NR 439 Literature and Levels of Evidence DQ

NR 439 Literature and Levels of Evidence DQ
NR 439 Literature and Levels of Evidence DQ

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Reflect on your practice, and identify a significant nursing clinical issue or change project that you would like to search for evidence in online sources. Formulate searchable, clinical questions in the PICO(T) format for your nursing clinical issue.
Next, review the guidelines for the PICOT Assignment due Week 3. Use your PICOT elements to search foronereport of a single, original study that has been published within the last 5 years from the CCN Library that is relevant to your nursing clinical issue.
Briefly describe how it is relevant to your nursing clinical issue. Remember to give a complete reference to the study.

Is All Evidence Created Equal?

The medical literature is immense, but only a small portion of it is immediately useful in answering clinical questions. The literature reports the whole spectrum of the scientific research process — the long journey from in-vitro studies to double-blind randomized controlled trials. This has been called the “wedge of evidence” or the “pyramid of evidence.”(for a visual representation see More Information)
An understanding of how various levels of evidence are reported and how this literature is organized will help the searcher retrieve the highest levels of evidence for a particular clinical question. High levels of evidence may not exist for all clinical questions because of the nature of medical problems and research and ethical limitations.
AddingMETHODOLOGYterms andCLINICAL FILTERStoSUBJECTterms will result in the most efficient and optimal retrieval in terms of finding the highest level of evidence in answering clinical questions.

Study Design Concepts

Studies can bedescriptive(or observational), such as :

case reports (a detailed description of a single case)
case series (descriptions of groups of patients with a disease)
cohort studies (defined populations which are followed in an attempt to determine distinguishing subgroup characteristics)

Orevaluative(interventional), such as a:

randomized/controlled clinical trials (a clinical trial involving one or more test treatments, at least one control treatment, specified outcome measures for evaluating the studied intervention, and a bias-free method for assigning patients to the test treatment)
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Levels of Clinical Evidence in the Primary Literature

Type of Question

Type of Study Methodology

MEDLINE Filters

Therapy: information needed about
treatments (effectiveness, cost, etc.)
Double-Blind
Randomized Controlled Trial
Randomized Controlled Trial [PT]
double [TW] and blind [TW]

Diagnosis: information needed about a
diagnostic test (sensitivity, accuracy, etc.)
Controlled Trial
Sensitivity and Specificity [MH]
Diagnosis [SH]

Prognosis: information needed about the
course of the disease over time, expected
complications, etc.
Cohort Studies
Case Control
Case Series
Cohort Studies [MH]
Prognosis [MH]
Survival Analysis [MH]

Etiology/Harm: information needed about
causes of disease or contributing factors of disease
Cohort Studies
Cohort Studies [MH]
Risk [TW]

Prevention: information needed about the
prevention of disease (immunization,
social factors, etc.)
Randomized Controlled Trial
Cohort Studies
Randomized Controlled Trial [PT]
Cohort Studies [MH]
Prevention and Control [SH]

Quality Improvement: information needed
about clients’ and health professionals’
experiences and concerns
Randomized Controlled Trial
Randomized Controlled Trial [PT]
Practice Guideline [PT]
Consensus Development Conference [PT]

(Abbreviations: MH=Medical Subject Heading; PT=Publication Type; SH=Subheading; TW=Text Word)

Secondary Literature

The practice and teaching of Evidence-Based Medicine has outcome products which help the health care provider and consumer keep up with the medical literature and assess the evidence. Thissecondary literaturesynthesizes, filters, and evaluates the primary research literature. Dissemination and incorporation of valid clinical research findings into medical practice is the ultimate goal.

Filtered or Synthesized Information

Description/Definition

How to Find This Type of Information

Systematic Reviews

differ from traditional review articles in that conclusions are evidence-based rather than commentary
start with a clearly articulated question
use explicit, rigorous methods to identify, critically appraise, and synthesize relevant studies
appraise relevant published and unpublished evidence before combining and analyzing data
include description of how primary data sources are identified
assess individual studies for validity

UseCochrane Collaboration

Cochrane Database of Systematic Reviews
York Database of Abstracts of Reviews of Effectiveness
Cochrane Controlled Trials Register
Cochrane Review Methodology Database

Use PubMed/MEDLINE searching

Review [PT] AND medline [TW]
(Quantitative OR Systematic OR Methodologic) AND (Review OR Overview)

Use PubMed Clinical Queries

“Systematic Review” is available as a limit option

Meta-Analyses

specific methodologic and statistical technique for combining quantitative data
type of systematic overview

UseCochrane Collaboration
Use PubMed/MEDLINE searching

Meta-analysis [PT]
meta-anal* [TW] OR
metaanal* [TW]

Evidence-Based Practice Guidelines

gather, appraise, combine evidence systematically
include statements designed to assist practitioner and patient decisions
developed by professional groups, government agencies, local practices
include a structured abstract: objective, option, outcomes, evidence, values, benefits/harms/costs, recommendation, validation, sponsors

UseNational Guideline Clearinghouse
UseAgency for Healthcare Research and Quality
UseUS Preventive Services Task Force Recommendations

Critically Appraised Topics (CATs)

scan literature for clinically relevant studies
critically appraise the studies
provide commentary on strength of study and clinical significance
provided in a one-page format

Use EBM Reviews

ACP Journal Club

Use Essential EvidencePLUS(UIC affiliate access)

InfoPOEMS

UseCATmaker software from CEBM

Decision Analyses/Decision Tools

studies that analyze decisions faced by clinicians for an individual patient, about clinical policy, or a global health care policy
application of explicit, quantitative methods to analyze decisions under conditions of uncertainty
risks and benefits of a decision are made fully explicit
decision tree is included

Use PubMed/MEDLINE searching

Decision Support Techniques [MH]
Cost-Benefit Analysis [MH]
decision analysis [TI]

Consensus Development Reports

assessments of emerging or critical health issues based on available research and expert opinion to identify needs for policy development and further research (description based on information from theNIH Consensus Development Programnow ‘retired’ in light of “many other organizations that conduct [evidence] reviews”)

Use PubMed/MEDLINE searching

“consensus statement” [TW] OR “consensus report” [TW]

Study Design Terminology

Control Group– the group that does not receive the treatment, etc.
Randomization– assigns participants by chance to either the treatment group or the control group.
Blinding– the participants and/or some of the researchers do not know the groups to which the participants have been assigned.
Loss to Follow-up/Intention to Treat– all of the participants should be accounted for even if they did not fully participate.
PValue– the probability of any observed differences having happened by chance. The convention is that .05 is required.
Power– the likelihood that a study will detect a statistically significant difference. The convention is that a power of at least 80% is required.
See alsoScientific Experiment Terminologyfrom theAppraisal tab.

More Information

SUNY Downstate Medical Center EBM Course: A Guide to Research Methods.
A visual “evidence pyramid”

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