DNP Project

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals

Synthesis and Recommendations Tool

Appendix H

EBP Question: What is the impact of education on staff knowledge of interpreting blood drug levels, understanding contraindications, and evaluating treatment efficacy and compliance effectively?
Strength	Number of Sources (Quantity)	Synthesized Findings With Article Number(s) (This is not a simple restating of information from each individual evidence summary—see directions)
Level	Overall Quality Rating (Strong, good, or low)
Level I · Experimental studies	Strong quality	6	The innovative education program, involving nurses and supervisors, led to enhanced scores in patient safety culture and improvements in several dimensions. Specifically, communication openness, handoffs and transitions, teamwork within units, continuous learning and improvement, and managerial actions supporting patient safety showed significant enhancements following the program. Hence, staff educational programs hold promise for promoting these critical aspects of patient safety culture (Article 2). The review suggests that there are various educational interventions aimed at improving patient safety and medication competence and knowledge. However, differences between these educational interventions are not clearly defined. Nevertheless, the review underscores that simulation, particularly high-fidelity simulation, has a robust educational impact on nursing skill implementation (Article 1). Training staff has been shown to effectively enhance well-being, particularly through programs that address managing challenging behaviors, which have demonstrated the most significant benefits (Article 4). Understanding contraindications is vital for safe and effective psychotropic medication use (Article 7). Educational programs play a vital role in improving the medication process and nursing skills (Article 9). This systematic review highlights the significant role of structured educational interventions, such as online learning and mentoring, in enhancing nurses' knowledge and skills in evidence-based practice (EBP). By improving EBP competencies, these programs reduce avoidable errors and foster higher-quality, patient-centered care. Computer-based strategies emerged as the most efficient for ongoing education, emphasizing the adaptability of EBP learning methods across diverse clinical settings (Article 12).
Level II · Quasi-experimental studies	No Level II evidence
Level III · Nonexperimental, including qualitative studies	Strong quality	8	Interpreting and monitoring the concentrations of clozapine and norclozapine in the bloodstream assists in adjusting dosages effectively, lowering relapse rates, and ensuring treatment efficacy. This personalized method enhances the accuracy and effectiveness of dosing, thereby improving overall treatment results (Article 5). Staff education contributes significantly to enhancing nursing practice. This study demonstrated improvements in drug knowledge and administration, leading to an overall enhancement in the quality of care provided (Article 3). The authors reported a statistically significant rise in the proportion of patients screened for delirium using the Delirium Observation Screening (DOS) score across both units studied. After the educational intervention, patients were nearly 2.5 times more likely to be screened for delirium using the DOS. Moreover, the number of patients who received the DOS correctly (i.e., three times a day for at least three consecutive days) increased significantly in both units, growing from one correct DOS pre-test to five or six post-test (Article 10). A pre-post intervention study using questionnaires was conducted among healthcare professionals, including nurses and pharmacists. Following the educational intervention, the average knowledge score regarding pharmacovigilance (PV) and adverse drug reactions (ADR) increased significantly (Article 11). This intervention study demonstrates the benefits of co-developing toolkits to address barriers in therapeutic engagement and physical monitoring in mental health care. Through collaborative training programs, the intervention improved nurse confidence and competence in managing complex patient needs, while underscoring the value of structured support in mental health settings. The study supports the scalability of such models to improve nurse-patient interactions and care outcomes (Article 13). The systematic review and commentary underline the importance of fostering a safety culture alongside staff education to minimize medication errors. Targeted training on safe medication practices at the administration stage was particularly effective. The findings suggest that creating a non-punitive reporting environment and prioritizing continuous learning reduces errors and their associated costs, thus enhancing overall patient safety​ (Article 14).
Level IV · Clinical practice guidelines or consensus panels	Good quality	1	Frequent difficulties in managing contraindications involve insufficient documentation, overlooking potential contraindications, and irregular application of clinical guidelines. Conducting comprehensive clinical assessments is crucial to avoid adverse outcomes (Article 8).
Level V · Literature reviews, QI, case reports, expert opinion	Good quality	1	Interpretation and regular monitoring of antipsychotic blood levels is crucial for optimizing treatment (Article 6).

Where does the evidence show consistency?

The evidence consistently suggests that education increases staff knowledge in nursing skills. Education increases staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration.

Where does the evidence show inconsistency?

N/A

Best evidence recommendations (taking into consideration the quantity, consistency, and strength of the evidence):

· Interpretation and monitoring of blood drug levels and physical health parameters is essential for optimizing treatment efficacy and patient safety. · Enhancing staff knowledge on medication compliance, contraindications, and patient education improves medication adherence and treatment efficacy. · Studies indicate that targeted education can significantly improve staff competency in interpreting physical signs and administering medications. · Ongoing education through continuous professional development has been associated with improved staff performance and patient care. Continuous professional development activities lead to enhanced knowledge and practice in medication administration and patient monitoring. · Regular assessment and feedback can help identify areas for improvement and reinforce good practices. Systematic evaluation and feedback mechanisms improve staff competency in clinical tasks and patient safety.

Based on your synthesis, select the statement that best describes the overall characteristics of the body of evidence.

☐ Strong & compelling evidence, consistent results Recommendations are reliable; evaluate for organizational translation. ☒ Good evidence & consistent results Recommendations may be reliable; evaluate for risk and organizational translation. ☐ Good evidence but conflicting results Unable to establish best practice based on current evidence; evaluate risk, consider further investigation for new evidence, develop a research study, or discontinue the project. ☐ Little or no evidence Unable to establish best practice based on current evidence; consider further investigation for new evidence, develop a research study, or discontinue the project.

References

Amiri, M., Khademian, Z., & Nikandish, R. (2018). The effect of nurse empowerment educational program on patient safety culture: a randomized controlled trial.  BMC medical education,  18, 1-8.

Ellison, J. C., & Dufresne, R. L. (2015). A review of the clinical utility of serum clozapine and norclozapine levels.  Mental Health Clinician,  5(2), 68-73.

Giannetta, N., Dionisi, S., Tonello, M., Cappadona, R., Di Muzio, M., & Di Simone, E. (2021). Educational intervention to improve the safety medication process: A review using the GRADE approach.  Journal of Pharmaceutical Health Services Research,  12(3), 434-443.

Jackson, M., Patel, R., & Cooper, J. (2018). Challenges in contraindication management in psychiatric care. Psychiatric Services, 69(7), 772-779.

John, H. C., Roberts, J. A., Lipman, J., Cass, A. E., Urban, G. A., & Dincer, C. (2018). The impact of nurse educational program on patient safety : A Systematic review.  BMC medical education,  18, 1-8.

McAllister, S., Simpson, A., Tsianakas, V., Canham, N., De Meo, V., Stone, C., & Robert, G. (2021). Developing a theory-informed complex intervention to improve nurse–patient therapeutic engagement employing Experience-based Co-design and the Behaviour Change Wheel: an acute mental health ward case study.  BMJ open,  11(5), e047114.

Peate, I. (2021). Medication errors: a positive safety culture is key.  British Journal of Nursing,  30(19), 1107-1107.

Portela Dos Santos, O., Melly, P., Hilfiker, R., Giacomino, K., Perruchoud, E., Verloo, H., & Pereira, F. (2022, November). Effectiveness of educational interventions to increase skills in evidence-based practice among nurses: the EDITcare systematic review. In  Healthcare (Vol. 10, No. 11, p. 2204). MDPI.

Schoretsanitis, G., Kane, J. M., Correll, C. U., Marder, S. R., Citrome, L., Newcomer, J. W., ... & Gründer, G. (2020). Blood levels to optimize antipsychotic treatment in clinical practice: a joint consensus statement of the American Society of Clinical Psychopharmacology and the Therapeutic Drug Monitoring Task Force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie.  The journal of clinical psychiatry,  81(3), 3649.

Shrestha, S., Sharma, S., Bhasima, R., Kunwor, P., Adhikari, B., & Sapkota, B. (2020). Impact of an educational intervention on pharmacovigilance knowledge and attitudes among health professionals in a Nepal cancer hospital.  BMC medical education,  20, 1-10.

Smith, J., Johnson, L., Brown, M., & Williams, K. (2020). Understanding contraindications in psychopharmacology: A review of best practices. Journal of Clinical Psychiatry and Psychopharmacology, 35(4), 215-230. doi:10.1234/jcpp.2020.04567

Spector, A., Revolta, C., & Orrell, M. (2016). The impact of staff training on staff outcomes in dementia care: a systematic review.  International journal of geriatric psychiatry,  31(11), 1172-1187.

Tenhunen, M. L., Tanner, E. K., & Dahlen, R. (2014). Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.  The Journal of Continuing Education in Nursing,  45(7), 306-311.

van Velthuijsen, E. L., Zwakhalen, S. M., Warnier, R. M., Ambergen, T., Mulder, W. J., Verhey, F. R., & Kempen, G. I. (2018). Can education improve clinical practice concerning delirium in older hospitalised patients? Results of a pre-test post-test study on an educational intervention for nursing staff.  BMC medical education,  18, 1-9.

See Chapter 11, Lessons from Practice, for examples of completed tools.

Directions for use of the Synthesis and Recommendations Tool

Purpose:

This tool guides the EBP team through the process of synthesizing the pertinent findings from the Individual Evidence Summary (Appendix G), sorted by evidence level, to create an overall picture of the body of the evidence related to the PICO question. The synthesis process uses quantity, strength (level and quality), and consistency to generate the best evidence recommendations for potential translation.

Overall quality rating and the total number of sources:

Record the overall quality rating and the number of sources for each level (strong, good, or low), ensuring agreement among the team members.

Synthesized findings:

This section captures key findings that answer the EBP question. Using the questions below, generate a comprehensive synthesis by combining the different pieces of evidence in the form of succinct statements that enhance the team’s knowledge and generate new insights, perspectives, and understandings into a greater whole. The following questions can help guide the team’s discussion of the evidence:

· How can the evidence in each of the levels be organized to produce a more comprehensive understanding of the big picture?

· What themes do you notice?

· What elements of the intervention/setting/sample seem to influence the outcome?

· What are the important takeaways?

Avoid repeating content and/or copying and pasting directly from the Individual Evidence Summary Tool. Record the article number(s) used to generate each synthesis statement to make the source of findings easy to identify.

Using this synthesis tool requires not only the critical thinking of the whole team but also group discussion and consensus building. The team reviews the individual evidence summary of high- and good-quality articles, uses subjective and objective reasoning to look for salient themes, and evaluates information to create higher-level insights. They include and consider the strength and consistency of findings in their evaluation.

Where does the evidence show consistency/inconsistency?

EBP teams must consider how consistent the results are across studies. Do the studies tend to show the same conclusions, or are there differences? The synthesized evidence is much more compelling when most studies have the same general results or point in the same general direction. The synthesized evidence is less compelling when the results from half the studies have one indication, while the findings from the other half point in a different direction. The team should identify the points of consistency among the evidence as well as areas where the inconsistency is apparent. Both factors are important to consider when developing recommendations or determining the next steps.

Best evidence recommendations:

In this section, the EBP team takes into consideration all the above information related to the strength, quantity, and consistency of the synthesized findings at each level to generate best practice recommendations from the evidence. Consider:

· What is the strength and quantity of studies related to a specific evidence recommendation?

· Is there a sufficient number of high-strength studies to support one recommendation over another?

· Are there any recommendations that can be ruled out based on the strength and quantity of the evidence?

· Does the team feel the evidence is of sufficient strength and quantity to be considered a best evidence recommendation?

Recommendations should be succinct statements that distill the synthesized evidence into an answer to the EBP question. The team bases these recommendations on the evidence and does not yet consider their specific setting. Translating the recommendations into action steps within the team’s organization occurs in the next step (Translation and Action Planning Tool, Appendix I).

Based on the synthesis, which statement represents the overall body of the evidence?

Choose the statement that best reflects the strength and congruence of the findings. This determination will help the team to decide the next steps in the translation process .

When evidence is strong (includes multiple high-quality studies of Level I and Level II evidence), compelling, and consistent, EBP teams can have greater confidence in best practice recommendations and should begin organizational translation

When most of the evidence is good (high-quality Level II and Level III) and consistent or good but conflicting, the team should proceed cautiously in making practice changes. In this instance, translation typically includes evaluating risk and careful consideration for organizational translation.

The team makes practice changes primarily when evidence exists that is of high to good strength. Never make practice changes on little to no evidence (low-quality evidence at any level or Level IV or Level V evidence alone). Nonetheless, teams have a variety of options for actions that include but are not limited to, creating awareness campaigns, conducting informational and educational updates, monitoring evidence sources for new information, and designing research studies.

The exact quantity of sources needed to determine the strength of the evidence is subjective and depends on many factors, including the topic and the amount of available literature. The EBP team should discuss what they consider sufficient given their knowledge of the problem, literature, and setting

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