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CONTENTS 1 Introduction to Nursing Research and Evidence-Based Practice, 1 2 Introduction to Quantitative Research, 31 3 4 5 6 Introduction to Qualitative Research, 66 Examining Ethics in Nursing Research, 93 Research Problems, Purposes, and Hypotheses, 129 Understanding and Critically Appraising the Literature Review, 162 7 Understanding Theory and Research Frameworks, 189 8 Clarifying Quantitative Research Designs, 210 9 Examining Populations and Samples in Research, 248 10 Clarifying Measurement and Data Collection in Quantitative Research, 281 11 Understanding Statistics in Research, 317 12 Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice, 361 13 Building an Evidence-Based Nursing Practice, 414 14 Outcomes Research, 466 Glossary, 500 Index, 515 This page intentionally left blank 6th Edition Understanding Nursing Research Building an Evidence-Based Practice 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 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 C O N T R I B U TO R A N D 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 Lawrence, 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 v vi CONTRIBUTOR AND REVIEWERS 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 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 P R E FAC E 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, meta-analysis, meta-synthesis, and mixedmethods 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. viii PREFACE ix 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, quasiexperimental, 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 x PREFACE 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, meta-synthesis, 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 PREFACE xi 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-by-chapter 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. xii PREFACE • 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 time-tested 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 evidence-based 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. AC KN OWLE D GM E NT S 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 Jennifer R. Gray PhD, RN, ANP-BC, GNP-BC PhD, RN, FAAN Nancy Burns PhD, RN, FCN, FAAN xiii This page intentionally left blank CHAPTER 1 Introduction to Nursing Research and Evidence-Based Practice C H A P T E R OV E RV I E W What Is Nursing Research? 3 What Is Evidence-Based Practice? 3 Purposes of Research for Implementing an Evidence-Based Nursing Practice, 6 Description, 6 Explanation, 7 Prediction, 7 Control, 8 Historical Development of Research in Nursing, 9 Florence Nightingale, 11 Nursing Research: 1900s through the 1970s, 11 Nursing Research: 1980s and 1990s, 12 Nursing Research: in the Twenty-First Century, 14 Acquiring Knowledge in Nursing, 15 Traditions, 16 Authority, 16 Borrowing, 16 Trial and Error, 17 Personal Experience, 17 Role Modeling, 17 Intuition, 18 Reasoning, 18 Acquiring Knowledge through Nursing Research, 19 Introduction to Quantitative and Qualitative Research, 19 Introduction to Outcomes Research, 21 Understanding Best Research Evidence for Practice, 21 Strategies Used to Synthesize Research Evidence, 22 Levels of Research Evidence, 24 Introduction to Evidence-Based Guidelines, 25 What Is Your Role in Nursing Research? 25 Key Concepts, 27 References, 28 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. 1 2 CHAPTER 1 Introduction to Nursing Research 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 evidence-based 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. CHAPTER 1 Introduction to Nursing Research 3 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 evidence-based 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 costeffective 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 4 CHAPTER 1 Introduction to Nursing Research Best Research Evidence Clinical Expertise Patient Needs & Values EvidenceBased Practice FIG 1-1 Model of Evidence-Based Practice (EBP). 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. 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 cost-effective 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 1-1). These guidelines include the classification of blood pressure as normal, prehypertension, hypertension stage 1, and hypertension stage 2. Both guidelines also recommend CHAPTER 1 Introduction to Nursing Research TABLE 1-1 CLASSIFICATION OF BLOOD PRESSURE WITH NURSING INTERVENTIONS FOR EVIDENCE-BASED PRACTICE (EBP) NURSING INTERVENTIONS{ CLASSIFICATION OF BLOOD PRESSURE (BP) BP CATEGORY Normal Prehypertension Stage 1 hypertension Stage 2 hypertension 5 SYSTOLIC BP (mm Hg)* DIASTOLIC BP (mm Hg)* LIFESTYLE MODIFICATION{ CARDIOVASCULAR DISEASE (CVD) RISK FACTORS EDUCATION}
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