DNP 810 Explain why research articles that fail to meet these criteria cannot be used to provide evidence for the DPI Project

DNP 810 Explain why research articles that fail to meet these criteria cannot be used to provide evidence for the DPI Project

DNP 810 Explain why research articles that fail to meet these criteria cannot be used to provide evidence for the DPI Project

The collection of facts that are true, through intense research is called evidence. Therefore, there are different levels of evidence in the form of a pyramid to determine the validity of any research from the lowest being the weakest to the highest being the most authentic. However, as much as there is a level of evidence, there is not one standardized way of interpreting evidence. The level of evidence also known as the hierarchy of evidence is used as a guide to the various types of research that could be performed and helps to place them in categories, so that if the research is conducted properly, the answers will be most reliable (Melnyk, & Fineout-Overholt, 2018). 

The highest-ranking level of evidence is the quantitative research which is the systematic review of the randomized control trials (RCT). It gives the best answer for what caused a situation and the effect of the situation because it synthesizes several studies compared with the lower levels of evidence which is based on descriptive and case studies, expert opinions. It is the strongest research method that produces the same results from multiple studies to produce the same outcome results (Melnyk, & Fineout-Overholt, 2018). 

The DPI project that I have chosen is about finding out what is causing the reoccurrence of stroke and how it can be prevented. In my facility, there are many patients who are readmitted for stroke reoccurrence. So, the first article is a prospective study that is attempting to discover the clinical and the neuro imaging aspects that may be contributing the reoccurrence of stroke in these patients after they had been treated and are on medications (Hervella, et al., 2021). They conducted a retrospective study with a large number of people and it is primary research because there was ongoing observation and participation by the researchers and the participants (GCU, 2022).

The second article is also primary research because it is a summary of the study data that was conducted by others (GCU, 2022). Though the method used was the RCT method that was taken from a multiple center randomized double blind controlled trial. The purpose of the article was to asses the effect of the medication aspirin to prevent the reoccurrence of stroke compared to the other medicine nicametate and to identify the cause of stroke recurrence (Wang, et al., 2021).

These articles demonstrate support for my DPI project to find what is causing stroke reoccurrence and what interventions that needs to be taken to prevent the stroke reoccurrence.


Grand Canyon University (GCU), (2022). Levels of evidence in research.

Hervella, P., Pérez-Mato, M., Rodríguez-Yáñez, M., López-Dequidt, I., Pumar, J. M., Sobrino, T., Campos, F., Castillo, J., Da Silva-Candal, A., & Iglesias-Rey, R. (2021). STWEAK as predictor of stroke recurrence in ischemic stroke patients treated with Reperfusion therapies. Frontiers in Neurology12

Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice. LWW.

Wang, T., Wu, T., Pan, S., Chen, H., & Chiu, S. Y. (2021). Impacts of treatments on recurrence and 28-year survival of ischemic stroke patients. Scientific Reports11(1).

Grand Canyon University. Levels of evidence in research. (2022).

Grand Canyon University. Doctor of Nursing Practice. What are empirical/research articles? (nd)

Hain, D. J. (2017). Exploring the Evidence. Focusing on the Fundamentals: Comparing and Contrasting Nursing Research and Quality Improvement. Nephrology Nursing Journal, 44(6), 541–544.

Health and Human Services. Agency for Healthcare Research and Quality. (2019)

James, C. V., Moonesinghe, R., Wilson-Frederick, S. M., Hall, J. E., Penman-Aguilar, A., & Bouye, K. (2017).

Racial/Ethnic Health Disparities Among Rural Adults — United States, 2012-2015. MMWR Surveillance Summaries66(23), 1–9.

Martino, S. C., Mathews, M., Agniel, D., Orr, N., Wilson, F. S., Ng, J. H., Ormson, A. E., Elliott, M. N., & Wilson-Frederick, S. (2019). National racial/ethnic and geographic disparities in experiences with health care among adult Medicaid beneficiaries. Health Services Research, 54, 287–296.

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Stroke is one of the leading causes of death similar to STEMI’s and Sepsis. I have never analyzed the thought of recurring stroke however as I think back to all the patients I have cared for there are multiple causes of stroke-like symptoms after the initial stroke. I gathered information from a prospective cohort study that found recurring stroke has a higher mortality rate. The associated risk factors with second stroke were hypertension, chronic infarcts, and age. An astonishing 35.7% of the 1872 patients died during the follow-up of this study (Khanevski,, 2019). The organization I work for has recently became a stroke center and I receive data on all the patients our department activates a hyper-acute stroke protocol on. For 2021, the department activated approximately 54 potential stroke patients and of the 54, three were diagnosed with stroke. The challenging portion is educating patients and families to call 911 if stroke-like symptoms occur as time is brain. Patient and families decline to use ‘911’ and decide to drive themselves to clinics, their primary care offices and to the department I work in, Advanced Urgent Care. Patients tend to report they don’t want to “wait” in the ED. Nurses and providers continue to educate the population in our area that there is no wait when it comes to stroke-like symptoms.

DNP 810 Explain why research articles that fail to meet these criteria cannot be used to provide evidence for the DPI Project
DNP 810 Explain why research articles that fail to meet these criteria cannot be used to provide evidence for the DPI Project

I look forward to hearing about your progress with the DPI project.

Khanevski AN, Bjerkreim AT, Novotny V, Naess H, Thomassen L, Logallo N, Kvistad CE; NOR-STROKE study group. Recurrent ischemic stroke: Incidence, predictors, and impact on mortality. Acta Neurol Scand. 2019 Jul;140(1):3-8. doi: 10.1111/ane.13093. Epub 2019 Apr 11. PMID: 30929256; PMCID: PMC6594196.

Evidence is key for a successful evidence-based implementation project such as the Direct Practice Improve (DPI) project. The different levels of evidence in research are based on the methodology of the study (Dang & Dearhold, 2018). For instance, level one includes randomized-controlled trials, systematic reviews, and meta-analyses while level two includes cohort studies. Such levels are important as they determine the grade and strength of the study (Dang & Dearhold, 2018). In addition to the levels of evidence, research can be divided into primary and secondary research. Primary research refers to studies that include active participation by the research, while secondary research are summaries or synthesis of data. Research articles that fail to meet the required level of evidence cannot be used as the lack of strength may lead to issues and ultimately lead to poor outcomes.

The DNP project that I would like to focus on revolves around the skill of inserting intravenous (IV) catheter skills and the confidence levels of nurses in an acute medical-surgical unit. 

The first article by Ramer et al. (2016) qualifies as a primary research article because it utilized a randomized controlled trial to determine the effectiveness of using intravenous assistive devices (such as the VeinViewer) when inserting IV catheters. In the study, 53 patients were randomly assigned to either the standard methods group or the VeinViewer group. After each IV insertion, nurses filled out a questionnaire that evaluated their confidence level and competency assessment (Ramer et al., 2016).

The second article by Marsh et al. (2018) also qualifies as a primary research article because a randomized control trial was performed to determine which insertion method was more effective in eliminating complications (such as phlebitis and infiltration) while increasing dwell time, insertion attempts, and insertion success (March et al., 2018). 


Dang, D., & Dearholt, S.L. (2018). Johns Hopkins nursing evidence-based practice : Model & guidelines (3rd ed). Sigma Theta Tau International

Marsh, N., Webster, J., Larsen, E., Genzel, J., Cooke, M., Mihala, G., Cadigan, S., & Rickard, C. (2018). Expert versus generalist inserters for peripheral intravenous catheter insertion: a pilot randomised controlled trial. Trials,

19(1), 1–10.

Ramer, L., Hunt, P., Ortega, E., Knowlton, J., Briggs, R., & Hirokawa, S. (2016). Effect of intravenous (IV) assistive device (VeinViewer) on IV access attempts, procedural time, and patient and nurse satisfaction. Journal of Pediatric Oncology Nursing33(4), 273–281.

There are seven levels of evidence in the hierarchy of evidence namely, systematic reviews, critically appraised topics, critically appraised individual articles, randomized controlled trials, cohort studies, case-controlled studies, case series, case reports, background information, and expert opinion. The levels of evidence pyramid provide a way to visualize both the quality of evidence and the amount of evidence available. Not all evidence is the same and appraising the quality of the evidence is part of evidence-based practice research. The hierarchy of evidence is typically represented as a pyramid shape, with the smaller, weaker, and more abundant research studies near the base of the pyramid, and systematic reviews and meta-analyses at the top with higher validity but a more limited range of topics(Gugiu PC, Gugiu MR, 2018). A high-quality randomized trial or prospective study is where the previously developed diagnostic criteria on consecutive patients are tested. The criterion 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 the researcher feel confident in using findings from high-ranked evidence in their own work or practice (Melnyk BM, Fineout-Overholt, E, 2018). There are primary and secondary sources, primary sources contain the original data and analysis from research studies. No outside evaluation or interpretation is provided. An example of a primary literature source is a peer-reviewed research article. Other primary sources include preprints, theses, reports, and conference proceedings. Secondary sources provide analysis, synthesis, interpretation, and evaluation of primary works. Secondary sources are not evidence, but rather provide a commentary on and discussion of evidence. e.g., systematic review.

For the DPI project proposal, I would want to focus on a non-pharmacological approach for the treatment of PTSD which includes laughter, yoga, music therapy, mindfulness meditation, breathing exercises, and support groups. The main goals of PTSD therapy are to improve symptoms, restore one self-esteem, and teach an individual the skills to deal and cope with it (Bryant, 2019). Consequently, various treatment modalities have been developed, spanning from pharmacotherapy to cognitive behavioral therapy to mind-body interventions. For DNP learners, whose daily activity depends on available clinical evidence to support decision-making, this really helps to know which evidence to trust the most. Research can be graded according to the evidential strength determined by different study designs.

The second will be the effect of ADHD in college students which began in the 1990s and has been steadily increasing in recent years. Because young adults with ADHD who attend college have experienced greater academic success during high school than many peers with the disorder, which is likely to be associated with better overall functioning, the degree to which they experience similar patterns of adjustment difficulties was not initially known.


Bryant, R. A. (2019). Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry: Official Journal of the World Psychiatric Association (WPA)18(3), 259–269.

Gugiu PC, Gugiu MR. A critical appraisal of standard guidelines for grading levels of evidence. Eval Health Prof. 2018;33(3):233-255. doi:10.1177/0163278710373980.

Melnyk BM, Fineout-Overholt, E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2017.

Literature used in the evidence-based practice is organized by its level of evidence. Categorization is completed by evaluation, data collected, and the design of the research. Randomized controlled trials are at the top of the list and are considered the most reliable. While studies that include case reports or opinions from experts are less valuable. (Saeed et al., 2018) The DNP DPI project needs to use current and accurate data to base quality improvement processes and procedures on. By evaluating the level of evidence on research, we can categorize the information obtained and determine if it is useful, biased, or in line with the project being completed. Not meeting the level of evidence criteria can lead to process change that inevitably fails related to misinformation from research.  The DPI project relies on evidence-based information that can be verified as factual and unbiased.

The project I have chosen surrounds the triage process and Emergency Severity Index (ESI) assignment in the emergency department. In my organization, we see many patients being under-triaged, thereby having increased wait times. This can and does lead to poor patient outcomes. Currently, we are using the Emergency Nurses Association ESI triage system, which is a standard for the emergency room.

The first article I decided to review, “Are Emergency Departments in the United States Following Recommendations by the Emergency Severity Index to Promote Quality Triage and Reliability?” in the Journal of Emergency Nursing (2019), is a primary research article using a descriptive correlation study. The data was collected using a survey with a sample size of 1,456 registered nurses. Each RN must have been currently working in an emergency department and understand the procedures for the ESI system. This study showed that many organizations lacked the structure and processes to guide the triage system. Few procedures guided the triage and ESI system being used.

           The second article reviewed for this project from the Journal of Emergency Nursing is a primary research study collecting data from two different emergency departments. Each used the ESI triage system, and nurses were trained on such. Data was collected from both sites and entered into the KATE computerized triage system. The study noted significantly higher ESI levels for patients compared to current practice. This article demonstrated the under-triage of patients using clinical opinion alone. By taking opinion out of the equation, ESI levels were vastly different.  


Ivanov, O., Wolf, L., Brecher, D., Lewis, E., Masek, K., Montgomery, K., Andrieiev, Y., McLaughlin, M., Liu, S., Dunne, R., Klauer, K., & Reilly, C. (2021). Improving ed emergency severity index acuity assignment using machine learning and clinical natural language processing. Journal of Emergency Nursing47(2), 265–278.e7.

Saeed, M., Swaroop, M., Ackerman, D., Tarone, D., Rowbotham, J., & Stawicki, S. P. (2018). Fact versus conjecture: Exploring levels of evidence in the context of patient safety and care quality. In Vignettes in patient safety – volume 3. InTech.

Worth, M., Davis, L. L., Wallace, D. C., Bartlett, R., & Travers, D. (2019). Are emergency departments in the united states following recommendations by the emergency severity index to promote quality triage and reliability? Journal of Emergency Nursing45(6), 677–684.