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nursing research

Chapter 8 Clarifying Quantitative Research Designs Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 1 Research Design   Blueprint or detailed plan for conducting a study Purpose, review of literature, and framework provide the basis for the design Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 2 Study Purpose       To describe variables To examine relationships To determine differences To test a treatment To provide a base of evidence for practice A combination of above Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 3 Design Characteristics    Maximizes control over factors to increase validity of the findings Guides the researcher in planning and implementing a study Not specific to a particular study, but linked to other steps of the research process Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 4 Concepts Relevant to Design       Causality Multicausality Probability Bias Control Manipulation Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 5 Causality    There is a cause-and-effect relationship between the variables. The simplest view is one independent variable causing a change in one dependent variable. Independent variable (X) causes Y (a change in the dependent variable). Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 6 Multicausality   There is a cause-and-effect relationship between interrelating variables. There are multiple independent variables causing a change in the dependent variable. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 7 Diagram of Causality and Multicausality Causality: A B Pressure Ulcer Multicausality: Years smoking High-fat diet Limited exercise Heart disease Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 8 Probability     The likelihood of accurately predicting an event Variations in variables occur. Is there relative causality? Therefore, what is the likelihood that a specific cause will result in a specific effect? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 9 Bias    The slanting of findings away from the truth Bias distorts the findings. Research designs should be developed to reduce the likelihood of bias or to control for it. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 10 Potential Causes of Bias in Designs         Researchers Components of the environment and/or setting Individual subjects and/or sample How groups were formed Measurement tools Data collection process Data and duration of study (maturation) Statistical tests and analysis interpretation Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 11 Control     Implemented throughout the design Improved accuracy of findings Increased control in quasi-experimental research Greatest in experimental research Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 12 Manipulation     Implementation of a treatment or intervention The independent variable is controlled. Must be careful to avoid introduction of bias into the study Usually done only in quasi-experimental and experimental designs Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 13 Elements of a Strong Design      Controlling environment: selection of study setting Controlling equivalence of subjects and groups Controlling treatment (Tx) Controlling measurement Controlling extraneous variables Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 14 Critiquing a Study Design    Was the type of design identified? Was the study design linked to the purpose and/or objectives, questions, or hypotheses? Were all variables manipulated or measured? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 15 Critiquing a Study Design (cont’d)    If the study included a treatment, was it clearly described and consistently implemented? Were extraneous variables identified and controlled? What were threats to design validity in study? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 16 Critiquing a Study Design (cont’d)   Was a pilot study performed? What was reason for pilot and the outcome? ➢ ➢ ➢ Study feasibility Refine design or treatment Examine validity and reliability of measurement methods Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 17

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Critiquing a Study Design (cont’d)     How adequate was the manipulation? What elements should have been manipulated to improve the validity of the findings? Based on your assessment of the adequacy of the design, how valid are the findings? Is there another reasonable (valid) explanation (rival hypothesis) for the study findings other than that proposed by the researcher? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 18 Critiquing a Study Design (cont’d)     Identify elements controlled in the study. Identify possible sources of bias. Are there elements that could have been controlled to improve the study design? What elements of the design were manipulated and how were they manipulated? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 19 Types of Quantitative Research Designs     Descriptive study designs Correlational study designs Quasi-experimental study designs Experimental study designs Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 20 Diagramming the Design     Clarifies variables to be measured or manipulated Indicates focus of study: description, relationships, differences, and/or testing a treatment Identifies data collection process: time for study, treatment implementation, measurement of variables Provides direction to data analysis Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 21 Descriptive Study Designs    Typical descriptive design Comparative descriptive design Case study design Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 22 Typical Descriptive Design    Most commonly used design Examines characteristics of a single sample Identifies phenomenon, variables, conceptual and operational definitions, and describes definitions Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 23 Comparative Descriptive Design   Examines differences in variables in two or more groups that occur naturally in a setting Results obtained from these analyses are frequently not generalizable to a population Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 24 Case Study Design      Exploration of single unit of study (i.e., family, group, or community) Even though sample is small, number of variables studied is large. Design can be source of descriptive information to support or invalidate theories. It has potential to reveal important findings that can generate new hypotheses for testing. There is no control. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 25 Correlational Design    Descriptive correlational design Predictive correlational design Model testing design Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 26 Determining Type of Correlational Design Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 27 Descriptive Correlational Design   Describes variables and relationships between variables There is no attempt to control or manipulate the situation. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 28 Predictive Correlational Design     Predicts value of one variable based on values obtained for other variables Independent and dependent variables are defined. Independent variables most effective in prediction are highly correlated with dependent variables Required development of theory-based mathematical hypothesis proposing variables expected to effectively predict dependent variable Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 29 Model Testing Design     Tests accuracy of hypothesized causal model (middle-range theory) All variables are relevant to the model being measured. A large, heterogeneous sample is required. All paths expressing relationships between concepts are identified. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 30 Advantages of Experimental Designs    More controls: design and conduct of study Increased internal validity: decreased threats to design validity Fewer rival hypotheses Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 31 Essential Elements of Experiments Random assignment of subjects to groups Researcher-controlled manipulation of independent variable 3. Researcher control of experimental situation and setting, including control/comparison group 4. Control of variance 1. 2. • • • Clearly spelled out sampling criteria Precisely defined independent variable Carefully measured dependent variable Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 32 Quasi-experimental Design    Untreated control group design with pretest and posttest Nonequivalent dependent variables design Removed-treatment design with pretest and posttest Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 33 Advantages of Quasi-experimental Design    More practical: ease of implementation More feasible: resources, subjects, time, setting More readily generalized: comparable to practice Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 34 Study Groups     Groups in comparative descriptive studies Control group Comparison group Equivalent vs. nonequivalent groups Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 35 Randomized Clinical Trial     The design uses large number of subjects to test a treatment’s effect and compare results with a control group who did not receive the treatment. The subjects come from a reference population. Randomization of subjects is essential. Usually multiple geographic locations are used. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 36 Experimental Interventions    Interventions should result in differences in posttest measures between the treatment and control or comparison groups. Intervention could be physiological, psychosocial, educational, or a combination. Nursing is developing a classification system for interventions. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 37 Critiquing Guidelines for Interventions     Was the experimental intervention described in detail? Was justification from the literature provided for development of the intervention, and what is the current knowledge? Was a protocol developed to ensure consistent implementation of the treatment? Did the study report who implemented the treatment? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 38 Critiquing Guidelines for Interventions (cont’d)   Was any control group intervention described? Was an intervention theory provided to explain conclusions? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 39 Mapping the Design   O = Observation or measurement T = Treatment Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 40 Two-Group Experimental Design Experimental group Control or comparison group Pretest Treatment Posttest O1 T O2 O1 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. O2 41 Quasi-experiment with Several Posttests Posttests Pretest Treatment Experimental group Control or comparison group O1 O1 T 1 Mo 2 Mo 3 4 Mo Mo O2 O3 O4 O5 O2 O3 O4 O5 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 42 Replication Research     Replication or repeating a study to confirm original findings Establishes credibility for the findings Provides support for theory development Encouraged for novice or new researchers ➢ First clinical research project Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 43 Chapter 2 Introduction to the Quantitative Research Process Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 1 Quantitative Research     Formal, objective, rigorous, systematic process for generating information Describes new situations, events, or concepts Examines relationships among variables Determines the effectiveness of treatments Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 2 Quantitative Research (cont’d)     Descriptive Correlational Quasi-experimental Experimental Increased control with type of study Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 3 Descriptive Research    Exploration and description of phenomena in real-life situations New meaning is discovered and the description of concepts is accomplished Helps to identify relationships Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 4 Correlational Research     Looks at the relationship between two or more variables Determines the strength and type of relationships Explains what is seen No cause and effect Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 5 Quasi-experimental Research     Examines cause-and-effect relationships Less control by researcher than true experimental designs Samples are not randomly selected. All variables in the study cannot be controlled by the researcher. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 6 Experimental Research    Looks at cause-and-effect relationships Highly controlled, objective, systematic studies Involves the measurement of independent and dependent variables Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 7 Experimental Research (cont’d)  Main characteristics: ➢ ➢ ➢ Controlled manipulation of at least one independent variable Uses experimental and control groups Random assignment of the sample to the experimental and control groups Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 8 Concepts Relevant to Quantitative Research       Basic research Applied research Rigor Control Extraneous variables Sampling Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 9 Basic Research    Research for the sake of research Research to find out the truth Investigating “what is” Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 10 Applied Research    Attempts to solve real problems in clinical practice Concerns what effects the intervention may have on patients Applies findings in the real world on real patients Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 11 Rigor in Quantitative Research     Striving for excellence in research and adherence to detail Precise measurement tools, a representative sample, and a tightly controlled study design Logical reasoning is essential. Precision, accuracy, detail, and order required Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 12 Control in Quantitative Research   Rules are followed to decrease the possibility of error, and are the design of the study. Different levels of control depending on study ➢ ➢ Quasi-experimental studies partially controlled regarding selection of subjects Experimental studies highly controlled because of precision of sample selection Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 13 Extraneous Variables in Quantitative Research    These occur in all research studies. They may interfere with the hypothesized relationships between variables. The influence of extraneous variables can be decreased through sample selection and the use of defined research settings. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 14 Sampling in Quantitative Research   Process of selecting subjects who are representative of the population Random sampling ➢ ➢  Each member has an equal chance of being selected. Has the most control Convenience sampling ➢ Whoever is available Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 15 Settings in Quantitative Research     The location where studies take place Must be defined in advance Involved in the rigor and control of the study Types of research settings: ➢ ➢ ➢ Natural or field settings Partially controlled settings Highly controlled or laboratory settings Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 16 Control in Quantitative Research Type of Quantitative Research Researcher Control Research Setting Descriptive Uncontrolled Natural or partially controlled Correlational Uncontrolled or partially controlled Natural or partially controlled Quasi-experimental Partially controlled Partially controlled Experimental Highly controlled Laboratory Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 17 Problem-Solving Process    Data collection Problem definition Plan ➢ ➢   Setting goals Identifying solutions Implementation Evaluation and revision Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 18 Steps of the Quantitative Research Process      Research problem and purpose Literature review Study framework Objectives, questions, or hypotheses Study variables Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 19 Steps of the Quantitative Research Process (cont’d)   Assumptions Limitations ➢ ➢    Methodological Theoretical Research design Population and sample Methods of measurement Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 20 Steps of the Quantitative Research Process (cont’d)    Data collection and analysis Research outcomes Communication of findings Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 21 Research Problem and Purpose  Research problem is an area of concern needing research for nursing practice. ➢  The problem identifies, describes, or predicts the research situation. Research purpose comes from the problem and identifies the specific goal or aim of the study. ➢ The purpose includes variables, population, and setting for the study. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 22 Literature Review   Collecting pertinent literature to give in-depth knowledge about the problem Understanding what knowledge exists to make changes in practice Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 23 Study Framework   Framework is the abstract, theoretical basis for a study that enables the researcher to link the findings to nursing’s body of knowledge. Theory is an integrated set of defined concepts and relational statements that present a view of a phenomenon and can be used to describe, explain, predict, or control phenomena. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 24 Research Objectives, Questions, and Hypotheses   All identify relationship between variables and indicate population to be studied Narrower in focus than the purpose and often specify only one or two research variables Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 25 Study Variables  Variables are concepts that are measured, manipulated, or controlled in a study. ➢ ➢   Concrete variables: temperature, weight Abstract variables: creativity, empathy Conceptual definition: gives meaning to a concept Operational definition: variable can be measured using this description Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 26 Example of Definitions: Physical Symptoms  Conceptual definition ➢ Physical symptoms are “behavioral manifestations that result directly from the traumagenic dynamics of child sexual abuse.” (Hulme & Grove, 1994, p. 522)  Operational definition ➢ ASI questionnaire was used to measure physical symptoms Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 27 Assumptions     Statements are taken for granted or are considered true. Assumptions are often unrecognized in thinking and behavior. Sources of assumptions are universally accepted truths. They are often embedded in the philosophical base of the study’s framework. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 28 Limitations   Restrictions in a study that may decrease the credibility and generalizability of the findings Theoretical limitations ➢ ➢  Restrict the generalization of the findings Reflected in the framework and definitions Methodological limitations ➢ Restrict the population to which the findings can be generalized ➢ May result from an unrepresentative sample or weak design Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 29 Research Design    Blueprint for conducting the study Maximizes control over factors that could interfere with the study’s desired outcome Directs the selection of the population, sampling, methods of measure, plans for data collection, and analysis Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 30 Population and Sample Population   Sample All elements that meet certain criteria for inclusion in study Example: all women students in higher education   A subset of the population that is selected for study Example: women students in three state universities in the Southwest (Hulme & Grove, 1994) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 31 Methods of Measurement     Assigning numbers to objects Application of rules to development of a measurement device or instrument Data are gathered at the nominal, ordinal, interval, or ratio level of measurement. Must examine reliability and validity of measurement tool ➢ ➢ Reliability: consistency of the tool Validity: does it measure what it is supposed to measure? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 32 Data Collection     Precise, systematic gathering of information for the study Consent must be obtained from the sample. Researchers use observation, interviews, questionnaires, or scales to gather information. Described under the “procedures” section of a research article Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 33 Data Analysis   Reduce, organize, and give meaning to data Descriptive and inferential analysis of data Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 34 Results   Descriptions of findings after data were analyzed Usually organized by research objectives, questions, or hypotheses Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 35 Research Outcomes     Interprets data findings in meaningful manner Involves forming conclusions and considering implications for nursing Suggests future studies Generalizes the findings Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 36 Research Reports and Communication of Findings   Summarizes major elements of a study and identifies contributions of study to nursing knowledge Presented at professional meetings and conferences and published in journals and books Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 37 Content of Research Reports       Abstract—summary of study in 100 to 250 words Introduction—problem, purpose, literature, framework, and hypothesis Methods—design, sample, setting, tool Results—data analysis procedures Discussion—findings, conclusions, implications Reference list—all sources cited Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 38 Skimming a Research Report     Quickly review source for broad overview. Read title, author’s name, abstract, introduction, and discussion. Examine conclusions and implications. Give preliminary judgment of study. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 39 Comprehending a Research Report    Type of study conducted—highlight key points Knowledge available on topic Expertise of researcher ➢  Replication versus original research Funding resources of researcher ➢ ➢ Amount of funding Sources of funding Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 40 Analyzing a Research Report    Examine parts of report in depth for accuracy, completeness, uniqueness of information, and organization. Was research process logically presented? Examine discussion section for critical arguments. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 41 Initial Research Report Critique      What type of study was conducted? What was the setting for the study? Were steps for the research process clearly identified? Were any of steps missing? Did the steps logically link together? Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 42 Chapter 3 Introduction to the Qualitative Research Process Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 1 Qualitative Research     A systematic, subjective approach used to describe life experiences and give them meaning Useful in understanding human experiences such as pain, caring, powerlessness, and comfort Focuses on understanding the whole Consistent with holistic philosophy of nursing Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 2 Frameworks for Qualitative Studies    The goal of qualitative research is not hypothesis testing. Frameworks are used in a different sense in qualitative research. Each type of qualitative research is guided by a particular philosophical stance. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 3 Data from Qualitative Studies   Are subjective Incorporate perceptions and beliefs of researcher and participants Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 4 Four Approaches to Qualitative Research     Phenomenological: Describes and captures the “lived experience” of study participants Grounded theory: Explores how people define reality and how their beliefs are related to actions Ethnographic: Seeks to understand people (ways of living, believing, adapting, etc.) Historical research: Searches throughout history for generalities Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 5 Methods Similar in Qualitative and Quantitative Research       Select topic. State problem or question. Justify significance of study. Design study. Identify and gain access to data sources. Select study subjects. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 6 Methods Unique to Qualitative Research       Selection of subjects Researcher-participant relationship Data collection methods Data management Data analysis Interpretation Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 7 Selection of Subjects (Participants)    Subjects are referred to as participants. May volunteer to be involved in study May be selected by researcher because of their particular knowledge, experience, or views related to study Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 8 Purposive Sampling Methods    May select individuals typical in relation to the phenomenon under study May seek out individuals different in some way from other participants to get diverse perspectives Snowballing technique is commonly used. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 9 Sample Size  Decisions regarding sample size differ from quantitative studies. ➢ ➢ ➢ ➢ Based on needs related to study purpose Number of subjects is usually smaller Case studies with only one subject may be used Six to 10 subjects not unusual Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 10 Characteristics of ResearcherParticipant Relationships    Participants are treated as colleagues rather than subjects. The researcher must have the support and confidence of participants to the complete study. Maintaining relationships is of utmost importance. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 11 Data Collection Methods: Observation       What is going on here? Look and listen carefully. Note routine activities. Focus on details. Note processes as well as discrete events. Note unexpected events. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 12 Data Collection Methods: Interviews      Open-ended format Researcher defines focus. No fixed sequence of questions Questions tend to change as researcher gains insights from previous interviews and/or observations. Respondents are encouraged to raise issues not addressed by researcher. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 13 Data Collection Methods: Text     May be written by participants on a particular topic at request of researcher Narratives may be solicited by mail rather than in person. Text developed for other purposes, such as patient records or procedure manuals, can be accessed for qualitative analysis. Published text (books, newspapers, etc.) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 14 Data Management Characteristics   Qualitative data analysis occurs concurrently with data collection rather than sequentially, as in quantitative research. The researcher is simultaneously gathering data, managing a growing bulk of collected data, and interpreting the meaning of data. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 15 Goals of Description  Become familiar with data. ➢ ➢ ➢ ➢  Read and reread notes and transcripts. Recall observations and experiences. Listen to audiotapes. View videotapes. Become immersed in data. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 16 Types of Descriptive Analysis     Reflexive thought Bracketing Data reduction Coding Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 17 Reflexive Thought   Researcher explores personal feelings and experiences that may influence study and integrates this understanding into study. Requires conscious awareness of self Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 18 Bracketing   Used in some phenomenological research to help researcher avoid misinterpreting phenomenon as it is being experienced by participants Bracketing is suspending or laying aside what researcher knows about experience being studied. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 19 Data Reduction    Analysis focuses on reducing large volume of acquired data to facilitate examination. Researcher begins to attach meaning to elements of data. Researcher discovers classes of things, persons, events, and properties. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 20 Coding    Way of indexing or identifying categories in data Codes may be placed in data at time of data collection, when entering data into computer, and during later examination of data. Data segments can then be retrieved by coding category. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 21 Data Displays    Are equivalent to summary tables used in quantitative studies Allow researcher to convey succinctly main ideas of study Codes used to organize the display Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 22 Types of Data Analysis     Coding Memos Storytelling Narrative analysis Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 23 Coding  Coding, used earlier for description, also can be used to expand, transform, and reconceptualize data, providing opportunities for more diverse analyses. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 24 Memos    Used to record insights or ideas related to notes, transcripts, or codes Moves researcher toward theorizing and is conceptual rather than factual May link data or use specific piece of data as an example of conceptual idea Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 25 Storytelling    Can be instructive in understanding a phenomenon of interest Includes a sequence of events with a beginning, middle, and an end Stories have their own logic and are temporal. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 26 Narrative Analysis    A qualitative means of formally analyzing stories Researcher unpacks story structure. Can be used to determine how people tell stories ➢ ➢ ➢ ➢ How they shape the events How they make a point How they “package” events and react to them How they communicate their stories to audiences Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 27 Interpretation of Qualitative Results     The researcher offers his or her interpretation of what is going on. The focus is on understanding and explaining beyond that which can be stated with certainty. May focus on usefulness of findings for clinical practice. Researcher develops hunches about relationships that can be used to formulate tentative propositions. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 28 Rigor in Qualitative Research   Rigor needs to be defined differently in qualitative research because desired outcome is different. Evaluation of rigor is based, in part, on logic of emerging theory and clarity with which it sheds light on phenomenon studied. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 29 Characteristics of Rigor     Openness Scrupulous adherence to a philosophical perspective Thoroughness in collecting data Consideration of all data in subjective theory development phase Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 30 Causes for Lack of Rigor       Inconsistency in adhering to philosophy of approach being used Failure to get away from older ideas Poorly developed methods Insufficient time spent collecting data Poor observations Failure to give careful consideration to all data Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 31 Description of Decision Trails   Strategies by which other researchers, using the same data, can follow logic of original researcher and arrive at same conclusions Requires researcher to establish rules for categorizing data, arriving at ratings, or making judgments Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 32 Requirements for Decision Trails   A record is kept of all decision rules used in data analysis to support the study’s conclusions and emerging theory. All raw data are stored and available for review, if requested. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 33 Opposition to Decision Trails   Some qualitative researchers are concerned that data analysis would become too mechanistic. Some qualitative researchers are opposed to the expectation that other researchers will reach the same conclusions when each researcher’s work is unique. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 34 Understanding Nursing Research Building an Evidence-Based Practice SIXTH EDITION Susan K. Grove, PhD, RN, ANP-BC, GNP-BC Professor Emerita, College of Nursing, The University of Texas at Arlington, Arlington, Texas Adult Nurse Practitioner, Family Practice, Grand Prairie, Texas Jennifer R. Gray, PhD, RN, FAAN George W. and Hazel M. Jay Professor, College of Nursing, Associate Dean, College of Nursing, The University of Texas at Arlington, Arlington, Texas Nancy Burns, PhD, RN, FCN, FAAN Professor Emerita, College of Nursing, The University of Texas at Arlington, Arlington, Texas Faith Community Nurse, St. Matthew Cumberland Presbyterian Church, Burleson, Texas Table of Contents Cover image Title page Inside Front Cover Copyright Contributor and Reviewers Dedication Preface Acknowledgments Chapter 1: Introduction to Nursing Research and Evidence-Based Practice What is Nursing Research? What is Evidence-Based Practice? Purposes of Research for Implementing an Evidence-Based Nursing Practice Historical Development of Research in Nursing Acquiring Knowledge in Nursing Acquiring Knowledge Through Nursing Research Understanding Best Research Evidence for Practice What Is Your Role in Nursing Research? Key Concepts Chapter 2: Introduction to Quantitative Research What is Quantitative Research? Problem-Solving and Nursing Processes: Basis for Understanding the Quantitative Research Process Identifying the Steps of the Quantitative Research Process Reading Research Reports Practice Reading Quasi-Experimental and Experimental Studies Key Concepts Chapter 3: Introduction to Qualitative Research Values of Qualitative Researchers Rigor in Qualitative Research Qualitative Research Approaches Qualitative Research Methodologies Data Collection Methods Data Management Data Analysis Key Concepts Chapter 4: Examining Ethics in Nursing Research Historical Events Influencing the Development of Ethical Codes and Regulations Protecting Human Rights Understanding Informed Consent Understanding Institutional Review Examining the Benefit-Risk Ratio of a Study Understanding Research Misconduct Examining the Use of Animals in Research Key Concepts Chapter 5: Research Problems, Purposes, and Hypotheses What Are Research Problems and Purposes? Identifying the Problem and Purpose in Quantitative, Qualitative, and Outcomes Studies Determining the Significance of a Study Problem and Purpose Examining the Feasibility of a Problem and Purpose Examining Research Objectives, Questions, and Hypotheses in Research Reports Understanding Study Variables and Research Concepts Key Concepts Chapter 6: Understanding and Critically Appraising the Literature Review Purpose of the Literature Review Sources Included in a Literature Review Critically Appraising Literature Reviews Reviewing the Literature Key Concepts Chapter 7: Understanding Theory and Research Frameworks What is a Theory? Understanding the Elements of Theory Levels of Theoretical Thinking Examples of Critical Appraisal Key Concepts Chapter 8: Clarifying Quantitative Research Designs Identifying Designs Used in Nursing Studies Descriptive Designs Correlational Designs Understanding Concepts Important to Causality in Designs Examining the Validity of Studies Elements of Designs Examining Causality Quasi-Experimental Designs Experimental Designs Randomized Controlled Trials Introduction to Mixed-Methods Approaches Key Concepts Chapter 9: Examining Populations and Samples in Research Understanding Sampling Concepts Representativeness of a Sample in Quantitative and Outcomes Research Probability Sampling Methods Nonprobability Sampling Methods Commonly Used in Quantitative Research Sample Size in Quantitative Studies Sampling in Qualitative Research Sample Size in Qualitative Studies Research Settings Key Concepts Chapter 10: Clarifying Measurement and Data Collection in Quantitative Research Concepts of Measurement Theory Accuracy, Precision, and Error of Physiological Measures Use of Sensitivity, Specificity, and Likelihood Ratios to Determine the Quality of Diagnostic AND Screening Tests Measurement Strategies in Nursing Data Collection Process Key Concepts Chapter 11: Understanding Statistics in Research Understanding the Elements of the Statistical Analysis Process Understanding Theories and Concepts of the Statistical Analysis Process Using Statistics to Describe Determining the Appropriateness of Inferential Statistics in Studies Using Statistics to Examine Relationships Using Statistics to Predict Outcomes Using Statistics to Examine Differences Interpreting Research Outcomes Key Concepts Chapter 12: Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice When are Critical Appraisals of Studies Implemented in Nursing? What are the Key Principles for Conducting Intellectual Critical Appraisals of Quantitative and Qualitative Studies? Understanding the Quantitative Research Critical Appraisal Process Example of a Critical Appraisal of a Quantitative Study Understanding the Qualitative Research Critical Appraisal Process Example of a Critical Appraisal of a Qualitative Study Key Concepts Chapter 13: Building an Evidence-Based Nursing Practice Benefits and Barriers Related to Evidence-Based Nursing Practice Searching for Evidence-Based Sources Critically Appraising Research Syntheses Developing Clinical Questions to Identify Existing Research-Based Evidence for Use in Practice Models to Promote Evidence-Based Practice in Nursing Implementing Evidence-Based Guidelines in Practice Introduction to Evidence-Based Practice Centers Introduction to Translational Research Key Concepts Chapter 14: Outcomes Research Theoretical Basis of Outcomes Research Nursing-Sensitive Outcomes Origins of Outcomes and Performance Monitoring Federal Government Involvement in Outcomes Research Advanced Practice Nursing Outcomes Research Outcomes Research and Nursing Practice Methodologies for Outcomes Studies Statistical Methods for Outcomes Studies Critical Appraisal of Outcomes Studies Key Concepts Glossary Index Inside Back Cover Inside Front Cover Copyright 3251 Riverport Lane St. Louis, Missouri 63043 UNDERSTANDING NURSING RESEARCH: BUILDING AN EVIDENCE-BASED PRACTICE, EDITION SIX ISBN: 978-1-4557-7060-1 Copyright © 2015, 2011, 2007, 2003, 1999, 1995 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher ’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-7060-1 Executive Content Strategist: Lee Henderson Content Development Manager: Billie Sharp Content Development Specialist: Charlene Ketchum Publishing Services Manager: Deborah L. Vogel Project Manager: Bridget Healy Design Direction: Maggie Reid Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 Contributor and Reviewers Contributor Diane Doran, RN, PhD, FCAHS, Professor Emerita, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario Revised Chapter 14 Reviewers Lisa D. Brodersen, EdD, MA, RN , Professor, Coordinator of Institutional Research and Effectiveness, Allen College, Waterloo, Iowa Sara L. Clutter, PhD, RN , Associate Professor of Nursing, Waynesburg University, Waynesburg, Pennsylvania Jacalyn P. Dougherty, PhD, RN , Nursing Research Consultant, JP Dougherty LLC, Aurora, Colorado Joanne T. Ehrmin, RN, COA-CNS, PhD, MSN, BSN , Professor, University of Toledo, College of Nursing, Toledo, Ohio Betsy Frank, PhD, RN, ANEF , Professor Emerita, Indiana State University College of Nursing, Health, and Human Services, Terre Haute, Indiana Tamara Kear, PhD, RN, CNS, CNN , Assistant Professor of Nursing, Villanova University, Villanova, Pennsylvania Sharon Kitchie, PhD, RN , Adjunct Instructor, Keuka College, Keuka Park, New York Madelaine Law rence, PhD, RN , Associate Professor, University of North Carolina at Wilmington, Wilmington, North Carolina Robin Moyers, PhD, RN-BC, Nurse Educator, Carl Vinson VA Medical Center, Dublin, Georgia Sue E. Odom, DSN, RN , Professor of Nursing, Clayton State University, Morrow, Georgia Teresa M. O’Neill, PhD, APRN, RNC, Professor, Our Lady of Holy Cross College, New Orleans, Louisiana Sandra L. Siedlecki, PhD, RN, CNS, Senior Nurse Scientist, Cleveland Clinic, Cleveland, Ohio Sharon Souter, PhD, RN, CNE, Dean and Professor, University of Mary Hardin Baylor, Belton, Texas Molly J. Walker, PhD, RN, CNS, CNE, Professor, Angelo State University, San Angelo, Texas Cynthia Ward, DNP, RN-BC, CMSRN, ACNS-BC, Surgical Clinical Nurse Specialist, Carilion Roanoke Memorial Hospital, Roanoke, Virginia Angela Wood, PhD, RN, Certified High-Risk Prenatal Nurse, Associate Professor and Chair, Department of Nursing, Carson-Newman University, Jefferson City, Tennessee Fatma A. Youssef, RN, DNSc, MPH , Professor Emerita, Marymount University, School of Health Professions, Arlington, Virginia Dedication To all nurses who change the lives of patients through applying the best research evidence. —Susan, Jennifer, and Nancy To my husband Jay Suggs who has provided me endless love and support during my development of research textbooks over the last 30 years. —Susan To my husband Randy Gray who is my love and my cheerleader. —Jennifer To my husband Jerry who has supported all of my academic endeavors through 58 years of marriage. —Nancy Preface Research is a major force in nursing, and the evidence generated from research is constantly changing practice, education, and health policy. Our aim in developing this essentials research text, Understanding Nursing Research: Building an Evidence-Based Practice, is to create an excitement about research in undergraduate students. The text emphasizes the importance of baccalaureate-educated nurses being able to read, critically appraise, and synthesize research so this evidence can be used to make changes in practice. A major goal of professional nursing and health care is the delivery of evidence-based care. By making nursing research an integral part of baccalaureate education, we hope to facilitate the movement of research into the mainstream of nursing. We also hope this text increases student awareness of the knowledge that has been generated through nursing research and that this knowledge is relevant to their practice. Only through research can nursing truly be recognized as a profession with documented effective outcomes for the patient, family, nurse provider, and healthcare system. Because of this expanded focus on evidence-based practice (EBP), we have subtitled this edition Building an Evidence-Based Practice. Developing a sixth edition of Understanding Nursing Research has provided us with an opportunity to clarify and refine the essential content for an undergraduate research text. The text is designed to assist undergraduate students in overcoming the barriers they frequently encounter in understanding the language used in nursing research. The revisions in this edition are based on our own experiences with the text and input from dedicated reviewers, inquisitive students, and supportive faculty from across the country who provided us with many helpful suggestions. Chapter 1, Introduction to Nursing Research and Evidence-Based Practice, introduces the reader to nursing research, the history of research, and the significance of research evidence for nursing practice. This chapter has been revised to include the most relevant types of research synthesis being conducted in nursing—systematic review, metaanalysis, meta-synthesis, and mixed-methods systematic review. The discussion of research methodologies and their importance in generating an evidence-based practice for nursing has been updated and expanded to include the exploratory-descriptive qualitative research method. A discussion of the Quality and Safety Education for Nursing (QSEN) competencies and their link to research has been included in this edition. Selected QSEN competencies are linked to the findings from studies presented as examples throughout the text to increase students’ understanding of the importance in delivering quality, safe health care to patients and families. Chapter 2, Introduction to Quantitative Research, presents the steps of the quantitative research process in a concise, clear manner and introduces students to the focus and findings of quantitative studies. Extensive, recent examples of descriptive, correlational, quasi-experimental, and experimental studies are provided, which reflect the quality of current nursing research. Chapter 3, Introduction to Qualitative Research, describes five approaches to qualitative research and the philosophies upon which they are based. These approaches include phenomenology, grounded theory, ethnography, exploratory-descriptive qualitative, and historical research. Data collection and analysis methods specific to qualitative research are discussed. Guidelines for reading and critically appraising qualitative studies are explained using examples of published studies. Chapter 4, Examining Ethics in Nursing Research, provides an extensive discussion of the use of ethics in research and the regulations that govern the research process. Detailed content and current websites are provided to promote students’ understanding of the Health Insurance Portability and Accountability Act (HIPAA), the U.S. Department of Health and Human Services Protection of Human Subjects, and the Federal Drug Administration regulations. Guidelines are provided to assist students in critically appraising the ethical discussions in published studies and to participate in the ethical review of research in clinical agencies. Chapter 5, Research Problems, Purposes, and Hypotheses, clarifies the difference between a problem and a purpose. Example problem and purpose statements are included from current qualitative, quantitative, and outcome studies. Detailed guidelines are provided with examples to direct students in critically appraising the problems, purposes, hypotheses, and variables in studies. Chapter 6, Understanding and Critically Appraising the Literature Review, begins with a description of the content and quality of different types of publications that might be included in a review. Guidelines for critically appraising published literature reviews are explored with a focus on the differences in the purpose and timing of the literature review in quantitative and qualitative studies. The steps for finding appropriate sources, reading publications, and synthesizing information into a logical, cohesive review are presented. Chapter 7, Understanding Theory and Research Frameworks, briefly describes grand, middle range, physiological, and scientific theories as the bases for study frameworks. The purpose of a research framework is discussed with the acknowledgement that the framework may be implicit. Guidelines for critically appraising the study framework are presented as well. The guidelines are applied to studies with frameworks derived from research findings and from different types of theories. Chapter 8, Clarifying Quantitative Research Designs, addresses descriptive, correlational, quasi-experimental, and experimental designs and criteria for critically appraising these designs in studies. The major strengths and threats to design validity are summarized in a table and discussed related to current studies. This chapter has been expanded to include an introduction to randomized controlled trials (RCT) and mixed-methods approaches being conducted by nurses. Chapter 9, Examining Populations and Samples in Research, provides a detailed discussion of the concepts of sampling in research. Different types of sampling methods for both qualitative and quantitative research are described. Guidelines are included for critically appraising the sampling criteria, sampling method, and sample size of quantitative and qualitative studies. Chapter 10, Clarifying Measurement and Data Collection in Quantitative Research, has been updated to reflect current knowledge about measurement methods used in nursing research. Content has been expanded and uniquely organized to assist students in critically appraising the reliability and validity of scales; precision and accuracy of physiologic measures; and the sensitivity, specificity, and likelihood ratios of diagnostic and screening tests. Chapter 11, Understanding Statistics in Research, focuses on the theories and concepts of the statistical analysis process and the statistics used to describe variables, examine relationships, predict outcomes, and examine group differences in studies. Guidelines are provided for critically appraising the results and discussion sections of nursing studies. The results from selected studies are critically appraised and presented as examples throughout this chapter. Chapter 12, Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice, summarizes and builds on the critical appraisal content provided in previous chapters and offers direction for conducting critical appraisals of quantitative and qualitative studies. The guidelines for critically appraising qualitative studies have been significantly revised and simplified. This chapter also includes a current qualitative and quantitative study, and these two studies are critically appraised using the guidelines provided in this chapter. Chapter 13, Building an Evidence-Based Nursing Practice, has been significantly updated to reflect the current trends in health care to provide evidence-based nursing practice. Detailed guidelines are provided for critically appraising the four common types of research synthesis conducted in nursing (systematic review, meta-analysis, metasynthesis, and mixed-method systematic review). These guidelines were used to critically appraise current research syntheses to assist students in examining the quality of published research syntheses and the potential use of research evidence in practice. The chapter includes theories to assist nurses and agencies in moving toward EBP. Translational research is introduced as a method for promoting the use of research evidence in practice. Chapter 14, Introduction to Outcomes Research, was significantly revised by Dr. Diane Doran, one of the leading authorities in the conduct of outcomes research. The goal of this chapter is to increase students’ understanding of the impact of outcomes research on nursing and health care. Content and guidelines are provided to assist students in reading and critically appraising the outcomes studies appearing in the nursing literature. The sixth edition is written and organized to facilitate ease in reading, understanding, and critically appraising studies. The major strengths of the text are as follows: • State-of-the art coverage of EBP—a topic of vital importance in nursing. • Balanced coverage of qualitative and quantitative research methodologies. • Rich and frequent illustration of major points and concepts from the most current nursing research literature from a variety of clinical practice areas. • Study findings implications for practice and link to QSEN competencies were provided. • A clear, concise writing style that is consistent among the chapters to facilitate student learning. • Electronic references and websites that direct the student to an extensive array of information that is important in reading, critically appraising, and using research knowledge in practice. This sixth edition of Understanding Nursing Research is appropriate for use in a variety of undergraduate research courses for both RN and general students because it provides an introduction to quantitative, qualitative, and outcomes research methodologies. This text not only will assist students in reading research literature, critically appraising published studies, and summarizing research evidence to make changes in practice, but it also can serve as a valuable resource for practicing nurses in critically appraising studies and implementing research evidence in their clinical settings. Learning Resources to Accompany Understanding Nursing Research, 6th Edition The teaching/learning resources to accompany Understanding Nursing Research have been expanded for both the instructor and student to allow a maximum level of flexibility in course design and student review. Evolve Instructor Resources A comprehensive suite of Instructor Resources is available online at and consists of a Test Bank, PowerPoint slides, an Image Collection, Answer Guidelines for the Appraisal Exercises provided for students, and new TEACH for Nurses Lesson Plans, which replace and enhance the Instructor’s Manual provided for previous editions. Test Bank The Test Bank consists of approximately 550 NCLEX® Examination–style questions, including approximately 10% of questions in alternate item formats. Each question is coded with the correct answer, a rationale from the textbook, a page cross-reference, and the cognitive level in the new Bloom’s Taxonomy (with the cognitive level from the original Bloom’s Taxonomy in parentheses). The Test Bank is provided in ExamView and Evolve LMS formats. PowerPoint Slides The PowerPoint slide collection contains approximately 800 slides, now including seamlessly integrated Audience Response System Questions, images, and new Unfolding Case Studies. The PowerPoints have been simplified and converted into bulleted-list format (using less narrative). Content details in the slides have been moved as appropriate into the Notes area of the slides. New Unfolding Case Studies focus on practical EBP/PICO questions, such as a nurse on a unit needing to perform a literature search or to identify a systematic review or meta-analysis. PowerPoint presentations are fully customizable. Image Collection The electronic Image Collection consists of all images from the text. This collection can be used in classroom or online presentations to reinforce student learning. New TEACH for Nurses Lesson Plans TEACH for Nurses is a robust, customizable, ready-to-use collection of chapter-bychapter Lesson Plans that provide everything you need to create an engaging and effective course. Each chapter includes the following: • Objectives • Teaching Focus • Key Terms • Nursing Curriculum Standards QSEN/NLN Competencies Concepts BSN Essentials • Student Chapter Resources • Instructor Chapter Resources • Teaching Strategies • In-Class/Online Case Study Evolve Student Resources The Evolve Student Resources include interactive Review Questions, a Research Article Library consisting of 10 full-text research articles, Critical Appraisal Exercises based on the articles in the Research Article Library, and new Printable Key Points. • The interactive Review Questions (approximately 25 per chapter) aid the student in reviewing and focusing on the chapter material. • The Research Article Library is an updated collection of 10 research articles, taken from leading nursing journals. • The Critical Appraisal Exercises are a collection of application exercises, based on the articles in the Research Article Library, that help students learn to appraise and apply research findings. Answer Guidelines are provided for the instructor. • New Printable Key Points provide students with a convenient review tool. Study Guide The companion Study Guide, written by the authors of the main text, provides both timetested and innovative exercises for each chapter in Understanding Nursing Research, 6th Edition. Included for each chapter are a brief Introduction, a Key Terms exercise, Key Ideas exercises, Making Connections exercises, Exercises in Critical Analysis, and Going Beyond exercises. An integral part of the Study Guide is an appendix of three published research studies, which are referenced throughout. These three recently published nursing studies (two quantitative studies and one qualitative study) can be used in classroom or online discussions, as well as to address the Study Guide questions. The Study Guide provides exercises that target comprehension of concepts used in each chapter. Exercises — including fill-in-the-blank, matching, and multiple-choice questions — encourage students to validate their understanding of the chapter content. Critical Appraisal Activities provide students with opportunities to apply their new research knowledge to evaluate the quantitative and qualitative studies provided in the back of the Study Guide. New to this edition are the following features: an increased emphasis on evidencebased practice; new Web-Based Activities, an increased emphasis on high-value learning activities, reorganized back-matter for quick reference, and quick-reference printed tabs. • Increased emphasis on evidence-based practice: This edition of the Study Guide features an expanded focus on evidence-based practice (EBP) to match that of the revised textbook. This focus helps students who are new to nursing research see the value of understanding the research process and applying it to evidence-based nursing practice. • Web-Based Activities: Each chapter now includes a Web-Based Activity section, to teach students to use the Internet appropriately for scholarly research and EBP. • Increased high-value learning activities: The use of crossword puzzles has been reduced to allow room for the addition of learning activities with greater learning value. • Back matter reorganized for quick reference: The “Answers to Study Guide Exercises” has been retitled “Answer Key” and not numbered as an appendix. Each of the three published studies are now separate appendix (three appendices total), rather than a single appendix. This simplifies cross referencing in the body of the Study Guide. • Quick-reference printed tabs: Quick-reference printed tabs have been added to differentiate the Answer Key and each of the book’s three published studies (four tabs total), for improved navigation and usability. Acknowledgments Developing this essentials research text was a 2-year project, and there are many people we would like to thank. We want to extend a very special thank you to Dr. Diane Doran for her revision of Chapter 14 focused on outcomes research. We are very fortunate that she was willing to share her expertise and time so that students might have the most current information about outcomes research. We want to express our appreciation to the Dean and faculty of The University of Texas at Arlington College of Nursing for their support and encouragement. We also would like to thank other nursing faculty members across the world who are using our book to teach research and have spent valuable time to send us ideas and to identify errors in the text. Special thanks to the students who have read our book and provided honest feedback on its clarity and usefulness to them. We would also like to recognize the excellent reviews of the colleagues, listed on the previous pages, who helped us make important revisions in the text. In conclusion, we would like to thank the people at Elsevier who helped produce this book. We thank the following individuals who have devoted extensive time to the development of this sixth edition, the instructor’s ancillary materials, student study guide, and all of the web-based components. These individuals include: Lee Henderson, Billie Sharp, Charlene Ketchum, Bridget Healy, Jayashree Balasubramaniam, and Vallavan Udayaraj. Susan K. Grove PhD, RN, ANP-BC, GNP-BC Jennifer R. Gray PhD, RN, FAAN Nancy Burns PhD, RN, FCN, FAAN C H AP T E R 1 Introduction to Nursing Research and Evidence-Based Practice CHAPTER OVERVIEW What Is Nursing Research? What Is Evidence-Based Practice? Purposes of Research for Implementing an Evidence-Based Nursing Practice Description Explanation Prediction Control Historical Development of Research in Nursing Florence Nightingale Nursing Research: 1900s through the 1970s Nursing Research: 1980s and 1990s Nursing Research: in the Twenty-First Century Acquiring Knowledge in Nursing Traditions Authority Borrowing Trial and Error Personal Experience Role Modeling Intuition Reasoning Acquiring Knowledge through Nursing Research Introduction to Quantitative and Qualitative Research Introduction to Outcomes Research Understanding Best Research Evidence for Practice Strategies Used to Synthesize Research Evidence Levels of Research Evidence Introduction to Evidence-Based Guidelines What Is Your Role in Nursing Research? Key Concepts References Learning Outcomes After completing this chapter, you should be able to: 1. Define research, nursing research, and evidence-based practice. 2. Describe the purposes of research in implementing an evidence-based practice for nursing. 3. Describe the past and present activities influencing research in nursing. 4. Discuss the link of Quality and Safety Education for Nurses (QSEN) to research. 5. Apply the ways of acquiring nursing knowledge (tradition, authority, borrowing, trial and error, personal experience, role modeling, intuition, reasoning, and research) to the interventions implemented in your practice. 6. Identify the common types of research—quantitative, qualitative, or outcomes— conducted to generate essential evidence for nursing practice. 7. Describe the following strategies for synthesizing healthcare research: systematic review, meta-analysis, meta-synthesis, and mixed-methods systematic review. 8. Identify the levels of research evidence available to nurses for practice. 9. Describe the use of evidence-based guidelines in implementing evidence-based practice. 10. Identify your role in research as a professional nurse. Key Terms Authority, p. 16 Best research evidence, p. 3 Borrowing, p. 16 Case study, p. 11 Clinical expertise, p. 4 Control, p. 8 Critical appraisal of research, p. 27 Deductive reasoning, p. 18 Description, p. 6 Evidence-based guidelines, p. 25 Evidence-based practice (EBP), p. 3 Explanation, p. 7 Gold standard, p. 25 Inductive reasoning, p. 18 Intuition, p. 18 Knowledge, p. 15 Mentorship, p. 18 Meta-analysis, p. 22 Meta-synthesis, p. 23 Mixed-methods systematic review, p. 23 Nursing research, p. 3 Outcomes research, p. 21 Personal experience, p. 17 Prediction, p. 7 Premise, p. 18 Qualitative research, p. 20 Qualitative research synthesis, p. 23 Quality and Safety Education for Nurses (QSEN), p. 15 Quantitative research, p. 19 Reasoning, p. 18 Research, p. 3 Role modeling, p. 17 Systematic review, p. 22 Traditions, p. 16 Trial and error, p. 17 Welcome to the world of nursing research. You may think it strange to consider research a world, but it is a truly new way of experiencing reality. Entering a new world means learning a unique language, incorporating new rules, and using new experiences to learn how to interact effectively within that world. As you become a part of this new world, you will modify and expand your perceptions and methods of reasoning. For example, using research to guide your practice involves questioning, and you will be encouraged to ask such questions as these: • What is the patient’s healthcare problem? • What nursing intervention would effectively manage this problem in your practice? • Is this nursing intervention based on sound research evidence? • Would another intervention be more effective in improving your patient’s outcomes? • How can you use research most effectively in promoting an evidence-based practice (EBP)? Because research is a new world to many of you, we have developed this text to facilitate your entry into and understanding of this world and its contribution to the delivery of quality, safe nursing care. This first chapter clarifies the meaning of nursing research and its significance in developing an evidence-based practice (EBP) for nursing. This chapter also explores the research accomplishments in the profession over the last 160 years. The ways of acquiring knowledge in nursing are discussed, and the common research methodologies used for generating research evidence for practice (quantitative, qualitative, and outcomes research) are introduced. The critical elements of evidencebased nursing practice are introduced, including strategies for synthesizing research evidence, levels of research evidence or knowledge, and evidence-based guidelines. Nurses’ roles in research are described based on their level of education and their contributions to the implementation of EBP. What is Nursing Research? The word research means “to search again” or “to examine carefully.” More specifically, research is a diligent, systematic inquiry, or study that validates and refines existing knowledge and develops new knowledge. Diligent, systematic study indicates planning, organization, and persistence. The ultimate goal of research is the development of an empirical body of knowledge for a discipline or profession, such as nursing. Defining nursing research requires determining the relevant knowledge needed by nurses. Because nursing is a practice profession, research is essential to develop and refine knowledge that nurses can use to improve clinical practice and promote quality outcomes (Brown, 2014; Doran, 2011). Expert researchers have studied many interventions, and clinicians have synthesized these studies to provide guidelines and protocols for use in practice. Practicing nurses and nursing students, like you, need to be able to read research reports and syntheses of research findings to implement evidencebased interventions in practice and promote positive outcomes for patients and families. For example, extensive research has been conducted to determine the most effective technique for administering medications through an intramuscular (IM) injection. This research was synthesized and used to develop evidence-based guidelines for administering IM injections (Cocoman & Murray, 2008; Nicoll & Hesby, 2002). Nursing research is also needed to generate knowledge about nursing education, nursing administration, healthcare services, characteristics of nurses, and nursing roles. The findings from these studies influence nursing practice indirectly and add to nursing’s body of knowledge. Research is needed to provide high-quality learning experiences for nursing students. Through research, nurses can develop and refine the best methods for delivering distance nursing education and for using simulation to improve student learning. Nursing administration and health services studies are needed to improve the quality, safety, and cost-effectiveness of the healthcare delivery system. Studies of nurses and nursing roles can influence nurses’ quality of care, productivity, job satisfaction, and retention. In this era of a nursing shortage, additional research is needed to determine effective ways to recruit individuals and retain them in the profession of nursing. This type of research could have a major impact on the quality and number of nurses providing care to patients and families in the future. In summary, nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice. Nursing research is the key to building an EBP for nursing (Brown, 2014). What is Evidence-Based Practice? The ultimate goal of nursing is an evidence-based practice that promotes quality, safe, and cost-effective outcomes for patients, families, healthcare providers, and the healthcare system (Brown, 2014; Craig & Smyth, 2012; Melnyk & Fineout-Overholt, 2011). Evidence-based practice (EBP) evolves from the integration of the best research evidence with clinical expertise and patients’ needs and values (Institute of Medicine [IOM], 2001; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Figure 1-1 identifies the elements of EBP and demonstrates the major contribution of the best research evidence to the delivery of this practice. The best research evidence is the empirical knowledge generated from the synthesis of quality study findings to address a practice problem. Later, this chapter discusses the strategies used to synthesize research, levels of best research evidence, and sources for this evidence. A team of expert researchers, healthcare professionals, and sometimes policy makers and consumers will synthesize the best research evidence to develop standardized guidelines for clinical practice. For example, a team of experts conducted, critically appraised, and synthesized research related to the chronic health problem of hypertension (HTN) to develop an EBP guideline. Research evidence from this guideline is presented as an example later in this section. FIG 1-1 Model of Evidence-Based Practice (EBP). Clinical expertise is the knowledge and skills of the healthcare professional who is providing care. The clinical expertise of a nurse depends on his or her years of clinical experience, current knowledge of the research and clinical literature, and educational preparation. The stronger the nurse’s clinical expertise, the better is his or her clinical judgment in using the best research evidence in practice (Brown, 2014; Craig & Smyth, 2012). EBP also incorporates the needs and values of the patient (see Figure 1-1). The patient’s need(s) might focus on health promotion, illness prevention, acute or chronic illness management, rehabilitation, and/or a peaceful death. In addition, patients bring values or unique preferences, expectations, concerns, and cultural beliefs to the clinical encounter. With EBP, patients and their families are encouraged to take an active role in the management of their health. It is the unique combination of the best research evidence being applied by expert nurse clinicians in providing quality, safe, and costeffective care to a patient and family with specific health needs and values that results in EBP. Extensive research is needed to develop sound empirical knowledge for synthesis into the best research evidence needed for practice. Findings from a single study are not enough evidence for determining the effectiveness of an intervention in practice. Research evidence from multiple studies are synthesized to develop guidelines, standards, protocols, algorithms (clinical decision trees), or policies to direct the implementation of a variety of nursing interventions. As noted earlier, a national guideline has been developed for the management of hypertension, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). The complete JNC 7 guideline for the management of high blood pressure is available online at (National Heart, Lung, and Blood Institute [NHLBI], 2003). In January of 2014, the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) published new clinical practice guidelines for the management of hypertension in the community (Weber et al, 2014). The JNC 7 guideline and the ASH and ISH clinical practice guideline identified the same classification system for blood pressure (Table 11). These guidelines include the classification of blood pressure as normal, prehypertension, hypertension stage 1, and hypertension stage 2. Both guidelines also recommend life style modifications (balanced diet, exercise program, normal weight, and nonsmoker) and cardiovascular disease (CVD) risk factors (hypertension, obesity, dyslipidemia, diabetes mellitus, cigarette smoking, physical inactivity, microalbuminuria, and family history of premature CVD) education. You need to use an evidence-based guideline in monitoring your patients’ blood pressure (BP) and educating them about lifestyle modifications to improve their BP and reduce their CVD risk factors (NHLBI, 2003; Weber et al., 2014). Table 1-1 Classification of Blood Pressure with Nursing Interventions for Evidence-Based Practice (EBP) * Treatment is determined by the highest BP category, systolic or diastolic. † Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80 mm Hg. ‡ Lifestyle modification—balanced diet, exercise program, normal weight, and nonsmoker. § CVD risk factors—hypertension; obesity (body mass index ≥ 30 kg/m 2), dyslipidemia, diabetes mellitus, cigarette smoking, physical inactivity, microalbuminuria, estimated glomerular filtration rate < 60 mL/min, age (> 55 years for men, > 65 years for women), and family history of premature CVD (men < 55 years, women < 65 years). Adapted from National Heart, Lung, and Blood Institute. (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Retrieved June 18, 2013 from,; and Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S., Lindholm, L. H., Kenerson, J. G., et al. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32(1), 4-5. The Eighth Joint National Committee (JNC 8) published “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults” in December of 2013 (James et al. 2013). However, these guidelines currently lack the recognition of any national organization. Additional work is needed to ensure that the guidelines are approved by the NHLBI, ASH, the American Heart Association (AHA), and/or the American College of Cardiology (ACC). For this textbook, the evidence-based guidelines for management of hypertension presented in Table 1-1 are recommended for students and nurses to use in caring for their patients (Weber et al., 2014). Figure 1-2 provides an example of the delivery of evidence-based nursing care to African American women with high BP. In this example, the best research evidence is classification of BP and education on lifestyle modification (LSM) and CVD risk factors based on the ASH (Weber et al., 2014) and JNC 7 (NHLBI, 2003) guidelines for management of high BP (see Table 1-1). These guidelines, developed from the best research evidence related to BP, LSM, and CVD risks monitoring and education, is translated by registered nurses and nursing students to meet the needs and values of African American women with high BP. The quality outcome of EBP in this example is women with a BP less than 140/90 mm Hg or referral for medication treatment (see Figure 1-2). A detailed discussion of how to locate, critically appraise, and use national standardized guidelines in practice is found in Chapter 13. FIG 1-2 Evidence-based practice for African American women with high blood pressure (BP). Purposes of Research for Implementing an Evidence-Based Nursing Practice Through nursing research, empirical knowledge can be developed to improve nursing care, patient outcomes, and the healthcare delivery system. For example, nurses need a solid research base to implement and document the effectiveness of selected nursing interventions in treating particular patient problems and promoting positive patient and family outcomes. Also, nurses need to use research findings to determine the best way to deliver healthcare services to ensure that the greatest number of people receive quality, safe care. Accomplishing these goals will require you to locate EBP guidelines or to appraise critically, synthesize, and apply research evidence that provides a description, explanation, prediction, and control of phenomena in your clinical practice. Description Description involves identifying and understanding the nature of nursing phenomena and, sometimes, the relationships among them (Chinn & Kramer, 2011). Through research, nurses are able to (1) describe what exists in nursing practice; (2) discover new information; (3) promote understanding of situations; and (4) classify information for use in the discipline. Some examples of clinically important research evidence that have been developed from research focused on description include: • Identification of the incidence and spread of infection in healthcare agencies • Identification of the cluster of symptoms for a particular disease • Description of the responses of individuals to a variety of health conditions and aging • Description of the health promotion and illness prevention strategies used by a variety of populations • Determination of the incidence of a disease locally (e.g., incidence of West Nile virus in Texas), nationally, and internationally (e.g., spread of bird flu). Rush, Watts, and Janke (2013, p. 10) have conducted a qualitative study to describe “rural and urban older adults’ perspectives of strength in their daily lives.” (The types of research conducted in nursing—quantitative, qualitative, and outcomes—are discussed later in this chapter.) They noted the following in this study: “Nurses’ strength enhancement efforts should raise older adults’ awareness that strength is not an unlimited resource but needs to be constantly replenished…. Older adult participants described changes in strength that ranged from fluctuating daily changes to insidious, gradual declines and to drastic and unexpected losses…. Older adults’ strategies for staying strong were consistent with their more holistic views of strength but may not be approaches nurses typically take into account. Although nurses need to give continued emphasis to promoting physical activity, they must also give equal attention to encouraging mental and social activities because of the important role they play for older adults staying strong.” Rush et al., 2013, p. 15 The findings from this study provided nurses with descriptions of older adults’ perspectives of strength and the strategies that they use to stay strong. You can use the findings from this study to encourage physical, mental, and social activities to assist older adults in staying strong. This type of research, focused on description, is essential groundwork for studies to provide explanations, predictions, and control of nursing phenomena in practice. Explanation Explanation clarifies the relationships among phenomena and identifies possible reasons why certain events occur. Research focused on explanation provides the following types of evidence essential for practice: • Determination of assessment data (subjective data from the health history and objective data from the physical examination) that need to be gathered to address a patient’s health need • The link of assessment data to a diagnosis • The link of causative risk factors or causes to illness, morbidity, and mortality • Determination of the relationships among health risks, health behaviors, and health status • Determination of links among demographic characteristics, disease status, psychosocial factors, and patients’ responses to treatment. For example, Manojlovich, Sidani, Covell, and Antonakos (2011) conducted an outcomes study to examine the links or relationships between a “nurse dose” (nurse characteristics and staffing) and adverse patient outcomes. The nurse characteristics examined were education, experience, and skill mix. The staffing variables included fulltime employees, registered nurse (RN)-to-patient ratio, and RN hours per patient day. The adverse outcomes examined were methicillin-resistant Staphylococcus aureus (MRSA) infections and reported patient falls for a sample of inpatient adults in acute care units. The researchers found that the nurse characteristics and staffing variables were significantly correlated with MRSA infections and reported patient falls. Therefore the nursing characteristics and staffing were potential predictors of the incidence of MRSA infections and patient falls. This study illustrates how explanatory research can identify relationships among nursing phenomena that can be the basis for future research focused on prediction and control. Prediction Through prediction, one can estimate the probability of a specific outcome in a given situation (Chinn & Kramer, 2011). However, predicting an outcome does not necessarily enable one to modify or control the outcome. It is through prediction that the risk of illness or injury is identified and linked to possible screening methods to identify and prevent health problems. Knowledge generated from research focused on prediction is critical for EBP and includes the following: • Prediction of the risk for a disease or injury in different populations • Prediction of behaviors that promote health and prevent illness • Prediction of the health care required based on a patient’s need and values Lee, Faucett, Gillen, Krause, and Landry (2013) conducted a quantitative study to examine the factors that were perceived by critical care nurses (CCNs) to predict the risk of musculoskeletal (MSK) injury from work. They found that greater physical workload, greater job strain, more frequent patient-handling tasks, and lack of a lifting team or devices were predictive of the CCNs’ perceptions of risk of MSK injury. They recommended that “occupational health professionals, nurse managers, and nursing organizations should make concerted efforts to ensure the safety of nurses by providing effective preventive measures. Improving the physical and psychosocial work environment may make nursing jobs safer, reduce the risk of MSK injury, and improve nurses’ perceptions of job safety” (Lee et al., 2013, p. 43). This predictive study isolated independent variables (physical workload, job strain, patient-handling tasks, and lack of lifting devices or teams) that were predictive of MSK injuries in CCNs. The variables identified in predictive studies require additional research to ensure that their manipulation or control results in quality outcomes for patients, healthcare professionals, and healthcare agencies (Creswell, 2014; Doran, 2011; Kerlinger & Lee, 2000). Control If one can predict the outcome of a situation, the next step is to control or manipulate the situation to produce the desired outcome. In health care, control is the ability to write a prescription to produce the desired results. Using the best research evidence, nurses could prescribe specific interventions to meet the needs of patients and their families (Brown, 2014; Craig & Smyth, 2012). The results of multiple studies in the following areas have enabled nurses to deliver care that increases the control over the outcomes desired for practice: • Testing interventions to improve the health status of individuals, families, and communities • Testing interventions to improve healthcare delivery • Synthesis of research for development into EBP guidelines • Testing the effectiveness of EBP guideline in clinical agencies Extensive research has been conducted in the area of safe administration of IM injections. This research has been critically appraised, synthesized, and developed into evidence-based guidelines to direct the administration of medications by an IM route to infants, children, and adults in a variety of practice settings (Cocoman & Murray, 2008; Nicoll & Hesby, 2002). The EBP guideline for IM injections is based on the best research evidence and identifies the appropriate needle size and length to use for administering different types of medications, the safest injection site (ventrogluteal) for many medications, and the best injection technique to deliver a medication, minimize patient discomfort, and prevent physical damage (Cocoman & Murray, 2008; Greenway, 2004; Nicoll & Hesby, 2002; Rodger & King, 2000). Using the evidence-based knowledge for administering IM injections helps control the achievement of the following outcomes in practice: (1) adequate administration of medication to promote patient health; (2) minimal patient discomfort; and (3) no physical damage to the patient. Broadly, the nursing profession is accountable to society for providing quality, safe, and cost-effective care for patients and families. Therefore the care provided by nurses must be constantly evaluated and improved on the basis of new and refined research knowledge. Studies that document the effectiveness of specific nursing interventions make it possible to implement evidence-based care that will produce the best outcomes for patients and their families. The quality of research conducted in nursing affects not only the quality of care delivered, but also the power of nurses in making decisions about the healthcare delivery system. The extensive number of clinical studies conducted in the last 50 years has greatly expanded the scientific knowledge available to you for describing, explaining, predicting, and controlling phenomena within your nursing practice. Historical Development of Research in Nursing The development of research in nursing has changed drastically over the last 160 years and holds great promise for the twenty-first century. Initially, nursing research evolved slowly, from the investigations of Nightingale in the nineteenth century to the studies of nursing education in the 1930s and 1940s and the research of nurses and nursing roles in the 1950s and 1960s. From the 1970s through the 2010s, an increasing number of nursing studies that focused on clinical problems have produced findings that directly affected practice. Clinical research continues to be a major focus today, with the goal of developing an EBP for nursing. Reviewing the history of nursing research enables you to identify the accomplishments and understand the need for further research to determine the best research evidence for use in practice. Table 1-2 outlines the key historical events that have influenced the development of research in nursing. Table 1-2 Historical Events Influencing the Development of Research in Nursing Year 1850 1900 1923 1929 1932 1950 1952 1953 1955 1957 Event Florenc e Nightingale is rec ognized as the first nurse researc her. America n Journa l of Nursing is published. Teac hers College at Columbia University offers the first educ ational doc toral program for nurses. First Master’s in Nursing Degree is offered at Yale University. Assoc iation of Collegiate S c hools of Nursing is organized to promote c onduc t of researc h. Americ an Nurses Assoc iation (ANA) publishes study of nursing func tions and ac tivities. First researc h journal in nursing, Nursing Resea rch, is published. Institute of Researc h and S ervic e in Nursing Educ ation is established. Americ an Nurses Foundation is established to fund nursing researc h. S outhern Regional Educ ational Board (S REB), Western Interstate Commission on Higher Educ ation (WICHE), Midwestern Nursing Researc h S oc iety (MNRS ), and New England Board of Higher Educ ation (NEBHE) are established to support and disseminate nursing researc h. 1963 Interna tiona l Journa l of Nursing Studies is published. 1965 ANA sponsors the first nursing researc h c onferenc es. 1967 S igma Theta Tau International Honor S oc iety of Nursing publishes Ima ge, emphasizing nursing sc holarship; now Journa l of Nursing Schola rship. 1970 ANA Commission on Nursing Researc h is established. 1972 Coc hrane published Effectiveness a nd Efficiency, introduc ing c onc epts relevant to evidenc e-based prac tic e (EBP). ANA Counc il of Nurse Researc hers is established. 1973 First Nursing Diagnosis Conferenc e is held, whic h evolved into North Americ an Nursing Diagnosis Assoc iation (NANDA). 1976 S tetler/Marram Model for Applic ation of Researc h Findings to Prac tic e is published. 1978 Resea rch in Nursing & Hea lth and Adva nces in Nursing Science are published. 1979 Western Journa l of Nursing Resea rch is published. 1980s- S ac kett and c olleagues developed methodologies to determine “best evidenc e” for prac tic e. 1990s 1982- Conduc t and Utilization of Researc h in Nursing (CURN) Projec t is published. 1983 1983 Annua l Review of Nursing Resea rch is published. 1985 National Center for Nursing Researc h (NCNR) is established to support and fund nursing researc h. 1987 Schola rly Inquiry for Nursing Pra ctice is published. 1988 Applied Nursing Resea rch and Nursing Science Qua rterly are published. 1989 Agenc y for Healthc are Polic y and Researc h (AHCPR) is established and publishes EBP guidelines. 1990 Nursing Dia gnosis, offic ial journal of NANDA, is published; now Interna tiona l Journa l of Nursing Terminologies a nd Cla ssifica tions. ANA established the Americ an Nurses Credentialing Center (ANCC), whic h implemented the Magnet Hospital Designation Program for Exc ellenc e in Nursing S ervic es. 1992 Hea lthy People 2000 is published by U.S . Department of Health and Human S ervic es (U.S . DHHS ). Clinica l Nursing Resea rch is published. 1993 NCNR is renamed the National Institute of Nursing Researc h (NINR) to expand funding for nursing researc h. Journa l of Nursing Mea surement is published. Coc hrane Collaboration is initiated, providing systematic reviews and EBP guidelines (http://www.c oc 1994 Qua lita tive Hea lth Resea rch is published. 1999 AHCPR is renamed Agenc y for Healthc are Researc h and Quality (AHRQ). 2000 Hea lthy People 2010 is published by U.S . DHHS . Biologica l Resea rch for Nursing is published. 2001 S tetler publishes her model Steps of Resea rch Utiliza tion to Fa cilita te Evidence-Ba sed Pra ctice. Institute of Medic ine (IOM) report Crossing the Qua lity Cha sm: A New Hea lth System for the 21st Century published, foc using on key healthc are issues of quality and safety. 2002 The Joint Commission revises ac c reditation polic ies for hospitals supporting evidenc e-based health c are. NANDA bec omes international—NANDA-I. 2003 IOM report Hea lth Professions Educa tion: A Bridge to Qua lity published, identifying six c ompetenc ies essential for educ ation of nurses and other health professionals. 2004 Worldviews on Evidence-Ba sed Nursing is published. 2005 Quality and S afety Educ ation for Nurses (QS EN) initiative for development of c ompetenc ies for prelic ensure and graduate educ ation is developed. 2006 Americ an Assoc iation of Colleges of Nursing (AACN) position statement on nursing researc h is published. 2007 QS EN website ( is launc hed, featuring teac hing strategies and resourc es to fac ilitate the attainment of the QS EN c ompetenc ies. 2010 IOM report The Future of Nursing: Lea ding Cha nge rec ommends that 80% of the nursing workforc e be prepared at the bac c alaureate level by the year 2020. 2011 NINR c urrent strategic plan published. Americ an Nurses Assoc iation (ANA) c urrent researc h agenda is developed. 2013 Current QS EN c ompetenc ies for prelic ensure nurses available online at ompetenc ies/pre-lic ensure-ksas. 2013 Hea lthy People 2020 available at U.S . DHHS website, sobjec tives2020/default.aspx. AHRQ c urrent mission and funding priorities available online ( NINR c urrent mission and funding opportunities available online ( Florence Nightingale Nightingale (1859) is recognized as the first nurse researcher, with her initial studies focused on the importance of a healthy environment in promoting patients’ physical and mental well-being. She studied aspects of the environment, such as ventilation, cleanliness, purity of water, and diet, to determine the influence on patients’ health, which continue to be important areas of study today (Herbert, 1981). Nightingale is also noted for her data collection and statistical analyses, especially during the Crimean War. She gathered data on soldier morbidity and mortality rates and the factors influencing them and presented her results in tables and pie charts, a sophisticated type of data presentation for the period (Palmer, 1977). Nightingale was the first woman elected to the Royal Statistical Society (Oakley, 2010) and her research was highlighted in Scientific American (Cohen, 1984). Nightingale’s research enabled her to instigate attitudinal, organizational, and social changes. She changed the attitudes of the military and society about the care of the sick. The military began to view the sick as having the right to adequate food, suitable quarters, and appropriate medical treatment, which greatly reduced the mortality rate (Cook, 1913). Nightingale improved the organization of army administration, hospital management, and hospital construction. Because of Nightingale’s research evidence and influence, society began to accept responsibility for testing public water, improving sanitation, preventing starvation, and decreasing morbidity and mortality rates (Palmer, 1977). Nursing Research: 1900s through the 1970s The American Journal of Nursing was first published in 1900 and, late in the 1920s and 1930s, case studies began appearing in this journal. A case study involves an in-depth analysis and systematic description of one patient or group of similar patients to promote understanding of healthcare interventions. Case studies are one example of the practice-related research that has been conducted in nursing over the last century. Nursing educational opportunities expanded, with Teachers College at Columbia University offering the first educational doctoral program for nurses in 1923 and Yale University offering the first master ’s degree in nursing in 1929. In 1950 the American Nurses Association (ANA) initiated a 5-year study on nursing functions and activities. In 1959 the findings from this study were used to develop statements on functions, standards, and qualifications for professional nurses. During that time, clinical research began expanding as nursing specialty groups, such as community health, psychiatricmental health, medical-surgical, pediatrics, and obstetrics, developed standards of care. The research conducted by the ANA and specialty groups provided the basis for the nursing practice standards that curre…
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