Group Number: Group 8
Group Members:
1. JACINTA JULIUS 20213797
2. WINNIE WILBERT KARUGABA 20206904
3. EMAD ISAM HAJER 20210655
4. UMURERWA DIVINE 20205207
5. WAD MADANI ALI 20213892
6. BAMIDELE OLUWAFIKEMI 20226488
7. ARİWAJOYE OLALEKAN OLATUBOSUN 20213978
8. UTULU EMMANUEL 20213489
9. OBIAMAKA FRANCISCA ACHIKEH 20206762
10. AISHAT ADEWUNMI AZEEZ 20213806
11. OLUWATOMISIN VİCTORIA OLORUNETO 20213817
12. ROSE JELAGAT MAIYO 20205876
13. OLUWATOBILOBA ELIJAH IBRAHIM 20205934
Topic: evidence based nurising level 3 and 4
Date: 27/11/2024
Index
1. Introduction of evidence level ...................................3
2. Definition of level 3 evidence...................................3-4
3. Types of level 3 evidence.........................................4-5
4. Cohort studies............................................................6
5. Level 4 evidence.........................................................7
6. Types of level 4 evidence............................................7
7. Examples of level 3 and 4 evidence..........................8-9
8. Conclusion................................................................10
9. Reference.............................................................10-11
Introduction (min 5 pages)
Introduction to Level of Evidence 3 and 4
In nursing evidence-based practice [EBP]plays an essential role because it allows clinicals to
make a up-date decisions based on patient preferences,clinical experience,and research
findings.in the hierararchy of evidence,which evalutes study findings on thier credibility,level
3and 4 evidence occupy the middle positions.when a new hospital policy is implemented in
one ward compared to another ,for example,it can yield valuable information even though
there is higher risk of selection bias (Melnyk & Fineout-overholt, 2011). Evidence -based
nursing [EBN] is a methodical approach to nursing that prioritizes using the best available
evidence from research, clinical experience, and patience preferences to guide decisions
regarding patient care. The aim of EBN is to enhance patient outcomes and improve the
quality of care by merging scientific knowledge with practical application in clinical
environments (Melnyk & Fineout-overholt, 2019).
Observational studies that fall under level 4 evevidence include cohort and case-control
designs.These studies are applicable in studing risk factors or the disease causes because they
examine the links between exposures and outcome without relying on direct interventions
(Pilot & Beck, 2017). When higher-level data, such systematic reviews or randomized
controlled trials [RCTs], are not feasible or accessible, these levels are especially helpful.
Quasi-experimental research using therapies without randomly assiging participants to groups
comprise level 3 evidence.these studies are frequently employed because they offer a
moderate level of dependability in suituationships where randomization is immoral or
logistically difficult .Level 3and level 4 evidence are both useful in nursing practice in
situations where experimental designs are unfeasible .Although studies cannot demonstrate
casuality,their findings are critical for resolving current clinical concerns and guiding future
research (LoBiondo-wood & Haber, 2022)
Level of Evidence 3
At Level 3 of evidence ,we find information gathered from systematic reviews and meta -
analyses of cohort and case-control studies.This level of evidence is important because it
aggregates data from mutiple studies,offering a more comprehensive view of a specific
intervention or phenomenon .It is especially valuable when randomized controlled
trials[RCTs]cannot be conducted for ethical reasons. For example,in cases where a treatment
cannot be randomized due to ethical issues,researchers might depend on observationable
studies to collect data.systemictic reviews at this level evaluate the quality of the included
studies and combine their results,making it easier for nurses to utilize this evidence in their
practice (Polit & Beck,2017).
Additional to systematic reviews and meta -analyse ,level 3 evidence can also consist of
guidlines greated from the analysis of exitting research .These guidlines can support nurses in
their clinical decision -making by offering evidence -based recommendations for their
practice .Additionally ,it’s important for nurses to recognize the strenths and limitations of
Level 3 evidence so they can effectively asses how applicable the findings are to their
particular patient groups İn summary,evidence -based nursing is essential for delivering high-
quality care,and level3 evidence plays a crucial role in this proccess. By relying on systematic
reviews and meta-analyses, as well clinical guidlines,nurses can make informed decisions that
reflect the best available evidence,ultimately leading to improved patient outcomes.
TYPES OF LEVEL3 STUDIES
Level 3 studies in research are mostly observational studies, such as cohort, case-control
studies.These investigations are less detailed than Level 1 randomized controlled trials
[RCTs] or level2 quasi -experiment are not practical or unethical.The following are the types
of level3 studies in accordance to the evidence -based research;
1.COHORT STUDIES:
A cohort study is a type of observational study that trace a group of people of over time to see
how particular characteristics for instance exposure to a certain risk factor affect their healt
outcomes. İndividuals in cohort share a certain characteristic or lived experience such as age,
geographic location, ethnicity and financial similarity. While there are other types of cohort
studies likes open, closed and dynamic, two are particularly common or mostly used which
are prospective cohort studies and restropective cohort studies. In short, cohort studies trace a
group of people or a cohort overtime to see how exposure to particular conditions affects
outcomes. (George, T.2023)
Key Characteristics :These studies might be prospective [most likely to happen / forward
looking ]or retrospective [looking backwards ].They are frequently attended by big numbers
and last for long periods of time.
Strengths: İt’s perfect for studying about disease progression.It can determine time-related
correlations between exposure and result.
Weakness: It is time-consuming and very costly .There is high risk of losses e.g experimental
data loss due to inability to keep up, which could bias results. (Wayne.W, 2016)
2. CASE CONTROL STUDIES:
A case control study is an in- depth or comprehensive analysis of a specific subject,as an
individual group,location ,event organisation ,or phenomena .case studies have a universal use
in social educational,clinical,and business research which i helpful.
A case study research design often uses qualitative methodologies, while quantitative
methodology approaches are also occasionally.case studies are useful and practical for
describing, contrasting analyzing, and comprehending various elements of study subject
(McCombes,S2023)
A case-control study often compare a persons with a certain specific risk factor is more
common in those cases.
Key Characteristics: These studies are frequently analytical and logical and very beneficial
for researching unusual disorders or diseases
Strengths: They’re very efficient and cost -effective . They are a perfect fit in research for
rare disease or consequences (Tenny S,Kerndt CC,Hoffman.2023).
Weaknesses: They include the potential for reminiscience causing a baised data information
due to the individual to inability of the individual to remember factors correctly. They cannot
establish relationships based on time whereby an individual didn’t have an outcome or
diseaseas well as cohort studies.
3.CROSS-SECTIONAL STUDIES:
A Cross-sectional study is a kind of study design or research in which a researcher accumulate
and gather details from a variety of dfferent individuals or people from one moment at a time.
İn which researcher observes variables in cross-sectional research without changing
Cross-sectional studies are used by researchers in
epidemiology,medicine,psychology ,economics,and other social sciences.For
instance,epidemiologists may make use of a cross-sectional design to design to collect and
examine suitable data if they are interested in current prevalence of a disease in a particular
segment or part of population (Thomas,L.2023).
Key Characteristics:These stusdies are frequently used to evaluate the burden and severity
of disease in a population in public health research.
Strengths:
It’s fast and mostly reasonably priced.
It gives a quick overview and otline of a population’s health problems.
Weakness:
It’s not able establish causation and sourse.
It’s very prone to bias, especially in cases when then sample is not representative and
indicative (Cornell,D. 2024).
Cohort studies
Cohort studies are essential to research design in epidemiology, used to research the causes of
complaint and to established links between threat factors and health issues. İn a cohort study,
groups of individualities who participate a common characteristics e.g., (age, gender,
occupation or exposure to a unique threat factors) are followed over time to assess differences
in health issues.
This type of experimental study is particularly preciousfor studying conditions with a long
suspense periode, similar as cancer cardiovascular complaint, and diabetes.
Types of cohort studies
There are two main type of cohort studies prospective and retrospective.
1. prospective cohort study: it is the experimenters elect a chort of
individualities grounded on their exposure to a certain threat factor and also
follow them forward in time to observe the developement of health issues.
This design is generally preferred for its capability to established temporal
connections between exposure and outgrowth (Melnyk & Fineout-
overholt.2019).
2. Retrospective cohort study: inaretrospective cohort study, experimenters
look back in time to dissectexposure status and after health issus. This design
is frequently briskly and less pricey than prospective studies but maybe
subject to impulses due to deficient or inaccurate literal data(Thomas, L.2023).
Advantage of cohort studies
Temporal relationship: cohort studies give precious sapience into the non-religious
sequence of events, which is essential for inferring unproductive connections between
exposure and outgrowth.
Multiple issues: experimenters can study multiple issues associated with a single exposure
making cohort studies protean.
Natural setting: as experimental studies, cohort studies observe subjects in real world
settings, which may enchance the external validity of the findings.
Disadvantage of cohort studies
Time consuming: particularly for prospective studies, the follow up periodcan be long
making studies.
Loss to follow up: cohort studies frequently suffer from party waste over time which can lead
to prejudiced result if the dropouts are not arbitrary.
Confounding: all experimental studies, cohort studies are susceptible to confounding
variables that may disfort the relationship between exposure and outgrowth (George, T.
2023).
Operations of cohort studies
Cohort studies are extensively used in public health exploration and clinical studies. For
illustration, the framingham heart study is a well known cohort study that has handed
inestimable perceptively into the threat factors for cardiovascular complain. Cohort studies
are also pivotal in relating threat factors for habitual conditions similar as smoking and lung
cancer, and assessing the goods of interventions or life changing on health issues (McCombes,
S.2023).
Level of Evidence 4
The hierarchy of evidence is essential to evidence-based nursing (EBN) because it guarantees
that clinical judgments are founded on the best available information. Although level four
evidence is seen as being lower on the ladder than cohort studies, randomized controlled
trials, or systematic reviews, it nevertheless offers insightful information, especially in
situations where higher-level studies are unavailable. Expert opinion, case series, and case-
control studies are examples of level four evidence. An outline of several kinds of level four
evidence is provided below.
• CASE CONTROL STUDIES: An observational study that compares two groups—those
with a certain condition (the "cases") and those without the condition (the "controls")—is
known as a case-control study. To identify the variables or exposures that might have
influenced the onset of the illness, researchers go back in time. When researching uncommon
diseases or disorders where doing a randomized controlled trial (RCT) is challenging, this
kind of study is especially helpful.
Nursing Example: To investigate the risk factors for postoperative infections in patients who
have had abdominal surgery, a case-control study may be employed. Researchers examine
past medical histories, hygiene habits, and antibiotic use in order to compare patients who
contracted infections (cases) with those who did not (controls).
Limitations: While case-control studies are useful for finding correlations, they are unable to
prove causation. Additionally, they are susceptible to biases including selection and
recollection bias. (Wayne & LaMorte2016)
• CASE SERIES: Limitations: While case-control studies are useful for finding correlations,
they are unable to prove causation. Additionally, they are susceptible to biases including
selection and recollection bias. An example in nursing would be a case series that documents
the results of a group of patients treated with a particular dressing or therapy over time in
order to explore a novel approach to wound care for diabetic patients. Limitations: Case series
have low generalizability and don't offer any comparative data. They are unable to account for
confounding variables and frequently lack the scientific rigor of randomized trials. (Tenny et
al., 2023)
• EXPERT OPINION: Another type of level four evidence is expert opinion. Expert opinion
can provide insightful information even though it is not supported by systematic research or
data, especially in situations where strong evidence is lacking. Recommendations are made by
subject-matter experts, who are frequently highly experienced doctors or researchers, based
on their theoretical knowledge, clinical expertise, and in-depth knowledge of the subject.
Example in Nursing: A wound care specialist may offer recommendations based on their
own experience and understanding of the larger literature if there are no scientific studies
available on the treatment of a rare kind of wound.
Limitations: The opinions of experts may not be appropriate to all patient populations and
can be subjective. Additionally, it has little empirical backing, which reduces its credibility
than other types of evidence. (Cornell,D. 2024)
When performing research is impractical or higher-level evidence is unavailable, level four
evidence is frequently utilized. Case-control studies and case series, for example, might
provide preliminary information about the efficacy of treatments in nursing prior to the
completion of larger, more thorough research. Expert opinion can be helpful in navigating
clinical uncertainty, but in order to guarantee that patient care is founded on the best available
data, it should be carefully evaluated in conjunction with other forms of evidence. (Wang &
Kattan, 2020)
EXAMPLES OF LEVEL 3 AND 4 EVIDENCE BASED
Evidence from non- randomized controlled trials, case-control studies, cohort studies, or
other observational research is frequently categorized as level 3 evidence. It usually falls
below Levels 1 and 2, which include systematic reviews and randomized controlled trials
(RCTs), and is regarded as having a moderate quality of evidence. Groups of patients (at least
two) are assigned at random to participate in a randomized study evaluating a drug's efficacy
for a certain ailment. This allows participant groupings to have a practical identity in
quantitative and qualitative markers. Examine and assess the efficacy of a certain kind of
medical intervention. If a random distribution is not feasible for ethical or technological
reasons, non-randomized trials recommend grouping patients in a nonrandom way (Barrett &
Nobel, 2019).
CASE-CONTROL STUDIES: research relies on archive data, it can only be conducted
retrospectively. In case-control studies, the data typically comes from patient memories,
medical records kept in medical institutions' archives, or their family members in an interview
or based on a survey This kind of research can be done as an initial investigation into the
causal links between a particular disease and the purported risk factor.
The period of case-control studies is rather brief. Rare causes of the disease cannot be found
in a case-control study. In these situations, the lack of data makes it impossible to evaluate the
validity of variations in the risk factor's frequency across the comparison groups and as a
result, we must make conclusions regarding whether a causal relationship exists or not (Burns
& Grove, 2011)
TRANSVERSAL STUDIES OR CROSS SECTION
(Simultaneous studies, prevalence studies)A cross-sectional (one-stage) study's objective is to
characterize the connection between a disease (and other health conditions) and the variables
present in a specific population at a specific moment and affect people in both positive and
negative ways. When discussing operational management, concurrent studies are frequently
the starting point. Although this study is conducted at a certain moment in time, the
information acquired may be related to earlier occurrences (for instance, looking at outpatient
records to see how frequently blood pressure was taken over the previous six years). A study
that is cross-sectional evaluates the frequency of risk factors, the frequency of instances, and
the combination of these (Pilot & Beck, 2017).
Three analytical investigations' comparative features a transversal study (transverse to the
time axis) examines risk factors and diseases in contrast to cohort and case-control studies,
which are longitudinal studies. At the same time (Melnyk & Fineout-overholt, 2019).
Phases of a cross-cutting investigation
• Information gathering on disease and risk factor prevalence. Every research subject has a
medical checkup that includes laboratory testing, a physical examination, and the required
functional diagnostics, Experts typically rely on patients' recollection and awareness to learn
about the impact of risk factors They gather industrial background, data regarding the
socioeconomic and household circumstances of individuals, genetics, etc. (Downier et al.,
2023).
The study's benefits include an explanation of the disease's clinical picture while documenting
the influence of the investigated cause, an easy-to-follow algorithm, and informative content.
Modest financial expenses.The study's shortcomings include the absence of a comparison
group and the inability to conclusively prove causal linkages because cross-sectional studies
do not obtain direct information on the order of occurrences (Al Thani et al., 2019).
According to a cross-sectional study, women with arthritis are more likely to be overweight,
and as a result, they are less likely to be overweight than women without arthritis. Could
being overweight put too much strain on the joints, which led to the development of arthritis,
or, on the other hand, women with Low levels of physical activity in people with arthritis led
to them gaining too much weight. Cross-sectional studies cannot provide solutions to these
concerns Because it is not feasible to determine the incidence of new instances of the disease
in prevalence studies (as in cohort studies), this kind of research is not appropriate for
prognostic analysis. As a result, the indicator cannot be used to determine the probability that
individuals with comparable traits will experience the same incident in the future.
Conclusion
The nursing levels of evidence play major role in medicine, understanding the levels helps to
identify information and reader’s needs to be careful when interpreting the results. Level 3
and level 4 are very important in level of evidence in clinical nursing. Level 3 consists of
controlled, non-randomized trials, while level 4 includes Evidence from well-designed case-
control or cohort studies. Although levels 3 and level 4 are less strong then level 1&2 but
level 3& 4 support scientific decisions and provide valuable data in the real world. Each level
play a specific role in the level of evidence and the strength of evidence can from one study to
another based on the methods used and the quality of the reports provided by the researcher.
Various level of evidence and study designs work in tandem to ensure the best evidence in
clinical practice.
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