Although lacking a single and resolute model of implementation, Evidence-Based Practice (EBP) is universally considered to bring together three chief components of medical decision-making: First, the practitioner’s clinical expertise. Secondly, the best external evidence, and lastly, the patient’s preference (Gardner et al., 2016). The discussion considers Becky Ingham-Broomfield’s paper, “A nurses’ guide to the hierarchy of research designs and evidence,” to review the levels of evidence as applied in EBP.
In Becky’s guide, the levels of evidence in EBP is presented as a pyramid of seven levels, with the most concrete sources of evidence occupying the lowest strata. At the very top (level 7) are ideas, opinions, and editorials, which she considers abstract and intangible. While she admits that at times, they are convincing and unyielding, she collectively fails them for being “transferrable or easily explained” (p.39). Other forms of evidence in level seven are newspaper editorials, anecdotes, and gut feelings. As we go down the pyramid, the trustworthiness increases, judging from how levels five and six feature studies. Case-controlled studies and case reports occupy level six, while cohort studies occupy level 5. The difference is the studies at level 5 are monitored for a long time, and thus more reliable. However, Becky (2016) believes they are weighed down by subjectivity and inadequate data.
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At level 4 are random controlled trials (RCT), which she admits have equal merits and demerits. She tentatively approves them, although with caution and attention to context. Level two (evidence synthesis) and three (article synopses) comprise forms of evidence that are well structured, and most importantly, collectively investigated and documented, with proper consideration of environmental parameters. For instance, level two has studies conducted by individuals and small teams. At the core, the bottom is systematic reviews and meta-analyses, prioritized for their information savviness, thorough reviews, and multidimensional cross-examination of the subject. Becky (2016) also adds that among other factors, meta-analyses are the most trusted since they appreciate earlier studies, and often consider their contributions.
Becky’s guide is rigorous and comprehensive, and her rationale is sound. As one goes down the pyramid, the amount, reliability, and objectiveness of the evidence improve. Also, the guide appreciates the need for evidence to be critiqued and review. For instance, RCTs at level 4 are more believable than article synopses since the former contains information contributed by more people, with more robust techniques, over a longer time. However, her model does not indicate where to place institutional issues and whitepapers. All in all, the guide is shrewd.
References
Becky, J. R. (2016). A nurses' guide to the hierarchy of research designs and evidence. Australian Journal of Advanced Nursing (Online), 33(3), 38.
Gardner Jr, K., Kanaskie, M. L., Knehans, A. C., Salisbury, S., Doheny, K. K., & Schirm, V. (2016). Implementing and sustaining evidence-based practice through a nursing journal club. Applied Nursing Research, 31, 139-145.
