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CONTENTS

1 Introduction to Nursing Research and Evidence-Based Practice, 1

2 Introduction to Quantitative Research, 31

3 Introduction to Qualitative Research, 66

4 Examining Ethics in Nursing Research, 93

5 Research Problems, Purposes, and Hypotheses, 129

6 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

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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, tomake 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

http://www.elsevier.com/permissions
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 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

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

vi CONTRIBUTOR AND REVIEWERS

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 chang-

ing 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 gen-

erated 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 oppor-

tunity 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 syn-

thesis being conducted in nursing—systematic review, meta-analysis, 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 experi-

mental 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 phenomenol-

ogy, 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

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 cur-

rent 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 qual-

itative 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 stud-

ies. 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 random-

ized 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. Con-

tent has been expanded and uniquely organized to assist students in critically appraising the reli-

ability 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, pre-

dict 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

ixPREFACE

chapter also includes a current qualitative and quantitative study, and these two studies are crit-

ically 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 guide-

lines 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 stu-

dents 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 amethod 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 out-

comes studies appearing in the nursing literature.

The sixth edition is written and organized to facilitate ease in reading, understanding, and crit-

ically 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 informa-

tion that is important in reading, critically appraising, and using research knowledge in

practice.

This sixth edition ofUnderstanding Nursing Research is appropriate for use in a variety of under-

graduate 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 stu-

dents 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 prac-

ticing 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

x PREFACE

http://evolve.elsevier.com/Grove/understanding/
http://evolve.elsevier.com/Grove/understanding/
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 inte-

grated 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. Power-

Point 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.

xiPREFACE

• 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 inUnderstanding Nursing Research, 6th Edition. Included

for each chapter are a brief Introduction, a Key Terms exercise, Key Ideas exercises, Making Con-

nections 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 through-

out. 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 ques-

tions. 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 Activ-

ities 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 prac-

tice; new Web-Based Activities, an increased emphasis on high-value learning activities, reorga-

nized 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 stu-

dents 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 nav-

igation and usability.

xii PREFACE

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 compo-

nents. 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

xiii

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CHA P T E R

1 Introduction to Nursing Research and

Evidence-Based Practice

CHA P T E R OV E RV I EW

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

L E A RN I NG 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

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.

K E Y T E RMS

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 per-

ceptions 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 newworld tomany 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 (quan-

titative, 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.

2 CHAPTER 1 Introduction to Nursing Research

WHAT IS NURSING RESEARCH?

The word researchmeans “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 stu-

dents, like you, need to be able to read research reports and syntheses of research findings to imple-

ment 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 tech-

nique 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 deter-

mine 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 knowl-

edge 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 evi-

dence, 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

3CHAPTER 1 Introduction to Nursing Research

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 evi-

dence 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 pre-

vention, 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 clin-

ical 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 frommultiple stud-

ies 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 guide-

lines for the management of hypertension in the community (Weber et al, 2014). The JNC 7 guide-

line 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

Best Research Evidence

Clinical Expertise

Patient Needs & Values

Evidence- Based

Practice

FIG 1-1 Model of Evidence-Based Practice (EBP).

4 CHAPTER 1 Introduction to Nursing Research

http://www.nhlbi.nih.gov/guidelines/hypertension
life style modifications (balanced diet, exercise program, normal weight, and nonsmoker) and car-

diovascular disease (CVD) risk factors (hypertension, obesity, dyslipidemia, diabetes mellitus, cig-

arette smoking, physical inactivity, microalbuminuria, and family history of premature CVD)

education. You need to use an evidence-based guideline in monitoring your patients’ blood pres-

sure (BP) and educating them about lifestyle modifications to improve their BP and reduce their

CVD risk factors (NHLBI, 2003; Weber et al., 2014).

The Eighth Joint National Committee (JNC 8) published “2014 Evidence-Based Guideline for

theManagement of High Blood Pressure in Adults” in December of 2013 (James et al. 2013). How-

ever, 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 recom-

mended 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 Amer-

ican 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 moni-

toring 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 mmHg or referral for medication treatment (see Figure 1-2). A