types of evidence based research

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Evidence-Based Research: Levels of Evidence Pyramid

Introduction.

One way to organize the different types of evidence involved in evidence-based practice research is the levels of evidence pyramid. The pyramid includes a variety of evidence types and levels.

• systematic reviews
• critically-appraised topics
• critically-appraised individual articles
• randomized controlled trials
• cohort studies
• case-controlled studies, case series, and case reports
• Background information, expert opinion

Levels of evidence pyramid

The levels of evidence pyramid provides a way to visualize both the quality of evidence and the amount of evidence available. For example, systematic reviews are at the top of the pyramid, meaning they are both the highest level of evidence and the least common. As you go down the pyramid, the amount of evidence will increase as the quality of the evidence decreases.

Text alternative for Levels of Evidence Pyramid diagram

EBM Pyramid and EBM Page Generator, copyright 2006 Trustees of Dartmouth College and Yale University. All Rights Reserved. Produced by Jan Glover, David Izzo, Karen Odato and Lei Wang.

Filtered Resources

Filtered resources appraise the quality of studies and often make recommendations for practice. The main types of filtered resources in evidence-based practice are:

Scroll down the page to the Systematic reviews , Critically-appraised topics , and Critically-appraised individual articles sections for links to resources where you can find each of these types of filtered information.

Systematic reviews

Authors of a systematic review ask a specific clinical question, perform a comprehensive literature review, eliminate the poorly done studies, and attempt to make practice recommendations based on the well-done studies. Systematic reviews include only experimental, or quantitative, studies, and often include only randomized controlled trials.

You can find systematic reviews in these filtered databases :

• Cochrane Database of Systematic Reviews Cochrane systematic reviews are considered the gold standard for systematic reviews. This database contains both systematic reviews and review protocols. To find only systematic reviews, select Cochrane Reviews in the Document Type box.
• JBI EBP Database (formerly Joanna Briggs Institute EBP Database) This database includes systematic reviews, evidence summaries, and best practice information sheets. To find only systematic reviews, click on Limits and then select Systematic Reviews in the Publication Types box. To see how to use the limit and find full text, please see our Joanna Briggs Institute Search Help page .

You can also find systematic reviews in this unfiltered database :

To learn more about finding systematic reviews, please see our guide:

• Filtered Resources: Systematic Reviews

Critically-appraised topics

Authors of critically-appraised topics evaluate and synthesize multiple research studies. Critically-appraised topics are like short systematic reviews focused on a particular topic.

You can find critically-appraised topics in these resources:

• Annual Reviews This collection offers comprehensive, timely collections of critical reviews written by leading scientists. To find reviews on your topic, use the search box in the upper-right corner.
• Guideline Central This free database offers quick-reference guideline summaries organized by a new non-profit initiative which will aim to fill the gap left by the sudden closure of AHRQ’s National Guideline Clearinghouse (NGC).
• JBI EBP Database (formerly Joanna Briggs Institute EBP Database) To find critically-appraised topics in JBI, click on Limits and then select Evidence Summaries from the Publication Types box. To see how to use the limit and find full text, please see our Joanna Briggs Institute Search Help page .
• National Institute for Health and Care Excellence (NICE) Evidence-based recommendations for health and care in England.
• Filtered Resources: Critically-Appraised Topics

Critically-appraised individual articles

Authors of critically-appraised individual articles evaluate and synopsize individual research studies.

You can find critically-appraised individual articles in these resources:

• EvidenceAlerts Quality articles from over 120 clinical journals are selected by research staff and then rated for clinical relevance and interest by an international group of physicians. Note: You must create a free account to search EvidenceAlerts.
• ACP Journal Club This journal publishes reviews of research on the care of adults and adolescents. You can either browse this journal or use the Search within this publication feature.
• Evidence-Based Nursing This journal reviews research studies that are relevant to best nursing practice. You can either browse individual issues or use the search box in the upper-right corner.

To learn more about finding critically-appraised individual articles, please see our guide:

• Filtered Resources: Critically-Appraised Individual Articles

Unfiltered resources

You may not always be able to find information on your topic in the filtered literature. When this happens, you'll need to search the primary or unfiltered literature. Keep in mind that with unfiltered resources, you take on the role of reviewing what you find to make sure it is valid and reliable.

Note: You can also find systematic reviews and other filtered resources in these unfiltered databases.

The Levels of Evidence Pyramid includes unfiltered study types in this order of evidence from higher to lower:

You can search for each of these types of evidence in the following databases:

TRIP database

Background information & expert opinion.

Background information and expert opinions are not necessarily backed by research studies. They include point-of-care resources, textbooks, conference proceedings, etc.

• Family Physicians Inquiries Network: Clinical Inquiries Provide the ideal answers to clinical questions using a structured search, critical appraisal, authoritative recommendations, clinical perspective, and rigorous peer review. Clinical Inquiries deliver best evidence for point-of-care use.
• Harrison, T. R., & Fauci, A. S. (2009). Harrison's Manual of Medicine . New York: McGraw-Hill Professional. Contains the clinical portions of Harrison's Principles of Internal Medicine .
• Lippincott manual of nursing practice (8th ed.). (2006). Philadelphia, PA: Lippincott Williams & Wilkins. Provides background information on clinical nursing practice.
• Medscape: Drugs & Diseases An open-access, point-of-care medical reference that includes clinical information from top physicians and pharmacists in the United States and worldwide.
• Virginia Henderson Global Nursing e-Repository An open-access repository that contains works by nurses and is sponsored by Sigma Theta Tau International, the Honor Society of Nursing. Note: This resource contains both expert opinion and evidence-based practice articles.
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Types of Research

Once you have your focused question, it's time to decide on the type of evidence you need to answer it. Understanding the types of research will help guide you to proper evidence that will support your question.

Evidence Based Pyramid

Hierarchy of evidence and research designs.

As you move up the pyramid, the study designs are more rigorous and are less biased.

What type of study should you use?

Question definitions:.

Intervention/Therapy: Questions addressing the treatment of an illness or disability.

Etiology: Questions addressing the causes or origins of disease (i.e., factors that produce or predispose toward a certain disease or disorder).

Diagnosis: Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation.

Prognosis/Prediction: Questions addressing the prediction of the course of a disease.

The type of question you have will often lead you to the type of research that will best answer the question:

Intervention/Prevention:   RCT > Cohort Study > Case Control > Case Series

Therapy:   RCT > Cohort > Case Control > Case Series

Prognosis/Prediction:   Cohort Study > Case Control > Case Series

Diagnosis/Diagnostic:   Prospective, blind comparison to Gold Standard

Etiology:   RCT > Cohort Study > Case Control > Case Series

Definitions

Cebm study design tree.

The type of study can generally be worked at by looking at three issues:

Q1. What was the aim of the study?

• To simply describe a population (PO questions) descriptive
• To quantify the relationship between factors (PICO questions) analytic.

Q2. If analytic, was the intervention randomly allocated?

• Yes? RCT
• No? Observational study

For observational study the main types will then depend on the timing of the measurement of outcome, so our third question is:

Q3. When were the outcomes determined?

• Some time after the exposure or intervention? cohort study (‘prospective study’)
• At the same time as the exposure or intervention? cross sectional study or survey
• Before the exposure was determined? case-control study (‘retrospective study’ based on recall of the exposure)

from Centre for Evidence-Based Medicine https://www.cebm.net/2014/04/study-designs/

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Evidence-Based Practice: Types of Research

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Quantitative Research

• Case report or case series - a report on one or more individual patients.  There is no "control group" so this study type is considered to have low statistical validity
• Case control study - looks at patients with a particular outcome (cases) as well as "control patients" who don't have that outcome. Is useful in aetiology (causation) research but prone to causation error
• Cohort study – identifies and follows two groups (cohorts) of patients, one having received the intervention being studied, and one having not. Useful in both aetiology and prognosis research. Because the groups are not randomised, they may differ in ways other than in the variable being studied
• Randomised Controlled Trial (RCT) - a clinical trial in which participants are randomly allocated to a test treatment and a control. This is considered the “gold standard” in testing the efficacy of an intervention. RCTs incorporate the techniques of  randomisation and blinding , which reduce the potential for bias and provide good evidence for cause and effect.

Qualitative Research

• Documents - the study of documentary accounts of events, such as minutes of meetings
• Passive observation - the systematic watching and recording of behaviour  
• Participant observation – here, the researcher occupies a role or part in the setting, in addition to observing
• In-depth interview - a face-to-face conversation to explore issues or topics in detail
• Focus group - a method of group interview which explicitly includes and makes use of the group interaction to generate data.

Mixed Methods

A research study does not have to be exclusively quantitative or qualitative. Many studies will use a combination of both types of research.

In the Dictionary of Statistics and Methodology , Mixed-Method Research is defined as:

"Inquiry that combines two or more methods. This particular term usually refers to mixing that crosses the quantitative-qualitative boundary. However, that boundary is not necessarily the most difficult one to cross. For example, mixing surveys and experiments (both quantitative methods) may require more effort for many researchers than combining surveys and focus groups (the first quantitative and the second qualitative)."

Mixed method research. (2005). In P. W. Vogt (Ed.),  Dictionary of statistics & methodology (3rd ed.). http://dx.doi.org.ezproxy.csu.edu.au/10.4135/9781412983907.n1190

SAGE Research Methods

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The Evidence Hierarchy

Evidence based medicine: the evidence hierarchy.

• Introduction
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The hierarchy of evidence  is   a core principal of EBM.  EBM hierarchies rank study types based on the strength and precision of their research methods.  Different hierarchies exist for different question types, and even experts may disagree on the exact rank of information in the evidence hierarchies. Still, most agree that current, well designed systematic reviews and meta-analyses are at the top of the pyramid, and that expert opinion and anecdotal experience are at the bottom.

The Evidence Hierarchy, Questions about Treatment

Figure adapted from Greenhalgh T. How to Read a Paper: The Basics of Evidence-Based Medicine. Hoboken: John Wiley & Sons, Incorporated; 2010. Figure 2.1 A simple hierarchy of evidence for assessing the quality of trial design in therapy studies.

Systematic Reviews

A systematic review is "a review that uses explicit, systematic methods to collate and synthesise findings of studies that address a clearly formulated question". 1

Systematic reviews are useful for:

• confirming current practices
• guiding decision-making
• informing future research

Meta-analyses,  while often part of systematic reviews, are not interchangeable with them. They use statistical analysis to combine data from the studies found in the systematic review process. These studies must be homogenous enough that the data from them can be pooled together.

Limitations of systematic reviews include:

• That since they are focused on a clearly formulated question, their conclusions only answer that particular question and cannot be generalized
• That the synthesis of materials is only as reliable as the primary studies the review analyzed
• Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . BMJ. 2021 Mar 29;372.
• Garg AX, Hackam D, Tonelli M. Systematic review and meta-analysis: when one study is just not enough . Clinical Journal of the American Society of Nephrology. 2008 Jan 1;3(1):253-60.

Primary Studies

In the absence of a current, well designed systematic review is not available, practitioners turn to the primary studies to answer their questions. The best research design depends on the question type. The table below lists optimal study methodologies for common types of clinical questions.

• Oxford Centre for Evidence-Based Medicine Working Group Oxford (OCEBM). The Oxford Levels of Evidence 2 [Internet]. University of Oxford, Oxford UK; [cited 2021 Dec 13]. Available from: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
• Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011 Jul;128(1):305-310. doi: 10.1097/PRS.0b013e318219c171. PMID: 21701348; PMCID: PMC3124652.
• ACP Journal Club Inclusion Criteria [Internet]. American College of Physicians (ACP); [updated 2013 Nov 14; cited 2021 Dec 13]. Available from: https://www.acpjournals.org/journal/aim/acpjc/inclusion-criteria
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Evidence Based Practice Context

Levels of Evidence

Levels of evidence (sometimes called hierarchy of evidence) are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. These decisions gives the "grade (or strength) of recommendation."

This level of effectiveness rating scheme is based on the following: Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008).  Evidence-based nursing care guidelines: Medical-surgical interventions.  (p. 7) .  St. Louis, MO: Mosby Elsevier.

Research Study Designs

Different types of clinical questions are best answered by different types of research studies.  You might not always find the highest level of evidence (i.e., systematic review or meta-analysis) to answer your question. When this happens, work your way down to the next highest level of evidence.

This table suggests study designs best suited to answer each type of clinical question.

Types of Resources

When searching for evidence-based information, one should select the highest level of evidence possible--systematic reviews or meta-analyses. Systematic reviews, meta-analyses, and critically-appraised topics/articles have all gone through an evaluation process: they have been "filtered."   Information that has not been critically appraised is considered "unfiltered."

As you move up the pyramid, however, fewer studies are available; it's important to recognize that high levels of evidence may not exist for your clinical question.  If this is the case, you'll need to move down the pyramid if your quest for resources at the top of the pyramid is unsuccessful.

• Meta-Analysis:  A systematic review that uses quantitative methods to summarize the results.
• Systematic Review:  Authors have systematically searched for, appraised, and summarised all of the medical literature for a specific topic.
• Critically Appraised Topic:  Authors evaluate and synthesize multiple research studies.
• Critically Appraised Articles : Authors evaluate and synopsize individual research studies.
• Randomized Controlled Trials : Include a randomized group of patients in an experimental group and a control group. These groups are followed up for the variables/outcomes of interest.
• Cohort Study:  Identifies two groups (cohorts) of patients, one which did receive the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest.
• Case-Control Study:  Identifies patients who have the outcome of interest (cases) and control patients without the same outcome, and looks for exposure of interest.
• Background Information/Expert Opinion:  Handbooks, encyclopedias, and textbooks often provide a good foundation or introduction and often include generalized information about a condition.  While background information presents a convenient summary, often it takes about three years for this type of literature to be published.
• Animal Research/Lab Studies: Information begins at the bottom of the pyramid: this is where ideas and laboratory research takes place. Ideas turn into therapies and diagnostic tools, which then are tested with lab models and animals.

Use the TRIP database to find unfiltered and filtered information sources online.

Sources: Greenhalgh, Trisha.   How to Read a Paper: the Basics of Evidence Based Medicine .  London: BMJ, 2000.  Glover, Jan; Izzo, David; Odato, Karen & Lei Wang.  EBM Pyramid .  Dartmouth University/Yale University. 2006.

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Evidence-Based Practice Guide

The Evidence-Based Practice (EBP) guide explains what EBP is, key concepts and steps involved in EBP, and the different types of clinical evidence. Use the tabs at the top of the page to navigate through the guide. 

Remember: the Library team provides a range of research support services to Monash Health employees and students. Attend a live webinar , book a research consultation , or request a literature search and  get in touch with the Library team  if you have any questions.

• EBP Pyramid

Evidence-Based Pyramid

The Evidence-Based Pyramid is divided into levels to indicate:

• the volume of information at each level
• that different study types have differing rigor, quality and reliability.

As we ascend the pyramid, the quality of evidence increases. However, study design always has an impact. A well designed cohort study for example, is likely to provide better evidence than a poorly designed randomised controlled trial (RCT). The quality of each individual study still needs to be critically appraised. 

Best study type to answer different clinical questions

As demonstrated by the pyramid above, not all evidence has the same power. In addition, different types of questions are best answered by particular study types (see below).

• Therapy - determining the effect of interventions = RCT, systematic review, meta-analysis.
• Prognosis - likely outcome for a patient population = RCT, cohort study, case-control study.
• Harm - outcomes from an activity of exposure = RCT, cohort study, case-control study.
• Diagnosis - accuracy of diagnostic tests = Cross-sectional analytic study, blind comparison to a gold standard.
• Prevention - reducing chance of disease by identifying risk factors = RCT, systematic review.

A note about systematic reviews

As you can see in the EBP pyramid, systematic reviews are the highest level of evidence. Most researchers want to find a systematic review to answer their clinical question, as systematic reviews synthesise evidence from all existing studies in a particular area to provide a thorough analysis of the collated results, strengths and weaknesses. 

Systematic reviews may or may not include a meta-analysis to summarise and analyse the statistical results from included studies. Researchers should note that systematic reviews have a very different design to narrative reviews, which are only useful for background information as they are designed as opinion reviews with selective illustrations from a literature search.

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Evidence-Based Practice: Research Guide

5 steps of ebp.

• Find: Databases for EBP
• Appraise: Building an Evidence Table
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• Ask : Convert the need for information into an answerable question.
• Find : Track down the best evidence with which to answer that question.
• Appraise : Critically appraise that evidence for its validity and applicability.
• Apply : Integrate the critical appraisal with clinical expertise and with the patient's unique biology, values, and circumstances.
• Evaluate : Evaluate the effectiveness and efficiency in executing steps 1-4 and seek ways to improve them both for next time.

1. ASK: Using PICO

Formulating a strong clinical question is the first step in the research process.  PICO is a way of building clinical research questions that allow you to focus your research, and to create a query that better matches most medical databases.

• Patient – Describe your patient or population.  What are the most important characteristics?  Include information on age, race, gender, medical conditions, etc.
• Intervention – What is the main intervention or therapy you are considering? The can be as general as treat or observe, or as specific as a specific test or therapy.
• Comparison Intervention – An alternative intervention or therapy you wish to compare to the first.
• Outcome – What are you trying to do for the patient?  What is the clinical outcome?  What are the relevant outcomes?

Example: In a (describe patient) can (intervention A) affect (outcome) compared with (intervention B)?

• Patient - 50 yr old man with diabetes
• Intervention - weight loss and exercise
• Comparison - medication
• Outcome - maintaining blood sugar levels

2. FIND: Formulate a Search Strategy

Think about the keywords for each of the PICO parts of the clinical question.

Sample Question: Is prophylactic physical therapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?

The PICO parts with keywords for this question would look like this:

You might also see PICO with an added T. The T often stands for either “time” or “type of study.” Time helps you consider the timeframe of an intervention or outcome, while type of study is a way to define the types or levels of evidence that you will need in order to answer your question. 

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3. APPRAISE: Evidence & Evaluation

Different types of information provide different standards or levels of evidence. These levels depend on things like a study's design, objectives, and review process. You may be familiar with a pyramid diagram showing a hierarchy of types of evidence. Often included in pyramids of evidence are the following types of information: 

• Clinical practice guidelines—recommendations for applying current medical knowledge (or evidence) to the treatment and care of a patient. 
• Meta-analyses and systematic reviews—an approach to literature reviews that identifies all studies addressing a given research question based on specific inclusion criteria and analyzes the results of each study to produce a summary result. 
• Randomized controlled trials (RCTs)—eligible participants are randomly assigned to study groups to test a treatment against a control group. In blinded trials, the participants and researchers do not know which study group participants have been assigned to. 
• Cohort studies—follow a group of subjects over a period of time to determine the incidence or identify predictors of a certain condition. 
• Case-control studies—compare two groups of subjects, one with the outcome and one without, to identify predictor variables associated with the outcome. 
• Case reports/series, expert opinions, and editorials—reports on individual cases with no control groups involved, opinions based on one person’s experience and expertise 
• Animal and laboratory studies—studies that do not involve humans 

The pyramid hierarchy places some types of evidence above others in terms of validity, objectivity, and transferability. It’s important to remember, however, that the best type of evidence to answer your research question depends on the nature of your question and what purpose you have for searching for evidence in the first place. Conducting a literature review, for example, is a very different situation than searching for an answer to a specific question about a particular case, patient, or situation. 

Evaluation Criteria:

• Credibility (Internal Validity)
• Transferability (External Validity)
• Dependability (Reliability)
• Confirmability (Objectivity)

Credibility: looks at truth and quality and asks, "Can you believe the results?"

Some questions you might ask are: Were patients randomized? Were patients analyzed in the groups to which they were (originally) randomized? Were patients in the treatment and control groups similar with respect to known prognostic factors?

Transferability: looks at external validity of the data and asks, "Can the results be transferred to other situations?"

Some questions you might ask are: Were patients in the treatment and control groups similar with respect to known prognostic factors? Was there a blind comparison with an independent gold standard? Were objective and unbiased outcome criteria used? Are the results of this study valid?

Dependability: looks at consistency of results and asks, "Would the results be similar if the study was repeated with the same subjects in a similar context?"

Some questions you might ask are: Aside from the experimental intervention, were the groups treated equally? Was follow-up complete? Was the sample of patients representative? Were the patients sufficiently homogeneous with respect to prognostic factors?

Confirmability: looks at neutrality and asks, "Was there an attempt to enhance objectivity by reducing research bias?"

Some questions you might ask are: Were 5 important groups (patients, care givers, collectors of outcome data, adjudicators of outcome, data analysis) aware of group allocations? Was randomization concealed?

4. APPLY: Use Evidence in Clinical Practice

Other good resources for both appraisal and applying evidence in clinical practice can be found on these two websites:

• KT Clearinghouse/Centre for Evidence-Based Medicine, Toronto
• Centre for Evidence Based Medicine, University of Oxford

5. EVALUATE: Look at Your Performance

Ask yourself:

• Did you ask an answerable clinical question?
• Did you find the best external evidence?
• Did you critically appraise the evidence and evaluate it for its validity and potential usefulness?
• Did you integrate critical appraisal of the best available external evidence from systematic research with individual clinical expertise in personal daily clinical practice?
• What were the outcomes of your application of the best evidence for your patient(s)?
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Evidence Pyramid

Depending on their purpose, design, and mode of reporting or dissemination, health-related research studies can be ranked according to the strength of evidence they provide, with the sources of strongest evidence at the top, and the weakest at the bottom:

Secondary Sources: studies of studies

Systematic Review

• Identifies, appraises, and synthesizes all empirical evidence that meets pre-specified eligibility criteria
• Methods section outlines a detailed search strategy used to identify and appraise articles
• May include a meta-analysis, but not required (see Meta-Analysis below)

Meta-Analysis

• A subset of systematic reviews: uses quantitative methods to combine the results of independent studies and synthesize the summaries and conclusions
• Methods section outlines a detailed search strategy used to identify and appraise articles; often surveys clinical trials
• Can be conducted independently, or as a part of a systematic review
• All meta-analyses are systematic reviews, but not all systematic reviews are meta-analyses

Evidence-Based Guideline

• Provides a brief summary of evidence for a general clinical question or condition
• Produced by professional health care organizations, practices, and agencies that systematically gather, appraise, and combine the evidence
• Click on the 'Evidence-Based Care Sheets' link located at the top of the  CINAHL  screen to find short overviews of evidence-based care recommendations covering 140 or more health care topics.

Meta-Synthesis or Qualitative Synthesis (Systematic Review of Qualitative or Descriptive Studies)

• a systematic review of qualitative or descriptive studies, low strength level

Primary Sources: original studies

Randomized Controlled Trial

• Experiment where individuals are randomly assigned to an experimental or control group to test the value or efficiency of a treatment or intervention

Non-Randomized Controlled Clinical Trial (Quasi-Experimental)

• Involves one or more test treatments, at least one control treatment, specified outcome measures for evaluating the studied intervention, and a bias-free method for assigning patients to the test treatment

Case-Control or Case-Comparison Study (Non-Experimental)

• Individuals with a particular condition or disease (the cases) are selected for comparison with individuals who do not have the condition or disease (the controls)

Cohort Study (Non-Experimental)

• Identifies subsets (cohorts) of a defined population
• Cohorts may or may not be exposed to factors that researchers hypothesize will influence the probability that participants will have a particular disease or other outcome
• Researchers follow cohorts in an attempt to determine distinguishing subgroup characteristics

Further Reading

• Levels of Evidence - EBP Toolkit Winona State University
• Levels of Evidence Northern Virginia Community College
• Types of Evidence University of Missouri - St Louis
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• Evidence-Based Research

On This Guide

About this guide, understand evidence-based practice, identify research study types.

• Quantitative Studies
• Qualitative Studies
• Meta-Analysis
• Systematic Reviews
• Randomized Controlled Trials
• Observational Studies
• Literature Reviews
• Finding Research Tools This link opens in a new window

Throughout your schooling, you may need to find different types of evidence and research to support your course work. This guide provides a high-level overview of evidence-based practice as well as the different types of research and study designs. Each page of this guide offers an overview and search tips for finding articles that fit that study design.

Note! If you need help finding a specific type of study, visit the  Get Research Help guide  to contact the librarians.

What is Evidence-Based Practice?

One of the requirements for your coursework is to find articles that support evidence-based practice. But what exactly is evidence-based practice? Evidence-based practice is a method that uses relevant and current evidence to plan, implement and evaluate patient care. This definition is included in the video below, which explains all the steps of evidence-based practice in greater detail.

• Video - Evidence-based practice: What it is and what it is not. Medcom (Producer), & Cobb, D. (Director). (2017). Evidence-based practice: What it is and what it is not [Streaming Video]. United States of America: Producer. Retrieved from Alexander Street Press Nursing Education Collection

Quantitative and Qualitative Studies

Research is broken down into two different types: quantitative and qualitative. Quantitative studies are all about measurement. They will report statistics of things that can be physically measured like blood pressure, weight and oxygen saturation. Qualitative studies, on the other hand, are about people's experiences and how they feel about something. This type of information cannot be measured using statistics. Both of these types of studies report original research and are considered single studies. Watch the video below for more information.

Study Designs

Some research study types that you will encounter include:

• Case-Control Studies
• Cohort Studies
• Cross-Sectional Studies

Studies that Synthesize Other Studies

Sometimes, a research study will look at the results of many studies and look for trends and draw conclusions. These types of studies include:

• Meta Analyses

Tip! How do you determine the research article's study type or level of evidence? First, look at the article abstract. Most of the time the abstract will have a methodology section, which should tell you what type of study design the researchers are using. If it is not in the abstract, look for the methodology section of the article. It should tell you all about what type of study the researcher is doing and the steps they used to carry out the study.

Read the book below to learn how to read a clinical paper, including the types of study designs you will encounter.

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• Research Process

Levels of evidence in research

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Table of Contents

Level of evidence hierarchy

When carrying out a project you might have noticed that while searching for information, there seems to be different levels of credibility given to different types of scientific results. For example, it is not the same to use a systematic review or an expert opinion as a basis for an argument. It’s almost common sense that the first will demonstrate more accurate results than the latter, which ultimately derives from a personal opinion.

In the medical and health care area, for example, it is very important that professionals not only have access to information but also have instruments to determine which evidence is stronger and more trustworthy, building up the confidence to diagnose and treat their patients.

5 levels of evidence

With the increasing need from physicians – as well as scientists of different fields of study-, to know from which kind of research they can expect the best clinical evidence, experts decided to rank this evidence to help them identify the best sources of information to answer their questions. The criteria for ranking evidence is based on the design, methodology, validity and applicability of the different types of studies. The outcome is called “levels of evidence” or “levels of evidence hierarchy”. By organizing a well-defined hierarchy of evidence, academia experts were aiming to help scientists feel confident in using findings from high-ranked evidence in their own work or practice. For Physicians, whose daily activity depends on available clinical evidence to support decision-making, this really helps them to know which evidence to trust the most.

So, by now you know that research can be graded according to the evidential strength determined by different study designs. But how many grades are there? Which evidence should be high-ranked and low-ranked?

There are five levels of evidence in the hierarchy of evidence – being 1 (or in some cases A) for strong and high-quality evidence and 5 (or E) for evidence with effectiveness not established, as you can see in the pyramidal scheme below:

Level 1: (higher quality of evidence) – High-quality randomized trial or prospective study; testing of previously developed diagnostic criteria on consecutive patients; sensible costs and alternatives; values obtained from many studies with multiway sensitivity analyses; systematic review of Level I RCTs and Level I studies.

Level 2: Lesser quality RCT; prospective comparative study; retrospective study; untreated controls from an RCT; lesser quality prospective study; development of diagnostic criteria on consecutive patients; sensible costs and alternatives; values obtained from limited stud- ies; with multiway sensitivity analyses; systematic review of Level II studies or Level I studies with inconsistent results.

Level 3: Case-control study (therapeutic and prognostic studies); retrospective comparative study; study of nonconsecutive patients without consistently applied reference “gold” standard; analyses based on limited alternatives and costs and poor estimates; systematic review of Level III studies.

Level 4: Case series; case-control study (diagnostic studies); poor reference standard; analyses with no sensitivity analyses.

Level 5: (lower quality of evidence) – Expert opinion.

By looking at the pyramid, you can roughly distinguish what type of research gives you the highest quality of evidence and which gives you the lowest. Basically, level 1 and level 2 are filtered information – that means an author has gathered evidence from well-designed studies, with credible results, and has produced findings and conclusions appraised by renowned experts, who consider them valid and strong enough to serve researchers and scientists. Levels 3, 4 and 5 include evidence coming from unfiltered information. Because this evidence hasn’t been appraised by experts, it might be questionable, but not necessarily false or wrong.

Examples of levels of evidence

As you move up the pyramid, you will surely find higher-quality evidence. However, you will notice there is also less research available. So, if there are no resources for you available at the top, you may have to start moving down in order to find the answers you are looking for.

• Systematic Reviews: -Exhaustive summaries of all the existent literature about a certain topic. When drafting a systematic review, authors are expected to deliver a critical assessment and evaluation of all this literature rather than a simple list. Researchers that produce systematic reviews have their own criteria to locate, assemble and evaluate a body of literature.
• Meta-Analysis: Uses quantitative methods to synthesize a combination of results from independent studies. Normally, they function as an overview of clinical trials. Read more: Systematic review vs meta-analysis .
• Critically Appraised Topic: Evaluation of several research studies.
• Critically Appraised Article: Evaluation of individual research studies.
• Randomized Controlled Trial: a clinical trial in which participants or subjects (people that agree to participate in the trial) are randomly divided into groups. Placebo (control) is given to one of the groups whereas the other is treated with medication. This kind of research is key to learning about a treatment’s effectiveness.
• Cohort studies: A longitudinal study design, in which one or more samples called cohorts (individuals sharing a defining characteristic, like a disease) are exposed to an event and monitored prospectively and evaluated in predefined time intervals. They are commonly used to correlate diseases with risk factors and health outcomes.
• Case-Control Study: Selects patients with an outcome of interest (cases) and looks for an exposure factor of interest.
• Background Information/Expert Opinion: Information you can find in encyclopedias, textbooks and handbooks. This kind of evidence just serves as a good foundation for further research – or clinical practice – for it is usually too generalized.

Of course, it is recommended to use level A and/or 1 evidence for more accurate results but that doesn’t mean that all other study designs are unhelpful or useless. It all depends on your research question. Focusing once more on the healthcare and medical field, see how different study designs fit into particular questions, that are not necessarily located at the tip of the pyramid:

• Questions concerning therapy: “Which is the most efficient treatment for my patient?” >> RCT | Cohort studies | Case-Control | Case Studies
• Questions concerning diagnosis: “Which diagnose method should I use?” >> Prospective blind comparison
• Questions concerning prognosis: “How will the patient’s disease will develop over time?” >> Cohort Studies | Case Studies
• Questions concerning etiology: “What are the causes for this disease?” >> RCT | Cohort Studies | Case Studies
• Questions concerning costs: “What is the most cost-effective but safe option for my patient?” >> Economic evaluation
• Questions concerning meaning/quality of life: “What’s the quality of life of my patient going to be like?” >> Qualitative study

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Home » About » About Evidence-Based Research (EBR)

About Evidence-Based Research (EBR)

Introduction A number of studies show that researchers, research funders, regulators, sponsors and publishers of research fail to use earlier research when preparing to start, fund, regulate, sponsor or publish the results of new studies. To embark on research without systematically reviewing the evidence of what is already known, particularly when the research involves people or animals, is unethical, unscientific, and wasteful.

Therefore, we have chosen to focus the concept of EBR on ensuring valuable research.

Our answers to the many challenges:

• Use scientific methods to evaluate performance of research
• Use scientific methods to improve the way research is conducted
• Use scientific methods to monitor research practice over time

We promote the following to achieve these aims:

• … the use of a systematic and transparent approach when justifying and designing a new study
• … the use of a systematic and transparent approach when placing new results in the context of existing evidence
• … more efficient production, updating and dissemination of systematic reviews

Traditionally, when formulating a new research question researchers use their scientific environment and context, personal interests and ambitions, and the knowledge base (underpinning epidemiological and basic science research). The EBR approach suggests that, in addition, a systematic and transparent approach should be followed to explicitly use all earlier studies and to consider end user perspectives.

QUESTION 1: How often do scientific authors refer to the totality of earlier research? Studies analysing how often scientific authors refer to the totality of earlier research found a general lack of a systematic approach. The main conclusion is, as one of the study authors said:

“No matter how many randomized clinical trials have been done on a particular topic, about half the clinical trials cite none or only one of them. As cynical as I am about such things, I didn’t realize the situation was this bad”. Dr. Steve Goodman, New York Times, 17th January 2011

Goodman was referring to a study he co-authored with Karen Robinson and published in 2011 . They examined all systematic reviews (SRs) of health care questions, published in 2004 that included a meta-analysis combining 4 or more randomised controlled trials (RCTs), so identifying studies that could potentially refer to 3 or more studies within the same area. Even though a great number of the included studies could have referred to 10 or more previous pieces of research, the median number of references for these studies was consistently 2!

ANSWER 1: A systematic and transparent approach is rarely used when citing earlier similar trials .

QUESTION 2: Are systematic reviews used to justify a new study? In a descriptive cross-sectional analysis of 622 RCTs published between 2014 and 2016, only 20% explicitly mentioned a SR as justifications for the new study. 44% did not cite a single SR!

ANSWER 2: A systematic and transparent approach is rarely used to justify new studies .

QUESTION 3: Are systematic reviews used to inform the design of a new study? A retrospective study used applications for funding to see if a SR is used in the planning and design of new RCTs. In the first cohort (2006-2008), 42 of 46 (89%) referred to a SR; in the second cohort (2013) 34 of 34 (100%) referred to a SR. However, very few studies used SRs to inform the design of their new trial beyond justifying the treatment comparison (>90% in both cohorts).

ANSWER 3: A systematic and transparent approach is rarely used to design new studies .

QUESTION 4: Do authors put their results in the context of earlier similar research? In a series of studies, Clarke and Chalmers [ 1998 , 2002 , 2007 & 2010 ] repeatedly showed that RCTs published in the month of May in the five highest ranking medical journals (JAMA; BMJ; NEJM; Lancet and Annals of Internal Medicine) almost never used a SR.

In 2013 Clarke and Hopewell updated this series and found there was still no improvement over time, with only 3% of RCTs containing an updated systematic review integrating their results and only 37% making any systematic attempt to place new results in context.

ANSWER 4: A systematic and transparent approach is rarely used when placing new results in the context of existing results .

Thus, while many people assume that all research is evidence-based, the evidence clearly indicates that this is not the case!

• We encourage researchers to make greater demands on themselves and thus achieve more credible and valuable results.
• We agree research must be free, but not at the expense of increased waste!
• We state that all phases of research must be systematic and transparent, including the planning of new research and the interpretation of new results

The Evidence-Based Research Network

To address the problem outlined above a group of Norwegian and Danish researchers initiated an international network, the ‘Evidence-Based Research Network’. The EBRNetwork was established in Bergen, Norway in December 2014 with initial partners from Australia, Canada, Denmark, the Netherlands, Norway, the UK, and USA.

The  aim  of the EBRNetwork is to reduce waste in research by promoting:

• No new studies without prior systematic review of existing evidence
• Efficient production, updating and dissemination of systematic reviews

The EBRNetwork has suggested a new working definition of a systematic review:

“a systematic review is a structured and preplanned synthesis of original studies that consists of predefined research questions, inclusion criteria, search methods, selection procedures, quality assessment, data extraction, and data analysis. No original research study should be deliberately excluded without explanation, and the results from each study should justify the conclusion.” 

In 2016 members of the EBRNetwork published an analysis article in the BMJ “ Towards evidence-based research ” discussing EBR and its role in preventing research waste. The article contained the EBR Statement , detailing the different stakeholders’ responsibilities in meeting the aims of EBR, and a flow chart for EBR.

Using scientific methods to evaluate performance of research A Scoping Review (under preparation by the EBRNetwork) identified 83 meta-research studies dealing with the different aspects of the EBR concept.

In October 2020 a series of three article was published in the Journal of Clinical Epidemiology further developing the concept of EBR and its use in justifying new studies and putting the results in context: #1- What Evidence-Based Research is and why is it important? #2- Using an Evidence-Based Research approach before a new study is conducted to ensure value #3- Using an Evidence-Based Research approach to place your results into context after the study is performed to ensure usefulness of the conclusion

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Home » Evidence – Definition, Types and Example

Evidence – Definition, Types and Example

Table of Contents

Definition:

Evidence is any information or data that supports or refutes a claim, hypothesis, or argument. It is the basis for making decisions, drawing conclusions, and establishing the truth or validity of a statement.

Types of Evidence

Types of Evidence are as follows:

Empirical evidence

This type of evidence comes from direct observation or measurement, and is usually based on data collected through scientific or other systematic methods.

Expert Testimony

This is evidence provided by individuals who have specialized knowledge or expertise in a particular area, and can provide insight into the validity or reliability of a claim.

Personal Experience

This type of evidence comes from firsthand accounts of events or situations, and can be useful in providing context or a sense of perspective.

Statistical Evidence

This type of evidence involves the use of numbers and data to support a claim, and can include things like surveys, polls, and other types of quantitative analysis.

Analogical Evidence

This involves making comparisons between similar situations or cases, and can be used to draw conclusions about the validity or applicability of a claim.

Documentary Evidence

This includes written or recorded materials, such as contracts, emails, or other types of documents, that can provide support for a claim.

Circumstantial Evidence

This type of evidence involves drawing inferences based on indirect or circumstantial evidence, and can be used to support a claim when direct evidence is not available.

Examples of Evidence

Here are some examples of different types of evidence that could be used to support a claim or argument:

• A study conducted on a new drug, showing its effectiveness in treating a particular disease, based on clinical trials and medical data.
• A doctor providing testimony in court about a patient’s medical condition or injuries.
• A patient sharing their personal experience with a particular medical treatment or therapy.
• A study showing that a particular type of cancer is more common in certain demographics or geographic areas.
• Comparing the benefits of a healthy diet and exercise to maintaining a car with regular oil changes and maintenance.
• A contract showing that two parties agreed to a particular set of terms and conditions.
• The presence of a suspect’s DNA at the crime scene can be used as circumstantial evidence to suggest their involvement in the crime.

Applications of Evidence

Here are some applications of evidence:

• Law : In the legal system, evidence is used to establish facts and to prove or disprove a case. Lawyers use different types of evidence, such as witness testimony, physical evidence, and documentary evidence, to present their arguments and persuade judges and juries.
• Science : Evidence is the foundation of scientific inquiry. Scientists use evidence to support or refute hypotheses and theories, and to advance knowledge in their fields. The scientific method relies on evidence-based observations, experiments, and data analysis.
• Medicine : Evidence-based medicine (EBM) is a medical approach that emphasizes the use of scientific evidence to inform clinical decision-making. EBM relies on clinical trials, systematic reviews, and meta-analyses to determine the best treatments for patients.
• Public policy : Evidence is crucial in informing public policy decisions. Policymakers rely on research studies, evaluations, and other forms of evidence to develop and implement policies that are effective, efficient, and equitable.
• Business : Evidence-based decision-making is becoming increasingly important in the business world. Companies use data analytics, market research, and other forms of evidence to make strategic decisions, evaluate performance, and optimize operations.

Purpose of Evidence

The purpose of evidence is to support or prove a claim or argument. Evidence can take many forms, including statistics, examples, anecdotes, expert opinions, and research studies. The use of evidence is important in fields such as science, law, and journalism to ensure that claims are backed up by factual information and to make decisions based on reliable information. Evidence can also be used to challenge or question existing beliefs and assumptions, and to uncover new knowledge and insights. Overall, the purpose of evidence is to provide a foundation for understanding and decision-making that is grounded in empirical facts and data.

Characteristics of Evidence

Some Characteristics of Evidence are as follows:

• Relevance : Evidence must be relevant to the claim or argument it is intended to support. It should directly address the issue at hand and not be tangential or unrelated.
• Reliability : Evidence should come from a trustworthy and reliable source. The credibility of the source should be established, and the information should be accurate and free from bias.
• Sufficiency : Evidence should be sufficient to support the claim or argument. It should provide enough information to make a strong case, but not be overly repetitive or redundant.
• Validity : Evidence should be based on sound reasoning and logic. It should be based on established principles or theories, and should be consistent with other evidence and observations.
• Timeliness : Evidence should be current and up-to-date. It should reflect the most recent developments or research in the field.
• Accessibility : Evidence should be easily accessible to others who may want to review or evaluate it. It should be clear and easy to understand, and should be presented in a way that is appropriate for the intended audience.

Advantages of Evidence

The use of evidence has several advantages, including:

• Supports informed decision-making: Evidence-based decision-making enables individuals or organizations to make informed choices based on reliable information rather than assumptions or opinions.
• Enhances credibility: The use of evidence can enhance the credibility of claims or arguments by providing factual support.
• Promotes transparency: The use of evidence promotes transparency in decision-making processes by providing a clear and objective basis for decisions.
• Facilitates evaluation : Evidence-based decision-making enables the evaluation of the effectiveness of policies, programs, and interventions.
• Provides insights: The use of evidence can provide new insights and perspectives on complex issues, enabling individuals or organizations to approach problems from different angles.
• Enhances problem-solving : Evidence-based decision-making can help individuals or organizations to identify the root causes of problems and develop more effective solutions.

Limitations of Evidence

Some Limitations of Evidence are as follows:

• Limited availability : Evidence may not always be available or accessible, particularly in areas where research is limited or where data collection is difficult.
• Interpretation challenges: Evidence can be open to interpretation, and individuals may interpret the same evidence differently based on their biases, experiences, or values.
• Time-consuming: Gathering and evaluating evidence can be time-consuming and require significant resources, which may not always be feasible in certain contexts.
• May not apply universally : Evidence may be context-specific and may not apply universally to other situations or populations.
• Potential for bias: Even well-designed studies or research can be influenced by biases, such as selection bias, measurement bias, or publication bias.
• Ethical concerns : Evidence may raise ethical concerns, such as the use of personal data or the potential harm to research participants.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Nursing Research

Evidence-based research.

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Search Strategies

• Graduate Research
• Getting Started
• Finding EBP Articles
• Picking a Topic
• PICO(T) Questions
• Levels of Evidence
• Qualitative Studies
• Quantitative Studies
• How to Read an Article
• Evidence Appraisal
• Validity and Reliability

Nursing research can feel intimidating and confusing, so these resources were created to guide you through the process. Start by watching the video below to learn the differences between evidence-based practice articles and scholarly, research articles. You may also download the comparison chart to save as a quick reference. Knowing the differences will help you as you search for and evaluate nursing research.

• Differentiating research, evidence-based practice, and quality improvement
• EBP vs. Scholarly Research Article Comparison Chart

Start your search in one or more of these databases:

Discovery is an all-in-one search platform. Search most of our academic databases at one time on our familiar, easy-to-use EBSCO platform.

• CINAHL Complete This link opens in a new window Rasmussen has upgraded from CINAHL Plus with Full Text to CINAHL Complete! We now have access to 62% more full-text journals for your use! As always, CINAHL is geared towards nurses and medical professionals and is the definitive research tool for nursing and allied health literature.
• Ovid Nursing Journals This link opens in a new window Articles from more than 90 nursing journals in full text, searchable as far back as 1995.
• Health Sciences and Nursing (ProQuest) This link opens in a new window Health sciences, biology, science, and pharmaceutical information from ProQuest. Includes articles from scholarly, peer-reviewed journals, practical and professional development content from professional journals, and general interest articles from magazines and newspapers.

In the search box, enter in the nursing topic that you are interested in. Then, include the phrase "best practice" or "evidence-based", keeping the quotation marks around the words. Best practices are informed by evidence, so try using both phrases to see how they affect your search results. The phrase "best practice" may not show up in the article title, so be sure to read the abstract before ruling out an article. 

You can also change the publication date range so that only articles published in the last five years are shown.

If you are struggling to tell the difference between evidence-based and scholarly research articles, check out the video in the Getting Started tab.

It can be challenging to pick a topic from such a huge pool of possibilities. It is important to pick a topic that interests you because you will be spending a lot of time researching and writing about it! 

Check out the table below for ideas of selecting an evidence-based practice problem. After selecting your broad topic, create a concept map to narrow down your topic and develop your PICO question.

Adapted from Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals (4th ed., p. 81), by D. Dang, S. L. Dearholt, K. Bissett, J. Ascenzi, and M. Whalen, 2021, Sigma Theta Tau International Honor Society of Nursing (https://ebookcentral.proquest.com/lib/ras/reader.action?docID=6677828&ppg=1). Copyright 2022 by Sigma Theta Tau International Honor Society of Nursing.

• Searching for proof: Creating and using an actionable PICO question
• To make your case, start with a PICOT question
• A nurses’ guide to the hierarchy of research designs and evidence more... less... This article provides a breakdown of the components of the hierarchy, or pyramid, of research designs. Its intention is to simplify the components of the hierarchy to enable novice readers of research to better understand the differing approaches and levels of evidence.

Hierarchy of Evidence Guide

Research Evidence

• Experimental study, randomized controlled trial (RCT)
• Explanatory mixed methods design that includes only a Level I quantitative study
• Systematic review of RCTs, with or without meta-analysis
• Quasi-experimental Study
• Explanatory mixed methods design that includes only a Level II quantitative study
• Systematic review of a combination of RCTs and quasi-experimental, or quasi-experimental studies only, with or without meta-analysis
• Non-experimental study
• Systematic review of a combination of RCTs, quasi-experimental and nonexperimental studies, or nonexperimental studies only, with or without meta-analysis
• Exploratory, convergent, or multiphasic mixed methods studies
• Explanatory mixed methods design that includes only a Level III quantitative study
• Qualitative study
• Systematic review of qualitative studies, with or without meta-synthesis

Nonresearch Evidence

Opinion of respected authorities and/or nationally recognized expert committees or consensus panels based on scientific evidence. Includes:

• Clinical practice guidelines
• Consensus panels/position statements

Level V Based on experiential and non-research evidence. Includes:

• Scoping reviews
• Integrative reviews
• Literature reviews
• Quality improvement, program or financial evaluation
• Case reports
• Opinion of nationally recognized expert(s) based on experiential evidence

Adapted from  Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals  (4th ed., p. 296), by D. Dang, S. L. Dearholt, K. Bissett, J. Ascenzi, and M. Whalen, 2021, Sigma Theta Tau International Honor Society of Nursing (https://ebookcentral.proquest.com/lib/ras/reader.action?docID=6677828&ppg=1). Copyright 2022 by Sigma Theta Tau International Honor Society of Nursing.

• Do not enter your entire PICO(T) into the search box
• Identify two to three keywords at most for your first search
• Scholarly (Peer Reviewed) Journals
• Publication Date Range
• If you have too few results, take out a search term
• Make sure you read the abstract and do not make a decision on an article only by its title
• Create a free MyEBSCOhost account so you can save articles to a folder for access later
• Start your searching early so that you have time to request articles through interlibrary loan
• Make an appointment with the School of Nursing librarian for research help

Adapted from "A Nurses’ Guide to Qualitative Research," by R. Ingham-Broomfield, 2015, Australian Journal Of Advanced Nursing, 32 (3), p. 39 (https://www.ajan.com.au/archive/Vol32/Issue3/4Broomfield.pdf). Copyright 2015 by the Australian Nursing & Midwifery Federation.

Adapted from Research Ready: Quantitative Approaches , by Center for Innovation in Research on Teaching, n.d., Grand Canyon University (https://cirt.gcu.edu/research/develop/research_ready/quantresearch/6).

• How to read a research paper
• Reading and critiquing a research article

• Evidence Appraisal Worksheet, from Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals,Fourth Edition Use this worksheet to help evaluate a nursing research article you have found. It will walk you through determining what level of evidence was used and then identifying the quality of the study.

• Reliability and validity in research
• The language of research (part 5): Research terminology — validity
• The language of research (part 7): Research terminology — reliability

Validity: The extent to which a variable or intervention measures what it is supposed to measure or accomplishes what it is supposed to accomplish. 

Internal validity refers specifically to whether an experimental treatment/condition makes a difference or not, and whether there is sufficient evidence to support the claim.

External validity refers to the generalizability of the treatment/condition outcomes.

Factors which jeopardize internal validity

• History --the specific events which occur between the first and second measurement.
• Maturation --the processes within subjects which act as a function of the passage of time. i.e. if the project lasts a few years, most participants may improve their performance regardless of treatment.
• Testing --the effects of taking a test on the outcomes of taking a second test.
• Instrumentation --the changes in the instrument, observers, or scorers which may produce changes in outcomes.
• Statistical regression --It is also known as regression to the mean. This threat is caused by the selection of subjects on the basis of extreme scores or characteristics. Give me forty worst students and I guarantee that they will show immediate improvement right after my treatment.
• Selection of subjects --the biases which may result in selection of comparison groups. Randomization (Random assignment) of group membership is a counter-attack against this threat. However, when the sample size is small, randomization may lead to Simpson Paradox.
• Experimental mortality --the loss of subjects. For example, in a Web-based instruction project entitled Eruditio, it started with 161 subjects and only 95 of them completed the entire module. Those who stayed in the project all the way to end may be more motivated to learn and thus achieved higher performance.
• Selection-maturation interaction --the selection of comparison groups and maturation interacting which may lead to confounding outcomes, and erroneous interpretation that the treatment caused the effect.
• John Henry effect --John Henry was a worker who outperformed a machine under an experimental setting because he was aware that his performance was compared with that of a machine.

Factors which jeopardize external validity

• Reactive or interaction effect of testing --a pretest might increase or decrease a subject's sensitivity or responsiveness to the experimental variable.
• Interaction effects of selection biases and the experimental variable
• Reactive effects of experimental arrangements --it is difficult to generalize to non-experimental settings if the effect was attributable to the experimental arrangement of the research.
• Multiple treatment interference --as multiple treatments are given to the same subjects, it is difficult to control for the effects of prior treatments.

(Content credit: UW-Madison Ebling Library https://researchguides.library.wisc.edu/nursing)

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• Last Updated: Apr 23, 2024 8:51 AM

• Library Mission & Policies

• Open access
• Published: 19 April 2024

A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact

• Aklilu Endalamaw 1 , 2 ,
• Resham B Khatri 1 , 3 ,
• Tesfaye Setegn Mengistu 1 , 2 ,
• Daniel Erku 1 , 4 , 5 ,
• Eskinder Wolka 6 ,
• Anteneh Zewdie 6 &
• Yibeltal Assefa 1  

BMC Health Services Research volume  24 , Article number:  487 ( 2024 ) Cite this article

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The growing adoption of continuous quality improvement (CQI) initiatives in healthcare has generated a surge in research interest to gain a deeper understanding of CQI. However, comprehensive evidence regarding the diverse facets of CQI in healthcare has been limited. Our review sought to comprehensively grasp the conceptualization and principles of CQI, explore existing models and tools, analyze barriers and facilitators, and investigate its overall impacts.

This qualitative scoping review was conducted using Arksey and O’Malley’s methodological framework. We searched articles in PubMed, Web of Science, Scopus, and EMBASE databases. In addition, we accessed articles from Google Scholar. We used mixed-method analysis, including qualitative content analysis and quantitative descriptive for quantitative findings to summarize findings and PRISMA extension for scoping reviews (PRISMA-ScR) framework to report the overall works.

A total of 87 articles, which covered 14 CQI models, were included in the review. While 19 tools were used for CQI models and initiatives, Plan-Do-Study/Check-Act cycle was the commonly employed model to understand the CQI implementation process. The main reported purposes of using CQI, as its positive impact, are to improve the structure of the health system (e.g., leadership, health workforce, health technology use, supplies, and costs), enhance healthcare delivery processes and outputs (e.g., care coordination and linkages, satisfaction, accessibility, continuity of care, safety, and efficiency), and improve treatment outcome (reduce morbidity and mortality). The implementation of CQI is not without challenges. There are cultural (i.e., resistance/reluctance to quality-focused culture and fear of blame or punishment), technical, structural (related to organizational structure, processes, and systems), and strategic (inadequate planning and inappropriate goals) related barriers that were commonly reported during the implementation of CQI.

Conclusions

Implementing CQI initiatives necessitates thoroughly comprehending key principles such as teamwork and timeline. To effectively address challenges, it’s crucial to identify obstacles and implement optimal interventions proactively. Healthcare professionals and leaders need to be mentally equipped and cognizant of the significant role CQI initiatives play in achieving purposes for quality of care.

Peer Review reports

Continuous quality improvement (CQI) initiative is a crucial initiative aimed at enhancing quality in the health system that has gradually been adopted in the healthcare industry. In the early 20th century, Shewhart laid the foundation for quality improvement by describing three essential steps for process improvement: specification, production, and inspection [ 1 , 2 ]. Then, Deming expanded Shewhart’s three-step model into ‘plan, do, study/check, and act’ (PDSA or PDCA) cycle, which was applied to management practices in Japan in the 1950s [ 3 ] and was gradually translated into the health system. In 1991, Kuperman applied a CQI approach to healthcare, comprising selecting a process to be improved, assembling a team of expert clinicians that understands the process and the outcomes, determining key steps in the process and expected outcomes, collecting data that measure the key process steps and outcomes, and providing data feedback to the practitioners [ 4 ]. These philosophies have served as the baseline for the foundation of principles for continuous improvement [ 5 ].

Continuous quality improvement fosters a culture of continuous learning, innovation, and improvement. It encourages proactive identification and resolution of problems, promotes employee engagement and empowerment, encourages trust and respect, and aims for better quality of care [ 6 , 7 ]. These characteristics drive the interaction of CQI with other quality improvement projects, such as quality assurance and total quality management [ 8 ]. Quality assurance primarily focuses on identifying deviations or errors through inspections, audits, and formal reviews, often settling for what is considered ‘good enough’, rather than pursuing the highest possible standards [ 9 , 10 ], while total quality management is implemented as the management philosophy and system to improve all aspects of an organization continuously [ 11 ].

Continuous quality improvement has been implemented to provide quality care. However, providing effective healthcare is a complicated and complex task in achieving the desired health outcomes and the overall well-being of individuals and populations. It necessitates tackling issues, including access, patient safety, medical advances, care coordination, patient-centered care, and quality monitoring [ 12 , 13 ], rooted long ago. It is assumed that the history of quality improvement in healthcare started in 1854 when Florence Nightingale introduced quality improvement documentation [ 14 ]. Over the passing decades, Donabedian introduced structure, processes, and outcomes as quality of care components in 1966 [ 15 ]. More comprehensively, the Institute of Medicine in the United States of America (USA) has identified effectiveness, efficiency, equity, patient-centredness, safety, and timeliness as the components of quality of care [ 16 ]. Moreover, quality of care has recently been considered an integral part of universal health coverage (UHC) [ 17 ], which requires initiatives to mobilise essential inputs [ 18 ].

While the overall objective of CQI in health system is to enhance the quality of care, it is important to note that the purposes and principles of CQI can vary across different contexts [ 19 , 20 ]. This variation has sparked growing research interest. For instance, a review of CQI approaches for capacity building addressed its role in health workforce development [ 21 ]. Another systematic review, based on random-controlled design studies, assessed the effectiveness of CQI using training as an intervention and the PDSA model [ 22 ]. As a research gap, the former review was not directly related to the comprehensive elements of quality of care, while the latter focused solely on the impact of training using the PDSA model, among other potential models. Additionally, a review conducted in 2015 aimed to identify barriers and facilitators of CQI in Canadian contexts [ 23 ]. However, all these reviews presented different perspectives and investigated distinct outcomes. This suggests that there is still much to explore in terms of comprehensively understanding the various aspects of CQI initiatives in healthcare.

As a result, we conducted a scoping review to address several aspects of CQI. Scoping reviews serve as a valuable tool for systematically mapping the existing literature on a specific topic. They are instrumental when dealing with heterogeneous or complex bodies of research. Scoping reviews provide a comprehensive overview by summarizing and disseminating findings across multiple studies, even when evidence varies significantly [ 24 ]. In our specific scoping review, we included various types of literature, including systematic reviews, to enhance our understanding of CQI.

This scoping review examined how CQI is conceptualized and measured and investigated models and tools for its application while identifying implementation challenges and facilitators. It also analyzed the purposes and impact of CQI on the health systems, providing valuable insights for enhancing healthcare quality.

Protocol registration and results reporting

Protocol registration for this scoping review was not conducted. Arksey and O’Malley’s methodological framework was utilized to conduct this scoping review [ 25 ]. The scoping review procedures start by defining the research questions, identifying relevant literature, selecting articles, extracting data, and summarizing the results. The review findings are reported using the PRISMA extension for a scoping review (PRISMA-ScR) [ 26 ]. McGowan and colleagues also advised researchers to report findings from scoping reviews using PRISMA-ScR [ 27 ].

Defining the research problems

This review aims to comprehensively explore the conceptualization, models, tools, barriers, facilitators, and impacts of CQI within the healthcare system worldwide. Specifically, we address the following research questions: (1) How has CQI been defined across various contexts? (2) What are the diverse approaches to implementing CQI in healthcare settings? (3) Which tools are commonly employed for CQI implementation ? (4) What barriers hinder and facilitators support successful CQI initiatives? and (5) What effects CQI initiatives have on the overall care quality?

Information source and search strategy

We conducted the search in PubMed, Web of Science, Scopus, and EMBASE databases, and the Google Scholar search engine. The search terms were selected based on three main distinct concepts. One group was CQI-related terms. The second group included terms related to the purpose for which CQI has been implemented, and the third group included processes and impact. These terms were selected based on the Donabedian framework of structure, process, and outcome [ 28 ]. Additionally, the detailed keywords were recruited from the primary health framework, which has described lists of dimensions under process, output, outcome, and health system goals of any intervention for health [ 29 ]. The detailed search strategy is presented in the Supplementary file 1 (Search strategy). The search for articles was initiated on August 12, 2023, and the last search was conducted on September 01, 2023.

Eligibility criteria and article selection

Based on the scoping review’s population, concept, and context frameworks [ 30 ], the population included any patients or clients. Additionally, the concepts explored in the review encompassed definitions, implementation, models, tools, barriers, facilitators, and impacts of CQI. Furthermore, the review considered contexts at any level of health systems. We included articles if they reported results of qualitative or quantitative empirical study, case studies, analytic or descriptive synthesis, any review, and other written documents, were published in peer-reviewed journals, and were designed to address at least one of the identified research questions or one of the identified implementation outcomes or their synonymous taxonomy as described in the search strategy. Based on additional contexts, we included articles published in English without geographic and time limitations. We excluded articles with abstracts only, conference abstracts, letters to editors, commentators, and corrections.

We exported all citations to EndNote x20 to remove duplicates and screen relevant articles. The article selection process includes automatic duplicate removal by using EndNote x20, unmatched title and abstract removal, citation and abstract-only materials removal, and full-text assessment. The article selection process was mainly conducted by the first author (AE) and reported to the team during the weekly meetings. The first author encountered papers that caused confusion regarding whether to include or exclude them and discussed them with the last author (YA). Then, decisions were ultimately made. Whenever disagreements happened, they were resolved by discussion and reconsideration of the review questions in relation to the written documents of the article. Further statistical analysis, such as calculating Kappa, was not performed to determine article inclusion or exclusion.

Data extraction and data items

We extracted first author, publication year, country, settings, health problem, the purpose of the study, study design, types of intervention if applicable, CQI approaches/steps if applicable, CQI tools and procedures if applicable, and main findings using a customized Microsoft Excel form.

Summarizing and reporting the results

The main findings were summarized and described based on the main themes, including concepts under conceptualizing, principles, teams, timelines, models, tools, barriers, facilitators, and impacts of CQI. Results-based convergent synthesis, achieved through mixed-method analysis, involved content analysis to identify the thematic presentation of findings. Additionally, a narrative description was used for quantitative findings, aligning them with the appropriate theme. The authors meticulously reviewed the primary findings from each included material and contextualized these findings concerning the main themes1. This approach provides a comprehensive understanding of complex interventions and health systems, acknowledging quantitative and qualitative evidence.

Search results

A total of 11,251 documents were identified from various databases: SCOPUS ( n  = 4,339), PubMed ( n  = 2,893), Web of Science ( n  = 225), EMBASE ( n  = 3,651), and Google Scholar ( n  = 143). After removing duplicates ( n  = 5,061), 6,190 articles were evaluated by title and abstract. Subsequently, 208 articles were assessed for full-text eligibility. Following the eligibility criteria, 121 articles were excluded, leaving 87 included in the current review (Fig.  1 ).

Article selection process

Operationalizing continuous quality improvement

Continuous Quality Improvement (CQI) is operationalized as a cyclic process that requires commitment to implementation, teamwork, time allocation, and celebrating successes and failures.

CQI is a cyclic ongoing process that is followed reflexive, analytical and iterative steps, including identifying gaps, generating data, developing and implementing action plans, evaluating performance, providing feedback to implementers and leaders, and proposing necessary adjustments [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ].

CQI requires committing to the philosophy, involving continuous improvement [ 19 , 38 ], establishing a mission statement [ 37 ], and understanding quality definition [ 19 ].

CQI involves a wide range of patient-oriented measures and performance indicators, specifically satisfying internal and external customers, developing quality assurance, adopting common quality measures, and selecting process measures [ 8 , 19 , 35 , 36 , 37 , 39 , 40 ].

CQI requires celebrating success and failure without personalization, leading each team member to develop error-free attitudes [ 19 ]. Success and failure are related to underlying organizational processes and systems as causes of failure rather than blaming individuals [ 8 ] because CQI is process-focused based on collaborative, data-driven, responsive, rigorous and problem-solving statistical analysis [ 8 , 19 , 38 ]. Furthermore, a gap or failure opens another opportunity for establishing a data-driven learning organization [ 41 ].

CQI cannot be implemented without a CQI team [ 8 , 19 , 37 , 39 , 42 , 43 , 44 , 45 , 46 ]. A CQI team comprises individuals from various disciplines, often comprising a team leader, a subject matter expert (physician or other healthcare provider), a data analyst, a facilitator, frontline staff, and stakeholders [ 39 , 43 , 47 , 48 , 49 ]. It is also important to note that inviting stakeholders or partners as part of the CQI support intervention is crucial [ 19 , 38 , 48 ].

The timeline is another distinct feature of CQI because the results of CQI vary based on the implementation duration of each cycle [ 35 ]. There is no specific time limit for CQI implementation, although there is a general consensus that a cycle of CQI should be relatively short [ 35 ]. For instance, a CQI implementation took 2 months [ 42 ], 4 months [ 50 ], 9 months [ 51 , 52 ], 12 months [ 53 , 54 , 55 ], and one year and 5 months [ 49 ] duration to achieve the desired positive outcome, while bi-weekly [ 47 ] and monthly data reviews and analyses [ 44 , 48 , 56 ], and activities over 3 months [ 57 ] have also resulted in a positive outcome.

Continuous quality improvement models and tools

There have been several models are utilized. The Plan-Do-Study/Check-Act cycle is a stepwise process involving project initiation, situation analysis, root cause identification, solution generation and selection, implementation, result evaluation, standardization, and future planning [ 7 , 36 , 37 , 45 , 47 , 48 , 49 , 50 , 51 , 53 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ]. The FOCUS-PDCA cycle enhances the PDCA process by adding steps to find and improve a process (F), organize a knowledgeable team (O), clarify the process (C), understand variations (U), and select improvements (S) [ 55 , 71 , 72 , 73 ]. The FADE cycle involves identifying a problem (Focus), understanding it through data analysis (Analyze), devising solutions (Develop), and implementing the plan (Execute) [ 74 ]. The Logic Framework involves brainstorming to identify improvement areas, conducting root cause analysis to develop a problem tree, logically reasoning to create an objective tree, formulating the framework, and executing improvement projects [ 75 ]. Breakthrough series approach requires CQI teams to meet in quarterly collaborative learning sessions, share learning experiences, and continue discussion by telephone and cross-site visits to strengthen learning and idea exchange [ 47 ]. Another CQI model is the Lean approach, which has been conducted with Kaizen principles [ 52 ], 5 S principles, and the Six Sigma model. The 5 S (Sort, Set/Straighten, Shine, Standardize, Sustain) systematically organises and improves the workplace, focusing on sorting, setting order, shining, standardizing, and sustaining the improvement [ 54 , 76 ]. Kaizen principles guide CQI by advocating for continuous improvement, valuing all ideas, solving problems, focusing on practical, low-cost improvements, using data to drive change, acknowledging process defects, reducing variability and waste, recognizing every interaction as a customer-supplier relationship, empowering workers, responding to all ideas, and maintaining a disciplined workplace [ 77 ]. Lean Six Sigma, a CQI model, applies the DMAIC methodology, which involves defining (D) and measuring the problem (M), analyzing root causes (A), improving by finding solutions (I), and controlling by assessing process stability (C) [ 78 , 79 ]. The 5 C-cyclic model (consultation, collection, consideration, collaboration, and celebration), the first CQI framework for volunteer dental services in Aboriginal communities, ensures quality care based on community needs [ 80 ]. One study used meetings involving activities such as reviewing objectives, assigning roles, discussing the agenda, completing tasks, retaining key outputs, planning future steps, and evaluating the meeting’s effectiveness [ 81 ].

Various tools are involved in the implementation or evaluation of CQI initiatives: checklists [ 53 , 82 ], flowcharts [ 81 , 82 , 83 ], cause-and-effect diagrams (fishbone or Ishikawa diagrams) [ 60 , 62 , 79 , 81 , 82 ], fuzzy Pareto diagram [ 82 ], process maps [ 60 ], time series charts [ 48 ], why-why analysis [ 79 ], affinity diagrams and multivoting [ 81 ], and run chart [ 47 , 48 , 51 , 60 , 84 ], and others mentioned in the table (Table  1 ).

Barriers and facilitators of continuous quality improvement implementation

Implementing CQI initiatives is determined by various barriers and facilitators, which can be thematized into four dimensions. These dimensions are cultural, technical, structural, and strategic dimensions.

Continuous quality improvement initiatives face various cultural, strategic, technical, and structural barriers. Cultural dimension barriers involve resistance to change (e.g., not accepting online technology), lack of quality-focused culture, staff reporting apprehensiveness, and fear of blame or punishment [ 36 , 41 , 85 , 86 ]. The technical dimension barriers of CQI can include various factors that hinder the effective implementation and execution of CQI processes [ 36 , 86 , 87 , 88 , 89 ]. Structural dimension barriers of CQI arise from the organization structure, process, and systems that can impede the effective implementation and sustainability of CQI [ 36 , 85 , 86 , 87 , 88 ]. Strategic dimension barriers are, for example, the inability to select proper CQI goals and failure to integrate CQI into organizational planning and goals [ 36 , 85 , 86 , 87 , 88 , 90 ].

Facilitators are also grouped to cultural, structural, technical, and strategic dimensions to provide solutions to CQI barriers. Cultural challenges were addressed by developing a group culture to CQI and other rewards [ 39 , 41 , 80 , 85 , 86 , 87 , 90 , 91 , 92 ]. Technical facilitators are pivotal to improving technical barriers [ 39 , 42 , 53 , 69 , 86 , 90 , 91 ]. Structural-related facilitators are related to improving communication, infrastructure, and systems [ 86 , 92 , 93 ]. Strategic dimension facilitators include strengthening leadership and improving decision-making skills [ 43 , 53 , 67 , 86 , 87 , 92 , 94 , 95 ] (Table  2 ).

Impact of continuous quality improvement

Continuous quality improvement initiatives can significantly impact the quality of healthcare in a wide range of health areas, focusing on improving structure, the health service delivery process and improving client wellbeing and reducing mortality.

Structure components

These are health leadership, financing, workforce, technology, and equipment and supplies. CQI has improved planning, monitoring and evaluation [ 48 , 53 ], and leadership and planning [ 48 ], indicating improvement in leadership perspectives. Implementing CQI in primary health care (PHC) settings has shown potential for maintaining or reducing operation costs [ 67 ]. Findings from another study indicate that the costs associated with implementing CQI interventions per facility ranged from approximately $2,000 to $10,500 per year, with an average cost of approximately $10 to $60 per admitted client [ 57 ]. However, based on model predictions, the average cost savings after implementing CQI were estimated to be $5430 [ 31 ]. CQI can also be applied to health workforce development [ 32 ]. CQI in the institutional system improved medical education [ 66 , 96 , 97 ], human resources management [ 53 ], motivated staffs [ 76 ], and increased staff health awareness [ 69 ], while concerns raised about CQI impartiality, independence, and public accountability [ 96 ]. Regarding health technology, CQI also improved registration and documentation [ 48 , 53 , 98 ]. Furthermore, the CQI initiatives increased cleanliness [ 54 ] and improved logistics, supplies, and equipment [ 48 , 53 , 68 ].

Process and output components

The process component focuses on the activities and actions involved in delivering healthcare services.

Service delivery

CQI interventions improved service delivery [ 53 , 56 , 99 ], particularly a significant 18% increase in the overall quality of service performance [ 48 ], improved patient counselling, adherence to appropriate procedures, and infection prevention [ 48 , 68 ], and optimised workflow [ 52 ].

Coordination and collaboration

CQI initiatives improved coordination and collaboration through collecting and analysing data, onsite technical support, training, supportive supervision [ 53 ] and facilitating linkages between work processes and a quality control group [ 65 ].

Patient satisfaction

The CQI initiatives increased patient satisfaction and improved quality of life by optimizing care quality management, improving the quality of clinical nursing, reducing nursing defects and enhancing the wellbeing of clients [ 54 , 76 , 100 ], although CQI was not associated with changes in adolescent and young adults’ satisfaction [ 51 ].

CQI initiatives reduced medication error reports from 16 to 6 [ 101 ], and it significantly reduced the administration of inappropriate prophylactic antibiotics [ 44 ], decreased errors in inpatient care [ 52 ], decreased the overall episiotomy rate from 44.5 to 33.3% [ 83 ], reduced the overall incidence of unplanned endotracheal extubation [ 102 ], improving appropriate use of computed tomography angiography [ 103 ], and appropriate diagnosis and treatment selection [ 47 ].

Continuity of care

CQI initiatives effectively improve continuity of care by improving client and physician interaction. For instance, provider continuity levels showed a 64% increase [ 55 ]. Modifying electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives in post-natal follow-up care increased continuity of care to 74% in 2018 compared to baseline 13% in 2012 [ 84 ].

The CQI initiative yielded enhanced efficiency in the cardiac catheterization laboratory, as evidenced by improved punctuality in procedure starts and increased efficiency in manual sheath-pulls inside [ 78 ].

Accessibility

CQI initiatives were effective in improving accessibility in terms of increasing service coverage and utilization rate. For instance, screening for cigarettes, nutrition counselling, folate prescription, maternal care, immunization coverage [ 53 , 81 , 104 , 105 ], reducing the percentage of non-attending patients to surgery to 0.9% from the baseline 3.9% [ 43 ], increasing Chlamydia screening rates from 29 to 60% [ 45 ], increasing HIV care continuum coverage [ 51 , 59 , 60 ], increasing in the uptake of postpartum long-acting reversible contraceptive use from 6.9% at the baseline to 25.4% [ 42 ], increasing post-caesarean section prophylaxis from 36 to 89% [ 62 ], a 31% increase of kangaroo care practice [ 50 ], and increased follow-up [ 65 ]. Similarly, the QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7%, and correct active third-stage labour management, a 19.6% improvement from the baseline, but not significantly associated with improvement in contraceptive service uptake [ 61 ].

Timely access

CQI interventions improved the time care provision [ 52 ], and reduced waiting time [ 62 , 74 , 76 , 106 ]. For instance, the discharge process waiting time in the emergency department decreased from 76 min to 22 min [ 79 ]. It also reduced mean postprocedural length of stay from 2.8 days to 2.0 days [ 31 ].

Acceptability

Acceptability of CQI by healthcare providers was satisfactory. For instance, 88% of the faculty, 64% of the residents, and 82% of the staff believed CQI to be useful in the healthcare clinic [ 107 ].

Outcome components

Morbidity and mortality.

CQI efforts have demonstrated better management outcomes among diabetic patients [ 40 ], patients with oral mucositis [ 71 ], and anaemic patients [ 72 ]. It has also reduced infection rate in post-caesarean Sect. [ 62 ], reduced post-peritoneal dialysis peritonitis [ 49 , 108 ], and prevented pressure ulcers [ 70 ]. It is explained by peritonitis incidence from once every 40.1 patient months at baseline to once every 70.8 patient months after CQI [ 49 ] and a 63% reduction in pressure ulcer prevalence within 2 years from 2008 to 2010 [ 70 ]. Furthermore, CQI initiatives significantly reduced in-hospital deaths [ 31 ] and increased patient survival rates [ 108 ]. Figure  2 displays the overall process of the CQI implementations.

The overall mechanisms of continuous quality improvement implementation

In this review, we examined the fundamental concepts and principles underlying CQI, the factors that either hinder or assist in its successful application and implementation, and the purpose of CQI in enhancing quality of care across various health issues.

Our findings have brought attention to the application and implementation of CQI, emphasizing its underlying concepts and principles, as evident in the existing literature [ 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 , 43 , 45 , 46 ]. Continuous quality improvement has shared with the principles of continuous improvement, such as a customer-driven focus, effective leadership, active participation of individuals, a process-oriented approach, systematic implementation, emphasis on design improvement and prevention, evidence-based decision-making, and fostering partnership [ 5 ]. Moreover, Deming’s 14 principles laid the foundation for CQI principles [ 109 ]. These principles have been adapted and put into practice in various ways: ten [ 19 ] and five [ 38 ] principles in hospitals, five principles for capacity building [ 38 ], and two principles for medication error prevention [ 41 ]. As a principle, the application of CQI can be process-focused [ 8 , 19 ] or impact-focused [ 38 ]. Impact-focused CQI focuses on achieving specific outcomes or impacts, whereas process-focused CQI prioritizes and improves the underlying processes and systems. These principles complement each other and can be utilized based on the objectives of quality improvement initiatives in healthcare settings. Overall, CQI is an ongoing educational process that requires top management’s involvement, demands coordination across departments, encourages the incorporation of views beyond clinical area, and provides non-judgemental evidence based on objective data [ 110 ].

The current review recognized that it was not easy to implement CQI. It requires reasonable utilization of various models and tools. The application of each tool can be varied based on the studied health problem and the purpose of CQI initiative [ 111 ], varied in context, content, structure, and usability [ 112 ]. Additionally, overcoming the cultural, technical, structural, and strategic-related barriers. These barriers have emerged from clinical staff, managers, and health systems perspectives. Of the cultural obstacles, staff non-involvement, resistance to change, and reluctance to report error were staff-related. In contrast, others, such as the absence of celebration for success and hierarchical and rational culture, may require staff and manager involvement. Staff members may exhibit reluctance in reporting errors due to various cultural factors, including lack of trust, hierarchical structures, fear of retribution, and a blame-oriented culture. These challenges pose obstacles to implementing standardized CQI practices, as observed, for instance, in community pharmacy settings [ 85 ]. The hierarchical culture, characterized by clearly defined levels of power, authority, and decision-making, posed challenges to implementing CQI initiatives in public health [ 41 , 86 ]. Although rational culture, a type of organizational culture, emphasizes logical thinking and rational decision-making, it can also create challenges for CQI implementation [ 41 , 86 ] because hierarchical and rational cultures, which emphasize bureaucratic norms and narrow definitions of achievement, were found to act as barriers to the implementation of CQI [ 86 ]. These could be solved by developing a shared mindset and collective commitment, establishing a shared purpose, developing group norms, and cultivating psychological preparedness among staff, managers, and clients to implement and sustain CQI initiatives. Furthermore, reversing cultural-related barriers necessitates cultural-related solutions: development of a culture and group culture to CQI [ 41 , 86 ], positive comprehensive perception [ 91 ], commitment [ 85 ], involving patients, families, leaders, and staff [ 39 , 92 ], collaborating for a common goal [ 80 , 86 ], effective teamwork [ 86 , 87 ], and rewarding and celebrating successes [ 80 , 90 ].

The technical dimension barriers of CQI can include inadequate capitalization of a project and insufficient support for CQI facilitators and data entry managers [ 36 ], immature electronic medical records or poor information systems [ 36 , 86 ], and the lack of training and skills [ 86 , 87 , 88 ]. These challenges may cause the CQI team to rely on outdated information and technologies. The presence of barriers on the technical dimension may challenge the solid foundation of CQI expertise among staff, the ability to recognize opportunities for improvement, a comprehensive understanding of how services are produced and delivered, and routine use of expertise in daily work. Addressing these technical barriers requires knowledge creation activities (training, seminar, and education) [ 39 , 42 , 53 , 69 , 86 , 90 , 91 ], availability of quality data [ 86 ], reliable information [ 92 ], and a manual-online hybrid reporting system [ 85 ].

Structural dimension barriers of CQI include inadequate communication channels and lack of standardized process, specifically weak physician-to-physician synergies [ 36 ], lack of mechanisms for disseminating knowledge and limited use of communication mechanisms [ 86 ]. Lack of communication mechanism endangers sharing ideas and feedback among CQI teams, leading to misunderstandings, limited participation and misinterpretations, and a lack of learning [ 113 ]. Knowledge translation facilitates the co-production of research, subsequent diffusion of knowledge, and the developing stakeholder’s capacity and skills [ 114 ]. Thus, the absence of a knowledge translation mechanism may cause missed opportunities for learning, inefficient problem-solving, and limited creativity. To overcome these challenges, organizations should establish effective communication and information systems [ 86 , 93 ] and learning systems [ 92 ]. Though CQI and knowledge translation have interacted with each other, it is essential to recognize that they are distinct. CQI focuses on process improvement within health care systems, aiming to optimize existing processes, reduce errors, and enhance efficiency.

In contrast, knowledge translation bridges the gap between research evidence and clinical practice, translating research findings into actionable knowledge for practitioners. While both CQI and knowledge translation aim to enhance health care quality and patient outcomes, they employ different strategies: CQI utilizes tools like Plan-Do-Study-Act cycles and statistical process control, while knowledge translation involves knowledge synthesis and dissemination. Additionally, knowledge translation can also serve as a strategy to enhance CQI. Both concepts share the same principle: continuous improvement is essential for both. Therefore, effective strategies on the structural dimension may build efficient and effective steering councils, information systems, and structures to diffuse learning throughout the organization.

Strategic factors, such as goals, planning, funds, and resources, determine the overall purpose of CQI initiatives. Specific barriers were improper goals and poor planning [ 36 , 86 , 88 ], fragmentation of quality assurance policies [ 87 ], inadequate reinforcement to staff [ 36 , 90 ], time constraints [ 85 , 86 ], resource inadequacy [ 86 ], and work overload [ 86 ]. These barriers can be addressed through strengthening leadership [ 86 , 87 ], CQI-based mentoring [ 94 ], periodic monitoring, supportive supervision and coaching [ 43 , 53 , 87 , 92 , 95 ], participation, empowerment, and accountability [ 67 ], involving all stakeholders in decision-making [ 86 , 87 ], a provider-payer partnership [ 64 ], and compensating staff for after-hours meetings on CQI [ 85 ]. The strategic dimension, characterized by a strategic plan and integrated CQI efforts, is devoted to processes that are central to achieving strategic priorities. Roles and responsibilities are defined in terms of integrated strategic and quality-related goals [ 115 ].

The utmost goal of CQI has been to improve the quality of care, which is usually revealed by structure, process, and outcome. After resolving challenges and effectively using tools and running models, the goal of CQI reflects the ultimate reason and purpose of its implementation. First, effectively implemented CQI initiatives can improve leadership, health financing, health workforce development, health information technology, and availability of supplies as the building blocks of a health system [ 31 , 48 , 53 , 68 , 98 ]. Second, effectively implemented CQI initiatives improved care delivery process (counselling, adherence with standards, coordination, collaboration, and linkages) [ 48 , 53 , 65 , 68 ]. Third, the CQI can improve outputs of healthcare delivery, such as satisfaction, accessibility (timely access, utilization), continuity of care, safety, efficiency, and acceptability [ 52 , 54 , 55 , 76 , 78 ]. Finally, the effectiveness of the CQI initiatives has been tested in enhancing responses related to key aspects of the HIV response, maternal and child health, non-communicable disease control, and others (e.g., surgery and peritonitis). However, it is worth noting that CQI initiative has not always been effective. For instance, CQI using a two- to nine-times audit cycle model through systems assessment tools did not bring significant change to increase syphilis testing performance [ 116 ]. This study was conducted within the context of Aboriginal and Torres Strait Islander people’s primary health care settings. Notably, ‘the clinics may not have consistently prioritized syphilis testing performance in their improvement strategies, as facilitated by the CQI program’ [ 116 ]. Additionally, by applying CQI-based mentoring, uptake of facility-based interventions was not significantly improved, though it was effective in increasing community health worker visits during pregnancy and the postnatal period, knowledge about maternal and child health and exclusive breastfeeding practice, and HIV disclosure status [ 117 ]. The study conducted in South Africa revealed no significant association between the coverage of facility-based interventions and Continuous Quality Improvement (CQI) implementation. This lack of association was attributed to the already high antenatal and postnatal attendance rates in both control and intervention groups at baseline, leaving little room for improvement. Additionally, the coverage of HIV interventions remained consistently high throughout the study period [ 117 ].

Regarding health care and policy implications, CQI has played a vital role in advancing PHC and fostering the realization of UHC goals worldwide. The indicators found in Donabedian’s framework that are positively influenced by CQI efforts are comparable to those included in the PHC performance initiative’s conceptual framework [ 29 , 118 , 119 ]. It is clearly explained that PHC serves as the roadmap to realizing the vision of UHC [ 120 , 121 ]. Given these circumstances, implementing CQI can contribute to the achievement of PHC principles and the objectives of UHC. For instance, by implementing CQI methods, countries have enhanced the accessibility, affordability, and quality of PHC services, leading to better health outcomes for their populations. CQI has facilitated identifying and resolving healthcare gaps and inefficiencies, enabling countries to optimize resource allocation and deliver more effective and patient-centered care. However, it is crucial to recognize that the successful implementation of Continuous Quality Improvement (CQI) necessitates optimizing the duration of each cycle, understanding challenges and barriers that extend beyond the health system and settings, and acknowledging that its effectiveness may be compromised if these challenges are not adequately addressed.

Despite abundant literature, there are still gaps regarding the relationship between CQI and other dimensions within the healthcare system. No studies have examined the impact of CQI initiatives on catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness.

Limitations

In conducting this review, it has some limitations to consider. Firstly, only articles published in English were included, which may introduce the exclusion of relevant non-English articles. Additionally, as this review follows a scoping methodology, the focus is on synthesising available evidence rather than critically evaluating or scoring the quality of the included articles.

Continuous quality improvement is investigated as a continuous and ongoing intervention, where the implementation time can vary across different cycles. The CQI team and implementation timelines were critical elements of CQI in different models. Among the commonly used approaches, the PDSA or PDCA is frequently employed. In most CQI models, a wide range of tools, nineteen tools, are commonly utilized to support the improvement process. Cultural, technical, structural, and strategic barriers and facilitators are significant in implementing CQI initiatives. Implementing the CQI initiative aims to improve health system blocks, enhance health service delivery process and output, and ultimately prevent morbidity and reduce mortality. For future researchers, considering that CQI is context-dependent approach, conducting scale-up implementation research about catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness across various settings and health issues would be valuable.

Availability of data and materials

The data used and/or analyzed during the current study are available in this manuscript and/or the supplementary file.

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Endalamaw, A., Khatri, R.B., Mengistu, T.S. et al. A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Serv Res 24 , 487 (2024). https://doi.org/10.1186/s12913-024-10828-0

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Evidence-Based? Research-Based? What does it all Mean?

Have you ever felt puzzled by trying to discern the difference between the terms, evidence-based and research-based ? Or have you ever found yourself feeling intimidated when someone asked you, “But is that program/practice evidence-based?” I know I have. To help me clarify my understanding, I reached out to my colleagues here at the Center and my old friend, Google. I’ve come to the following understandings and a bit of friendly advice – stay curious! Please keep reading if you’re feeling as perplexed as I am.

Clarifying the Difference between Research-Based and Evidence-Based

My current working definition of research-based instruction has come to mean those practices/programs that are based on well-supported and documented theories of learning. The instructional approach is based on research that supports the principles it incorporates, but there may not be specific research or its own evidence to directly demonstrate its effectiveness.

Defining evidence-based practice has been more headache-inducing as the term is frequently and widely used to mean a myriad of things. Currently, I have come to understand that evidence-based practices are those that have been researched with either experimental studies (think randomly assigned control groups), quasi-experimental studies (comparison groups that are not randomized), or studies that were well-designed and well-implemented correlational studies with statistical controls for selection bias. In brief, a specific study (or studies) has been done to test its effectiveness.

By no means are these definitions ready for Merriam-Webster, but they are helping me to make sense of the terms.

So what do you say or ask when “research” is thrown your way?

Recently, I met with a group of literacy coaches and we discussed how to respond when a fellow educator approaches them with “research” either supporting or refuting an instructional practice or program. My best advice to them probably sounded like a Viking River Cruise commercial – “Be curious!” Below are some examples of ways to respond to demonstrate that you are open to learning more.

• Thank you for bringing that information to my attention. Can you share your source of information or the article so I can read it too and we can talk about it together?
• Please talk more about what you have learned (or read or heard). I’m curious to learn more about: a. Whether the research was published in a peer-reviewed journal or if the research was sponsored by a publisher or other interested party. b. The sample size or the number of schools/students involved in the study. c. The demographics of the subjects involved in the study. d. The type of research conducted.

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• Open access
• Published: 26 April 2024

Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

• Mira-Catalá Pablo 1 ,
• Hernández-Aguado Ildefonso 1 , 2 &
• Chilet-Rosell Elisa 1 , 2  

BMC Pregnancy and Childbirth volume  24 , Article number:  322 ( 2024 ) Cite this article

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Introduction

Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities.

A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected.

Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback.

These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour.

The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.

Plain english summary

Women giving birth experience mistreatment, disrespect, and abuse during labour in health facilities around the world, which constitutes a serious human rights violation. This scoping review synthetises all available information on interventions specifically designed to reduce these negative experiences and to promote respectful maternity care. Although research in this regard is still scarce and focused in low-resource countries, our results indicate that there are promising initiatives to tackle this phenomenon. The most tested strategy is respectful maternity care training for providers, the results of which suggest that it is successful in improving the experiences of care received by women in labour. Other different strategies have been explored, such as open maternity days, clinical checklists, wall posters and constant user feedback. This review shows that there are promising interventions to reduce disrespect and abuse and promote respectful maternity care for women during facility-based childbirth, which should be implemented by health institutions to ensure human-rights based maternity care for women giving birth in health facilities around the world.

Peer Review reports

Over the last decade, there has been an increasing number of studies worldwide regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth [ 1 ]. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing fear of childbirth and severe postpartum depression among the women who experienced them [ 2 , 3 ].

This is not only a quality-of-care issue, but also constitutes a serious violation of human rights. Every woman has the right to the highest attainable level of health, including the right to respectful health care during pregnancy and labour, as stated by the Assertion of Universal Rights of Childbearing Women [ 4 ].

It is important to note that these behaviours by healthcare providers are by definition not intentional and may overlap with other respectful care practices. Nevertheless, women’s experiences of D&A should be considered as such regardless of intentionality. In addition, the characteristics of the healthcare system may explain some of these negative experiences, but should not be used as justification for this mistreatment of women [ 5 ].

Many of the evaluations of D&A during childbirth were initially carried out in low-resource settings. Systematic reviews and meta-analysis in Africa and India have estimated its prevalence at 44% and 71%, respectively [ 6 , 7 ]. However, childbearing women from middle and high-resource countries have also reported mistreatment and D&A during labour. In Latin America, two national surveys in Mexico and Ecuador have described prevalence rates higher than 30% [ 8 , 9 ]. Similar research in the U.S. has reported results over 17% [ 10 ], ranging up to 27%-54% in the Netherlands [ 11 , 12 ], and 38%-67% in Spain [ 13 , 14 ]. However, it is not possible to compare these prevalence studies, as different definitions are used to assess D&A in each of them.

The need for standardised typology and operational definitions of this phenomenon impedes wider research in this area [ 5 ]. In 2010, Bowser and Hill reported seven types of disrespectful and abusive practices during childbirth: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in health facilities [ 15 ]. In 2015, Bohren et al. suggested the term “mistreatment of women”, since they believed it to be broader and more inclusive for the complete range of negative experiences described in the literature. In their systematic review, they also proposed a new categorisation system: physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints [ 5 ].

In Latin America, discussions have not focused on D&A, but rather on terminology referring to “obstetric violence” as one of the various types of violence against women [ 16 ].

Gender inequalities have been fundamental to the conceptualisation of this term. In this regard, Nagle et al. observed a significant relationship between structural sexism and C-section rates in the U.S. [ 17 ]. This finding is in line with the theoretical framing that categorizes it as being a symptom of structural violence and sexism towards women.

Sadler et al. proposed that obstetric violence as a term could address these structural determinants of violence. One reason why this term is not more widely used is that healthcare providers are resistant to the use of the concept of violence [ 18 ]. Focusing the debate on individual malpractices can give rise to unproductive hostility, which is why it is a priority to avoid blaming health professionals as a group [ 19 ]. With this in mind, we will refer to these negative experiences of childbirth using the terms noted above (mistreatment and D&A) and avoid using the term obstetric violence.

Based on the principle that the absence of D&A alone is not enough, respectful maternity care (RMC) is an alternative approach which also highlights the rights of women, promotes equitable access to evidence-based practices and recognises the unique needs and preferences of women. This initiative has been recommended by the WHO as an approach to care for a positive childbirth experience [ 20 ].

Shakibazadeh et al. described some of the concepts that constitute RMC [ 21 ]. Jolivet et al. operationalised these concepts into seven human rights-based categories of RMC: the right to be free from harm and ill treatment; the right to dignity and respect; the right to information, informed consent and respect for choices and preferences (including the right to companionship of choice wherever possible); the right to privacy and confidentiality; the right to non-discrimination, equality and equitable care; the right to timely healthcare and to the highest attainable level of health; and the right to liberty, autonomy, self-determination and freedom from coercion [ 22 ]. Both respectful and disrespectful care should be taken into account, given that some practices may not seem very disrespectful but should not be considered acceptable as part of respectful maternity care [ 23 ].

Women’s healthcare should be based on the best available scientific evidence, subject to systematic review and adapted to each patient’s preferences, respecting their rights and principles. This evidence-based approach supports safe, effective and individualised care, while avoiding inappropriate or unnecessarily risky interventions that do not benefit women´s health [ 24 ].

Identifying successful interventions that have addressed these negative experiences during childbirth or that have been directed towards improving RMC may help to design and implement interventions based on best practice in other maternity services and countries. The aim of this article is to summarise the available evidence regarding the initiatives that have been taken to eradicate the mistreatment and D&A that women undergo during childbirth and to promote RMC in health facilities worldwide.

Study design

We conducted a descriptive scoping review of the available peer-reviewed literature. We followed the Arksey and O’Malley’s five-stage framework [ 25 ]. Research was conducted to answer the following question: What interventions have been proven as effective to reduce mistreatment, D&A during facility-based childbirth?

Search strategy

To identify relevant articles, published literature was searched in PubMed using Mesh and free-text terms referring to two main concepts: mistreatment of women and obstetrics.

The search formula was: “Obstetric violence” OR ((“Violence”[Mesh] OR “Gender-Based Violence”[Mesh] OR “Dehumanization”[Mesh] OR “Human Rights”[Mesh] OR “Human Rights Abuses”[Mesh] OR “Physical Abuse”[Mesh] OR “Emotional Abuse”[Mesh] OR “Malpractice”[Mesh] OR “Health Services Misuse”[Mesh] OR “Disrespect” OR “Disrespectful” OR “Respectful” OR “Mistreatment” OR “Abuse” OR “Medicalization” OR “Industrialization”) AND (“Delivery, Obstetric”[Mesh] OR “Parturition”[Mesh] OR “Obstetrics”[Mesh])).

The “Abstract” search filter was used (see “Eligibility Criteria”).

No year restrictions were applied. Any article published previously to the date of the search was included in the review. The search was conducted on June 7, 2022.

Eligibility criteria

We selected any original study that assessed the effectiveness of interventions specifically designed to reduce experiences of mistreatment and D&A or to promote RMC during facility-based childbirth. Both clinical and institutional interventions were included.

The concepts mistreatment and D&A were considered inherently as presented in the original studies that proposed these two terms, as detailed in the introduction.

Articles were selected in English, Spanish, French, Portuguese and Italian.

Articles without an abstract were excluded. We also discarded studies whose methodology was not explicitly detailed (study protocols, commentaries, and conferences).

According to the definition stated before, these negative experiences of care would also encompass medicalization of childbirth. This includes unnecessary C-sections and similar procedures. Nevertheless, the problem on these avoidable medical interventions was recognised decades before research started to focus on mistreatment and D&A as a continuum. Consequently, a large body of literature has been published to this respect, which will require specific reviews on this subject. Moreover, most of the studies regarding this question lack the mistreatment lens when analyzing this issue. For these reasons, articles that only evaluated initiatives to reduce unnecessary C-sections and comparable medical interventions were also excluded.

A particular case are the studies that exclusively analysed programs on the presence of a companion of choice during labor. We also discarded these articles in order not to interfere with the overall scope of the review, since these only evaluated the change on some concrete first-order theme.

Study selection

The three authors participated in the study selection. Each abstract was screened by two different researchers. The same procedure was followed for the full-text evaluation, so that every article was selected by two researchers independently. Discrepancies during these two stages were discussed with the third author until consensus was reached.

Data extraction

The following data were extracted: study type; target and objectives of the intervention (reducing mistreatment and D&A, increasing RMC); approach (quality of care, human rights, gender violence); description and scope of the intervention; evaluation methods; outcomes; and limitations and conclusion of the articles.

The selection of articles and data extraction were performed independently by two authors. Any discrepancies were resolved by consensus.

The initial search yielded 2,279 citations. After screening for their titles and abstract, 40 studies remained. Concordance reached 90%.

After discussion, 15 additional articles were excluded. In case of any doubt, the article was considered for full-text analysis, prioritising the sensitivity of the search. Of the 25 articles that went through full-text analysis, 10 studies were finally included. No article was excluded for language reasons. This whole process is represented on Fig.  1 .

PRISMA flowchart of search and study inclusion process

The publication years ranged from 2015 to 2022, and all were located in Africa except for two, whose settings were Mexico [ 26 ] and the United States [ 27 ].

Of these 10 articles that were included, 5 did a before-and-after study [ 28 , 29 , 30 , 31 , 32 ], 3 used mixed-methods [ 26 , 33 , 34 ], one was a comparative study between birth centers [ 27 ], and another a quasi-experimental study [ 35 ]. Three of them focused on reducing D&A, and 5 on increasing RMC. One sought birth racial equity [ 27 ], and another aimed at humanised childbirth [ 33 ]. Every study approached this phenomenon as a quality-of-care issue, but only 5 of them addressed this topic from a human rights perspective (apart from the one approaching it as an ethnic disparity). Table 1 summarises the main characteristics of these articles.

Most of the interventions were conducted at facility level with different action plans, none of the articles was designed as a policy or as a community-level approach.

The most common feature was to include some sort of RMC training for providers at the intervention center [ 26 , 28 , 29 , 30 , 32 , 33 , 34 , 35 ]. Four of them considered the implementation of D&A continuous feedback [ 28 , 31 , 32 , 35 ], and another 3 were aimed at improving the infrastructure and/or available equipment [ 26 , 31 , 33 ]. Two of them proposed Maternity Open Days [ 28 , 34 ], and another two, counselling for providers [ 28 , 31 ]. One of them also included wall posters [ 30 ], another one, RMC checklists [ 26 ], and other, a provider-patient document on agreed behaviours during labour and delivery [ 35 ].

The article by Almanza et al. did not assess a concrete intervention but a comparison between Roots (a Black-owned culturally centred birth clinic) and other centers [ 27 ]. More detailed information about the studied interventions and the way they were evaluated is presented at Table  2 .

All the studies concluded that the implemented intervention resulted in an improvement in the care received by the delivering women. Kujawski et al. and Smith et al. reported 66% and 15% reduced odds of suffering D&A, respectively [ 31 , 35 ]. Abuya et al. reported a decrease in D&A from 20 to 13% [ 28 ], and Asefa et al. found an 18% reduction in the number of experienced mistreatment components [ 30 ]. Afulani et al. observed a RMC increase from 12 to 64%, although their results differed from the other studies in that verbal and physical abuse paradoxically increased (despite the improvement in reports of being treated with respect) [ 29 ].

Oosthuizen et al. documented that different RMC components improved with the intervention [ 32 ], Molina et al. reported that satisfaction and the perceived quality of care improved [ 26 ], and for Gélinas et al. it was the way in which women were received at the health facility and the attitude of health professionals that were decisive for this level of satisfaction with care [ 33 ].

Ratcliffe et al. found that there was an increase in patient and provider knowledge of user rights, as well as women’s knowledge of the labour and delivery process and provider’s empathy for the women they served, with improved communication and user reports of satisfaction and perceptions of care quality [ 34 ]. Almanza et al. described that autonomy and respect scores were statistically higher for clients receiving culturally centered care at Roots, but no statistical significance was found in scores between black, indigenous and people of colour, and white clients [ 27 ]. More detailed results are presented at Table  2 .

This scoping review synthetised 10 articles testing any kind of initiative specifically designed to reduce D&A or to promote RMC for women seeking care during childbirth in health facilities around the world.

Our results indicate that there are promising interventions to tackle this phenomenon. Even though it was a small sample of articles and in some cases the improvements were not extraordinary, they were sufficiently encouraging to implement context-specific programmes, to make the step from explanatory research to intervention and implementability.

Only 10 articles met the eligibility criteria. This points to a lack of evidence regarding initiatives specifically designed to tackle this phenomenon. Most of the efforts so far have been directed at determining the frequency of D&A and debating its terminology. This is especially relevant in high-income countries, as illustrated by the fact that all the interventions were studied in Africa, with the exceptions of Mexico [ 26 ] and the United States [ 27 ].

As noted before, childbearing women from middle and high-resource countries have also reported mistreatment and D&A during hospital births [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ]. Although the evidence presented by this article can be of value for these higher-income settings, it is important to acknowledge that in many African countries or other developing nations, women’s social status is very low, they have less access to information and education, and live in very closed patriarchal societies, making them a vulnerable population. Therefore, investment on this type of approach could have a different impact in women’s lives in this context. Nevertheless, this should not restrain high and middle-income countries from implementing similar initiatives to the described in this study, since women in these higher-resource settings could also benefit from reducing mistreatment, D&A during childbirth and promoting RMC.

Most of the articles reviewed included training as a relevant part of the intervention. Every study that did so, concluded that it resulted in an improvement of the care received by the delivering women [ 26 , 28 , 29 , 30 , 32 , 33 , 34 , 35 ]. Physical abuse was the most consistently reduced [ 28 , 30 , 31 ]. These results suggest that provider education should include a form of RMC training, which should be encouraged by Gynecology and Obstetrics services.

In the case of Afulani et al. their results differed from the other studies in that verbal and physical abuse paradoxically increased (despite the improvement in reports of being treated with respect). A potential reason they found was that, while treating women with dignity and respect was emphasised in the training, verbal and physical abuse never actually occurred in their simulations, not giving a chance for improvement [ 29 ]. Relative to this, specific types of provider training should be assessed by further scientific research.

Effort should also be headed towards finding any other kind of tools that could complement or enhance these trainings when implemented. Other strategies that only a few articles explored included open maternity days [ 28 , 34 ], clinical checklists [ 26 ], wall posters [ 30 ], and constant user feedback [ 28 , 31 , 32 , 35 ]. While only tested by 1–4 studies each, every one of them seemed to complement the training effectively.

Most of the interventions addressed this issue from a RMC approach [ 26 , 29 , 30 , 32 , 35 ], especially apart from the ones centred on reducing mistreatment and D&A directly. This suggests that RMC constitutes the main initiative currently addressing women experiences of care during childbirth.

In the case of Asefa et al. although physical abuse was indeed reduced, no change was observed in the level of verbal abuse and neglect and discrimination, pointing to the fact that ingrained negative and normalised behaviours require time to change and are strongly associated with age and experience of service providers [ 30 ].

Evidence shows that women’s healthcare is profoundly influenced by sociocultural factors and entrenched gender norms. Health providers often incorporate their own beliefs and biases into their practices, which shape the care they deliver. Addressing these problems requires not only changing the attitudes of health professionals, but also confronting the broader sociocultural beliefs prevalent within communities. Without challenging and transforming these ingrained norms, efforts to improve women’s healthcare will continue to face significant obstacles [ 36 , 37 ].

Relative to this, all the interventions were carried out at facility level, without directly addressing the structural determinants of health related to gender-discrimination at policy level, which although difficult to achieve, could potentially be more effective [ 16 , 17 ]. Besides, efforts directed towards designing community level interventions should also be made.

Our results are similar to those described by Downe et al. In their systematic review [ 38 ], they analysed the articles by Abuya et al. [ 28 ], Kujawski et al. [ 31 ] and Ratcliffe et al. [ 34 ], and two other studies (one placed in South Africa only assessing birth companions, and another one in Sudan testing a communication-building package with staff). They found that RMC interventions increased women’s experiences of respectful care by almost four times, and reduced D&A by about two-thirds. In terms of specific attitudes and behaviours, they found that RMC initiatives could reduce physical abuse, with less evidence on other components of D&A. These results coincide with the ones presented in our study.

The articles included in our review shared several limitations. Most of them lacked a control group, which removed the ability to properly distinguish the intervention’s effect from other contextual factors during the implementation period. In addition, the majority of the initiatives were short (one took place during a year and a half [ 28 ], but the rest only lasted for a few months). Added to the fact noted before, that ingrained negative and normalised behaviours require time to change, this could have underestimated the potential effects of the interventions, but it also made it impossible to assess their long-term sustainability. Finally, for the articles that interviewed women as a means of intervention evaluation, social desirability and recall bias could have altered the results, and studies that included direct labour observations could have also been influenced by the Hawthorne effect (as observed providers may have acted more self-consciously).

Our study also has its own limitations. Being a scoping review, it lacked the degree of control that a systematic review could have offered. However, we felt that this allowed us to explore further findings, serving as a useful landscape analysis. PubMed was the only search engine screened, and we only considered articles with an abstract. Furthermore, given the changing terminology regarding this topic, a standardised search formula could not be used, which might have left some studies out of our scope. Nevertheless, we consider that most of the available evidence was reviewed within this article, providing a comprehensive approach regarding interventions to address this issue.

The 10 articles reviewed in this study indicate that there are promising interventions to reduce D&A and promote RMC for women during facility-based childbirth. Provider training is the most proven strategy, and physical abuse the most consistently reduced. The specific types of training and different initiatives that complement them should be evaluated through further scientific research, and RMC interventions that apply these strategies should be implemented by health institutions. Beyond the need for further research and implementation of the actions already examined, there is an urgent need to establish and evaluate more structural interventions and policies, in order to modify the social and health contexts that impede full RMC to ensure a human rights-based maternity care for women giving birth in health facilities around the world.

Availability of data and materials

All data analysed during this study are included in the published articles cited.

Abbreviations

Disrespect and Abuse

Respectful Maternity Care

World Health Organisation

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Public Health Department, Miguel Hernández University, 03550, Alicante, Spain

Mira-Catalá Pablo, Hernández-Aguado Ildefonso & Chilet-Rosell Elisa

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Research on Digital Transformation Driving the High-Quality Development of Cultural and Tourism Enterprises—Evidence Based on Listed Cultural and Tourism Companies

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• Rui Tang 1 ,
• Pishi Xiu   ORCID: orcid.org/0000-0002-7238-4272 2 &
• Haoxiang Dong 1  

Digital transformation has become an important means for cultural and tourism enterprises to achieve high-quality development. The role of digital transformation in driving the development of cultural and tourism enterprises deserves to be fully explored. Based on the data of 98 listed cultural and tourism companies in China, this paper uses Python text mining, a two-way fixed effects model, and other methods to find that digital transformation could promote high-quality development of cultural and tourism enterprises. The positive effects of digital transformation are not limited by the nature of enterprise ownership, enterprise growth, or the competitive environment. The positive influence of digital transformation is significant when facing a high degree of marketization. Mechanism tests show that improvement in management efficiency, operational efficiency, quality of workforce, and industry spillovers are effective ways for digital transformation to promote high-quality development of cultural and tourism enterprises. The findings provide a decision-making basis for cultural and tourism enterprises to explore the potential of digital technology and cultivate digital transformation as an important driving force for high-quality development of enterprises.

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Tang, R., Xiu, P. & Dong, H. Research on Digital Transformation Driving the High-Quality Development of Cultural and Tourism Enterprises—Evidence Based on Listed Cultural and Tourism Companies. J Knowl Econ (2024). https://doi.org/10.1007/s13132-024-01972-3

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What the data says about crime in the U.S.

A growing share of Americans say reducing crime should be a top priority for the president and Congress to address this year. Around six-in-ten U.S. adults (58%) hold that view today, up from 47% at the beginning of Joe Biden’s presidency in 2021.

We conducted this analysis to learn more about U.S. crime patterns and how those patterns have changed over time.

The analysis relies on statistics published by the FBI, which we accessed through the Crime Data Explorer , and the Bureau of Justice Statistics (BJS), which we accessed through the  National Crime Victimization Survey data analysis tool .

To measure public attitudes about crime in the U.S., we relied on survey data from Pew Research Center and Gallup.

Additional details about each data source, including survey methodologies, are available by following the links in the text of this analysis.

With the issue likely to come up in this year’s presidential election, here’s what we know about crime in the United States, based on the latest available data from the federal government and other sources.

How much crime is there in the U.S.?

It’s difficult to say for certain. The  two primary sources of government crime statistics  – the Federal Bureau of Investigation (FBI) and the Bureau of Justice Statistics (BJS) – paint an incomplete picture.

The FBI publishes  annual data  on crimes that have been reported to law enforcement, but not crimes that haven’t been reported. Historically, the FBI has also only published statistics about a handful of specific violent and property crimes, but not many other types of crime, such as drug crime. And while the FBI’s data is based on information from thousands of federal, state, county, city and other police departments, not all law enforcement agencies participate every year. In 2022, the most recent full year with available statistics, the FBI received data from 83% of participating agencies .

BJS, for its part, tracks crime by fielding a  large annual survey of Americans ages 12 and older and asking them whether they were the victim of certain types of crime in the past six months. One advantage of this approach is that it captures both reported and unreported crimes. But the BJS survey has limitations of its own. Like the FBI, it focuses mainly on a handful of violent and property crimes. And since the BJS data is based on after-the-fact interviews with crime victims, it cannot provide information about one especially high-profile type of offense: murder.

All those caveats aside, looking at the FBI and BJS statistics side-by-side  does  give researchers a good picture of U.S. violent and property crime rates and how they have changed over time. In addition, the FBI is transitioning to a new data collection system – known as the National Incident-Based Reporting System – that eventually will provide national information on a much larger set of crimes , as well as details such as the time and place they occur and the types of weapons involved, if applicable.

Which kinds of crime are most and least common?

Property crime in the U.S. is much more common than violent crime. In 2022, the FBI reported a total of 1,954.4 property crimes per 100,000 people, compared with 380.7 violent crimes per 100,000 people.  

By far the most common form of property crime in 2022 was larceny/theft, followed by motor vehicle theft and burglary. Among violent crimes, aggravated assault was the most common offense, followed by robbery, rape, and murder/nonnegligent manslaughter.

BJS tracks a slightly different set of offenses from the FBI, but it finds the same overall patterns, with theft the most common form of property crime in 2022 and assault the most common form of violent crime.

How have crime rates in the U.S. changed over time?

Both the FBI and BJS data show dramatic declines in U.S. violent and property crime rates since the early 1990s, when crime spiked across much of the nation.

Using the FBI data, the violent crime rate fell 49% between 1993 and 2022, with large decreases in the rates of robbery (-74%), aggravated assault (-39%) and murder/nonnegligent manslaughter (-34%). It’s not possible to calculate the change in the rape rate during this period because the FBI  revised its definition of the offense in 2013 .

The FBI data also shows a 59% reduction in the U.S. property crime rate between 1993 and 2022, with big declines in the rates of burglary (-75%), larceny/theft (-54%) and motor vehicle theft (-53%).

Using the BJS statistics, the declines in the violent and property crime rates are even steeper than those captured in the FBI data. Per BJS, the U.S. violent and property crime rates each fell 71% between 1993 and 2022.

While crime rates have fallen sharply over the long term, the decline hasn’t always been steady. There have been notable increases in certain kinds of crime in some years, including recently.

In 2020, for example, the U.S. murder rate saw its largest single-year increase on record – and by 2022, it remained considerably higher than before the coronavirus pandemic. Preliminary data for 2023, however, suggests that the murder rate fell substantially last year .

How do Americans perceive crime in their country?

Americans tend to believe crime is up, even when official data shows it is down.

In 23 of 27 Gallup surveys conducted since 1993 , at least 60% of U.S. adults have said there is more crime nationally than there was the year before, despite the downward trend in crime rates during most of that period.

While perceptions of rising crime at the national level are common, fewer Americans believe crime is up in their own communities. In every Gallup crime survey since the 1990s, Americans have been much less likely to say crime is up in their area than to say the same about crime nationally.

Public attitudes about crime differ widely by Americans’ party affiliation, race and ethnicity, and other factors . For example, Republicans and Republican-leaning independents are much more likely than Democrats and Democratic leaners to say reducing crime should be a top priority for the president and Congress this year (68% vs. 47%), according to a recent Pew Research Center survey.

How does crime in the U.S. differ by demographic characteristics?

Some groups of Americans are more likely than others to be victims of crime. In the  2022 BJS survey , for example, younger people and those with lower incomes were far more likely to report being the victim of a violent crime than older and higher-income people.

There were no major differences in violent crime victimization rates between male and female respondents or between those who identified as White, Black or Hispanic. But the victimization rate among Asian Americans (a category that includes Native Hawaiians and other Pacific Islanders) was substantially lower than among other racial and ethnic groups.

The same BJS survey asks victims about the demographic characteristics of the offenders in the incidents they experienced.

In 2022, those who are male, younger people and those who are Black accounted for considerably larger shares of perceived offenders in violent incidents than their respective shares of the U.S. population. Men, for instance, accounted for 79% of perceived offenders in violent incidents, compared with 49% of the nation’s 12-and-older population that year. Black Americans accounted for 25% of perceived offenders in violent incidents, about twice their share of the 12-and-older population (12%).

As with all surveys, however, there are several potential sources of error, including the possibility that crime victims’ perceptions about offenders are incorrect.

How does crime in the U.S. differ geographically?

There are big geographic differences in violent and property crime rates.

For example, in 2022, there were more than 700 violent crimes per 100,000 residents in New Mexico and Alaska. That compares with fewer than 200 per 100,000 people in Rhode Island, Connecticut, New Hampshire and Maine, according to the FBI.

The FBI notes that various factors might influence an area’s crime rate, including its population density and economic conditions.

What percentage of crimes are reported to police? What percentage are solved?

Most violent and property crimes in the U.S. are not reported to police, and most of the crimes that  are  reported are not solved.

In its annual survey, BJS asks crime victims whether they reported their crime to police. It found that in 2022, only 41.5% of violent crimes and 31.8% of household property crimes were reported to authorities. BJS notes that there are many reasons why crime might not be reported, including fear of reprisal or of “getting the offender in trouble,” a feeling that police “would not or could not do anything to help,” or a belief that the crime is “a personal issue or too trivial to report.”

Most of the crimes that are reported to police, meanwhile,  are not solved , at least based on an FBI measure known as the clearance rate . That’s the share of cases each year that are closed, or “cleared,” through the arrest, charging and referral of a suspect for prosecution, or due to “exceptional” circumstances such as the death of a suspect or a victim’s refusal to cooperate with a prosecution. In 2022, police nationwide cleared 36.7% of violent crimes that were reported to them and 12.1% of the property crimes that came to their attention.

Which crimes are most likely to be reported to police? Which are most likely to be solved?

Around eight-in-ten motor vehicle thefts (80.9%) were reported to police in 2022, making them by far the most commonly reported property crime tracked by BJS. Household burglaries and trespassing offenses were reported to police at much lower rates (44.9% and 41.2%, respectively), while personal theft/larceny and other types of theft were only reported around a quarter of the time.

Among violent crimes – excluding homicide, which BJS doesn’t track – robbery was the most likely to be reported to law enforcement in 2022 (64.0%). It was followed by aggravated assault (49.9%), simple assault (36.8%) and rape/sexual assault (21.4%).

The list of crimes  cleared  by police in 2022 looks different from the list of crimes reported. Law enforcement officers were generally much more likely to solve violent crimes than property crimes, according to the FBI.

The most frequently solved violent crime tends to be homicide. Police cleared around half of murders and nonnegligent manslaughters (52.3%) in 2022. The clearance rates were lower for aggravated assault (41.4%), rape (26.1%) and robbery (23.2%).

When it comes to property crime, law enforcement agencies cleared 13.0% of burglaries, 12.4% of larcenies/thefts and 9.3% of motor vehicle thefts in 2022.

Are police solving more or fewer crimes than they used to?

Nationwide clearance rates for both violent and property crime are at their lowest levels since at least 1993, the FBI data shows.

Police cleared a little over a third (36.7%) of the violent crimes that came to their attention in 2022, down from nearly half (48.1%) as recently as 2013. During the same period, there were decreases for each of the four types of violent crime the FBI tracks:

• Police cleared 52.3% of reported murders and nonnegligent homicides in 2022, down from 64.1% in 2013.
• They cleared 41.4% of aggravated assaults, down from 57.7%.
• They cleared 26.1% of rapes, down from 40.6%.
• They cleared 23.2% of robberies, down from 29.4%.

The pattern is less pronounced for property crime. Overall, law enforcement agencies cleared 12.1% of reported property crimes in 2022, down from 19.7% in 2013. The clearance rate for burglary didn’t change much, but it fell for larceny/theft (to 12.4% in 2022 from 22.4% in 2013) and motor vehicle theft (to 9.3% from 14.2%).

Note: This is an update of a post originally published on Nov. 20, 2020.

• Criminal Justice

John Gramlich is an associate director at Pew Research Center

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Original research

Evidence-based practice models and frameworks in the healthcare setting: a scoping review, jarrod dusin.

1 Department of Evidence Based Practice, Children’s Mercy Hospitals and Clinics, Kansas City, Missouri, USA

2 Therapeutic Science, The University of Kansas Medical Center, Kansas City, Kansas, USA

Andrea Melanson

Lisa mische-lawson, associated data.

bmjopen-2022-071188supp001.pdf

bmjopen-2022-071188supp002.pdf

No data are available.

The aim of this scoping review was to identify and review current evidence-based practice (EBP) models and frameworks. Specifically, how EBP models and frameworks used in healthcare settings align with the original model of (1) asking the question, (2) acquiring the best evidence, (3) appraising the evidence, (4) applying the findings to clinical practice and (5) evaluating the outcomes of change, along with patient values and preferences and clinical skills.

A Scoping review.

Included sources and articles

Published articles were identified through searches within electronic databases (MEDLINE, EMBASE, Scopus) from January 1990 to April 2022. The English language EBP models and frameworks included in the review all included the five main steps of EBP. Excluded were models and frameworks focused on one domain or strategy (eg, frameworks focused on applying findings).

Of the 20 097 articles found by our search, 19 models and frameworks met our inclusion criteria. The results showed a diverse collection of models and frameworks. Many models and frameworks were well developed and widely used, with supporting validation and updates. Some models and frameworks provided many tools and contextual instruction, while others provided only general process instruction. The models and frameworks reviewed demonstrated that the user must possess EBP expertise and knowledge for the step of assessing evidence. The models and frameworks varied greatly in the level of instruction to assess the evidence. Only seven models and frameworks integrated patient values and preferences into their processes.

Many EBP models and frameworks currently exist that provide diverse instructions on the best way to use EBP. However, the inclusion of patient values and preferences needs to be better integrated into EBP models and frameworks. Also, the issues of EBP expertise and knowledge to assess evidence must be considered when choosing a model or framework.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Currently, no comprehensive review exists of evidence-based practice (EBP) models and frameworks.
• Well-developed models and frameworks may have been excluded for not including all five steps of original model for EBP.
• This review did not measure the quality of the models and frameworks based on validated studies.

Introduction

Evidence-based practice (EBP) grew from evidence-based medicine (EBM) to provide a process to review, translate and implement research with practice to improve patient care, treatment and outcomes. Guyatt 1 coined the term EBM in the early 1990s. Over the last 25 years, the field of EBM has continued to evolve and is now a cornerstone of healthcare and a core competency for all medical professionals. 2 3 At first, the term EBM was used only in medicine. However, the term EBP now applies to the principles of other health professions. This expansion of the concept of EBM increases its complexity. 4 The term EBP is used for this paper because it is universal across professions.

Early in the development of EBP, Sackett 5 created an innovative five-step model. This foundational medical model provided a concise overview of the process of EBP. The five steps are (1) asking the question, (2) acquiring the best evidence, (3) appraising the evidence, (4) applying the findings to clinical practice and (5) evaluating the outcomes of change. Other critical components of Sackett’s model are considering patient value and preferences and clinical skills with the best available evidence. 5 The influence of this model has led to its integration and adaption into every field of healthcare. Historically, the foundation of EBP has focused on asking the question, acquiring the literature and appraising the evidence but has had difficulty integrating evidence into practice. 6 Although the five steps appear simple, each area includes a vast number of ways to review the literature (eg, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Newcastle-Ottawa Scale) and entire fields of study, such as implementation science, a field dedicated to implementing EBP. 7 8 Implementation science can be traced to the 1960s with Everett Rogers’ Diffusion of Innovation Theory and has grown alongside EBP over the last 25 years. 7 9

One way to manage the complexity of EBP in healthcare is by developing EBP models and frameworks that establish strategies to determine resource needs, identify barriers and facilitators, and guide processes. 10 EBP models and frameworks provide insight into the complexity of transforming evidence into clinical practice. 11 They also allow organisations to determine readiness, willingness and potential outcomes for a hospital system. 12 EBP can differ from implementation science, as EBP models include all five of Sackett’s steps of EBP, while the non-process models of implementation science typically focus on the final two steps. 5 10 There are published scoping reviews of implementation science, 13 however, no comprehensive review of EBP models and frameworks currently exists. Although there is overlap of EBP, implementation science and knowledge translation models and frameworks 10 14 the purpose of the scoping review was to explore how EBP models and frameworks used in healthcare settings align with the original EBP five-step model.

A scoping review synthesises findings across various study types and provides a broad overview of the selected topic. 15 The Arksey and O’Malley method and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) procedures guided this review (see online supplemental PRISMA-ScR checklist ). 15 16 The primary author established the research question and inclusion and exclusion criteria before conducting the review. An a priori protocol was not pre-registered. One research question guided the review: Which EBP models and frameworks align with Sackett’s original model?

Supplementary data

Eligibility criteria.

To be included in the review, English language published EBP models and frameworks needed to include the five main steps of EBP (asking the question, acquiring the best evidence, appraising the evidence, applying the findings to clinical practice and assessing the outcomes of change) based on Sackett’s model. 5 If the models or frameworks involved identifying problems or measured readiness for change, the criteria of ‘asking the question’ was met. Exclusions included models or frameworks focused on one domain or strategy (eg, frameworks focused on applying findings). Also, non-peer-reviewed abstracts, letters, editorials, opinion articles, and dissertations were excluded.

Search and selection

To identify potential studies, a medical librarian searched the databases from January 1990 to April 2022 in MEDLINE, EMBASE and Scopus in collaboration with the primary author. The search was limited to 1990 because the term EBP was coined in the early 90s. The search strategy employed the following keywords: ‘Evidence-Based Practice’ OR ‘evidence based medicine’ OR ‘evidence-based medicine’ OR ‘evidence based nursing’ OR ‘evidence-based nursing’ OR ‘evidence based practice’ OR ‘evidence-based practice’ OR ‘evidence based medicine’ OR ‘evidence-based medicine’ OR ‘evidence based nursing’ OR ‘evidence-based nursing’ OR ‘evidence based practice’ OR ‘evidence-based practice’ AND ‘Hospitals’ OR ‘Hospital Medicine’ OR ‘Nursing’ OR ‘Advanced Practice Nursing’ OR ‘Academic Medical Centers’ OR ‘healthcare’ OR ‘hospital’ OR ‘healthcare’ OR ‘hospital’ AND ‘Models, Organizational’ OR ‘Models, Nursing’ OR ‘framework’ OR ‘theory’ OR ‘theories’ OR ‘model’ OR ‘framework’ OR ‘theory’ OR ‘theories’ OR ‘model’. Additionally, reference lists in publications included for full-text review were screened to identify eligible models and frameworks (see online supplemental appendix A for searches).

Selection of sources of evidence

Two authors (JD and AM) independently screened titles and abstracts and selected studies for potential inclusion in the study, applying the predefined inclusion and exclusion criteria. Both authors then read the full texts of these articles to assess eligibility for final inclusion. Disagreement between the authors regarding eligibility was resolved by consensus between the three authors (JD, AM and LM-L). During the selection process, many models and frameworks were found more than once. Once a model or framework article was identified, the seminal article was reviewed for inclusion. If models or frameworks had been changed or updated since the publication of their seminal article, the most current iteration published was reviewed for inclusion. Once a model or framework was identified and verified for inclusion, all other articles listing the model or framework were excluded. This scoping review intended to identify model or framework aligned with Sackett’s model; therefore, analysing every article that used the included model or framework was unnecessary (see online supplemental appendix B for tracking form).

Data extraction and analysis

Data were collected on the following study characteristics: (1) authors, (2) publication year, (3) model or framework and (4) area(s) of focus in reference to Sackett’s five-step model. After initial selection, models and frameworks were analysed for key features and alignment to the five-step EBP process. A data analysis form was developed to map detailed information (see online supplemental appendix C for full data capture form). Data analysis focused on identifying (1) the general themes of the model or frameworks, and (2) any knowledge gaps. Data extraction and analysis were done by the primary author (JD) and verified by one other author (AM). 15

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

The search identified 6523 potentially relevant references (see figure 1 ). Following a review of the titles and abstracts, the primary author completed a more detailed screening of 37 full papers. From these, 19 models and frameworks were included. Table 1 summarises the 19 models and frameworks. Of the 19 models and frameworks assessed and mapped, 15 had broad target audiences, including healthcare or public health organisations or health systems. Only five models and frameworks included a target audience of individual clinicians (eg, physicians and nurses). 17–22

Retrieval and selection process.

Models and frameworks organised by integration of patient preferences and values

EBP, evidence-based practice.

Asking the question

All 19 models and frameworks included a process for asking questions. Most focused on identifying problems that needed to be addressed on an organisational or hospital level. Five used the PICO (population, intervention, comparator, outcome) format to ask specific questions related to patient care. 19–25

Acquiring the evidence

The models and frameworks gave basic instructions on acquiring literature, such as ‘conduct systematic search’ or ‘acquire resource’. 20 Four recommended sources from previously generated evidence, such as guidelines and systematic reviews. 6 21 22 26 Although most models and frameworks did not provide specifics, others suggested this work be done through EBP mentors/experts. 20 21 25 27 Seven models included qualitative evidence in the use of evidence, 6 19 21 24 27–29 while only four models considered the use of patient preference and values as evidence. 21 22 24 27 Six models recommended internal data be used in acquiring information. 17 20–22 24 27

Assessing the evidence

The models and frameworks varied greatly in the level of instruction provided in assessing the best evidence. All provided a general overview in assessing and grading the evidence. Four recommended this work be done by EBP mentors and experts. 20 25 27 30 Seven models developed specific tools to be used to assess the levels of evidence. 6 17 21 22 24 25 27

Applying the evidence

The application of evidence also varied greatly for the different models and frameworks. Seven models recommended pilot programmes to implement change. 6 21–25 31 Five recommended the use of EBP mentors and experts to assist in the implementation of evidence and quality improvement as a strategy of the models and frameworks. 20 24 25 27 Thirteen models and frameworks discussed patient values and preferences, 6 17–19 21–27 31 32 but only seven incorporated this topic into the model or framework, 21–27 and only five included tools and instructions. 21–25 Twelve of the 20 models discussed using clinical skill, but specifics of how this was incorporated was lacking in models and frameworks. 6 17–19 21–27 31

Evaluating the outcomes of change

Evaluation varied among the models and frameworks, but most involved using implementation outcome measures to determine the project’s success. Five models and frameworks provide tools and in-depth instruction for evaluation. 21 22 24–26 Monash Partners Learning Health Systems provided detailed instruction on using internal institutional data to determine success of application. 26 This framework uses internal and external data along with evidence in decision making as a benchmark for successful implementation.

EBP models and frameworks provide a process for transforming evidence into clinical practice and allow organisations to determine readiness and willingness for change in a complex hospital system. 12 The large number of models and frameworks complicates the process by confusing what the best tool is for healthcare organisations. This review examined many models and frameworks and assessed the characteristics and gaps that can better assist healthcare organisations to determine the right tool for themselves. This review identified 19 EBP models and frameworks that included the five main steps of EBP as described by Sackett. 5 The results showed that the themes of the models and frameworks are as diverse as the models and frameworks themselves. Some are well developed and widely used, with supporting validation and updates. 21 22 24 27 One such model, the Iowa EBP model, has received over 3900 requests for permission to use it and has been updated from its initial development and publication. 24 Other models provided tools and contextual instruction such as the Johns Hopkin’s model which includes a large number of supporting tools for developing PICOs, instructions for grading literature and project implementation. 17 21 22 24 27 By contrast, the ACE Star model and the An Evidence Implementation Model for Public Health Systems only provide high level overview and general instructions compared with other models and frameworks. 19 29 33

Gaps in the evidence

A consistent finding in research of clinician experience with EBP is the lack of expertise that is needed to assess the literature. 24 34 35 The models and frameworks reviewed demonstrated that the user must possess the knowledge and related skills for this step in the process. The models and frameworks varied greatly in the level of instruction to assess the evidence. Most provided a general overview in assessing and grading the evidence, though a few recommended that this work be done by EBP mentors and experts. 20 25 27 ARCC, JBI and Johns Hopkins provided robust tools and resources that would require administrative time and financial support. 21 22 27 Some models and frameworks offered vital resources or pointed to other resources for assessing evidence, 24 but most did not. While a few used mentors and experts to assist with assessing the literature, a majority did not address this persistent issue.

Sackett’s five-step model included another important consideration when implementing EBP: patient values and preferences. One criticism of EBP is that it ignores patient values and preferences. 36 Over half of the models and frameworks reported the need to include patient values and preferences, but the tools, instruction or resources for including them were limited. The ARCC model integrates patient preferences and values into the model, but it is up to the EBP mentor to accomplish this task. 37 There are many tools for assessing evidence, but few models and frameworks provide this level of guidance for incorporating patient preference and values. The inclusion of patient and family values and preferences can be misunderstood, insincere, and even tokenistic but without it there is reduced chance of success of implementation of EBP. 38 39

Strengths and limitations

Similar to other well-designed scoping reviews, the strengths of this review include a rigorous search conducted by a skilled librarian, literature evaluation by more than one person, and the utilisation of an established methodological framework (PRISMA-ScR). 14 15 Additionally, utilising the EBP five-step models as a point of alignment allows for a more comprehensive breakdown and established reference points for the reviewed models and frameworks. While scoping reviews have been completed on implementation science and knowledge translation models and framework, to our knowledge, this is the first scoping review of EBP models and frameworks. 13 14 Limitations of the study include that well-developed models and frameworks may have been excluded for not including all five steps. 40 For example, the Promoting Action on Research Implementation in Health Services (PARIHS) framework is a well-developed and validated implementation framework but did not include all five steps of an EBP model. 40 Also, some models and frameworks have been studied and validated over many years. It was beyond the scope of the review to measure the quality of the models and frameworks based on these other validated studies.

Implications and future research

Healthcare organisations can support EBP by choosing a model or framework that best suits their environment and providing clear guidance for implementing the best evidence. Some organisations may find the best fit with the ARCC and the Clinical Scholars Model because of the emphasis on mentors or the Johns Hopkins model for its tools for grading the level of evidence. 21 25 27 In contrast, other organisations may find the Iowa model useful with its feedback loops throughout its process. 24

Another implication of this study is the opportunity to better define and develop robust tools for patient and family values and preferences within EBP models and frameworks. Patient experiences are complex and require thorough exploration, so it is not overlooked, which is often the case. 39 41 The utilisation of EBP models and frameworks provide an opportunity to explore this area and provide the resources and understanding that are often lacking. 38 Though varying, models such as the Iowa Model, JBI and Johns Hopkins developed tools to incorporate patient and family values and preferences, but a majority of the models and frameworks did not. 21 22 24 An opportunity exists to create broad tools that can incorporate patient and family values and preferences into EBP to a similar extent as many of the models and frameworks used for developing tools for literature assessment and implementation. 21–25

Future research should consider appraising the quality and use of the different EBP models and frameworks to determine success. Additionally, greater clarification on what is considered patient and family values and preferences and how they can be integrated into the different models and frameworks is needed.

This scoping review of 19 models and frameworks shows considerable variation regarding how the EBP models and frameworks integrate the five steps of EBP. Most of the included models and frameworks provided a narrow description of the steps needed to assess and implement EBP, while a few provided robust instruction and tools. The reviewed models and frameworks provided diverse instructions on the best way to use EBP. However, the inclusion of patient values and preferences needs to be better integrated into EBP models. Also, the issues of EBP expertise to assess evidence must be considered when selecting a model or framework.

Supplementary Material

Acknowledgments.

We thank Keri Swaggart for completing the database searches and the Medical Writing Center at Children's Mercy Kansas City for editing this manuscript.

Contributors: All authors have read and approved the final manuscript. JD conceptualised the study design, screened the articles for eligibility, extracted data from included studies and contributed to the writing and revision of the manuscript. LM-L conceptualised the study design, provided critical feedback on the manuscript and revised the manuscript. AM screened the articles for eligibility, extracted data from the studies, provided critical feedback on the manuscript and revised the manuscript. JD is the guarantor of this work.

Funding: The article processing charges related to the publication of this article were supported by The University of Kansas (KU) One University Open Access Author Fund sponsored jointly by the KU Provost, KU Vice Chancellor for Research, and KUMC Vice Chancellor for Research and managed jointly by the Libraries at the Medical Center and KU - Lawrence

Disclaimer: No funding agencies had input into the content of this manuscript.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.