Understanding if the literature is good enough for answering a clinical question is a critical step in developing a solution to the problem and improving patient outcomes.

Purpose: Understanding if the literature is good enough for answering a clinical question is a critical step in developing a solution to the problem and improving patient outcomes.

Description: Using the literature selected in the Part 3 assignment, you will categorize your selections and assign a level of evidence to each. See the grading rubric embedded in BS.

Instructions:

1. Using the 4 (possibly 5, if a CPG was found) articles you found for your EBP Project, Part 3 assignment, include the first author’s last name and year of publication in the first column of the table on this document. (this document is included below)

2. Include the journal title in which the article appeared along with whether or not the journal is peer-reviewed in the second column.

3. Categorize each article as primary-quantitative, primary-qualitative, secondary, other-CPG, or other-not a CPG. Provide a rationale for your categorization for each article. Record your evaluation in the table on this document.

4. Based on your categorization, assign a level of evidence to each, per the pyramid in this Week’s presentation. Record the level of evidence in the table on this document.

5. Based on your assignment of the level of evidence, reflect on whether the literature you found—AS A WHOLE—is sufficient to help answer your clinical question. If yes, why? If not, why and what are the next steps to find the literature you need to support the answer to your clinical question? Include this reflection on the last page of the grid.

6. On a separate Word document, provide properly formatted APA citations for all articles used for Part 4 (include replacement articles). Use the last page of the APA Paper Example #1 from the Oak Point APA Resources page to see how the reference page should look. Also, refer to the APA and Writing Overview with Citation Examples PPT on the LibGuide for additional information.

7. Upload this grid/reflection document, your APA reference document, and pdfs of all your chosen articles to the appropriate assignment dropbox

Requirements: complete the grid and a page for APA reference document | .doc file

Requirements: need in 5-6 hours | .doc file

EBP Project, Part 4: Levels of Evidence

Reflection on the body of evidence as a whole to answer your research question.

TYPES OF RESEARCH (SLIDE 3) What is evidence? The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology. NOT ALL EVIDENCE IS CREATED EQUAL. Case reports Systematic reviews Practice guidelines Meta-analyses Cohort studies Expert opinions Data sources Comparative studies Randomized controlled studies WHERE TO FIND THE EVIDENCE: Example: The medication administration rights have really evolved over time. We started out the 5 rights, which really lay the foundation for the nurse’s safety checks during medication administration. However, the number of rights has grown and you have probably heard of the 5 Rights, 7 Rights, 9 Rights, and 10 Rights etc. As a nurse, you want to perform these rights every time you give medications. If something doesn’t seem right or make sense ALWAYS take the time to investigate it. Primary and secondary research•Via organizational interfaces (OPU’s EBSCO, OVID interfaces)➢CINAHL, PubMed/MedLineClinical Practice Guidelines and Evidence Summaries•Joanna Briggs•Cochrane Collaboration•US Preventative Services Task Force•Websites of clinical specialty organizations ➢Registered Nurses Association of Ontario➢Infusion Nursing Society•CDC•WHO•NICE

5 Rights of Medication Administration *Right patient Confirm you have the right patient for the medication by using at least TWO patient identifiers. Example: Have patient state their full name and date of birth and compare this information to the patient’s identification band and to the MAR (medication administration record). *Right medication Check the medication order and make sure the medication name on the order matches the name of the medication you’re administering. Be sure to look at it fully because some medications have similar names and if you do a quick glance you may not catch it. Here is an example: Acetazolamide (diuretic) vs. Acetohexamide (treats diabetes and helps lower blood glucose) Also, during this step confirm that the medication is not expired or damaged along with the patient’s allergies. *Right dose Check that the dosage ordered matches the dosage you plan to administer. Many times you’re not going to be dispensed with the exact dose because the pill needs to be split or the vial contains more medication than what was ordered. But whatever the reason is, you want to always double check your math if calculating and if needed, have another nurse double check it with you. *Right route Check the prescribed route on the order with how you plan to administer it. Medications can be given various ways. Most common routes are oral, IV, subq, IM, topically etc. Make sure you have the right supplies for the prescribed route. For example if giving IV: confirm the IV access works by flushing it and once the med has been given flush the access again, IM: select the best muscle to use with the right sized needle, orally: check how well your patient swallows, do they need them crushed or mixed in apple sauce or pudding, and if so, can that particular medication be crushed, topically: remove and clean previous dose off the skin before applying the fresh dose. *Right time/frequency Check how often the medication was prescribed and that it matches how often you will be administering the dose. Make sure you’re familiar with the common frequencies.

In addition, make sure you are administering the medication at the right time…not too late or too soon (especially with PRN medications). The facility you work at should have a specific policy that outlines the time frames for administering medications, and this is very important for time critical meds like antibiotics, anticoagulants, insulin etc. ——More Rights——– *Right documentation Chart after giving the medication. This is very important because remember the phrase if you didn’t chart it, it didn’t happen. Documentation helps tell other caregivers when the patient’s last dose was, which is very important for the next shift, when the patient is being transferred to another unit, or being discharged. In the documentation be sure to include: the medication name, dose, time, route, site you used (example: fentanyl patch….where did u place it), any numerical data that is needed like: vital signs (hr, bp, temp, pain rating), lab values, descriptive words and location of pain if giving pain medication, follow-up to how it helped the pt (pain meds) etc. *Right education Inform the patient or their caregiver about what medications you’re administering, why it’s prescribed, how often it’s taken, dosage, technique for administering like with an injection, and expected vs. abnormal side effects…the patient needs to be included in their care so when they go home they understand how to take the medication and what to monitor for. *Right Assessment Collect important assessment data that is needed for certain meds before administering them. This can be vital sign data (ex: heart rate with beta blockers), lab values (ex: warfarin…know INR level), health history information (their last dose, other meds they’re taking that could interact, allergies, underlying health conditions) *Right reason When you see the order as yourself “why was this medication ordered?” “What condition is the med treating?” For example, let’s say your patient has right-sided heart failure and is in fluid volume overload. The doctor orders Furosemide. Ask yourself…how will this medication help my patient? It will help pull fluid from the blood into the urinary system to be voided. Therefore, the nurse should prepare the patient with easy access to the bathroom, monitor for dehydration, and for a low potassium level. Furosemide is a loop diuretic that wastes potassium. *Right to refuse

The patient can refuse medications. If after educating the patient about why it’s ordered and assessing the patient’s concern for why they don’t want to take it, they still decline to take it, be sure to document thoroughly. In addition, let the prescribing physician know. *Right Evaluation Follow-up and assess if the medication provides the right effect and document. Example: Your patient is experiencing uncontrollable a-fib. You receive an order to start a Diltiazem drip. You need to evaluate if this medication is providing the proper effect. It should control the rate which may help convert the rhythm back to normal sinus rhythm. Therefore, the nurse will be evaluating the patient regularly by monitoring the patient’s rhythm, heart rate and blood pressure. PYRAMID OF EVIDENCE How strong is strong enough EBP? A strong enough evidence is needed to make practice change. The level of evidence plus the quality of evidence equals the strength of the evidence, enough to provide confidence among clinicians to initiate the needed change of practice (Melnyk & Fineout-Overholt, 2019). Ranks evidence based on reliability & quality. Top point is the highest level of evidence, bottom is the lowest. Strongest level obtained evidence from randomized control trials and systematic review or meta-analysis, which provide the meticulous reviews of the best evidence on specific topics.

Primary sources: (Gather own data) Primary sources contain the original data and analysis from research studies. No outside evaluation or interpretation is provided. Ex. Randomized Controlled Trial. “We measured”. Other primary sources: Cohort studies, case-control studies. EBP Resources: Primary sources, peer-reviewed sources. Remember health data from sources such as Healthline, Mayo Clinic, Cleveland Clinic provide health information geared toward the general public, and are not EBP sources. Info is not reviewed (peer-reviewed) enough to be considered based on the best-established evidence. Qualitative Quantitative Qualitative research: is expressed in words. It is used to understand concepts, thoughts or experiences. This type of research enables you to gather in-depth insights on topics that are not well understood. Common qualitative methods include interviews with open-ended questions, observations Quantitative research is expressed in numbers and graphs. It is used to test or confirm theories and assumptions. This type of research can be used to establish generalizable facts about a topic. Common quantitative methods include experiments, observations recorded as numbers, and surveys with closed-ended questions.

described in words, and literature reviews that explore concepts and theories. Qualitative research is also at risk for certain research biases including the Hawthorne effect, observer bias, recall bias, and social desirability bias. Hawthorne effect: The Hawthorne Experiments, conducted at Western Electric’s Hawthorne plant in the 1920s and 30s, fundamentally influenced management theories. They highlighted the importance of psychological and social factors in workplace productivity, such as employee attention and group dynamics, leading to a more human-centric approach in management practices. Illumination Experiment The first and most influential of these studies is known as the “Illumination Experiment”, conducted between 1924 and 1927 (sponsored by the National Research Council). The company had sought to ascertain whether there was a relationship between productivity and the work environments (e.g., the level of lighting in a factory). Quantitative research is at risk for research biases including information bias, omitted variable bias, sampling bias, or selection bias. Selection bias Example: Selection bias Health studies that recruit participants directly from clinics miss all the cases who don’t attend those clinics or seek care during the study. Due to this, the sample and the target population may differ in significant ways, limiting your ability to generalize your findings. Selection bias may threaten the validity of your research, as the study population is not representative of the target population. Quantitative=Precise measurements, numerical data.

During the first study, a group of workers who made electrical relays experienced several changes in lighting. Their performance was observed in response to the minutest alterations in illumination. What the original researchers found was that any change in a variable, such as lighting levels, led to an improvement in productivity. This was true even when the change was negative, such as a return to poor lighting. ). Qualitative methods are concerned with experiences, feelings, attitudes, (words Subjective Objective Interviews, focus groups Objectively measures an hypothesis. Lower levels of evidence are typically more qualitative. Editorials and expert opinions are subjective and often qualitative. Seeks a concrete objective answer to a set of hypothesis, using statistical analysis. Study designs of randomized controlled trials and other advanced study types are quantitative. They depend on eliminating bias & subjectivity. Anything from case studies to randomized controlled trials can be quantitative. IMPORTANT: The research methods you use depend on the type of data you need to answer your research question. *If you want to measure something or test a hypothesis, use quantitative methods. If you want to explore ideas, thoughts and meanings, use qualitative methods.

*If you want to analyze a large amount of readily-available data, use secondary data. If you want data specific to your purposes with control over how it is generated, collect primary data. *If you want to establish cause-and-effect relationships between variables, use experimental methods. If you want to understand the characteristics of a research subject, use descriptive methods. ▪ Quantitative Experimental research design utilizes the principle of manipulation of the independent variables and examines its cause-and-effect relationship on the dependent variables by controlling the effects of other variables. Usually, the experimenter assigns two or more groups with similar characteristics. Different interventions will be given to the groups. In case there are differences in the outcomes among the groups, the experimenter can conclude that the differences result from the interventions that the experimenter performed. Nonexperimental designs are research designs that examine social phenomena without direct manipulation of the conditions that the subjects experience. There is also no random assignment of subjects to different groups. As such, evidence that supports the cause-and-effect relationships is largely limited. NOTE: There are many times in which non-experimental research is preferred, including when: • the research question or hypothesis relates to a single variable rather than a statistical relationship between two variables (e.g., How accurate are people’s first impressions?). • the research question pertains to a non-causal statistical relationship between variables (e.g., is there a correlation between verbal intelligence and mathematical intelligence?).

What is the main advantage of experimental research? Experimental Method: in an experiment, an independent variable (the cause) is manipulated and the dependent variable (the effect) is measured; any extraneous variables are controlled. An advantage is that experiments should be objective. The views and opinions of the researcher should not affect the results of a study. What is experimental research design according to experts? Experimental research is a study that strictly adheres to a scientific research design. It includes a hypothesis, a variable that can be manipulated by the researcher, and variables that can be measured, calculated and compared. Most importantly, experimental research is completed in a controlled environment. The choice between the experimental and non-experimental approaches is generally dictated by the nature of the research question. Recall the three goals of science are to describe, to predict, and to explain. If the goal is to explain and the research question pertains to causal relationships, then the experimental approach is typically preferred. If the goal is to describe or to predict, a non-experimental approach will suffice. Secondary sources: (Use other people’s data to draw conclusions, and reviews of multiple studies). analysis, synthesis, interpretation and evaluation of primary sources. Use studies that already exist, and you can mold the data into something new. Systematic Reviews: Rigorous research that synthesizes all relevant primary evidence to answer a research question. Compilation of research from original or primary resources, therefore not primary sources. (SECONDARY SOURCE) CLINICAL PRACTICE GUIDELINES: Clinical Practice Guidelines: uses primary sources (individual studies), other secondary sources (systematic reviews), and expert opinion to create recommendations for care of a specific population of patients.

Evidence Summaries: a synopsis of existing evidence on healthcare interventions or activities; based on structured searches of the literature; does not follow the rigorous systematic review methodology. CPGs: Other literature that is not research, but is credible in answering a clinical question. According to the Institute of Medicine, “clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” Clinical practice guidelines can be found can be found in databases such as OVID, CINAHL. Finding Clinical Practice Guidelines in CINAHL: • Put a topic in the SEARCH bar • Scroll down to Publication type • Choose practice guidelines • Scroll back up to the top, hit SEARCH. Search results will now be limited to practice guidelines (until you change it). Clinical practice guidelines condense a large amount of evidence into a practical source for busy clinicians. Evidence-based CPGs are summaries and syntheses of best evidence, ideally, from rigorous systematic reviews, which are then delineated as recommendations for practice – a big help for practicing healthcare providers. Examples of clinical guidelines include12: • Acute Pain Management • Urinary Incontinence in Adults • Pressure Ulcer Prevention • Cataract in Adults Summary of recommendations/ CPGs; Give people with cataracts, and their family members or carers (as appropriate), both oral and written information. Information should be tailored to the person’s needs, for example, in an accessible format. For more guidance on giving information to people and discussing their preferences, see the NICE guideline on patient experience in adult NHS

services, particularly recommendations 1.2.12 and 1.2.13 on capacity and consent. 2. At referral for cataract surgery, give people information about: • cataracts: o what cataracts are o how they can affect vision o how they can affect quality of life • cataract surgery: o what it involves and how long it takes o possible risks and benefits o what support might be needed after surgery o likely recovery time o likely long-term outcomes, including the possibility that people might need spectacles for some tasks o how vision and quality of life may be affected without surgery. 3. At the preoperative outpatient appointment, review and expand on the topics in recommendation 2, and give people information about: • the refractive implications of different intraocular lenses (see recommendation 28) • types of anaesthesia • the person’s individual risk of complications during or after surgery (for example, the risk of postoperative retinal detachment in people with high myopia; also see recommendations 17 and • what to do and what to expect on the day of cataract surgery • what to do and what to expect after cataract surgery • what support might be needed after surgery

• medicines after surgery (for example, eye drops) and medicines that people may be already taking (for example, anticoagulants). • the refractive implications after previous corneal refractive surgery, if appropriate (see recommendation 13) • bilateral simultaneous cataract surgery, if appropriate (also see recommendations 36 and 37). 4. On the day of surgery, before the operation, give people information about: • Depression in Primary Care • Sickle Cell Disease • Early HIV Infection • Benign Prostatic Hyperplasia: Clinical recommendation Evidence rating References Men with suspected BPH can be evaluated with a validated questionnaire to quantify symptom severity. C 6 In men with symptoms of BPH, a digital rectal examination and urinalysis should be performed to screen for other urologic disorders. C 6 Watchful waiting with annual follow-up is appropriate for men with mild BPH. C 6, 10 Alpha blockers provide symptomatic relief of moderate to severe BPH symptoms. A 7, 12 In men with a prostate volume greater than 40 mL, 5-alpha reductase inhibitors should be considered for the treatment of BPH. A 8, 14 Refer patients for a surgical consultation if medical therapy fails; the patient develops refractory urinary retention, persistent hematuria, or bladder stones; or the patient chooses primary surgical therapy. C 6, 31, 32 Benign prostatic hyperplasia is a common condition affecting older men. A condition in which the flow of urine is blocked due to the enlargement of

prostate gland. The symptoms include increased frequency of urination at night and difficulty in urinating. Typical presenting symptoms include urinary hesitancy, weak stream, nocturia, incontinence, and recurrent urinary tract infections. Acute urinary retention, which requires urgent bladder catheterization, is relatively uncommon. Irreversible renal damage is rare. The initial evaluation should assess the frequency and severity of symptoms and the impact of symptoms on the patient’s quality of life. The American Urological Association Symptom Index is a validated instrument for the objective assessment of symptom severity. The initial evaluation should also include a digital rectal examination and urinalysis. Men with hematuria should be evaluated for bladder cancer. A palpable nodule or induration of the prostate requires referral for assessment to rule out prostate cancer. For men with mild symptoms, watchful waiting with annual reassessment is appropriate. Over the past decade, numerous medical and surgical interventions have been shown to be effective in relieving symptoms of benign prostatic hyperplasia. Alpha blockers improve symptoms relatively quickly. Although 5-alpha reductase inhibitors have a slower onset of action, they may decrease prostate size and alter the disease course. Limited evidence shows that the herbal agents saw palmetto extract, rye grass pollen extract, and pygeum relieve symptoms. Transurethral resection of the prostate (TURP: often provides permanent relief. Newer laser-based surgical techniques have comparable effectiveness to transurethral resection up to two years after surgery with lower perioperative morbidity. Various outpatient surgical techniques are associated with reduced morbidity, but symptom relief may be less durable. Treatment: Transurethral resection of the prostate (TURP): Whole except the outer part of the prostate is removed. Transurethral incision of the prostate (TUIP): One or two cuts are made in the prostate. Transurethral microwave thermotherapy (TUMT): Inner portion of the prostate is destroyed by inserting an electrode. Transurethral needle ablation (TUNA): Excess prostate tissue blocking urine flow is destroyed by radio waves. Laser therapy: Laser beams are used to destroy the overgrown prostate.

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