Summarize the Evidence

Now that you have compiled and read the evidence, what's next? How can you combine the findings to come up with a solution to the original clinical problem or concern? When you put it together, how do you use it to build a case to support clinical decision-making or to sell the idea to others?

• A huge intellectual job involving a move from the literature search and critique phase into the synthesis phase.
• Research evidence is combined with other evidence to make concrete practice recommendations.

• Use a multidisciplinary group.
• If the planning group was well designed it can continue throughout the process. If you find that you do not have team members who have done such synthesis work in the past you may want to add a member with such experience.
• The group leader will need to be a good facilitator, moving the group through the steps of the synthesis work. Early steps that should have been accomplished by the group prior to searching for evidence are determining the status of current practice and the reason that the group thinks it needs change.
• Assign readers of primary sources; helpful for continuity; all members may not have read all sources.Group members at this point need to be excellent thinkers who are practical, analytical, and able to use words well. It is important that your group leader or co-leaders reflect this expertise.
• Organize multiple results by concepts, setting, and variables.
• Creating a visual display of information is often helpful. Group leaders or a core group may have decided the organizational method or the total group may discuss and decide. Have a rationale for the method of organizing results.
• Comparative evaluation (Stetler, Morsi et al. 1998): Work by subconcepts to evaluate applicability to practice (e.g., for catheter care, synthesize findings about insertion, insertion sites, catheter type, care of site - cleansing, care of site - dressings, etc.) by substantiating evidence, fit, and feasibility.
• Questions to ask throughout: Is there a sufficient rationale to use synthesized findings or recommendations? How should findings/recommendations be used: update for practice, policy or procedure, algorithm, program, position paper?

• Strength of the research base (synthesis of two or more studies)
• Does the research base include more than one study?
• Have the sample, design, methodology, results, and conclusions of each study been examined for scientific merit?

• What is the potential risk to patients if an innovation developed upon the compiled results is developed and used?

• Do nurses have control over the intervention(s) studied? If not, is there multidisciplinary support for the intervention?
• Does the evidence support the intervention in the particular care setting? If not what are the issues/differences?

• Are the resources available to make a change based upon the research base?
• Do the benefits of the change outweigh the costs?
• Will there be administrative support for such a change if it impacts resources?

In developing a protocol to prevent opioid-induced constipation, Robinson, et al (2000) had the synthesis work bridge the roles of two groups:

• The quality assurance/quality improvement committee, nurses from the Nursing Research Utilization Committee, and a nurse from each shift from the oncology unit reviewed the literature.
• Representatives from nursing, medicine, pharmacy, nursing information systems, and home health developed the protocol. The synthesis work bridged the roles of the two groups.

Product summaries may be called protocols or guidelines, or may be integrated into existing policies and procedures. A protocol may include the following information (Horsley, et al. 1983; Titler, Mentes et al. 1999):

• Need for change; purpose statement which describes the patient care problem
• Description of the practice change which may include operational definitions of major terms used in the protocol (e.g., constipation), description of patient populations for whom the protocol is appropriate, patient assessment criteria
• Summary of the evidence base (including the research), usually organized by breaking the change down into pieces (e.g., for catheter care: care of the skin at insertion, care of the skin after insertion, care of the catheter before insertion, care of the catheter after insertion, flushing solutions, flushing frequencies, fluids, etc.)
• Limitations of the research base
• A step-by-step guideline that tells a practitioner how to carry out the practice with literature, research, and/or principles for each
• Evaluation guide including what outcomes should be monitored and suggested procedures and tools
• References used in developing the protocol

• Bowel protocol for prevention of opioid induced constipation and discharge information protocol (Robinson, et al. 2000)
• Components of a written research-based practice standard (policy, procedure, protocol): Preventing constipation in the hospitalized elderly adult undergoing surgery (Titler 1997).
• Guideline for use of transdermal fentanyl (Wakefield, et al. 1998) .

The written report of the summarized research sometimes may oversimplify this complex process.

Robinson and colleagues (2000) clearly delineate the evidence (research-based literature, expert consultation, and scientific principles) which helped them develop a bowel protocol for preventing opioid-induced constipation.

Wakefield, et al (1998) also describe what type of evidence they used (existing literature, clinical expert knowledge, manufacturer recommendations, and cost considerations) in coming up with a protocol for transdermal fentanyl. "Articles were identified using a computerized library search of the medical, nursing, and pharmacy literature. Bibliographies of these articles also were reviewed for additional references. The literature was reviewed for scientific merit and applicability to the investigators' patient population. The experienced clinicians on the task force employed their knowledge and experience from working with patients with cancer and previous clinical experience with transdermal fentanyl in developing the guideline. In recommending conversions from other opioids to transdermal fentanyl, the investigators used manufacturers' guidelines to ensure accurate dose conversions." (p. 1508)