Evidence Base practice and Clinical Decision Making
formally integrating the findings from qualitative studies (Sandelowski & Barroso, 2007). The process for
synthesizing qualitative research is still evolving, and a variety of synthesis methods have appeared in the
literature (Barnett-Page & Thomas, 2009; Finfgeld-Connett, 2010; Higgins & Green, 2008). In this text, the concept
of meta-synthesis is used to describe the process for synthesizing qualitative research. Meta-synthesis is
defined as the systematic compilation and integration of qualitative study results to expand understanding and
develop a unique interpretation of study findings in a selected area. The focus is on interpretation rather than on
combining study results, as with quantitative research synthesis (see Table 1-4). The process for critically
appraising a meta-synthesis is discussed in Chapter 13.
Over the last 10 to 15 years, nurse researchers have conducted mixed-methods studies that include
quantitative and qualitative research methods (Creswell, 2014). In addition, determining the current research
evidence in an area might require synthesizing quantitative and qualitative studies. Higgins and Green (2008)
refer to this synthesis of quantitative, qualitative, and mixed- methods studies as a mixed-methods systematic
review (see Table 1-4). Mixed-methods systematic reviews might include a variety of study designs, such as
qualitative research and quasi-experimental, correlational, and/or descriptive studies (Higgins & Green, 2008).
Some researchers have conducted syntheses of quantitative and/or qualitative studies, termed integrative
reviews of research. The value of these reviews depends on the standards used to conduct them. The process
for critically appraising a mixed-method systematic review is discussed in Chapter 13.
Levels of Research Evidence
The strength or validity of the best research evidence in an area depends on the quality and quantity of the
studies that have been conducted in an area. Quantitative studies, especially experimental studies such as the
RCT, provide the strongest research evidence (see Chapter 8). Also, the replication or repeating of studies with
similar methodology increases the strength of the research evidence generated. The levels of the research
evidence are a continuum, with the highest quality of research evidence at one end and the weakest research
evidence at the other (Brown, 2014; Craig & Smyth, 2012; Melnyk & Fineout-Overholt, 2011; Figure 1-3).
The systematic research reviews and meta-analyses of high-quality experimental studies provide the strongest or
best research evidence for use by expert clinicians in practice. Meta-analyses and integrative reviews of quasi-experimental, experimental, and outcomes studies also provide very strong research evidence for managing
practice problems. Mixed-methods systematic reviews and meta-synthesis provide quality syntheses of
quantitative, qualitative, and/or mixed-methods studies. Correlational, descriptive, and qualitative studies often
provide initial knowledge, which serves as a basis for generating quasi-experimental and outcomes studies (see
The weakest evidence comes from expert opinions, which can include expert clinicians’ opinions or
the opinions expressed in committee reports. When making a decision in your clinical practice, be sure to base
that decision on the best research evidence available.
1339996 – Elsevier Health Sciences ©
FIG 1-3 Levels of Research Evidence.
The levels of research evidence identified in Figure 1-3 (also included in the front cover of this text) will help
you determine the quality of the evidence that is available for practice. The best research evidence generated
from systematic reviews, meta-analyses, meta-syntheses, and mixed-methods systematic reviews is used to
develop standardized, evidence-based guidelines for use in practice.
Introduction to Evidence-Based Guidelines
Evidence-based guidelines are rigorous, explicit clinical guidelines that have been developed based on the best
research evidence available in that area. These guidelines are usually developed by a team or panel of expert
clinicians (nurses, physicians, pharmacists, and other health professionals), researchers, and sometimes
consumers, policy makers, and economists. The expert panel works to achieve consensus on the content of the
guideline to provide clinicians with the best information for making clinical decisions in practice. There has been
a dramatic growth in the production of evidence-based guidelines to assist healthcare providers in building an
EBP and improving healthcare outcomes for patients, families, providers, and healthcare agencies.
Every year, new guidelines are developed, and some of the existing guidelines are revised based on new
research evidence. These guidelines have become the gold standard (or standard of excellence) for patient care,
and nurses and other healthcare providers are encouraged to incorporate these standardized guidelines into their
practice. Many of these evidence-based guidelines have been made available online by national and international
government agencies, professional organizations, and centers of excellence. When selecting a guideline for
practice, be sure that the guideline was developed by a credible agency or organization and that the reference list
reflects the synthesis of extensive number of studies.
1339996 – Elsevier Health Sciences ©
An extremely important source for evidence-based guidelines in the United States is the National Guideline
Clearinghouse (NGC), initiated in 1998 by the AHRQ. The NGC started with 200 guidelines and has expanded to
more than 1400 evidence-based guidelines (see http://www.guideline.gov). Another excellent source of
systematic reviews and evidence-based guidelines is the Cochrane Collaboration and Library in the United
Kingdom, which can be accessed at http://cochrane.org. Professional nursing organizations, such as the
Oncology Nursing Society (http://www.ons.org) and National Association of Neonatal Nurses
Review Figure 1-3, on page 60, in Understanding Nursing Research. Why it is important to employ the highest level of available research evidence in clinical decision-making?
Note: Integrate rules of evidence into the clinical decision-making process.
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Evidence Base practice and Clinical Decision Making
Clinical decision-making is one of the most complex undertakings, given the weight of evidence required, as well as health professional expertise in regard to the clinical situation at hand. In this regard, it is vital for the health professionals to employ the available research evidence in their decision-making (Fen-Fang Chung et al., 2021). Nevertheless, not every available research evidence can result in the right decision. One thus has to determine the current research evidence and employ the systematic review and meta-analysis of such evidence in order to come up with a strong evidence-based practice. When selecting evidence to review, expert opinions and single correlation and qualitative studies should be avoided. The best research is thus generated from research, which takes the nature of systematic reviews, meta-analyses, meta-syntheses, and mixed-methods systematic reviews, which are used in the development of standardized, evidence-based guidelines for application in the clinical practice.
That said, it is always important for the health professionals to make sure that the rules of evidence into the clinical decision-making process are obeyed, and that the decisions utilize evidence-based practice through the application of the available evidence, patient values, as well as the clinical expertise exhibited by the health professionals (Marzorati & Pravettoni, 2017). Through the evidence-based practice, the health professional stands a good chance of performing the correct diagnosis, assessing the extent of case severity, as well as provision of high-quality care management (Martin et al., 2021). This utilization of the evidence-based clinical care assists a lot in the provision of patient-centered care, health policy development, as well as the practice management. Therefore, the utilization of the available research evidence is crucial in every process of the clinical decision-making, therefore, elevating the quality of care, as well as display of professionalism among the healthcare workers.
Fen-Fang Chung, Pao-Yu, W., Lin, S., Yu-Hsia, L., Hon-Yen, W., & Mei-Hsiang, L. (2021).
Shared clinical decision-making experiences in nursing: A qualitative study. BMC Nursing, 20, 1-9. doi:http://dx.doi.org/10.1186/s12912-021-00597-0
Martin, P., Lizarondo, L., Kumar, S., & Snowdon, D. (2021). Impact of clinical supervision on
healthcare organisational outcomes: A mixed methods systematic review. PLoS One, 16(11) doi:http://dx.doi.org/10.1371/journal.pone.0260156
Marzorati, C., & Pravettoni, G. (2017). Value as the key concept in the health care system: How
it has influenced medical practice and clinical decision-making processes. Journal of Multidisciplinary Healthcare, 10, 101-106. doi:http://dx.doi.org/10.2147/JMDH.S122383