power point

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power point

Description
Create a 10-12 slide PowerPoint health promotion

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Include the following in your presentation:

Describe the selected environmental factor. Explain how the environmental factor you selected can potentially affect the health or safety of infants.
Create a health promotion plan that can be presented to caregivers to address the environmental factor and improve the overall health and well-being of infants.
Offer recommendations on accident prevention and safety promotion as they relate to the selected environmental factor and the health or safety of infants.
Offer examples, interventions, and suggestions from evidence-based research. At least three scholarly resources are required. Two of the three resources must be peer-reviewed and no more than 6 years old.
Provide readers with two community resources, a national resource, and a Web-based resource. Include a brief description and contact information for each resource.
In developing your PowerPoint, take into consideration the health care literacy level of your target audience, as well as the demographic of the caregiver/patient (socioeconomic level, language, culture, and any other relevant characteristic of the caregiver) for which the presentation is tailored

NRS427 GCU Community Teaching Work Plan Proposal

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NRS427 GCU Community Teaching Work Plan Proposal

Community Teaching Work Plan Proposal Planning and Topic Directions: Develop an educational series proposal for

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your community using one of the following four topics: 1. Bioterrorism/Disaster 2. Environmental Issues 3. Primary Prevention/Health Promotion 4. Secondary Prevention/Screenings for a Vulnerable Population Planning Before Teaching: Name and Credentials of Teacher: Estimated Time Teaching Will Last: Location of Teaching: Supplies, Material, Equipment Needed: Estimated Cost: Community and Target Aggregate: Topic: Identification of Focus for Community Teaching (Topic Selection): Epidemiological Rationale for Topic (Statistics Related to Topic): © 2019. Grand Canyon University. All Rights Reserved. Teaching Plan Criteria Your teaching plan will be graded based on its effectiveness and relevance to the population selected. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Nursing Diagnosis: Readiness for Learning: Identify the factors that would indicate the readiness to learn for the target aggregate. Include emotional and experiential readiness to learn. Learning Theory to Be Utilized: Explain how the theory will be applied. Goal: Healthy People 2020 (HP2020) objective(s) utilized as the goal for the teaching. Include the appropriate objective number and rationale for using the selected HP2020 objective (use at least one objective from one of the 24 focus areas). If an HP2020 objective does not support your teaching, explain how your teaching applies to one of the two overarching HP2020 goals. How Does This HP2020 Objective Relate to Alma Ata’s Health for All Global Initiatives 2 Develop Behavioral Objectives (Including Domains), Content, and Strategies/Methods: Behavioral Objective and Domain Content (be specific) Strategies/Methods (label and describe) Example – Third-grade students will name one healthy food choice in each of the five food groups by the end of the presentation. (Cognitive Domain) Example – The Food Pyramid has five food groups which are…. Healthy foods from each group are…. Unhealthy foods containing a lot of sugar or fat are…. Example – Interactive poster presentation of the Food Pyramid. After an explanation of the poster and each food category, allow students to place pictures of foods on the correct spot on the pyramid. Also, have the class analyze what a child had for lunch by putting names of foods on the poster and discussing what food group still needs to be eaten throughout day. 1. 1. 1. 2. 2. 2. 3. 3. 3. 4. 4. 4. Creativity: How was creativity applied in the teaching methods/strategies? 3 Planned Evaluation of Objectives (Outcome Evaluation): Describe what you will measure for each objective and how. 1. 2. 3. 4. Planned Evaluation of Goal: Describe how and when you could evaluate the overall effectiveness of your teaching plan. Planned Evaluation of Lesson and Teacher (Process Evaluation): Barriers: What are potential barriers that may arise during teaching and how will those be handled? Therapeutic Communication 4.2 Communicate therapeutically with patients. How will you begin your presentation and capture the interest of your audience? Describe the type of activity will you use with your audience to exhibit active listening? Describe how you applied active listening in tailoring your presentation to your audience? How will you conclude your presentation? What nonverbal communication techniques will you employ? 4
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Affordable Care And Nurses Responses Assignment

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Affordable Care And Nurses Responses Assignment

What Could Happen If The Affordable Care Act Were Completely Repealed? What Could Happen If The Affordable

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Care Act was Completely Repealed? 1 What Could Happen If The Affordable Care Act Were Completely Repealed? The Affordable Care Act is a comprehensive healthcare reform law whose primary goal is to provide quality and affordable healthcare for all Americans. In 2017, the House of Representatives passed the American HealthCare Act to repeal components of the Affordable Care Act. Some of the changes of the ACA include, changing the amount of subsidies, eliminating the mandate for insurance, decreasing the expansion of Medicaid and capping the amount available in Medicare. (Renji, 2017). Other changes in this legislation included the end of the risk adjustment program (Kodjak 2018). The risk adjustment program was created to ensure that insurance companies provide payments for a substantial amount of ill individuals receiving funding from other insurance companies who have a lesser amount (Kodjak 2018). This program provided balance amongst insurance companies and allowed healthcare to remain affordable. If the Affordable care act were repealed, low-income individuals/families, clients with chronic conditions and the elderly population would be adversely affected. Groups that could benefit from this repeal include younger, healthier, middle-higher income Americans. The profession of nursing would experience a decrease in job opportunities and quality of care, private healthcare providers will experience changes and decreases in client demographics and major healthcare organizations will have to readjust prices due to the changes in subsidies that the federal government provide to individuals/families from certain socioeconomic statuses. Nurses can stay informed with this current legislation by joining organizations that lobby to support the cause of making healthcare accessible to all Americans and others. Groups that would be adversely affected if the Affordable Care Act were repealed include, low-income individuals/ families, clients with chronic health conditions and the 2 What Could Happen If The Affordable Care Act Were Completely Repealed? elderly population. (Obama, 2016) If the ACA were eliminated, low-income individuals/ families would have to deal with the lack of subsidizes/tax credits that the federal government provides based on income and manage the cost of paying high deductibles and premiums at market prices. Clients with chronic health conditions like Diabetes and Hypertension would be responsible to finance the cost of maintenance medications, lifestyle changes and procedures if necessary. (Ranji, 2017) Managing chronic health conditions would also be costly for the elderly, especially if they are retired and living on a fixed income and have medical insurance that provides partial coverage (ex, Medicare) on medications and medical services. (Obama, 2016) Groups that would benefit if the Affordable Care Act bill were repealed include younger, healthy people, and middle-higher income Americans. (Ranji, 2017) Younger and healthier people would partially benefit if the bill were repealed because they could select cheaper healthcare plans that offer less coverage such as the catastrophic health plan. The catastrophic health plan is a health insurance plan that offers people under the age of 30 who are in good health with the opportunity to purchase a plan that has low premiums but a high deductible cost because it is “emergency” insurance. (HealthCare. gov, 2019) The middle-higher income Americans could benefit from the repeal because more tax credits will be available to individuals that make more than 75,000 by the federal government. (Ranji, 2017) The healthcare reform efforts would threaten the nursing workforce, making it more difficult for nurses to provide high quality, safe, and efficient care to their clients. If the ACA of 2010 bill is repealed, the nursing profession will be deeply impacted. Undoing the gains made under the ACA would go against all of the American Nurses 3 What Could Happen If The Affordable Care Act Were Completely Repealed? Association’s Principles of Health System Transformation and would represent an enormous step backward in the march toward quality healthcare for all. Nurses will have bigger client loads resulting in diminished care for clients. It also will result in massive job losses. Nurses would have to deal with cuts in their work hours, which will impact their lifestyle and family members. If the Affordable Care Act is repealed, private healthcare providers will also be adversely affected. Since some families struggle with maintaining affordable healthcare coverage, private healthcare providers will receive fewer clients at their office. Clients have the option of visiting hospitals for services since they are required by federal law to treat them (Dobson, DaVanzo & Haught, 2016). As a result, uncompensated care will be a major issue for private healthcare providers resulting in financial deficits. Unfortunately, some practices may have to downsize or close their businesses due to the lack of clients with coverage. If the ACA bill is repealed, major healthcare organizations will be affected because they will have to adjust their healthcare plans due to limited or reduced subsidies from the federal government (Blumberg, Buettgens & Holahan 2017). As a result, there will be a strain to service the low-income and uninsured population. To manage the situation, major healthcare organizations will try to collect more funds through various strategies such as individual donations, corporate contributions, foundation grants, interest from investments, tax revenue, and membership dues and fees. Many healthcare organizations will also struggle with competitors due to their incapacity to respond to the healthcare needs of the uninsured population (Blumberg et al., 2017). 4 What Could Happen If The Affordable Care Act Were Completely Repealed? To utilize power and influence effectively, nurses need to develop awareness of the legislative process and gain a working knowledge of the political arena. Nurses also need to get informed about how the Affordable Care Act affects the constituents. Websites such The Library of Congress THOMAS; (which is a database) allows people to look up information about federal bills. GovTrack.us also informs the public about actions in Washington. This site requires registration. Www.Ballotpedia.org is “an interactive almanac of U.S. politics,” including neutral descriptions of federal and state measures. The New York State Board of Nursing (www.ncsbn.org) website often provides useful information on pending legislation. The BON’s legislative committee examines all measures and decides whether the board should support, oppose or watch each measure. Professional organizations such as The American Nurses Association (www.ananewyork.nursingnetwork.com) also monitors relevant legislation. These organizations’ information may be available only to members. Some professional organizations also organize “lobby days,” which are great opportunities for nurses to learn about important current issues and the political process in general. Every nurse should be a registered voter because it is important to understand how he or she is represented in Washington. Nurses can therefore get involved by using their power collectively. 5 What Could Happen If The Affordable Care Act Were Completely Repealed? References Affordable Care act and Reconciliation Act. (n.d.). Retrieved February 01, 2019, from www.Healthcare.gov Blumberg, L.J., Buettgens, M., Holahan, J. (2017). Implications of Partial Repeal of the ACA Through Reconciliation (Urban Institute, Dec. 2016). Dobson, A., DaVanzo, J., Haught, R. (2016). Estimating the Impact of Repealing the Affordable Care Act on Hospitals (Dobson, DaVanzo & Associates, LLC, Dec. 6, 2016). Hilliard, J. I., Lienbenberg, A. P., Lienbenberg, I. A., & Ruhland, J. (2018). The market impact of the Supreme Court decision regarding the patient protection and affordable care: Evidence from the health insurance industry [abstract]. Journal Of Insurance Issues, 135-187. Leavitt, J.K. Linking practice, policy and politics: Using nursing power to improve health. Presentation: Arlington, VA. Nurse in Washington Internship (NIWI) Program. New York State Board of Nursing (www.ncsbn.org) Obama B. (2016). United States Health Care Reform: Progress to Date and Next Steps. JAMA, 316(5), 525-32. Ranji, U., Rosenzweig, C., Salganicoff, A., & Sobel, L., (2017, May 08). Ten Ways That the House American Health Care Act Could Affect Women. https://www.kff.org/womens-health-policy/issue-brief/ten-ways-that-the-house-americanhealth-care-act-could-affect-women/ https://www.healthcare.gov/glossary/catastrophic-health-plan/ 6 What Could Happen If The Affordable Care Act Were Completely Repealed? The American Nurses Association (www.ananewyork.nursingnetwork.com) The Library of Congress THOMAS The State Of The Affordable Care Act [Audio blog interview]. (2018. July 18). Retrieved February 01, 2019, from www.npr.org U.S. Department of Health and Human Services (2017). About the Affordable Care Act. Retrieved from https://www.hhs.gov/healthcare/about-the-aca/index.html www.Ballotpedia.org www.GovTrack.us 7 Restrictions for Advanced Practice Nurses Restrictions for Advanced Practice Nurses 1 Restrictions for Advanced Practice Nurses 2 According to the Bureau Labor of Statistics, an Advanced Practice Nurse is defined as a nurse who “provides and coordinates patient care,” including “primary and specialty health care.” Advanced practice nurses work in a variety of settings depending on state level. There are four different APRNs, which includes clinical nurse specialists, nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives. Although these nurses are highly trained and able to provide a huge variety of services, they are they are not able to do so because of certain barriers. Are Nurses with Advanced Degrees Restricted in Their Practice? It has been proven that graduates of advanced practice degree programs have a harder time finding employment that would allow them to practice to the full extent of their education and training due to barriers of scope of practice. As advanced practice nurses transition from school to the working environment, they are faced with barriers imposed by the state of which licensure and certification was obtained. State laws, federal policies, insurance reimbursement models, and even culture stands in the way (Gutchell, 2014). The two main barriers that will be discussed are physician’s barriers and Payer’s Policy. As more nurses graduate with advanced practice degrees, it’s important for other health care professionals to know and understand their scope of practice. Some professional organizations such as the American Medical Association believe that nurse practitioners are not as qualified as physicians because of their lack of extensive trainings. It is also believed that nurse practitioners are not able to provide safe quality patient care. A nurse practitioner’s scope of practice is often misunderstood, which creates a barrier known as a “physician’s barrier” (Haine 2014). Although a physician and nurse practitioner have the same goal when treating a patient, physicians often feel that nurse practitioners are not qualified to make certain decisions. Restrictions for Advanced Practice Nurses 3 Creating an environment where nurse practitioners and physicians can work together will help overcome this barrier. Payer’s Policy is another barrier where NP’s are often not recognized as primary care providers. NP’s ability to practice independently are restricted by State practice regulation and licensure. NP’s cannot bill for their services directly. Because of this Restrictive scope of practice many NP’s find it difficult to perform their duties as a healthcare provider. Essentially, they are forced to work under physician professional organization. The Centers for Medicare & Medicaid Services state that “billing ‘incident-to’ requires that the physician establishes the initial plan of care and the nurse practitioner performs follow up care with the physician on site” (Hain et al., 2014). This type of barrier would prevent NP’s from practicing to the full extent of their education and training. According to the ANA journal, in 2014 legislative passed a bill that would allow New York State NP’s to complete 3600 hours and signed an attestation of collaboration agreement with a physician. Nurse practitioners are “recognized in state policy as primary care providers” (Scope of Practice Policy, 2019). There are three types of practices a nurse practitioner can be a part of: full practice, reduced practice, and restricted practice. Full practice is where the nurse practitioner is completely independent and provide all the patient care. The NP can evaluate, diagnose, order and interpret diagnostic tests, and can initiate and manage treatments for a patient. Reduced practice is where the NP can take part in at least one element of practice, but the physician’s oversight is required to provide patient care and prescribe medication. Restricted practice is where full physician oversight is required to take part in any element of practice. Twenty-three states that allows full scope of practice for a nurse practitioner. New York State is not one of them. Restrictions for Advanced Practice Nurses 4 New York state requires a “mandatory collaboration” relationship between a nurse practitioner and a medical doctor. Such a relationship is defined by a written practice agreement that can be as restricted or broad as the physician pleases. Unlike New York State, there are 18 other states (AK, AZ, CO, HI, ID, IA, ME, MD, MT, ND, NH, NM, OR, RI, UT, VT, WA, WY) that allow a nurse practitioner complete independence (Senate Bill S4611B, 2014). New York State’s law asserts that the practice of the nurse practitioner “may include the diagnosis of illness and physical conditions and the performance of therapeutic and corrective measures within a specialty area of practice, in collaboration with a licensed physician qualified to collaborate in the specialty involved, provided such services are performed in accordance with a written practice agreement and written practice protocols” (NYSED Professions, 2018). Written protocols must be developed, including “explicit provisions for the resolution of any disagreement between the physician and the nurse practitioner regarding diagnosis and treatment of patients” (Scope of Practice Policy, 2019), however if a conflict arises that cannot be resolved, the recommendation, diagnosis, or treatment of the physician ultimately triumphs. According to New York State law, advanced practice nurses can only prescribe in their specialty. They cannot provide initial certification for hospice care. However, nurse practitioners can recertify patients for their eligibility for hospice care. Informal Interviews with Advanced Practice Nurses As discussed in an informal interview with a certified registered nurse anesthetist, the top barrier faced is the anesthesiologist, whom does not want to give up his “power.” The anesthesiologist restricts certain procedures the CRNA can perform because by law they must provide supervision. Based on the informal interview, New York State prohibits CRNAs from performing tasks that allow them to practice to the full extent of their education and training. Restrictions for Advanced Practice Nurses 5 One example is that the anesthesiologist is responsible for the medical decisions made on the patient’s condition for the procedure. Also, they cannot provide services with a dentist because dentists are not considered “physicians” in New York state. Whereas in California they are more lenient with the roles CRNAs play in the healthcare setting. Another informal interview was with a current Assistant Director of Nursing of a medical surgical/stepdown department, who has recently received his degree in family nurse practitioner. He claims that he would have to take a pay-cut if he were to switch positions and work as a family nurse practitioner in the same facility. He explains that he would not be able to work independently right away, unlike the full autonomy he was taught to have while studying for his FNP degree. Upon speaking to a registered nurse that was employed in an emergency department while she was matriculated in a NP program, she confirmed that based on New York State law, she was restricted from practicing to the full extent of her training after receiving her advanced practice degree. Although she was secured a job as a nurse practitioner in the emergency department, she was not able to fully make decisions as a healthcare provider without first conferring with a physician. Conclusion Based on the IOM’s report, we are validating the statement that nurses who graduate from advance practice degree programs do have a difficult time finding employment that would allow them to practice to the full extent of their education and training based on the state laws under which they work, specifically in New York State. As more advanced practice nurses continue to obtain degrees, it’s important to develop an interprofessional relationship where physicians can work together with advanced practice nurses to provide patient centered care. We Restrictions for Advanced Practice Nurses 6 must continue to advocate for a universal bill that will remove such barriers discussed that many advanced practice nurses face. Restrictions for Advanced Practice Nurses 7 References Donaworth, S.L., (July 25, 2017) “Making the Case for Adult-Gerontology Critical Care Nurse Practitioner Fellowships” OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 3. Gutchell, V., Idzik, S., & Lazear, J. (2014). An Evidence-based Path to Removing APRN Practice Barriers. The Journal for Nurse Practitioners, 10(4), 255-261. Hain, D., Fleck, L., (May 31, 2014) “Barriers to Nurse Practitioner Practice that Impact Healthcare Redesign” OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 2. New York State Education Department. (2018). Section 6902. Definition of practice of nursing. NYSED Professions, Education Law (Article 139). New York. Available at: http://www.op.nysed.gov/prof/nurse/article139.htm The Nurse Practitioners Modernization Act, S4611B, Senate (2014). Available at: https://www.nysenate.gov/legislation/bills/2013/S4611 Scope of Practice Policy. (2019). New York 2019 Scope of Practice Policy. Health Resources and Services Administration of the U.S. Department of Health and Human Services. Available at: http://scopeofpracticepolicy.org/states/ny/ Sullivan-Bentz, M., Humbert, J., Cragg, B., Legault, F., Laflamme, C., Bailey, P. H., & Doucette, S. (2010). Supporting primary health care nurse practitioners’ transition to practice. Canadian Family Physician, 56(November 2010).
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Article of Interest Response Letter to Editor

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Article of Interest Response Letter to Editor

(Student’s name) (address) Student’s e-mail address Feb. 2, 2010 Name of Editor The American Journal of Nursing

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7777 Pyramid Lane Pina Colata, CA 33133 Dear Editor, In the article titled “Whose Death Is It Anyway?”, published in the March 2014 edition of The American Journal of Nursing, Theresa Brown recounted the story of a friend of hers faced with a patient refusing chemotherapy and a doctor refusing to let him. The focus of her column was on a patient’s right to die in the way that reflects his or her own values and the health care provider’s responsibility to enable that to happen. As a student nurse, I believe that the emphasis of Mrs. Brown’s article missed an essential aspect of the story: the enormous impact of the nurse. In this case, the nurse insisted on remaining with the patient during the physician consultation and ensured that the patient was placed in hospice as he wished, even though the physician would not comply with his requests. Without the nurse functioning as a patient advocate, the patient could have easily been manipulated into a procedure he did not want and would not have received the services he so clearly needed. The 1997 Woodhull study on Nursing and the Media reported that “less than 10% of newspaper and magazine articles are related to health care, and when nurses are discussed, they are portrayed as incidental to health care”.1 In reality, the evidence demonstrates that nurses are essential to patients receiving high- quality care. A 2006 study of 799 nonfederal acute care general hospitals in 11 states showed that increasing the number of RNs and LPNs as well as the number of patient care hours provided by RNs would result in “reduced adverse outcomes by 70,000, hospital days by 4.1 million, and deaths by 6700”.2 The ANA and other nursing organizations, along with companies such as Johnson & Johnson, have created programs with the goal of raising the public’s awareness of the importance of nurses. However, it is also the responsibility of each individual nurse to highlight the significance of the care nurses provide. Mrs. Brown would have done a great service to nurses and patients alike by championing the vital role her friend played in the compassionate care, and advocacy of a dying patient. 1 Zerwekh, J., & Claborn, J.C. (2006). Nursing Today: Transition and Trends. pp. 180. St. Louis, MO: Saunders Elsevier. 2 Cherry, B., and Jacob, S. (2008). Contemporary Nursing: Issues, Trends and Management. pp. 37. St. Louis: MO: Mosby Elsevier.
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NRBS3600 SUNY Learning Activities & Legislative Acts

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NRBS3600 SUNY Learning Activities & Legislative Acts

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Unionization and the Nursing Profession discussion

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Unionization and the Nursing Profession discussion

Discussion: Unionization and the Nursing Profession

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Unionization is a highly charged topic. No matter what your beliefs or thoughts are on the subject, one thing is clear—nurse managers have a significant responsibility to promote the goals of their organizations while appreciating the labor concerns that may prompt employees to join unions. Beyond that, it is helpful to reflect on the core values of nursing and consider the extent to which they align with unionization.
To Prepare

Review the information in the Learning Resources. Conduct additional research on unionization in health care.
Consider the professional basis of nursing and the presence of unions in health care. Does unionization conflict with a professional nursing orientation?
Reflect on the experiences you have had working in unionized settings, or consider what would be required of you in such a setting if you do not have that experience.
Consider how you would address transitioning from being a member of a collective bargaining unit to being a manager who cannot be a member of a collective bargaining unit. How you might prepare to make this sort of transition?
BY DAY 3
Post your position on whether unionization aligns with or conflicts with a professional nursing orientation and what this may mean for the role as a nurse manager. Share your experiences working in a unionized setting or describe what might be required of you when transitioning from one circumstance to another.

Read a selection of your colleagues’ responses

Learning Resources
REQUIRED READINGS
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Chapter 22, “Collective Bargaining, Unionization, and Employment Laws”
Chapter 22 discusses several key topics surrounding unions and collective bargaining in nursing and health care organizations.
Manthous, C. A. (2014). Labor unions in medicine: The intersection of patient advocacy and self–advocacy. Medical care, 52(5), 387–392.
Copyright 2014 by Llippincott Williams & Wilkins – Journals. Reprinted by permission of Llippincott Williams & Wilkins – Journals via the Copyright Clearance Center.

Ash, M., Seago, J. A., & Spetz, J. (2014). What do Health Care Unions do?: A Response to Manthous. Medical care, 52(5), 393–397. DOI: 10.1097/MLR.0000000000000124.
Copyright 2014 by Llippincott Williams & Wilkins – Journals. Reprinted by permission of Llippincott Williams & Wilkins – Journals via the Copyright Clearance Center.

Johnson, J. E. and Billingsley, M. (2014). Convergence: How nursing unions and magnet are advancing nursing. Nursing Forum, 49(4), 225–232. DOI: 10.1111/nuf.12074.
Copyright 2014 by John Wiley & Sons – Journals. Reprinted by permission of John Wiley & Sons – Journals via the Copyright Clearance Center.

nursing research Evidence-Based Practice Discussion Questions

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nursing research Evidence-Based Practice Discussion Questions

Chapter 1 Introduction to Nursing Research and Evidence-Based Practice Copyright © 2011 by Saunders, an imprint

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of Elsevier Inc. 1 What Is Research?      To search again To examine carefully Diligent and systematic inquiry Discovery Goal is to develop an empirical body of knowledge for a discipline Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 2 Definition of Nursing Research   A scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice. It is the key to building an evidence-based practice for nursing. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 3 Using Research in Practice     Synthesis of knowledge (research, theory, and clinical experiences) Effect of philosophy Making a change in practice Evaluation of change for patient, provider, and health care system Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 4 Integrative Review of Research   Critique of studies on a selected topic or practice problem Development of evidence-based practice guidelines: ➢ Example: safe administration of intramuscular injections • Summarize the findings. • Draw conclusions about what is known or not known about the topic. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 5 Evidence-Based Practice Guidelines   Conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of highquality, cost-effective health care Synthesis of knowledge for development of guidelines, standards, protocols, or policies to direct nursing interventions and practice Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 6 Why Is Research Important for Evidence-Based Practice?    Develops empirical knowledge base Identifies best practices that are based on clinical practices Improves outcomes for: ➢ ➢ ➢ Patient and family Nurse Health care system Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 7 Nursing Research Provides:     Description Explanation Prediction Control Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 8 Description  Identifying and understanding the nature of nursing phenomena and the relationships among the phenomena to: ➢ ➢ ➢ ➢ Describe what exists in nursing practice. Discover new information. Promote understanding of situations. Classify information for use in the discipline. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 9 Explanation  Clarifying the relationships among phenomena and identifying the reasons why certain events occur Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 10 Prediction  Estimating and anticipating the outcomes in a particular situation Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 11 Control  Manipulating a situation so as to achieve a particular outcome Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 12 Research Participation at Various Levels of Educational Preparation Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 13 BSN Researcher Role     Identify research problems. Assist with data collection. Critique research studies. Summarize research findings for use in practice. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 14 History of Nursing Research    Nursing research has evolved slowly over the years. Nursing research began in the 19th century with Florence Nightingale. Clinical research is the current major focus of nursing research and will continue to be so throughout the 21st century. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 15 Florence Nightingale   Nightingale focused on the importance of a healthy environment for patients. Aspects of her research included: ➢ ➢ ➢ ➢ Ventilation Cleanliness Purity of water Healthy diet Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 16 Nursing Research: 1900–1940s     American Journal of Nursing first published in 1900. Case studies reported in the 1920s and 1930s. Graduate programs in nursing began in the 1920s. Research conducted by nurses in the 1940s. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 17 Nursing Research: 1950s     1950—American Nurses Association begins 5-year study of nursing functions and activities. 1952—Nursing Research published BSN and MS nursing programs add research to their curricula. 1953—Institute for Research and Service in Nursing Education established by Teacher’s College, Columbia University. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 18 Nursing Research: 1960s   1963—International Journal of Nursing Studies 1967—Image published by Sigma Theta Tau (now titled The Journal of Nursing Scholarship) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 19 Nursing Research: 1970s      1970—ANA Commission on Nursing Research 1972—Council of Nurse Researchers 1978—Advances in Nursing Science 1978—Research in Nursing and Health 1979—Western Journal of Nursing Research Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 20 Nursing Research: 1980s       1982–1983—Conduct and Utilization of Research in Nursing project (CURN) 1983—Annual Review of Nursing Research 1985—National Center for Nursing Research (NCNR) 1987—Scholarly Inquiry for Nursing Practice 1988—Applied Nursing Research and Nursing Science Quarterly 1989—Agency for Health Care Policy and Research (AHCPR) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 21 Nursing Research: 1990s       1992—Clinical Nursing Research 1993—National Institute of Nursing Research (NINR) 1993—Journal of Nursing Measurement 1994—Qualitative Health Research AHCPR renamed Agency for Healthcare Research and Quality (AHRQ). 1999—AACN position statement on nursing research Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 22 Nursing Research: 21st Century     2000—Healthy People 2010 2000—Biological Research for Nursing 2002—Joint Commission revised policies to support evidence-based care. 2004—Worldviews on Evidence-Based Nursing Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 23 21st Century  2005—AHRQ guidelines and priorities ➢  2005—NINR priorities ➢  www.ahrq.gov www.nih.gov/nin 2006—Revised AACN position statements on nursing research Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 24 Ways of Acquiring Knowledge in Nursing     Traditions Authority Borrowing Trial and error     Personal experience Role modeling Intuition Reasoning Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 25 Practice Knowledge Base    Identify two common behaviors used in your practice. Indicate the knowledge base for these behaviors. Is your practice based mainly on research or on other types of knowledge? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 26 Nursing Research Methods    Quantitative research Qualitative research Outcomes research Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 27 Quantitative Research Methods     Descriptive research Correlational research Quasi-experimental research Experimental research Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 28 Quantitative Research Characteristics      Philosophical origin: logical positivism Focus: concise, objective, reductionistic Reasoning: logistic, deductive Basis of knowing: cause-and-effect relationships Theoretical focus: tests theory Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 29 Qualitative Research Methods      Phenomenological research Ground theory research Ethnographic research Historical research Focus groups Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 30 Qualitative Research Characteristics      Philosophical origin: naturalistic, interpretive, humanistic Focus: broad, subjective, holistic Reasoning: dialectic, inductive Basis of knowing: meaning, discovery, understanding Theoretical focus: theory development Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 31 Outcomes Research  Focus of outcomes: ➢ ➢ ➢  Patients and families Providers (nurses, physicians) Health care systems Outcomes used change practice and develop policy. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 32 Chapter 13 Building an Evidence-Based Nursing Practice Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 1 Evidence-Based Practice    Conscientious integration of best research evidence with clinical expertise and patient values and needs in delivery of quality costeffective health care Has a broader focus than research use Goal is implementation of quality costeffective care to promote positive outcomes Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 2 Barriers to EBP    Practical Conceptual May create a “cookbook” approach to care Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 3 Benefits to EBP    Improved patient outcomes for patients, providers, and agencies Leads to best treatment (Gold Standard) plan An integral part of the Magnet Status process Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 4 Evidence-Based Sources      Systematic reviews Meta-analyses Integrative reviews Metasummaries Metasyntheses Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 5 Developing Evidence-Based Practice for Nursing   Findings from a study are different from research evidence. Research evidence is a synthesis of quality, relevant studies to form a body of empirical knowledge for selected area of practice. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 6 Synthesis of Research Findings   Knowledge comes from quantitative, qualitative, and outcomes research. Content clustering: integration of findings from scientifically sound research to determine what is currently known or not known ➢ Accomplished through: • Integrative reviews • Systematic reviews • Meta-analyses, metasummaries, metasyntheses Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 7 Integrative Reviews     Identifies, analyzes, and synthesizes results from independent quantitative and qualitative studies to determine current knowledge Includes multiple types of research designs and literature types A complicated review, but gives breadth and depth to conclusions Annual Review of Nursing Research publishes integrative reviews. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 8 Qualitative Research Contributions to Integrative Reviews       Identifies and refines questions and outcomes Identifies types of participants and interventions Augments and provides data for research synthesis Highlights inadequacies in methods Explains findings and interpretation of findings Helps make recommendations Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 9 Systematic Reviews of Research    A narrowly focused synthesis of research findings from quantitative studies Looks at studies of similar methodology Has same standards of clarity, rigor, and replication as primary research studies Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 10 Steps in Systematic Reviews     Formulate purpose and identify scope. Develop specific questions or hypotheses. Establish criteria for inclusion/exclusion of studies. Conduct extensive literature search of all sources. (Melnyk & Fineout-Overholt, 2005; Whittemore, 2005) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 11 Steps in Systematic Reviews (cont’d)     Develop questionnaire and contact authors to gather data. Critique studies for scientific merit and data analysis. Analyze and interpret data. Report the review. (Melnyk & Fineout-Overholt, 2005; Whittemore, 2005) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 12 Meta-analyses of the Research Literature   Statistically pools results from previous studies into single quantitative analysis Allows for application of scientific criteria ➢ For example, sample size, level of significance, variables Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 13 Results of Meta-analysis     A large, diverse sample that is more representative of target population Determination of overall significance of probability of pooled data Indication of the efficacy of the intervention from the average effect size determined from several quality studies Strength of relationship between variables Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 14 Metasummaries in Qualitative Research   Definition: a synthesis of multiple primary qualitative studies to produce a narrative about a selected phenomenon Expands our knowledge base Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 15 Metasynthesis of Qualitative Research  Synthesizes qualitative research with a critical analysis of primary studies and synthesis of findings into a new theory Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 16 Best Evidence for Use in Practice   The strength of the evidence is on a continuum from high-quality results to lowerquality results. Evidence-based guidelines are essential in developing evidence-based practice for nursing. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 17 Continuum of Strength of Research Evidence Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 18 Strength of Evidence  Strongest evidence 1. 2. 3. Meta-analysis Integrative reviews Experimental studies  Weakest evidence 1. 2. 3. 4. Descriptive surveys Qualitative studies Correlational studies Quasi-experimental studies Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 19 Stetler Model of Research Utilization      Phase I: Preparation Phase II: Validation Phase III: Comparative Evaluation/Decision Making Phase IV: Translation/Application Phase V: Evaluation Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 20 Iowa Model of Evidence-Based Practice   Provides direction for development of evidence-based practice in an agency Looks at triggers for change, such as: ➢ ➢ ➢ ➢ Risk management data Financial data Organizational standards Philosophy of care Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 21 Iowa Model of Evidence-Based Practice (cont’d) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 22 Application of the Iowa Model     What are effective strategies for implementation? What are outcomes from using the research findings? Do the data support the change? Is the proposed change an agency priority? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 23 Scientific Merit Critique  According to the Iowa model, research should be examined for: Conceptualization and internal consistency of the study 2. Methodological rigor of the design, sample methods, data, and analysis 3. Generalizability of the findings 4. Number of replications 1. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 24 Determining Agency Compatibility with the Change in Practice      Who needs to approve the change in the agency? What steps are needed to get the change approved in the institution? Do physicians support the change? Do nurses support the change? Who are the leaders and will they support the change? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 25 Instituting the Change in Practice    Will the implementation take a long time? What support is needed to make the change? Are there barriers to instituting change in the agency? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 26 Utilization Barriers  Administration barriers ➢ ➢ ➢ Research not valued Limited change in agency or change not based on research Limited resources to make research-based change Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 27 Utilization Barriers (cont’d)  Clinician barriers ➢ ➢ ➢ ➢ Do not read research reports Lack education about research process Do not believe research findings Do not know how to implement findings Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 28 Monitoring Outcomes    After the change is effected, the outcomes must be monitored for effectiveness. Change should be documented regarding improved quality of care, decreased costs, saved nursing time, and improved access to care. Feedback is needed. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 29 The Cochran Collaboration     P – Population or participant of interest I – Intervention needed for practice C – Comparison of interventions to determine best practice O – Outcomes needed for practice Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 30 Development of Evidence-Based Guidelines     AHRQ helps with guidelines through development of an expert panel. The group designates the scope of the guidelines. They synthesize the findings to develop recommendations for practice. Guidelines developed are presented at meetings and published. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 31 Examples of AHRQ Practice Guidelines        Pain management Decubiti prediction/prevention Cataract treatment in adults Depression treatment Screening, diagnosis, management of sickle cell disease in newborns and infants Otitis media treatment in children Availability of cardiac rehabilitation services Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 32 Access to Evidence-Based Guidelines      Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse (NGC) Academic Center for Evidence-Based Nursing American College of Physicians American Academy of Pediatrics Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 33 Implementing a Model of EvidenceBased Practice    Identify practice problem. Search for best research evidence. Determine quality of guideline by assessing: ➢ ➢ ➢ ➢ ➢ Authors Significance of problem Strength of evidence Link to national standards Cost-effectiveness of guideline Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 34 Translational Research   An evolving concept defined by the NIH as the translation of basic scientific discoveries into practical application Encouraged by nursing and medicine to increase the implementation of evidencebased interventions in practice and determine if these interventions are effective Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 35 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 NINR (2013) website (http://ninr.nih.gov) provides the most current information on the institute’s research funding opportunities and supported studies. The strategic plan for the NINR (2011) is available online at https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ninr-strategic-plan-2011.pdf. Linking Quality and Safety Education for Nursing Competencies and Nursing Research In 2001 the Institute of Medicine (IOM) published a report, Crossing the Quality Chasm: A New Health System for the 21st Century, that emphasized the importance of quality and safety in the delivery of health care. In 2003 the IOM published a report, Health Professions Education: A Bridge to Quality, which identified the six competency areas essential for inclusion in nursing education to ensure that students were able to deliver quality, safe care. Specific competencies were identified for the following six areas: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. The Quality and Safety Education for Nurses (QSEN) initiative is focused on developing the requisite knowledge, skills, and attitude (KSA) statements for each of the competencies for pre-licensure and graduate education. The QSEN initiative has been funded since 2005 by the Robert Wood Johnson Foundation. The QSEN Institute website (http://qsen.org), launched in 2007, features teaching strategies and resources to facilitate the accomplishments of the QSEN competencies in nursing educational programs. The most current competencies for the prelicensure educational programs can be found online at http://qsen.org/competencies/pre-licenrueksas (QSEN, 2013; Sherwood & Barnsteiner, 2012). The EBP competency is defined as “integrating the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care” (QSEN, 2013). Undergraduate nursing students need to be skilled in critical appraisal of studies, use of appropriate research evidence in practice, adherence to institutional review board (IRB) guidelines, and appropriate data collection. Diffusion of the QSEN competencies across nursing educational programs is a major focus for educators who are shaping students’ learning experiences and outcomes based on these competencies (Barnsteiner, Disch, Johnson, McGuinn, Chappell, & Swartwout, 2013). In this text, the QSEN com…
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Geopolitical and Phenomenological

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Geopolitical and Phenomenological

Discuss how geopolitical and phenomenological place influence the context of a population or community assessment and intervention. Describe how the nursing process is utilized to assist in identifying health issues (local or global in nature) and in creating an appropriate intervention, including screenings and referrals, for the community or population.(minimum 200 words)

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Group Power Point Project for Peptic Ulcer Disease

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Group Power Point Project for Peptic Ulcer Disease

• Points None The goals for this project are to • • • • promote collaboration understand real-life applications of

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Microbiology. promote familiarity with audio/visual techniques. enhance the ability to communicate verbally Project Parameters: Students will work in teams of 2 students (higher at instructor’s discretion). Working as a team, students will pick a pathogen in week 5. Students must get approval for pathogen from the instructor. The pathogen can be a bacteria, fungus, protozoa or virus. Topics to be included in the presentation are- morphology, cellular characteristics, gram stain characteristics, virulence factors, susceptibility to antibiotics, host cells, nutritional needs, growth conditions, how it evades the immune system and mode of invasion into the host(s), interactions with the hosts and diseases caused and body systems that are affected. Additionally, explain symptoms when the pathogen infects a host, diagnosis and therapeutic intervention needed. You may also add information on statistics related to infection (epidemiology) and any new research findings related to the pathogen. Working as a group, students will also pick a newspaper article or publication related to the pathogen of choice and include a brief summary of the newspaper article or publication to the presentation. Students will present their project as a voice over powerpoint which will be graded in week 8. Each student must contribute meaningfully and equally to the project preparation, presentation, and writing. Instructors may have additional requirements. Students are encouraged to check with instructor regarding the presentation topic and any additional requirements. Grading Rubric: Important Note: ALL students from a group must participate in research, preparation and writing of the essay. Category and Points Introduction Properly describes in-detail the pathogen of choice and its importance (5 points) The paper explains in detail the characteristics of the pathogen chosen with accuracy and relates well to concepts learned in the course. 1) morphology, cellular characteristics, and gram stain characteristics, virulence factors, 2) susceptibility to antibiotics, 3)host cells, nutritional needs, growth conditions, Body of the essay/paper: Quality of Information/ 4) how it evades the immune system and mode of invasion into the host(s), Accuracy of Facts (20 points) 5) Interactions with the hosts and diseases caused and body systems that are affected. 6) symptoms when the pathogen infects a host, 7) Diagnosis and therapeutic intervention needed. (2 points per required topic = 14 pts) (6 points for equal participation by all students. Each student has an equal speaking part) 1)Article summary is accurate and includes supporting details and/or examples from lecture material. (5 pts) Article related to pathogen (20 points) 2)The bigger picture question “why does this matter?” has been addressed. (5 pts) 3The article is included with the review. (4pts) (6 points for equal participation by all students. Each student has an equal speaking part) Grammar, spelling and Citation (APA format) (5 points) Rubric There are none or minimal errors in grammar or spelling. Sources were accurately cited in the reference page in APA format. Criteria This criterion is linked to a Learning OutcomeIntroduction This criterion is linked to a Learning OutcomeBody of the essay/paper: Quality of Information/ Accuracy of Facts This criterion is linked to a Learning OutcomeEqual Participation on Body of Papter This criterion is linked to a Learning OutcomeArticle Summary Ratings 5.0 pts Properly describes in-detail the pathogen of choice and its importance 0.0 pts Does not describe in-detail the pathogen of choice and its importance 14.0 to >0.0 pts 2 Points earned for each required item listed below 1) morphology, cellular characteristics, and gram stain characteristics, virulence factors, 2) susceptibility to antibiotics, 3)host cells, nutritional needs, growth conditions, 4) how it evades the immune system and mode of invasion into the host(s), 5) interactions with the hosts and diseases caused and body systems that are affected. 6) symptoms when the pathogen infects a host, 7) diagnosis and therapeutic intervention needed. 0.0 pts All items listed below are missing. 1) morphology, cellular characteristics, and gram stain characteristics, virulence factors, 2) susceptibility to antibiotics, 3)host cells, nutritional needs, growth conditions, 4) how it evades the immune system and mode of invasion into the host(s), 5) interactions with the hosts and diseases caused and body systems that are affected. 6) symptoms when the pathogen infects a host, 7) diagnosis and therapeutic intervention needed. 6.0 pts Each student has an equal speaking part 5.0 pts Article summary is accurate and includes supporting details and/or examples from lecture material. Pts 5.0 pts 14.0 pts 0.0 pts Each student does not have an equal speaking part 6.0 pts 0.0 pts No Marks Article summary is NOT accurate OR does NOT include supporting details and/or examples from lecture material. 5.0 pts Criteria This criterion is linked to a Learning OutcomeBigger Picture Question This criterion is linked to a Learning OutcomeArticle Inlcuded This criterion is linked to a Learning OutcomeEqual Participation on Article This criterion is linked to a Learning OutcomeGrammar, spelling and Citation Total Points: 50.0 PreviousNext Ratings Pts 5.0 pts The bigger picture question “why does this matter?” has been addressed. 0.0 pts The bigger picture question “why does this matter?” has NOT been addressed. 5.0 pts 4.0 pts The article is included with the review. 0.0 pts The article is NOT included with the review. 4.0 pts 6.0 pts Each student has an equal speaking part 0.0 pts Each student does not have an equal speaking part 5.0 pts There are none or minimal errors in grammar or spelling. – AND – Sources were accurately cited in the reference page in APA format. 0.0 pts There are multiple errors in grammar or spelling. AND/OR Sources were accurately cited in the reference page in APA format. 6.0 pts 5.0 pts
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Describe nurse theories

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Describe nurse theories

Describe Nursing theories are tested and systematic ways to implement nursing practice. Select a nursing theory and its conceptual model. Prepare a 10-15 slide PowerPoint in which you describe the nursing theory and its conceptual model and demonstrate its application in nursing practice. Include the following:

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Present an overview of the nursing theory. Provide evidence that demonstrates support for the model’s efficacy in nursing practice. Explain how the theory proves the conceptual model.
Explain how the nursing theory incorporates the four metaparadigm concepts.
Provide three evidence-based examples that demonstrate how the nursing theory supports nursing practice. Provide support and rationale for each.
Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

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