Evidence Digest

Evidence Digest

Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN

The purpose of the evidence digest, a recurring columnin Worldviews, is to provide concise summaries of well-designed, recent studies along with implications for clini-cal practice, research, administration, and/or health policy.The articles highlighted in this column may include quan-titative and qualitative studies, systematic and integrativereviews, as well as consensus statements by expert pan-els. Along with relevant implications, the level of evidencegenerated by studies or reports highlighted in this columnis included at the end of each summary so that readerscan integrate the strength of evidence into their health caredecisions.

Levels of Evidence.

Rating systems or hierarchies of evidence are commonlyused in evidence-based practice (EBP) to grade the strengthor quality of evidence generated from a study or report.There is agreement in the literature that a systematic reviewor meta-analysis (i.e., a systematic review that incorporatesquantitative methods to summarize the results from mul-tiple studies) of randomized controlled trials (RCTs) andevidence-based clinical practice guidelines is the strongestlevel of evidence upon which to base health care deci-sions, followed by evidence obtained from at least one well-designed RCT (Sackett, Straus, Richardson, Rosenberg, &Haynes 2000; Guyatt & Rennie 2002). However, evidencehierarchies have been criticized for not including evidencegained from qualitative studies. Since different types of re-search questions require various types of designs to answerthem (Glasziou, Vandenbroucke & Chalmers 2004), it isimportant to include qualitative studies in evidence hier-archies. Non-experimental studies, such as case reports,are valuable in that they can alert clinicians to potentialbenefits or harms of a treatment (Glasziou et al. 2004). Inaddition, qualitative evidence incorporates patients’ voicesinto the process of EBP (Pearson 2002). As such, it is im-portant to include descriptive and qualitative studies inevidence hierarchies. Therefore, this column will use a rat-ing system that encompasses evidence from a variety ofsources, including quantitative and qualitative studies (seeFigure 1).

Copyright ©2004 Sigma Theta Tau International1545-102X1/04

Since EBP is a problem-solving approach to practice, itshould be remembered that a clinician’s expertise as wellas patient preferences and values should be integrated withevidence from well-designed studies in making decisionsabout patient care. For example, even if a systematic reviewsupports the effectiveness of a certain treatment, a patient’svalues (e.g., religious beliefs) may be in direct conflict withthat treatment. As a result, a clinician may decide upon analternative therapy for that particular patient instead of thetreatment supported as most efficacious by RCTs in orderto support his or her beliefs.

Evidence to Improve Clinical Practice withVulnerable Populations: High-Risk Mothers

and Children and Older Adultsin Nursing Homes.

Beck C.T. (2004). Birth trauma: In the eye of the beholder.Nursing Research, 53(1), 28–35.

This qualitative study, using descriptive phenomenol-ogy, described the meaning of women’s birth trauma ex-periences. A purposeful sample of 40 mothers with per-ceived birth trauma was drawn from New Zealand, theUnited States, Australia, and the United Kingdom. Sub-jects were recruited through the Internet, mainly throughTrauma and Birth Stress (TABS), a charitable trust locatedin New Zealand. Sample inclusion criteria required that themother: (1) had experienced birth trauma, (2) was willingto articulate her experience, and (3) could read and writeEnglish. Each mother was asked to describe her experienceof traumatic birth in as much detail as she could rememberor that she wished to share. Mothers who participated inthe study were from 5 weeks to 14 years beyond the trau-matic event (e.g., stillbirth, emergency cesarean delivery/fetal distress, premature birth, separation from their in-fants in the neonatal intensive care unit). Thirty-two of thewomen had been diagnosed with post-traumatic stress dis-order (PTSD) as a result of the birth experience, and theother eight women had PTSD symptoms but had not yetreceived mental health treatment.

Colaizzi’s method of analysis was used to analyze thedata. Findings indicated that four themes emerged fromthe data, including: (1) To care for me: Was that toomuch to ask? (2) To communicate with me: Why wasthis neglected? (3) To provide safe care: You betrayed

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• Level I: Evidence from a systematic review or meta-analysis of all relevant

randomized controlled trials (RCTs), or evidence-based clinical

practice guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT

• Level III: Evidence obtained from well-designed controlled trials without

randomization

• 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

Modified from Guyatt & Rennie 2002; Harris et al. 2001

Figure 1. Rating system for the hierarchy of evidence (fromMelnyk & Fineout-Overholt, 2004)

my trust and I felt powerless, and (4) The end jus-tifies the means: At whose expense? At what price?

Commentary with Implications for Research and Clin-ical Practice. Although up to 5.6% of women expe-rience PTSD after childbirth, little research has beenconducted to describe and understand this experience.Further studies are needed to determine demographicand clinical variables that predict PTSD in women whoexperience traumatic birth so that preventive interven-tions can be developed and tested. From this study, clini-cians must be diligent about eliciting important history-taking questions regarding particular fears that womenhave regarding their impending birth, as well as pro-viding women with as much of a sense of control aspossible over their birth experience. Women need tobe encouraged to express their feelings about the child-birth process and be helped to cope with unmet expec-tations about it. Finally, health care providers need tobe alert to the signs and symptoms of PTSD in womenfollowing the birth experience (e.g., recurrent and in-trusive distressing recollections of the event, recurrentdistressing dreams of the event) so that PTSD symp-toms can be detected and early interventions imple-mented to prevent long-term negative mental healthoutcomes.

Level of Evidence: VI.

Yoos H.L., Kitzman H. & McMullen A. (2003). Barriersto anti-inflammatory medication use in childhood asthma.Ambulatory Paediatrics, 3(4), 181–190.

This report emphasizes the escalating morbidity andmortality associated with childhood asthma, emphasizingthat Black children and those from low socioeconomicbackgrounds traditionally have had the poorest outcomes.The objectives of this descriptive correlational study wereto: (1) describe parental barriers to anti-inflammatory med-ication use, (2) identify risk factors for the under useof medications, and (3) develop a valid and reliable in-strument that could be used in research as well as clin-ical practice to identify at-risk populations of childrenand circumstances of treatment non-adherence. Subjectswere recruited from urban clinics, suburban pediatric prac-tices, and several rural pediatric sites in the upstate NewYork region of the United States. The sample for deter-mining the psychometric properties of the instrument in-cluded 109 parents of children with asthma, ranging inage from 2 to 19 years. Sixty-seven percent of the fami-lies were White and 33% were of minority race/ethnicity.Twenty-eight percent of the children had mild inter-mittent asthma and 72% had mild persistent-to-severeasthma.

Findings indicated that parental barriers to asthma man-agement included diminished beliefs/expectations abouttreatment and fears about anti-inflammatory medications.Minority families were more likely to perceive asthma asunpredictable and uncontrollable, as well as to have nega-tive attitudes toward anti-inflammatory medications, thanwere White families and, therefore, were more at risk formedication non-adherence.

The final version of the instrument, comprising 51questions across five domains (i.e., nature of disease,cause, ideas about medications, treatment expectations,and health care provider relationship), was found to bevalid and reliable (i.e., Cronbach’s alpha = .87). Specifi-cally, responses to the following eight statements (basedon a Likert scale from strongly disagree to strongly agree)on the instrument were significantly related to a subopti-mal regimen of asthma management:

1. There is little I can do to control my child’s symptoms.2. Using inhaled steroids should be a last resort in treat-

ing asthma.3. After a child has taken inhaled steroids for a

while, the steroids won’t work when they are reallyneeded.

4. My child thinks that taking daily medicine is a hassle.5. I believe that my child can be symptom-free most of

the time.6. I expect that asthma will not affect my child’s school

attendance.7. I expect that my child can fully participate in gym and

normal physical activity.

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Evidence Digest

8. I expect that my child will have no emergency-roomvisits or hospitalizations because of asthma.

Commentary with Implications for Research and ClinicalPractice. Findings from this study have important impli-cations for practicing clinicians as well as researchers.Clinicians must devote time interviewing parents ofnewly diagnosed children with asthma to determinetheir beliefs and expectations about the disease andits management. Routinely incorporating the previouseight statements into clinical practice as a screening toolfor parents of children with asthma could alert clini-cians to those families at highest risk for non-adherenceto prescribed treatments. Identification of these at-riskfamilies could result in early intervention strategies toimprove asthma management and clinical outcomes inchildren with asthma. Further studies are needed withsamples comprising a greater percentage of minoritychildren who are receiving Medicaid, as the majorityof this sample was White and non-Medicaid recipients.

Level of Evidence: VI.

McClellan J.M. & Werry J.S. (2003). Evidence-basedtreatments in child and adolescent psychiatry: An inven-tory. Journal of the American Academy of Child AdolescentPsychiatry, 42(12), 1388–1400.

This integrative review captures the state of child psy-chiatry with regard to effective evidence-based treatments.The authors conducted an extensive review of the litera-ture for systematic reviews of randomized controlled trials(RCTs) and single RCTs evaluating the effectiveness of psy-chopharmacological or psychotherapeutic interventions inorder to compile a list of evidence-based treatments forcommon child and adolescent mental health disorders.

Findings revealed that the effectiveness of stimulantmedications for attention deficit/hyperactivity disorder,as well as the effectiveness of selective serotonin reup-take inhibitors (SSRIs) for obsessive-compulsive disor-der, is well supported in RCTs. There is also accumu-lating evidence to support the effectiveness of SSRIs foranxiety disorders and moderate-to-severe major depres-sive disorder. Risperidone, an atypical antipsychotic med-ication, has also been empirically supported as an effec-tive treatment for autism. Psychosocial interventions thathave the most evidence to support their effectiveness formood, anxiety, and behavioral disorders include cognitive-behavioral and behavioral interventions. The authors con-cluded that there is an urgent need for further RCTs toevaluate the effectiveness of clinical treatments on out-comes of children and teens with mental health prob-lems, as much of the clinical practice with this popu-lation is based on adult literature and models of care.

Commentary with Implications for Research and ClinicalPractice. Since approximately 20–25% of all children andadolescents are currently affected by mental health prob-lems, there is an urgent need for clinicians to be up todate with treatments that have been found to be the mostefficacious for these disorders. This article provides anexcellent overview of evidence-based medications andpsychosocial interventions for common pediatric men-tal health problems and, as such, provides a useful guidefor clinicians. However, dissemination and implementa-tion studies are now needed to determine how these in-terventions will translate into clinical practice settings.Future research to determine what factors may moder-ate the effects of these evidence-based interventions isalso needed.

Level of Evidence: I.

American Geriatrics Society and American Associationfor Geriatric Psychiatry (2003). Consensus statement onimproving the quality of mental health care in U.S. nursinghomes: Management of depression and behavioral symp-toms associated with dementia. Journal of the AmericanGeriatrics Society, 51(9), 1287–1298.

This article describes the recommendations of an in-terdisciplinary expert panel convened to identify effectiveapproaches for addressing the mental health needs of olderpersons with depression and behavior symptoms accom-panying dementia who reside in nursing homes. Expertswho participated in this panel were nominated from a va-riety of stakeholder organizations. The goal of the panelwas to develop evidence-based statements that would beclinically relevant to a wide variety of clinicians practicingin nursing homes.

The panel, comprising 17 interdisciplinary members,reached consensus on 89 of 131 (68%) statements rankedin the area of depression and 105 of the 139 (76%) state-ments dealing with the assessment and management of be-havioral symptoms. Each of the ranked statements was ac-companied by the level of evidence that supported eachstatement (e.g., Level I: evidence generated by one or morewell-designed randomized controlled clinical trials, includ-ing meta-analyses of such trials). Consensus on a varietyof statements resulted in a total of 11 recommendationsfor depression (e.g., screening for depression should beconducted 2–4 weeks after admission and repeated at leastevery 6 months; the panel supports the use of nonpharma-cological interventions in combination with antidepressantmedications for treating major depression). In addition,consensus on statements for the management of behav-ioral symptoms resulted in 12 recommendations (e.g., ed-ucation and training of mental health professionals work-ing in nursing homes and of nursing home staff for the

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recognition, assessment, treatment, and monitoring of be-havioral symptoms in nursing home residents is essential;residents with new onset of or changes in behavioral symp-toms should have their vital signs taken and evaluated foradverse medication effects, infections, dehydration, painor discomfort, delirium, fecal impaction, and injury).

Commentary with Implications for Clinical Practice andAdministration. A major strength of this consensus panelis that it used evidence to support each of its consensusstatements. A second strength is that the panel com-prised interdisciplinary membership. Although the rec-ommendations produced by this panel can serve as avery useful guide for practice, clinicians must still in-corporate their clinical judgment and patient/family val-ues and preferences in making decisions about patients’care. This document will also be particularly useful foradministrators in assisting them with creating nursinghome systems committed to quality health care.

Level of Evidence: I.

Watson N.M., Brink C.A., Zimmer J.G. & Mayer R.D.(2003). Use of the Agency for Health Care Policy and Re-search Urinary Incontinence Guideline in nursing homes.Journal of the American Geriatrics Society, 51(12), 1779–1786.

This descriptive study assessed the use of the 1996 Uri-nary Incontinence Guideline developed by the Agency forHealth Care Policy and Research (now called the Agency forHealthcare Research and Quality [AHRQ]) in 52 nursinghomes in the northeastern region of the United States. Themethods used were retrospective chart review and screen-ing interviews with nursing assistants. Two hundred resi-dents who developed a new urinary infection (UI) or werenewly admitted with a urinary infection and who met thecriteria for evaluation and treatment were assessed in the12 weeks after onset of or admission with a UI. Fifteenpercent of newly admitted residents required evaluation.

Findings indicated that components of UI evaluationthat were rarely conducted were rectal examination, digi-tal prostate evaluation, and pelvic examination. Sixty-eightpercent of these residents had a urine culture and sensitiv-ity, 56% had a urinalysis, and 6% had a post-void residualas part of their UI evaluation. Only 3% received treatment,but it was common for the management to include toi-leting and the use of absorbent products. Many nursingassistants reported that they thought urinary incontinencewas normal and that nothing could essentially be done toresolve it.

These results support that the quality of UI manage-ment is not adequate, as only 20% of guideline standardsapplicable were met. The major reasons for failure to use

the UI guideline were the lack of awareness of a new UIand unfamiliarity with the guide. One major limitation ofthe current guideline discussed in the report is that theguideline is generic and does not take into considerationthe individualized needs of various nursing homes in theassessment and management of UI. The investigators em-phasize the importance of developing an updated guidelinebased on current evidence.

Commentary with Implications for Clinical Practice andAdministration. As a large percentage of nursing homeresidents have UI and few receive evaluation and treat-ment, there is an urgent need for clinicians to screen forand provide effective interventions to resolve this prob-lem. Clinicians should be especially attentive to screenfor reversible causes of UI (e.g., urinary tract infection)and to use evidence-based effective treatments (e.g., an-ticholinergics and bladder training exercises) for olderadults with UI. Although there is now a major clear-inghouse of evidence-based clinical practice guidelinesat www.guideline.gov, which is supported by AHRQand the American Medical Association, important ques-tions remain, especially for nursing home administra-tors, regarding: (1) how best to raise clinician awarenessof evidence-based guidelines, (2) the best strategies toprompt clinician use of this comprehensive guidelinesite, and (3) how best to translate these guidelines rou-tinely into clinical practice.

Level of Evidence: VI.

ReferencesGlasziou P., Vandenbroucke J. & Chalmers I. (2004). As-

sessing the quality of research. British Medical Journal,328, 39–41.

Guyatt G. & Rennie D. (2002). Users’ guides to the medicalliterature. Washington, DC: American Medical Associa-tion Press.

Harris R.P., Hefland M., Woolf S.H., Lohr K.N., MulrowC.D., Teutsch S.M., et al. (2001). Current methods ofthe U.S. Preventive Services Task Force: A review of theprocess. American Journal of Preventive Medicine, 20(3Suppl), 21–35.

Melnyk B.M. & Fineout-Overholt E. (2004). Evidence-based practice in nursing & healthcare. A guide tobest practice. Philadelphia: Lippincott Williams &Wilkins.

Pearson A. (2002). Nursing takes the lead. Redefining whatcounts as evidence in Australian health care. Reflectionson Nursing Leadership, 28(4), 18–21, 37.

Sackett D.L., Straus S.E., Richardson W.S., Rosenberg W.& Haynes R.B. (2000). Evidence-based medicine: How topractice and teach EBM. London: Churchill Livingstone.

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