Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals Synthesis and Recommendations Tool Appendix H
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EBP Question: |
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Strength |
Number
of Sources (Quantity) |
Synthesized Findings With Article Number(s) (This is not a simple restating of information from each
individual evidence summary—see directions) |
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Level |
Overall
Quality Rating (Strong,
good, or low) |
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Level
I § Experimental studies |
Good |
3? |
Article 3 sought
to understand if interventional education on hand hygiene would change hand
hygiene compliance compared to a control group. This article also utilized
surveys to understand facilitators and barriers to hand hygiene. As a result,
the authors did see an improvement in hand hygiene with the intervention. Article 9 was an observational
and experimental study with a control group and multiple interventional
groups to understand how the visibility, or salience of hand hygiene stations
and educational signs may improve hand hygiene compliance. Some of their
results illustrated that manipulation of placement, salience, assertion, and
sometimes campaigns (signs) could improve hand hygiene compliance. Mar: Both studies
shed light on hand hygiene perceptions among visitors of ICUs (intensive care
units) and their contribution in transmission of pathogens. They emphasize
the chances of infections to visitors who neglect physical sanitary measures,
demonstrating that pathogens including Gram-negative rods and MRSA are still
around on the hands of those who don’t use the provided barriers. Both
underline an urgent requirement for enhanced hand hygiene procedures so that
critically ill ICU patients can be protected from healthcare-associated
infections. |
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Level
II § Quasi-experimental studies |
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0 |
Mar: These
sources emphasize the need to integrate behavioral programs to improve hand
hygiene in the hospital. These sources also emphasize the need to place
washing detergents at visible locations to motivate hygiene. |
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Level III § Nonexperimental, including
qualitative studies. |
Strong |
6? |
Articles 1 and 2
sought to understand the growth of microorganisms on hand cultures. These
sources revealed that the performance of hand hygiene did show a decrease or
elimination of pathogenic microorganisms that could result in poor patient
outcomes. Articles 4, 5,
and 10 were qualitative studies focusing on the behavioral aspects of hand
hygiene compliance and noncompliance. Ultimately, these articles recommended improvement
measures to improve hand hygiene education and compliance based on behavior. Article 7 was a
qualitative study utilizing surveys to understand barriers to hand hygiene
from multiple healthcare workers. The three categories of barriers involved
were tied to individual lack of knowledge, management barriers (role models
or lack of training) or organization barriers, such as heavy workloads or lack
of equipment. Mar: These
sources embrace the educational programs to improve hand hygiene in the
hospital. They champion for continuous reinforcement of hand hygiene
behaviors. |
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Level
IV § Clinical practice guidelines or
consensus panels |
N/A |
N/A |
N/A |
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Level
V § Literature reviews, QI, case
reports, expert opinion |
Good |
2? |
Article 6 is the first
research agenda from the World Health Organization to gather evidence on how
to improve hand hygiene practices. This agenda identified key areas that may
hand hygiene, such as communication among healthcare workers and the safety of
institutions. Article 7 was a
systematic review of literature to understand how technology can play a
significant role in hand hygiene monitoring and compliance. Due to the
growing nature of technology, further research should be conducted. Mar: These
sources incorporate the use of evidence-based approaches in improving hand
hygiene. They are supporting the continuous monitoring of the hand hygiene
program. |
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Where
does the evidence show consistency? |
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Articles
1 and 2 show consistency in hand being a reservoir for pathogenic organisms,
and the importance of hand hygiene to decrease these organisms. Articles
4,5,7 and 10 provide consistent barrier considerations for healthcare workers
and incoming hospital visitors, specifically placement or availability of
hand hygiene stations. Articles 3 and 9 illustrate how interventional
measures may improve hand hygiene compliance. |
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Where
does the evidence show inconsistency? |
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Best
evidence recommendations (taking into consideration quantity, consistency,
and strength of the evidence): |
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·
Improve
visibility and access to hand hygiene stations. ·
Establishing
the “expectation” of hand hygiene could improve compliance. ·
Educational
interventions at point of entry can improve hand hygiene compliance. |
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Based
on your synthesis, select the statement that best describes the overall characteristics
of the body of evidence? |
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Directions for use of the Synthesis and Recommendations Tool
Purpose:
This tool guides the EBP team through the process of synthesizing the pertinent findings from the Individual Evidence Summary (Appendix G), sorted by evidence level, to create an overall picture of the body of the evidence related to the PICO question. The synthesis process uses quantity, strength (level and quality), and consistency to generate best evidence recommendations for potential translation.
Overall quality rating and total number of sources:
Record the overall quality rating and the number of sources for each level (strong, good, or low), ensuring agreement among the team members.
Synthesized findings:
This section captures key findings that answer the EBP question. Using the questions below, generate a comprehensive synthesis by combining the different pieces of evidence in the form of succinct statements that enhance the team’s knowledge and generate new insights, perspectives, and understandings into a greater whole. The following questions can help guide the team’s discussion of the evidence:
· How can the evidence in each of the levels be organized to produce a more comprehensive understanding of the big picture?
· What themes do you notice?
· What elements of the intervention/setting/sample seem to influence the outcome?
· What are the important takeaways?
Avoid repeating content and/or copying and pasting directly from the Individual Evidence Summary Tool. Record the article number(s) used to generate each synthesis statement to make the source of findings easy to identify.
Using this synthesis tool requires not only the critical thinking of the whole team, but also group discussion and consensus building. The team reviews the individual evidence summary of high- and good-quality articles, uses subjective and objective reasoning to look for salient themes, and evaluates information to create higher-level insights. They include and consider the strength and consistency of findings in their evaluation.
Where does the evidence show consistency/inconsistency?
EBP teams must consider how consistent the results are across studies. Do the studies tend to show the same conclusions, or are there differences? The synthesized evidence is much more compelling when most studies have the same general results or point in the same general direction. The synthesized evidence is less compelling when the results from half the studies have one indication, while the findings from the other half point in a different direction. The team should identify the points of consistency among the evidence as well as areas where inconsistency is apparent. Both factors are important to consider when developing recommendations or determining next steps.
Best evidence recommendations:
In this section, the EBP team takes into consideration all the above information related to strength, quantity, and consistency of the synthesized findings at each level to generate best practice recommendations from the evidence. Consider:
· What is the strength and quantity of studies related to a specific evidence recommendation?
· Is there a sufficient number of high-strength studies to support one recommendation over another?
· Are there any recommendations that can be ruled out based on the strength and quantity of the evidence?
· Does the team feel the evidence is of sufficient strength and quantity to be considered a best evidence recommendation?
Recommendations should be succinct statements that distill the synthesized evidence into an answer to the EBP question. The team bases these recommendations on the evidence and does not yet consider their specific setting. Translating the recommendations into action steps within the team’s organization occurs in the next step (Translation and Action Planning Tool, Appendix I).
Based on the synthesis, which statement represents the overall body of the evidence?
Choose the statement that best reflects the strength and congruence of the findings. This determination will help the team to decide next steps in the translation process.
When evidence is strong (includes multiple high-quality studies of Level I and Level II evidence), compelling, and consistent, EBP teams can have greater confidence in best practice recommendations and should begin organizational translation
When most of the evidence is good (high-quality Level II and Level III) and consistent or good but conflicting, the team should proceed cautiously in making practice changes. In this instance, translation typically includes evaluating risk and careful consideration for organizational translation.
The team makes practice changes primarily when evidence exists that is of high to good strength. Never make practice changes on little to no evidence (low-quality evidence at any level or Level IV or Level V evidence alone). Nonetheless, teams have a variety of options for actions that include, but are not limited to, creating awareness campaigns, conducting informational and educational updates, monitoring evidence sources for new information, and designing research studies.
The exact quantity of sources needed to determine the strength of the evidence is subjective and depends on many factors, including the topic and amount of available literature. The EBP team should discuss what they consider sufficient given their knowledge of the problem, literature, and setting