Level II at Best: Rating the Level and Quality of Twelve Sources on Debriefing After In-Hospital Cardiac Arrest
Student Name
American College of Education
NUR5023: Advanced Nursing Research and Practice I
Module 3 Assignment
Instructor Name
May 17, 2027
The Rating Model
Two separate judgments are made for each source: its level, which reflects the strength of the study design for answering a question about effectiveness, and its quality, which reflects how well that design was carried out and reported. This paper rates the sources with the evidence-based practice model developed at Johns Hopkins (Dang et al., 2022). Under its scheme, Level I evidence comes from randomized controlled trials or systematic reviews of them; Level II from quasi-experimental studies or systematic reviews that combine trials and quasi-experimental studies; Level III from nonexperimental studies or reviews that include them, along with qualitative research; Level IV from clinical practice guidelines and consensus statements based on scientific evidence; and Level V from literature reviews, quality improvement reports, case reports and expert opinion. Quality is graded A for high, B for good and C for low or major flaws, using separate appraisal tools for research and nonresearch evidence.
Other hierarchies exist. Melnyk and Fineout-Overholt (2019) describe a seven-level hierarchy that separates descriptive and qualitative studies from expert opinion more finely. The Johns Hopkins model was chosen because the hospital's evidence-based practice council already uses it, which means the ratings in this paper can be read by the committee that will act on them. A rating scale is only useful if the people making the decision already understand it.
Rating the Central Sources
The systematic review and meta-analysis by Couper et al. (2013) was rated Level II, quality A. It is a systematic review, but the 27 studies it included were mostly quasi-experimental rather than randomized, which places it at Level II in this model rather than Level I. Its quality is high: it searched several databases with citation tracking, assessed study quality with the GRADE system, reported its methods fully and was cautious in its conclusions, reporting gains in the share of each arrest spent doing compressions and in pulses regained, alongside no measurable change in how many patients survived to go home. Its one weakness for this project is that the four arrest studies it could pool were small and varied in how debriefing was delivered.
The adult study by Edelson et al. (2008) was rated Level II, quality B. It compared 123 patients resuscitated during a year of weekly debriefing using recorded compression data with 101 patients in an earlier cohort who had the same feedback defibrillator but no debriefing. That is a quasi-experimental design with a historical control. It reported improved ventilation rate and compression depth and a higher rate of return of spontaneous circulation, 59.4 percent against 44.6 percent, with no change in survival to discharge. It was graded B rather than A because a historical control cannot rule out other changes over time, and because it was conducted at one academic center with resident-led resuscitation teams.
The pediatric study by Wolfe et al. (2014) was also rated Level II, quality B. It compared arrest events in a pediatric intensive care unit before and after interdisciplinary debriefing was introduced, with 60 control and 59 intervention events. The intervention was associated with a trend toward improved survival to discharge that did not reach statistical significance after adjustment, and with a significant improvement in survival with favorable neurologic outcome. The grade reflects a well-defined outcome and prospective data collection offset by a small sample and a single-center, pre-post design.
Nonresearch and Supporting Sources
The practical guide by Kessler et al. (2015) was rated Level V, quality B. It offers expert guidance on how to conduct debriefing after clinical events in the emergency department, including who should lead, when to hold the session and how to structure it. It is not research and makes no claim about outcomes, but it is written by recognized experts, draws on published work and is clear about its purpose, which earns a good quality grade within its level. Its value is for implementation, not for deciding whether debriefing works.
The seven remaining sources were rated as a group after individual appraisal. Three were quality improvement reports of debriefing programs at single hospitals, rated Level V with quality grades of B for two and C for one that reported no measures beyond participation. Two were cross-sectional surveys of nurses and physicians about their experience of debriefing after arrests, rated Level III, quality B. One was a qualitative study of team members' perceptions of hot debriefing, rated Level III, quality A for its clear methods and rich data. The last was a narrative literature review, rated Level V, quality C, because it did not describe how sources were found or selected.
Two Judgment Calls
Two ratings required judgment that another rater might make differently. The first was the Edelson study's quality grade. It is widely cited and its measurements of compression quality were objective, captured by the defibrillator rather than by observers, which argues for an A. The historical control and the concurrent use of a feedback device in both periods argue for a B, since it is difficult to separate the effect of debriefing from other changes in training or staffing over two years. The B was chosen, and the reason is recorded so the council can revisit it.
The second was whether the Couper meta-analysis should be rated Level I because it is a systematic review. The Johns Hopkins model rates a systematic review by the designs it contains, not by the fact that it is a review, so a review of mostly quasi-experimental studies belongs at Level II. The top of a hierarchy is a property of the evidence underneath a review, not of the word systematic in its title. This matters because a council reading Level I might assume a certainty the evidence does not have.
What the Profile Means
Across the twelve sources, none reached Level I. Three were Level II, three were Level III and six were Level V. Quality was mostly good, with two sources rated high and two rated low. The profile is typical of practice questions in resuscitation, where randomizing patients to receive or not receive a team debriefing after their arrest is rarely feasible. It means the synthesis in the next module will rest mainly on quasi-experimental evidence supported by a systematic review, with qualitative and survey studies explaining how debriefing works for the people who take part, and with expert guidance shaping how it should be done. Recommendations drawn from this body of evidence can be firm about process measures, where the Level II studies agree, and should be cautious about survival, where they do not.
Conclusion
Rating twelve sources on debriefing after in-hospital cardiac arrest produced an honest picture: good-quality evidence that stops at Level II, a meta-analysis that sits there because of the studies it contains, and a set of lower-level sources that are useful for implementation rather than for proving effect. Recording the reasons for each rating, especially the two judgment calls, lets the evidence-based practice council see where the confidence in the evidence comes from and where it runs out.
References
Couper, K., Salman, B., Soar, J., Finn, J., & Perkins, G. D. (2013). Debriefing to improve outcomes from critical illness: A systematic review and meta-analysis. Intensive Care Medicine, 39(9), 1513-1523. https://doi.org/10.1007/s00134-013-2951-7
Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.
Edelson, D. P., Litzinger, B., Arora, V., Walsh, D., Kim, S., Lauderdale, D. S., Vanden Hoek, T. L., Becker, L. B., & Abella, B. S. (2008). Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Archives of Internal Medicine, 168(10), 1063-1069. https://doi.org/10.1001/archinte.168.10.1063
Kessler, D. O., Cheng, A., & Mullan, P. C. (2015). Debriefing in the emergency department after clinical events: A practical guide. Annals of Emergency Medicine, 65(6), 690-698. https://doi.org/10.1016/j.annemergmed.2014.10.019
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
Wolfe, H., Zebuhr, C., Topjian, A. A., Nishisaki, A., Niles, D. E., Meaney, P. A., Boyle, L., Giordano, R. T., Davis, D., Priestley, M., Apkon, M., Berg, R. A., Nadkarni, V. M., & Sutton, R. M. (2014). Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. Critical Care Medicine, 42(7), 1688-1695. https://doi.org/10.1097/CCM.0000000000000327
How this NUR 5023 Module 3 example is structured
NUR 5023 Module 3 usually assigns levels of evidence and rates the quality of what survived screening; your classroom's instructions decide which hierarchy and quality tool to use. This example names the rating model and its definitions first, then rates the five most important sources one by one with the features that decided each level and grade, and summarizes the remaining seven as a group. A section on judgment calls explains the two ratings that were hardest to assign. The conclusion states what the overall profile of the evidence means for the synthesis in the next module.
NUR5023 Module 3 questions, answered
What does NUR5023 Module 3 usually ask for?
NUR5023 Module 3 usually asks students to assign levels of evidence and rate the quality of the sources found in their search, often using a named model such as the Johns Hopkins evidence-based practice model. Many sections expect an evidence table. Your classroom's instructions decide which hierarchy and appraisal tools to use.
Is a systematic review always Level I evidence?
Not in every model. In the Johns Hopkins model, a systematic review is rated by the designs it includes: a review of randomized trials is Level I, but a review that combines trials with quasi-experimental studies, or includes mostly quasi-experimental studies, is Level II. Check how your assigned hierarchy treats reviews before rating them.
What is the difference between level and quality?
Level describes the strength of a study's design for answering a question, such as a trial compared with a survey. Quality describes how well that particular study was designed, carried out and reported. A well-conducted Level II study can be more useful than a poorly conducted Level I study, so report both.
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