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Article Title: Evidence Level and Quality:_______________________

Number: Author(s): Publication Date: Journal: Setting: Sample (Composition & size):

Does this evidence address my EBP question? Yes No Do not proceed with appraisal of this evidence.

Level of Evidence (Study Design) A. Is this a report of a single research study? If No, go to B.

1. Was there manipulation of an independent variable? 2. Was there a control group? 3. Were study participants randomly assigned to the intervention and control groups?

If Yes to all three, this is a Randomized Controlled Trial (RCT) or Experimental Study. If Yes to #1 and #2 and No to #3, OR Yes to #1 and No to #2 and #3, this is Quasi Experimental (some degree of investigator control, some manipulation of an independent variable, lacks random assignment to groups, may have a control group). If No to #1, #2, and #3, this is Non-Experimental (no manipulation of independent variable, can be descriptive, comparative, or correlational, often uses secondary data) or Qualitative (exploratory in nature such as interviews or focus groups, a starting point for studies for which little research currently exists, has small sample sizes, may use results to design empirical studies).

NEXT, complete THE BOTTOM SECTION ON THE FOLLOWING PAGE, “STUDY FINDINGS THAT HELP YOU ANSWER THE EBP QUESTION.”

LEVEL I LEVEL II LEVEL III Yes Yes Yes Yes No No No No B. Is this a summary of multiple research studies? If No, go to Non-Research Evidence Appraisal Form.

1. Does it employ a comprehensive search strategy and rigorous appraisal method (Systematic Review)? If No, use Non-Research Evidence Appraisal Tool; if Yes:

a. Does it combine and analyze results from the studies to generate a new statistic (effect size)? (Systematic review with meta-analysis).

b. Does it analyze and synthesize concepts from qualitative studies? (Systematic review with meta-synthesis).

If Yes to either a or b, go to #2B below.

2. For Systematic Reviews and Systematic Reviews with meta-analysis or meta-synthesis:

a. Are all studies included RCTs?

b. Are the studies a combination of RCTs and quasi-experimental or quasi-experimental only?

c. Are the studies a combination of RCTs, quasi-experimental and non-experimental or non-experimental only?

d. Are any or all of the included studies qualitative? complete THE NEXT SECTION, “STUDY FINDINGS THAT HELP YOU ANSWER THE EBP QUESTION.”

LEVEL I LEVEL II LEVEL III LEVEL III Yes Yes Yes Yes No No No No

Study findings that help you answer the EBP question: NOW COMPLETE THE FOLLOWING PAGE, “QUALITY APPRAISAL OF RESEARCH STUDIES,” AND ASSIGN A QUALITY SCORE TO YOUR ARTICLE.

Quality Appraisal of Research Studies:

  • Does the researcher identify what is known and not known about the problem and how the study will address any gaps in knowledge?

  • Was the purpose of the study clearly presented?

  • Was the literature review current (most sources within last 5 years or classic)?

  • Was sample size sufficient based on study design and rationale?

  • If there is a control group:

  • Were the characteristics and/or demographics similar in both the control and intervention groups?

  • If multiple settings were used, were the settings similar?

  • Were all groups equally treated except for the intervention group(s)?

  • Are data collection methods described clearly?

  • Were the instruments reliable (Cronbach's α [alpha] > 0.70)?

  • Was instrument validity discussed?

  • If surveys/questionnaires were used, was the response rate > 25%?

  • Were the results presented clearly?

  • If tables were presented, was the narrative consistent with the table content?

  • Were study limitations identified and addressed?

  • Were conclusions based on results?

Quality Appraisal of Systematic Review with or without Meta-Analysis or Meta-Synthesis:

  • Was the purpose of the systematic review clearly stated?

  • Were reports comprehensive, with reproducible search strategy?

  • Key search terms stated.

  • Multiple databases searched and identified.

  • Inclusion and exclusion criteria stated.

  • Was there a flow diagram showing the number of studies eliminated at each level of review?

  • Were details of included studies presented (design, sample, methods, results, outcomes, strengths and limitations)?

  • Were methods for appraising the strength of evidence (level and quality) described?

  • Were conclusions based on results?

  • Results were interpreted.

  • Conclusions flowed logically from the interpretation and systematic review question.

  • Did the systematic review include both a section addressing limitations and how they were addressed?

Quality Rating Based on quality appraisal:

  • A High quality: consistent, generalizable results; sufficient sample size for the study design; adequate control; definitive conclusions; consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence.

  • B Good quality: reasonably consistent results; sufficient sample size for the study design; some control, and fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence.

  • C Low quality or major flaws: little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn.

Paper For Above Instructions

The appraisal of research evidence is critical for integrating evidence-based practice (EBP) in healthcare. This approach ensures that healthcare professionals utilize the most reliable and pertinent research to inform their clinical decisions. Central to this methodology is the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Appraisal Tool, which assists in evaluating the strength and validity of research studies.

The first step in the appraisal process is to ascertain whether the evidence directly addresses the EBP question at hand. If it does not, the appraisal process should be halted. In evaluating single research studies, it is essential to identify the level of evidence and the design of the study. A study is categorized as a Randomized Controlled Trial (RCT) if it involves manipulation of an independent variable, a control group, and random assignment of participants. If any of these criteria are not met, the study may be classified as Quasi-experimental or Non-experimental.

Subsequently, when assessing systematic reviews or meta-analyses, it is vital to ensure that comprehensive search strategies were employed and that the studies included were rigorously appraised. For systematic reviews that synthesize data from multiple RCTs, additional scrutiny is necessary to confirm that the analysis produces a new, reliable statistic or effectively synthesizes qualitative insights.

The appraisal should continue with a detailed examination of the quality of the studies included in the review. Important factors to assess include the clarity of the research purpose, the currency of the literature reviewed, and whether the sample size is sufficient for the study design. Additionally, it is essential to evaluate if studies controlled for demographic similarities between intervention and control groups, if data collection methods were clearly outlined, and if the reliability and validity of instruments used in the studies were established.

Specific metrics, such as the response rate of surveys, presentation clarity of study results, and a logical flow from results to conclusions, are also crucial. Identifying study limitations is essential for understanding the context and credibility of conclusions drawn.

Inherent in this process is the necessity to provide a quality rating based on the overall appraisal outcomes. Evidence may be categorized into high quality (consistent, generalizable results with comprehensive literature reviews), good quality (reasonably consistent results with sufficient evidence), or low quality (evidence with significant inconsistencies and insufficient sample sizes). This structured evaluation process allows for informed and science-based decisions in practice.

Ultimately, it is essential to synthesize the findings from studies in terms of how they address the original EBP question posed. This synthesis should also incorporate a discussion on how the evidence impacts clinical practice, patient outcomes, and healthcare delivery as a whole.

The integration of rigorous evidence appraisal tools, such as the Johns Hopkins model, not only fosters a culture of evidence-based practice but also empowers healthcare professionals with the confidence to make data-driven decisions that optimize patient care and health outcomes.

References

  • Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Lippincott Williams & Wilkins.

  • Polit, D. F., & Beck, C. T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Wolters Kluwer.

  • Gray, J. R., Grove, S. K., & Sutherland, S. (2017). The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. Elsevier.

  • Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Wolters Kluwer.

  • Johns Hopkins Nursing Evidence-Based Practice. (2017). Evidence Level and Quality Appraisal Tool. Johns Hopkins University.

  • Burns, N., & Grove, S. K. (2016). The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. Elsevier.

  • Polit, D. F., Beck, C. T. (2014). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins.

  • Hoffman, T., Ebert, L., & Almeida, F. A. (2017). Evidence-based practice: Perspectives and challenges in clinical settings. Worldviews on Evidence-Based Nursing, 14(3), 163-171.

  • Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. BMJ, 312(7023), 71-72.

  • Thomas, A. J., & Waddell, G. (2017). Integrating research into clinical practice: Implications for nurse managers. Nursing Management, 44(2), 46-52.

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