Inside: a finished NUR 440 Module 6 evidence synthesis on awake prone positioning, with an evidence matrix of four studies, a narrative synthesis explaining conflicting results, a practice recommendation, limits and references. Searches like "nur 440 module 6 assignment", "nur440 module 6 evidence synthesis" and "nur 440 module 6 example" land here.
The NUR 440 Module 6 example, in full
Who Benefits From Lying Prone While Awake? An Evidence Synthesis on Awake Prone Positioning for COVID-19 Hypoxemia
[Student Name]
Southern New Hampshire University
NUR 440: Research and Evidence-Based Practice
Module Six Evidence Synthesis
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Who Benefits From Lying Prone While Awake? An Evidence Synthesis on Awake Prone Positioning for COVID-19 Hypoxemia
The Practice Question
During the COVID-19 pandemic, nurses on a composite 24-bed respiratory step-down unit coached many non-intubated patients with low oxygen levels to lie on their stomachs for hours at a time. The practice spread quickly on the basis of physiology and early observational reports. With respiratory illness surges still possible, the unit's practice council asked whether the evidence supports keeping an awake proning protocol. The question is: in adults with COVID-19 and hypoxemic respiratory failure who are not intubated (P), does awake prone positioning (I), set against usual care (C), lower the chance of needing intubation (O)?
Four studies were selected for synthesis: three randomized trials and one systematic review with meta-analysis. They were chosen because they are the largest and most rigorous available and because they represent different patient groups and settings.
Evidence Matrix
Table 1 presents the four studies in parallel.
Table 1
Evidence Matrix: Awake Prone Positioning in Non-Intubated Adults With COVID-19
| Study | Design and setting | Sample | Intervention delivered | Main result |
|---|---|---|---|---|
| Ehrmann et al. (2021) | Meta-trial of six randomized trials, several countries | 1,126 adults on high-flow nasal oxygen | Awake prone positioning versus standard care | Treatment failure 40 percent versus 46 percent; fewer intubations with proning; no clear difference in mortality |
| Alhazzani et al. (2022) | Pragmatic randomized trial, 21 hospitals, unblinded | 400 adults needing 40 percent oxygen or more, or noninvasive ventilation | Median about 4.8 hours prone per day in the first 4 days | Intubation by day 30: 34.1 percent versus 40.5 percent; difference not statistically significant |
| Fralick et al. (2022) | Pragmatic randomized trial, 15 hospitals, stopped early for futility | 248 non-critically ill adults on up to 50 percent oxygen, mostly nasal prongs | Median 6 hours prone in total over the first 72 hours | Composite of death, ventilation or worsening failure 14 percent in both groups |
| Li et al. (2022) | Systematic review and meta-analysis | 10 randomized trials with 1,985 patients plus observational studies | Awake prone positioning versus supine | Reduced intubation overall; benefit seen with advanced respiratory support and in intensive care, not with conventional oxygen |
Synthesis
At first glance the trials disagree. The large meta-trial found that awake proning reduced treatment failure and intubation among patients receiving high-flow nasal oxygen (Ehrmann et al., 2021). The trial by Alhazzani et al. (2022) found a similar direction, fewer intubations with proning, but the difference was not statistically significant, and the trial by Fralick et al. (2022) found no difference at all and was stopped early.
Two features explain much of the disagreement. The first is who was enrolled. The meta-trial and the Alhazzani trial studied sicker patients, those on high-flow oxygen or noninvasive ventilation, while the Fralick trial enrolled patients on the ward who were mostly receiving oxygen by nasal prongs and whose risk of deterioration was lower; with only 14 percent of patients reaching the composite outcome in either group, a small benefit would be hard to detect. The second is how much proning patients actually did. In the Alhazzani trial, the median time prone was about five hours a day in the first days, and in the Fralick trial it was about six hours in total over three days. An intervention that patients find uncomfortable and practice for only a few hours a day cannot show its full effect, so negative trials may partly reflect low adherence rather than an ineffective intervention.
The meta-analysis tests this explanation. Pooling ten randomized trials, Li et al. (2022) found that awake proning reduced the need for intubation overall, and that the benefit was concentrated among patients receiving advanced respiratory support and those cared for in intensive care settings, with no clear benefit among patients on conventional oxygen or outside intensive care. The pattern across studies is therefore consistent: benefit is most likely in more severely hypoxemic patients, while evidence for patients on low-flow oxygen is weak.
Recommendation for the Unit
The evidence supports offering awake prone positioning to non-intubated adults with COVID-19-related hypoxemic respiratory failure who require high-flow nasal oxygen or noninvasive ventilation, with the aim of reducing intubation. For patients on low-flow nasal oxygen, the evidence does not show a clear benefit, and proning may reasonably be offered for comfort if the patient wishes but should not be presented as proven. Because benefit appears to depend on time spent prone, the unit's protocol should include nursing support to help patients tolerate longer sessions, such as pillows, pain management, frequent repositioning between prone and side-lying positions and coaching, and adverse events such as discomfort, desaturation and line dislodgement should be monitored.
Safety Across the Studies
A synthesis must also weigh harms. Across the trials, serious adverse events attributed to proning were rare. In the trial by Alhazzani et al. (2022), about one in ten patients in the proning group had an adverse event, most often musculoskeletal pain or discomfort, with a small number of desaturation episodes and no serious adverse events in either group. The meta-trial reported that prespecified adverse events were uncommon and similar between groups (Ehrmann et al., 2021). Discomfort matters for nursing in two ways: it is a burden for patients, and it is the main reason patients stop lying prone, which reduces any benefit. The low rate of serious harm means that the practical question for the unit is not whether proning is safe but how to make it tolerable enough to be effective.
Limitations of the Evidence
The trials were unblinded, which is unavoidable for a positioning intervention but may influence decisions about intubation. Adherence varied widely and was often low. Most studies were conducted during particular phases of the pandemic, with changing treatments such as corticosteroids and different virus variants, which may limit how well results apply to future patients or to other causes of hypoxemic respiratory failure. None of the trials showed a clear effect on mortality, so the main demonstrated benefit is avoiding intubation.
Conclusion
Placing four studies in a matrix and comparing them reveals a consistent pattern behind apparently conflicting results: awake prone positioning reduces the need for intubation in more severely hypoxemic patients on advanced respiratory support, while benefit in patients on low-flow oxygen is unproven, and trials with little time spent prone may understate the effect. For the unit, that points to a targeted protocol with strong nursing support for adherence rather than proning every patient on oxygen.
References
Alhazzani, W., Parhar, K. K. S., Weatherald, J., Al Duhailib, Z., Alshahrani, M., Al-Fares, A., Buabbas, S., Cherian, S. V., Munshi, L., Fan, E., Al-Hameed, F., Chalabi, J., Rahmatullah, A. A., Duan, E., Tsang, J. L. Y., Lewis, K., Lauzier, F., Centofanti, J., Rochwerg, B., . . . Arabi, Y. M. (2022). Effect of awake prone positioning on endotracheal intubation in patients with COVID-19 and acute respiratory failure: A randomized clinical trial. JAMA, 327(21), 2104-2113. https://doi.org/10.1001/jama.2022.7993
Ehrmann, S., Li, J., Ibarra-Estrada, M., Perez, Y., Pavlov, I., McNicholas, B., Roca, O., Mirza, S., Vines, D., Garcia-Salcido, R., Aguirre-Avalos, G., Trump, M. W., Nay, M.-A., Dellamonica, J., Nseir, S., Mogri, I., Cosgrave, D., Jayaraman, D., Masclans, J. R., . . . Tavernier, E. (2021). Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: A randomised, controlled, multinational, open-label meta-trial. The Lancet Respiratory Medicine, 9(12), 1387-1395. https://doi.org/10.1016/S2213-2600(21)00356-8
Fralick, M., Colacci, M., Munshi, L., Venus, K., Fidler, L., Hussein, H., Britto, K., Fowler, R., da Costa, B. R., Dhalla, I., Dunbar-Yaffe, R., Branfield Day, L., MacMillan, T. E., Zipursky, J., Carpenter, T., Tang, T., Cooke, A., Hensel, R., Bregger, M., . . . Verma, A. A. (2022). Prone positioning of patients with moderate hypoxaemia due to covid-19: Multicentre pragmatic randomised trial (COVID-PRONE). BMJ, 376, Article e068585. https://doi.org/10.1136/bmj-2021-068585
Li, J., Luo, J., Pavlov, I., Perez, Y., Tan, W., Roca, O., Tavernier, E., Kharat, A., McNicholas, B., Ibarra-Estrada, M., Vines, D. L., Bosch, N. A., Rampon, G., Simpson, S. Q., Walkey, A. J., Fralick, M., Verma, A., Razak, F., Harris, T., . . . Ehrmann, S. (2022). Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: A systematic review and meta-analysis. The Lancet Respiratory Medicine, 10(6), 573-583. https://doi.org/10.1016/S2213-2600(22)00043-1
How this NUR 440 Module 6 example is structured
Synthesis is different from summary, so the paper spends its words on comparison. After stating the practice question, it presents an evidence matrix with each study's design, sample, intervention, main outcome and result in the same columns, which makes differences visible. The synthesis section then asks why two randomized trials reached different conclusions and finds the answer in who was enrolled and how much time patients actually spent prone. A meta-analysis is used to test that explanation. The paper ends with a recommendation that depends on the patient group, followed by the limits of the evidence and how the unit would apply it.
Get NUR 440 Module 6 written to your instructions
Send your NUR 440 Module 6 synthesis instructions, the rubric and the studies you have gathered. The desk writes an evidence synthesis and matrix to that brief in 24 to 48 hours, and the first sample is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
NUR 440 Module 6 questions, answered
What does NUR 440 Module 6 usually ask for?
Later in the course, students typically move from appraising individual studies to synthesizing them, often with an evidence table or matrix and a narrative that compares findings. This work feeds directly into the final integrative review. The format and number of studies come from your guidelines.
What is an evidence matrix?
An evidence matrix is a table that lists each study in a row and uses the same columns for key features, such as design, sample, intervention, outcomes, results and level of evidence. Putting studies in parallel makes patterns and differences easier to see and helps structure the written synthesis.
How do I handle studies that disagree?
Look for differences that could explain the conflict: the population, the setting, how the intervention was delivered, how outcomes were measured and whether the study was large enough. A good synthesis explains the disagreement rather than averaging it away, and a meta-analysis can help test the explanation.