Synthesis Process and Recommendations Tool

Key Points:
 Evidence synthesis is best done through group discussion. All team members share their
perspectives, and the team uses critical thinking to arrive at a judgment based on consensus
during the synthesis process. The synthesis process involves both subjective and objective
reasoning by the full EBP team. Through reasoning, the team:
 Review the quality appraisal of the individual pieces of evidence
 Assesses and assimilates consistencies in findings
 Evaluates the meaning and relevance of the findings
 Merges findings that may either enhance the team’s knowledge or generate new
insights, perspectives, and understandings
 Highlights inconsistencies in findings
 Makes recommendations based on the synthesis process
 When evidence includes multiple studies of Level I and Level II evidence, there is a similar
population or setting of interest, and there is consistency across findings, EBP teams can
have greater confidence in recommending a practice change. However, with a majority of
Level II and Level III evidence, the team should proceed cautiously in making practice
changes. In this instance, recommendation(s) typically include completing a pilot before
deciding to implement a full-scale change.
 Generally, practice changes are not made on Level IV or Level V evidence alone. Nonetheless,
teams have a variety of options for actions that include, but are not limited to: creating
awareness campaigns, conducting informational and educational updates, monitoring evidence
sources for new information, and designing research studies.
 The quality rating (see Appendix D) is used to appraise both the individual quality of
evidence and the overall quality of evidence.

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Date: EBP Question: In at-risk hypertensive patients (P), does implementing tailored staff training centered on patient education in
medication compliance (I), compared to no training (C), improve staff knowledge/skills on hypertension, medication
adherence best practices, communication and increase patient self-efficacy and knowledge on hypertension management, and
improve pressure control and medication adherence (O), over six months?

Article
Number Author and Date Evidence
Type
Sample, Sample Size, Setting Findings That
Help Answer
the EBP
Question

Observable
Measures Limitations

Evidence
Level,
Quality

1. Sany S. B., Behzhard, F.,
   Ferns, G., & Peyman, N.
   (2020)

Randomized
controlled
trial (RCT)

A sample size of 35 physicians and
240 hypertensive patients was
recruited across several health clinics
in Mashhad, Iran, between 2013 and

2014. Physicians randomized to the
      intervention group obtained
      educational training over three
      sessions (2 workshops and one group
      discussion). The control group was
      given routine care.

Physician training in
communication
skills (intervention
group) significantly
boosted physician-
patient
communication
skills, medication
adherence,
hypertension
outcomes, and self-
efficacy, compared
to the
comparison/control
group.

Reduction or
decrease in diastolic
and systolic blood
pressures between
baseline to six
months. Promoting
health literacy skills
among hypertensive
patients.

The period of
clinical
communication
between patients
and the clinician
was not
assessed. The
use of self-
reported items to
establish
medication
compliance and
health literature
skills may lead
to bias and
overestimation
of score levels.

Evidence Level: I
Evidence
quality: Strong,
compelling
evidence, with
consistent
findings

2. Yao, M., Zhou, X., Xu, Z.,
   Lehman, R., Haroon, S.,
   Jackson, D., & Cheng, K. K.
   (2021)

Systemic
review and
meta-
analysis of
randomized
controlled
trials
(RCTs)

A systematic review of RCTs was
performed to evaluate the impact of
clinician training on communication
skills in improving hypertension and
diabetes management and outcomes
compared to no education (training)
or usual care. Articles were searched
in eight databases, including the

Training included
psychological skill
drilling, cultural
competency
education, shared
decision-making,
CVD risk
communication,

Variables observed
and measured
include patient-
doctor
relationships,
medication
adherence, patient
understanding and

Serious pitfalls
exist in evidence
required to
support the
design of
effective
educational
programs for

Evidence Level: I
Evidence
quality: Strong,
compelling
evidence, with
consistent
findings

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing
World Health Organization
International Clinical Trials Registry
Platform, ClinicalTrials.gov, CDSR,
CENTRAL, PsycINFO, CINAHL,
Embase, and Medline. Out of the
7011 abstracts searched and
identified, only 19 articles met the
inclusion criteria. A total of 785
professionals and 21,762 patients
were observed.

patient-centered care
communication, and
motivational
interviewing. The
outcomes showed no
statistical
significance in
systolic blood
pressure, diastolic
pressure, and HbA1c
levels.

experiences, blood
pressure levels, and
HbA1c levels.

clinicians
involved in the
care of
hypertensive and
diabetic patients.
Most of the
interventions are
heterogeneous
and poorly
characterized. It
is also
challenging to
extrapolate and
compare
outcomes since
the RCTs span
nine nations
with varying
cultures and
patient
expectations.

3. Sartori, A., C., Lucena, T. F.,
   Lopes, C. T., Bernuci, M. P.,
   & Yamaguchi, M. U. (2020)
   A
   randomized
   controlled
   trial

An RCT was conducted with
403 patients diagnosed with
hypertension and diabetes in
thirty-three Maringa-PR Basic
Health Units in Brazil. Patients
were randomized to two groups:
intervention (n=203) and control
(n=200). The intervention group
was given usual care and
educational/promotional
messages on WhatsApp (text,
image, or audio), stressing
medication compliance. The
control group only received the
usual care.

After four months of
follow-up, patients
in the intervention
were more adherent
(67.5%) than those
in the control group
(58.5%) (p = 0.007;
CI 0.99-1.34; RR
1.15).

Adherence to
medication was
measured using the
Morisky-Green Test

MTG is a self-
reporting test
tool, which is
difficult to
measure and can
present bias and
errors in
reporting blood
pressure and
HbA1c levels.

Evidence Level: I
Evidence
quality: Strong,
compelling
evidence, with
consistent
findings

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

EBP Question:

Category (Level Type) Total Number of
Sources/Level

Overall Quality
Rating

Synthesis of Findings
Evidence That Answers the EBP Question

Level I
 Experimental study
 Randomized controlled trial (RCT)
 Systematic review of RCTs with or without
meta-analysis
 Explanatory mixed method design that
includes only a Level I quantitative study

Total number of
sources: 3
Evidence level: I

Strong, compelling
evidence, with
consistent findings

Patient education on medication adherence training is one of the primary
nonpharmacologic interventions clinicians can leverage to improve
adherence to medications, especially among at-risk patients suffering from
chronic illnesses like hypertension. A randomized controlled trial (RCT)
involving 403 patients confirms patient education can significantly
improve medication adherence among patients with hypertension or
diabetes (Sartori et al., 2020). Patients given usual care and education on
medication adherence (intervention group) recorded a 67.5% increase in
compliance compared to those given usual care alone (control group)
(58.5%) (p = 0.007; CI 0.99-1.34; RR 1.15).
For clinicians to effectively deliver appropriate patient education on
medication adherence, they must have the appropriate knowledge and
skills to do so; this can be achieved by training them on core areas of
patient education on medication compliance, including communication
skills, medication adherence best practices, and hypertension elements.
Several studies have also shown that training clinicians on medication
adherence can improve their knowledge/skills in patient education and
improve patient outcomes, including adherence, self-efficacy, and lower
systolic levels.
For example, a randomized controlled trial involving 35 physicians and
240 hypertensive patients found that doctor training in communication
skills (intervention group) significantly boosted physician-patient
communication skills, medication adherence, hypertension outcomes, and
self-efficacy, compared to the comparison/control group (Sany et al.,
2020). However, other studies have found no statistical significance of
clinician training. For example, one systematic review of 19 RCTs found
no statistical significance between clinician training and systolic blood
pressure, diastolic pressure, and HbA1c levels among patients with
hypertension and diabetes (Yao et al., 2021).

Level II
 Quasi-experimental studies

Not Applicable Not Applicable Not Applicable

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

 Systematic review of a combination of RCTs
and quasi-experimental studies, or quasi-
experimental studies only, with or without
meta-analysis
 Explanatory mixed method design that
includes only a Level II quantitative study
Level III
 Nonexperimental study
 A systematic review of a combination of RCTs,
quasi-experimental and nonexperimental studies,
or nonexperimental studies only, with or without
meta-analysis
 Qualitative study or meta-synthesis
 Exploratory, convergent, or multiphasic
mixed-methods studies
 Explanatory mixed method design that
includes only a level III Quantitative study

Not Applicable Not Applicable Not Applicable

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Category (Level Type) Total Number of
Sources/Level

Overall Quality
Rating

Synthesis of Findings
Evidence That Answers the EBP Question

Level IV
 Opinions of respected authorities and/or
reports of nationally recognized expert
committees or consensus panels based on
scientific evidence

Not Applicable Not Applicable Not Applicable

Level V
 Evidence obtained from literature or
integrative reviews, quality improvement,
program evaluation, financial evaluation, or case
reports
 Opinion of nationally recognized expert(s)
based on experiential evidence

Not Applicable Not Applicable Not Applicable

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Based on your synthesis, which of the following four pathways to translation represents the overall strength of
the evidence?
❑Strong, compelling evidence, consistent results: A solid indication for a practice change is indicated.
❑Good and consistent evidence: Consider pilot of change or further investigation.
❑Good but conflicting evidence: No indication for practice change; consider further investigation for new evidence or
develop a research study.
❑Little or no evidence: No indication for practice change; consider further investigation for new evidence, develop a
research study, or discontinue the project.
If you selected either the first option or the second option, continue. If not, STOP, translation is not indicated.
Recommendations based on evidence synthesis and selected translation pathway
Based on the evidence synthesis and chosen translation pathway, implementing tailored staff training centered on patient
education in medication compliance can improve staff knowledge/skills and patient outcomes, including systolic pressure levels and
compliance with antihypertensive drugs. Thus, the intervention should be applied.

Consider the following as you examine fit:
Are the recommendations:
 Compatible with the unit/departmental/organizational cultural values or norms?
 Consistent with unit/departmental/organizational assumptions, structures, attitudes, beliefs, and/or practices?
 Consistent with the unit/departmental/organizational priorities?

Consider the following as you examine feasibility:
 Can we do what they did in our work environment?
 Are the following supports available?
 Resources
 Funding
 Approval from administration and clinical leaders
 Stakeholder support
 Is it likely that the recommendations can be implemented within the unit/department/organization?

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Directions for Use of This Form
Purpose of form
Use this form to compile the results of the individual evidence appraisal to answer the EBP question. The pertinent
findings for each level of evidence are synthesized, and a quality rating is assigned to each level.
Total number of sources per level
Record the number of sources of evidence for each level.
Overall quality rating
Summarize the overall quality of evidence for each level. Use Appendix D to rate the quality of evidence.
Synthesis of findings: evidence that answers the EBP question
 Include only findings from evidence of A or B quality.
 Include only statements that directly answer the EBP question.
 Summarize findings within each level of evidence.
 Record article number(s) from individual evidence summary in parentheses next to each statement so that the
source of the finding is easy to identify.
Develop recommendations based on evidence synthesis and the selected translation pathway
Review the synthesis of findings and determine which of the following four pathways to translation
represents the overall strength of the evidence:
 Strong, compelling evidence, consistent results: Solid indication for a practice change.
 Good and consistent evidence: Consider pilot of change or further investigation.
 Good but conflicting evidence: No indication for practice change; consider further investigation for new
evidence or develop a research study.
 Little or no evidence: No indication for practice change; consider further investigation for new
evidence, develop a research study, or discontinue the project.
Fit and feasibility
Even when evidence is strong and of high quality, it may not be appropriate to implement a change in practice. It is
crucial to examine feasibility that considers the resources available, the readiness for change, and the balance
between risk and benefit. Fit refers to the compatibility of the proposed change with the organization’s mission,
goals, objectives, and priorities. A change that does not fit within the organizational priorities will be less likely to
receive leadership and financial support, making success difficult. Implementing processes with a low likelihood of
success wastes valuable time and resources on efforts that produce negligible benefits.

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

References

Sany, S. B., Behzhad, F., Ferns, G., & Peyman, N. (2020). Communication skills training for physicians improves
health literacy and medical outcomes among patients with hypertension: A randomized controlled trial. BMC
Health Services Research, 20(1). doi: 10.1186/s12913-020-4901-8.
Sartori, A., C., Lucena, T. F., Lopes, C. T., Bernuci, M. P., & Yamaguchi, M. U. (2020). Educational intervention
using WhatsApp on medication adherence in hypertension and diabetes patients: A randomized clinical trial.
Telemedicine Journal and e-Health, 26(12), 1526-1532. doi: 10.1089/tmj.2019.0305
Yao, M., Zhou, X., Xu, Z., Lehman, R., Haroon, S., Jackson, D., & Cheng, K. K. (2021). The impact of training
healthcare professionals’ communication skills on the clinical care of diabetes and hypertension: A systematic
review and meta-analysis. BMC Family Practice, 22(1). doi: 10.1186/s12875-021-01504-x