NURS 839 Week 2 Assignment 2 Level of Evidence Table Using the Melnyk Pyramid Example

Ten Sources, Seven Levels: A Melnyk Pyramid Evidence Table for a Scholarly Project on Prophylactic Silicone Foam Dressings in Long Surgeries

Introduction

The scholarly project asks whether, for adults whose operations are booked at three hours or longer, multilayer silicone foam dressings on the sacrum and heels placed before positioning reduce stage 1 or higher pressure injuries within 72 hours, compared with standard prevention. The seven-step pyramid of Melnyk and Fineout-Overholt (2015) runs from pooled randomized evidence at the top, through single trials, nonrandomized comparisons and observational designs, down to descriptive and qualitative work and, at the base, expert opinion. The table below places ten sources selected for the project on that pyramid, and a note after the table explains the judgment calls.

Level of Evidence Table

Notes on Leveling Decisions

Three placements required judgment. First, the Johansson et al. (2026) review pooled cohort and case-control studies rather than trials or descriptive studies, so it was placed at level IV with the designs it synthesizes rather than at level I, which the pyramid reserves for syntheses of randomized trials. Second, the Bates-Jensen et al. (2024) study compared an intervention group with pre-intervention and historical controls without randomization, which fits level III. Third, the international guideline was placed at level VII because its recommendations on prophylactic dressings were reached through expert consensus on the evidence then available, and it predates the most recent trials; a guideline built directly on a systematic review of trials could reasonably be placed higher. Stating these decisions makes the table easier to check and to revise if a reviewer or committee member disagrees.

Narrative Synthesis

The evidence is strongest exactly where the project needs it most: on whether the intervention works. Three level I syntheses agree that silicone foam dressings reduce pressure injuries, with Fu et al. (2025) reporting an 82% reduction in stage 1 sacral injuries, Rahman-Synthia et al. (2023) a 70% reduction in sacral injuries across settings and Al Jehani et al. (2026) ranking silicone first among six dressing options. Two level II trials bring the effect into surgical patients: Wang et al. (2026) during surgery and Yeo et al. (2023) after it. A level III trial in prone surgery adds that preoperative dressings reduced moisture-defined injuries and that subepidermal moisture detected more damage than visual inspection (Bates-Jensen et al., 2024).

The evidence thins on the questions the project's implementation depends on. Which surgical patients are at highest risk rests on a level IV review of observational studies, which found diabetes, obesity, low preoperative albumin and vasoactive infusions associated with injury but, unexpectedly, not surgery duration (Johansson et al., 2026). How common injuries are in long surgeries rests on a level VI descriptive study (Adıgüzel Akbaba et al., 2026), and why prevention stalls in operating rooms rests on a level VI qualitative study (Gao et al., 2026). The international guideline at level VII supports prophylactic dressings for at-risk patients but predates most of the trials (European Pressure Ulcer Advisory Panel et al., 2019). The pyramid is tall where we ask whether the dressing works and short where we ask how to make people use it.

This pattern has two implications for the project. First, the recommendation to use the dressings is strong, and the project need not test whether they work in principle. Second, the implementation questions, eligibility and adoption, rest on lower-level evidence, so the project's own data on who is injured and how consistently dressings are applied will add genuine knowledge. Moran et al. (2017) describe the DNP project as translating evidence into practice rather than generating new efficacy evidence, which this distribution of evidence supports.

Conclusion

Ten sources across seven levels support a strong recommendation for prophylactic silicone foam dressings and a careful approach to implementation. The table will anchor the introduction and literature review in Module/Week 3, organized by the same themes: effectiveness, risk and implementation. Before then, I will search once more for any trial published since these were gathered, since a new randomized trial in surgical patients would strengthen the level II row and could change how the review is framed.

References

Adıgüzel Akbaba, M., Uslu, Y., Aytar, F., & Eren, E. (2026). Intraoperative device-related pressure injuries in patients undergoing prolonged surgery. Advances in Skin & Wound Care. Advance online publication. https://doi.org/10.1097/ASW.0000000000000510

Al Jehani, M., Al Mazrou, F., Bafail, A., Alhwsawi, H., Albalawi, I., Alanazi, G., Halawani, I., Alhije, F., & Alalola, R. (2026). Prophylactic dressing in the prevention of bedsore: A network meta-analysis. Journal of Surgical Research, 317, 235-243. https://doi.org/10.1016/j.jss.2025.09.065

Bates-Jensen, B. M., Crocker, J., Nguyen, V., Robertson, L., Nourmand, D., Chirila, E., Laayouni, M., Offendel, O., Peng, K., Romero, S. A., Fulgentes, G., & McCreath, H. E. (2024). Decreasing intraoperative skin damage in prone-position surgeries. Advances in Skin & Wound Care, 37(8), 413-421. https://doi.org/10.1097/ASW.0000000000000186

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. The international guideline (E. Haesler, Ed.; 3rd ed.). EPUAP/NPIAP/PPPIA.

Fu, T., Wu, X., & Yu, B. (2025). Efficacy of silicone foam dressings in preventing pressure injuries in the sacral and heel areas of patients: A meta-analysis. Frontiers in Medicine, 12, Article 1644290. https://doi.org/10.3389/fmed.2025.1644290

Gao, Y., Chen, J., Guang, W., Xu, W., Wei, Z., & Yang, H. (2026). A qualitative study of facilitators and barriers to intraoperative acquired pressure injury prevention implementation in operating room nurses based on the CFIR framework. Frontiers in Health Services, 6, Article 1877556. https://doi.org/10.3389/frhs.2026.1877556

Johansson, V. R., Dahl, O., Falk, A. C., Nilsson, U., Dehara, M., & von Vogelsang, A. C. (2026). Risk factors for position-related injuries in adult surgical patients: A systematic review and meta-analysis. International Journal of Nursing Studies Advances, 11, Article 100676. https://doi.org/10.1016/j.ijnsa.2026.100676

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Wolters Kluwer.

Moran, K., Burson, R., & Conrad, D. (Eds.). (2017). The doctor of nursing practice scholarly project: A framework for success (2nd ed.). Jones & Bartlett Learning.

Rahman-Synthia, S. S., Kumar, S., Boparai, S., Gupta, S., Mohtashim, A., & Ali, D. (2023). Prophylactic use of silicone dressing to minimize pressure injuries: Systematic review and meta-analysis. Enfermería Clínica, 33(1), 4-13. https://doi.org/10.1016/j.enfcle.2022.05.002

Wang, C. Y., Liao, H. H., Hsieh, M. Y., & Lee, C. H. (2026). Soft silicone foam dressing for preventing intraoperative pressure injuries: A randomized controlled trial. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.08.022

Yeo, H., Hwang, J., Lee, M., No, D., & Jang, I. (2023). Effect of a prophylactic dressing for sacral pressure injuries in non-critically ill patients after general surgery: A randomized controlled trial. Worldviews on Evidence-Based Nursing, 20(3), 259-268. https://doi.org/10.1111/wvn.12651