteria to incorporate observational ( nonexperimental ) studies . Specify Criteria Related to Type and Form of Publication Review ers also need to consider issues related to type and form of publication . Ideally , all of the relevant studies would be published as peer- review ed journal articles . However , some completed studies may be published only as abstract s , in non-peer- review ed form , or not at all . Review ers decide whether to include these incompletely reported studies when planning their literature search . By including all articles in various stages of publication and subjecting them to rigorous critical appraisal , review ers minimize the threat of publication bias ( the preferential reporting of studies with positive results ) [ 10 - 12 ] , which could generate misleading review s. Other studies may be reported more than once . To avoid over-representing duplicate studies in the review , investigators should plan to look for and exclude duplicate publications [ 13 ] . Finally , because studies may be published in different language s and because excluding studies published in different language s may bias the results of review s [ 14 , 15 ] , articles should be included , as appropriate , regardless of the language of publication ( translating as necessary ) . Limited time and re sources , however , may preclude such an approach . Construct and Pretest Selection Forms After deciding on selection criteria , review ers can prepare customized forms that contain checklists of the selection criteria ( Figure 1 ) . Using these forms can simplify the selection process , increase reliability , and provide a record of the judgments made about each study . After drafting form prototypes , review ers pretest these forms for clarity , ease of application , and reliability . To pretest the forms , two or more independent review ers typically apply them to a r and om sample of studies identified by the literature search . Review ers compare their results to identify sources of ambiguity and then revise the forms accordingly . If the revisions are substantial , this process may need to be repeated before the forms can be used . Figure 1 . Example of a form that might be developed for the selection of studies for a systematic review evaluating the efficacy of -blockers for secondary prevention of variceal bleeding .  Write a Detailed Protocol Having a selection protocol as part of a larger protocol for the entire review helps review ers in two ways . First , it provides a document that explicitly states the review question and the selection criteria , making the process accountable . Review ers can later return to the protocol for guidance in resolving disagreements about article selection . Second , the selection protocol identifies what work will be done , by whom , in what manner , when , and for what reason ; thus , it provides a mode of communication within the review team . When review ers have a very large sample of studies from which to select , they can simplify this task by review ing all of the titles , then the abstract s , and then the full articles , excluding studies that do not meet one or more selection criteria at each step . In doing so , review ers should record ( on the selection forms ) the reasons for exclusion . After review ers have selected studies for the systematic review , they will move to the next task of critical appraisal . This procedure also requires careful planning . Appraising Studies for Systematic Review s Review ers appraise the studies selected for review with three objectives in mind : 1 ) to underst and the validity of the studies , 2 ) to uncover reasons for differences among study results other than chance , and 3 ) to provide readers with sufficient information with which to judge for themselves the applicability of the systematic review to their clinical practice . To achieve these goals , review ers use the strategies outlined in Table 2 and Table 3 to carefully reexamine many important features of the primary studies . Table 3 . Planning Study Appraisal Examine Important Clinical Features Although the selection criteria for a systematic review define the population , interventions , and outcomes of interest , the appraisal process involves a detailed assessment of the patients ( for example , high , medium , or low risk ) , the study interventions ( for example , frequency , degree , and duration ) , and the outcome measurements ( for example , definitions and degree of surveillance ) Cluster r and omized controlled trial ( RCT ) , in which groups or clusters of individuals rather than individuals themselves are r and omized , are increasingly common . Indeed , for the evaluation of certain types of intervention ( such as those used in health promotion and educational interventions ) a cluster r and omized trial is virtually the only valid approach . However , cluster trials are generally more difficult to design and execute than individually r and omized studies , and some design features of a cluster trial may make it particularly vulnerable to a range of threats that can introduce bias . In this paper we discuss the issues that can lead to bias in cluster r and omized trials and conclude with some suggestions for avoiding these problems The employment of  unlicensed personnel in Canadian acute care hospitals has been undertaken without clear evidence of outcomes for patients , caregivers , and hospital organizations . This quasi-experimental evaluation study was completed in a metropolitan Toronto acute care hospital to examine the effects of a new nursing care delivery system which included  unlicensed assistive personnel .  Most of the expected benefits of the newly implemented nursing care delivery system did not material ize leading to the conclusion that the employment of unlicensed assistive personnel in acute care hospital systems may not offer additional benefits for patients , caregivers , or hospital organizations . The processes and results of this study provide useful information for nurse administrators who are seeking effective and innovative care delivery systems that are design ed to optimize patient , caregiver , and hospital outcomes BACKGROUND Many studies have examined predictors of nurses ' intention to work in their job , including desire to quit . Intent has been a good predictor of actual turnover . Few longitudinal studies exist that consider regional variables . OBJECTIVES To extend the conceptual framework of turnover research to the whole nursing workforce and determine : ( 1 ) how do demographics , region ( metropolitan statistical area : MSA ) , movement opportunities , and work setting variables affect registered nurses ' ( RNs ) intent to work and desire to quit ; and ( 2 ) how do demographics , MSA variables , movement opportunities , and work setting variables affect RNs ' work behavior at time 2 ? DESIGN Panel study using Dillman 's design method . SETTING S AND PARTICIPANTS R and omly selected national cluster sample from 40 urban geographic regions ( MSAs ) in 29 states of the United States . METHODS Four thous and surveys were sent . There were 1907 female RNs under 65 ( 48 % response rate ) from year 1 of which 1348 responded at year 2 ( 70 % response rate ) . RESULTS The first analyses used desire to quit ( explained 65 % of the variance ) and intent to work from year 1 as dependent variables . Satisfaction and organizational commitment were significant negative predictors of desire to quit . In the logistic regression on intent to work , the work motivation and work-family conflict were positive and significant as well as wages ( negative ) and three benefit variables . In year 2 , the dependent variable was working or not and if working , full-time or not . For this bivariate probit regression no attitudes influenced the work/not work decision , but MSA level variables , wages ( positive ) and benefits ( positive ) did . Organizational commitment and higher workload increased the probability of working FT . CONCLUSIONS Regional differences across markets need to be controlled and their influence investigated . In addition , attitudes as well as wages and benefits were important in certain decisions : these factors are clearly under the influence of employers Day Surgery ( DS ) and prehospitalization emerged in Italy -- as it had previously in the United States and other European countries -- as able to improve healthcare and reduce costs . The purpose of this study was to evaluate the impact of the Nurse Case Manager ( NCM ) Model on patients undergoing DS procedures .  The study assessed the intensity of pain , anxiety , and stress factors , and the level of discomfort experienced . The quasi-experimental study design involved two groups of patients ( at two different DS hospital centers ) : one using the NCM model ( Ward A ) the other based on team nursing ( Ward B ) . All patients undergoing DS for ( a ) varicose veins , ( b ) inguinal hernia , ( c ) breast biopsy , and ( d ) hemorrhoids were included . A valid question naire interview based on 22 questions was used ( 1 ) the morning before surgery , ( 2 ) the evening after surgery , and ( 3 ) 48 hr after the operation , by telephone . Of the 145 patients that were involved , 66 were from Ward A ( 45.5 % ) and 79 from Ward B ( 54.5 % ) . When patient care was based on the NCM Model ( Ward A ) , it seemed that ( a ) the pathway before DS was more efficient ; ( b ) they perceived lower levels of perioperative anxiety and pain ; and ( c ) they recognized the DS center as a unique point of reference for all postoperative problems 
    Output:
    
The results reveal that implementation of the team nursing model of care result ed in significantly decreased incidence of medication errors and adverse intravenous outcomes , as well as lower pain scores among patients ; however , there was no effect of this model of care on the incidence of falls .
Wards that used a hybrid model demonstrated significant improvement in quality of patient care , but no difference in incidence of pressure areas or infection rates .
There were no significant differences in nursing outcomes relating to role clarity , job satisfaction and nurse absenteeism rates between any of the models of care .
Based on the available evidence , a predominance of team nursing within the comparisons is suggestive of its popularity .
Patient outcomes , nurse satisfaction , absenteeism and role clarity/confusion did not differ across model comparisons .
Little benefit was found within primary nursing comparisons and the cost effectiveness of team nursing over other models remains debatable .
Nonetheless , team nursing does present a better model for inexperienced staff to develop , a key aspect in units where skill mix or experience is diverse