Chinese Nursing Research xxx (2016) 1e9

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Chinese Nursing Research

j o u r n a l h o m e p a g e : http://www.journals.elsevier.com/chinese-nursing-research

Original article

Systematic evaluation of the clinical nursing pathway with the GRADE

approach applied to functional exercise in patients with hip
replacements before and after surgery
Lin Yang a, Xin-Man Wang b, Xiao-Lin Zuo a, Shang-Qun Gong a, Fan-Jie Meng a, *
a
Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China
b
North AnHui Health Vocational College, Suzhou, Anhui 234000, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To evaluate the effect of the clinical nursing pathway applied to functional exercise in patients
Received 20 June 2016 with hip replacements before and after the operation.
Received in revised form Methods: The China National Knowledge Infrastructure (CNKI), WanFang Data, Chinese science and
24 July 2016
technology journal database (VIP), PubMed, Web of Science, EMBASE, CBM and the Cochrane Library
Accepted 9 September 2016
Available online xxx
(2015-5) were searched for randomized controlled trials (RCTs) on clinical nursing pathways for func-
tional exercise in patients with hip replacements before and after surgery from June 2015 to January
2010. The references included in the literature were also retrieved. To meet the literature standard, 2
Keywords:
Hip replacement
reviewers independently selected and extracted data according to the inclusion criteria and assessed the
Functional exercise risks of bias. RevMan 5.3 software was used in this meta-analysis. The quality of evidence was evaluated
Clinical nursing pathway using grade profiler3.6 software, the level recommended for grading.
Randomized controlled trial (RCT) Results: A total of 15 RCTs and 1248 patients were included. The meta-analysis showed that, in the
System evaluation clinical nursing path group, the Harris score of hip function [SMD ¼ 3.35, 95%CI (2.53, 4.16), P < 0.00001]
GRADE approach and incidence of thrombosis embolism [RR ¼ 0.28, 95%CI (0.15, 0.53), P < 0.0001], pulmonary infection
[RR ¼ 0.33, 95%CI (0.14, 0.82), P ¼ 0.02], urinary retention [RR ¼ 0.22, 95%CI (0.09, 0.52), P ¼ 0.0005],
constipation [RR ¼ 0.20, 95%CI (0.10, 0.40), P < 0.00001], patients' satisfaction for nursing care [RR ¼ 1.26,
95%CI (1.17, 1.36), P < 0.00001] and shortened hospitalization times [SMD ¼ 1.91, 95%CI (2.39, 1.43),
P < 0.0001]were statistically significantly better than those in the control group. However, in reducing
joint dislocations [RR ¼ 0.25, 95%CI (0.05, 1.15), P ¼ 0.08], pressure ulcers [RR ¼ 0.25, 95%CI (0.03, 2.19),
P ¼ 0.21], and incidence of complications [RR ¼ 0.42, 95%CI (0.15, 1.12), P ¼ 0.08], there was no statis-
tically significant difference between the two groups. Funnel plot analysis of the average length of stay
showed that there might be some publication bias in the literature. The GRADE evaluation results
showed that the level of Harris scores for hip function was moderate and the incidence of thrombosis,
urinary retention and satisfaction of patients regarding nursing were low, and the rest of the factors
analyzed were very low.
Conclusions: The effect of the clinical nursing pathway applied to functional exercises in patients with
hip replacements before and after surgery was significantly better than that of routine nursing. However,
it was restricted by the evaluation grade of the research results and the standardization and uniformity of
the research. The results of the above study need to be verified by more high-quality RCTs.
© 2016 Shanxi Medical Periodical Press. Publishing services by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Hip replacement is a type of arthroplasty that includes the use of

* Corresponding author.
E-mail address: mfj127@tjutcm.edu.cn (F.-J. Meng).
Peer review under responsibility of Shanxi Medical Periodical Press.
a prosthesis with good biocompatibility and mechanical properties
to replace damaged joints due to illness or injury.1 It has become
the most commonly used treatment for hip diseases and injuries
because of its superiority in solving joint pain, restoring joint

http://dx.doi.org/10.1016/j.cnre.2016.11.008
2095-7718/© 2016 Shanxi Medical Periodical Press. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
2 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9
function and improving walking ability.1 Hip replacement has been
extensively used in clinical practice. According to the 2012 Annual
Report of the National Joint Registry (NJR) for England and Wales,
71,672 primary hip replacements were undertaken in 2011, which
was an increase from just over 56,000 in 2005.2 The indications of
the operation include femoral neck fracture, necrosis of the femoral
head, bone arthritis and bone tumors. To consolidate the curative
effect of an operation, prevent the occurrence of complications,
promote the recovery of the patient's joint function and improve
quality of life after surgery, early and correct functional exercises
are necessary. The clinical nursing pathway (CNP) is a new care
management mode with high quality, high efficiency and low cost.
It allows nurses to perform nursing care according to a path table
based on the needs of medical care for a disease.3 As a new nursing
mode, it specifies the treatment and nursing activities that the
hospitalized patients should complete. It is more rigorous and
standardized than the traditional nursing mode, in which medical
care processes are carried out simply in accordance with the doc-
tor's advice.4 Although the CNP has been used in clinical practice
since the 1980s, there has been many controversy regarding what it
really is and how it affects patients' nursing processes and out-
comes.5 To provide a clearer, standardized and effective basis for
the application of CNP in functional exercises of patients with hip
replacements before and after the operation, we carried out a
systematic evaluation using the GRADE approach.
2. Methods
2.1. Criteria for relevant studies enrolled in this review
2.1.1. Type of study
The study only employed randomized controlled trials (RCTs)
and did not consider whether they used concealment or blinding.
2.1.2. Types of participants
Patients who received hip replacement surgery (not considering
types of diseases and surgeries) of any ethnicity, region, gender or
age.
2.1.3. Types of interventions
The CNP group served as the experimental group. Education and
guidance regarding contraction training of lower limb muscles,
active and passive activities of hip and knee joints before surgery
and related functional exercises and nursing care after surgery
were included.
The control group received routine nursing, including health
education for routine functional exercises, symptomatic care and
drugs, diet and psychological guidance.
2.1.4. Types of outcomes
2.1.4.1. Critical outcomes. The critical outcome measures were the
Harris scores of hip functions and the incidence of joint
dislocations.
2.1.4.2. Secondary outcomes. The secondary outcome measures
included the incidence of thrombosis embolism, pulmonary
infection, pressure ulcer, urinary retention, constipation, all com-
plications, patients' satisfaction regarding nursing care and hospi-
talization time.
2.2. Search strategies
The China journal full text database (CNKI), digital periodical full
text database (WanFang Data), Chinese science and technology
journals database (VIP), PubMed, Web of Science, EMBASE, CBM
Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
and Cochrane Library (2015-5) were searched, and RCTs regarding
the clinical nursing pathway for functional exercise in patients with
hip replacements before and after surgery were retrieved from June
2015 to January 2010. The MeSH term combined with free words
was used. The search terms included: “Arthroplasty, Replacement,
Hip” (Mesh) OR “hip arthroplasty*” (Title/Abstract) OR “hip
replacement*” (Title/Abstract) OR “Hip Prosthesis Implantation*”
(Title/Abstract) AND [“Critical Pathways” (Mesh) OR “Critical
Pathway” (Title/Abstract) OR “Critical Path*” (Title/Abstract) OR
“Clinical Path*” (Title/Abstract) OR “Clinical Pathway*” (Title/Ab-
stract) OR “clinical nursing pathway*” (Title/Abstract) OR “clinical
care path*” (Title/Abstract)] AND [“Clinical Trial” (Publication Type)
OR “Observational Study” (Publication Type) OR random* (all
fields)].
2.3. Study selection and data extraction
Literature screening, process recording, final determination of
the studies and data extraction were performed independently by
two reviewers. Any differences were resolved by a third reviewer.
Data extraction mainly included: basic information on the
included studies, such as title, first author, publication year; char-
acteristics, such as the number of cases, general conditions of the
patients, intervention measures and follow-up; and primary and
secondary outcomes. If there was any missing information, the
original author was contacted.
2.4. Statistical analyses
The Cochrane Review Manager software, RevMan 5.3, was used
for data processing and analysis of all of the included studies. We
used the relative risk (RR) and 95% confidence interval (95%CI) to
analyze discontinuous data. The measuring tools for continuous
data in this review were consistent, and the standardized mean
difference (SMD) and 95%CI were adopted. The heterogeneity of
each result was tested with a Chi-squares test. When the P value
was larger than or equal to 0.10 or I2 was less than or equal to 50%,
we used a fixed effects model. Otherwise, subgroup analysis was
performed to determine the sources of heterogeneity. If the data
could be combined, we used a random effects model; otherwise,
descriptive analysis was implemented.
If the number of included studies for the outcome was more
than or equal to 10, a Begg's funnel plot was mapped using Stata
12.0 software. Potential publication bias was evaluated according to
the funnel plot. When the P value was less than 0.05, it suggested a
larger publication bias; when the P value was more than 0.05, it
suggested that a publication bias was not obvious.
2.5. Assessment of the risk of bias in the included studies
Risk assessment was carried out using 6 items in the bias risk
assessment tools recommended by the Cochrane Handbook 5.1.0.6
The 6 items, including randomization, allocation concealment,
blinding, incomplete outcome data, selective reporting and other
bias, were described by yes (low risk of bias), no (high risk of bias)
and unclear (no description or uncertainty).
2.6. The GRADE approach
Classification of the quality of evidence for the outcomes of the
included studies was completed using the GRADE approach. The
default was that the quality of all of the evidence was high as the
included studies were RCTs. However, there were 5 factors that
could reduce confidence: risk of bias, inconsistency, indirectness,
imprecision and reporting bias.
 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9 3

3. Results
3.1. Literature search
Initially, 308 relevant studies were detected; after screening,
fifteen studies with a total of 1248 patients who met the inclusion
criteria were included for the meta-analysis.1,7e20 A flow chart of
the selection process is illustrated in Fig. 1.
3.2. The basic characteristics of the included studies
The specific characteristics of the 15 reviewed studies are
summarized in Table 1.
discharge group [SMD ¼ 4.05, 95%CI (3.55, 4.54), P < 0.00001], the
differences were statistically significantly different.
3.4.2. The incidence of joint dislocation
The incidence of dislocation of the hip joint, incidence of pros-
thesis dislocation and incidence of dislocation of the femoral head
were combined and was called the incidence of joint dislocation.
There were three12,15,17 studies with 222 patients that reported
incidence of joint dislocation. The results of the meta-analysis
showed that, although the incidence of joint dislocation in the
CNP group was lower than that in the control group (Fig. 3), there
was no statistically significant difference between the two groups
[RR ¼ 0.25, 95%CI (0.05, 1.15), P ¼ 0.08].

3.3. Assessment of the risk of bias in the included studies

The assessment of the risk of bias with the GRADE approach is
shown in Table 2.
3.4. Meta-analysis
3.4.1. Harris score of hip function
There were five7,8,17,18,20 studies with 438 patients that reported
the Harris score of hip function. We divided the 5 studies into 3
subgroups according to the measurement time of the Harris score.
The results of the meta-analysis showed that the Harris score of hip
function in the CNP group was higher than that in the control group
(Fig. 2). In the first year after surgery group [SMD ¼ 3.22, 95%CI
(2.74, 3.70), P < 0.00001], the 7 days after surgery group
[SMD ¼ 2.04, 95%CI (1.49, 2.58), P < 0.00001] and the before
3.4.3. The incidence of thrombosis embolism
The incidence of venous thrombosis, incidence of deep venous
thrombosis and incidence of thrombosis embolism were combined.
Eight studies including 664 patients reported the incidence of
thrombosis embolism.8,11e13,15,17,18,20 The results showed that the
incidence of thrombosis embolism in the CNP group was lower
than that in the control group (Fig. 4), and the difference was sta-
tistically significant [RR ¼ 0.28, 95%CI (0.15, 0.53), P < 0.0001].
3.4.4. The incidence of pulmonary infection
The incidence of pulmonary infection and incidence of hypo-
static pneumonia were combined into the incidence of pulmonary
infection. It was reported by three13,17,18 studies with 298 partici-
pants. The results showed that the incidence of pulmonary infec-
tion in the CNP group was lower than that in the control group

Electronic database (n=308) Other resources (n=0)

Records after duplicates removed (n=147)

Records screened (n=147)

Exclusion (n=98):
Non-relevant articles (n=94)
Review/Observational study (n=4)

Full-text articles assessed for eligibility (n=49)

Exclusion (n=34):
Not randomized (n=0)
Not meet intervention (n=34)

Included studies for review (n=15)

Fig. 1. Flow chart of the selection process.

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
4 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9

Table 1
Characteristics of the included studies.

Study Number of Surgery type Interventions Follow-up Outcomes

patients (EG/CG)
EG CG

Yan 20147 80 (40/40) I A C Unclear aþj

Ling 20101 120 (60/60) I A DþF Unclear i
Tang 20108 46 (23/23) I A CþG 12e18 days aþbþfþgþj
Zhang 20139 84 (42/42) I A E Unclear hþj
Li 201310 96 (48/48) II B E 6 months k
Li 201111 64 (32/32) II A E Unclear bþfþgþj
Li 201212 48 (24/24) II A CþG 7e15 days bþcþeþgþiþj
Wang 201313 100 (50/50) II A C Unclear bþdþgþiþj
Nie 201014 120 (60/60) II, III A C Unclear iþj
Xiao 201215 94 (47/47) IV A DþE Unclear bþcþj
Hu 201216 24 (12/12) I A C Unclear iþj
Tan 201517 80 (40/40) II A E Unclear aþbþcþdþj
Kan 201318 118 (59/59) IV A CþG 3/6/12 month after operation aþbþdþeþfþj
Chen 201419 60 (30/30) I A C 3/6 month after operation hþiþj
Ma 201320 114 (72/72) I A C 12 month after operation aþbþfþj

Notes: EG ¼ CNP group; CG ¼ control group; I ¼ hip replacement, II ¼ total hip replacement, III ¼ hemiarthroplasty, IV ¼ unilateral hip replacement; A ¼ clinical nursing path
table, B ¼ clinical nursing and health education path table, C ¼ orthopedic routine nursing, D ¼ holistic nursing, E ¼ traditional nursing, F ¼ random rehabilitation training,
G ¼ random health education; a ¼ Harris score of hip function, b ¼ incidence of thrombosis embolism, c ¼ incidence of joint dislocation, d ¼ incidence of pulmonary infection,
e ¼ incidence of pressure ulcer, f ¼ incidence of urinary retention, g ¼ incidence of constipation, h ¼ incidence of all complications, i ¼ patients' satisfaction for nursing care,
j ¼ hospitalization time, k ¼ recovery rate of the hip function.

Table 2
Assessment of the risk of bias.

Study Randomization Allocation Blinding Incomplete Selective Other bias

concealment outcome data reporting
Practitioners and Outcome assessor
patients

Yan 20147 No Unclear Unclear Unclear Yes Unclear Unclear

Ling 20101 No Unclear Unclear Unclear Yes Unclear Unclear
Tang 20108 No Unclear Unclear Unclear Yes Unclear Unclear
Zhang 20139 No Unclear Unclear Unclear Yes Unclear Unclear
Li 201310 No Unclear Unclear Unclear Yes Unclear Unclear
Li 201111 No Unclear Unclear Unclear Yes Unclear Unclear
Li 201212 No Unclear Unclear Unclear Yes Unclear Unclear
Wang 201313 No Unclear Unclear Unclear Yes Unclear Unclear
Nie 201014 No Unclear Unclear Unclear Yes Unclear Unclear
Xiao 201215 No Unclear Unclear Unclear Yes Unclear Unclear
Hu 201216 No Unclear Unclear Unclear Yes Unclear Unclear
Tan 201517 No Unclear Unclear Unclear Yes Unclear Unclear
Kan 201318 Yes Unclear Unclear Unclear Yes Unclear Unclear
Chen 201419 No Unclear Unclear Unclear Yes Unclear Unclear
Ma 201320 No Unclear Unclear Unclear Yes Unclear Unclear

Fig. 2. Forest plot of comparisons: Harris scores of hip function.

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9 5

Fig. 3. Forest plot of comparisons: the incidence of joint dislocation.

(Fig. 5), and the difference was statistically significant [RR ¼ 0.33,
95%CI (0.14, 0.82), P ¼ 0.02].
3.4.5. The incidence of pressure ulcers
There were two12,18 studies with 166 patients that reported the
incidence of pressure ulcers. The results of the meta-analysis
showed that the incidence of pressure ulcers in the CNP group
was lower than that in the control group (Fig. 6), but there was no
statistically significant difference between the two groups
[RR ¼ 0.25, 95%CI (0.03, 2.19), P ¼ 0.21].
3.4.6. The incidence of urinary retention
Four studies including 242 patients reported the incidence of
urinary retention.8,11,18,20 The results showed that the incidence of
urinary retention in the CNP group was lower than that in the
control group (Fig. 7), and the difference was statistically significant
[RR ¼ 0.22, 95%CI (0.09, 0.52), P ¼ 0.0005].
3.4.7. The incidence of constipation
Four studies including 258 patients reported the incidence of
constipation.8,11e13 The results showed that the incidence of con-
stipation in the CNP group was lower than that in the control group
(Fig. 8), the difference was statistically significant [RR ¼ 0.20, 95%CI
(0.10, 0.40), P < 0.00001].
3.4.8. The incidence of all complications
Two studies with 144 patients reported the incidence of all
complications.9,19 The results showed that the incidence of all
complications in the CNP group was lower than that in the control
group (Fig. 9) and that the difference was not statistically significant
[RR ¼ 0.42, 95%CI (0.15, 1.12), P ¼ 0.08].
that patients' satisfaction levels for nursing care in the experi-
mental group were better than those in the control group (Fig. 10)
and that the difference was statistically significant [RR ¼ 1.26, 95%CI
(1.17, 1.36), P < 0.00001].
3.4.10. Hospitalization time
There were thirteen studies that reported hospitalization
times.7e9,11e20 We divided the 13 studies into 2 subgroups ac-
cording to the ages of the patients. The results of the meta-analysis
showed that the hospitalization times in the CNP group were
shorter than those in the control group (Fig. 11). In the patients with
all ages group [SMD ¼ 2.22, 95%CI (2.78, 1.66), P < 0.00001]
and the elderly patients group [SMD ¼ 0.96, 95%CI (1.20, 0.72),
P < 0.00001], the differences were statistically significant.
3.5. Publication bias
Meta-analysis of the efficacy evaluations described above
showed that the number of included studies for hospitalization
time was more than 10. A Begg's funnel plot (Fig. 12) based on the
hospitalization time indicated that there might be some publica-
tion bias. The results might be explained by the presence of nega-
tive test results that were not published. After sensitivity analyses,
each study that included the hospitalization time was removed one
by one, and the differences were still statistically significant and the
results of the meta-analysis were relatively stable.
3.6. Quality of evidence by the GRADE approach

3.4.9. Patients' satisfaction levels for nursing care The quality of evidence and level recommended for grading
Six studies with a total of 472 participants reported patients' were evaluated by using GRADE profiler3.6 software. A summary of
satisfaction levels for nursing care.1,12e14,16,19 The results showed the findings tables is shown in Table 3.

Fig. 4. Forest plot of comparisons: the incidence of thrombosis embolism.

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
6 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9

Fig. 5. Forest plot of comparisons: the incidence of pulmonary infection.

Fig. 6. Forest plot of comparisons: the incidence of pressure ulcers.

Fig. 7. Forest plot of comparisons: the incidence of urinary retention.

Fig. 8. Forest plot of comparisons: the incidence of constipation.

Fig. 9. Forest plot of comparisons: the incidence of all complications.

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9 7

Fig. 10. Forest plot of comparisons: patients' satisfaction levels for nursing care.

Fig. 11. Forest plot of comparisons: hospitalization time.

significant results on functional exercises, and some are afraid of

Fig. 12. Begg's funnel plot based on hospitalization time.
4. Discussion
4.1. Efficacy analysis
In clinical nursing, some patients give little thought to func-
tional exercise after hip replacement, some are anxious to achieve
the pain and do not want to exercise on their own.21 To a certain
extent, the nursing staff, patients and their families participate in
the formulation and implementation of clinical pathways and
improve the enthusiasm and compliance of the patients as well as
help avoid the incidence of nursing errors due to work overloads.22
Functional exercise is complex and needs to be accomplished
chronically, accurately and orderly. CNP can ensure that patients
have a continuous and regular exercise program, which will
enhance the effect of functional exercises.23
The clinical and economic benefits of the CNP applied to the care
of patients after hip and knee replacements was confirmed by the
meta-analysis reported by Barbieri5 in 2009. Barbieri proposed that
the CNP has important significance in improving the quality of care,
reducing the incidence of postoperative complications, shortening
the hospitalization time and decreasing hospitalization expenses.
However, his research ignored the specific principles and contents
of the CNP table and condition of the recovery of hip joint function
after application. Leigheb et al.24 noted that there was still con-
troversy regarding the CNP for functional exercises after a hip
replacement and that the effects of the CNP need to be verified by
further studies.
This review emphasizes that the formulation principles of the
CNP table are: (1) the education and guidance of functional exercise

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
8 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9

Table 3
Summary of findings.

Outcome No. of No. of patients 95%CI Quality assessment Quality Importance

studies
CNP Control Risk of Inconsistency Indirectness Imprecision Reporting bias
group group bias

Harris score of 5 219 219 SMD 3.35 (2.53, 4.16) Seriousa None None None Undetected ÅÅÅO Critical
hip function moderate
a b
Incidence of 8 10/332 39/332 RR 0.28 (0.15, 0.53) Serious None Serious None Undetected ÅÅOO Important
thrombosis embolism low
Incidence of joint 3 1/111 7/111 RR 0.25 (0.05,1.15) Seriousa None None Very seriousc, d
Undetected ÅOOO Important
dislocation very low
Incidence of 3 6/149 18/149 RR 0.33 (0.14,0.82) Seriousa None Seriousb Seriousc Undetected ÅOOO Important
pulmonary infection very low
b c, d
Incidence of 2 0/83 3/83 RR 0.25 (0.03,2.19) None None Serious Very serious Undetected ÅOOO Important
pressure ulcer very low
a b c
Incidence of 4 6/171 27/171 RR 0.22 (0.09,0.52) Serious None Serious Serious Undetected ÅÅOO Important
urinary retention low
Incidence of 4 8/129 41/129 RR 0.20 (0.1,0.4) Seriousa None Seriousb Seriousc Undetected ÅOOO Important
constipation very low
Incidence of 2 5/72 12/72 RR 0.42 (0.15,1.12) Seriousa None Seriousb Very seriousc, d
Undetected ÅOOO Important
all complications very low
a b
Patients' satisfaction 6 228/236 181/236 RR 1.26 (1.17,1.36) Serious None Serious None Undetected ÅÅOO Important
for nursing care low
Hospitalization time 13 516 516 SMD 1.91 (0,1.43) Seriousa None Seriousb None Strongly ÅOOO Important
suspectede very low

Note:
a
Lack of allocation concealment and blinding.
b
Lack of directness.
c
Not reach the optimal information size (OIS).
d
95%CI includes appreciable benefit or harm.
e
Funnel plot shows the existence of publication bias.

should be carried out before surgery to allow the patient to master
the program of functional exercises and strengthen their attention
to the importance of functional exercises; (2) the correction of
functional exercises after surgery can reduce the anxiety of patients
and monitor their daily exercises to ensure that they are able to
adapt to the functional exercises more quickly and improve the
accuracy of functional exercises.
The research findings indicated that the CNP table established in
accordance with the above principles could reduce the incidence of
thrombosis/embolisms, pulmonary infections, urinary retention
and constipation; improve patients' satisfaction regarding nursing
care; shorten the hospitalization time; and improve the Harris
score of hip function compared to routine nursing. In addition, it
can promote the recovery of hip function and ease postoperative
pain to some degree. There was no significant difference in
reducing the incidence of joint dislocations and pressure ulcers. The
GRADE evaluation results suggested that the level of the Harris
scores for hip function was moderate and the rest were low or very
low. Therefore, the results of this study should be treated with
discretion.
4.2. Study limitations
(1) All of the included studies were in Chinese.
(2) Among the 15 RCTs included, only one study provided a
description of the randomization, and all of the studies did
not account for the implementation of allocation conceal-
ment and blinding. The experimental design should be
improved.
(3) Since all 15 studies were published and there may be some
negative test results not reported, publication bias may exist
in this review.
(4) The Harris score for hip function, excellent and good
Harris scores and recovery rates of hip function all re-
flected the recovery conditions of hip joints, which was
one of the most important outcomes. However, as a result
of the inconsistency in the selection of measurement
methods among the studies, the studies could not be
included in the meta-analysis. In addition, the accuracy
rate of postoperative functional exercises and the scores
for postoperative pain were also very important, but only
one study reported them.
4.3. Suggestions for subsequent research
The included studies lacked a description and assessment of the
time and costs of the development process of the CNP table, and
therefore, its economic benefit cannot be estimated. It also lacked a
measurement of the accuracy of preoperative functional exercises,
and the mastery of functional exercises before surgery cannot be
evaluated. The renovation rate of the hip joint was high because of
various complications after hip replacements, which mainly
included the wear of the acetabulum, pain and fracture around the
prosthesis.25 To evaluate the long-term recovery of hip joints, we
hope that a long-term review and follow-up of joint function will be
carried out in subsequent trials and that detailed results of the
review will be recorded as a reference.
Based on the above evaluation, it is necessary to carry out more
comprehensive RCTs to further improve the accuracy of clinical
research and provide a more reliable foundation for later clinical
practice.
Conflicts of interest
All of the contributing authors declare no conflicts of interest.
Acknowledgements
L. Yang and X. -M. Wang contributed equally to this work.

Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008
 L. Yang et al. / Chinese Nursing Research xxx (2016) 1e9 9

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Please cite this article in press as: Yang L, et al., Systematic evaluation of the clinical nursing pathway with the GRADE approach applied to
functional exercise in patients with hip replacements before and after surgery, Chin Nurs Res (2016), http://dx.doi.org/10.1016/
j.cnre.2016.11.008