Evidences

Research Gaps
and Evidences in
Perioperative
Nursing Care in a
Culturally Diverse
Healthcare
RYAN MICHAEL F. ODUCADO, MAN, MAEd, RN, RM, LPT

Hello!
Nice to meet you
2
RYAN MICHAEL F. ODUCADO
Faculty, College of Nursing
West Visayas State University
Contact at:
▪ rmoducado@wvsu.edu.ph
A nursing faculty
and researcher
Not an operating
room nurse
Most studies
conducted are of
Level 5 and 6
evidence
Major references of
this presentation are
available at www
Not intended to be a
comprehensive
lecture
Declares no conflict
of interest

Major
References
Ingham-Broomfield, R. (2016). A nurses' guide to the
hierarchy of research designs and evidence. Australian
Journal of Advance Nursing , 33(3), 38-43
3

Major
References
Aba, Y.A., & Aslan, F. (2017). Evidence-based practices in
health sciences.
4

Major
References
Samnani, S.S., Vaska, M., Ahmed, S., & Turin, T.C. (2017).
Review typology: The basic types of reviews for synthesizing
evidence for the purpose of knowledge translation. Journal
of the College of Physicians and Surgeons Pakistan,
27(10), 635-641
11

Major
References
Grant, M.J. & Booth, A. (2009). A typology of reviews: an
analysis of 14 review types and associated methodologies.
Health Information and Libraries Journal, 26, 91-108
12

Major
References
Paré, G., & Kitsiou, S. (2017). Chapter 9 methods for
literature reviews. In F. Lau & C. Kuziemsky (Eds).
Handbook of ehealth evaluation: An evidence-based
approach. Victoria (BC): University of Victoria;
13

Intended Learning Outcomes
1. enumerate methods that can be
used to identify gaps in literature
in perioperative nursing care in a
culturally diverse healthcare;
2. identify hierarchy of reseach
designs and evaluate levels of
evidence in nursing research;
and
3. appreciate the role of nursing
research in producing
evidences that support
knowledge translation in
perioperative nursing practice.
14
After 45 minutes of lecture-
discussion, the participants
shall:

Evidence-based Practice
15
👉

“
What is evidence-based practice (EBP) ?
“the conscientious, explicit, and judicious use of the
current best evidence in making decisions about
the care of individual patients”
Sackett, Rosenberg, Gray, Hayes, & Richardson (1996)
16

20
https://guides.library.uwm.edu/EBPtutorial

1.
Ask a
question
21
https://guides.library.uwm.edu/EBPtutorial/picot

Gaps in nursing literature
To enumerate methods that can be used to identify gaps in
literature in perioperative nursing care in a culturally diverse
healthcare
22
👉

2.
Finding
evidence
▪ The next step after formulating the clinical
problem is to investigate the relevant
evidence to answer the question.
▪ Some research designs are stronger than
others in terms of their ability to respond to
research questions.
▪ Systematically reviewing all available work
for each type of question is better than any
work (Huic, 2008).
23

2.
Finding
evidence
▪ The best evidence research should begin
especially by taking the elements of PICOT
question into account.
▪ Each key word coming from the PICOT
question is used to start searching (Melnyk
et al., 2011).
▪ However, the quality and relevance of a
research is variational.
▪ Therefore, the strength of the researches
should be understood.
24

2.
Finding
evidence
▪ Systematic Review of Randomized
Controlled Trials (RCT) is regarded as the
best research type.
▪ The MEDLINE database, the world's
largest electronic data source in the field of
health sciences, can be accessed through
search channels such as PubMed or Ovid.
▪ Cochrane Library, Clinician Guides, Policy
Maker Guides, Consumer Guides National
Guideline Clearinghouse, The National
Institute for Health and Clinical Excellence,
The Guidelines International Network etc.
25

Where to
search?
26
https://guides.library.uwm.edu/EBPtutorial/picot

27
https://libguides.uwf.edu/c.php?g=215270&p=3955780

• Literature Review or Traditional Review
• Summarizes a topic that is broad in scope
• May use sources that are biased
• Does not define what types of studies will be included
• Generally descriptive
• Methodology of the literature search is not always
given
• Good source for starting reading lists and literature
searches
• Not generally considered a good source for clinical
decision making
28
Narrative Review

• Answers broader questions beyond those related to
the effectiveness of treatments or interventions.
• Is still as comprehensive but much broader; may
involve multiple structured searches
• They may examine the extent, range, and nature of the
evidence on a topic or question; determine the value of
undertaking a systematic review; summarize findings
from a body of knowledge that is heterogeneous in
methods or discipline; or identify gaps in the literature
to aid the planning and commissioning of future
research
• Joanna Briggs Institute (JBI)
29
Narrative Review

• Useful in formulation of a problem, may be related to
practice and/or policy especially in nursing
• Commonly include non-experimental research, such as
case studies, observational studies, and meta-
analyses, but may also include practice applications,
theory, and guidelines
• Have a clear and precise search and selection criteria,
• Selected literature are analyzed, not just summarized
--articles and groups of articles compared, themes
identified, gaps noted, etc.
30
Integrative Review

• Answers a specific clinical question; specifically include
experimental research studies
• Defines a specific search strategy; list what will be
included and excluded in articles selected
• Purpose is to reach some conclusion regarding the
topic.
• The first stage of meta-analysis studies.
• PRISMA (Preferred Reporting Items for
Systematic reviews and Meta-Analyses)
31
Systematic Reviews

• Looks at studies from a systematic review
• Combines similar studies and pulls data to get a
statistically significant result
• Importance because statistical analysis may overturn
results of smaller clinical trials
32
Meta-analysis

PRISMA
is an evidence-
based minimum
set of items for
reporting in
systematic
reviews and
meta-analyses..
33

Evidence
Table
37
Author,
Year
Purpose/
Aim of the
study
Design,
Sample
and size
Measurements
and analysis
Main
results and
conclusion
Strength of evidence/
Study Quality Appraisal
(1) the aims and
objectives of the research
are clearly stated,
(2) the design is clearly
specified and appropriate
for the aims and
objectives of the research,
(3) the researchers
provide a clear account of
the process by which their
findings were reproduced,
(4) the researchers
include enough data to
support their
interpretations and
conclusions, and
(5) the method of analysis
is appropriate and
adequately executed
Dixon-Woods, et al, (2006) Criteria for Quality Appraisal &
modified Best Evidence Medical Education Coding sheet

39
Objective: To search for the scientific evidence available on nursing
professional actions during the anesthetic procedure.
Method: An integrative review of articles in Portuguese, English and
Spanish, indexed in MEDLINE/PubMed, CINAHL, LILACS, National
Cochrane, SciELO databases and the VHL portal.
Results: Seven studies were analyzed, showing nurse anesthetists’ work
in countries such as the United States and parts of Europe, with the
formulation of a plan for anesthesia and patient care regarding the
verification of materials and intraoperative controls. The barriers to their
performance involved working in conjunction with or supervised by
anesthesiologists, the lack of government guidelines and policies for the
legal exercise of the profession, and the conflict between nursing and the
health system for maintenance of the performance in places with
legislation and defined protocols for the specialty.
Conclusion: Despite the methodological weaknesses found, the studies
indicated a wide diversity of nursing work. Furthermore, in countries
absent of the specialty, like Brazil, the need to develop guidelines for care
during the anesthetic procedure was observed.

40
Objective: to know the nursing care performed in the perioperative period.
Method: Integrative Review of literature in the databases Base de Dados
de Enfermagem (BDENF) and Literatura Latino-Americana e do Caribe em
Ciências da Saúde (LILACS). Content analysis has been applied for
analysis.
Results: 23 papers and two categories: Perioperative nursing care and the
organization of perioperative nursing care. In the first category, the
guidelines in nursing care in are identified, as well as the prevention of
hypothermia and skin lesions. In the second category, the studies show
strategies to offer quality assistance through the organization of nursing
work such as implementing models of care.
Conclusion: The results reflect the characteristics of nursing care in the
perioperative period and allow reflection on nursing care in different periods
of the surgical experience. Descriptors: Nursing care, Perioperative
nursing, Nursing.

41
Background and Aims: Operating room is a quiet place and serious that
there will be any extra noise to the distraction and interfere with verbal
communication between people. However, numerous studies have
shown that a signi ficant relaxation in the operating room does not
establish silence and may be used to achieve this purpose; the quiet
sound of music .This study is a systematic review about the effects of
music on the healing process of patients in the operating room.
Methods: We systematically reviewed the literature from Medline
(PubMed), The Cochrane Library, Ovid, Scopus, Embase, ProQuest and
Google Scholar published between 2000 and 2016. The search strategy
included a combination of Mesh and Free Keywords, “Music ” , “Music
Therapy ” , “Operating room ” , “operating theatre ” , “surgery room ”, in
all fields. Also the publication types of review and articles were included
and meetings abstract, editorials, brief commentaries, letters, errata and
papers that Subtopics were also excluded.

42
Results: Our initial search identi fied 480 abstracts. Application of the
inclusion/exclusion criteria resulted in 17 articles for review. Findings
indicated that music has a positive effect on patient perception of anxiety,
pain and satisfaction some times, but it was relatively ineffective when
there is a severe pain. Also findings showed that loud music played in
operating theatres hinders the ability of nurses to hear instructions. On
the other hand surgeons speed increase with music played in operating
theaters.
Discussion: Music is a free way to improve patients stress and pain
before and during surgery. Although there isn ’t enough evidence in order
to draw a net conclusion about the effect of music in operating rooms.

43
Objectives To define the target domains of culture-improvement
interventions, to assess the impact of these interventions on surgical culture
and to determine whether culture improvements lead to better patient
outcomes and improved healthcare efficiency. Background Healthcare
systems are investing considerable resources in improving workplace culture.
It remains unclear whether these interventions, when aimed at surgical care,
are successful and whether they are associated with changes in patient
outcomes.
Methods: PubMed, Cochrane, Web of Science and Scopus databases were
searched from January 1980 to January 2015. We included studies on
interventions that aimed to improve surgical culture, defined as the
interpersonal, social and organisational factors that affect the healthcare
environment and patient care. The quality of studies was assessed using an
adapted tool to focus the review on higher-quality studies. Due to study
heterogeneity, findings were narratively reviewed.

44
Findings: The 47 studies meeting inclusion criteria (4 randomised trials and
10 moderatequality observational studies) reported on interventions that
targeted three domains of culture: teamwork (n=28), communication (n=26)
and safety climate (n=19); several targeted more than one domain. All
moderate quality studies showed improvements in at least one of these
domains. Two studies also demonstrated improvements in patient outcomes,
such as reduced postoperative complications and even reduced
postoperative mortality (absolute risk reduction 1.7%). Two studies reported
improvements in healthcare efficiency, including fewer operating room
delays. These findings were supported by similar results from low-quality
studies.
Conclusions: The literature provides promising evidence for various
strategies to improve surgical culture, although these approaches differ in
terms of the interventions employed as well as the techniques used to
measure culture. Nevertheless, culture improvement appears to be
associated with other positive effects, including better patient outcomes and
enhanced healthcare efficiency.

45
Background: Meta-analyses of the implementation of a
surgical safety checklist (SSC) in observational studies have
shown a significant decrease in mortality and surgical
complications.
Objective: To determine the efficacy of the SSC using data
from randomised controlled trials (RCTs).
Methods: This meta-analysis followed the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
guidelines and was registered with PROSPERO
(CRD42015017546). A comprehensive search of six
databases was conducted using the OvidSP search engine.

46
Results: Four hundred and sixty-four citations revealed three
eligible trials conducted in tertiary hospitals and a community
hospital, with a total of 6 060 patients. All trials had allocation
concealment bias and a lack of blinding of participants and
personnel. A single trial that contributed 5 295 of the 6 060
patients to the meta-analysis had no detection, attrition or
reporting biases. The SSC was associated with significantly
decreased mortality (risk ratio (RR) 0.59, 95% confidence
interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical
complications (RR 0.64, 95% CI 0.57 -
0.71; p<0.00001; I2=0%). The efficacy of the SSC on specific
surgical complications was as follows: respiratory complications
RR 0.59, 95% CI 0.21 - 1.70; p=0.33, cardiac complications RR
0.74, 95% CI 0.28 - 1.95; p=0.54, infectious complications RR
0.61, 95% CI 0.29 - 1.27; p=0.18, and perioperative bleeding
RR 0.36, 95% CI 0.23 - 0.56; p<0.00001.

47
Conclusions: There is sufficient RCT evidence to suggest that
SSCs decrease hospital mortality and surgical outcomes in
tertiary and community hospitals. However, randomised
evidence of the efficacy of the SSC at rural hospital level is
absent.

2.
Finding
evidence
▪ Articles obtained as a result of literature
review may not always contain clinical
evidence at the same quality level.
▪ Therefore, the "quality level" (evidence
strength pyramid) of the resources and the
information used in the clinical decision-
making process that concerns the treatment
and care of the patient should be
considered.
48

Evidence in nursing research
To identify hierarchy of reseach designs and evaluate levels of
evidence in nursing research.
49
👉

▪ Nurses are required to use evidence-based
practice as they are responsible for a
significant amount of judgments and
decisions every day, and therefore, they
must use research literature as part of their
clinical decision-making.
▪ Understanding the differing levels of
evidence, and their reliability, is paramount
to making correct and appropriate health
care decisions.
50

3.
Critical
assessment
of the
evidence
▪ The third step in the EBP process is of vital
importance because it involves a critical
assessment of evidence from the search process
(Melnyk et al., 2011).
▪ When an article is evaluated, it is first determined
which type of study has been used, that is, where
in the evidence strength pyramid it is located
(Yılmaz & Çöl, 2014).
▪ The answers to these questions show that the
evidence is effective on a specific population in
health practices.
51

Critical assessment is carried out by responding to three
key questions that are part of the assessment process
so that the trial can be valid.
1. Are the trial questions valid? (Validity)
2. What is the outcome? (Reliability)
3. Can the results be helpful to patient care
and treatment? (Practicality)
52
3.
Critical
assessment
of the
evidence

1. Are the trial questions valid? (Validity):
Are the results of work as close to reality as
possible?
Did the researchers carry out the study using the
best research methods?
53
3.
Critical
assessment
of the
evidence

2. What is the outcome? (Reliability):
Did the intervention work?
How big is the treatment effect?
Can the clinicians obtain similar results with the
intervention method they practiced in their clinics?
54
3.
Critical
assessment
of the
evidence

3. Can the results be helpful to patient care and
treatment? (Practicality):
Is the trail subject related to the patients currently
under treatment?
Do the benefits of the treatment outnumber its
harms?
Is the environment convenient for the treatment?
Is the patient willing for the treatment?
55
3.
Critical
assessment
of the
evidence

Levels of
Evidence in
MEDICINE
Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009)
57

Nursing
Research
Pyramid
Nursing Research
Hierarchy / Levels of
Evidence
59
• Provides a visual and systematic depiction of
forms of research from the least reliable (base)
to the most reliable (apex).
• Pyramids vary slightly from source to source
which can be confusing.
• To further add to the varying hierarchies “there
is currently no universally agreed upon
hierarchy of evidence for study types that seek
to answer questions about patient’s experiences
and concerns (Del Mar et al, 2013).

Level 7.
Ideas, Opinions,
Editorials,
Anecdotes
▪ Least reliable.
▪ Basically anecdotal.
▪ Unscientific reports and observations
(Usher and Fitzgerald, 2008)
61

Level 6.
Case Controlled
Studies, Case
series and Case
Reports
▪ A case controlled study, or a case report, can be
defined as an in-depth research study of an individual
unit, a group or other social unit (Burns and Grove,
2009; Jackson and Borbasi, 2008).
▪ A case series is defined as a report on a series of
patients, or cases, who have an outcome of interest or
may have received some intervention (Del Mar et al,
2013) whereas the NHMRC (2009) state it is a single
group of people exposed to a intervention (factor
under study).
▪ Slightly more reliable but there is a potential for bias in
recalling information and the quality may be affected if
the information is collected retrospectively (Jirojwong
and Pepper, 2013).
62

Level 5.
Cohort studies
▪ Cohort studies is defined as a study which
categorises participants according to the level of
exposure to risk factors who are then followed over
a period of time to observe the possible occurrence
of a disease (Jirawong and Pepper, 2013)
▪ It a longitudinal, observational study where
differences in outcome are observed and related to
the initial differences (Del Mar et al, 2013).
▪ Becoming more reliable.
▪ Observational studies are good at answering
questions about prognosis, diagnosis, frequency
and aetiology but not questions regarding the effect
of an intervention (Del Mar et al 2013 p.24).
63

Level 4.
Random
Control Trials
▪ This is an experimental form of research where
participants are randomised in to two, or more,
different groups with each group receiving a
different intervention. At the end of the trial the
effects of the different interventions are then
measured (Del Mar et al 2013 p.25).
▪ The results are gathered and decisions can be
made once it is evident that one intervention is
more effective than another.
▪ Very Reliable/Gold Standard.
▪ Random Controlled Trials are able to quantify the
effects of intervention hence they are higher up the
pyramid than Cohort studies (Koch et al 2008)
64

Level 3.
Critically-
Appraised
Individual
Articles (Article
Synopses)
▪ Increasing reliability of findings.
▪ A synopses is the evidence of an individual
article with an expert telling you its strengths
(Wilczynski and McKibbon 2013).
▪ This is less reliable than Critically Appraised
Topics as there is less evidence on single
articles than in a synthesis of a topic using
several papers.
65

Level 2.
Critically
Appraised
Topics
(Evidence
Syntheses)
▪ Very high reliability.
▪ Synthesising research publications entails the
categorising of a series of related studies,
analysing and interpreting their findings and then
summarising those findings in to unified
statements.
▪ The potential lack of standardisation can
undermine the validity.
66

Level
1a/1b.
Systematic
Reviews and
Metaanalysis
▪ The most reliable of all.
▪ Systematic reviews, and Meta-analyses, of
primary research into human health care and
health policy are recognised internationally as
the highest standard in evidence-based care
(Cochrane Community 2015; Jirojwong and
Welch 2013 p.284).
67

69
Retrieved from: https://guides.lib.umich.edu/c.php?g=282802&p=1888246

Thank you very much
for your time.
79
If you have any questions about my presentation
please don’t hesitate ask.
Presentation is available at:
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Evidences

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