Levels of Evidence
Levels of evidence are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. The combination of these attributes gives the level of evidence for a study. In nursing, the system for assigning levels of evidence is often from Melnyk & Fineout-Overholt's 2011 book, Evidence-based Practice in Nursing and Healthcare: A Guide to Best Practice. The Levels of Evidence below are adapted from Melnyk & Fineout-Overholt's (2011) model.
About Levels of Evidence and the Hierarchy of Evidence: While Levels of Evidence correlate roughly with the hierarchy of evidence (discussed elsewhere on this page), levels of evidence don't always match the categories from the Hierarchy of Evidence, reflecting the fact that study design alone doesn't guarantee good evidence.
About Levels of Evidence and Strength of Recommendation: The fact that a study is located lower on the Hierarchy of Evidence does not necessarily mean that the strength of recommendation made from that and other studies is low--if evidence is consistent across studies on a topic and/or very compelling, strong recommendations can be made from evidence found in studies with lower levels of evidence, and study types located at the bottom of the Hierarchy of Evidence. In other words, strong recommendations can be made from lower levels of evidence.
For example: a case series observed in 1961 in which two physicians who noted a high incidence (approximately 20%) of children born with birth defects to mothers taking thalidomide resulted in very strong recommendations against the prescription and eventually, manufacture and marketing of thalidomide. In other words, as a result of the case series, a strong recommendation was made from a study that was in one of the lowest positions on the hierarchy of evidence.
Additional Evaluation Resources
- IF I APPLYIF I APPLY is a method for identifying bias, both personal and external, and then using this as a baseline for determining the credibility of a resource. Information is neither good nor bad. Resources, and information, have a time and place when they will be useful for a specific topic or need.
IF I APPLY is not meant to be used as a checklist, but rather as a tool to facilitate and guide critical thinking. - Evaluating Information RubricProvides a table of general questions you should ask when evaluating print sources and websites.
Structuring Research Questions
The PICO format is used in healthcare to help construct research questions used in systematic reviews
P= Patient, Population, Problem
I= Intervention
C= Comparison
O= Outcomes
RQ: What is the best diet for patients who have high blood pressure to prevent future heart attacks?
P= Patients with high blood pressure
I= Low sodium diet
C= Low fat diet
O= Heart attack prevention
How to search this in a database:
high blood pressure AND (low sodium diet OR low fat diet) AND heart attack
Other ways to breakdown or construct research questions
BeHEMoTh - identification of theories for realist synthesis questions
B Behaviour of interest
H Health context (the service, policy, program or intervention)
E Exclusions (for reviewers to exclude non theories)
MoTh: Models or Theories
CLIP –Health service management questions
ECLIPS(E) – Health service management questions
MIP – Medical ethics questions
SPICE – Social science questions
SPIDER – Qualitative evidence synthesis