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guide their evidence-based regulatory decisions. Primary sources of research data (such as peer-reviewed and refereed journals) rather than secondary sources should always be used. Volume 1/Issue 1 www.journalofnursingregulation.com 33 TABLE 2 Traditional Hierarchy of Evidence Hierarchy systems for rating the quality of evidence vary slightly depending on the organizations or disciplines using them. This table shows a traditional hierarchy-of-evidence rating system used in evidence-based health care. The lower the level, the higher the quality of evidence. Level I evidence is of higher quality than Level II evidence, and so on. Level I Systematic reviews, meta-analyses, integrative reviews of well-designed RCTs Level II Well-designed RCTs Level III Well-designed quasi-experimental studies Level IV Well-designed nonexperimental studies Level V Consensus or expert opinions Note: RCTs = randomized controlled trials. Retrieval sources for such data may be fee-based or free. Common fee-based source providers include Aries Knowledge Finder, EBSCOhost, and Ovid Technologies. Regulators who do not have access to fee-based providers can use free retrieval sources, such as PubMed, Google Scholar, Infotrieve, and ProQuest Research Library. ProQuest has more than 4,000 titles (with 2,800 in full text) from 1971 forward; this database may be available from a public library. Other important databases for nursing regulation are: ● Cumulative Index to Nursing and Allied Health Literature (CINAHL), owned and operated by EBSCO Publishing, which has nearly 3,000 journals ● Medline (http://medlineplus.gov), which has more than 4,300 journal titles and 11 million records. The Cochrane Collaboration (http://www.cochrane.org/) provides systematic reviews—the backbone of evidence-based health care. Other databases of interest to nurse regulators include the Education Resources Information Center (ERIC), with more than 650 journals on education; and PsychINFO, which has more than 2,450 journals addressing psychiatric, education, and related issues. (Regulators might want to use PsychINFO to obtain, for instance, literature on chemical dependency.) Examples of How Regulators Might Use Evidence How might nurse regulators use evidence when making decisions? States currently are implementing the Consensus Model for Advanced Practice, for which regulators need evidence on the outcomes of nurse practitioners (NPs) compared to those of physicians to present to legislators and other stakeholders. A classic study of primary care outcomes in patients treated by NPs or physicians was published in 2000 (Mundinger, Kane, Lenz, Totten, Tsai, Cleary, Friedewald, Siu, & Shelanski). This randomized controlled trial concluded that NPs and primary care physicians had comparable outcomes when practicing in an ambulatory care situation. Similarly, a systematic review of randomized controlled studies and prospective observational studies conducted by Horrocks, Anderson, & Salisbury (2002) found no differences in outcomes between NPs and physicians. A 2009 study (Mehrotra, Liu, Adams, Wang, Lave, Thygeson, Solberg, & McGlynn, 2009) showed that retail clinics provided less costly treatment than physician offices, with no adverse effect on the quality of care. Rudavsky, Pollack, & Mehrotra (2009) found retail clinics were positioned to provide adequate care for simple acute conditions in an urban U.S. population; such data support the practice of NPs. Because the latter two studies were conducted less rigorously than the previous two, the evidence is not as strong. Of the four studies, the systematic review holds the most weight for those making evidence-based regulatory decisions. 34 Journal of Nursing Regulation TABLE 3 A New Hierarchy that Ranks Effectiveness, Appropriateness, and Feasibility Evans (2003) proposes a new hierarchy of evidence that might be more appropriate for nursing regulation than the traditional hierarchy, because it considers the contributions of a wider range of research methodologies. Ranking Excellent Good Fair Poor Note: RCTs = randomized controlled trials. From Evans, D. (2003). Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12, 77-84. Reprinted with permission from Wiley-Blackwell. Effectiveness ● Systematic review ● Multicenter studies ● RCTs ● Observational studies ● Uncontrolled trials with dramatic results ● Before and after studies ● Nonrandomized controlled trials ● Descriptive studies ● Case studies ● Expert opinions ● Studies of poor methodological quality Appropriateness ● Systematic review ● Multicenter studies ● RCTs ● Observational studies ● Interpretive studies ● Descriptive studies ● Focus groups ● Case studies ● Expert opinions ● Studies of poor methodological quality Feasibility ● Systematic review ● Multicenter studies ● RCTs ● Observational studies ● Interpretive studies ● Descriptive studies ● Action research ● Before and after studies ● Focus groups ● Case studies ● Expert opinions ● Studies of poor methodological quality Research findings also support other aspects of regulatory functions. For example, BONs approve prelicensure nursing education programs; in light of the increased use of simulation in these programs, regulators are seeking to determine how simulation affects nursing
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