Critical Appraisal of Literature Review and Suggested Best Practices
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Evaluation Table
Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical
Appraisal of Research
Full citation of
selected article
Article #1 Article #2 Article #3 Article #4
Muralidharan S, Fenton M. (2006).
Containment strategies for people
Iozzino L, Ferrari C,
Large M, Nielssen O, de
Girolamo G. (2015).
Humera Saeed, M.
Shameel Khan, Syeda
Maheen Batool, Asma
Price O, Baker J, Bee P,
(2018). Patient
perspectives on barriers
© 2018 Laureate Education Inc. 1
C Appraisal Tools
W Template
with serious mental illness.
Cochrane Database of Systematic
Reviews 2006, Issue 3. Art. No.:
CD002084. DOI:
10.1002/14651858.CD002084.pub2.
Prevalence and risk
factors of violence by
psychiatric acute
inpatients: a systematic
review and meta-analysis.
PLoS ONE. 2015 Jun 10
[cited 2015 Oct
16];10(6):e0128536.
Akbar Ladak, Nadia
Karim and Rabeeka
Aftab. (2019). Need of
Physical and Chemical
Restraints: Experiences
at Inpatient Psychiatric
Ward in a Tertiary Care
Hospital in Karachi,
Pakistan. Journal of the
College of Physicians
and Surgeons Pakistan
2019, Vol. 29 (5): 486-
488
and enablers to the use
and effectiveness of de-
escalation techniques for
the management of
violence and aggression
in mental health settings.
J Adv Nurs. 2018;
74:614–625
Conceptual
Framework
Describe the
theoretical basis for
the study
These strategies are based on social
learning theory and address patient
behaviors or symptoms rather than
diagnostic categories.
The study adopted social
learning theory
The study is guided by
the assumption that
chemical restraint should
be carefully administered
to enable rapid and short-
term behavioral control.
The theoretical basis for
the study was a priori
assumption which is
theme to staff, patient
and environmental
modifiers.
Design/Method
Describe the design
and how the study
was carried out
Systematic meta-analysis of articles
searched on the Ovid interface of
CINAHL, CENTRAL, EMBASE,
MEDLINE, PsycINFO.
Systematic meta-analysis
of published studies
between January 1995 and
December 2014 that
identified rates of violence
in high-income nations in
acute psychiatric wards of
specialized and psychiatric
hospitals.
At Aga Khan University
Hospital (AKUH),
Karachi, this was a
descriptive study of
retrospective nature. This
study was conducted
between February 2015
and January 2016. Case
files are analyzed in
order to obtain
appropriate medical data
on physical and chemical
restriction procedures
The study used
Descriptive qualitative
methodology using semi-
structured
interviews and
Framework Analysis.
© 2018 Laureate Education Inc. 2
and to define
opportunities for
improvement.
Sample/Setting
The number and
characteristics of
patients,
attrition rate, etc.
Relevant randomized controlled
trials targeting people with severe
mental illness, comparing some
non-pharmacological strategies
designed to contain people at risk of
injuring themselves or others (such
as methods that adjust rates of
monitoring, lock wards, monitor
staA patient proportions, use de-
escalation strategies or therapeutic
contracts).
Questions were restricted
to articles published
between January 1995 and
December 2014 and
information on abuse in
adult psychiatric patients
was collected.
The sample size
comprised of 104
patients out of 477
patients admitted to
psychiatric ward
who were given any
form of restraint?
.
Used for function
sampling. Samples were
searched for: respondent
race, age, ethnicity, status
of the Mental Health Act,
drug abuse, diagnosis,
knowledge of restrictive
practices. Seven wards
responded from 14
selected wards. Seven
wards in four hospitals in
three British mental
health institutions in
North-West England
participated in the study
of 14 wards visited.
Major Variables
Studied
List and define
dependent and
independent variables
Concept: The effects of various
strategies used to contain acutely
disturbed people during periods of
psychiatric crisis.
Independent variable:
Strategies used to contain acutely
disturbed people
Dependent variable:
Contain acutely disturbed people
Concept: Prevalence and
risk factors of violence by
psychiatric acute
inpatients: a systematic
review and meta-analysis
Independent variable:
Prevalence and risk
factors of violence by
psychiatric acute
inpatients
Dependent variable:
Reduce cases of violence
Concept: Need of
Physical and Chemical
Restraints: Experiences
at Inpatient Psychiatric
Ward in a Tertiary Care
Hospital in Karachi,
Pakistan.
Independent variable:
Need of Physical and
Chemical Restraints
Dependent variable:
Concept: Patient
perspectives on barriers
and enablers to the use
and effectiveness of de-
escalation techniques for
the management of
violence and aggression
in mental health settings
Independent variable:
Patient perspectives on
barriers and enablers to
the use and effectiveness
of de-escalation
© 2018 Laureate Education Inc. 3
and aggression in mental
health settings
Strategic measure against
violence and aggression
in mental health settings
techniques
Dependent variable:
The management of
violence and aggression
in mental health settings
Measurement
Identify primary
statistics used to
answer clinical
questions
Systematic literature reviews Systematic literature
reviews
Percentages, frequencies
tables were used to
answer clinical questions
Semi-structured
interviews and review of
the process. Studies used
the three stages of
Process Review:
indexing, summarizing,
mapping and interpreting.
Large obstacles to de-
escalation are insufficient
workplace input on
values and training.
Data Analysis
Statistical or
qualitative
findings
Over 2000 reports and 2006
upgrade quest were found in the
original 1999 search, an extra 2808
articles. Of these, only six seems to
have the potential to be significant,
but it was obvious that they could
not be used once they were
received. None centered on non-
pharmacological approaches of
This study's findings
indicate that
approximately 1 in 5
patients hospitalized to
emergency psychiatric
units can commit acts of
violence.
In total, 94.5% of
patients had both
physical and chemical
restraints, with both
being used as the first
preference in 70 patients;
while 67.1% of patient
relatives were not
notified until restraints
The findings indicated
that obstacles to de-
escalation are
insufficient workplace
input on values and
training.
© 2018 Laureate Education Inc. 4
abuse control or self-harm in people
with severe mental illness
were applied.
Findings and
Recommendations
General findings and
recommendations of
the research
No data from controlled studies
supports current non-
pharmacological strategies to
manage dysfunctional or aggressive
behavior. It is hard to justify clinical
practice based on evidence not
obtained from research and current
practice well beyond well-designed,
performed and published
randomized studies.
Measuring rates of
violence and recognizing
the factors associated with
individual scenes of
violence are an important
aspect of strategies for
protecting patients and
staff from acts of violence
This study confirms the
results of other studies
that violence and
aggression are the most
common predictor of
restraint use and that
many patients have
undergone both chemical
and physical restraints.
Chemical control has
been used in almost
everything as a first
option. Audits are
required to assess good
practice; and also, to
establish effective
training programs to
disseminate knowledge
among medical
personnel. Because in
psychiatric settings the
use of restraints may be
necessary, a good
monitoring system is
also needed to prevent its
unnecessary use.
The results suggested that
the underuse of de-
escalation methods was
due to: poor reflection on
culture and procedure by
the staff and a need to
preserve patient control.
Appraisal
Describe the general
worth of this research
to practice. What are
the strengths and
A high form of proof is a systematic
review. The findings help medical
experts to come to terms with the
best form of treatment. This work
can be used by medical
The results allow health
professionals to come to
terms with the correct
form of treatment. The
results also inform state
The limitations of this
study are that the sample
size was not large but
may not be the real
representative in
This research is critical in
identifying obstacles that
may hinder the
implementation of
strategies for de-
© 2018 Laureate Education Inc. 5
limitations of study?
What are the risks
associated with
implementation of the
suggested practices or
processes detailed in
the research? What is
the feasibility of
use in your practice?
professionals in the implementation
of different strategies used during
times of psychological distress to
handle severely sick individuals.
The articles produced from the
search, however, were limited and
would therefore yield results that
were not comprehensive.
healthcare systems '
strategies, such as whether
to support a new drug.
Pakistan of all mentally
ill participants. The main
focus of this study,
however, was centered
on the introduction of a
suitable restraint
monitoring system.
escalation. There was,
however, a disparity
between women (16) and
male (8) participants, but
sufficient coverage was
received by eight males.
One risk involved in
enforcing the procedures
is perceived bullying by
caregivers.
General
Notes/Comments
© 2018 Laureate Education Inc. 6
Levels of Evidence Table
Use this document to complete the levels of evidence table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A:
Critical Appraisal of Research
Author and year of
selected article
A #1 A #2 A #3 A #4
Muralidharan S, Fenton
M. (2006).
Iozzino L, Ferrari C,
Large M, Nielssen O, de
Girolamo G. (2015).
Humera Saeed, M.
Shameel Khan, Syeda
Maheen Batool, Asma
Akbar Ladak, Nadia
Karim and Rabeeka
Aftab. (2019).
Price O, Baker J, Bee P,
(2018).
Study Design
Theoretical basis for the
study
These strategies are based on
social learning theory and
address patient behaviors or
symptoms rather than
diagnostic categories.
The study adopted social
learning theory
The study is guided by the
assumption that chemical
restraint should be carefully
administered to enable rapid
and short-term behavioral
control.
The theoretical basis for the
study wasa priori assumption
which is theme to staff, patient
and environmental modifiers.
Sample/Setting
The number and
characteristics of
patients
Relevant randomized
controlled trials targeting
people with severe mental
illness, comparing some
non-pharmacological
strategies designed to
contain people at risk of
injuring themselves or
others (such as methods that
adjust rates of monitoring,
lock wards, monitor staA
Questions were restricted to
articles published between
January 1995 and December
2014 and information on abuse
in adult psychiatric patients
was collected.
The sample size comprised of
104
patients out of 477 patients
admitted to psychiatric ward
who were given any form of
restraint.
.
Used for function sampling.
Samples were searched for:
respondent race, age, ethnicity,
status of the Mental Health
Act, drug abuse, diagnosis,
knowledge of restrictive
practices. Seven wards
responded from 14 selected
wards. Seven wards in four
hospitals in three British
mental health institutions in
North-West England
© 2018 Laureate Education Inc. 7
patient proportions, use de-
escalation strategies or
therapeutic contracts).
participated in the study of 14
wards visited.
Evidence Level *
(I, II, or III) Level 1
Level 1 Level 1 Level 1
Outcomes
No data from controlled
studies supports current non-
pharmacological strategies to
manage dysfunctional or
aggressive behavior. It is hard
to justify clinical practice
based on evidence not obtained
from research and current
practice well beyond well-
designed, performed and
published randomized studies.
Measuring rates of violence
and recognizing the factors
associated with individual
scenes of violence are an
important aspect of strategies
for protecting patients and staff
from acts of violence
This study confirms the results
of other studies that violence
and aggression are the most
common predictor of restraint
use and that many patients
have undergone both chemical
and physical restraints.
Chemical control has been
used in almost everything as a
first option. Audits are required
to assess good practice; and
also, to establish effective
training programs to
disseminate knowledge among
medical personnel. Because in
psychiatric settings the use of
restraints may be necessary, a
good monitoring system is also
needed to prevent its
unnecessary use.
The results suggested that the
underuse of de-escalation
methods was due to: poor
reflection on culture and
procedure by the staff and a
need to preserve patient
control.
General
Notes/Comments
* Evidence Levels:
© 2018 Laureate Education Inc. 8
Level I
Experimental, randomized controlled trial (RCT), systematic review RTCs with or without meta-analysis
Level II
Quasi-experimental studies, systematic review of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only, with or
without meta-analysis
Level III
Nonexperimental, systematic review of RCTs, quasi-experimental with/without meta-analysis, qualitative, qualitative systematic review with/without
meta-synthesis
Level IV
Respected authorities’ opinions, nationally recognized expert committee/consensus panel reports based on scientific evidence
Level V
Literature reviews, quality improvement, program evaluation, financial evaluation, case reports, nationally recognized expert(s) opinion based on
experiential evidence
© 2018 Laureate Education Inc. 9
Outcomes Synthesis Table
Use this document to complete the outcomes synthesis table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A:
Critical Appraisal of Research
Author and year of
selected article
A #1 A #2 A #3 A #4
Muralidharan S, Fenton
M. (2006).
Iozzino L, Ferrari C,
Large M, Nielssen O, de
Girolamo G. (2015).
Humera Saeed, M.
Shameel Khan, Syeda
Maheen Batool, Asma
Akbar Ladak, Nadia
Karim and Rabeeka
Aftab. (2019).
Price O, Baker J, Bee P,
(2018).
Sample/Setting
The number and
characteristics of
patients
Relevant randomized
controlled trials targeting
people with severe mental
illness, comparing some non-
pharmacological strategies
designed to contain people at
risk of injuring themselves or
others (such as methods that
adjust rates of monitoring, lock
wards, monitor staA patient
proportions, use de-escalation
strategies or therapeutic
contracts).
Questions were restricted to
articles published between
January 1995 and December
2014 and information on abuse
in adult psychiatric patients
was collected.
The sample size comprised of
104
patients out of 477 patients
admitted to psychiatric ward
who were given any form of
restraint?
Used for function sampling.
Samples were searched for:
respondent race, age, ethnicity,
status of the Mental Health
Act, drug abuse, diagnosis,
knowledge of restrictive
practices. Seven wards
responded from 14 selected
wards. Seven wards in four
hospitals in three British
mental health institutions in
North-West England
participated in the study of 14
wards visited.
Outcomes
No data from controlled
studies supports current non-
pharmacological strategies to
manage dysfunctional or
aggressive behavior. It is hard
Measuring rates of violence
and recognizing the factors
associated with individual
scenes of violence are an
important aspect of strategies
for protecting patients and staff
This study confirms the results
of other studies that violence
and aggression are the most
common predictor of restraint
use and that many patients
have undergone both chemical
The results suggested that the
underuse of de-escalation
methods was due to: poor
reflection on culture and
procedure by the staff and a
need to preserve patient
© 2018 Laureate Education Inc. 10
to justify clinical practice
based on evidence not obtained
from research and current
practice well beyond well-
designed, performed and
published randomized studies.
from acts of violence and physical restraints.
Chemical control has been
used in almost everything as a
first option. Audits are required
to assess good practice; and
also, to establish effective
training programs to
disseminate knowledge among
medical personnel. Because in
psychiatric settings the use of
restraints may be necessary, a
good monitoring system is also
needed to prevent its
unnecessary use.
control.
Key Findings No data from controlled
studies supports current non-
pharmacological strategies to
manage dysfunctional or
aggressive behavior. It is hard
to justify clinical practice
based on evidence not obtained
from research and current
practice well beyond well-
designed, performed and
published randomized studies.
This study's findings indicate
that approximately 1 in 5
patients hospitalized to
emergency psychiatric units
can commit acts of violence.
In total, 94.5% of patients had
both physical and chemical
restraints, with both being used
as the first preference in 70
patients; while 67.1% of
patient relatives were not
notified until restraints were
applied.
The findings indicated that
obstacles to de-escalation are
insufficient workplace input on
values and training.
Appraisal and Study
Quality
A high form of proof is a
systematic review. The
findings help medical experts
to come to terms with the best
form of treatment. This work
can be used by medical
professionals in the
implementation of different
strategies used during times of
psychological distress to
handle severely sick
individuals. The articles
The results allow health
professionals to come to terms
with the correct form of
treatment. The results also
inform state healthcare systems
' strategies, such as whether to
support a new drug.
The limitations of this study
are that the sample size was
not large but may not be the
real representative in Pakistan
of all mentally ill participants.
The main focus of this study,
however, was centered on the
introduction of a suitable
restraint monitoring system.
This research is critical in
identifying obstacles that may
hinder the implementation of
strategies for de-escalation.
There was, however, a
disparity between women (16)
and male (8) participants, but
sufficient coverage was
received by eight males. One
risk involved in enforcing the
procedures is perceived
bullying by caregivers.
© 2018 Laureate Education Inc. 11
produced from the search,
however, were limited and
would therefore yield results
that were not comprehensive.
General
Notes/Comments
© 2018 Laureate Education Inc. 12
