Why is it important to conduct or perform a quality literature review? Characterize or distinguish between the 4 major types of reviews discussed in our textbook? What are the essential components of a quality literature review?
Appraisal andApplication of
Research
EVIDENCE-BASED
FOR NURSESPRACTICE
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THE PEDAGOGYEvidence-Based Practice for Nurses: Appraisal and Application of Research, Fourth Edi-tion, drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approachaddresses different learning styles, making this the ideal text to ensure mastery of key concepts.The pedagogical aids that appear in most chapters include the following:
Chapter ObjectivesThese objectives provideinstructors and studentswith a snapshot of thekey information they willencounter in each chapter.They serve as a checklist tohelp guide and focus study.
Key TermsFound in a list at thebeginning of each chapterand in bold within thechapter, these termswill create an expandedvocabulary in evidence-basedpractice.
At the end of this chapter, you will be able to:
Key terms
CHAPter OBJeCtiVes
‹ Define evidence-based practice (EBP)‹ List sources of evidence for nursingpractice
‹ Identify barriers to the adoptionof EBP and pinpoint strategies toovercome them
‹ Explain how the process of diffusionfacilitates moving evidence intonursing practice
‹ Define research‹ Discuss the contribution of researchto EBP
‹ Categorize types of research‹ Distinguish between quantitative andqualitative research approaches
‹ Describe the sections found inresearch articles
‹ Describe the cycle of scientificdevelopment
‹ Identify historical occurrences thatshaped the development of nursingas a science
‹ Identify factors that will continue tomove nursing forward as a science
‹ Discuss what future trends mayinfluence how nurses use evidence toimprove the quality of patient care
‹ Identify five unethical studiesinvolving the violation of the rights ofhuman subjects
abstractapplied researchbarriersbasic researchcycle of scientific
developmentdeductive reasoningdescriptive researchdiscussion sectionearly adoptersempirical evidenceevidence-based practice
(EBP)explanatory research
inductive reasoninginnovationintroductionJewish Chronic Disease
Hospital studylaggardslist of referencesmethods sectionmodel of diffusion of
innovationsNazi experimentsNuremberg Codepredictive researchpyramid of evidence
qualitative researchquantitative researchreplication studyresearchresearch utilizationresults sectionreview of literaturetheoretical frameworktheoryTuskegee studyWillowbrook studies
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Critical Thinking ExercisesAs an integral part of the learningprocess, the authors presentscenarios and questions to sparkinsight into situations faced inpractice.
Test Your KnowledgeThese questions serveas benchmarks for theknowledge acquiredthroughout the chapter.
After an outcome has been selected and measured, data are compiled andevaluated to draw conclusions. Demonstrating the effectiveness of aninnovation is a challenge, and conclusions must not extend beyond thescope of the data. Evaluation is facilitated when appropriate outcomesand associated indicators are chosen. If the outcome is not clearly defined,then the measurements and subsequent evaluation will be flawed. Forexample, suppose that you are a member of an interdisciplinary teamthat has developed a nursing protocol that reduces the amount of timethe patient remains on bed rest after a cardiac catheterization procedurefrom 6 hours to 4 hours. The outcome selected is absence of bleeding fromthe femoral arterial puncture site. No other indicators are measured. Theresults obtained after implementing the protocol revealed that there wasan increase in bleeding at the femoral arterial site in the 4-hour bed restpatients compared to the 6-hour bed rest patients. Before concluding thata shorter bed rest time leads to an increase in femoral bleeding, a fewadditional questions need to be considered. First, was absence of bleed-ing defined in a measurable way? Because bleeding might be interpretedin several different ways, a precise definition of bleeding should havebeen provided to ensure consistency in reporting. Second, when shouldpatients be assessed for absence of bleeding? Is the absence of bleeding tobe assessed when the patient first ambulates or at a later time? Input fromthe staff prior to changing the nursing protocol could have clarified thesequestions, resulting in more reliable results.
Another consideration in outcome evaluation is to obtain data relative tocurrent practice for comparison purposes. To document the need for a practicechange and to support a new protocol, baseline data might need to be collected
tEst YOur knOWlEdgE 18-3
true/False
1. Baseline data are unimportant in outcome measurement.
2. Precise description of indicators is essential.
3. For complex analyses, the assistance of a statistician may be needed.
4. Input from staff can help clarify outcome measurement.
How did you do? 1. F; 2. T; 3. T; 4. T
FYi
After an outcomehas beenselected andmeasured, dataare compiledand evaluated todraw conclusions.Evaluation isfacilitated whenappropriateoutcomes andassociatedindicatorsare chosen—conversely, ifthe outcomeis not clearlydefined, then themeasurementsand subsequentevaluation will beflawed.
498 ChaptER 18 Evaluating Outcomes of Innovations
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treatment of human response, and advocacy in the care of individuals, fami-lies, communities, and populations” (ANA, 2003, p. 6). From the early days ofthe profession, students have been taught that a scientific attitude and methodof work combined with “experience, trained senses, a mind trained to think,and the necessary characteristics of patience, accuracy, open-mindedness,truthfulness, persistence, and industry” (Harmer, 1933, p. 47) are essentialcomponents of good practice. Harmer goes on to say, “Each time this habit oflooking, listening, feeling, or thinking is repeated it is strengthened until thehabit of observation is firmly established” (p. 47). This still holds true today.Benner (1984) studied nurses in practice and concluded that to become anexpert nurse one has to practice nursing a minimum of 5 years. There are noshortcuts to becoming an expert in one’s field. The development of knowledgeand skill takes time and work. As nurses encounter new situations, learningtakes place. Nursing knowledge develops and is refined as nurses practice(Waterman, Webb, & Williams, 1995). In this way, nurses adapt theories tofit their practices. Unfortunately, much that is learned about theory duringpractice remains with the nurse because nurses rarely share their practiceexpertise through conference presentations and publications. The disciplinewill be enriched when nurses engage more formally in disseminating theirknowledge about theory in practice.
The Relationships Among Theory,Research, and PracticePractice relies on research and theory and also provides the questions thatrequire more work by theorists and researchers. Each informs and supportsthe other in the application and development of nursing knowledge. Whenthe relationships among theory, research, and practice are in harmony, thediscipline is best served, ultimately resulting in better patient outcomes(Maas, 2006). The relationships are dynamic and flow in all directions.
CRiTiCAL THinking ExERCisE 5-2
A nurse on a surgical floor observes that several new approaches are being used to dress wounds.She observes that some methods appear to promote healing faster than others do. Whilereviewing the research literature, she is unable to locate any research about the dressings she isusing. How might she go about testing her theory that some methods are better than others? Canthis be done deductively, inductively, or using mixed methods? Are any theories presently availablerelated to wound healing, and if so, where might she locate these? What concepts might beimportant in forming the question?
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5.1 How Are Theory, Research, and Practice Related? 141
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FYIQuick tidbits and facts arepulled out in chapter marginsto highlight importantaspects of the chapter topic.
THE PEDAGOGY iii
Rapid ReviewThis succinct list at the endof the chapter compilesthe most pertinent and keyinformation for quick reviewand later reference.
Apply What You HaveLearnedThis outstanding featureapplies newly acquiredknowledge to specificevidence-based practicescenarios and researchstudies.
apparent. Organizing the review with a grid is a positive strategy to overcomethe barrier of lack of time because it reduces the need to repeatedly sort througharticles during future discussions. Also, within this text’s digital resources, youwill find a grid to use for this exercise. Two articles (Cohen & Shastay, 2008;Tomietto, Sartor, Mazzocoli, & Palese, 2012) are summarized as an example.
Read Kliger, Blegen, Gootee, and O’Neil (2009). Enter information aboutthis article into the first two columns. In column 1, use APA format, likein the example, because this is the most commonly used style for nursingpublications.
Rapid Review» Today’s work environment requires that nurses be adept at gathering
and appraising evidence for clinical practice and assisting patients withhealthcare information needs.
» Literature reviews provide syntheses of current research and scholarlyliterature. A well-done literature review can provide support for EBP.
» An understanding of the scientific literature publication cycle providesa basis for making decisions about the most current information on atopic.
» Primary sources are original sources of information presented by thepeople who created them. Secondary sources are resulting commentar-ies, summaries, reviews, or interpretations of primary sources.
» Many research journals involve peer review.
» There are many ways to categorize sources. Scholarly, trade, and popularliterature is one way. Another categorizing system involves periodicals,journals, and magazines.
» There are four types of review: narrative, integrative, meta-analysis, andsystematic.
» Understanding how sources are structured can simplify a search of theliterature.
» Sources can be identified through both print indexes and electronic data-bases. Topics, subject matter, and format may vary but all include citationinformation.
» Helpful strategies to use when conducting a search include cita-tion chasing, measurements of recall and precision, keyword andcontrolled vocabulary searches, Boolean operators, truncation,
4.5 Keeping It Ethical 129
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reFerenCesAitken, L. M., Hackwood, B., Crouch, S., Clayton, S., West, N., Carney, D., &
Jack, L. (2011). Creating an environment to implement and sustainevidence based practice: A developmental process. Australian CriticalCare, 24, 244–254.
American Medical Association. (1998). Information from unethicalexperiments (CEJA Report 5–A-98). Retrieved from http://www.ama-assn.org/resources/doc/code-medical-ethics/230a.pdf
American Nurses Association. (2010). National Database of Nursing QualityIndicators: Guidelines for data collection on the American NursesAssociation’s National Quality forum endorsed measures: Nursing CareHours per Patient Day, Skill Mix, Falls, Falls with Injury. Retrieved fromhttp://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/dspc/health%20care%20service/nursestaffing7-13-10materials.ashx
Barnsteiner, J., & Prevost, S. (2002). How to implement evidence-basedpractice. Some tried and true pointers. Reflections on Nursing Leadership,28(2), 18–21.
Barta, K. M. (1995). Information-seeking, research utilization, and barriersto research utilization of pediatric nurse educators. Journal of ProfessionalNursing, 11, 49–57.
Benner, P. (1984). From novice to expert: Excellence and power in clinicalnursing practice. Menlo Park, CA: Addison-Wesley.
aPPlY What YOu havE lEarnED
Sign into a database for nursing literature (i.e., CINAHL, ProQuest, PubMed). For this chapter, youwill need to obtain the following two articles:
Pipe, T. B., Kelly, A., LeBrun, G., Schmidt, D., Atherton, P., & Robinson, C. (2008).A prospective descriptive study exploring hope, spiritual well-being, and quality of life inhospitalized patients. MEDSURG Nursing, 17, 247–257.
Flanagan, J. M., Carroll, D. L., & Hamilton, G. A. (2010). The long-term lived experience ofpatients with implantable cardioverter defibrillators. MEDSURG Nursing, 19, 113–119.
One of these articles used qualitative methods, and the other used quantitative methods. Identifywhich is which. After you have done that, for each article identify the various sections that makeup a research article. You may want to share these articles with nurses during your next clinicalexperience and consider ways the recommendations can be incorporated into practice.
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36 CHAPter 1 What Is Evidence-Based Practice?
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iv THE PEDAGOGY
Case ExamplesFound in select chapters,these vignettes illustrateresearch questions andstudies in actual clinicalsettings and provide criticalthinking challenges.
Some researchers claim their work is nursing research because the researcheris a nurse or because the researcher studied nurses. But it is the focus on nurs-ing practice that defines nursing research. The mere fact that the research wasconducted by a nurse or that nurses were studied does not necessarily qualifythe research as nursing research. Historically, and even today, approaches topractice are often based on “professional opinion” when research is absent.Case Example 5-1 provides such a historical illustration. It also demonstratesthe value of systematically studying the effects of interventions.
CAsE ExAmPLE 5-1
Early methods of Resuscitation: An Example of Practice Based on Untested Theory
Throughout the past century, nursing students have been taught how to resuscitate patientswho stop breathing. As early as 1912, students were taught a variety of methods forproviding artificial respiration. It was theorized that moving air in and out of the lungs
would be effective. One of these techniques was designed for resuscitating infants. Byrd‘s Methodof Infant Resuscitation (Goodnow, 1919) directed the nurse to hold the infant‘s legs in one hand,and the head and back in the other. The nurse would then double the child over by pressing thehead and the knees against the chest. Then the nurse would extend the knees to undouble thechild. This would be repeated, but “not too rapidly” (Goodnow, 1919, p. 305). At intervals,the nurse would dip the child into a mustard bath in the hope that this would also stimulaterespiration. The nurse would continue this until help arrived.
Other methods of artificial respiration taught included Sylvester‘s method for adults (Goodnow,1919). The patient was placed flat on his back. The nurse would grasp the patient‘s elbows andpress them close to his sides, pushing in the ribs to expel air from the chest. The arms would thenbe slowly pulled over the head, allowing the chest to expand. The arms would be lowered to putpressure on the chest, and the cycle was then repeated. This was to be done at the rate of 18 to20 cycles per minute.
By 1939, postmortem examinations after unsuccessful resuscitations showed veins to be engorgedwhile the arteries were empty (Harmer & Henderson, 1942). Although this evidence indicatedother factors needed to be considered, resuscitation techniques continued to focus only on therespiratory system. The same methods of resuscitation that were in use in 1919 were still beingtaught in 1942. Although students were still being taught the Sylvester method, they were alsolearning the new “Schäfer method” (Harmer & Henderson, 1942, p. 9401). This method involvedplacing the patient in a prone position. The nurse would straddle the thighs, facing the patient‘shead, and alternatively apply and remove pressure to the thorax.
Eventually, it was noted that what was believed to be best practice was not effective. Resultsof postmortem examinations indicated that something was missing in the techniques, andtherefore research was begun to determine best practice. Today, nursing students are taughtcardiopulmonary resuscitation techniques based on updated research and theories.
136 CHAPTER 5 Linking Theory, Research, and Practice
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fully operational in 1996. It aims to improve the effectiveness of nursing practiceand healthcare outcomes. Some initiatives include conducting systematic reviews,collaborating with expert researchers to facilitate development of practice infor-mation sheets, and designing, promoting, and delivering short courses about EBP.
2.2 keeping It Ethical
Ethical research exists because international, national, organizational, andindividual factors are in place to protect the rights of individuals. Withoutthese factors, scientific studies that violate human rights, such as the Naziexperiments, could proceed unchecked. Many factors of ethical research,which evolved in response to unethical scientific conduct, are aimed at pro-tecting human rights. Human rights are “freedoms, to which all humans areentitled, often held to include the right to life and liberty, freedom of thoughtand expression, and equality before the law” (Houghton Mifflin, 2007). Rightscannot be claimed unless they are justified in the eyes of another individual orgroup of individuals (Haber, 2006). When individuals have rights, others haveobligations, that is, they are required to act in particular ways. This meansthat when nursing research is being conducted, subjects participating in stud-ies have rights, and all nurses are obligated to protect those rights.
International and National Factors:guidelines for Conducting EthicalresearchOne of the earliest international responses to unethical scientific conduct wasthe Nuremberg Code. This code was contained in the written verdict at thetrial of the German Nazi physicians accused of torturing prisoners duringmedical experiments. Writers of the Nuremberg Code (Table 2-3) identifiedthat voluntary consent was absolutely necessary for participation in research.Research that avoided harm, produced results that benefited society, andallowed participants to withdraw at will was deemed ethical. The NurembergCode became the standard for other codes of conduct.
Key Termshuman rights:Freedoms to which allhumans are entitled
obligations:Requirements to act inparticular ways
At the end of this section, you will be able to:
‹ Discuss international and national initiatives designed to promote ethical conduct‹ Describe the rights that must be protected and the three ethical principles that must beupheld when conducting research
‹ Explain the composition and functions of IRBs at the organizational level‹ Discuss the nurse’s role as patient advocate in research situations
2.2 Keeping It Ethical 55
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Keeping It EthicalRelevant ethical contentconcludes each chapterto ensure that ethics are aconsideration during everystep of the nursing process.
THE PEDAGOGY v
Appraisal andApplication of
Research
Edited byNola A. Schmidt, PhD, RN, CNE
ProfessorCollege of Nursing and Health Professions
Valparaiso UniversityValparaiso, Indiana
Janet M. Brown, PhD, RNProfessor Emeritus
College of Nursing and Health ProfessionsValparaiso UniversityValparaiso, Indiana
FOURTH EDITION
EVIDENCE-BASED
FOR NURSESPRACTICE
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Library of Congress Cataloging-in-Publication DataNames: Schmidt, Nola A., editor. | Brown, Janet M. (Janet Marie), 1947– editor.Title: Evidence-based practice for nurses : appraisal and application of research / [edited by] Nola A. Schmidt and Janet M. Brown.Description: Fourth edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2019] | Includes bibliographical references and index.Identifiers: LCCN 2017036581 | ISBN 9781284122909Subjects: | MESH: Nursing Research–methods | Evidence-Based NursingClassification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072–dc23LC record available at https://lccn.loc.gov/2017036581
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DEDICATIONFor Mom, whose love and support are endless.
—N. A. S.
To my husband, my children, and my granddaughters and grandson, who enrich my life in every way.
—J. M. B.
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Contributors xixReviewers xxiPreface xxiiiAcknowledgments xxix
UNIT 1 Introduction to Evidence-BasedPractice 1
CHAPTER 1 What Is Evidence-Based Practice? 3Nola A. Schmidt and Janet M. Brown
1.1 EBP: What Is It? 31.2 What Is Nursing Research? 141.3 How Has Nursing Evolved as a Science? 231.4 What Lies Ahead? 311.5 Keeping It Ethical 34
CONTENTS
CHAPTER 2 Using Evidence Through Collaborationto Promote Excellence in NursingPractice 43Emily Griffin and Marita G. Titler
2.1 The Five Levels of Collaboration 432.2 Keeping It Ethical 54
UNIT 2 Acquisition of Knowledge 67
CHAPTER 3 Identifying Research Questions 69Susie Adams
3.1 How Clinical Problems GuideResearch Questions 69
3.2 Developing Hypotheses 773.3 Formulating EBP Questions 843.4 Keeping It Ethical 87
CHAPTER 4 Finding Sources of Evidence 93Patricia Mileham
4.1 Purpose of Finding Evidence 934.2 Types of Evidence 964.3 How Sources Are Organized 1024.4 How to Search for Evidence 1104.5 Keeping It Ethical 123
CHAPTER 5 Linking Theory, Research, and Practice 131Elsabeth Jensen
5.1 How Are Theory, Research, and PracticeRelated? 131
5.2 Keeping It Ethical 141
xii CONTENTS
UNIT 3 Persuasion 147
CHAPTER 6 Key Principles of Quantitative Designs 149Rosalind M. Peters
6.1 Chart the Course: Selecting the Best Design 1496.2 What Is Validity? 1556.3 Categorizing Designs According to Time 1616.4 Keeping It Ethical 166
CHAPTER 7 Quantitative Designs: Using Numbers toProvide Evidence 171Rosalind M. Peters
7.1 Experimental Designs 1717.2 Quasi-Experimental Designs 1777.3 Nonexperimental Designs 1807.4 Specific Uses for Quantitative Designs 1867.5 Keeping It Ethical 188
CHAPTER 8 Epidemiologic Designs: Using Data toUnderstand Populations 193Amy C. Cory
8.1 Epidemiology and Nursing 1938.2 Infectious Diseases and Outbreak
Investigations 1958.3 Measures of Disease Frequency 1978.4 Descriptive Epidemiology 2008.5 Descriptive Study Designs 204
CONTENTS xiii
8.6 Analytic Study Designs 2088.7 Screening 2138.8 Evaluating Health Outcomes and Services 2158.9 Keeping It Ethical 216
CHAPTER 9 Qualitative Designs: Using Words to ProvideEvidence 221Kristen L. Mauk
9.1 What Is Qualitative Research? 2219.2 The Four Major Types of Qualitative
Research 2309.3 Keeping It Ethical 244
CHAPTER 10 Collecting Evidence 253Jan Dougherty
10.1 Data Collection: Planning and Piloting 25310.2 Collecting Quantitative Data 25510.3 Validity and Reliability 26310.4 Collecting Qualitative Data 27110.5 Keeping It Ethical 278
CHAPTER 11 Using Samples to Provide Evidence 285Ann H. White
11.1 Fundamentals of Sampling 28511.2 Sampling Methods 29011.3 Sample Size: Does It Matter? 29911.4 Keeping It Ethical 302
xiv CONTENTS
CHAPTER 12 Other Sources of Evidence 309Cynthia L. Russell
12.1 The Pyramid of the 5 Ss 30912.2 Using the Pyramid of the 5 Ss for Evidence-Based
Practice 32012.3 Keeping It Ethical 324
UNIT 4 Decision 329
CHAPTER 13 What Do the Quantitative Data Mean? 331Rosalind M. Peters, Nola A. Schmidt,and Moira Fearncombe
13.1 Using Statistics to Describe the Sample 33113.2 Using Frequencies to Describe Samples 33313.3 Measures of Central Tendency 33713.4 Distribution Patterns 34113.5 Measures of Variability 34413.6 Inferential Statistics: Can the Findings
Be Applied to the Population? 35213.7 Reducing Error When Deciding About
Hypotheses 35513.8 Using Statistical Tests to Make Inferences About
Populations 36113.9 What Does All This Mean for EBP? 37013.10 Keeping It Ethical 373
CHAPTER 14 What Do the Qualitative Data Mean? 379Kristen L. Mauk
14.1 Qualitative Data Analysis 379
CONTENTS xv
14.2 Qualitative Data Interpretation 38514.3 Qualitative Data Evaluation 39114.4 Keeping It Ethical 396
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