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The evidence-based health care movement has generated new opportunity for scholars to generate synthesized sources of evidence. Systematic reviews are rigorous forms of synthesized evidence that scholars can conduct if they have requisite skills, time, and access to excellent library resources. Systematic reviews play an important role in synthesizing what is known and unknown about a particular health issue. Thus, they have a synergistic relationship with primary research. They can both inform clinical decisions when the evidence is adequate and identify gaps in knowledge to inform research priorities. Systematic reviews can be conducted of quantitative and qualitative evidence to answer many types of questions. They all share characteristics of rigor that arise from a priori protocol development, transparency, exhaustive searching, dual independent reviewers who critically appraise studies using standardized tools, rigor in synthesis, and peer review at multiple stages in the conduct and reporting of the systematic review.

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Building the science for nursing practice has never been more important. However, shrunken federal and state research budgets mean that investigators must find alternative sources of financial support and develop projects that are less costly to carry out. New investigators often build beginning programs of research with limited funding. This article provides an overview of some cost-effective research approaches and gives suggestions for finding other sources of funding. Examples of more cost-effective research approaches include adding complementary questions to existing funded research projects; conducting primary analysis of electronic patient records and social media content; conducting secondary analysis of data from completed studies; reviewing and synthesizing previously completed research; implementing community-based participatory research; participating in collaborative research efforts such as inter-campus team research, practice-based research networks (PBRNs), and involving undergraduate and doctoral students in research efforts. Instead of relying on funding from the National Institutes of Health (NIH) and other government agencies, nurse researchers may be able to find support for research from local sources such as businesses, organizations, or clinical agencies. Investigators will increasingly have to rely on these and other creative approaches to fund and implement their research programs if granting agency budgets do not significantly expand.

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Risk of bias is an inherent quality of primary research and therefore of systematic reviews. This column addresses the Cochrane Collaboration's approach to assessing, risks of bias, the meaning of each, indicators of low, high and uncertain, and ways that risk of bias can be represented in a Cochrane systematic review report. The sources of risk of bias that reviewers evaluate include selection, performance, detection, attrition and reporting bias. Each poses threat to the internal validity of the primary studies and requires the reviewer to judge the level of risk as high, low or unclear. Reviewers need to address how studies of higher risk of bias might impact the pooled effect.

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Systematic reviews provide robust evidence for nursing practice because of the exhaustiveness of search, the critical appraisal methods to determine the risks of bias, and synthesis methods that pool evidence to increase the power of statistical estimates or credibility of aggregated metasynthesis of qualitative findings. More consistency in publication standards will enhance the rigor of available evidence and allow nursing to live up to the promise of best available evidence.

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OBJECTIVE: The aim of this systematic review was to examine the effect of arm exercise on exercise-related and usual dyspnea in patients with stable, moderate-to-severe chronic obstructive pulmonary disease. Dyspnea is a disabling symptom that is particularly troublesome when patients perform activities of daily living that involves using their arms. INCLUSION CRITERIA: We included any study where the effect of arm exercise could be isolated from other pulmonary rehabilitation strategies like whole body exercise, lower extremity training, and sham or control interventions. The participants were stable, moderate-to-severe patients with COPD, who were breathing without mechanical ventilation. The methods needed to include a measurement of exercise-related and/or chronic dyspnea. SEARCH STRATEGY: We conducted an exhaustive, comprehensive search of the published and grey literature using a three-phase approach with no language or year of publication limits. We searched CINAHL and MEDLINE to identify all key words. Subsequently, we used a structured Boolean search of all relevant bibliographic and grey literature databases. Finally, we hand-searched the reference lists of included and other highly relevant, recent articles. Two independent investigators reviewed the search results to make the decision to retrieve studies for critical appraisal. METHODOLOGICAL QUALITY: Two independent reviewers appraised all reports using standardized critical appraisal tools of the Joanna Briggs Institute, specific for the particular research design. RESULTS: The search netted 269 unique reports; we appraised 18 studies and included 5 randomized controlled trials. Eleven studies were excluded because they were of poor methodological quality or because the effect of arm exercise could not be isolated. Two studies were not available from any library source. Arm exercise regimens varied but most included some type of low resistance, high repetition arm lift combinations. No findings could be pooled for meta-analysis. Only one study found significant improvements in exercise-related dyspnea but all studies were underpowered and many had significant dropout rates. These weaknesses may have masked some of the positive effects of arm exercise. CONCLUSION: Arm exercise is safe but its effectiveness remains in question. Upper extremity training is theoretically sound but evidence from these low powered randomized controlled trials only suggests that it may be effective. If data can be pooled from future studies, this common rehabilitative practice may gain further empirical support.If clinicians integrate arm exercise into a program of pulmonary rehabilitation, one randomized controlled trial supported simple low resistance, high repetition training like ball and sand bag tossing and lifting weighted bars of wood with arms raised to the height of the shoulder or above. Patients should be supervised and intensity and duration of the arm exercises increased incrementally to symptom tolerance. Clinicians should monitor dyspnea during exercise and activities of daily living to assess clinical benefits. More research is necessary that uses reliable measurement of dyspnea and arm endurance. Investigators need to anticipate dropouts in this population, plan for intention-to-treat analyses and report data in a manner that will allow meta-analyses to pool smaller powered work in future studies.

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