Write one paragraph discussing the differences between systematic reviews and meta-analyses; Include one clear reason when you would use each of them, or when done together (using

5.4 DiscussionSystematic Reviews & Guidelines

Students will post their initial replies before being able to see other students' posts.

In the introduction to Week 5, there were links and readings about systematic reviews and clinical guidelines.  We use clinical guidelines in practice – all the time (although you did not know what you were following was a clinical practice guideline).

In preparation for this discussion, please read Chapter 13 in your text and these resources:

Systematic Review and Meta-Analysis

· Systematic Review & Meta-Analysis video: 

· https://youtu.be/qc7M1r45jwc 

· TARG Bristol (2017).  A three-minute primer on meta-analysis (Links to an external site.)

· Fontaine, G., Cossette, S., Maheu-Cadotte, M., Deschenes, M., Rouleau, G., Lavallee, A., Pepin, C., …Mailhot, T. (2019). Effect of implementation interventions on nurses' behavior in clinical practice: A systematic review, meta-analysis, and meta-regression protocol.  Systematic Reviews, 8, 305.  https://doi.org/10.1186/s13643-019-1227-x (Links to an external site.)   

Clinical Practice Guidelines 

· FNU Library. (2021, April 2). Introduction to clinical practice guidelines. (YouTube).   https://www.youtube.com/watch?v=3Nu8i4PBbtQLinks to an external site.  

· Duke University. (2022). Nursing Tools.  Find Guidelines.   https://guides.mclibrary.duke.edu/nursing/guidelines#s-lg-box-24690616Links to an external site.  

· California State University (2022). Nursing: Clinical practice guidelines. A guide for students in the CSUF nursing program.  https://libraryguides.fullerton.edu/nursing/CPGsLinks to an external site.  

Approved Resources to Use in Writing Discussion Posts:

· The course textbook,

· any published peer-reviewed full-text article from the CINAHL database

· .org, or .gov website with published credible information. 

· The use of AI is not permitted in this DQ.

· All sources must be published within the last 5 years.

· The initial DQ response must include the course textbook.

Instructions

It is important to stay current in these discussion threads. Read all discussion postings. You must be an active and regular participant. One or two sentences or just simply agreeing with a classmate's post will not be sufficient. 

For posts on this topic: 

· Submit your original post to the topic below by the  due date before 11:59 pm EST. This post must be a minimum of 200 words.

· APA Format is required for writing in-text citations and references. No direct quotes should be used.

Click Here to Review Discussion Rubric and Grading Information

Discussion Topic

Initial Post

 For your initial post, complete the following:

· Write one paragraph discussing the differences between systematic reviews and meta-analyses; Include one clear reason when you would use each of them, or when done together (using both).

· Write one paragraph on clinical practice guidelines and locate/read one guideline that you use or should use in your current clinical practice.  Use the resources above.

,

CHAPTER 13

Building an Evidence-Based Nursing Practice

Research evidence has greatly expanded over the last 30 years as numerous quality studies in nursing and other healthcare disciplines have been conducted and disseminated. These studies are commonly communicated via conferences, journals, and the Internet. The expectations of society and the goals of healthcare systems are the delivery of quality, safe, cost-effective health care to patients, families, and communities (Sherwood & Barnsteiner, 2017; Straus, Glasziou, Richardson, Rosenberg, & Haynes, 2011). To ensure the delivery of quality health care, the care must be based on the current best research evidence available. Over the last 15 years, nursing programs have provided students with knowledge about evidence-based practice (EBP) to encourage graduates to base their practice on current research. The emphasis on EBP in nursing education programs and clinical agencies has improved outcomes for patients and families, nurses, and healthcare agencies (Mackey & Bassendowski, 2017; Melnyk, Gallagher-Ford, & Fineout-Overholt, 2017).

Evidence-based practice (EBP) is an important theme in this text that was defined in Chapter 1 as the integration of the best research evidence with nurses’ clinical expertise and patients’ circumstances and values in the delivery of quality, safe, and cost-effective health care (Straus et al., 2011). Best research evidence is produced by the conduct and synthesis of numerous high-quality studies in a selected health-related area. This chapter builds on previous EBP discussions in this text to provide you with strategies for implementing the best research evidence in your practice and moving the nursing profession toward EBP.

The benefits and challenges associated with EBP are described to increase your understanding of evidence-based nursing practice. A format is provided for developing clinical questions to direct your searches for existing research-based evidence to use in practice. Guidelines are provided for critically appraising research syntheses (systematic reviews, meta-analyses, meta- syntheses, and mixed-methods systematic reviews) to determine the knowledge that is ready for use in practice. Two nursing models that have been developed to facilitate EBP in healthcare agencies are introduced. Expert researchers, clinicians, and consumers—through government agencies, professional organizations, and healthcare agencies—have developed an extensive number of evidence-based guidelines. A framework for reviewing the quality of these evidence-based guidelines and for using them in practice is provided. This chapter concludes with a discussion of the nationally designated EBP centers and translational research implemented to promote evidence-based health care.

Benefits and challenges related to evidence-based nursing practice

EBP is a goal for the nursing profession and each practicing nurse. At the present time, some nursing interventions are evidence-based, but many interventions require additional research to generate essential knowledge for making changes in practice. Some clinical agencies are supportive of the EBP process, and others are not. This section identifies some of the benefits and challenges associated with implementing evidence-based nursing.

Benefits of Evidence-Based Nursing Practice

The greatest benefits of EBP are improved outcomes for patients, providers, and healthcare agencies (Melnyk et al., 2016; Moorhead, Johnson, Maas, & Swanson, 2013). Agencies and organizations nationally and internationally have promoted the synthesis of the best research evidence in thousands of healthcare areas by teams of expert researchers and clinicians. These research syntheses, such as systematic reviews and meta-analyses, have provided the basis for developing strong evidence-based guidelines for practice. These guidelines identify the best treatment plan, or the gold standard for patient care, in selected areas to improve patient outcomes. Students and clinical nurses have electronic access to numerous evidence-based guidelines to assist them in making the best clinical decisions for their patients. These evidence-based syntheses and guidelines are available nationally and internationally and can be easily accessed online through different institutions, such as the National Guideline Clearinghouse (NGC, 2017a) in the United States, the Cochrane Collaboration (2017) in the United Kingdom, and the Joanna Briggs Institute (2017) in Australia.

Some chief nurse executives (CNEs) and healthcare agencies are highly supportive of EBP, as indicated by their attitudes and provision of resources to support EBP (Melnyk, Fineout-Overholt, Giggleman, & Choy 2017). Leaders in these clinical agencies recognize that EBP promotes quality outcomes, improves nurses’ satisfaction, and facilitates achievement of accreditation requirements. In a national study of CNEs, Melnyk et al. (2016) found that an organization with an EBP culture of conducting and using research evidence in practice had substantial improvements in several patient outcomes. The Joint Commission (2017) revised their accreditation criteria to emphasize patient care outcomes achieved through EBP.

Many CNEs and chief nursing officers (CNOs) are trying to obtain or maintain Magnet status, which documents the excellence of nursing care in healthcare agencies. Approval for Magnet status is obtained through the American Nurses Credentialing Center (ANCC), and the national and international healthcare agencies that currently have Magnet status can be viewed online (ANCC, 2017). The Magnet Recognition Program® emphasizes EBP as a way to improve the quality of patient care and revitalize the nursing environment. Clinical agencies seeking or maintaining Magnet status must document research-related outcomes, including nursing studies conducted and professional publications and presentations by nurses. For each study, the title of the study, principal investigator or investigators, role of nurses in the study, and study status need to be documented in Magnet applications and reports (ANCC, 2017).

The Quality and Safety Education for Nurses (QSEN, 2017) project was implemented to improve prelicensure nurses’ “knowledge, skills, and attitudes (KSAs) that are necessary to continuously improve the quality and safety of the healthcare systems within which they work.” QSEN competencies were developed in six areas essential for students and registered nurses’ (RNs) practice: patient-centered care, teamwork and collaboration, EBP, quality improvement (QI), safety, and informatics. EBP is an important area in your prelicensure education, and educators are assisting students in achieving the following EBP competencies:

• Participate effectively in appropriate data collection and other research activities.

• Adhere to institutional review board (IRB) guidelines.

• Base individualized care plan on patient values, clinical expertise, and evidence.

• Read original research and evidence reports related to area of practice.

• Locate evidence reports related to clinical practice topics and guidelines.

• Participate in structuring the work environment to facilitate the integration of new evidence into standards of practice.

• Question rationale for routine approaches to care that result in less than desired outcomes or adverse events.

• Consult with clinical experts before deciding to deviate from evidence-based protocols (QSEN, 2017).

Educators have changed nursing curricula to include EBP content and added courses that have improved students’ perceptions and confidence in research and EBP (Keib, Cailor, Kiersma, & Chen, 2017). Warren et al. (2016, p. 15) found that “younger RNs with fewer years in practice were more likely to have positive beliefs toward EBP and embedding it into the organization culture.” In working toward EBP, students and practicing RNs are encouraged to embrace the benefits of EBP; critically appraise current research evidence; refine agency protocols, algorithms (clinical decision trees), and policies based on current research; use evidence-based guidelines that are available; and collect data as needed for research projects.

Challenges to Evidence-Based Nursing Practice

Challenges to the EBP movement in nursing have been practical and conceptual. One of the most serious concerns is the limited research evidence available regarding the effectiveness of many nursing interventions. EBP requires synthesizing research evidence from randomized controlled trials (RCTs) and other types of intervention studies, which are still limited in nursing. Systematic reviews and meta-analyses conducted in nursing also are limited when compared with other disciplines, such as medicine and psychology (Cochrane Collaboration, 2017; Gray, Grove, & Sutherland, 2017; NGC, 2017b).

Another challenge is that research evidence is generated based on population data and then is applied in practice to individual patients. Sometimes it is difficult to transfer research knowledge to individual patients, who respond in unique ways or have unique circumstances and values. More work is needed to promote the use of evidence-based guidelines with individual patients. In response to this concern, the National Institutes of Health (NIH, 2017) is supporting translational research (discussed later in this chapter) to improve the use of research evidence with different patient populations in various settings. Patients who have poor outcomes when managed according to an evidence-based guideline need to be reported and, if possible, their circumstances should be published as a case study. Electronic health records (EHRs) make it more feasible to determine patient outcomes of care that have been delivered using EBP guidelines.

Another serious challenge is that some healthcare agencies and administrators do not provide the resources or support necessary for nurses to implement EBP. In their national study, Melnyk and colleagues (2016, p. 9) reported, “Although the CNEs and CNOs stated that their highest priorities were quality and safety, EBP was not listed as a top priority and very little of their budgets were allocated to implementing and sustaining evidence-based care.” Lack of support and resources for EBP included: (1) inadequate access to research journals and other sources of synthesized research findings and evidence-based guidelines; (2) inadequate knowledge or mentoring on how to implement evidence-based changes in practice; (3) heavy workload, with limited time to make research-based changes in practice; (4) limited authority to change patient care based on research findings; (5) limited support from nursing administrators or medical staff to make evidence-based changes in practice; (6) limited funds to support research projects and research-based changes in practice; and (7) minimal rewards for providing evidence-based care to patients and families (Eizenberg, 2010; Melnyk et al., 2016; Melnyk et al., 2017; Straka, Brandt, & Brytus, 2013; Warren et al., 2016). The success of EBP is determined by all involved, including healthcare agencies, administrators, nurses, physicians, and other healthcare professionals. The following content was developed to assist students and RNs in facilitating evidence-based nursing practice.

Developing clinical questions to search for existing research-based evidence for use in practice

Developing a clinical question in an area of interest and conducting an extensive search of evidence-based sources is an effective way to identify current evidence for use in practice. The clinical question often is developed using the PICO format, which includes the following elements:

P – population or participants of interest in your clinical setting

I – intervention needed for practice

C – comparisons of interventions to determine the best intervention for your practice

O– outcomes needed for practice and ways to measure the outcomes in your practice

The PICO format helps you organize the search for research evidence in a variety of databases and websites. You can identify research syntheses (systematic reviews, meta-analyses, meta-syntheses, and mixed-methods systematic reviews); evidence-based guidelines, protocols, and algorithms; and individual studies through searches of electronic databases, national library sites, and EBP organizations and collections. Some of the key resources for EBP are identified in Table 13.1. At least 2500 new systematic reviews are reported in English and indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE) each year. The Cochrane Collaboration (2017) library of systematic reviews is an excellent resource, with more than 11,000 entries relevant to nursing and health care. In 2009, the Cochrane Nursing Care (CNC) Field was developed to support the conduct, dissemination, and use of systematic reviews in nursing. The CNC Field produces the Cochrane Corner columns (summaries of Cochrane Reviews relevant to nursing care) that are regularly published in collaborating nursing care − related journals (CNC, 2017). The Joanna Briggs Institute (2017) also provides resources for locating and conducting research syntheses in nursing. The Nursing Reference Center (NRC) includes evidence-based care sheets for numerous nursing interventions and clinical conditions (see Table 13.1).

Table 13.1

Evidence-based practice resources

RESOURCE DESCRIPTION

Electronic Databases

CINAHL (Cumulative Index to Nursing and Allied Health Literature) CINAHL is an authoritative resource covering the English language journal literature for nursing and allied health. The database was developed in the United States and includes sources published from 1982 to the present.

MEDLINE (PubMed, National Library of Medicine) MEDLINE was developed by the National Library of Medicine in the United States; it provides access to more than 11 million MEDLINE citations back to the mid-1960s and to additional life science journals.

MEDLINE with MeSH Also developed by the National Library of Medicine, MEDLINE with MeSH provides authoritative medical information on medicine, nursing, dentistry, veterinary medicine, the healthcare system, preclinical services, and more.

PsycINFO The American Psychological Association developed this database that includes professional and academic literature for psychology and related disciplines from 1887 to the present.

CANCERLIT CANCERLIT, containing information on cancer, was developed by the National Cancer Institute in the United States.

National Library Sites

Cochrane Library The Cochrane Library provides high-quality evidence for those providing and receiving health care and those involved in research, teaching, funding, and administration of health care at all levels. Included is the Cochrane Collaboration, which has many systematic reviews of research (http://www.cochrane.org/evidence).

National Library of Health (NLH) The NLH, located in the United Kingdom, provides searchable evidence-based sources at http://www.evidence.nhs.uk.

Evidence-Based Practice Organizations and Collections

National Guideline Clearinghouse (NGC) The Agency for Healthcare Research and Quality (AHRQ) developed the NGC to house the thousands of evidence-based guidelines that have been developed for use in clinical practice; these can be accessed online at http://www.guidelines.gov.

Cochrane Nursing Care (CNC) Field The Cochrane Collaboration includes over 8000 reviews in 11 different fields; one is the CNC, which supports the conduct, dissemination, and use of systematic reviews in nursing. Most libraries subscribe to the Cochrane Collaboration but free access to abstracts and reviews can be found at http://cncf.cochrane.org.

National Institute for Health and Clinical Excellence (NICE) The NICE was organized in the United Kingdom to provide access to current evidence-based guidelines, similar to the NGC (http://nice.org.uk).

Joanna Briggs Institute (JBI) JBI, an international evidence-based organization originating in Australia, has a search website that includes evidence summaries, systematic reviews, systematic review protocols, evidence-based recommendations for practice, best practice information sheets, consumer information sheets, and technical reports; see “Search the Joanna Briggs Institute” (http://www.joannabriggs.org).

Nursing Reference Center (NRC) The NRC includes a collection of rigorously reviewed, evidence-based care sheets that provide current best practice for over 700 interventions and clinical conditions. This source requires a subscription, so check with your librarian. You can access this resource at http://www.ebscohost.com/nursing.

Evidence Focused on Aspiration During Intramuscular Injections

You might pose a clinical question about whether nurses should aspirate or not when giving intramuscular (IM) injections. Using the PICO format you can identify the evidence needed for practice.

P – populations: infants, toddlers, children, and adults receiving immunizations by the IM route for prophylactic purposes.

I – intervention: IM injection given without aspiration in the right site based on the volume of medication and age of patient (Ogston-Tuck, 2014; Sisson, 2015; Thomas, Mraz, & Rajcan, 2016; Wynaden et al., 2015).

C – comparison intervention: IM injection given with 5 to 10 seconds of aspiration in all sites, regardless of the age of the patient and the volume of medication (Cocoman & Murray, 2008; Nicoll & Hesby, 2002).

O – outcome: IM injection of vaccine without complications.

Older evidence-based guidelines by Nicoll and Hesby (2002) and Cocoman and Murray (2008) recommended aspiration for 5 to 10 seconds with each IM injection to prevent injecting substances directly into a patient’s bloodstream. However, a systematic review by Sisson (2015) recommended no aspiration with IM injections given in the deltoid, ventrogluteal, and vastus lateralis sites. Nurses should only aspirate when giving IM injections in the dorsogluteal site because of the close proximity of the gluteal artery. However, researchers recommended that the dorsogluteal site not be used, if possible (Ogston-Tuck, 2014; Sisson, 2015; Wynaden et al., 2015). The current research evidence regarding aspiration during IM injections is summarized in Box 13.1. However, many nurses are not using this current research evidence about IM injections in practice. Thomas et al. (2016) found that 74% of the nurses were still aspirating after IM injections 90% of the time. Wynaden et al. (2015) found a higher use of the dorsogluteal site, even though current research recommends use of the ventrogluteal site. Therefore these researchers recommended additional education in nursing programs and continuing education that ensure nurses are knowledgeable about and use the most current research evidence in practice.

Box 13.1

Clinical Practice Guideline: Intramuscular Injections Without Aspiration

Patient Population

Infants, toddlers, children, and adults receiving immunizations by the IM route for prophylactic purposes

Objective

Administration of IM immunizations to eliminate patient injury and discomfort

Intervention: IM Injection

Site selection based on the age of the patient

(Nicoll & Hesby, 2002; Ogston-Tuck, 2014; Sisson, 2015; Wynaden et al., 2015):

• Infants – vastus lateralis is the preferred site

• Toddlers and children – vastus lateralis or deltoid sites

• Adults – ventrogluteal or deltoid sites

Medication volume

(Nicoll & Hesby, 2002; Sisson, 2015; Wynaden et al., 2015)

• Small volumes of medication (≤ 2 mL) may be given in the deltoid site for toddlers, children, and adults and in the vastus lateralis for infants.

• Large volumes of medication (2 − 5 mL) should be given in the ventrogluteal site for adults. Volume must be limited and injected in the vastus lateralis for infants, toddlers, and children.

Injection without and with aspiration

•  Cleanse the site with alcohol and allow it to dry.

•  Insert the needle into the appropriate site.

• There should be no aspiration with deltoid, ventrogluteal, and vastus lateralis sites (Sisson, 2015; Thomas et al., 2016; Wynaden et al., 2015).

• Aspirate for 5 to 10 seconds when using the dorsogluteal site because of the proximity to the gluteal artery, but current research recommends not to use this site (Sisson, 2015; Stringer, 2010; Thomas et al., 2016; Wynaden et al., 2015).

•  Inject medication slowly.

•  Withdraw needle slowly; apply gentle pressure with a dry sponge.

Outcome

•  Assess site for complications, immediately and 2 to 4 hours later, if possible.

•  Record the number and type of complications: pain, redness, and/or warmth.

•  Properly and promptly dispose of all equipment.

IM, Intramuscular.

Adapted from Nicoll, L. H., & Hesby, A. (2002). Intramuscular injections: An integrative research review and guideline for evidence-based practice. Applied Nursing Research, 16(2), 149–162; Ogston-Tuck, S. (2014). Intramuscular injection technique: An evidence-based approach. Nursing Standard, 29(4), 52–59; Sisson, H. (2015). Aspirating during the intramuscular injection procedure: A systematic literature review. Journal of Clinical Nursing, 24(17/18) 2368–2375; Stringer, P. M. (2010). Sciatic nerve injury from intramuscular injections: A persistent and global problem. International Journal of Clinical Practice, 64(11), 1573–1579; Thomas, C. M., Mraz, M., & Rajcan, L. (2016). Blood aspiration during IM injection. Clinical Nursing Research, 25(5), 549–559; Wynaden, D., Tohotoa, J., Omari, O. A., Happell, B., Heslop, K., Barr, L., & Sourinathan, V. (2015). Administering intramuscular injections: How does research translate into practice over time in the mental health setting? Nurse Education Today, 35(1), 620–624.

Critically appraising research syntheses: systematic reviews and meta-analyses

Research evidence is usually synthesized using systematic review, meta-analysis, meta-synthesis, and mixed-methods systematic review (Whittemore, Chao, Jang, Minges, & Park, 2014). As noted earlier, Sisson (2015) conducted a systematic review to synthesize research related to IM injections and recommended that nurses not aspirate when giving most IM injections (see Box 13.1). Nursing students and RNs must be able to review research syntheses and determine the evidence to use in practice. This section provides guidelines for understanding and critically appraising systematic reviews and meta-analyses.

Critically Appraising Systematic Reviews

A systematic review is a structured, comprehensive synthesis of the research literature to determine the best research evidence available to address a healthcare question or problem. A systematic review involves identifying, locating, appraising, and synthesizing quality research evidence for clinicians to use in practice (Bettany-Saltikov, 2010a, 2010b; Cooper, 2017; Liberati et al., 2009; Moher, Liberati, Tezlaff, Altman, & PRISMA Group, 2009; Setia, 2016). Systematic reviews are often conducted by two or more researchers and/or expert clinicians in a selected healthcare area to determine the best research knowledge in that area.

Systematic reviews should include rigorous research methodology to promote the accuracy of the findings and minimize the reviewers’ bias. Table 13.2 provides a checklist for critically appraising the steps or elements of systematic reviews and meta-analyses. These steps are based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Liberati et al., 2009; Moher et al., 2009). The PRISMA statement was developed in 2009 by an international group of expert researchers and clinicians to improve the quality of reporting for systematic reviews and meta-analyses. It includes 27 items, which can be found at http://prisma-statement.org and are detailed in the articles by Liberati et al. (2009) and Moher et al. (2009). These 27 items were consolidated into the checklist in Table 13.2 to assist you in critically appraising systematic reviews and meta-analyses.

Table 13.2

Checklist for critically appraising published systematic reviews and meta-analyses

SYSTEMATIC REVIEW STEPS OR ELEMENTS STEP COMPLETE? (YES OR NO) COMMENTS: QUALITY AND RATIONALE

1.  Did the title indicate that a systematic review, meta-analysis, or both were conducted?

2.  Was an abstract included that provided a structured summary of purpose, data sources, study eligibility criteria, study appraisal and synthesis methods, participants, interventions, outcomes, key findings, conclusions, and/or implicat