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Understanding Nursing Research Building an Evidence-Based Practice SIXTH EDITION Susan K. Grove, PhD, RN, ANP-BC, GNP-BC Professor Emerita, College of Nursing, The University of Texas at Arlington, Arlington, Texas Adult Nurse Practitioner, Family Practice, Grand Prairie, Texas Jennifer R. Gray, PhD, RN, FAAN George W. and Hazel M. Jay Professor, College of Nursing, Associate Dean, College of Nursing, The University of Texas at Arlington, Arlington, Texas Nancy Burns, PhD, RN, FCN, FAAN Professor Emerita, College of Nursing, The University of Texas at Arlington, Arlington, Texas Faith Community Nurse, St. Matthew Cumberland Presbyterian Church, Burleson, Texas Table of Contents Cover image Title page Inside Front Cover Copyright Contributor and Reviewers Dedication Preface Acknowledgments Chapter 1: Introduction to Nursing Research and Evidence-Based Practice What is Nursing Research? What is Evidence-Based Practice? Purposes of Research for Implementing an Evidence-Based Nursing Practice Historical Development of Research in Nursing Acquiring Knowledge in Nursing Acquiring Knowledge Through Nursing Research Understanding Best Research Evidence for Practice What Is Your Role in Nursing Research? Key Concepts Chapter 2: Introduction to Quantitative Research What is Quantitative Research? Problem-Solving and Nursing Processes: Basis for Understanding the Quantitative Research Process Identifying the Steps of the Quantitative Research Process Reading Research Reports Practice Reading Quasi-Experimental and Experimental Studies Key Concepts Chapter 3: Introduction to Qualitative Research Values of Qualitative Researchers Rigor in Qualitative Research Qualitative Research Approaches Qualitative Research Methodologies Data Collection Methods Data Management Data Analysis Key Concepts Chapter 4: Examining Ethics in Nursing Research Historical Events Influencing the Development of Ethical Codes and Regulations Protecting Human Rights Understanding Informed Consent Understanding Institutional Review Examining the Benefit-Risk Ratio of a Study Understanding Research Misconduct Examining the Use of Animals in Research Key Concepts Chapter 5: Research Problems, Purposes, and Hypotheses What Are Research Problems and Purposes? Identifying the Problem and Purpose in Quantitative, Qualitative, and Outcomes Studies Determining the Significance of a Study Problem and Purpose Examining the Feasibility of a Problem and Purpose Examining Research Objectives, Questions, and Hypotheses in Research Reports Understanding Study Variables and Research Concepts Key Concepts Chapter 6: Understanding and Critically Appraising the Literature Review Purpose of the Literature Review Sources Included in a Literature Review Critically Appraising Literature Reviews Reviewing the Literature Key Concepts Chapter 7: Understanding Theory and Research Frameworks What is a Theory? Understanding the Elements of Theory Levels of Theoretical Thinking Examples of Critical Appraisal Key Concepts Chapter 8: Clarifying Quantitative Research Designs Identifying Designs Used in Nursing Studies Descriptive Designs Correlational Designs Understanding Concepts Important to Causality in Designs Examining the Validity of Studies Elements of Designs Examining Causality Quasi-Experimental Designs Experimental Designs Randomized Controlled Trials Introduction to Mixed-Methods Approaches Key Concepts Chapter 9: Examining Populations and Samples in Research Understanding Sampling Concepts Representativeness of a Sample in Quantitative and Outcomes Research Probability Sampling Methods Nonprobability Sampling Methods Commonly Used in Quantitative Research Sample Size in Quantitative Studies Sampling in Qualitative Research Sample Size in Qualitative Studies Research Settings Key Concepts Chapter 10: Clarifying Measurement and Data Collection in Quantitative Research Concepts of Measurement Theory Accuracy, Precision, and Error of Physiological Measures Use of Sensitivity, Specificity, and Likelihood Ratios to Determine the Quality of Diagnostic AND Screening Tests Measurement Strategies in Nursing Data Collection Process Key Concepts Chapter 11: Understanding Statistics in Research Understanding the Elements of the Statistical Analysis Process Understanding Theories and Concepts of the Statistical Analysis Process Using Statistics to Describe Determining the Appropriateness of Inferential Statistics in Studies Using Statistics to Examine Relationships Using Statistics to Predict Outcomes Using Statistics to Examine Differences Interpreting Research Outcomes Key Concepts Chapter 12: Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice When are Critical Appraisals of Studies Implemented in Nursing? What are the Key Principles for Conducting Intellectual Critical Appraisals of Quantitative and Qualitative Studies? Understanding the Quantitative Research Critical Appraisal Process Example of a Critical Appraisal of a Quantitative Study Understanding the Qualitative Research Critical Appraisal Process Example of a Critical Appraisal of a Qualitative Study Key Concepts Chapter 13: Building an Evidence-Based Nursing Practice Benefits and Barriers Related to Evidence-Based Nursing Practice Searching for Evidence-Based Sources Critically Appraising Research Syntheses Developing Clinical Questions to Identify Existing Research-Based Evidence for Use in Practice Models to Promote Evidence-Based Practice in Nursing Implementing Evidence-Based Guidelines in Practice Introduction to Evidence-Based Practice Centers Introduction to Translational Research Key Concepts Chapter 14: Outcomes Research Theoretical Basis of Outcomes Research Nursing-Sensitive Outcomes Origins of Outcomes and Performance Monitoring Federal Government Involvement in Outcomes Research Advanced Practice Nursing Outcomes Research Outcomes Research and Nursing Practice Methodologies for Outcomes Studies Statistical Methods for Outcomes Studies Critical Appraisal of Outcomes Studies Key Concepts Glossary Index Inside Back Cover Inside Front Cover Copyright 3251 Riverport Lane St. Louis, Missouri 63043 UNDERSTANDING NURSING RESEARCH: BUILDING AN EVIDENCE-BASED PRACTICE, EDITION SIX ISBN: 978-1-4557-7060-1 Copyright © 2015, 2011, 2007, 2003, 1999, 1995 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher ’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-7060-1 Executive Content Strategist: Lee Henderson Content Development Manager: Billie Sharp Content Development Specialist: Charlene Ketchum Publishing Services Manager: Deborah L. Vogel Project Manager: Bridget Healy Design Direction: Maggie Reid Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 Contributor and Reviewers Contributor Diane Doran, RN, PhD, FCAHS, Professor Emerita, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario Revised Chapter 14 Reviewers Lisa D. Brodersen, EdD, MA, RN , Professor, Coordinator of Institutional Research and Effectiveness, Allen College, Waterloo, Iowa Sara L. Clutter, PhD, RN , Associate Professor of Nursing, Waynesburg University, Waynesburg, Pennsylvania Jacalyn P. Dougherty, PhD, RN , Nursing Research Consultant, JP Dougherty LLC, Aurora, Colorado Joanne T. Ehrmin, RN, COA-CNS, PhD, MSN, BSN , Professor, University of Toledo, College of Nursing, Toledo, Ohio Betsy Frank, PhD, RN, ANEF , Professor Emerita, Indiana State University College of Nursing, Health, and Human Services, Terre Haute, Indiana Tamara Kear, PhD, RN, CNS, CNN , Assistant Professor of Nursing, Villanova University, Villanova, Pennsylvania Sharon Kitchie, PhD, RN , Adjunct Instructor, Keuka College, Keuka Park, New York Madelaine Law rence, PhD, RN , Associate Professor, University of North Carolina at Wilmington, Wilmington, North Carolina Robin Moyers, PhD, RN-BC, Nurse Educator, Carl Vinson VA Medical Center, Dublin, Georgia Sue E. Odom, DSN, RN , Professor of Nursing, Clayton State University, Morrow, Georgia Teresa M. O’Neill, PhD, APRN, RNC, Professor, Our Lady of Holy Cross College, New Orleans, Louisiana Sandra L. Siedlecki, PhD, RN, CNS, Senior Nurse Scientist, Cleveland Clinic, Cleveland, Ohio Sharon Souter, PhD, RN, CNE, Dean and Professor, University of Mary Hardin Baylor, Belton, Texas Molly J. Walker, PhD, RN, CNS, CNE, Professor, Angelo State University, San Angelo, Texas Cynthia Ward, DNP, RN-BC, CMSRN, ACNS-BC, Surgical Clinical Nurse Specialist, Carilion Roanoke Memorial Hospital, Roanoke, Virginia Angela Wood, PhD, RN, Certified High-Risk Prenatal Nurse, Associate Professor and Chair, Department of Nursing, Carson-Newman University, Jefferson City, Tennessee Fatma A. Youssef, RN, DNSc, MPH , Professor Emerita, Marymount University, School of Health Professions, Arlington, Virginia Dedication To all nurses who change the lives of patients through applying the best research evidence. —Susan, Jennifer, and Nancy To my husband Jay Suggs who has provided me endless love and support during my development of research textbooks over the last 30 years. —Susan To my husband Randy Gray who is my love and my cheerleader. —Jennifer To my husband Jerry who has supported all of my academic endeavors through 58 years of marriage. —Nancy Preface Research is a major force in nursing, and the evidence generated from research is constantly changing practice, education, and health policy. Our aim in developing this essentials research text, Understanding Nursing Research: Building an Evidence-Based Practice, is to create an excitement about research in undergraduate students. The text emphasizes the importance of baccalaureate-educated nurses being able to read, critically appraise, and synthesize research so this evidence can be used to make changes in practice. A major goal of professional nursing and health care is the delivery of evidence-based care. By making nursing research an integral part of baccalaureate education, we hope to facilitate the movement of research into the mainstream of nursing. We also hope this text increases student awareness of the knowledge that has been generated through nursing research and that this knowledge is relevant to their practice. Only through research can nursing truly be recognized as a profession with documented effective outcomes for the patient, family, nurse provider, and healthcare system. Because of this expanded focus on evidence-based practice (EBP), we have subtitled this edition Building an Evidence-Based Practice. Developing a sixth edition of Understanding Nursing Research has provided us with an opportunity to clarify and refine the essential content for an undergraduate research text. The text is designed to assist undergraduate students in overcoming the barriers they frequently encounter in understanding the language used in nursing research. The revisions in this edition are based on our own experiences with the text and input from dedicated reviewers, inquisitive students, and supportive faculty from across the country who provided us with many helpful suggestions. Chapter 1, Introduction to Nursing Research and Evidence-Based Practice, introduces the reader to nursing research, the history of research, and the significance of research evidence for nursing practice. This chapter has been revised to include the most relevant types of research synthesis being conducted in nursing—systematic review, metaanalysis, meta-synthesis, and mixed-methods systematic review. The discussion of research methodologies and their importance in generating an evidence-based practice for nursing has been updated and expanded to include the exploratory-descriptive qualitative research method. A discussion of the Quality and Safety Education for Nursing (QSEN) competencies and their link to research has been included in this edition. Selected QSEN competencies are linked to the findings from studies presented as examples throughout the text to increase students’ understanding of the importance in delivering quality, safe health care to patients and families. Chapter 2, Introduction to Quantitative Research, presents the steps of the quantitative research process in a concise, clear manner and introduces students to the focus and findings of quantitative studies. Extensive, recent examples of descriptive, correlational, quasi-experimental, and experimental studies are provided, which reflect the quality of current nursing research. Chapter 3, Introduction to Qualitative Research, describes five approaches to qualitative research and the philosophies upon which they are based. These approaches include phenomenology, grounded theory, ethnography, exploratory-descriptive qualitative, and historical research. Data collection and analysis methods specific to qualitative research are discussed. Guidelines for reading and critically appraising qualitative studies are explained using examples of published studies. Chapter 4, Examining Ethics in Nursing Research, provides an extensive discussion of the use of ethics in research and the regulations that govern the research process. Detailed content and current websites are provided to promote students’ understanding of the Health Insurance Portability and Accountability Act (HIPAA), the U.S. Department of Health and Human Services Protection of Human Subjects, and the Federal Drug Administration regulations. Guidelines are provided to assist students in critically appraising the ethical discussions in published studies and to participate in the ethical review of research in clinical agencies. Chapter 5, Research Problems, Purposes, and Hypotheses, clarifies the difference between a problem and a purpose. Example problem and purpose statements are included from current qualitative, quantitative, and outcome studies. Detailed guidelines are provided with examples to direct students in critically appraising the problems, purposes, hypotheses, and variables in studies. Chapter 6, Understanding and Critically Appraising the Literature Review, begins with a description of the content and quality of different types of publications that might be included in a review. Guidelines for critically appraising published literature reviews are explored with a focus on the differences in the purpose and timing of the literature review in quantitative and qualitative studies. The steps for finding appropriate sources, reading publications, and synthesizing information into a logical, cohesive review are presented. Chapter 7, Understanding Theory and Research Frameworks, briefly describes grand, middle range, physiological, and scientific theories as the bases for study frameworks. The purpose of a research framework is discussed with the acknowledgement that the framework may be implicit. Guidelines for critically appraising the study framework are presented as well. The guidelines are applied to studies with frameworks derived from research findings and from different types of theories. Chapter 8, Clarifying Quantitative Research Designs, addresses descriptive, correlational, quasi-experimental, and experimental designs and criteria for critically appraising these designs in studies. The major strengths and threats to design validity are summarized in a table and discussed related to current studies. This chapter has been expanded to include an introduction to randomized controlled trials (RCT) and mixed-methods approaches being conducted by nurses. Chapter 9, Examining Populations and Samples in Research, provides a detailed discussion of the concepts of sampling in research. Different types of sampling methods for both qualitative and quantitative research are described. Guidelines are included for critically appraising the sampling criteria, sampling method, and sample size of quantitative and qualitative studies. Chapter 10, Clarifying Measurement and Data Collection in Quantitative Research, has been updated to reflect current knowledge about measurement methods used in nursing research. Content has been expanded and uniquely organized to assist students in critically appraising the reliability and validity of scales; precision and accuracy of physiologic measures; and the sensitivity, specificity, and likelihood ratios of diagnostic and screening tests. Chapter 11, Understanding Statistics in Research, focuses on the theories and concepts of the statistical analysis process and the statistics used to describe variables, examine relationships, predict outcomes, and examine group differences in studies. Guidelines are provided for critically appraising the results and discussion sections of nursing studies. The results from selected studies are critically appraised and presented as examples throughout this chapter. Chapter 12, Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice, summarizes and builds on the critical appraisal content provided in previous chapters and offers direction for conducting critical appraisals of quantitative and qualitative studies. The guidelines for critically appraising qualitative studies have been significantly revised and simplified. This chapter also includes a current qualitative and quantitative study, and these two studies are critically appraised using the guidelines provided in this chapter. Chapter 13, Building an Evidence-Based Nursing Practice, has been significantly updated to reflect the current trends in health care to provide evidence-based nursing practice. Detailed guidelines are provided for critically appraising the four common types of research synthesis conducted in nursing (systematic review, meta-analysis, metasynthesis, and mixed-method systematic review). These guidelines were used to critically appraise current research syntheses to assist students in examining the quality of published research syntheses and the potential use of research evidence in practice. The chapter includes theories to assist nurses and agencies in moving toward EBP. Translational research is introduced as a method for promoting the use of research evidence in practice. Chapter 14, Introduction to Outcomes Research, was significantly revised by Dr. Diane Doran, one of the leading authorities in the conduct of outcomes research. The goal of this chapter is to increase students’ understanding of the impact of outcomes research on nursing and health care. Content and guidelines are provided to assist students in reading and critically appraising the outcomes studies appearing in the nursing literature. The sixth edition is written and organized to facilitate ease in reading, understanding, and critically appraising studies. The major strengths of the text are as follows: • State-of-the art coverage of EBP—a topic of vital importance in nursing. • Balanced coverage of qualitative and quantitative research methodologies. • Rich and frequent illustration of major points and concepts from the most current nursing research literature from a variety of clinical practice areas. • Study findings implications for practice and link to QSEN competencies were provided. • A clear, concise writing style that is consistent among the chapters to facilitate student learning. • Electronic references and websites that direct the student to an extensive array of information that is important in reading, critically appraising, and using research knowledge in practice. This sixth edition of Understanding Nursing Research is appropriate for use in a variety of undergraduate research courses for both RN and general students because it provides an introduction to quantitative, qualitative, and outcomes research methodologies. This text not only will assist students in reading research literature, critically appraising published studies, and summarizing research evidence to make changes in practice, but it also can serve as a valuable resource for practicing nurses in critically appraising studies and implementing research evidence in their clinical settings. Learning Resources to Accompany Understanding Nursing Research, 6th Edition The teaching/learning resources to accompany Understanding Nursing Research have been expanded for both the instructor and student to allow a maximum level of flexibility in course design and student review. Evolve Instructor Resources A comprehensive suite of Instructor Resources is available online at http://evolve.elsevier.com/Grove/understanding/ and consists of a Test Bank, PowerPoint slides, an Image Collection, Answer Guidelines for the Appraisal Exercises provided for students, and new TEACH for Nurses Lesson Plans, which replace and enhance the Instructor’s Manual provided for previous editions. Test Bank The Test Bank consists of approximately 550 NCLEX® Examination–style questions, including approximately 10% of questions in alternate item formats. Each question is coded with the correct answer, a rationale from the textbook, a page cross-reference, and the cognitive level in the new Bloom’s Taxonomy (with the cognitive level from the original Bloom’s Taxonomy in parentheses). The Test Bank is provided in ExamView and Evolve LMS formats. PowerPoint Slides The PowerPoint slide collection contains approximately 800 slides, now including seamlessly integrated Audience Response System Questions, images, and new Unfolding Case Studies. The PowerPoints have been simplified and converted into bulleted-list format (using less narrative). Content details in the slides have been moved as appropriate into the Notes area of the slides. New Unfolding Case Studies focus on practical EBP/PICO questions, such as a nurse on a unit needing to perform a literature search or to identify a systematic review or meta-analysis. PowerPoint presentations are fully customizable. Image Collection The electronic Image Collection consists of all images from the text. This collection can be used in classroom or online presentations to reinforce student learning. New TEACH for Nurses Lesson Plans TEACH for Nurses is a robust, customizable, ready-to-use collection of chapter-bychapter Lesson Plans that provide everything you need to create an engaging and effective course. Each chapter includes the following: • Objectives • Teaching Focus • Key Terms • Nursing Curriculum Standards QSEN/NLN Competencies Concepts BSN Essentials • Student Chapter Resources • Instructor Chapter Resources • Teaching Strategies • In-Class/Online Case Study Evolve Student Resources The Evolve Student Resources include interactive Review Questions, a Research Article Library consisting of 10 full-text research articles, Critical Appraisal Exercises based on the articles in the Research Article Library, and new Printable Key Points. • The interactive Review Questions (approximately 25 per chapter) aid the student in reviewing and focusing on the chapter material. • The Research Article Library is an updated collection of 10 research articles, taken from leading nursing journals. • The Critical Appraisal Exercises are a collection of application exercises, based on the articles in the Research Article Library, that help students learn to appraise and apply research findings. Answer Guidelines are provided for the instructor. • New Printable Key Points provide students with a convenient review tool. Study Guide The companion Study Guide, written by the authors of the main text, provides both timetested and innovative exercises for each chapter in Understanding Nursing Research, 6th Edition. Included for each chapter are a brief Introduction, a Key Terms exercise, Key Ideas exercises, Making Connections exercises, Exercises in Critical Analysis, and Going Beyond exercises. An integral part of the Study Guide is an appendix of three published research studies, which are referenced throughout. These three recently published nursing studies (two quantitative studies and one qualitative study) can be used in classroom or online discussions, as well as to address the Study Guide questions. The Study Guide provides exercises that target comprehension of concepts used in each chapter. Exercises — including fill-in-the-blank, matching, and multiple-choice questions — encourage students to validate their understanding of the chapter content. Critical Appraisal Activities provide students with opportunities to apply their new research knowledge to evaluate the quantitative and qualitative studies provided in the back of the Study Guide. New to this edition are the following features: an increased emphasis on evidencebased practice; new Web-Based Activities, an increased emphasis on high-value learning activities, reorganized back-matter for quick reference, and quick-reference printed tabs. • Increased emphasis on evidence-based practice: This edition of the Study Guide features an expanded focus on evidence-based practice (EBP) to match that of the revised textbook. This focus helps students who are new to nursing research see the value of understanding the research process and applying it to evidence-based nursing practice. • Web-Based Activities: Each chapter now includes a Web-Based Activity section, to teach students to use the Internet appropriately for scholarly research and EBP. • Increased high-value learning activities: The use of crossword puzzles has been reduced to allow room for the addition of learning activities with greater learning value. • Back matter reorganized for quick reference: The “Answers to Study Guide Exercises” has been retitled “Answer Key” and not numbered as an appendix. Each of the three published studies are now separate appendix (three appendices total), rather than a single appendix. This simplifies cross referencing in the body of the Study Guide. • Quick-reference printed tabs: Quick-reference printed tabs have been added to differentiate the Answer Key and each of the book’s three published studies (four tabs total), for improved navigation and usability. Acknowledgments Developing this essentials research text was a 2-year project, and there are many people we would like to thank. We want to extend a very special thank you to Dr. Diane Doran for her revision of Chapter 14 focused on outcomes research. We are very fortunate that she was willing to share her expertise and time so that students might have the most current information about outcomes research. We want to express our appreciation to the Dean and faculty of The University of Texas at Arlington College of Nursing for their support and encouragement. We also would like to thank other nursing faculty members across the world who are using our book to teach research and have spent valuable time to send us ideas and to identify errors in the text. Special thanks to the students who have read our book and provided honest feedback on its clarity and usefulness to them. We would also like to recognize the excellent reviews of the colleagues, listed on the previous pages, who helped us make important revisions in the text. In conclusion, we would like to thank the people at Elsevier who helped produce this book. We thank the following individuals who have devoted extensive time to the development of this sixth edition, the instructor’s ancillary materials, student study guide, and all of the web-based components. These individuals include: Lee Henderson, Billie Sharp, Charlene Ketchum, Bridget Healy, Jayashree Balasubramaniam, and Vallavan Udayaraj. Susan K. Grove PhD, RN, ANP-BC, GNP-BC Jennifer R. Gray PhD, RN, FAAN Nancy Burns PhD, RN, FCN, FAAN C H AP T E R 1 Introduction to Nursing Research and Evidence-Based Practice CHAPTER OVERVIEW What Is Nursing Research? What Is Evidence-Based Practice? Purposes of Research for Implementing an Evidence-Based Nursing Practice Description Explanation Prediction Control Historical Development of Research in Nursing Florence Nightingale Nursing Research: 1900s through the 1970s Nursing Research: 1980s and 1990s Nursing Research: in the Twenty-First Century Acquiring Knowledge in Nursing Traditions Authority Borrowing Trial and Error Personal Experience Role Modeling Intuition Reasoning Acquiring Knowledge through Nursing Research Introduction to Quantitative and Qualitative Research Introduction to Outcomes Research Understanding Best Research Evidence for Practice Strategies Used to Synthesize Research Evidence Levels of Research Evidence Introduction to Evidence-Based Guidelines What Is Your Role in Nursing Research? Key Concepts References Learning Outcomes After completing this chapter, you should be able to: 1. Define research, nursing research, and evidence-based practice. 2. Describe the purposes of research in implementing an evidence-based practice for nursing. 3. Describe the past and present activities influencing research in nursing. 4. Discuss the link of Quality and Safety Education for Nurses (QSEN) to research. 5. Apply the ways of acquiring nursing knowledge (tradition, authority, borrowing, trial and error, personal experience, role modeling, intuition, reasoning, and research) to the interventions implemented in your practice. 6. Identify the common types of research—quantitative, qualitative, or outcomes— conducted to generate essential evidence for nursing practice. 7. Describe the following strategies for synthesizing healthcare research: systematic review, meta-analysis, meta-synthesis, and mixed-methods systematic review. 8. Identify the levels of research evidence available to nurses for practice. 9. Describe the use of evidence-based guidelines in implementing evidence-based practice. 10. Identify your role in research as a professional nurse. Key Terms Authority, p. 16 Best research evidence, p. 3 Borrowing, p. 16 Case study, p. 11 Clinical expertise, p. 4 Control, p. 8 Critical appraisal of research, p. 27 Deductive reasoning, p. 18 Description, p. 6 Evidence-based guidelines, p. 25 Evidence-based practice (EBP), p. 3 Explanation, p. 7 Gold standard, p. 25 Inductive reasoning, p. 18 Intuition, p. 18 Knowledge, p. 15 Mentorship, p. 18 Meta-analysis, p. 22 Meta-synthesis, p. 23 Mixed-methods systematic review, p. 23 Nursing research, p. 3 Outcomes research, p. 21 Personal experience, p. 17 Prediction, p. 7 Premise, p. 18 Qualitative research, p. 20 Qualitative research synthesis, p. 23 Quality and Safety Education for Nurses (QSEN), p. 15 Quantitative research, p. 19 Reasoning, p. 18 Research, p. 3 Role modeling, p. 17 Systematic review, p. 22 Traditions, p. 16 Trial and error, p. 17 Welcome to the world of nursing research. You may think it strange to consider research a world, but it is a truly new way of experiencing reality. Entering a new world means learning a unique language, incorporating new rules, and using new experiences to learn how to interact effectively within that world. As you become a part of this new world, you will modify and expand your perceptions and methods of reasoning. For example, using research to guide your practice involves questioning, and you will be encouraged to ask such questions as these: • What is the patient’s healthcare problem? • What nursing intervention would effectively manage this problem in your practice? • Is this nursing intervention based on sound research evidence? • Would another intervention be more effective in improving your patient’s outcomes? • How can you use research most effectively in promoting an evidence-based practice (EBP)? Because research is a new world to many of you, we have developed this text to facilitate your entry into and understanding of this world and its contribution to the delivery of quality, safe nursing care. This first chapter clarifies the meaning of nursing research and its significance in developing an evidence-based practice (EBP) for nursing. This chapter also explores the research accomplishments in the profession over the last 160 years. The ways of acquiring knowledge in nursing are discussed, and the common research methodologies used for generating research evidence for practice (quantitative, qualitative, and outcomes research) are introduced. The critical elements of evidencebased nursing practice are introduced, including strategies for synthesizing research evidence, levels of research evidence or knowledge, and evidence-based guidelines. Nurses’ roles in research are described based on their level of education and their contributions to the implementation of EBP. What is Nursing Research? The word research means “to search again” or “to examine carefully.” More specifically, research is a diligent, systematic inquiry, or study that validates and refines existing knowledge and develops new knowledge. Diligent, systematic study indicates planning, organization, and persistence. The ultimate goal of research is the development of an empirical body of knowledge for a discipline or profession, such as nursing. Defining nursing research requires determining the relevant knowledge needed by nurses. Because nursing is a practice profession, research is essential to develop and refine knowledge that nurses can use to improve clinical practice and promote quality outcomes (Brown, 2014; Doran, 2011). Expert researchers have studied many interventions, and clinicians have synthesized these studies to provide guidelines and protocols for use in practice. Practicing nurses and nursing students, like you, need to be able to read research reports and syntheses of research findings to implement evidencebased interventions in practice and promote positive outcomes for patients and families. For example, extensive research has been conducted to determine the most effective technique for administering medications through an intramuscular (IM) injection. This research was synthesized and used to develop evidence-based guidelines for administering IM injections (Cocoman & Murray, 2008; Nicoll & Hesby, 2002). Nursing research is also needed to generate knowledge about nursing education, nursing administration, healthcare services, characteristics of nurses, and nursing roles. The findings from these studies influence nursing practice indirectly and add to nursing’s body of knowledge. Research is needed to provide high-quality learning experiences for nursing students. Through research, nurses can develop and refine the best methods for delivering distance nursing education and for using simulation to improve student learning. Nursing administration and health services studies are needed to improve the quality, safety, and cost-effectiveness of the healthcare delivery system. Studies of nurses and nursing roles can influence nurses’ quality of care, productivity, job satisfaction, and retention. In this era of a nursing shortage, additional research is needed to determine effective ways to recruit individuals and retain them in the profession of nursing. This type of research could have a major impact on the quality and number of nurses providing care to patients and families in the future. In summary, nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice. Nursing research is the key to building an EBP for nursing (Brown, 2014). What is Evidence-Based Practice? The ultimate goal of nursing is an evidence-based practice that promotes quality, safe, and cost-effective outcomes for patients, families, healthcare providers, and the healthcare system (Brown, 2014; Craig & Smyth, 2012; Melnyk & Fineout-Overholt, 2011). Evidence-based practice (EBP) evolves from the integration of the best research evidence with clinical expertise and patients’ needs and values (Institute of Medicine [IOM], 2001; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Figure 1-1 identifies the elements of EBP and demonstrates the major contribution of the best research evidence to the delivery of this practice. The best research evidence is the empirical knowledge generated from the synthesis of quality study findings to address a practice problem. Later, this chapter discusses the strategies used to synthesize research, levels of best research evidence, and sources for this evidence. A team of expert researchers, healthcare professionals, and sometimes policy makers and consumers will synthesize the best research evidence to develop standardized guidelines for clinical practice. For example, a team of experts conducted, critically appraised, and synthesized research related to the chronic health problem of hypertension (HTN) to develop an EBP guideline. Research evidence from this guideline is presented as an example later in this section. FIG 1-1 Model of Evidence-Based Practice (EBP). Clinical expertise is the knowledge and skills of the healthcare professional who is providing care. The clinical expertise of a nurse depends on his or her years of clinical experience, current knowledge of the research and clinical literature, and educational preparation. The stronger the nurse’s clinical expertise, the better is his or her clinical judgment in using the best research evidence in practice (Brown, 2014; Craig & Smyth, 2012). EBP also incorporates the needs and values of the patient (see Figure 1-1). The patient’s need(s) might focus on health promotion, illness prevention, acute or chronic illness management, rehabilitation, and/or a peaceful death. In addition, patients bring values or unique preferences, expectations, concerns, and cultural beliefs to the clinical encounter. With EBP, patients and their families are encouraged to take an active role in the management of their health. It is the unique combination of the best research evidence being applied by expert nurse clinicians in providing quality, safe, and costeffective care to a patient and family with specific health needs and values that results in EBP. Extensive research is needed to develop sound empirical knowledge for synthesis into the best research evidence needed for practice. Findings from a single study are not enough evidence for determining the effectiveness of an intervention in practice. Research evidence from multiple studies are synthesized to develop guidelines, standards, protocols, algorithms (clinical decision trees), or policies to direct the implementation of a variety of nursing interventions. As noted earlier, a national guideline has been developed for the management of hypertension, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). The complete JNC 7 guideline for the management of high blood pressure is available online at www.nhlbi.nih.gov/guidelines/hypertension (National Heart, Lung, and Blood Institute [NHLBI], 2003). In January of 2014, the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) published new clinical practice guidelines for the management of hypertension in the community (Weber et al, 2014). The JNC 7 guideline and the ASH and ISH clinical practice guideline identified the same classification system for blood pressure (Table 11). These guidelines include the classification of blood pressure as normal, prehypertension, hypertension stage 1, and hypertension stage 2. Both guidelines also recommend life style modifications (balanced diet, exercise program, normal weight, and nonsmoker) and cardiovascular disease (CVD) risk factors (hypertension, obesity, dyslipidemia, diabetes mellitus, cigarette smoking, physical inactivity, microalbuminuria, and family history of premature CVD) education. You need to use an evidence-based guideline in monitoring your patients’ blood pressure (BP) and educating them about lifestyle modifications to improve their BP and reduce their CVD risk factors (NHLBI, 2003; Weber et al., 2014). Table 1-1 Classification of Blood Pressure with Nursing Interventions for Evidence-Based Practice (EBP) * Treatment is determined by the highest BP category, systolic or diastolic. † Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80 mm Hg. ‡ Lifestyle modification—balanced diet, exercise program, normal weight, and nonsmoker. § CVD risk factors—hypertension; obesity (body mass index ≥ 30 kg/m 2), dyslipidemia, diabetes mellitus, cigarette smoking, physical inactivity, microalbuminuria, estimated glomerular filtration rate < 60 mL/min, age (> 55 years for men, > 65 years for women), and family history of premature CVD (men < 55 years, women < 65 years). Adapted from National Heart, Lung, and Blood Institute. (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Retrieved June 18, 2013 from, www.nhlbi.nih.gov/guidelines/hypertension/; and Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S., Lindholm, L. H., Kenerson, J. G., et al. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32(1), 4-5. The Eighth Joint National Committee (JNC 8) published “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults” in December of 2013 (James et al. 2013). However, these guidelines currently lack the recognition of any national organization. Additional work is needed to ensure that the guidelines are approved by the NHLBI, ASH, the American Heart Association (AHA), and/or the American College of Cardiology (ACC). For this textbook, the evidence-based guidelines for management of hypertension presented in Table 1-1 are recommended for students and nurses to use in caring for their patients (Weber et al., 2014). Figure 1-2 provides an example of the delivery of evidence-based nursing care to African American women with high BP. In this example, the best research evidence is classification of BP and education on lifestyle modification (LSM) and CVD risk factors based on the ASH (Weber et al., 2014) and JNC 7 (NHLBI, 2003) guidelines for management of high BP (see Table 1-1). These guidelines, developed from the best research evidence related to BP, LSM, and CVD risks monitoring and education, is translated by registered nurses and nursing students to meet the needs and values of African American women with high BP. The quality outcome of EBP in this example is women with a BP less than 140/90 mm Hg or referral for medication treatment (see Figure 1-2). A detailed discussion of how to locate, critically appraise, and use national standardized guidelines in practice is found in Chapter 13. FIG 1-2 Evidence-based practice for African American women with high blood pressure (BP). Purposes of Research for Implementing an Evidence-Based Nursing Practice Through nursing research, empirical knowledge can be developed to improve nursing care, patient outcomes, and the healthcare delivery system. For example, nurses need a solid research base to implement and document the effectiveness of selected nursing interventions in treating particular patient problems and promoting positive patient and family outcomes. Also, nurses need to use research findings to determine the best way to deliver healthcare services to ensure that the greatest number of people receive quality, safe care. Accomplishing these goals will require you to locate EBP guidelines or to appraise critically, synthesize, and apply research evidence that provides a description, explanation, prediction, and control of phenomena in your clinical practice. Description Description involves identifying and understanding the nature of nursing phenomena and, sometimes, the relationships among them (Chinn & Kramer, 2011). Through research, nurses are able to (1) describe what exists in nursing practice; (2) discover new information; (3) promote understanding of situations; and (4) classify information for use in the discipline. Some examples of clinically important research evidence that have been developed from research focused on description include: • Identification of the incidence and spread of infection in healthcare agencies • Identification of the cluster of symptoms for a particular disease • Description of the responses of individuals to a variety of health conditions and aging • Description of the health promotion and illness prevention strategies used by a variety of populations • Determination of the incidence of a disease locally (e.g., incidence of West Nile virus in Texas), nationally, and internationally (e.g., spread of bird flu). Rush, Watts, and Janke (2013, p. 10) have conducted a qualitative study to describe “rural and urban older adults’ perspectives of strength in their daily lives.” (The types of research conducted in nursing—quantitative, qualitative, and outcomes—are discussed later in this chapter.) They noted the following in this study: “Nurses’ strength enhancement efforts should raise older adults’ awareness that strength is not an unlimited resource but needs to be constantly replenished…. Older adult participants described changes in strength that ranged from fluctuating daily changes to insidious, gradual declines and to drastic and unexpected losses…. Older adults’ strategies for staying strong were consistent with their more holistic views of strength but may not be approaches nurses typically take into account. Although nurses need to give continued emphasis to promoting physical activity, they must also give equal attention to encouraging mental and social activities because of the important role they play for older adults staying strong.” Rush et al., 2013, p. 15 The findings from this study provided nurses with descriptions of older adults’ perspectives of strength and the strategies that they use to stay strong. You can use the findings from this study to encourage physical, mental, and social activities to assist older adults in staying strong. This type of research, focused on description, is essential groundwork for studies to provide explanations, predictions, and control of nursing phenomena in practice. Explanation Explanation clarifies the relationships among phenomena and identifies possible reasons why certain events occur. Research focused on explanation provides the following types of evidence essential for practice: • Determination of assessment data (subjective data from the health history and objective data from the physical examination) that need to be gathered to address a patient’s health need • The link of assessment data to a diagnosis • The link of causative risk factors or causes to illness, morbidity, and mortality • Determination of the relationships among health risks, health behaviors, and health status • Determination of links among demographic characteristics, disease status, psychosocial factors, and patients’ responses to treatment. For example, Manojlovich, Sidani, Covell, and Antonakos (2011) conducted an outcomes study to examine the links or relationships between a “nurse dose” (nurse characteristics and staffing) and adverse patient outcomes. The nurse characteristics examined were education, experience, and skill mix. The staffing variables included fulltime employees, registered nurse (RN)-to-patient ratio, and RN hours per patient day. The adverse outcomes examined were methicillin-resistant Staphylococcus aureus (MRSA) infections and reported patient falls for a sample of inpatient adults in acute care units. The researchers found that the nurse characteristics and staffing variables were significantly correlated with MRSA infections and reported patient falls. Therefore the nursing characteristics and staffing were potential predictors of the incidence of MRSA infections and patient falls. This study illustrates how explanatory research can identify relationships among nursing phenomena that can be the basis for future research focused on prediction and control. Prediction Through prediction, one can estimate the probability of a specific outcome in a given situation (Chinn & Kramer, 2011). However, predicting an outcome does not necessarily enable one to modify or control the outcome. It is through prediction that the risk of illness or injury is identified and linked to possible screening methods to identify and prevent health problems. Knowledge generated from research focused on prediction is critical for EBP and includes the following: • Prediction of the risk for a disease or injury in different populations • Prediction of behaviors that promote health and prevent illness • Prediction of the health care required based on a patient’s need and values Lee, Faucett, Gillen, Krause, and Landry (2013) conducted a quantitative study to examine the factors that were perceived by critical care nurses (CCNs) to predict the risk of musculoskeletal (MSK) injury from work. They found that greater physical workload, greater job strain, more frequent patient-handling tasks, and lack of a lifting team or devices were predictive of the CCNs’ perceptions of risk of MSK injury. They recommended that “occupational health professionals, nurse managers, and nursing organizations should make concerted efforts to ensure the safety of nurses by providing effective preventive measures. Improving the physical and psychosocial work environment may make nursing jobs safer, reduce the risk of MSK injury, and improve nurses’ perceptions of job safety” (Lee et al., 2013, p. 43). This predictive study isolated independent variables (physical workload, job strain, patient-handling tasks, and lack of lifting devices or teams) that were predictive of MSK injuries in CCNs. The variables identified in predictive studies require additional research to ensure that their manipulation or control results in quality outcomes for patients, healthcare professionals, and healthcare agencies (Creswell, 2014; Doran, 2011; Kerlinger & Lee, 2000). Control If one can predict the outcome of a situation, the next step is to control or manipulate the situation to produce the desired outcome. In health care, control is the ability to write a prescription to produce the desired results. Using the best research evidence, nurses could prescribe specific interventions to meet the needs of patients and their families (Brown, 2014; Craig & Smyth, 2012). The results of multiple studies in the following areas have enabled nurses to deliver care that increases the control over the outcomes desired for practice: • Testing interventions to improve the health status of individuals, families, and communities • Testing interventions to improve healthcare delivery • Synthesis of research for development into EBP guidelines • Testing the effectiveness of EBP guideline in clinical agencies Extensive research has been conducted in the area of safe administration of IM injections. This research has been critically appraised, synthesized, and developed into evidence-based guidelines to direct the administration of medications by an IM route to infants, children, and adults in a variety of practice settings (Cocoman & Murray, 2008; Nicoll & Hesby, 2002). The EBP guideline for IM injections is based on the best research evidence and identifies the appropriate needle size and length to use for administering different types of medications, the safest injection site (ventrogluteal) for many medications, and the best injection technique to deliver a medication, minimize patient discomfort, and prevent physical damage (Cocoman & Murray, 2008; Greenway, 2004; Nicoll & Hesby, 2002; Rodger & King, 2000). Using the evidence-based knowledge for administering IM injections helps control the achievement of the following outcomes in practice: (1) adequate administration of medication to promote patient health; (2) minimal patient discomfort; and (3) no physical damage to the patient. Broadly, the nursing profession is accountable to society for providing quality, safe, and cost-effective care for patients and families. Therefore the care provided by nurses must be constantly evaluated and improved on the basis of new and refined research knowledge. Studies that document the effectiveness of specific nursing interventions make it possible to implement evidence-based care that will produce the best outcomes for patients and their families. The quality of research conducted in nursing affects not only the quality of care delivered, but also the power of nurses in making decisions about the healthcare delivery system. The extensive number of clinical studies conducted in the last 50 years has greatly expanded the scientific knowledge available to you for describing, explaining, predicting, and controlling phenomena within your nursing practice. Historical Development of Research in Nursing The development of research in nursing has changed drastically over the last 160 years and holds great promise for the twenty-first century. Initially, nursing research evolved slowly, from the investigations of Nightingale in the nineteenth century to the studies of nursing education in the 1930s and 1940s and the research of nurses and nursing roles in the 1950s and 1960s. From the 1970s through the 2010s, an increasing number of nursing studies that focused on clinical problems have produced findings that directly affected practice. Clinical research continues to be a major focus today, with the goal of developing an EBP for nursing. Reviewing the history of nursing research enables you to identify the accomplishments and understand the need for further research to determine the best research evidence for use in practice. Table 1-2 outlines the key historical events that have influenced the development of research in nursing. Table 1-2 Historical Events Influencing the Development of Research in Nursing Year 1850 1900 1923 1929 1932 1950 1952 1953 1955 1957 Event Florenc e Nightingale is rec ognized as the first nurse researc her. America n Journa l of Nursing is published. Teac hers College at Columbia University offers the first educ ational doc toral program for nurses. First Master’s in Nursing Degree is offered at Yale University. Assoc iation of Collegiate S c hools of Nursing is organized to promote c onduc t of researc h. Americ an Nurses Assoc iation (ANA) publishes study of nursing func tions and ac tivities. First researc h journal in nursing, Nursing Resea rch, is published. Institute of Researc h and S ervic e in Nursing Educ ation is established. Americ an Nurses Foundation is established to fund nursing researc h. S outhern Regional Educ ational Board (S REB), Western Interstate Commission on Higher Educ ation (WICHE), Midwestern Nursing Researc h S oc iety (MNRS ), and New England Board of Higher Educ ation (NEBHE) are established to support and disseminate nursing researc h. 1963 Interna tiona l Journa l of Nursing Studies is published. 1965 ANA sponsors the first nursing researc h c onferenc es. 1967 S igma Theta Tau International Honor S oc iety of Nursing publishes Ima ge, emphasizing nursing sc holarship; now Journa l of Nursing Schola rship. 1970 ANA Commission on Nursing Researc h is established. 1972 Coc hrane published Effectiveness a nd Efficiency, introduc ing c onc epts relevant to evidenc e-based prac tic e (EBP). ANA Counc il of Nurse Researc hers is established. 1973 First Nursing Diagnosis Conferenc e is held, whic h evolved into North Americ an Nursing Diagnosis Assoc iation (NANDA). 1976 S tetler/Marram Model for Applic ation of Researc h Findings to Prac tic e is published. 1978 Resea rch in Nursing & Hea lth and Adva nces in Nursing Science are published. 1979 Western Journa l of Nursing Resea rch is published. 1980s- S ac kett and c olleagues developed methodologies to determine “best evidenc e” for prac tic e. 1990s 1982- Conduc t and Utilization of Researc h in Nursing (CURN) Projec t is published. 1983 1983 Annua l Review of Nursing Resea rch is published. 1985 National Center for Nursing Researc h (NCNR) is established to support and fund nursing researc h. 1987 Schola rly Inquiry for Nursing Pra ctice is published. 1988 Applied Nursing Resea rch and Nursing Science Qua rterly are published. 1989 Agenc y for Healthc are Polic y and Researc h (AHCPR) is established and publishes EBP guidelines. 1990 Nursing Dia gnosis, offic ial journal of NANDA, is published; now Interna tiona l Journa l of Nursing Terminologies a nd Cla ssifica tions. ANA established the Americ an Nurses Credentialing Center (ANCC), whic h implemented the Magnet Hospital Designation Program for Exc ellenc e in Nursing S ervic es. 1992 Hea lthy People 2000 is published by U.S . Department of Health and Human S ervic es (U.S . DHHS ). Clinica l Nursing Resea rch is published. 1993 NCNR is renamed the National Institute of Nursing Researc h (NINR) to expand funding for nursing researc h. Journa l of Nursing Mea surement is published. Coc hrane Collaboration is initiated, providing systematic reviews and EBP guidelines (http://www.c oc hrane.org). 1994 Qua lita tive Hea lth Resea rch is published. 1999 AHCPR is renamed Agenc y for Healthc are Researc h and Quality (AHRQ). 2000 Hea lthy People 2010 is published by U.S . DHHS . Biologica l Resea rch for Nursing is published. 2001 S tetler publishes her model Steps of Resea rch Utiliza tion to Fa cilita te Evidence-Ba sed Pra ctice. Institute of Medic ine (IOM) report Crossing the Qua lity Cha sm: A New Hea lth System for the 21st Century published, foc using on key healthc are issues of quality and safety. 2002 The Joint Commission revises ac c reditation polic ies for hospitals supporting evidenc e-based health c are. NANDA bec omes international—NANDA-I. 2003 IOM report Hea lth Professions Educa tion: A Bridge to Qua lity published, identifying six c ompetenc ies essential for educ ation of nurses and other health professionals. 2004 Worldviews on Evidence-Ba sed Nursing is published. 2005 Quality and S afety Educ ation for Nurses (QS EN) initiative for development of c ompetenc ies for prelic ensure and graduate educ ation is developed. 2006 Americ an Assoc iation of Colleges of Nursing (AACN) position statement on nursing researc h is published. 2007 QS EN website (http://qsen.org) is launc hed, featuring teac hing strategies and resourc es to fac ilitate the attainment of the QS EN c ompetenc ies. 2010 IOM report The Future of Nursing: Lea ding Cha nge rec ommends that 80% of the nursing workforc e be prepared at the bac c alaureate level by the year 2020. 2011 NINR c urrent strategic plan published. Americ an Nurses Assoc iation (ANA) c urrent researc h agenda is developed. 2013 Current QS EN c ompetenc ies for prelic ensure nurses available online at http://qsen.org/c ompetenc ies/pre-lic ensure-ksas. 2013 Hea lthy People 2020 available at U.S . DHHS website, http://www.healthypeople.gov/2020/topic sobjec tives2020/default.aspx. AHRQ c urrent mission and funding priorities available online (http://www.ahrq.gov/). NINR c urrent mission and funding opportunities available online (http://www.ninr.nih.gov/). Florence Nightingale Nightingale (1859) is recognized as the first nurse researcher, with her initial studies focused on the importance of a healthy environment in promoting patients’ physical and mental well-being. She studied aspects of the environment, such as ventilation, cleanliness, purity of water, and diet, to determine the influence on patients’ health, which continue to be important areas of study today (Herbert, 1981). Nightingale is also noted for her data collection and statistical analyses, especially during the Crimean War. She gathered data on soldier morbidity and mortality rates and the factors influencing them and presented her results in tables and pie charts, a sophisticated type of data presentation for the period (Palmer, 1977). Nightingale was the first woman elected to the Royal Statistical Society (Oakley, 2010) and her research was highlighted in Scientific American (Cohen, 1984). Nightingale’s research enabled her to instigate attitudinal, organizational, and social changes. She changed the attitudes of the military and society about the care of the sick. The military began to view the sick as having the right to adequate food, suitable quarters, and appropriate medical treatment, which greatly reduced the mortality rate (Cook, 1913). Nightingale improved the organization of army administration, hospital management, and hospital construction. Because of Nightingale’s research evidence and influence, society began to accept responsibility for testing public water, improving sanitation, preventing starvation, and decreasing morbidity and mortality rates (Palmer, 1977). Nursing Research: 1900s through the 1970s The American Journal of Nursing was first published in 1900 and, late in the 1920s and 1930s, case studies began appearing in this journal. A case study involves an in-depth analysis and systematic description of one patient or group of similar patients to promote understanding of healthcare interventions. Case studies are one example of the practice-related research that has been conducted in nursing over the last century. Nursing educational opportunities expanded, with Teachers College at Columbia University offering the first educational doctoral program for nurses in 1923 and Yale University offering the first master ’s degree in nursing in 1929. In 1950 the American Nurses Association (ANA) initiated a 5-year study on nursing functions and activities. In 1959 the findings from this study were used to develop statements on functions, standards, and qualifications for professional nurses. During that time, clinical research began expanding as nursing specialty groups, such as community health, psychiatricmental health, medical-surgical, pediatrics, and obstetrics, developed standards of care. The research conducted by the ANA and specialty groups provided the basis for the nursing practice standards that currently guide professional practice (Gortner & Nahm, 1977). In the 1950s and 1960s nursing schools began introducing research and the steps of the research process at the baccalaureate level, and Master of Science in Nursing (MSN) level nurses were provided a background for conducting small replication studies. In 1953 the Institute for Research and Service in Nursing Education was established at Teachers College of Columbia University and began providing research experiences for doctoral students (Gortner & Nahm, 1977). The increase in research activities prompted the publication of the first research journal, Nursing Research, in 1952. The American Nurses Foundation was established in 1955 to fund nursing research projects. The Southern Regional Educational Board (SREB), Western Interstate Commission on Higher Education (WICHE), Midwestern Nursing Research Society (MNRS), and New England Board of Higher Education (NEBHE) were formed in 1957 to support and disseminate nursing research across the United States. In the 1960s an increasing number of clinical studies focused on quality care and the development of criteria to measure patient outcomes. Intensive care units were developed, which promoted the investigation of nursing interventions, staffing patterns, and cost-effectiveness of care (Gortner & Nahm, 1977). An additional research journal, the International Journal of Nursing Studies, was published in 1963. In 1965 the ANA sponsored the first of a series of nursing research conferences to promote the communication of research findings and the use of these findings in clinical practice. In the late 1960s and 1970s nurses were involved in the development of models, conceptual frameworks, and theories to guide nursing practice. The nursing theorists’ work provided direction for future nursing research. In 1978, Chinn became the editor of a new journal, Advances in Nursing Science, which included nursing theorists’ work and related research. Another event influencing research was the establishment of the ANA Commission on Nursing Research in 1970. In 1972 the commission established the Council of Nurse Researchers to advance research activities, provide an exchange of ideas, and recognize excellence in research. The commission also influenced the development of federal guidelines for research with human subjects and sponsored research programs nationally and internationally (See, 1977). The communication of research findings was a major issue in the 1970s (Barnard, 1980). Sigma Theta Tau International, the Honor Society for Nursing, sponsored national and international research conferences, and chapters of this organization sponsored many local conferences to communicate research findings. Sigma Theta Tau first published Image, now entitled Journal of Nursing Scholarship, in 1967; it includes research articles and summaries of research conducted on selected topics. Stetler and Marram developed the first model in nursing to promote the application of research findings to practice in 1976. Two additional research journals were first published in the 1970s, Research in Nursing & Health in 1978 and the Western Journal of Nursing Research in 1979. Professor Archie Cochrane originated the concept of evidence-based practice with a book he published in 1972, Effectiveness and Efficiency: Random Reflections on Health Services. Cochrane advocated the provision of health care based on research to improve its quality. To facilitate the use of research evidence in practice, the Cochrane Center was established in 1992 and the Cochrane Collaboration in 1993. The Cochrane Collaboration and Library house numerous resources to promote EBP, such as systematic reviews of research and evidence-based guidelines for practice (see later; also see the Cochrane Collaboration at http://www.cochrane.org). In the 1970s the nursing process became the focus of many studies, with investigations of assessment techniques, nursing diagnoses classification, goal-setting methods, and specific nursing interventions. The first Nursing Diagnosis Conference, held in 1973, evolved into the North American Nursing Diagnosis Association (NANDA). In 2002 NANDA became international, known as NANDA-I. NANDA-I supports research activities focused on identifying appropriate diagnoses for nursing and generating an effective diagnostic process. NANDA’s journal, Nursing Diagnosis, was published in 1990 and was later renamed the International Journal of Nursing Terminologies and Classifications. Details on NANDA-I can be found on their website (http://www.nanda.org). Nursing Research: 1980s and 1990s The conduct of clinical research was the focus of the 1980s, and clinical journals began publishing more studies. One new research journal was published in 1987, Scholarly Inquiry for Nursing Practice, and two in 1988, Applied Nursing Research and Nursing Science Quarterly. Although the body of empirical knowledge generated through clinical research increased rapidly in the 1980s, little of this knowledge was used in practice. During 1982 and 1983, the studies from a federally funded project, Conduct and Utilization of Research in Nursing (CURN), were published to facilitate the use of research to improve practice (Horsley, Crane, Crabtree, & Wood, 1983). In 1983 the first volume of the Annual Review of Nursing Research was published (Werley & Fitzpatrick, 1983). These volumes include experts’ reviews of research organized into four areas—nursing practice, nursing care delivery, nursing education, and the nursing profession. These summaries of current research knowledge encourage the use of research findings in practice and provide direction for future research. Publication of the Annual Review of Nursing Research continues today, with leading expert nurse scientists providing summaries of research in their areas of expertise. The increased research activities in nursing resulted in the publication of Clinical Nursing Research in 1992 and the Journal of Nursing Measurement in 1993. Qualitative research was introduced in the late 1970s; the first studies appeared in nursing journals in the 1980s. The focus of qualitative research was holistic, with the intent to discover meaning and gain new insight and understanding of issues relevant to nursing. The number of qualitative researchers and studies expanded greatly in the 1990s, with qualitative studies appearing in most of the nursing research and clinical journals. In 1994 a journal focused on disseminating qualitative research, Qualitative Health Research, was first published. Another priority of the 1980s was to obtain increased funding for nursing research. Most of the federal funds in the 1980s were designated for medical studies involving the diagnosis and treatment of diseases. However, the ANA achieved a major political victory for nursing research with the creation of the National Center for Nursing Research (NCNR) in 1985. The purpose of this center was to support the conduct and dissemination of knowledge developed through basic and clinical nursing research, training, and other programs in patient care research (Bauknecht, 1985). Under the direction of Dr. Ada Sue Hinshaw, the NCNR became the National Institute of Nursing Research (NINR) in 1993 to increase the status of nursing research and obtain more funding. Outcomes research emerged as an important methodology for documenting the effectiveness of healthcare services in the 1980s and 1990s. This effectiveness research evolved from the quality assessment and quality assurance functions that originated with the professional standards review organizations (PSROs) in 1972. In 1989 the Agency for Healthcare Policy and Research (AHCPR) was established to facilitate the conduct of outcomes research (Rettig, 1991). AHCPR also had an active role in communicating research findings to healthcare practitioners and was responsible for publishing the first clinical practice guidelines. These guidelines included a synthesis of the best research evidence, with directives for practice developed by healthcare experts in various areas. Several of these evidence-based guidelines were published in the 1990s and provided standards for practice in nursing and medicine. The Healthcare Research and Quality Act of 1999 reauthorized the AHCPR, changing its name to the Agency for Healthcare Research and Quality (AHRQ). This significant change positioned the AHRQ as a scientific partner with the public and private sectors to improve the quality and safety of patient care. Building on the process of research utilization, physicians, nurses, and other healthcare professionals focused on the development of EBP for health care during the 1990s. A research group led by Dr. David Sackett at McMaster University in Canada developed explicit research methodologies to determine the “best evidence” for practice. David Eddy first used the term evidence-based in 1990, with the focus on providing EBP for medicine (Craig & Smyth, 2012; Sackett et al., 2000). The American Nurses Credentialing Center (ANCC) implemented the Magnet Hospital Designation Program for Excellence in Nursing Services in 1990, which emphasized EBP for nursing. The emphasis on EBP in nursing resulted in more biological studies and randomized controlled trials (RCTs) being conducted and led to the publication of Biological Research for Nursing in 2000. Nursing Research: in the Twenty-First Century The vision for nursing research in the twenty-first century includes conducting quality studies using a variety of methodologies, synthesizing the study findings into the best research evidence, and using this research evidence to guide practice (Brown, 2014; Craig & Smyth, 2012; Melnyk & Fineout-Overholt, 2011). EBP has become a stronger focus in nursing and healthcare agencies over the last 15 years. In 2002, The Joint Commission (formerly called the Joint Commission on Accreditation of Healthcare Organizations), responsible for accrediting healthcare organizations, revised the accreditation policies for hospitals to support the implementation of evidence-based health care. To facilitate the movement of nursing toward EBP in clinical agencies, Stetler (2001) developed her Research Utilization to Facilitate EBP Model (see Chapter 13 for a description of this model). The focus on EBP in nursing was supported with the initiation of the Worldviews on Evidence-Based Nursing journal in 2004. The American Association of Colleges of Nursing (AACN), established in 1932 to promote the quality of nursing education, revised their position statement on nursing research in 2006 to provide future directions for the discipline. To ensure an effective research enterprise in nursing, the discipline must (1) create a research culture, (2) provide high-quality educational programs (baccalaureate, master ’s, practice-focused doctorate, research-focused doctorate, and postdoctorate) to prepare a workforce of nurse scientists, (3) develop a sound research infrastructure, and (4) obtain sufficient funding for essential research (AACN, 2006). The complete AACN position statement on nursing research can be found online at http://www.aacn.nche.edu/publications/position/nursing-research. In 2011 the ANA published a research agenda compatible with the AACN (2006) research position statement. The focus of healthcare research and funding has expanded from the treatment of illness to include health promotion and illness prevention. Healthy People 2000 and Healthy People 2010, documents published by the U.S. Department of Health and Human Services (U.S. DHHS, 2000), have increased the visibility of health promotion goals and research. Healthy People 2020 information is now available at the U.S. DHHS (2013) website http://www.healthypeople.gov/2020/. Some of the new topics covered by Healthy People 2020 include adolescent health, blood disorders and blood safety, dementias (including Alzheimer ’s Disease), early and middle childhood, genomics, global health, healthcare-associated infections, lesbian, gay, bisexual, and transgender health, older adults, preparedness, sleep health, and social determinants of health. In the next decade, nurse researchers will have a major role in the development of interventions to promote health and prevent illness in individuals, families, and communities. The AHRQ is the lead agency supporting research designed to improve the quality of health care, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ (2013) conducts and sponsors research that provides evidence-based information on healthcare outcomes, quality, cost, use, and access. This research information is needed to promote effective healthcare decision making by patients, clinicians, health system executives, and policy makers. The AHRQ (2013) website (http://www.ahrq.gov) provides the most current information on this agency and includes current guidelines for clinical practice. Current Actions of the National Institute of Nursing Research The mission of the National Institute of Nursing Research (NINR) is to “promote and improve the health of individuals, families, communities, and populations. The Institute supports and conducts clinical and basic research and research training on health and illness across the lifespan to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and improve palliative and end-of-life care” (NINR, 2013). The NINR is seeking expanded funding for nursing research and is encouraging a variety of methodologies (quantitative, qualitative, and outcomes research) to be used to generate essential knowledge for nursing practice. The

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