NURSING RESEARCH READING, USING, AND CREATING EVIDENCE

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FOURTH EDITION

JANET HOUSER, PHD, RN Provost and Professor Rueckert-Hartman College for Health Professions Regis University Denver, Colorado

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Library of Congress Cataloging-in-Publication Data Names: Houser, Janet, 1954- author. Title: Nursing research : reading, using, and creating evidence / Janet Houser. Description: Fourth edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2016038194 | ISBN 9781284110043 Subjects: | MESH: Clinical Nursing Research–methods | Evidence-Based

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Contents Preface Acknowledgments Contributors About the Author

Part I: An Introduction to Research

1 The Importance of Research as Evidence in Nursing Research as Evidence for Nursing Practice

What Is Nursing Research?

Research: A Fundamental Nursing Skill

The Evolution of Research in Nursing

Contemporary Nursing Research Roles

Research Versus Problem Solving

Research as Evidence in Nursing Practice

Evidence-Based Practice

The Importance of Evidence-Based Practice in Nursing

How Can Evidence Be Used in Health Care?

Strategies for Implementing Evidence-Based Practice

Strategies for Overcoming Barriers

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Future Directions for Nursing Research

Summary of Key Concepts

For More Depth and Detail

References

2 The Research Process and Ways of Knowing Introduction

The Research Process

Classification of Research by Philosophical Assumptions About the Nature of the World

Choosing a Design

Classifications of Research by the Intent of the Researcher

Classifications of Research by the Nature of the Design

Classifications of Research by the Time Dimension

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

3 Ethical and Legal Considerations in Research Introduction

Learning from the Past, Protecting the Future

International Guides for the Researcher

National Guidelines for the Nurse Researcher

The Ethical Researcher

Legal and Regulatory Guidelines for Conducting Research

Institutional Review Boards

Research Involving Animals

Research Misconduct

The HIPAA Privacy Rule

Reading Research for Evidence-Based Practice

Using Research in Nursing Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

Part II: Planning for Research

4 Finding Problems and Writing Questions Introduction

Finding and Developing Research Problems

Developing the Research Question

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

5 The Successful Literature Review An Introduction to the Literature Review

Purpose, Importance, and Scope of the Literature Review

Types of Literature Used in the Review

Searching for the Evidence in a Research Problem

Competencies for Information Literacy

Reading the Literature Review Section

Using Evidence-Based Literature in Nursing Practice

Creating a Strong Literature Review

Summary of Key Concepts

For More Depth and Detail

References

6 Selecting an Appropriate Research Design Introduction

What Is a Design?

The Basis for Design Selection

The Design Decisions

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

Part III: Research Process

7 The Sampling Strategy Introduction

Selection Strategy: How Were the Subjects Chosen?

The Sample Selection Strategy

Reading the Sampling Section of a Research Study

Using Research as Evidence for Practice

Creating an Adequate Sampling Strategy

Summary of Key Concepts

For More Depth and Detail

References

8 Measurement and Data Collection Introduction

Measurement

The Measurement Strategy

Strategies to Minimize Measurement Error

Collecting Data Using Instruments

Data Management Procedures

Reading About Measurement and Data Collection

Using Measurements from a Research Study

Creating Measures and Collecting Data

Summary of Key Concepts

References

9 Enhancing the Validity of Research Introduction

Minimizing Threats to Internal Validity

Factors That Jeopardize Internal Validity

Factors That Jeopardize External Validity

Balancing Internal and External Validity

Trustworthiness in Qualitative Research

Strategies to Promote the Validity of Qualitative Research

Reading a Research Study to Determine Validity

Using Valid Studies as Evidence for Nursing Practice

Creating a Valid Research Study

Summary of Key Concepts

For More Depth and Detail

References

Part IV: Research That Describes Populations

10 Descriptive Research Questions and Procedures Introduction

Descriptive Research Studies

Characteristics of a Descriptive Design

Describing Groups Using Surveys

Describing Groups Relative to Time

Describing the Responses of Single Subjects

Designs That Describe Relationships

Reading Descriptive Research

Using Descriptive Research in Evidence-Based Nursing Practice

Creating Descriptive Research

Summary of Key Concepts

References

11 Summarizing and Reporting Descriptive Data Introduction

An Overview of Descriptive Data Analysis

Understanding Levels of Measurement

Identifying Shape and Distribution

Describing the Center and Spread

Common Errors in Summarizing Data

Reading the Descriptive Data Section in a Research Study

Using Descriptive Data Analysis in Practice

Creating Descriptive Data Summaries for a Research Study

Reporting Descriptive Results

Summary of Key Concepts

References

Part V: Studies that Measure Effectiveness

12 Quantitative Questions and Procedures Introduction

Quantitative Research Questions

Characteristics of a Quantitative Design

The Gold Standard: Experimental Design

More Common: Quasi-Experimental Designs

Designs That Focus on Intact Groups

Time-Series Designs

Reading Quantitative Research

Using Quantitative Research in Evidence-Based Nursing Practice

Generalizing the Results of Quantitative Studies

Creating Quantitative Research

Summary of Key Concepts

References

13 Analysis and Reporting of Quantitative Data Introduction

Some General Rules of Quantitative Analysis

Types of Quantitative Analysis

An Overview of Quantitative Analysis

Selecting the Appropriate Quantitative Test

Reading the Analysis Section of the Research Report

Using Quantitative Results as Evidence for Practice

Creating a Quantitative Analysis

Summary of Key Concepts

References

Part VI: Research That Describes the Meaning of an Experience

14 Qualitative Research Questions and Procedures An Introduction to Qualitative Research

Characteristics of Qualitative Research Methods

Enhancing the Trustworthiness of Qualitative Studies

Classifications of Qualitative Traditions

Reading Qualitative Research Studies

Using Qualitative Research Studies as Evidence

Creating Qualitative Evidence

Summary of Key Concepts

References

15 Analyzing and Reporting Qualitative Results Introduction to Qualitative Analysis

The Qualitative Analysis Process

Management and Organization of Data

Software for Qualitative Analysis

Reliability and Validity: The Qualitative Version

Reporting Qualitative Results

Reading the Qualitative Analysis Section of a Report

Using Qualitative Analysis in Nursing Practice

Creating Qualitative Analyses

Summary of Key Concepts

References

Part VII: Research Translation

16 Translating Research into Practice Introduction

The Nurse’s Role in Knowledge Translation

Identifying Problems for Knowledge Translation

Communicating Research Findings

Finding and Aggregating Evidence

Models for Translating Research into Practice

Summary of Key Concepts

References

Glossary

Index

The Pedagogy Nursing Research: Reading, Using, and Creating Evidence, Fourth Edition demonstrates how to use research as evidence for successful nursing practice. Fully updated and revised, this readerfriendly new edition provides students with a fundamental understanding of how to appraise and utilize research, translating it into actionable guidelines for practice. Organized around the different types of research that can be used in evidence-based practice, it addresses contemporary methods including the use of technology in data collection, advice for culturally competent research, and suggestions for accessing hard-to-reach subjects. Additionally, it explores both quantitative and qualitative traditions and encourages students to read, use, and participate in the research process. The pedagogical aids that appear in most chapters include the following:

Preface This nursing research text is based on the idea that research is essential for nurses as evidence for practice. Its contents are intended to be relevant for nursing students, and practicing nurses who must apply evidence to practice. All nurses should be able to read research, determine how to use it appropriately in their practice, and participate in the research process in some way during their careers as professionals. This text is intended to support all these efforts.

Evidence-based practice is one of the most exciting trends in nursing practice to emerge in decades. However, its integration into daily practice requires a solid understanding of the foundations of research design, validity, and application. This text is intended as a reader-friendly approach to a complex topic so that beginners can grasp the fundamentals of appraising research, experienced nurses can use research in practice, and practicing nurses can gain skills to create bedside research projects or participate effectively on research teams.

This text is presented in an uncluttered, straightforward manner. Although it uses many bulleted lists to make the material visually interesting, the sidebars, figures, and tables are limited to those that illustrate truly important concepts. This format allows the reader to grasp the information quickly and to navigate the text efficiently. Margin notes provide definitions of new terms when they first appear, and the Gray Matter features offer information about key concepts that are of particular importance.

This text differs in its approach from traditional texts in that it does not focus primarily on interpreting inferential research; rather, it seeks to impart a fundamental understanding of all types of research that may be used as evidence. It adds depth by considering the use of qualitative research in nursing practice—a natural fit with this holistic profession. This text also addresses contemporary concerns for today’s nurses, including ethical and legal issues. Although both ethics and legal issues are mentioned in many research texts, a full chapter is devoted to these topics in this text so that the intricacies of these issues can be thoroughly considered.

The integrated discussion of both the quantitative and the qualitative traditions is another unique facet of this text’s coverage of the research process. Most nurse researchers have learned to appreciate the need to consider all paradigms when approaching a research question; separating the two approaches when discussing the fundamental interests of researchers results in a polarized view. Intuitively, nurses know that the lines between quantitative

and qualitative designs are not always so clear in practice and that they should consider multiple ways of knowing when evaluating research questions. The planning process covered here helps the novice researcher consider the requirements of both approaches in the context of sampling, measurement, validity, and other crucial issues they share. Detailed descriptions of the procedures for each type of design are given attention in separate chapters.

The chapters are organized around the types of research processes that make up the evidence base for practice. The first section of the text provides information that is applicable to all research traditions, whether descriptive, quantitative, or qualitative. Part I provides an overview of issues relevant to all researchers: understanding the way research and practice are related, the ways that knowledge is generated, and legal and ethical considerations. Part II describes the processes that go into planning research. The chapters in Part III consider the various decisions that must be made in each phase of the research process.

The evidence generated by descriptive, survey, and qualitative designs is placed in the context of both the definition of evidence-based practice and application in practice guidelines. In Parts IV, V, and VI, each major classification of research is explored in depth through review of available designs, guidelines for methods and procedures, and discussion of appropriate analytic processes. Brief examples of each type of research are provided, along with notes explaining the features demonstrated in each case in point. Finally, Part VII details the models and processes used to translate research into clinical practice.

Many chapters begin with a feature called “Voices from the Field” that relates a real-life story of a nurse’s experience with the research process, illustrating the way that the material covered in that chapter might come to life. The main content for each chapter is broken into five parts:

A thorough review of the topic under consideration is presented first. This review lays out the fundamental knowledge related to the topic. Next, the nurse isa guided to consider the aspects of a study that should be appraised when reading research. All nurses—regardless of their experience—should be able to read research critically and apply it appropriately to practice, and the second section of each chapter addresses this skill. Added features include advice on where to look for the key elements of a research paper, the wording that might be used to describe them, and specific things to look for during the evaluation process. Evaluation checklists support this process. The third section of the chapter focuses on using research in practice. This section supports the nurse in determining if and how research findings might be used in his or her practice.

The fourth section is intended for nurses who may be involved with teams that are charged with creating research or who may plan bedside research projects to improve practice. This section gives practical advice and direction about the design and conduct of a realistic, focused nursing research project. The final section of each chapter contains summary points and a critical appraisal exercise so that the nurse can immediately apply the chapter concepts to a real research report.

All of these features are intended to help the reader gain a comprehensive view of the research process as it is used to provide evidence for professional nursing practice. The use of this text as a supportive resource for learning and for ongoing reference in clinical practice has been integrated into the design of each element of the text. The goal is to stimulate nurses to read, use, and participate in the process of improving nursing practice through the systematic use of evidence. Accomplishing this goal improves the profession for all of us.

Acknowledgments It is a bit misleading to conclude that a text is produced solely by the person whose name appears on the cover. Help and support are needed from many people on both professional and personal fronts to complete a project of this size. The help of editorial staff is always welcome; advice from Amanda Martin was invaluable in merging the interests of writing with those of producing a book that others will want to read. I appreciate Amanda Clerkin’s calm and steady approach after our sixth manuscript together, and I’ve learned a lot from reading Jill Hobbs’s edits, which I must begrudgingly admit make my writing much better.

My family—my husband, Floyd; my sisters, Anne and Ande; my niece, Stef; and mini-me, Amanda—provided me with enough encouragement to keep going, even as they reminded me there is life beyond the pages of a book.

I must thank Regis University profusely for providing me with inspirational colleagues and a place that supports my work. Pat Ladewig, as always, provided pragmatic advice and guidance from her impressive experience publishing her own texts. My contributors and reviewers each provided a unique viewpoint and helped me discover the best way to ensure that students “get it.”

Writing always makes me realize how much I miss my mom, Marty, who encouraged me to publish from the time she surreptitiously sent one of my poems to Highlights magazine when I was 9 years old. She was proud of that poem, framed the issue, and had my grandmother embroider it on a pillow. Seeing this book in print would have impressed her only slightly more, but I know she’s smiling.

Contributors Michael Cahill, MS, CPHQ Parker Adventist Hospital Parker, Colorado Summarizing and Reporting Descriptive Data

Sheila Carlon, PhD, RHIA, FAHIMA Regis University Denver, Colorado Ethical and Legal Considerations in Research

Phyllis Graham-Dickerson, PhD, RN, CNS Regis University Denver, Colorado Qualitative Research Questions and Procedures Analyzing and Reporting Qualitative Results

LeeAnn Hanna, PhD, RN, CPHQ, FNAHQ HCA, TriStar Centennial Medical Center Nashville, Tennessee Finding Problems and Writing Questions

Kimberly O’Neill, MS, MLIS Dayton Memorial Library, Regis University Denver, Colorado The Successful Literature Search

About the Author

Janet Houser, PhD, RN

Regis University

Dr. Janet Houser is currently Provost at Regis University in Denver, Colorado. Prior to her appointment, she was Dean of the Rueckert-Hartman College for Health Professions and the Vice Provost for Resource Planning.

Dr. Houser has a BSN, an MN in Maternal-Child Health, an MS in healthcare administration, and a PhD in applied statistics and research methods. She has taught nurses, administrators, pharmacists, and physical therapy students from undergraduate through doctoral level, primarily in the subjects of research methods, biostatistics, and quantitative methods. Previous to her position as Dean, Dr. Houser was faculty and Associate Dean for Research and Scholarship.

Dr. Houser spent 20 years in healthcare administration with the Mercy Health System. Her last position was as Regional Director for Professional Practice for Mercy Health Partners in Cincinnati, Ohio, where she was responsible for professional practice and clinical research in 29 facilities.

Dr. Houser has published five books, Clinical Research in Practice: A Guide for the Bedside Scientist, Nursing Research: Reading, Using, and Creating Evidence, which is in its fourth edition, and Evidence-Based Practice: An Implementation Guide. She has more than 30 peer-reviewed publications in journals and has presented her research at regional, national, and international conferences.

Part I: An Introduction to Research 1 The Importance of Research as Evidence in Nursing 2 The Research Process and Ways of Knowing 3 Ethical and Legal Considerations in Research

Chapter 1: The Importance of Research as Evidence in Nursing

CHAPTER OBJECTIVES The study of this chapter will help the learner to

Define nursing research and discuss how research is used in nursing practice. Describe the evolution of nursing research. Investigate the roles that nurses play in research processes. Contrast research and other types of problem solving. Explore how research is used as evidence guiding the practice of nursing. Read research and appraise the credibility of the journal, authors, and publication process.

KEY TERMS Blinded

Evidence-based practice

Evidence-based practice guideline

External validity

Journal club

Magnet status

National Institute of Nursing Research (NINR)

Nursing process

Nursing research

Outcomes measurement

Peer review

Principal investigator

Quality improvement

Randomized controlled trial

Replication

Systematic review

Research as Evidence for Nursing Practice The practice of nursing is deeply rooted in nursing knowledge, and nursing knowledge is generated and disseminated through reading, using, and creating nursing research. Professional nurses rely on research findings to inform their practice decisions; they use critical thinking to apply research directly to specific patient care situations. The research process allows nurses to ask and answer questions systematically that will ensure that their decisions are based on sound science and rigorous inquiry. Nursing research helps nurses in a variety of settings answer questions about patient care, education, and administration. It ensures that practices are based on evidence, rather than eloquence or tradition.

VOICES FROM THE FIELD I was working as the clinical nurse specialist in a busy surgical intensive care unit (ICU) when we received a critically ill patient. He was fresh from cardiac surgery and quite unstable; he needed multiple drugs and an intra-aortic balloon pump just to maintain his perfusion status. The patient was so sick that we were not able to place him on a special bed for pressure relief. For the first 24 hours, we were so busy trying to keep him alive that we did not even get a chance to turn him.

Approximately 36 hours into his ICU admission, he was stable enough to place on a low-air-loss mattress for pressure-ulcer prevention. When we were finally able to turn him, we noted he had a small stage II pressure ulcer on his coccyx. Despite the treatments that we used, the pressure ulcer evolved into a full-thickness wound. The patient recovered from his cardiac surgical procedure but, unfortunately, required surgeries and skin grafts to close the pressure ulcer wound.

The experience I had with this patient prompted me to review the evidence-based practice (EBP) guidelines we had in place to prevent pressure ulcers in critically ill patients. I wanted to make sure we could prevent this kind of incident from happening again, but I had a lot of questions. Could we preventively place high-risk patients on low-air- loss mattresses while they were still in the perioperative service? Did we even know which patients were at risk for pressure ulcers? Which assessment tools did nurses use to assess the patient’s risk? When a high-risk patient was identified, which interventions did the nurses use to prevent pressure ulcers? How were the ulcers treated once they appeared?

I was fortunate that my chief nursing officer (CNO) was a strong advocate for EBP, and she encouraged me to initiate an EBP review of pressure ulcer prevention and treatment. Specifically, I wanted to find out which nursing interventions were supported by research evidence when we were trying to prevent pressure ulcers in the surgical ICU. As

part of my review, I contacted other inpatient units at the hospital to determine what they were doing.

I discovered that the surgical ICU was no different from the other inpatient units in this regard: There was no standard, evidence-based nursing practice for pressure ulcer prevention. Units were not consistently using the same skin assessment tools, so it was difficult to objectively communicate risk from one unit to another. The tools we were using were not necessarily based on research. It was clear that we needed to identify the best available evidence and devise a protocol.

We started by establishing an evidence-based skin care council for the hospital. This team consisted of bedside nurses from all inpatient units and the perioperative service. Initially the council reviewed the hospital’s current nursing skin assessment forms, and we conducted a review of the literature on pressure ulcer prevention and interventions. We discovered the Agency for Healthcare Research and Quality (AHRQ) guidelines on pressure ulcer prevention and treatment—a key source of evidence for healthcare practices.

Over the course of the next year, we revised our nursing policy and procedure, incorporating the AHRQ evidence into a treatment guideline. This guideline included a procedure for skin assessment and nursing documentation, and pressure ulcer assessment and treatment decision algorithms. We reviewed skin-care products and narrowed down the list of products to those that were supported by evidence. One algorithm helped staff make selections between products that maximized prevention and treatment. Another algorithm guided nurses in the use of therapeutic surfaces (e.g., low-air-loss mattresses) to prevent pressure ulcers. To monitor our progress, we began quarterly pressure ulcer prevalence studies. As part of the implementation, we scheduled a skin-care seminar featuring a national expert on skin care.

At the beginning of our EBP skin-care journey, our facility’s pressure ulcer prevalence was 9%. Since implementing our EBP skin-care initiatives, it has dropped by two thirds. The EBP skin-care council continues to be active in our hospital. We meet monthly to seek out the best evidence to guide skin- and wound-care product decisions, practice guidelines, protocols, and policies. My initial search for a solution—based on my experience with one patient—led to improvements in practice that have benefited many patients since then.

Mary Beth Flynn Makic, PhD, RN

What Is Nursing Research? Nursing research is a systematic process of inquiry that uses rigorous guidelines to produce unbiased, trustworthy answers to questions about

nursing practice. Research is used as evidence in the evaluation and determination of best nursing practices. Original nursing research aims to generate new knowledge to inform the practice of nursing. More specifically, nurses may use research for the following purposes:

Synthesize the findings of others into a coherent guide for practice Explore and describe phenomena that affect health Find solutions to existing and emerging problems Test traditional approaches to patient care for continued relevance and effectiveness

Nursing research: A systematic process of inquiry that uses rigorous guidelines to produce unbiased, trustworthy answers to questions about nursing practice.

Nurse researchers use a variety of methods to generate new knowledge or summarize existing study results. They may measure observable characteristics, solicit perceptions directly from clients, assess words and phrases for underlying meaning, or analyze a group of study findings in aggregate. Nurse researchers have almost limitless options for research design. Moreover, they may assume a variety of roles, ranging from primary investigator for a large, multisite trial to staff nurse in a bedside science project. Nevertheless, the goal is always the same: to generate new knowledge that can be applied to improve nursing practice.

Regardless of the design, research is a rigorous endeavor that is subject to peer review and replication. These two characteristics are essential to ensure that research is unbiased and applicable to the real world. A study is subjected to peer review when experts in the field evaluate the quality of the research and determine whether it warrants presentation at a conference or publication in a professional journal. These reviews are generally blinded, meaning the reviewer remains unaware of the researcher’s identity. In blinded peer review, a research report is subjected to appraisal by a neutral party who is unassociated with the research and unaware of the report’s authorship. Reviewers determine whether the study process and outcome are of acceptable quality for communication to the broader professional community. Replication ensures that findings can be duplicated in different populations and at different times. This characteristic provides the nurse with confidence that the findings are not limited to a single sample, so that study outcomes will likely be similar in other patient populations.

Peer review: The process of subjecting research to the appraisal of a neutral third party. Common processes of peer review include selecting

research for conferences and evaluating research manuscripts for publication.

Blinded: A type of review in which the peer reviewer is unaware of the author’s identity, so personal influence is avoided.

Replication: Repeating a specific study in detail on a different sample. When a study has been replicated several times and similar results are found, the evidence can be used with more confidence.

Research: A Fundamental Nursing Skill Although many students and practitioners of nursing consider research to be the purview of academics and graduate students, it is actually fundamental to professional nursing practice. There are many reasons why research is critical for the nurse in any role. Nursing is a profession, and along with advanced education and self-regulation, research is one of the central tenets that defines a profession. For nurses to function on healthcare teams as colleagues with therapists, physicians, and other caregivers, they must speak the language of science and use the best available research evidence as the basis for collaborating in planning patient care.

As professionals, nurses are accountable for the outcomes they achieve and the effectiveness of interventions that they apply and recommend to patients. Their accountability is based on a solid understanding and evaluation of the best available evidence as the foundation for decision making and patient counseling. In current healthcare practice, access, cost, and patient safety are all areas that clearly benefit from nursing research.

Consumer demands also require that nurses be held accountable for their practice. Today’s consumers and their families are often well informed about the evidence that reveals the effectiveness of care. The Internet has given consumers unprecedented access to health information—some of it questionable, but much of it of high quality—that enables them to evaluate the basis for their own healthcare decisions.

In 2011, the Institute of Medicine issued a seminal report on the future of nursing. In this report, it set a goal that, by 2020, 90% of all clinical decisions would be based on research evidence. Given that the current estimated rate falls far short of that goal, there is an urgent need for healthcare leaders and clinicians to collaborate in designing and implementing effective strategies for research integration into clinical care. In particular, there is a need to enhance the rigor of nursing research studies, and to translate evidence into practice- friendly forms that nurses can use in daily care delivery.

Many nursing organizations are in the process of pursuing or maintaining Magnet status, which requires the organization to contribute to new knowledge and innovation in nursing care. Wilson and others (2015) found other benefits from an organization achieving Magnet status: Nurses in Magnet facilities express greater interest in using evidence in practice, report fewer barriers to implementation of EBP, and used EBP with more frequency than nurses in non-Magnet facilities. Integration of evidence into daily practice requires both resources and formalized processes; these assets must be evident and useful in a Magnet organization. To maintain Magnet status, hospitals must show quality outcomes, best practices, and nursing excellence —all of which require development and dissemination of new knowledge (Messmer & Turkel, 2011).

Magnet status: A designation for organizations that have characteristics that make them attractive to nurses as workplaces.

The Evolution of Research in Nursing Nursing is a relatively young field compared to fields such as philosophy or physics that boast hundreds of years of historical study. Moreover, nursing has not always relied on profession-specific research as a basis for practice. However, as the contemporary nursing literature makes clear, research is taking on fundamental importance as a source of evidence for practice.

More than 150 years ago, Florence Nightingale introduced the concept of scientific inquiry as a basis for nursing practice. Nightingale’s work focused on collecting information about factors that affected soldier mortality and morbidity during the Crimean War. Armed with these scientific data, she was able to instigate changes in nursing practice. Indeed, her work was so impressive that she was inducted into the Statistical Society of London.

The years following Nightingale’s breakthroughs were marked by relatively little scientific work in nursing, likely because nursing education was accomplished through apprenticeship rather than scholarly work. As more nursing education moved into university settings in the 1950s, however, research took on greater prominence as a key nursing activity. Journals were founded both in the United States and internationally that focused exclusively on publishing nursing research. More outlets for the publication of nursing research were established in the 1970s and 1980s, leading to the communication of research findings to a broader audience. The creation of the National Center for Research for Nursing within the National Institutes of Health (NIH) in 1986 was a seminal step in recognizing the importance of nursing research. In 1993, the center was given full institute status as the National Institute of Nursing Research (NINR). This move put nursing research on an even footing with medical research and the other health sciences, ensuring financial support and a national audience for disciplined

inquiry in the field. The NINR and other national agencies guide the overarching research agenda that focuses nursing research on professional priorities. The mission of the NINR is to support and conduct clinical and basic research on health and illness so as to build the scientific foundation for clinical practice. The ultimate goal is to improve the health of individuals, families, communities, and populations through evidence-based nursing practices (NINR, 2013).

National Institute of Nursing Research (NINR): A federal agency responsible for the support of nursing research by establishing a national research agenda, funding grants and research awards, and providing training.

In the 1980s and 1990s, leaders in nursing research met periodically at the Conference on Research Priorities in Nursing Science (CORP) to identify research priorities for the nursing profession. These priorities were established as 5-year agendas. In the 1990s, advances in nursing research were coming so quickly that a more flexible approach was required. The NINR recognized that the issues facing nursing science had evolved as health care had evolved, becoming more complex. The process that the NINR currently uses to develop its research priorities is both expansive and inclusive. The formal process begins with the identification of broad areas of health in which there is the greatest need, and identification of the areas of science in which nursing research could achieve the greatest impact. To maximize the amount and diversity of input into the research priorities, “Scientific Consultation Meetings” are held to bring together individuals from academia, government, industry, and patient advocacy. Experts in science and health care are consulted, and panels of experts discuss current health and research challenges as well as future strategies for research and education. These meetings focus on topics crucial to NINR’s future, including the following:

Preparing the next generation of nurse scientists Advancing nursing science through comparative effectiveness research Supporting research on end-of-life care Forecasting future needs for health promotion and prevention of disease Identification of emerging needs in the science of nursing (NINR, 2011)

Some examples of recent NINR nursing research priorities appear in Table 1.1.

GRAY MATTER Research is critical in nursing for the following reasons:

The use of research is inherent to the definition of a profession. Nurses are accountable for outcomes.

Consumers are demanding evidence-based care.

Table 1.1 National Institute of Nursing Research’s Proposed Strategic Research Investment Areas

Objective Examples

Enhance health promotion and disease prevention

Develop innovative behavioral interventions Study the behavior of systems that can promote personalized interventions Improve the ways in which individuals change health behaviors Develop models of lifelong health promotion Translate scientific advances into motivation for health behavior change Incorporate partnerships between community agencies and others in healthcare research

Improve quality of life by managing symptoms of acute and chronic illness

Improve knowledge of the biological and genomic mechanisms associated with symptoms Design interventions to improve the assessment and management of symptoms over the course of a disease Study the factors that influence symptom management and use this knowledge to implement personalized interventions Design strategies that help patients manage symptoms over the course of a disease Support individuals and caregivers in managing chronic illness in cost- effective ways

Improve palliative and end-of-life care

Enhance the scientific knowledge of issues and choices underlying end-of life and palliative care Develop and test interventions that provide palliative care across the lifespan Develop strategies to minimize the burden placed on caregivers Determine the impact of provider training on outcomes Create communication strategies to promote end-of-life care

Enhance innovation in science and practice

Develop technologies and informatics-based solutions for health problems Develop and apply technology for disseminating and analyzing health information Examine the use of healthcare technology to support self-management of health, decision making, and access to care Study the use of genetic and genomic technology to understand the biological basis of the symptoms of chronic disease

Develop the next generation of nurse scientists

Support the development of nurse scientists at all stages of their careers Facilitate the transition of nurses from student to scientist Recruit young nurse investigators, particularly those from diverse backgrounds Mobilize technology to form global partnerships to support research in areas central to NINR’s mission

Data from National Institute of Nursing Research. (2011). Bringing science to life: NINR strategic plan. NIH Publication #11-7783, Bethesda, MD: Author.

GRAY MATTER Nurses may play a variety of roles in research, including the following:

Informed consumer of research Participant in research-related activity, such as journal clubs Contributor to a systematic review Data collector for a research project Principal investigator for a research study

The 1990s and early twenty-first century saw a shift in emphasis from research as an academic activity to research that serves as a basis for nursing practice. The impetus for this shift was partially due to external influences that created demands for accountability, effectiveness, and efficiency. Internal influences in the profession also played a key role in this shift, as nursing professionals strive to create a norm of professional practice that is firmly grounded in best demonstrated practice.

Contemporary Nursing Research Roles The nurse may be an effective team member on any number of research projects and may take on responsibilities ranging from data collection to research design. The broad number of potential roles in the research setting provides nurses with the chance to participate at their individual comfort level while learning increasingly complex research skills. The professional clinician has both opportunities and responsibilities to use research in a variety of ways to improve practice. Table 1.2 contains the statement from the American Association of Colleges of Nursing (2006) that describes the expected roles of nurses in research processes.

Most nurses are first exposed to clinical research as informed consumers. The informed consumer of research is able to find appropriate research studies, read them critically, evaluate their findings for validity, and use the findings in practice. Nurses may also participate in other types of research-related activities, including journal clubs or groups whose members meet periodically to critique published studies or care standards. Journal clubs are relatively easy to implement and have been demonstrated to be one of the most effective means for sustaining staff nurse enthusiasm for and participation in EBP implementation (Gardner et al., 2016). Attending research presentations and discussing posters at conferences also expose nurses to a variety of research studies.

Journal club: A formally organized group that meets periodically to share and critique contemporary research in nursing, with a goal of both learning about the research process and finding evidence for practice.

Table 1.2 Research Expectations for Nurses

Educational Level

Research Role

Baccalaureate degree

Have a basic understanding of the processes of research. Apply research findings from nursing and other disciplines to practice. Understand the basic elements of evidence-based practice. Work with others to identify research problems. Collaborate on research teams.

Master’s degree

Evaluate research findings to develop and implement EBP guidelines. Form and lead teams focused on evidence-based practice. Identify practices and systems that require study. Collaborate with nurse scientists to initiate research.

Practice-based doctorates

Translate scientific knowledge into complex clinical interventions tailored to meet individual, family, and community health and illness needs. Use advanced leadership knowledge and skills to translate research into practice. Collaborate with scientists on new health research opportunities.

Research- focused doctorates

Pursue intellectual inquiry and conduct independent research for the purpose of extending knowledge. Plan and carry out an independent program of research. Seek support for initial phases of a research program. Involve others in research projects and programs.

Postdoctoral programs

Devote oneself fully to establishing a research program and developing as a nurse scientist.

Modified with permission from American Association of Colleges of Nursing. (2006). AACN position statement on nursing research. Washington, CD: Author.

As the nurse becomes more proficient in the research process, involvement in a systematic review is a logical next step. Conducting a systematic review that results in an evidence-based practice guideline requires the ability to develop research questions methodically, write inclusion criteria, conduct in- depth literature searches, and review the results of many studies critically. Participation in such activities also facilitates changes in clinical practice on a larger scale and requires the nurse to use leadership and communication skills.

Systematic review: A highly structured and controlled search of the available literature that minimizes the potential for bias and produces a practice recommendation as an outcome.

Evidence-based practice guideline: A guide for nursing practice that is the outcome of an unbiased, exhaustive review of the research

literature, combined with clinical expert opinion and evaluation of patient preferences. It is generally developed by a team of experts.

Involvement in actual research studies does not require complete control or in- depth design abilities. Indeed, assisting with data collection can take the form of helping measure outcomes on subjects or personally participating as a subject. Clinicians are frequently recruited to participate in studies or collect data directly from patients or their records. Collecting data for the studies of other researchers can give the nurse valuable insight into the methods used to maximize reliability and validity—experience that will help the nurse later if he or she chooses to design an experiment.

Most nurses do not immediately jump into research by undertaking an individual research study, but rather serve on a research team as an initial foray into this area. As part of a team, the nurse can learn the skills needed to conduct research while relying on the time and expertise of a group of individuals, some of whom may be much more experienced researchers. Serving on a team in this way gives the nurse the opportunity to participate in research in a collegial way, collaborating with others to achieve a mutual goal.

A contemporary means for enhancing staff nurse participation in research is through adoption of the clinical scholar or nurse scholar role. Nurse scholar programs typically seek out clinical nurses for specialized training in research and EBP. These nurses are then provided with releases from their usual workloads so that they can identify evidence-based problems, design studies to answer clinical questions, and carry out EBP projects. One study found that a nurse scholar program increased the number of EBP projects by as much as 10 times, led to significant practice improvements, and enhanced the confidence of the clinical nurses who participated in EBP development (Crabtree, Brennan, Davis, & Coyle, 2016).

The most advanced nurses may serve as principal investigators, or producers of research, who design and conduct their own research projects. Because individuals are rarely able to accomplish research projects on their own, it is more likely that the nurse will lead a research team. This role requires not only research and analytic skills, but also skills in leading groups, managing projects, and soliciting organizational commitment.

Principal investigator: The individual who is primarily responsible for a research study. The principal investigator is responsible for all elements of the study and is the first author listed on publications or presentations.

Research Versus Problem Solving

Research is distinct from other problem-solving processes. Many processes involve inquiry. In an organizational setting, quality improvement, performance improvement, and outcomes measurement all involve systematic processes and an emphasis on data as a basis for decisions. For an individual nurse, the nursing process requires that the nurse gather evidence before planning an intervention and subsequently guides the nurse to evaluate the effectiveness of care objectively. Although both organizational and individual problem-solving processes may be systematic and objective, these are not synonymous with research in intent, risks, or outcome (Lee, Johnson, Newhouse, & Warren, 2013). The correct identification of the type of inquiry that is being conducted and reported will help the nurse link the outcome to the appropriate level of practice recommendation (Baker et al., 2014).

Quality improvement: The systematic, databased monitoring and evaluation of organizational processes with the end goal of continuous improvement. The goal of data collection is internal application rather than external generalization.

Outcomes measurement: Measurement of the end results of nursing care or other interventions; stated in terms of effects on patients’ physiological condition, satisfaction, or psychosocial health.

Nursing process: A systematic process used by nurses to identify and address patient problems; includes the stages of assessment, planning, intervention, and evaluation.

The intent of quality improvement is to improve processes for the benefit of patients or customers within an organizational context. Studies in this area are often undertaken to determine if appropriate and existing standards of care are practiced in a specific clinical setting (Baker et al., 2014). Quality improvement is basically a management tool that is used to ensure continuous improvement and a focus on quality. Research, in contrast, has a broader intent. Its goal is to benefit the profession of nursing and to contribute to the knowledge base for practice. Research benefits more people because it is broadly applied; quality improvement is beneficial simply because of its specificity to a single organization.

The risk for a subject who participates in a quality improvement study is not much more than the risk associated with receiving clinical care. Such studies are frequently descriptive or measure relationships that are evidenced by existing data. Often, patients who are the subjects of study for a quality

improvement project are unaware they are even part of a study. In contrast, in a research project, subjects are clearly informed at the beginning of the project of the risks and benefits associated with participating in the study, and they are allowed to withdraw their information at any time. Upfront and informed consent is central to the research process.

Finally, the outcomes of a quality improvement study are intended to benefit a specific clinical group and so are reviewed by formal committees and communicated internally to organizational audiences. In contrast, research findings are subjected to rigorous peer review by neutral, external reviewers, and the results are expected to stand up to attempts to replicate them. When quality improvement projects are planned with an expectation of publication, the distinction becomes less clear. Is the goal of publication to share a perspective on a process or to generalize the results to a broader group of patients? If the latter goal is targeted, then quality improvement projects should be subjected to the same rigorous review and control as a research project.

The intent when an individual nurse applies the nursing process for problem solving is even more specific. The nursing process requires an individual nurse to gather data about a patient, draw conclusions about patient needs, and implement measures to address those needs. Data collected from the patient are used to evaluate the effectiveness of care and make modifications to the plan. These steps mirror the research process but take place at an individual level. Research is useful within the nursing process as a source of knowledge about assessment procedures, problem identification, and effective therapeutics, but simply using the nursing process does not constitute research.

GRAY MATTER The research process is distinct from other problem-solving processes in the following respects:

Research contributes to the profession of nursing as a whole, not just a single organization or patient. Research involves an explicit process of informed consent for subjects. Research is subjected to external peer review and replication.

Research as Evidence in Nursing Practice It would seem a foregone conclusion that effective nursing practice is based on the best possible, most rigorously tested evidence. Yet it is only in the past two decades that an emphasis on evidence as a basis for practice has reached the forefront of professional nursing. Although it may be surprising that the scientific basis for nursing practice has been so slow to be accepted,

many reasons exist to explain why evidence-based nursing practice is a relatively recent effort. The past decade has seen unprecedented advances in information technology, making research and other types of evidence widely available to healthcare practitioners. Whereas a nurse practicing in the 1980s might have read one or two professional journals per month and attended perhaps one clinical conference in a year, contemporary nursing professionals have access to an almost unlimited array of professional journal articles and other sources of research evidence via the Internet. Technology supports the communication of best practices and affords consumers open access to healthcare information as well. As a result, EBP is quickly becoming the norm for effective nursing practice.

Evidence-Based Practice What Evidence-Based Practice IS Evidence-based practice is the use of the best scientific evidence, integrated with clinical experience and incorporating patient values and preferences in the practice of professional nursing care. All three elements in this definition are important. As illustrated in FIGURE 1.1, the triad of rigorous evidence, clinical experience, and patient preferences must be balanced to achieve clinical practices that are both scientifically sound and acceptable to the individuals applying and benefiting from them.

Evidence-based practice: The use of the best scientific evidence, integrated with clinical experience and incorporating patient values and preferences in the practice of professional nursing care.

FIGURE 1.1 The Triad of Evidence-Based Practice

Although healthcare practitioners have long used research as a basis for practice, a systematic approach to the translation of research into practice has emerged only in relatively recent times. The impetus for EBP was a 1990

comment by a Canadian physician on the need to “bring critical appraisal to the bedside.” The first documented use of the term evidence-based practice appeared more than two decades ago, when a clinical epidemiology text (Sackett, Haynes, Guyatt, & Tugwell, 1991) used the term to describe the way students in medical school were taught to develop an attitude of “enlightened skepticism” toward the routine application of diagnostic technologies and clinical interventions in their daily practice. The authors described how effective practitioners rigorously review published studies to inform clinical decisions. The goal, as stated in this publication, was to achieve an awareness of the evidence on which professional practice is based and a critical assessment of the soundness of that evidence.

The term entered the U.S. literature in 1993 when an article in the Journal of the American Medical Association described the need for an established scientific basis for healthcare decisions (Oxman, Sackett, & Guyatt, 1993). The authors of the article noted that the goal of EBP is to help practitioners translate the results of research into clinical practice, and they recognized that the scientific practice of health care required sifting through and appraising evidence to make appropriate decisions.

EBP has rapidly evolved into an international standard for all healthcare practitioners. Using the best scientific evidence as a basis for practice makes intuitive sense and places nursing in the company of the other science-based health professions in using evidence as a foundation for clinical decision making.

What Evidence-Based Practice Is NOT A wide range of activities contributes to EBP. Many of these activities—such as reviewing research, consulting expert colleagues, and considering patient preferences—are common in nursing practice. Even so, many such activities are not considered EBP, but rather other forms of decision making used to solve problems.

Evidence-Based Practice Is Not Clinical Problem Solving Although EBP serves as a mechanism for solving clinical problems and making decisions about interventions, it remains distinct from traditional problem-solving approaches in health care. Conventional decision making about clinical practices relied on expert opinion—sometimes achieved by consensus, but rarely through experimentation— combined with standard practice. EBP, by comparison, is a systematic process of critically reviewing the best available research evidence and then incorporating clinical experience and patient preferences into the mix.

Evidence-Based Practice Is Not Solely Randomized Controlled Trials

EBP does not mean choosing only those interventions supported by randomized controlled trials—although these studies are clearly important in providing guidance for effective practices. A somewhat tongue-in-cheek article by Smith and Pell (2006) suggested that we did not need a randomized trial to inform practitioners of the importance of a parachute as a measure of preventing death when jumping from an airplane (and, in fact, noted the difficulty in recruiting a control group for such a trial!). EBP does not rely solely on one type of evidence, but rather is founded on a hierarchy of evidence, with individual studies rated on a scale from “strongest” to “weakest” based on the type of design and quality of execution. Evidence can come from many different types of studies in addition to randomized trials.

Randomized controlled trial: An experiment in which subjects are randomly assigned to groups, one of which receives an experimental treatment while another serves as a control group. The experiment has high internal validity, so the researcher can draw conclusions regarding the effects of treatments.

Evidence-Based Practice Is Not “Cookbook Medicine” The existence of guidelines based on the best available evidence does not mean the practitioner has an edict to practice in a single way. In fact, evidence alone is never sufficient to make a specific clinical decision about a specific patient. The nurse needs evidence plus good judgment, clinical skill, and knowledge of the patient’s unique needs to apply evidence to a specific patient care situation. The definition of EBP, in fact, holds evidence as only one element of the triad of decision making; that is, clinical judgment and patient values must also be considered when applying the evidence to a particular situation.

Evidence Is Not the Same as Theory Theoretical effects must be tested and retested before therapies can be determined to be effective. As late as the early twentieth century, physicians still believed that blood-letting was an effective treatment for a host of disorders. This belief was based on the empirical observation that a patient’s pulse rate slowed when he or she was bled and the theory that a slower pulse reduced irritation and inflammation. Although the empirical observations were accurate—the patient’s pulse would certainly slow when bloodletting was performed, but due to impending hypovolemic shock—the theoretical relationship to a therapeutic response was ill founded. Many contemporary healthcare interventions are, unfortunately, based on similar theoretical relationships that have been untested for years. Recent research has refuted many of these theoretical assumptions, including the protective value of hormone-replacement therapy, the use of rubbing alcohol to prevent infection in a neonate’s umbilical cord, and the use of heat to treat acute inflammation, among many others.

Evidence-Based Nursing Is Not Evidence-Based Medicine The nature and processes of research are likely to be unique for any given profession. In the health realm, medicine and nursing have different philosophical roots and approaches to patient care. Medicine relies on an extensive scientific knowledge base that is primarily concerned with the cause of disease and effects of treatment. The evidence for medical care, by necessity, focuses on scientific studies that quantify these effects. Nevertheless, medical evidence has been criticized for its sometimes artificial nature. It is a research paradox that the more an experiment is controlled, the less applicability the results will have in the real world. Randomized controlled trials, then, may provide the most rigorous scientific evidence, but that evidence may not apply very well to individual patients with a broad range of physical, psychological, and behavioral conditions.

Nursing, in contrast, requires a holistic approach to the care of individuals with physical, psychosocial, and/or spiritual needs. This care is founded on the nurse–patient relationship and the nurse’s appreciation for the patient’s unique needs. The evidence for nursing care, then, requires a broad range of methodologies as a basis for care. This is not to imply that these sources of evidence are not subjected to healthy skepticism and systematic inquiry, but rather that a broader range of evidence is considered as a basis for practice.

The Importance of Evidence-Based Practice in Nursing EBP is important to the nurse for many reasons. At the top of this list is the contribution of evidence to the effective care of patients. Studies have supported the contention that patient outcomes are substantially improved when health care is based on evidence from well-designed studies versus tradition or clinical expertise alone. Evidence has been shown to be effective in supporting practices that achieve optimal outcomes in a range of behavioral, physiological, and psychosocial outcomes. In one recent meta-analysis, Leufer and Cleary-Holdforth (2009) aggregated outcomes studies related to EBP changes. A wide range of effects was found in multiple specialties including orthopedic, cardiovascular, respiratory, and obstetric outcomes. EBPs in obstetrics and neonatal care reduced morbidity and mortality, sometimes dramatically. The use of corticosteroids in premature labor, for example, reduced the risk of premature infant death by 20%. In another study, Deighton et al. (2016) demonstrated an association between EBPs and mental health outcomes, particularly for interventions related to the treatment of emotional disorders. The linkage between EBPs and outcomes is an important one, and determining the scientific support for a practice prior to its implementation makes intuitive sense.

Today’s healthcare providers operate in an era of accountability, in which quality issues, patient safety, and cost concerns are primary drivers of patient care processes (Markon, Crowe, & Lemyre, 2013). Practices that are

unnecessary are eliminated; ineffective practices are replaced with practices that result in desired outcomes.

Existing practices may even be unintentionally harming patients (as was found in the hormone-replacement studies), so it is ethically unjustified to continue using untested interventions. Evidence can help healthcare professionals avoid errors in decision making relative to patient care. Using research decreases the need for trial and error, which is time consuming and may prove counterproductive. In any case, time is not wasted on practices that may be ineffective or unnecessarily time intensive.

Today’s consumers are well informed about their options for personal health care and often resist the traditional, paternalistic approach to health interventions. The public expects that care will be based on scientific evidence and believes that care processes should routinely lead to high-quality outcomes that are physically and mentally desirable. Healthcare professionals, in turn, must be able to respond to their patients’ questions about the scientific merit of interventions and about the relative benefit of treatment options.

GRAY MATTER EBP is important in nursing practice because research has shown that

Patient outcomes are better when evidence is used as a basis for practice. Nursing care is more efficient when ineffective processes are replaced. Errors in decision making become less frequent with EBP. Consumers want evidence-based information to make decisions.

Evidence can take a variety of forms—journal articles, policies, guidelines, professional consensus statements, and standards of practice as well as formalized research. Although EBP implies scientific evidence, the words relevant and rigorous might be better adjectives to describe the kind of evidence needed by healthcare professionals. Critical skills include the ability to judge both the type of evidence that is needed and the value of that evidence.

Healthcare practitioners do not practice in professional isolation, but rather explore what works and does not work using empirical methods. An increased emphasis on EBP can be viewed as a response to these broader forces influencing the context of healthcare delivery and as a logical progression toward the utilization of research as a basis for patient care decisions.

How Can Evidence Be Used in Health Care?

At its best, evidence provides the basis for effective, efficient patient care practices. At a minimum, an evidence-based approach can enhance practice by encouraging reflection on what we know about almost every aspect of daily patient care. The EBP process need not be onerous, because it basically entails just six elements: (1) Ask a relevant clinical question, (2) search for the best evidence in the literature, (3) critically appraise the evidence, (4) integrate the evidence with clinical experience and client preferences, (5) evaluate the outcome of the practice change, and (6) disseminate the outcome (Facchiano & Snyder, 2012). The original question can come from a variety of sources in a healthcare setting; likewise, evidence can improve outcomes for a wide range of organizational processes.

Evidence as a Basis for Healthcare Processes Evidence can be incorporated into virtually every phase of the healthcare process. For example, evidence exists for best practices in the following areas:

Assessment of patient conditions Diagnosis of patient problems Planning of patient care Interventions to improve the patient’s function or condition, or to prevent complications Evaluation of patient responses to intervention

Evidence as a Basis for Policies and Procedures Although healthcare professionals from different educational programs, backgrounds, and experience may have different ways of delivering patient care, few can argue with the need for best practices. EBP provides the foundation for policies and procedures that are tested and found effective, as opposed to “the way we’ve always done it.”

Evidence as a Basis for Patient Care Management Tools The evidence that is revealed through systematic review of research and other sources provides an excellent basis for patient care management tools such as care maps, critical paths, protocols, and standard order sets. A major benefit of using patient care management tools is reduction of variability in practices, and evidence serves as a rational basis for standardized practices.

Evidence as a Basis for Care of the Individual The complexity of patients who need care in the healthcare system can make the clinician wonder if evidence can ever be applied to an individual patient. It is easy to consider the question, “Is my patient so different from those in the research that results will not help me make a treatment decision?” This question, more than any other, may stand in the way of applying evidence to individual patient care situations. In fact, one study found that the more familiar

a patient was to a practitioner, the less likely the clinician was to use evidence as a basis for that person’s care (Summerskill & Pope, 2002).

As practitioners, we must ask whether these assumptions about the uniqueness of patients are in their best interests when it comes to clinical care. Uncertainty is inherent in the healthcare process; evidence helps to quantify that uncertainty. Concern for the uniqueness of the individual patient is not a reason to ignore the evidence, but rather an impetus to learn to apply the evidence both critically and appropriately. Evidence is not intended to be rigid, but rather—as our definition makes explicit—to be integrated with clinical experience and a patient’s unique values to arrive at optimal outcomes.

Evidence in clinical practice is not solely limited to patient care, however. Healthcare professionals might be interested in evidence as it relates to team functioning, the best way to communicate change, organizational models for research utilization, or even the effects of insurance on healthcare usage. Evidence in health care abounds on a variety of topics, and research utilization can improve patient care in a multitude of ways.

GRAY MATTER Evidence can be used as a basis for the following aspects of nursing practice:

Nursing care processes such as assessment, diagnosis, treatment, and evaluation Policies and procedures that guide nursing practice within an organization Patient care management tools such as care maps, standard order sets, and critical paths Care decisions regarding individual patient needs

Strategies for Implementing Evidence-Based Practice Considering the benefits of basing clinical nursing practice on evidence, it would make sense for evidence-based nursing practice to be the norm. Unfortunately, this is not the case. In an integrative review conducted by Saunders and Julkunen (2016), the vast majority of nurses were found to believe in the value of EBP in improving care quality and patient outcomes. Even so, most of the nurses considered their own knowledge and skills insufficient for employing EBP, and did not believe they were using evidence as a basis for their own practice.

Many reasons can be cited to explain why EBPs are the exception rather than the rule, including limitations created by EBP systems themselves. Some barriers are related to human factors, whereas others are related to the

organizations within which nursing care is delivered. Table 1.3 lists some of the common barriers to using evidence as a basis for practice.

Organizations do not commonly have systems in place to support clinicians in the development of EBP tools. Although more resources have become available to practitioners who want to participate in the development of practice guidelines, few operational models exist to guide healthcare organizations that want to implement pervasive EBP (Houser & Oman, 2011). Even when nurses are motivated and competent in the creation and use of EBPs, barriers in the organizational culture may hinder their ability to increase the use of EBP in the workplace (Williams, Perillo, & Brown, 2015). The impact of culture is a strong one; in Williams et al.’s study, nurses reported that their colleagues’ lack of support for changing practice was one of the most formidable barriers to EBP. A collaborative workplace where questioning of current practices is encouraged is needed for wide-scale adoption of EBPs, yet it remains the exception rather than the rule.

Table 1.3 Barriers to Using Evidence in Clinical Practice

Limitations in evidence- based practice systems

Overwhelming amount of information in the literature Sometimes contradictory findings in the research

Human factors that create barriers

Lack of knowledge about evidence-based practice Lack of skill in finding and/or appraising research studies Negative attitudes about research and evidence-based care Perception that research is for medicine, not nursing Patient expectations (e.g., demanding antibiotics)

Organizational factors that create barriers

Hierarchical structures that do not encourage autonomous decision making Lack of authority for clinicians to make changes in practice Colleagues’ lack of support for practice change Demanding workloads with no time for research activities Conflict in priorities between unit work and research Lack of administrative support or incentives

The complexities of changing practice based on evidence are daunting indeed. Majid and colleagues (2011) studied the barriers to and facilitators of EBP as perceived by more than 2000 nurses in organizational settings. Although the nurses in this study generally held positive views about the value of EBP, they also described several barriers to its implementation:

Not enough time to keep up with evidence review given their workload Lack of adequate training and educational support for appraisal of evidence Inability to understand statistical and research terminology Inadequate organizational and leadership support Lack of access to databases and search strategies

An additional barrier identified in the study by Williams et al. (2015) was the lack of authority to change practices in a hierarchical organization. These researchers found that top-down organizations and those in which nurses had little autonomy were the least likely to have a widespread EBP culture. To implement EBP effectively, nurses must believe that their inputs and ideas are valued, and must perceive that they have a level of power appropriate to enact changes within their practices.

An updated review of the literature from 2010 to 2015 conducted by Mallion and Brooke (2016) yielded more heartening findings. These researchers discovered that the traditional barriers of lack of time, knowledge, and skill continue to affect the wholesale adoption of EBPs, but that nurses’ attitudes toward EBP had changed over time. While still acknowledging the difficulty inherent in continuously adopting EBP, the nurses in these studies included in Mallion and Brooke’s literature review valued evidence and had positive impressions of their ability to improve practice.

Strategies for Overcoming Barriers Although little can be done to reduce the complexity of contemporary clinical care, some strategies can be undertaken to improve the rate at which healthcare professionals utilize research as a basis for their practice.

Begin the process by specifically identifying the facilitators of and barriers to evidence-based practices. Use of a self-assessment tool such as that tested by Gale and Schaffer (2009) can help identify organizational strengths and limitations in preparation for an EBP effort.

Education and training can improve knowledge and strengthen practitioners’ beliefs about the benefits of EBP. Clinicians may fear they will appear to lack competence if they engage in EBP, and greater knowledge will give them confidence in determining an evidence base for their practice.

One of the most helpful—and difficult—strategies is to create an environment that encourages an inquisitive approach about clinical care. The first step in identifying opportunities for best practices is questioning current practice. This can be accomplished by creating a culture in which EBPs is valued, supported, and expected, and in which nurses have the authority and autonomy to change practices within their scope of care.

Florczak (2016) has even more basic recommendations for improving research uptake: Nurse researchers, first and foremost, need to conduct studies that are of high quality, especially in terms of sampling methods and controls. Nurses will not be confident about incorporating evidence into practice unless that evidence is strong and convincing. Studies chosen by nurse researchers should focus on outcomes relevant to practice, in which considerations related to patient response, nurse burden, and costs are

addressed in addition to effectiveness. Researchers are well advised to collaborate with practitioners and patients in the design of studies and recommendations intended for application to practice.

Despite the barriers inherent in implementing EBP in clinical practice, it is imperative that nurses create structures and processes that reduce these obstacles. Regardless of the system within which the clinician practices, a systematic approach can be employed to find and document the best possible evidence for practice. This process involves defining a clinical question, identifying and appraising the best possible evidence, and drawing conclusions about best practice.

Reading Research for Evidence-Based Practice Reading research as evidence requires that the professional nurse have a basic understanding of research processes and can apply that understanding to the critical appraisal of individual studies. This systematic process of assessing the reliability, validity, and trustworthiness of studies is explored in detail throughout this text. The appraisal process begins by determining whether the journal, authors, and publication process are credible.

Consider the following key issues when assessing credibility:

Does the author have the appropriate clinical and educational credentials for the research study? If not, have team members been recruited who have the requisite knowledge and skill? Teams strengthen the results of a research project by providing a diversity of perspectives and enlarging the expertise that is accessible to the team members. Is there evidence of a conflict of interest that might introduce bias into the study? For example, does the financial sponsor of the study have something to gain from positive or negative results? Sponsors may unintentionally impose their own expectations on a study and a researcher that may introduce bias into the study. Do the authors have an association with any of the entities in the study? If the authors are employed by an agency being tested in the study, then researcher bias might potentially influence the interpretation of data or the selective reporting of findings. Is the journal unbiased? In other words, does the publication have anything to gain by publishing positive or negative results? The publication should have an external editorial board and a cadre of reviewers who are not associated financially with the publication. The names and credentials of the editorial board should be accessible in the publication. Has the research study undergone blinded peer review? Blinded peer review enables a critical appraisal of the research study by a neutral party who is not influenced by the stature (or lack of it) of the authors. Has the study been published within a reasonable time frame? Health care is characterized by a rapidly changing clinical environment, and studies whose publication is delayed may be outdated before they reach print.

Many journals note the date on which a manuscript was received and the length of time until it was reviewed and accepted. This type of notice enables the reader to determine if the information in the study is contemporary or subject to historical effects.

It is sometimes difficult to determine whether a journal is peer reviewed. This policy may be explicitly stated in the front of the journal, but the absence of such a description does not mean the journal is not a scholarly one. The reader may have to scrutinize the front matter of a journal (the masthead and publication information) or a journal webpage to determine the nature of the publication.

The front matter should also include the names of the external editorial board. The existence of an external editorial board means there is objective oversight of the content and quality of material published in the journal. The names of actual reviewers are rarely published, however; the peer review process is more likely a blinded one, meaning that article authors do not know the identity of the manuscript reviewer, and the reviewer does not know the identity of the authors.

If it is not clear whether the journal is peer reviewed, or if an article has been retrieved electronically and the journal’s front matter is not available, some hints may indicate whether a journal is a scholarly one. Characteristically, peer-reviewed journal issues are identified by volume and number, and the pages are numbered sequentially through the entire year instead of starting over with each issue. An article published in October, therefore, would likely have page numbers in the hundreds. The first page may also specify the date on which a manuscript was received, reviewed, and subsequently published. This information would confirm that a journal article has been peer reviewed.

The first page of the article should describe the author’s credentials and place of employment, along with contact information. Any potential conflicts of interest should be identified here as well. Funding sources for research studies might appear in the credentials section or at the end of the article. Ideally, the journal will also identify any potential conflicts of interest—such as companies owned by the journal’s parent company—that might introduce bias into the publication’s selection process.

Reading research, much like any nursing skill, becomes easier with practice. As a practicing nurse reads, studies, and engages in research projects, this process becomes more efficient and informative. The process of evaluating research, which may initially require a great deal of focus and effort, eventually becomes second nature. As the appraisal of research becomes part of the nurse’s routine, the ability to select studies for application to practice allows the nurse to ensure that his or her practice is based on sound evidence.

Using Research in Evidence-Based Practice Research is a key EBP. Scientific, rigorous, peer-reviewed studies are the foundation of evidence for professional nursing practice. Selecting, reviewing, and incorporating research findings into practice lie at the heart of professional nursing care delivery; however, EBP does not eliminate the need for professional clinical judgment. The application of a specific EBP guideline to a specific patient situation is based on the nurse’s assessment of the situation and an appraisal of the interventions that are most likely to be successful. The clinician remains responsible for combining evidence with clinical expertise and patient values in managing individual patients and achieving optimal outcomes.

Where to Begin? The process of applying research to EBP begins by identifying a problem that will be best addressed by a review of the evidence. The choice of a subject to study may be driven by a variety of factors. Newell-Stokes (2004) classifies three general categories that may uncover the need for EBP.

The first category includes problem-focused factors. These factors are generally clinical problems that are identified through quality improvement processes, benchmarking studies, regulatory agency feedback, practicing clinicians, or administrative data. For example, a hospital may identify a problem with skin breakdown through nurse observation, quality data indicating an increase in pressure ulcer rates, analysis indicating pressure ulcer rates that are higher than those in comparable hospital units, or data that demonstrate higher costs for patients with skin breakdown.

The second category includes factors related to nursing knowledge. A knowledge deficit may be evident, or new knowledge may emerge through research studies. In addition, a new professional association or new national guideline presents opportunities for incorporating evidence-based changes into practice. A practice change often has a better chance of implementation if users perceive the existence of a solid base of evidence for that practice change. For example, a nurse who attends a national conference may find that hydrotherapy is an evidence-based treatment for pressure ulcers and use the information to motivate a change in nursing practice.

The third category includes factors such as new equipment, technology, or products that become available to the nurse. All of these new developments present opportunities to use evidence in practice to improve outcomes.

Once the need is identified for a change in practice, the way the research is gathered and used may take a variety of forms.

CHECKLIST FOR EVALUATING THE CREDIBILITY OF A RESEARCH ARTICLE

❏ The authors have the appropriate clinical and educational credentials for this research study.

❏ There is no evidence of any conflict of interest for the authors that might introduce bias into the way the study is designed or the way the results are viewed.

❏ There is evidence that this journal is peer reviewed (at least one of these):

Pages are sequentially numbered for the entire year.

Issues are identified by volume and number.

The journal has an external editorial board.

The article indicates a review date.

❏ The publication has no financial connection to positive or negative results from the study.

❏ The study has been published in a reasonable time frame (i.e., a reasonable interval from the date of study to the date of publication).

Processes for linking Evidence to Practice Evidence can be incorporated into practice through several processes. For example, an individual nurse may appraise research studies and share findings with colleagues. Also, a specific question may be answered by reviewing the literature or attending research presentations at conferences.

Although reviewing research studies is a good beginning for establishing evidence for nursing practice, it is possible to introduce bias into the selection of the articles to review. Nurses may consciously or unconsciously select only those articles that support their point of view while ignoring studies that challenge their beliefs. Engaging in a systematic review process will control the potential for such bias to occur. A systematic review process is a structured approach to a comprehensive research review. It begins by establishing objective criteria for finding and selecting research articles, combined with documentation of the rationale for eliminating any study from the review.

Research studies that are selected for inclusion in the review should be subjected to careful and thorough appraisal of study quality and validity. They are graded based on the strength of evidence they provide as well as their design and quality criteria. Several different rating scales may be used to evaluate a research study’s strength as evidence, but it is important to recognize that one rating system is not necessarily better than another. Individual values, the nature of the practice question, and the kind of knowledge needed drive the choice of a rating system. Most grading systems

include between four and six levels. Table 1.4 depicts a rating system for levels of evidence that is a composite of the work of Armola et al. (2009), Ahrens (2005), and Rice (2008).

Table 1.4 Rating Systems for Grading levels of Evidence

Level of Rating

Type of Study

Level I Multiple randomized controlled trials (RCTs) reported as meta-analysis, systematic review, or meta-synthesis, with results that consistently support a specific intervention or treatment Randomized trials with large sample sizes and large effect sizes

Level II Evidence from well-designed controlled studies, either randomized or nonrandomized, with results that consistently support a specific intervention or treatment

Level III

Evidence from studies of intact groups Ex-post-facto and causal-comparative studies Case-control or cohort studies Evidence obtained from time series with and without an intervention Single experimental or quasi-experimental studies with dramatic effect sizes

Level IV

Evidence from integrative reviews Systematic reviews of qualitative or descriptive studies Theory-based evidence and expert opinion Peer-reviewed professional organization standards with supporting clinical studies

Using this scale, for example, a randomized trial of the use of aromatherapy in a post-anesthesia care unit to reduce nausea would be classified as the strongest level of evidence if the findings came from a large study with definitive results or if the results were successfully replicated several times at several sites. The same study conducted in a single setting with a small sample of convenience would provide evidence that was less authoritative. Weaker still would be evidence that was generated through observation or expert opinions.

These strength-of-evidence rating scales apply primarily to the evaluation of treatments, interventions, or the effectiveness of therapies. Recall the definition of EBP: practice based on the best demonstrated evidence combined with clinical experience and patient preferences. The hierarchy of evidence may look quite different depending on the nature of the practice under study.

Review and rating of the evidence should result in recommendations for practice, with the strength of these recommendations being commensurate with the level of evidence and the quality of the study. The link between the strength of the evidence and the strength of the resulting recommendation is

the way in which varying levels of evidence are incorporated into a single practice guideline. Table 1.5 depicts the way that the American Academy of Pediatrics (2004) recommends that evidence be linked to a subsequent system of recommendations. Based on the strength of the evidence and the preponderance of benefit or harm, recommendations are generated that are classified as strongly recommended, optional, or recommended. Some evidence results in no recommendation because a conclusion cannot be definitively drawn. Some evidence that shows harm to the patient may result in “not recommended” status.

The systematic review process is complex and time consuming, and should be undertaken only when no other EBP guidelines exist. The effort is warranted, though, when no clear guidance exists for specific practices, or when the development of a guideline is likely to be affected by practitioner bias.

Table 1.5 The link Between Evidence and Recommendations for Practice

Type of Evidence Clear Evidence of Benefit or Harm

Benefit and Harm Are Balanced

Well-designed, randomized controlled trials (RCTs) or reports of multiple RCTs

Strong recommendation for or against the intervention.

Action is optional.

RCTs with limitations of quasi- experimental studies

Recommendation for or against the intervention.

Action is optional.

Observational and descriptive studies, case controls, and cohort designs

Recommendation for or against the intervention.

Action is optional.

Expert opinion, case studies Action is optional. No recommendation for or against the intervention.

Reproduced with permission from American Academy of Pediatrics. (2004). American Academy of Pediatrics policy statement: Classifying recommendations for clinical practice guidelines. Pediatrics, 114, 874–877. Copyright © 2004 by the AAP.

Creating Evidence for Practice Nurses commonly serve as the primary investigators in studies that focus on the needs of patients and the effectiveness of nursing interventions. When a nurse conceives of, designs, and implements a research project, he or she is designated as a primary investigator. The primary investigator is responsible for all aspects of a research study’s conduct and outcome, even if a team is involved. The primary investigator also has the right to be the first author noted on a research publication.

Designing a research study is an advanced and complex skill that requires experience in the clinical processes under study as well as an understanding

of the complexity of research design and analysis. That is not to say that the professional nurse cannot gain the skill and experience needed to be a primary investigator—only that becoming a nurse researcher is an evolutionary process that occurs over time. It is the rare nurse who is able to design and conduct a brilliant study on the first attempt. More commonly, a nurse learns the process by becoming involved in the research of others in some way—either in data collection, through team participation, or even as a subject. Only gradually does he or she gain the ability to conceive of and lead a research project.

Creating nursing research is a systematic, rigorous process. The remainder of this text will guide the nurse as he or she gains the foundation needed to read, use, and create evidence.

Future Directions for Nursing Research It is clear that nursing research will continue to assume a prominent role in supporting the professional practice of nursing. The future of nursing research is exciting and requires that all nurses accept responsibility for seeking and using evidence as a basis for practice. As part of nursing’s future, research will likely evolve into a routine and integral part of the professional nursing practice environment. This requires the engagement of nurses in disciplined inquiry on some level, whether as informed consumers or as primary investigators and team leaders. Nurses must be involved in the promotion of research in support of nursing practices. As such, they must become adept at planning and implementing change in nursing practices. An open mind and adaptability are key characteristics for ensuring adoption of EBPs.

Collaboration with physicians and members of other disciplines in the design and implementation of patient-centered research will continue to elevate nurses to the level expected of all of the health science professions. Participation on a research team encourages other professions to treat nurses as respected colleagues and valued members of the healthcare team.

The future of nursing requires an emphasis on increasing the contribution of research to the knowledge of nursing based on a strategic research agenda. This includes a broadening of the opportunities for dissemination of nursing research findings through research conferences, clinical groups, electronic formats, and publication.

Summary of Key Concepts The practice of nursing is founded on nursing knowledge, and nursing knowledge is generated and disseminated through reading, using, and creating nursing research. Nursing research is a systematic process of inquiry that uses rigorous, systematic approaches to produce answers to questions and solutions to problems in nursing practice. Research is designed so that it is free of bias

and results are trustworthy. The hallmarks of solid, well-respected research are peer review and replication. Nurses may use research to synthesize the findings of others, explore and describe phenomena, find solutions to problems, or test traditional approaches for efficacy. Research is fundamental to nursing practice because conduct of research is characteristic of a profession and nurses are accountable for the care they deliver. Consumers and external agencies are demanding that healthcare professionals provide evidence for the effectiveness of the interventions they propose and implement. Nursing is a relatively young profession, but its practitioners have a proud history of disciplined inquiry. The NINR gives nursing research national stature and financial support and also establishes a national agenda of priorities for nursing research. Nurses may fulfill a variety of roles in contemporary nursing research practice, ranging from informed consumers to data collectors to primary investigators. As they become more proficient in nursing research, their roles may broaden and involve projects of increasing complexity. Research is not synonymous with problem solving; it is intended to benefit the profession as a whole. A systematic approach and upfront, informed consent of subjects are hallmarks of the research process. The benefit of research to nurses lies in its use as evidence for practice. EBP entails the use of the best scientific evidence integrated with clinical experience and incorporating patient values and preferences in the practice of professional nursing care. Numerous types of research are required to accomplish this goal. EBP is important in nursing because outcomes are improved, care is more efficient and effective, and errors are reduced when practitioners use evidence as a standard of care. Consumers are also asking for evidence to help them make decisions about their treatment options, and nurses are in a unique position to provide them with appropriate evidence. Evidence can be used as a basis for nursing practice in assessing the patient’s condition, diagnosing patient problems, planning patient care, evaluating interventions, and evaluating patient responses. Barriers to using evidence as a basis for nursing practice may be related to the nature of evidence in practice, individual issues, or organizational constraints. Nurses must identify barriers to the use of evidence in practice and implement strategies to overcome them. Translation of research into practice is based on a careful evaluation of the characteristics of a patient population, matched with an assessment of the credibility and external validity of studies relative to patient needs. Future directions in nursing research include focusing on research as an integral part of nursing practice in a collaborative environment. Collaboration with other healthcare team members in research enhances the value of the profession as a whole and garners respect for its practitioners.

External validity: The ability to generalize the findings from a research study to other populations, places, and situations.

For More Depth and Detail For a more in-depth look at the concepts in this chapter, try these references:

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Fitzsimmons, E., & Cooper, J. (2012). Embedding a culture of evidence-based practice. Nursing Management, 19(7), 14–21.

Foster, M., & Shurtz, S. (2013). Making the critical appraisal for summaries of evidence (CASE) for evidence-based medicine: Critical appraisal summaries of evidence. Journal of the Medical Library Association, 101(3), 192–198.

Sandstrom, B., Borglin, B., Nilsson, R., & Willman, A. (2011). Promoting the implementation of evidence-based practice: A literature review focusing on the role of nursing leadership. Worldviews on Evidence-Based Nursing, 4, 212–225.

Sullivan, D. (2013). A science perspective to guide evidence-based practice. International Journal of Childbirth Education, 28(1), 51–56.

Upton, P., Scurlock-Evans, L., Stephens, D., & Upton, D. (2012). The adoption and implementation of evidence-based practice (EBP) among allied health professions. International Journal of Therapy and Rehabilitation, 19(9), 497–505.

CRITICAL APPRAISAL EXERCISE Retrieve the following full-text article from the Cumulative Index to Nursing and Allied Health Literature, or a similar search database:

Ortiz, J., McGilligan, K., & Kelly, P. (2004). Duration of breast milk expression among working mothers enrolled in an employer-sponsored lactation program. Pediatric Nursing, 30(2), 111–118.

Review the article, including information about the authors and sponsors of the study. Consider the following appraisal questions in your critical review of this research article:

1. Do the authors have the appropriate clinical and educational credentials for this research study? What are the strengths and

weaknesses of this research team? 2. Is there evidence of any conflict of interest that might introduce

bias into the way the study is designed or the way the results are viewed? Do the authors have any potential to realize a financial gain from the results of this study?

3. What is the evidence that this journal is peer-reviewed? Find the home page of this journal on the Web. Does the journal have an editorial board?

4. Does the journal have anything to gain by publishing positive or negative results from this study?

5. Is there evidence of bias in the way the study was designed or implemented? If so, how does it affect the nurses’ use of these data in the practice setting?

6. Appraise the level of evidence this research study provides the nurse and the strength of the recommendation for practice provided by the results.

References Ahrens, T. (2005). Evidence-based practice: Priorities and

implementation strategies. AACN Clinical Issues, 16(1), 36– 42.

American Academy of Pediatrics. (2004). Policy statement: Classifying recommendations for clinical practice guidelines. Pediatrics, 114(3), 874–877.

American Association of Colleges of Nursing. (2006). AACN position statement on nursing research. Retrieved from http://www.aacn.nche.edu/publications/position/nursing- research

Armola, R., Bourgault, A., Halm, M., Board, R., Bucher, L., Harrington, L., . . . Medina, J. (2009). AACN’s levels of evidence: What’s new? Critical Care Nurse, 29(4), 70–73.

Baker, K., Clark, P., Henderson, D., Wolf, L., Carman, M., Manton, A., & Zavotsky, K. (2014). Identifying the differences between quality improvement, evidence-based practice, and original research. Journal of Emergency Nursing, 40(2), 195–198.

Crabtree, E., Brennan, E., Davis, A., & Coyle, A. (2016). Improving patient care through nursing engagement in evidence-based practice. Worldviews on Evidence-Based Nursing, 13(2), 172–175.

Deighton, J., Argent, R., Francesco, D., Edbrooke-Childs, J., Jacob, J., Fleming, I., . . . Wolpert, M. (2016). Associations between evidence-based practice and mental health outcomes in child and adolescent mental health services. Clinical Child Psychology and Psychiatry, 21(2), 287–296.

Facchiano, L., & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. Journal of the American Academy of Nurse Practitioners, 24, 579–586.

Florczak, K. (2016). Evidence-based practice: What’s new is old. Nursing Science Quarterly, 29(2), 108–112.

Gale, B., & Schaffer, M. (2009). Organizational readiness for evidence-based practice. Journal of Nursing Administration, 39(2), 91–97.

Gardner, K., Kanaskie, M., Knehans, A., Salisbury, S., Doheny, K., & Schirm, V. (2016). Implementing and sustaining evidence-based practice through a nursing journal club. Applied Nursing Research, 31, 139–145.

Houser, J., & Oman, K. (2011). Evidence-based practice: An implementation guide for healthcare organizations. Sudbury, MA: Jones & Bartlett Learning.

Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health. Prepared by Robert Wood Johnson Foundation Committee Initiative on the Future of Nursing. Washington, DC: National Academies Press.

Lee, M., Johnson, K., Newhouse, R., & Warren, J. (2013). Evidence-based practice process quality assessment:

EPQA guidelines. Worldviews on Evidence-Based Nursing, 10(3), 140–149.

Leufer, T., & Cleary-Holdforth, J. (2009). Evidence-based practice: Improving patient outcomes. Nursing Standard, 23(32), 35–39.

Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Yun-Ke, C., & Mokhtar, I. (2011). Adopting evidence-based practice in clinical decision-making: Nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229–236.

Mallion, J., & Brooke, J. (2016). Community- and hospital- based nurses’ implementation of evidence-based practice: Are there any differences? British Journal of Community Nursing, 21(3), 148–154.

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National Institute of Nursing Research (NINR). (2013, March). NINR mission and strategic plan. Retrieved from http://www.ninr.nih.gov/aboutninr/ninr-mission-and- strategic-plan#right-content

Newell-Stokes, G. (2004). Applying evidence-based practice: A place to start. Journal of Infusion Nursing, 27(6), 381–385.

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American Medical Association, 270, 2093–2095.

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Smith, G., & Pell, J. (2006). Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomized controlled trials. International Journal of Prosthodontics, 19(2), 126–128.

Summerskill, W., & Pope, C. (2002). An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Family Practitioner, 19, 605–610.

Williams, B., Perillo, S., & Brown, T. (2015). What are the factors of organizational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review. Nurse Education Today, 35, e34–e41.

Wilson, M., Sleutel, M., Newcomb, P., Behan, D., Walsh, J., Wells, J., & Baldwin, K. (2015). Empowering nurses with evidence-based practice environments: Surveying Magnet, Pathway to Excellence, and non-Magnet facilities in one healthcare system. Worldviews on Evidence-Based Nursing, 12(1), 12–21.

Chapter 2: The Research Process and Ways of Knowing

CHAPTER OBJECTIVES The study of this chapter will help the learner to

Discuss the philosophical orientations that influence the choice of a research design. Contrast the characteristics of quantitative and qualitative research. Review the steps involved in the research process. Determine the way that a design is linked to the research question. Classify research based on characteristics related to intent, type, and time. Evaluate which kind of evidence is best provided by quantitative and qualitative research.

KEY TERMS Applied research

Basic research

Cross-sectional methods

Experimental research

Longitudinal studies

Mixed methods

Paradigm

Prospective studies

Qualitative research

Quantitative research

Quasi-experimental studies

Retrospective studies

Introduction What is the nature of truth? It is hard to think of a more difficult question to answer. This fundamental question must be considered, however, to ensure that the research process is successful in providing evidence for practice. Research is about the search for truth. There are, however, multiple approaches to determining and describing truth. The successful researcher

understands which approach is effective for the particular problem to be solved. The key is to consider assumptions about the nature of the world, the question to be answered, and the intent of the researcher.

The most fundamental questions to be answered in the beginning of a research process are philosophical but necessary ones: What constitutes knowledge? What is the nature of the world, and how can this research reflect that nature? The researcher should carefully consider these issues before proceeding with the design of the inquiry. It is a mistake to jump straight from research question to design without considering the philosophical foundation on which the study will be built.

These philosophical considerations must represent more than the researcher’s view of the world. That is, they must be carefully matched to a design that will address the specific nature of the research question. The goal is to produce knowledge that is relevant and applicable to the body of nursing knowledge and that becomes evidence for practice.

VOICES FROM THE FIELD When I started my doctorate, I was sure I wanted to do a straightforward quantitative experiment. I like numbers and statistics, so this kind of study seemed to be a natural extension of my interests. My subject, however, was a bit novel: I was trying to build a comprehensive model to measure inpatient nurse workload. I had always worked in hospitals and used patient acuity systems (systems used to measure the intensity of a patient’s care needs) to assess the nursing workload, but a nurse said something that intrigued me: “If all I had to do was take care of my patients, I’d be fine.” I set out to find out what all those other demands were, and how they affected the nurse’s perception of workload.

I found out just how novel this topic was when I tried to do a literature review and discovered that I could not find any relevant literature. There were lots of opinion articles about measuring workload, and plenty of published quantitative studies focused on patient acuity, but none tried to look at workload holistically. Reluctantly, I concluded that I needed to utilize a mixed-methods design—that is, I needed first to figure out what the forces affecting the nurse’s workload were, and then to measure how much impact they had on the nurse’s day.

I conducted a series of focus groups with nurses, observed them during their regular workdays, and interviewed quite a few individually. I found that I could describe many nonpatient demands—equipment needed repair, supplies were missing, and other therapists and technicians interrupted patient care. In addition, there were some macro issues at play: Nurses said that strong teams were able to accomplish more work, but weak teams actually created more pressure. All of the nurses

mentioned the effects of good leadership on recruitment and retention, and subsequently on the stability of the nursing staff, which helped build teams.

After theme analysis and triangulating the data from my focus groups, observations, and interviews, I developed a model of the demands on a nurse’s time. This preparation seemed to take forever, but when I finally began to test the model quantitatively, the work went quickly. I was able to determine the elements that directly affected workload and those that had an indirect effect. I figured out that teamwork, leadership, and retention were central to efficient unit operations. Demonstrating caring, communicating with team members, and entering information into the health record also consumed a lot of time. I discovered that “hunting for things” is a legitimate time drain.

This study was a classic case in which answering the research question required both quantitative and qualitative methods. The qualitative phase helped me determine the fundamental things that frustrate a nurse, and the quantitative phase let me demonstrate whether those influences were real and strong.

Janet Houser, PhD, RN

The Research Process Regardless of the philosophical assumptions made in a specific study, some characteristics are universal to all research studies. Research by its very nature is systematic and rigorous; it is about a disciplined search for truth. “Systematic” implies that decisions are carefully considered, options weighed, and a rational basis documented to support the choices that are made. Those decisions and choices help form the foundation for and build a research study. They also make up phases of study that are more or less completed in sequence. These phases are depicted in FIGURE 2.1:

Define a research problem: Identify a gap in the knowledge of nursing practice that can be effectively addressed with evidence. Scan the literature: Complete a systematic review of the literature to determine basic knowledge about the problem, so as to identify relevant evidence and a potential theoretical framework. Determine an appropriate design: Select a design that is appropriate for the philosophical assumption, the nature of the question, the intent of the researcher, and the time dimension. Define a sampling strategy: Design a sampling plan that details both how subjects will be recruited and assigned to groups, if appropriate, and how many subjects will be needed. Collect data: Gather the data using appropriate data collection protocols and reliable, valid methods.

Analyze data: Apply analytic techniques that are appropriate for the type of data collected and that will answer the question. Communicate the findings: Disseminate the findings to the appropriate audiences through conferences and publication. Use the findings to support practice: Promote the uptake of the research by linking it to specific guidelines for nursing practice.

FIGURE 2.1 The Research Process: Building a Study

These phases may look as if they make up steps, with the end of one phase leading directly to the beginning of another. It is, however, misleading to call the research process a series of steps. Such a description implies that the tasks are done in a particular sequence and that the components are distinct and mutually exclusive. In reality, the design of a research study is a fluid process, one that may be considered a work in progress until the final plan is complete. The process may resemble an elaborate game of Chutes and Ladders more than anything else. In this game, progress is made until the player reaches a chute, which will take the player back to a lower level. In research, several things may happen more or less at the same time—for example, the search for a theoretical framework, the literature review, and construction of the research question. Although the researcher may complete most of these tasks and move on to the design of the study, occasionally a situation will arise that prompts the researcher to reconsider the phrasing of the question, or new literature may be published. As a consequence, the phases may be conducted out of sequence, or the researcher may go back and forth between phases. The phases may overlap, or some phases may not be visited at all. So many varieties of research are possible that any depiction of the research process must come with the caveat that it is a general guide that is adapted to the particular situation at hand.

In quantitative research, decisions are usually finalized before data collection begins, although emergent issues may, even then, require adaptation of the research plan. In contrast, in qualitative research, the research plan is adapted based on both the data generated by the respondents and the nature of those data. Qualitative design decisions may not be completed until the final report is written.

In general, the way the research process emerges and the particular phases that are implemented in a research study are based on many characteristics of both the research problem and the researcher. These characteristics and assumptions lend themselves to several general classifications of research. The choice of an overall research classification is the first step in determining the specifics of a research design.

Classification of Research by Philosophical Assumptions About the Nature of the World The philosophical assumptions that drive the design of a study are rooted in the paradigms of those who are doing the studying. A paradigm is an overall belief system, a view of the world that strives to make sense of the nature of reality and the basis of knowledge. The disciplined study of nursing phenomena is rooted in two broad paradigms, both of which are relevant for nursing research. These two broad paradigms reflect methods that are primarily quantitative (based on the measurement of observable phenomena) or qualitative (based on the analysis of the meaning of events as depicted in the words and actions of others).

Paradigm: An overall belief system or way of viewing the nature of reality and the basis of knowledge.

Quantitative Research Quantitative research is the traditional approach to scientific research. It is rooted in the philosophical assumptions of positivism and determinism. Positivism assumes that features of the environment have an objective reality; the world is viewed as something available for study in a more or less unchanging form. A related assumption underlying the scientific method is determinism: a belief that events are not random, but rather have antecedent causes. In the face of these beliefs—the existence of an objective reality, in which events can be linked to an associated cause—the researcher’s challenge is to understand the relationships among human phenomena. The task of positivist scientific inquiry, then, is to make unbiased observations of the natural and social world.

Quantitative research: A traditional approach to research in which variables are identified and measured in a reliable and valid way.

Quantitative research involves identifying the variables that represent characteristics of interest and then measuring them in a reliable, valid way. This type of research is characterized by a tightly controlled context that enables the researcher to rule out extraneous effects. Both the way subjects are selected and the protocols for the study are designed to eliminate bias. Statistical analysis is used to establish the level of confidence in the results and to rule out the effects of random error. These conclusions, then, constitute the contribution to scientific knowledge.

There is no doubt that the scientific study of cause and effect in nursing practice is necessary and important for evidence-based practice; quantitative approaches are particularly well suited for answering questions about the nursing actions that can influence outcomes. These studies produce some of the strongest evidence for the benefits of an intervention. Nevertheless, nurses pose many questions that are not adequately addressed by a strict adherence to measurement of an objective reality. In turn, the single adherence to a positivist view has drawn considerable criticism from nurse researchers, and many of these criticisms are legitimate. The nature of nursing care involves helping others attain their health goals, many of which are defined by the individual, not the nurse. Perceptions of quality of life, the meaning of a life event, and the willingness to endure side effects for a therapeutic result are all based on the patient’s construction of reality, not the nurse’s perceptions. In turn, many related questions are better addressed with a process of naturalistic inquiry.

Qualitative Research Qualitative research is based on a naturalistic paradigm. This belief system is represented by a view of reality that is constructed by the individual, not the researcher. In the naturalistic view, reality is not a fixed entity, but rather exists in the context of what the research participant believes it to be. Qualitative researchers believe that many different views of reality are possible, and all of them are right. An associated belief for the naturalistic researcher is relativism, or the belief that there are always multiple interpretations of reality, and that these interpretations can exist only within an individual. The qualitative researcher, then, believes there is no process in which the ultimate basis for a singular truth can be identified.

Qualitative research: A naturalistic approach to research in which the focus is on understanding the meaning of an experience from the individual’s perspective.

Qualitative methods focus on an understanding of the meaning of an experience from the individual’s perspective. Extended observation of participants, in-depth interviews or focus groups, case studies, and studies of social interaction are examples of qualitative methods. The inquiry process

focuses on verbal descriptions and observable behaviors as a basis for analysis and conclusions.

Qualitative methods are appropriate for addressing questions in which the meaning of the patient’s experience is central to understanding the best therapeutic approach. Issues of behavior change, motivation, compliance with a regimen, and tolerance of a treatment are all examples of topics in which the patient’s perception is central to assisting the patient to a healthy state. The analysis of themes that describe the meaning of the experience for the patient is based on words and observations, rather than on measurable phenomena. The researcher establishes a relationship with the subject, and bias is considered an inherent part of the research process. The findings from qualitative studies are used to enhance evidence-based practice by incorporating the patient’s preferences and values into guides for nursing practice.

The differences in philosophy, roles, and methods between quantitative and qualitative research are depicted in Table 2.1. These contrasts are made to help the student understand the variations between these two overall approaches. In reality, both types of research have many characteristics in common:

A disciplined, rigorous approach based on external evidence Methods that require samples and the cooperation of individuals A focus on the rights of human subjects and ethical guidelines An ultimate aim of discovering new knowledge that can be used to improve nursing practice

Table 2.1 Quantitative Versus Qualitative Characteristics

Element Quantitative Qualitative

View of reality Reality is objective and can be seen and measured.

Reality is constructed by the individual.

View of time Reality is relatively constant. Reality is continuously constructed.

Context Reality can be separated from its context.

Reality is embedded in its context.

Researcher approach

Objective, detached. Personally involved.

Populations studied

Samples that represent overall populations as subjects.

Individual cases, represented as informants.

Measures Human behavior or other observable phenomena.

Study the meanings that individuals create.

Observations Analyze reality as definable variables.

Make holistic observations of the total context.

Design Preconceived and highly controlled. Emergent and fluid, adaptable to informants’ views.

Analysis Descriptive and inferential statistics. Analytic induction to determine meaning.

Generalization Use inference to generalize from a sample to a defined population.

Transfer knowledge from case analysis to similar cases.

Reports Objective, impersonal reports in which the researcher’s opinions are undetectable.

Interpretive reports that reflect the researcher’s reconstruction of the meaning of the data.

Many nurse researchers assume they must select only one approach and carry out the study in a pure and inflexible way. In fact, it is the rare study that relies on just one approach or the other. The choices made in research design are probably less about a solely qualitative approach versus a solely quantitative approach, and more about selection from a continuum of choices that may overlap from one approach to the other. Many quantitative studies involve asking the subjects to respond to questions or give opinions in which the participants’ words are later analyzed to enhance the statistical findings. Experimental researchers may rate subject behaviors using scales that contain subjective elements, or they may record their own observations of behaviors. Conversely, many qualitative studies use measurement to determine the reliability of multiple raters in determining themes and to verify the trustworthiness of conclusions. A basic qualitative validation method is triangulation, or the search for multiple sources to confirm the same finding, in which numbers are often retrieved to confirm verbal data. There are many situations in which a blend of methods is appropriate, and these mixed methods designs are becoming more common.

Mixed Methods Mixed methods are becoming an important tool in nursing research, particularly in evaluation research. Evaluation research is the application of research methods to the study of p rograms, projects, or phenomena. Increasingly, the question is not whether mixed methods are appropriate, but rather how they should be used.

Mixed methods: A research approach that combines quantitative and qualitative elements; it involves the description of the measurable state of a phenomenon and the individual’s subjective response to it.

Mixed-method designs can provide pragmatic advantages when exploring novel or complex nursing problems (McCusker & Gunaydin, 2015). The qualitative data provide a deep understanding of the human experience, while

the quantitative data enable the researcher to identify and measure relationships. Research that draws on the strengths of both paradigms is increasingly recognized as essential in all fields—including in medicine, where it is needed to support effective patient care guidelines.

Mixed methods are often applied in an ad hoc way, meaning the researcher initiates the study by using a primarily quantitative or qualitative method, and then integrates elements of the alternative approach as an afterthought. The most effective use of mixed methods, however, occurs when they are employed in a systematic way (Kettles, Creswell & Zhange, 2011). Mixed methods are commonly used in descriptive studies, where they may be used to describe both the measurable state of a phenomenon and the individual responses to it. For example, mixed methods might be used for the following purposes:

Describe the rate of hand washing on a nursing unit (quantitative) as well as the nurses’ perceptions about the importance of hand washing (qualitative) Measure the presence of bacteria on a nurse’s hands after washing (quantitative) and observe the hand-washing steps the nurse used (qualitative) Count the number of times a nurse washed his or her hands between patients (quantitative) and record the nurse’s report on the convenience of hand-washing facilities (qualitative)

Choosing a Design Many considerations go into the choice of a general approach to research design. The philosophical orientation of the researcher is just one element. The nature of the research question, the skills and abilities of the researcher, and access to resources and samples all are important elements to consider prior to choosing the research methodology.

Of primary importance to the selection of an approach is the nature of the research question. Research questions that focus on the effectiveness of an intervention require a scientific approach (assuming effectiveness is defined as an objectively measured outcome). For example, the effectiveness of a skin-care regimen in preventing pressure ulcers is best studied by applying the proposed regimen to one group of patients, applying a standard regimen to another group of patients, and then measuring the rate of pressure ulcer development in both groups. If the regimen is effective, then the subjects getting the new regimen will have a lower pressure ulcer rate than those with the standard regimen. This is the traditional experiment, and it is still one of the most common research designs in health care.

In contrast, research questions that focus on the acceptability of an intervention may require a qualitative approach. The new regimen may be

effective, but it may be painful, have an unpleasant smell, or consist of a cream that sticks to clothing. Assessment of these attributes, which will almost certainly affect whether a patient complies with the skin-care regimen, requires asking the patients about their preferences for the treatment and whether the outcome outweighs the unpleasant side effects.

Some of the considerations when choosing an approach are researcher driven. Many researchers have a personal preference for one approach over another. When the research question may be answered in several different ways, or when various aspects of a phenomenon require study before evidence can be deduced, then the researcher’s personal preference may drive the selection of an approach. The skills that are required for quantitative research include the capacity to define variables, recruit subjects, use random assignment methods, create reliable and valid measurements, and analyze results with statistical techniques. The skills that are required for qualitative researchers are quite different. They include the ability to find and select those subjects who can best inform the question, observe and record actions and interactions in detail, skillfully interview subjects or focus groups, and distill meaning from large amounts of word-based data. Both skill sets can require years to develop and hone. It is natural, then, that most researchers find themselves specializing in one approach or the other.

GRAY MATTER Consider the following elements prior to choosing a research design:

Philosophical orientation of the researcher Nature of the research question or problem Skills, abilities, and preferences of the researcher Resources and sample access

GRAY MATTER The following skills are required for quantitative research:

Defining variables Recruiting subjects Using random assignment methods Creating reliable and valid measurements Analyzing results with statistical techniques

GRAY MATTER The following skills are required for qualitative research:

Finding and selecting subjects appropriate for the question Observing and recording actions and interactions in detail

Interviewing subjects skillfully Distilling meaning from large amounts of word-based data

A host of practical considerations must be addressed when selecting an approach. Quantitative methods require measurement tools, subjects who are willing to undergo experimental treatments (or the risk of no treatment), statistical software, and access to individuals knowledgeable in statistical analysis and interpretation. Qualitative methods need less in the way of tools and software, but they require informants who are willing to be observed or interviewed, often for extended periods of time. The particular individuals who are accessible as well as the material resources required may drive the selection of a feasible research approach.

The post NURSING RESEARCH READING, USING, AND CREATING EVIDENCE appeared first on Infinite Essays.

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NURSING RESEARCH READING, USING, AND CREATING EVIDENCE

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