evidence based practice and research

Appraising Evidence in Nursing Practice: Key for Implementing Evidence-Based Practice
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Appraising Evidence in Nursing Practice: Key for Implementing Evidence-Based Practice
Introduction
Nursing is a challenging profession as nurses have to ensure safe and quality healthcare under all circumstances. Safe and quality healthcare is essential for ensuring positive health outcomes in patients (Chambless & Hollon, 1998). Nurses have to extend the highest standards of care for ensuring quality care in their patients (Raines, 2008). Hence, nurses should be updated with evidence-based guidelines while extending healthcare interventions (Daly & Brater, 2000, Kelly et al., 2015). The specialty of nursing has witnessed radical transitions over the past two decades (Mariotto, 2010). The evidence is growing across all specialties of healthcare practice, and the field of nursing is no exception to such phenomenon (Ellrodt et al., 1997). Hence, different guidelines have endorsed the necessity for implementing evidence-based practice across clinical settings (Elstein, 2004).
Evidence-based practice and evidence-based guidelines is beneficial for setting highest standards of care (Sackett etal., 1996, Peile, 2004). Different sets of evidence provide the opportunity for incorporating beneficial changes in healthcare management (Cooper, 2003). Hence, evidence-based practice helps to incorporate effective and safe healthcare approaches for ensuring positive health outcomes (Buysse & Wesley, 2006).

However, most healthcare professionals rely upon their basic academic background for planning and extending healthcare services (Tonelli, 2001). On the other hand, such academic knowledge is often inadequate or inappropriate under the present circumstances (Duffy, Fischer & Munroe, 2008). Hence, nurses should be able to appraise different evidences and evidence-based guidelines for ensuring quality care in their practice settings (Thomas & Pring, 2004).
Healthcare professionals should be competent in appraising different forms of evidence. They should be able to judge the significance and quality of evidence before implementing them in their clinical settings (Mitchell, 1999, Patterson-Siver, Dulmus & Maguin, 2012). Different types of evidence are available in the field of healthcare services. Evidence might stem from original studies or it might stem from systematic reviews. Each type of evidence is classified according to the “Level” and “type” of evidence. The present article focused on the appraisal of two sets of evidence. These evidences were appraised based on their “Level of evidence” in the hierarchy system of evidence. The evidences were recently published in reputed nursing journals. Appraisal of different evidences is essential for ensuring their validity and reproducibility across clinical settings (Dale, 2005, DiCenso, Cullum & Ciliska, 1998). Hence, the present article would help nursing professionals in developing professional competence and awareness on different health and healthcare issues.
First of all, the article would implicate the importance of evidence-based practice across different clinical settings. Secondly, the article would portray the different levels and types of evidence, which are recognized in clinical settings based on their hierarchy. Thirdly, the article would implicate the qualitative aspects of different studies/research to be acknowledged as the highest level of evidence. Finally, the article would appraise two different research articles based on their level of evidence. A discussion and conclusion section would be included at the end of the article, for implicating future roadmaps, for implementing evidence-based practice.
Levels and Types of Evidence
Evidences are classified according to different “Levels” or “types”. The “level” of evidence is based on the content and methodology involved in presenting a piece of evidence. For example, Level-1 evidence is categorized as the highest level of evidence in the hierarchy system of rating evidences. On the other hand, Level-1 evidence is categorized as the lowest level of evidence in the hierarchy system of rating evidences (Mother et al., 2007).
Level-1 evidence denotes systematic review or meta-analysis of different randomized controlled trials (RCT) or evidence-based practice guidelines that were framed based on systematic reviews or meta-analysis. This type of evidence involves exploring a research question by multiple researches located at different locations. Hence, the validity, reliability and reproducibility of level-1 evidence are considered quite high. Level-II evidence indicates evidence that is obtained from at least one well-designed RCT. Level-III evidence indicates evidence obtained from well-designed controlled studies. However, such studies are not randomized and chances of bias are high. Level-IV evidence implicates well-designed case control trials and cohort trials. Level-V evidence indicates evidence that is drawn from systematic reviews of descriptive and qualitative trials. Level-VI evidence represents a piece of evidence obtained from a single descriptive or qualitative study. Level-VII evidence indicates the evidence that is constructed from an individual opinion of different authors, researchers, or reports of expert committees. Since Level-VI and Level-VII evidence represents the opinion or findings of a limited number of researchers, these evidences are rated as the lowest level of evidence in the hierarchy system of evidence. Although the hierarchy system of evidence creates rating of evidence, each level of evidence is unique from the perspective of a healthcare professional. Hence, Level-VI or Level-VII evidence might be as important as Level-1 evidence from the perspective of clinical practice. This is because Level-VI or Level-VII evidence often indicates current research findings. Such findings might be novel and effective in clinical practice settings. Therefore, healthcare professionals should explore evidences based on the methodology and statistical interpretations deployed for reporting the end-points (Rubin & Parrish, 2007).
On the other hand, clinical or nursing evidence could be also classified according to “types of evidence” (French, 2002). Evidence may be broadly classified into five types. Each type of evidence may be further divided into various sub-types. Type-1a evidence is considered the highest “type” of evidence in the hierarchy of evidence, while Type-5 evidence is considered the lowest “type” of evidence in the hierarchy of evidence. Type 1a evidence indicates systematic reviews or meta-analysis of homogenous RCTs. Type 1a- evidence indicates systematic reviews or meta-analysis of heterogeneous RCTs. Hence, type 1a- evidence may be diluted by the presence of different confounding which variables which might limit the reliability and reproducibility of the evidence. Type 1b evidence indicates individual RCTs with narrow confidence intervals. Type 1b- evidence indicates individual RCTs with wide confidence intervals. This suggests that type 1b evidence is more reproducible and uniform across different clinical settings compared to type 1b- evidence. Type 1c evidence indicates that study include all RCTs or did not include any RCTs in developing the piece of evidence. Type 2a evidence indicates systematic review of cohort trials. However, such trials have to be homogenous for being classified as type 2a evidence (Ezzo et al, 2001).
Type 2a- evidence indicates systematic review of cohort trials with marked heterogeneity. Type 2b evidence indicates individual cohort trials with poor randomization and narrow confidence intervals. Type 2b- evidence indicates individual cohort trials with poor randomization and wide confidence intervals. Type 2c evidence indicates outcome research and ecological studies. Type 3a evidence indicates systematic review of homogenous case-controlled studies. Type 3a- evidence indicates systematic review of heterogeneous case-controlled studies. Type 3b evidence indicates individual case-controlled study. Type 4 evidence indicates case studies and poor quality cohort and case-control studies. Type 5 evidence indicates expert opinion based on basic academic knowledge. However, such pieces of evidence lack critical appraisal of the findings (Vine, 2007).
Qualitative Aspects of Appraising a Piece of Evidence
Broadly, a piece of evidence could be appraised based on its “Level” or “Type” as discussed in the previous sections. However, there are different qualitative aspects of a research article that helps to ensure the reliability and validity of that piece of research across different clinical settings. First of all, study design is an important criterion for appraising a research article/study. Studies may be conducted as randomized, controlled, double-blinded trial or it may be conducted as non-randomized, non-controlled and open-ended trials. Randomized controlled trials represent the highest level of evidence as because the chances of subjective bias are minimized in such trials. On the other hand, element of subjective bias is high in non-randomized trials and trials conducted without appropriate controls and blinding (Shaneyfelt et al., 2006).
Apart from the approach of selecting samples (through randomization and non-randomization); the size of a sample is also important for appraising a research article. Studies conducted with small sample size are more biased compared to studies conducted with large sample sizes (Mercer & Pignotti, 2007). The inclusion and exclusion criteria for selecting different participants in an individual study or for selecting different studies in a systematic review are an important criterion for ensuring the validity of a study. Studies should be designed in such a manner so as to minimize the effects of different confounding variables on the end-points of a study. On the other, the approach of estimating the end-points of a study is also essential for increasing the reproducibility of the study.
Quantitative studies are more robust than qualitative studies for being accepted as a reliable source of evidence. This is because quantitative studies implicate objective findings, while qualitative studies implicate subjective findings. Moreover, chances of bias are higher in qualitative trials. However, in certain instances subjective responses are also preferred. Hence, appropriate software should be implemented for analyzing subjective responses. The tools and instruments implemented for conducting a study should be standardized so that they might be universally accepted across different experimental settings. Finally, the statistical inference of the end-points is vital for establishing a research article/study as the highest level of evidence. Hence, appropriate statistical tests should be implemented for reporting the end-points of a trial. The statistical findings should be backed by appropriate hypothesis testing. Hypothesis testing is based on the acceptance of null or alternative hypothesis.
The null hypothesis contends that there is no significant difference between two observations. It implies that any noted difference between two observations have happened due to chance factors associated with random sampling. The null hypothesis is accepted if the p-value for the statistical test of significance is greater than 0.05 (p>0.05). On the other hand, the alternative hypothesis contends that there is a significant difference between two observations. It implies that any noted difference between two observations have not happened due to chance factors associated with random sampling. The alternative hypothesis is accepted if the p-value for the statistical test of significance is less than 0.05 (p<0.05). End-points are also appraised based on the reported confidence intervals. End-points having narrow confidence intervals are more robust than end-points with wide confidence intervals. This is because confidence intervals represent the range in which the end-point could lie across different sets of same experimental studies. Therefore, studies reported with narrow confidence intervals are more reliable and reproducible.
Appraisal of the 1st Evidence
Citation Details of the Evidence: Kyle, R., Neall, R. & Atherton, I. (2016) Prevelence of overweight and obesity among nurses in Scoltand: A cross-sectional study using the Scottish Health Survey. International Journal of Nursing Studies.  53: 126-133.
The authors of the article tried to evaluate the prevalence of overweight and obesity amongst Scottish nurses. The authors conducted the study through a cross-sectional study design. The study was conducted based on a cross-sectional survey of the Scottish population. The study population was designed as per the criteria fixed by the Scottish Government for yielding a nationally representative sample. Hence, male participants were also included in the study. The study included nurses, allied healthcare professionals, unqualified healthcare staff and subjects who did not belong to the healthcare profession. Hence, the study design could be considered as a randomized control trial. Moreover, the randomization was based on stratified random sampling. This is because the study participants were selected based on a nationally representative sample. The sample size considered for the present study was also quite large (>13000 participants). On the other hand, the age range selected (17-65 years) for the study appropriately represented the experimental profession. The end-points were reported through objective variables. This is because overweight and obesity was reported as a function of body mass index (BMI). BMI is an objective variable as because it can be quantified based on the height and weight of an individual. A body mass index greater than 25kg/m2 signifies overweight or obesity. Logistic regression analysis was deployed for estimating the cause-and-effect relationship of obesity (Kyle, Neall,. & Atherton, 2016). Hence, the study appropriately accounted for different confounding variables. Therefore, the findings of the study were reliable and appropriate.
Although p-values were not reported for the end-points; the confidence interval for indicating the prevalence of overweight or obesity was quite narrow (95% CI: 69.1% to 73.6%). Hence, the study could be viewed as a highest level of evidence. Since, the article was based on a single descriptive study, it could be considered as Level-VI evidence. On the other hand, as the study was a RCT with narrow confidence interval, it could be considered as type 1b evidence (Lachin, Matts & Wei, 1988). Hence, the evidence reflected in this article could be considered quite high. Hence, the findings would be reproducible and viable across different studies, conducted with the same experimental population.
Appraisal of the 2nd Article
Citation details: Fen tan, M., Lopez, V. & Cleary, M. (2015) Nursing management of aggression in a Singapore emergency department: A qualitative study. Nursing and Health Sciences. 17: 307-312.
The authors of the article tried to evaluate the perception of registered nurses in managing aggressive incidents in emergency departments. The authors conducted the study in a emergency department of a hospital in Singapore. The study was not randomized and did not include appropriate controls. Moreover, only female participants were included in the study. The study was conducted as a qualitative trial as because it analyzed the subjective responses of study participants. The sample size considered for the respective study was too small (n=10). Hence, the chances of subjective bias were quite high in this study. Moreover, sensitivity analysis and power analysis was not implemented for designing the trial. The end-points were reported as subjective or qualitative variables (Fen tan, Lopez, & Cleary, 2015). This is because perception of aggression is a subjective measure. However, no effective tools were implemented to measure aggression amongst concerned individuals. Moreover, the perception of aggression amongst registered nurses was not assessed by any objective tools. Therefore, the cause-and-effect relationship between exposure to aggression and perception of aggression was not evident in the study.
Moreover, appropriate statistical measures like p-values or confidence intervals were not implemented to report the end-points of the study. Therefore, the findings of the study could not be considered reliable and reproducible. Since, the article was based on a single qualitative study, it could be considered as Level-VI evidence. On the other hand, as the study was not a RCT and was a qualitative study, it could be considered as type 4 evidence. Hence, the evidence reflected in this article is quite low. Therefore, the findings of this study might not be reproducible and viable across different clinical settings.
Discussion and Conclusion
Evidence-based practice speculates that all healthcare professionals should extend healthcare interventions based on the best available scientific evidence at any point of time (Shojania et al., 2007). However, before implementing such evidences in practice settings, the healthcare professionals should understand the preferences of patients for accepting such approaches (David et al., 1996). Moreover, before implementing novel or best scientific evidences in practice settings, healthcare professionals should appropriately weigh the risk-benefit ratio such interventions. Hence, appropriate appraisal of a piece of evidence is essential, for ensuring safe and quality healthcare in concerned stakeholders.
There is always an ongoing debate regarding the implementation of evidence-based practice across clinical settings. This is because healthcare professionals are often unsure regarding the validity and reliability of a piece of evidence (Ramos, Schafer & Tracz, 2003). Moreover, these individuals are often unable to recognize or appraise a piece of evidence based on different end-points. Such issues lead to negative health outcomes in patients and the concerned stakeholders are deprived of quality and safe healthcare interventions. Hence, nursing and allied healthcare professionals must implement evidence-based practice in their respective clinical settings. Evidence-based practice is essential for implementing robust decisions in clinical settings. Decision-making is an important attribute for all healthcare professionals. Nurses have to exhibit effective decision-making skills for ensuring pooitive health outcomes in patients. Therefore, nurse should be competent in appraising different sets of evidence for ensuring positive health outcomes in patients. Evidence-based guidelines help to improve decision-making skills in nurses and allied healthcare professionals (El Dib, Atallah & Andriolo, 2007). Nurses should deploy appropriate methodology for selecting different evidence pertinent to their clinical practice. They should be competent in undertaking literature search by visiting appropriate websites. Moreover, they should have adequate knowledge in implementing keyword search strategy for selecting the pertinent evidence. Appraisal of pertinent evidence would help to ensure professional competence in nurses and allied healthcare professionals. Organizations should endorse and encourage the implementation of evidence-based practice in clinical settings (Tanjong-Ghogomu, Tugwell, & Welch, 2009).
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