NRS 433 Describe the “levels of evidence” and provide an example of the type of practice change that could result from each

NRS 433 Describe the “levels of evidence” and provide an example of the type of practice change that could result from each

NRS 433 Describe the levels of evidence and provide an example of the type of practice change that could result from each

Health care profession requires professionals to be lifelong learners and educators to promote health, prevent disease and to bring the best possible outcome for their patient. Health care is drastically evolving and health care professionals such as the nurses are placed in the forefront of patient care and are expected to be the clinical expert in their area of nursing practice. In this pursuit of knowledge, they must become familiar with the health care research methods and process and continuously update their knowledge with the current evidence based practices (EBPs) that promote improved patient outcomes. Evidence-based practice (EBP) has been described as the integration of the best research evidence, expert clinical judgment, and the preferences and values of patients (Chan.,et,al2020).  The degree to which the health care professionals are evaluated as experts is based on their extent of knowledge that they bring to their clinical practice. Evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. The level of evidence is determined based on the confidence, validity and applicability and clinicians are encouraged to find the highest level of evidence to answer clinical questions. The level of evidence hierarchy is determined based on the confidence, validity and applicability. According to Burns,et al (2011), evidence from a systematic review or meta -analysis of all RCTs are considered as the level one level of evidence which is the highest level. At level 2, the evidence is collected through well designed RCT. Next is LOE (Level of evidence ) level 3 where the evidence is collected through controlled trails without randomization.  Case control or cohort studies are considered at level 4, while systematic reviews of descriptive and qualitative studies are under level 5 LOE. When evidence is collected through single descriptive or qualitative study it is considered as a level 6 LOE and lastly when the LOE is determined by evidence from an expert opinion it is considered as the lowest level of evidence. It is important that researcher have good understanding of the LOE while reviewing information needed for the study as it will help him/her to prioritize the information and guide them when interpreting the results.   

One example of the practice change that I have seen in the hospital that I work is the utilization of fluorescent solution shining under ultraviolet light to test the effectiveness of hand hygiene and to reinforce good HH behavior to prevent infection. One of the article supporting the use of fluorescent material intervention to improve HH training was a randomized control study done in 2021  by Kisacik, et al(2021). The study confirm that there was a significant difference between the intervention and control groups in terms of the total post-test hand hygiene belief score and final hand washing skill score of the students in the intervention group increased significantly for the seven regions of hands . (Kisacik, et al, 2021

Burns, P. B., Rohrich, R. J., & Chung, K. C. (2011). The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery128(1), 305–310.

Hariton, E., & Locascio, J. J. (2018). Randomised controlled trials – the gold standard for effectiveness research: Study design: randomised controlled trials. BJOG : an international journal of obstetrics and gynaecology125(13), 1716.

Kisacik, O. G., Cigerci, Y., & Gunes, U. (2021). Impact of the fluorescent concretization intervention on effectiveness of hand hygiene in nursing students: A randomized controlled study. NURSE EDUCATION TODAY97.

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Levels of evidence are something used in research studies to help with determines patient care by making decisions based on strength of recommendations. The studies are used with RCTs randomized controlled trials and use EBP evidence-based practice as a guideline. ( 9/2021) There are five levels that move up like a pyramid starting from the bottom for research studies, it starts with foundational evidence. Starting from the bottom of the pyramid, animal research/ lab studies is usually the start of research where you are doing lab work and theory testing before it is introduced to people, during this research helps weed out non-factors. Background information/expert opinion- this is where you get information from literature or other research studies that have previously been done and proved. Case-control study-uses patients for research that have diagnosis needed studying and a control group. A cohort study uses two groups of people one that is exposed to what is being researched the other group is not. RCTs Randomized controlled trials- these patients were randomly picked for the experimental group and for the control group. Critically appraised articles/critically appraised topics. A systematic review, and meta-analysis. The higher the level studies are available. ( 9/2021)

NRS 433 Describe the levels of evidence and provide an example of the type of practice change that could result from each
NRS 433 Describe the levels of evidence and provide an example of the type of practice change that could result from each

Levels of Evidence – Evidence-Based Practice for Health Professionals – LibGuides at Northern Virginia Community College ( September 2021

Each type of research study performed can be rated based on the level of evidence obtained. Levels of evidence is hierarchy of research methods based on quality of results. There is a hierarchy with regard to the way in which the research was performed. The levels of evidence from highest to lowest include randomized control trials, systematic reviews, experimental studies, quasi-experimental studies, nonexperimental studies, correlational studies, qualitative studies, descriptive studies, case studies, literature reviews and expert opinions (Helbig, 2018). Even though RCTs are rated the highest quality, one must continue to look at the evidence before a decision is made on whether to incorporate its use (Helbig, 2018).

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. 

Level 1-(Experimental study, randomized controlled trial (RCT))- Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. For instance, The Optic Neuritis Treatment Trial1 is an example of a randomized clinical trial which contains level 1 evidence.

Level 2- Evidence obtained from at least one well-designed RCT e.g. Large multi-site RCT

Level 3 – Evidence obtained from well-designed controlled trials without randomization. The practices are quasi-experimental.

Level 4- Evidence from well-designed case-control or cohort studies.

Level 5- Evidence from systematic reviews of descriptive and qualitative studies. It involves meta-synthesis practices.

Level 6-Evidence from a single descriptive or qualitative study.

Level 7- Evidence from the opinion of authorities and/or reports of expert committees. 

Helbig, J. (2018). History and process of nursing research, evidence-based nursing practice, and quantitative and qualitative research process. In Grand Canyon University (Ed.), Nursing research: Understanding methods for best practice. (1st ed.). Retrieved from

Winona State University. (2020). Evidence Based Practice Toolkit.

Levels of evidence are a ranking system used in evidence-based practices to describe the strength of the results measured in a clinical trial or research study (Libraries, 2017). The goal of nursing research is answering the research question formed from the nursing practice problem. In other word, giving recommendations to solve the practice problem. The grade of recommendation depends on the level of the evidence.

Level I: Evidence obtained from at least one properly designed randomized controlled trial. Systematic review or meta-analysis of randomized controlled trials (RCTs).

The practice, such as the methods of infection control and interventions of medications, results from the level I evidence that provides a strong recommendation to practice.

Level II-1: Evidence obtained from well-designed controlled trials without randomization.

The practice, such as certain interventions for particular conditions, could result from the level II evidence, such as the shoes should perfectly fit for the diabetic patient.

Level II-2: Evidence obtained from a well-designed cohort or case-control analytic studies, preferably from more than one center or research group. Quasi-experiments perfectly fit from this level of evidence.

Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

A practice change that could come from Level one is the implementation of a new medication based on the results of the randomized controlled trial (Grove et al., 2015). Moreover, the fourth level of evidence is the case-control or cohort studies. The case-control identifies patients that have a particular situation and compares them to those who do not to determine the level of interest (Ackley et al., 2008). On the other hand, the cohort study deals with the determination of the reason why people within a population develop a particular disease or behave in a certain manner while others do not. The practice change is the development of suitable prognosis of a particular case, for example in plastic surgery where RCTs is not possible. The fifth level of evidence is the descriptive and qualitative studies reviewed in a systematic manner. The type of practice change is that it focuses on answering clinical questions that arise during analysis. A practice change that could come from Level II is the removal of exposure to a certain substance that can cause a disease.


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

Grove, S., Gray, J., & Burns, N. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). St. Louis, MO: Elsevier.

 Libraries. (2017). Retrieved from

When it comes to research conducted, found, and utilized in the nursing profession, there are levels of evidence that separate one from the other. The levels are used to display the most reliable forms of evidence at the highest level, and the least reliable forms of evidence at the lowest level. From the highest level to the lowest it is: “Systematic reviews of randomized control trials, Individual randomized control trials, All or none randomized control trials, Systematic reviews of cohort studies, Individual cohort study/low quality randomized controlled trials, “Outcomes” Research, Systematic review of case-control studies, Case-series, and an Expert opinion” (EBM, 2022). Something very notable when looking at the levels is how the amount of randomization in the control trials decreases as the level of evidence decreases, ending at the lowest level where there is no control trial but rather an expert’s  “opinion”. This is important to note because it shows just how important it is for research to have randomized control trials rather than non-randomized. Randomized control trials allow for more genuine results from research since the trial isn’t being manipulated to produce specific results. This style of evidence is great as it shows what may cause the thing being researched in the actual world since it is randomized, much like how variables in life are random. This style of evidence can help change EBP in healthcare facilities as it directs focus onto variables that exist outside of those produced from non-randomized studies. This could be seen in utilizing a study on COVID-19 infection rates from multiple different races and socioeconomic statuses in contrast to a study that only focuses on one group. When looking at all of these levels of evidence, it is clear that the impact that can be made from each greatly decreases as the level of reliability decreases, ultimately ending at an expert’s opinion. Whilst an expert may be experienced in the field, as a single individual providing subjective data rather than conducting research on a largely randomized control trial, the depth and substance of that opinion can be greatly lacking and not supported by the other experts. It is important to use the highest level of evidence available at all times to ensure the most reliable results and in turn, the most beneficial changes. 


John Wiley & Sons, Inc. (2022). Levels of Evidence. EBM: Levels of Evidence – Essential Evidence Plus. Retrieved from 

Evidence-based practice for health professionals: Levels of evidence. LibGuides. (n.d.). Retrieved from

There are seven levels of evidence when it comes to evidence-based practice. The level of evidence pyramid is split between unfiltered and filtered information. Unfiltered information is information that has not been critically appraised and should be avoided for evidence-based information (NOVA, 2021). Filtered information has all gone through an evaluation process and is best for evidence-based information (NOVA, 2021). The top of the pyramid is systematic reviews, which is the highest quality of evidence and have the fewest number of studies available. If the information the researcher is studying cannot be found in systematic reviews, they will move down the pyramid to critically appraised topics and then further down to critically appraised individual articles. The unfiltered information includes randomized controlled trials, cohort studies, and case-controlled studies. The bottom of the pyramid is background information, which is your foundation and includes handbooks, encyclopedias, and textbooks.

The higher up the level of evidence the less biased the research. The lower levels of research have more opinions mixed in and are more biased, so they are harder to rely on for evidence-based practice. The lower levels of evidence are a good place to start to build a hypothesis to lead to more in-depth studies at higher levels of evidence. Burns et al. (2011) state that studies are ranked based on the probability of bias and that randomized controlled trials are given the highest level because they are designed to be unbiased.


Burns, P., Rohrich, R., Chung, K. (2011). The Levels of Evidence and Their Role in Evidence-Based Medicine. Journal of the American Society of Plastic Surgeons 128(1) 305-310.  10.1097/PRS.0b013e318219c171

NOVA (2021). Evidence-Based Practice for Health Professionals: Levels of Evidence.