NRS 433V Topic 4 DQ 2 Describe the seven levels of evidence

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Topic 4 DQ 2

Aug 15-19, 2022

Describe the seven “levels of evidence” and provide an example of the type of practice change that could result from each.

Mary-Korine Insunsa

Aug 20, 2022, 4:01 PM

Replies to Mary-Korine Insunsa

University of Wisconsin (2022) described the seven levels of evidence as the following. “Level I: Evidence from a systematic review of all relevant randomized controlled trials (RCT’s), or evidence-based clinical practice guidelines based on systematic reviews of RCT’s. Level II: Evidence obtained from at least one well-designed Randomized Controlled Trial (RCT). Level III: Evidence obtained from well-designed controlled trials without randomization, quasi-experimental. Level IV: Evidence from well-designed case-control and cohort studies. Level V: Evidence from systematic reviews of descriptive and qualitative studies. Level VI: Evidence from a single descriptive or qualitative study. Level VII: Evidence from the opinion of authorities and/or reports of expert committees” As you can see from this, as the studies become more reliable, they move from the higher levels to the lower levels. Based off of this system, opinion is usually considered the worst of the hierarchy of the studies while meta analysises of RCTs are the best. One example of a meta analysis of RCTs include one by Galie about PAH. The level 7 might be a group of experts giving their expert opinion about a certain subject, such as about hypertension. Level 6 would be one such as a study of how the wait times made a person feel about their experience in an ED. Level 5 would be a meta analysis of looking at those level 6 studies. Level 4 would be researching how antibiotics affected the ICU patients drug resistance over a time period, and 3 would be grouping those studies together to look at a meta analysis of it. The level two are RCTs such as a randomized trial of two antibiotics for Pseudomonas in the ICU over a time period.

Galie, N. (2009). A meta-analysis of randomized controlled trials in pulmonary arterial hypertension. Retrieved from https://academic.oup.com/eurheartj/article/30/4/394/415127

University of Wisconsin (2022). Nursing Resources : Levels of Evidence (I-VII). Retrieved from https://researchguides.library.wisc.edu/c.php?g=861013&p=6170092

Justina Aguilar

replied toMary-Korine Insunsa

Aug 21, 2022, 2:09 AM

Replies to Mary-Korine Insunsa

Hi Mary-Korine,

I liked your example of pulmonary arterial hypertension by the European Heart Journal (2009). A meta-analysis of all randomized controlled trials with drugs published in this condition was performed. The results of this meta-analysis suggested an improvement of survival in the patients treated with the targeted therapies approved for pulmonary arterial hypertension (Nazzareno Galiè, 2009). In the hierarchy of evidence this was a good example of level I, Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results (WSU, 2022).

Reference

Nazzareno Galiè, Alessandra Manes, Luca Negro, Massimiliano Palazzini, Maria Letizia Bacchi-Reggiani, Angelo Branzi, A meta-analysis of randomized controlled trials in pulmonary arterial hypertension, European Heart Journal, Volume 30, Issue 4, February 2009, Pages 394–403, https://doi.org/10.1093/eurheartj/ehp022

Research hub: Evidence based practice toolkit: Levels of evidence. WSU. (2022). https://libguides.winona.edu/ebptoolkit/Levels-Evidence

Calorine Mahungana

replied toMary-Korine Insunsa

Aug 21, 2022, 3:41 AM

Replies to Mary-Korine Insunsa

Hello Mary-Korine,

Thank you for your post. I would like to elaborate on stage V of evidence which is Cohort studies. It categorises participants according to the level of exposure to risk factors who are then followed over a period of time to observe the possible occurence of a disease. The NHMRC, (2009), explains that prospective cohorts are observed at a point in time to be exposed to an intervention whereas retrospective studies are usually done from medical records.

Reference

National Health and Medical Research Council., (2009). NHMRC levels of evidence and grades for recommendations for developers and guidelines.

Krishna Turner

replied toMary-Korine Insunsa

Aug 21, 2022, 8:43 PM

Replies to Mary-Korine Insunsa

Hi Mary,

Thank you for providing the different levels of evidence and using example of PAH. Level I of evidence which entails systematic or meta analysis this identify evidence synthesis. PAH study would include adults that are diagnosis with PAH, a couple of approved drugs that are appropriate for the study. This drug will show if it is effective and safe for future use of patients with PAH. The study will always start off with a smaller population and later increase population before being approved by the FDA for further treatment of PAH, and this will support the first 3 levels of evidence.

Reference:

Schlueter, M., Beaudet, A., Davies, E., Gurung, B., & Karabis, A. (2020, July 28). Evidence synthesis in pulmonary arterial hypertension: A systematic review and critical appraisal – BMC pulmonary medicine. BioMed Central. Retrieved August 21, 2022, from https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01241-4

Misty Diaz

replied toMary-Korine Insunsa

Aug 21, 2022, 10:21 PM

Replies to Mary-Korine Insunsa

Hello Mary-Korine!

Your levels of hierarchy are great! I just wanted to say, that it is difficult to get the levels of hierarchy down, and I noticed that the “pyramid” varies a little from source to source (Ingham-Broomfield, 2016). Now, there are only 5 levels of hierarchy to keep in mind, which does help out in trying to keep things clear. The best thing to keep in mind, is that there is a hierarchy of the research, and to continue to gather as much information as possible about the subject you are considering changing, discard the ones which are not-so-strong in their structure or statistics, and rely on those highest up on the hierarchy pyramid as possible. Nurses need to be competent in their ability to evaluate research for strengths and weaknesses, of which we are learning now (Ingham-Broomfield, 2016).

Ingham-Broomfield, R. (2016). A nurses guide to the hierarchy of research designs and evidence. Australian Journal of Advanced Nursing, 33(3): 38-43. https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN114833287&site=eds-live&scope=site

Justina Aguilar

Aug 19, 2022, 11:49 PM

Replies to Mary-Korine Insunsa

“Levels of evidence (sometimes called hierarchy of evidence) are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. These decisions gives the “grade (or strength) of recommendation” (WSU, 2022).

After each level are examples of the type of practice change that could result positively.

Level I

Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results(WSU, 2022) For example, There can be two or more groups in RCTs; one group in the study is always the control group receiving the routine drug, treatment, or procedure, and the other is the experimental group, receiving the experimental drug, treatment, or procedure. Testing placebo versus actual new medication (Helbig, 2018).

Level II

Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT).(WSU, 2022) For example, Implementing a new protocol in a hospital a new practice based on the findings of a single large-scale clinical trial (Helbig, 2018).

Level III

Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental).(WSU, 2022) An example of a quasi-experimental study, a hospital introduces a new order-entry system and wishes to study the impact of this intervention on the number of medication-related adverse events before and after the intervention (Harris et al., 2006).

Level IV

Evidence from well-designed case-control or cohort studies.(WSU, 2022) For example, gathering data regarding sequence of events such as falls and what events have lead up to those events via cohort study (Helbig, 2018).

Level V

Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).(WSU, 2022) For example, qualitative research may be performed either by observation or interviews-patient satisfaction surveys (Helbig, 2018).

Level VI

Evidence from a single descriptive or qualitative study.(WSU, 2022) For example, implementation of a new screening procedure in a hospital or medical practice based on the findings of a well-designed case-control or cohort study (Helbig, 2018).

Level VII

Evidence from the opinion of authorities and/or reports of expert committees.(WSU, 2022) For example, a new medical treatment that has been proven effective in multiple descriptive and qualitative studies (Helbig, 2018).

NRS 433V Topic 4 DQ 2 Describe the seven levels of evidence

Reference

Harris, A. D., McGregor, J. C., Perencevich, E. N., Furuno, J. P., Zhu, J., Peterson, D. E., & Finkelstein, J. (2006). The use and interpretation of quasi-experimental studies in medical informatics. Journal of the American Medical Informatics Association : JAMIA, 13(1), 16–23. https://doi.org/10.1197/jamia.M1749

Helbig, J. (2018). Nursing research: Understanding methods for best practice. Retrieved from https://lc.gcumedia.com/nrs433v/nursing-research-understanding-methods-for-best-practice/v1.1

Research hub: Evidence based practice toolkit: Levels of evidence. WSU. (2022). https://libguides.winona.edu/ebptoolkit/Levels-Evidence

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Grading Rubric Guidelines

Performance Category	10	9	8	4	0
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic decisions.	Provides relevant evidence of scholarly inquiry clearly stating how the evidence informed or changed professional or academic decisions Evaluates literature resources to develop a comprehensive analysis or synthesis. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion	Provides relevant evidence of scholarly inquiry but does not clearly state how the evidence informed or changed professional or academic decisions. Evaluates information from source(s) to develop a coherent analysis or synthesis. Uses some valid, relevant, reliable outside sources to contribute to the threaded discussion.	Discusses using scholarly inquiry but does not state how scholarly inquiry informed or changed professional or academic decisions. Information is taken from source(s) with some interpretation/evaluation, but not enough to develop a coherent analysis or synthesis. Little valid, relevant, or reliable outside sources are used to contribute to the threaded discussion. Demonstrates little or no understanding of the topic.	Discusses using scholarly inquiry but does not state how scholarly inquiry informed or changed professional or academic decisions. Information is taken from source(s) without any interpretation/evaluation. The posting uses information that is not valid, relevant, or reliable	No evidence of the use of scholarly inquiry to inform or change professional or academic decisions. Information is not valid, relevant, or reliable
Performance Category	10	9	8	4	0
Application of Course Knowledge – Demonstrate the ability to analyze, synthesize, and/or apply principles and concepts learned in the course lesson and outside readings and relate them to real-life professional situations	Posts make direct reference to concepts discussed in the lesson or drawn from relevant outside sources; Applies concepts to personal experience in the professional setting and or relevant application to real life.	Posts make direct reference to concepts discussed in the lesson or drawn from relevant outside sources. Applies concepts to personal experience in their professional setting and or relevant application to real life Interactions with classmates are relevant to the discussion topic but do not make direct reference to lesson content	Posts are generally on topic but do not build knowledge by incorporating concepts and principles from the lesson. Does not attempt to apply lesson concepts to personal experience in their professional setting and or relevant application to real life Does not demonstrate a solid understanding of the principles and concepts presented in the lesson	Posts do not adequately address the question posed either by the discussion prompt or the instructor’s launch post. Posts are superficial and do not reflect an understanding of the lesson content Does not attempt to apply lesson concepts to personal experience in their professional setting and or relevant application to real life	Posts are not related to the topics provided by the discussion prompt or by the instructor; attempts by the instructor to redirect the student are ignored No discussion of lesson concepts to personal experience in the professional setting and or relevant application to real life
Performance Category	5	4	3	2	0
Interactive Dialogue Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days. *(5 points possible per graded thread)*	Exceeds minimum post requirements Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts three or more times in each graded thread, over three separate days. Replies to a post posed by faculty and to a peer Summarizes what was learned from the lesson, readings, and other student posts for the week.	Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days Replies to a question posed by a peer Summarizes what was learned from the lesson, readings, and other student posts for the week.	Meets expectations of 2 posts on 2 different days. The main post is not made by the Wednesday deadline Does not reply to a question posed by a peer or faculty	Has only one post for the week Discussion posts contain few, if any, new ideas or applications; often are a rehashing or summary of other students’ comments	Does not post to the thread No connections are made to the topic
	Minus 1 Point	Minus 2 Point	Minus 3 Point	Minus 4 Point	Minus 5 Point
Grammar, Syntax, APA Note: if there are only a few errors in these criteria, please note this for the student in as an area for improvement. If the student does not make the needed corrections in upcoming weeks, then points should be deducted. Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition	2-3 errors in APA format. Written responses have 2-3 grammatical, spelling, and punctuation errors. Writing style is generally clear, focused, and facilitates communication.	4-5 errors in APA format. Writing responses have 4-5 grammatical, spelling and punctuation errors. Writing style is somewhat focused.	6-7 errors in APA format. Writing responses have 6-7 grammatical, spelling and punctuation errors. Writing style is slightly focused making discussion difficult to understand.	8-10 errors in APA format. Writing responses have 8-10 grammatical, spelling and punctuation errors. Writing style is not focused, making discussion difficult to understand.	Post contains greater than 10 errors in APA format. Written responses have more than 10 grammatical, spelling and punctuation errors. Writing style does not facilitate communication. The student continues to make repeated mistakes in any of the above areas after written correction by the instructor
	0 points lost				-5 points lost
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