There are different types of quantitative research designs that justify or support themselves in nursing research. Choose one quantitative type design and identify a major advantage and a major disadvantage of this design. Give an example how this quantitative research design could be used in nursing practice to solve a clinical problem (not one noted in your textbook).
EVIDENCE-BASED PRACTICE
FOR NURSES
Appraisal and Application of Research
2
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Evidence-Based Practice for Nurses: Appraisal and Application of Research,
Third Edition, drives comprehension through various strategies that meet the
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Chapter Objectives
These objectives provide instructors and students with a snapshot of the key
information they will encounter in each chapter. They serve as a checklist to
help guide and focus study.
Key Terms
Found in a list at the beginning of each chapter and in bold within the chapter,
these terms will create an expanded vocabulary in evidence-based practice.
Critical Thinking Exercises An integral part of the learning process, critical-
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FYI
Quick tidbits and facts are pulled out in chapter margins to highlight important
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These questions serve as benchmarks for the knowledge you are acquiring as
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Apply What You Have Learned
With this outstanding feature, you will be challenged to apply your newly
acquired knowledge to specific evidence-based practice scenarios and
research studies.
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Case Examples Found in select chapters, these vignettes illustrate research
questions and studies in actual clinical settings and provide critical-thinking
challenges for students.
8
Keeping It Ethical
Relevant ethical content concludes each chapter to ensure ethics are kept at the
forefront of every step of the nursing process.
9
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Library of Congre s s Cataloging-in-Publication Data Evidence-based practice for nurses : appraisal and
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Includes bibliographical references and index.
ISBN 978-1-284-05330-2 (pbk.) I. Schmidt, Nola A., editor. II. Brown, Janet M. (Janet Marie), 1947– editor.
[DNLM: 1. Nursing Research—methods. 2. Evidence-Based Nursing. WY 20.5]
RT81.5
610.73072—dc23
2014017978
6048
Printed in the United States of America 18 17 16 15 14 10 9 8 7 6 5 4 3 2 1
12
DEDICATION
For Mom, whose love and support are endless.
—N. A. S.
To my husband, my children, and my granddaughters, who enrich my life in every
way.
—J. M. B.
13
CONTENTS
Contributors
Reviewers
Preface
Acknowledgments
UNIT 1
Introduction to Evidence-Based
Practice
CHAPTER
1
What Is Evidence-Based Practice?
Nola A. Schmidt and Janet M. Brown
1.1 EBP: What Is It?
1.2 What Is Nursing Research?
1.3 How Has Nursing Evolved as a Science?
1.4 What Lies Ahead?
1.5 Keeping It Ethical
CHAPTER
2
Using Evidence Through Collaboration to
Promote Excellence in Nursing Practice
Emily Griffin and Marita G. Titler
2.1 The Five Levels of Collaboration
14
2.2 Keeping It Ethical
UNIT 2 Acquisition of Knowledge
CHAPTER
3
Identifying Research Questions
Susie Adams
3.1 How Clinical Problems Guide Research Questions
3.2 Developing Hypotheses
3.3 Formulating EBP Questions
3.4 Keeping It Ethical
CHAPTER
4
Finding Sources of Evidence
Patricia Mileham
4.1 Purpose of Finding Evidence
4.2 Types of Evidence
4.3 How Sources Are Organized
4.4 How to Search for Evidence
4.5 Keeping It Ethical
CHAPTER
15
5 Linking Theory, Research, and Practice
Elsabeth Jensen
5.1 How Are Theory, Research, and Practice Related?
5.2 Keeping It Ethical
UNIT 3 Persuasion
CHAPTER
6
Key Principles of Quantitative Designs
Rosalind M. Peters
6.1 Chart the Course: Selecting the Best Design
6.2 What Is Validity?
6.3 Categorizing Designs According to Time
6.4 Keeping It Ethical
CHAPTER
7
Quantitative Designs: Using Numbers to
Provide Evidence
Rosalind M. Peters
7.1 Experimental Designs
7.2 Quasi-Experimental Designs
16
7.3 Nonexperimental Designs
7.4 Specific Uses for Quantitative Designs
7.5 Keeping It Ethical
CHAPTER
8
Epidemiologic Designs: Using Data to
Understand Populations
Amy C. Cory
8.1 Epidemiology and Nursing
8.2 Infectious Diseases and Outbreak Investigations
8.3 Measures of Disease Frequency
8.4 Descriptive Epidemiology
8.5 Descriptive Study Designs
8.6 Analytic Study Designs
8.7 Screening
8.8 Evaluating Health Outcomes and Services
8.9 Keeping It Ethical
CHAPTER
9
Qualitative Designs: Using Words to Provide
Evidence
Kristen L. Mauk
17
9.1 What Is Qualitative Research?
9.2 The Four Major Types of Qualitative Research
9.3 Keeping It Ethical
CHAPTER
10
Collecting Evidence
Jan Dougherty
10.1 Data Collection: Planning and Piloting
10.2 Collecting Quantitative Data
10.3 Validity and Reliability
10.4 Collecting Qualitative Data
10.5 Keeping It Ethical
CHAPTER
11
Using Samples to Provide Evidence
Ann H. White
11.1 Fundamentals of Sampling
11.2 Sampling Methods
11.3 Sample Size: Does It Matter?
11.4 Keeping It Ethical
18
CHAPTER
12
Other Sources of Evidence
Cynthia L. Russell
12.1 The Pyramid of Evidence: The 5 Ss
12.2 Using the Pyramid for Evidence-Based Practice
12.3 Keeping It Ethical
UNIT 4 Decision
CHAPTER
13
What Do the Quantitative Data Mean?
Rosalind M. Peters, Nola A. Schmidt, and Moira Fearncombe
13.1 Using Statistics to Describe the Sample
13.2 Using Frequencies to Describe Samples
13.3 Measures of Central Tendency
13.4 Distribution Patterns
13.5 Measures of Variability
13.6
Inferential Statistics: Can the Findings Be Applied to the
Population?
13.7 Reducing Error When Deciding About Hypotheses
13.8
Using Statistical Tests to Make Inferences About
Populations
19
13.9 What Does All This Mean for EBP?
13.10 Keeping It Ethical
CHAPTER
14
What Do the Qualitative Data Mean?
Kristen L. Mauk
14.1 Qualitative Data Analysis
14.2 Qualitative Data Interpretation
14.3 Qualitative Data Evaluation
14.4 Keeping It Ethical
CHAPTER
15
Weighing In on the Evidence
Carol O. Long
15.1 Deciding What to Do
15.2 Appraising the Evidence
15.3
Clinical Practice Guidelines: Moving Ratings and
Recommendations into Practice
15.4 Keeping It Ethical
UNIT 5 Implementation
20
UNIT 5 Implementation
CHAPTER
16 Transitioning Evidence to Practice
Maria Young
16.1 Evidence-Based Practice Models to Overcome Barriers
16.2 Creating Change
16.3 Keeping It Ethical
CHAPTER
17
Developing Oneself as an Innovator
Diane McNally Forsyth
17.1 Who Is an Innovator?
17.2 Developing Oneself
17.3 Professionalism
17.4 Keeping It Ethical
UNIT 6 Confirmation
CHAPTER
18
Evaluating Outcomes of Innovations
21
18.1 What Is an Outcome?
18.2 Choosing Outcomes
18.3 Evaluating the Outcomes
18.4 Keeping It Ethical
CHAPTER
19
Sharing the Insights with Others
Janet M. Brown and Nola A. Schmidt
19.1 Dissemination: What Is My Role?
19.2 The 3 Ps of Dissemination
19.3 Using Technology to Disseminate Knowledge
19.4 Making the Most of Conferences
19.5 Keeping It Ethical
Glossary
Index
22
CONTRIBUTORS
Susie Adams, PhD, RN, PMHNP, FAANP
Professor and Director PMHNP Program School of Nursing
Vanderbilt University
Nashville, Tennessee
Janet M. Brown, PhD, RN
Dean and Professor
College of Nursing and Health Professions Valparaiso University
Valparaiso, Indiana
Amy C. Cory, PhD, RN, CPNP
Associate Professor
College of Nursing and Health Professions Valparaiso University
Valparaiso, Indiana
Jan Dougherty, MS, RN
Director
Family and Community Services Banner Alzheimer’s Institute Phoenix, Arizona
Moira Fearncombe
Associate Professor
The Illinois Institute of Art Schaumburg, Illinois
Diane McNally Forsyth, PhD, RN
Professor
Graduate Programs in Nursing Winona State University
Rochester, Minnesota
Emily Griffin, MSN, ARNP, FNP-C
Lecturer
23
College of Nursing
University of Iowa
Iowa City, Iowa
Elsabeth Jensen, PhD, RN
Associate Professor and Graduate Program Director School of Nursing
Faculty of Health
York University
Toronto, Ontario
Carol O. Long, PhD, RN, FPCN
Geriatric and Palliative Care Educator and Researcher Capstone Healthcare Group
Adjunct Faculty
College of Nursing and Health Innovation Arizona State University
Phoenix, Arizona
Kristen L. Mauk, PhD, DNP, RN, CRRN, GCNS-BC, GNP-BC, FAAN
Professor Kreft Endowed Chair for the Advancement of Nursing Science College
of Nursing and Health Professions Valparaiso University
Valparaiso, Indiana
Patricia Mileham, MA Associate Professor of Library Services, Director of
Public Service Christopher Center for Library & Information Resources
Valparaiso University
Valparaiso, Indiana
Rosalind M. Peters, PhD, RN, FAAN
Associate Professor
College of Nursing
Wayne State University
Detroit, Michigan
Kathleen A. Rich, PhD, RN, CCNS-CSC, CNN
Cardiovascular Clinical Specialist Patient Care Services
Indiana University Health La Porte Hospital La Porte, Indiana
Cynthia L. Russell, PhD, RN, ACNS-BC, FAAN
24
Professor
School of Nursing and Health Studies University of Missouri—Kansas City Kansas
City, Missouri
Nola A. Schmidt, PhD, RN, CNE
Professor
College of Nursing and Health Professions Valparaiso University
Valparaiso, Indiana
Marita G. Titler, PhD, RN, FAAN
Associate Dean for Practice and Clinical Scholarship Rhetaugh G. Dumas
Endowed Chair Division Chair Health Systems and Effectiveness Sciences
University of Michigan School of Nursing Ann Arbor, Michigan
Ann H. White, PhD, MBA, RN, NE-BC
Dean
College of Nursing and Health Professions University of Southern Indiana
Evansville, Indiana
Maria Young, PhD, RN, ACNS-BC
Cardiac Care Clinical Nurse Specialist Franciscan St. Elizabeth Health West
Lafayette, Indiana
25
REVIEWERS
Carol Beltz, MSN, RN
26
Lecturer
27
Kent State University
Kent, Ohio
Susan Weber Buchholz, PhD, ANP-BC
28
Professor
Department of Adult Health and Gerontological Nursing Rush University
Chicago, Illinois
Nathania A. Bush, MSN, APRN, BC
Assistant Professor of Nursing Morehead State University
Morehead, Kentucky
Janie Canty-Mitchell, PhD, RN
University of North Carolina—Wilmington Wilmington, North Carolina
Kim Clevenger, MSN, RN
Assistant Professor of Nursing Morehead State University
Morehead, Kentucky
Suzanne Edgett Collins, PhD, RN, MPH, JD
29
Associate Professor
30
Department of Nursing
31
University of Tampa
Tampa, Florida
Marianne Curia, PhD, MSN, RN
32
Assistant Professor
University of St. Francis College of Nursing and Allied Health Joliet, Illinois
Maureen B. Doyle, PhD, APRN
33
Assistant Professor
Fairleigh Dickinson University Henry P. Becton School of Nursing and Allied
Health Teaneck, New Jersey
Catherine M. Jennings, RN, MSN, APN-C
34
Felician College
Lodi, New Jersey
Jane Kapustin, PhD, CRNP
University of Maryland—Baltimore Baltimore, Maryland
Cathy Leahy, MSN, MEd, RN
35
Department of Nursing
36
Xavier University
Cincinnati, Ohio
Cheryl Martin, PhD
37
BSN Programs Director
38
Associate Professor
39
University of Indianapolis
Indianapolis, Indiana
Mary A. Megel, PhD, RN
40
Associate Professor
41
College of Nursing
Family & Systems Department University of Nebraska Medical Center Omaha,
Nebraska
Arlene Morris, EdD, RN, CNE
42
Associate Professor
43
Department of Nursing
Auburn University Montgomery School of Nursing Montgomery, Alabama
Iris Mullins, PhD, RN
44
Assistant Professor
45
School of Nursing
New Mexico State University Las Cruces, New Mexico
Jenenne P. Nelson, PhD, RN, CNS
Associate Professor and Kaiser Permanente Professorship in Nursing Beth-El
College of Nursing and Health Sciences Colorado Springs, Colorado
Katherine Peck, MSN, RN, CNS
46
Instructor
New Mexico State University Las Cruces, New Mexico
Michael Perlow, DNS, RN
47
Murray State University
Murray, Kentucky
Ginger Raterink, DNSc, ANP-C
48
School of Nursing
49
University of Colorado
Denver, Colorado
Jacquelyn Reid, EdD
50
Associate Professor
51
School of Nursing
Indiana University Southeast New Albany, Indiana
Linda S. Rieg, PhD, RN
52
Associate Professor
53
Xavier University
Cincinnati, Ohio
Kandy K. Smith, DNS, RN
54
Associate Professor
55
College of Nursing
University of South Alabama Mobile, Alabama
Claudette Spalding, PhD, ARNP, CNAA Associate Dean for Graduate Education
Associate Professor
Barry University School of Nursing Miami Shores, Florida
Nancy Wilk, DNS, WHNP
St. John Fisher College
Rochester, New York
56
PREFACE
We are most pleased to offer the third edition of this text. For this revision,
chapter authors have paid particular attention to updating information and
references. Of special note is a new chapter about statistics used in epidemiology.
We consider this an important addition because evidence-based practice (EBP) and
epidemiology are closely aligned. As more nursing literature involves
epidemiology, it is important for nurses to understand the methods used in order to
interpret information and apply it to their practices.
We are even more committed to the premise that baccalaureate-prepared nurses,
given the emphasis on leadership, critical thinking, and communication in their
curricula, are ideally positioned to advance best practices. Therefore, nursing
faculty must create educational strategies for students that develop a lifelong
commitment to critically examining nursing practice in light of scientific advances.
Although many texts and references deal with the principles, methods, and
appraisal of nursing research, few sources address the equally important aspect of
integrating evidence into practice. Because there is a growing expectation by
accrediting bodies that patient outcomes are addressed through best practice, it is
imperative that books be available to prepare nurses for implementing best
practices. This nursing research textbook provides substantive strategies to assist
students with applying evidence at the point of care.
The American Association of Colleges of Nursing (AACN) charges nursing
programs to prepare baccalaureate nurses with the basic understanding of the
processes of nursing research. This book includes content related to methods,
appraisal, and utilization, which is standard in many other texts. Furthermore, the
AACN expects BSN-prepared nurses to apply research findings from nursing and
other disciplines in their clinical practice. The framework for this text is the model
of diffusion of innovations (Rogers, 2003), which gives readers a logical and
useful means for creating an EBP. Readers are led step by step through the process
of examining the nursing practice problem of medication errors using the
innovation–decision process (IDP). It is recommended that faculty use this text with
students to guide them through assignments that might effect actual change in patient
care at a healthcare facility. Schmidt and Brown (2007) described this teaching
strategy more fully. Because students typically express that research content is
uninteresting and lacks application to real life, we have tried to create a textbook
that is less foreboding and more enjoyable through the use of friendly language and
assignments to make content more pertinent for students.
57
The primary audience for this textbook is baccalaureate undergraduate nursing
students and their faculty in an introductory nursing research course. All
baccalaureate nursing programs offer an introductory research course, for which
this text would be useful. Because the readership has grown, we recognize that
nursing graduate programs are also using this textbook. The addition of the chapter
about epidemiology may be especially pertinent to this audience.
In this third edition, input from students and feedback from faculty has been
incorporated. We are most grateful for their time and thoughtful critique. This
edition continues to follow the five steps of the IDP: knowledge, persuasion,
decision, implementation, and confirmation. This organizational approach allows
the research process to be linked with strategies that promote progression through
the IDP. The chapters follow a consistent format: chapter objectives, key terms,
major content, test your knowledge, case study, rapid review, and reference list.
Critical thinking exercises and user-friendly tables and charts are interspersed
throughout each chapter to allow readers to see essential information at a glance.
Textbook users will be pleased to find that efforts to provide consistency between
chapters have been made. The evidence hierarchy and questions to consider when
appraising nursing studies are printed inside the back cover for easy reference. The
chapter about qualitative methods was expanded to include more detail about the
philosophic underpinning of various methods. Additionally, content about the role
of technology in dissemination has also been enhanced.
The case study continues to be a significant feature of this textbook. More
recent evidence has been provided to challenge students to make decisions about
practice related to the elimination of medication errors. The case study unfolds in a
manner that integrates chapter content with each step of the EBP process. Concrete
strategies, in the form of exemplars and checklists, allow readers to master
competencies needed to perform these activities in the clinical setting.
The unique feature of integrating ethical content throughout the chapters
remains. Organizing content in this manner assists students to integrate ethical
principles into each step of the research process.
As a learning strategy, chapters are subdivided so that content is presented in
manageable “bites.” Students commented that they liked this feature. As in the
second edition, chapters begin with a complete list of all objectives addressed in
the chapter. Objectives are repeated for each subsection and are followed by
content, and the chapter ends with a section called Test Your Knowledge. Multiple-
choice and true-or-false questions, with an answer key, reinforce the objectives and
content. Chapters also include critical thinking exercises that challenge readers to
make decisions based on the content. Users will find significant alterations to the
digital resources available to readers.
58
New challenges arose while we wrote this third edition. Publishers are
becoming less inclined to allow their materials to be reproduced. Therefore, we
are disappointed that we can no longer offer the full-text reference articles within
this text’s digital resources. In response to this challenge, the Apply What You
Have Learned exercise for Chapter 4 was significantly transformed. Directions
have been provided for students so that they can search for the articles themselves,
thereby reinforcing behaviors that will be required of baccalaureate-prepared
nurses, who need to keep up with the ever-changing healthcare environment. We are
pleased with the result because this alteration has actually strengthened the
exercise. For readers’ convenience, following is a table containing the evidence
used throughout the Apply What You Have Learned exercises.
Articles to Search in CINAHL
Citation Chapter(s) Search Terms (Limiters)
Anthony, K., Wiencek, C., Bauer,
C., Daly, B., & Anthony, M. K.
(2010). No interruptions please.
Impact of a no interruption zone on
medication safety in intensive care
units. Critical Care Nurse, 30(3),
21–29.
6, 7, 10, 11, 13,
15
Anthony (author) “no
interruptions” (all fields)
Ausserhofer, D., Schubert, M.,
Desmedt, M., Blegen, M. A.,
DeGeest, S., & Schwendimann, R.
(2013). The association of patient
safety climate and nurse-related
organizational factors with selected
patient outcomes: A cross-sectional
survey. International Journal of
Nursing Studies, 50, 240–252.
8, 11, 13, 15
Ausserhofer (author) Schubert
(author) “safety climate” (title)
Biron, A. D., Loiselle, C. G., &
Lavoie-Tremblay, M. (2009). Work
interruptions and their contribution
to medication errors: An evidence
review. World Views on Evidence-
Based Nursing, 6, 70–86.
12, 13, 15 Biron (author) “evidence review”
(all fields)
Cohen, H., & Shastay, D. (2008).
Getting to the root of medication
errors. Nursing, 38(12), 39–49.
4
Cohen (author) Shastay (author)
2008 (publication date)
59
Flanagan, J. M., Carroll, D. L., &
Hamilton, G. A. (2010). The long-
term lived experience of patients
with implantable cardioverter
defibrillators. MEDSURG Nursing,
19, 113–119.
1
“lived experience” (title)
“implantable cardioverter
defibrillators” (title)
Flynn, L., Liang, Y., Dickson, G.
L., Xie, M., & Suh, D. (2013).
Nurses’ practice environments,
error interpretation practices, and
inpatient medication errors. Journal
of Nursing Scholarship, 44(2),
180–186.
10, 11, 13, 15
Flynn (author) Liang (author)
“Journal of Nursing Scholarship”
(publication name)
Kliger, J., Blegen, M. A., Gootee,
D., & O’Neil, E. (2009).
Empowering frontline nurses: A
structured intervention enables
nurses to improve medication
administration accuracy. The Joint
Commission Journal on Quality
and Patient Safety, 35, 604–612.
4, 6, 7, 10, 11,
13, 15
Kliger (author) Gootee (author)
Pipe, T. B., Kelly, A., LeBrun, G.,
Schmidt, D., Atherton, P., &
Robinson, C. (2008). A prospective
descriptive study exploring hope,
spiritual well-being, and quality of
life in hospitalized patients.
MEDSURG Nursing, 17, 247–257.
1
Pipe (author) hope (all fields)
“spiritual well-being” (all fields)
Rich, V. L. (2005). How we think
about medication errors: A model
and a charge for nurses. American
Journal of Nursing, 105(3 Suppl.),
10–11.
5, 10, 11, 12, 13,
15
Rich (author) “model” (title)
“American Journal of Nursing”
(publication name)
Schwappach, D. L. B.,
Hochreutener, M. A., & Wernli, M.
(2010). Oncology nurses’
perceptions about involving patients
in the prevention of chemotherapy
administration errors. Oncology
Nursing Forum, 37, E84–E91.
9, 11, 14, 15
Schwappach (author) “oncology“
(all fields) “qualitative“ (all fields)
60
Tomietto, M., Sartor, A.,
Mazzocoli, E., & Palese, A.
(2012). Paradoxical effects of a
hospital-based, multi-intervention
programme aimed at reducing
medication round interruptions.
Journal of Nursing Management,
20(3), 335–343.
4 Tomietto (all fields)
Evidence to Obtain from Web
Citation Chapters Web Link
Institute of Medicine. (2006).
Preventing medication errors.
Retrieved from
http://www.iom.edu/~/media/Files/
Report%20Files/2006/
Preventing-Medication-Errors-
Quality-Chasm-Series/
medicationerrorsnew.ashx
3
http://www.iom.edu/~/
media/Files/Report%20Files/
2006/Preventing-Medication-Errors
-Quality-Chasm-Series/
medicationerrorsnew
.ashx
Murphy, K. (2006, October 31).
What pilots can teach hospitals
about patient safety. New York
Times. Retrieved from
http://www.nytimes.com/2006/
10/31/health/31safe.html?
ex=1319950800&en=a
64123f3e689ea9f&
ei=5088&partner=rssnyt&emc=rss
12, 13, 15
http://www.nytimes.com/2006/
10/31/health/31safe.
html?ex=1319950800&en=
a64123f%203e689ea9f&
ei=5088&partner=rssnyt&
emc=rss&_r=0
National Cancer Institute. (n.d.).
Human participant protections
education for research teams.
Retrieved from
http://phrp.nihtraining.com/
users/login.php
2 http://phrp.nihtraining.com/
users/login.php
Xue, Y. (2013). Medication errors:
Double checking. Joanna Briggs 12, 13, 15
Connect to JBI website and sign in.
You will probably have to access
this site through your university’s
library. Enter the following phrase
61
http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.ashx
http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.ashx
http://www.nytimes.com/2006/10/31/health/31safe.html?ex=1319950800&en=a64123f3e689ea9f&ei=5088&partner=rssnyt&emc=rss
http://www.nytimes.com/2006/10/31/health/31safe.html?ex=1319950800&en=a64123f%203e689ea9f&ei=5088&partner=rssnyt&emc=rss&_r=0
http://phrp.nihtraining.com/users/login.php
http://phrp.nihtraining.com/users/login.php
in the search box: Medication
Errors: Double Checking.
Emotional Intelligence (EQ)
Assessment
17 http://www.ihhp.com/?
page=freeEQquiz
The New Enneagram Test 17 http://www.9types.com/
newtest/index.php)
Available in the Digital Resources
Resource Chapter
Grid 4
Visit this text’s accompanying
digital resources to find links to
these materials.
Table of Error Rates 18
Poster guideline for making an EBP
poster presentation
19
We hope that the variety of strategies incorporated in this textbook meet your
learning needs and generate enthusiasm about EBP. We wish you the best as you
begin your professional career as an innovator who provides care based on best
practices.
REFERENCES
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: Free Press.
Schmidt, N. A., & Brown, J. M. (2007). Use of the innovation–decision process teaching strategy to promote
evidence-based practice. Journal of Professional Nursing, 23, 150–156.
62
http://www.ihhp.com/?page=freeEQquiz
http://www.9types.com/newtest/index.php
ACKNOWLEDGMENTS
As with every endeavor, many individuals make accomplishing the goal a reality.
We wish to begin by expressing our gratitude to the contributors who shared our
vision to create a text that can excite undergraduate nurses about evidence-based
practice. We thank them for revising their chapters. We also want to welcome
aboard Dr. Cory, who wrote the new chapter. The efforts of Karen Stacy, Patti
Reid, and Julie Ault to protect sacred writing times were instrumental in allowing
us to meet deadlines. Without their help and understanding, writing sessions would
not have been as productive as they were. Special thanks are in order for Jones &
Bartlett Learning staff; especially, Amanda Martin, Rebecca Myrick, and Keith
Henry offered invaluable editorial assistance. We are grateful for the ways Jones &
Bartlett has developed and marketed the book over the three editions, and we are
delighted how the use of the book has surpassed our expectations. This success can
be attributed to nursing faculty who are also committed to our vision of creating
nurses who base their practices on evidence. Finally, we are indebted to our
families, who afforded us the time to complete this book. They provided invaluable
support throughout the process.
63
Introduction to Evidence-Based
Practice
UNIT 1
Without evidence, clinical practice
cannot advance scientifically.
64
CHAPTER 1
65
What Is Evidence-Based Practice?
Nola A. Schmidt and Janet M. Brown
66
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Define evidence-based practice (EBP)
‹ List sources of evidence for nursing practice
‹ Identify barriers to the adoption of EBP and pinpoint strategies to overcome
them
‹ Explain how the process of diffusion facilitates moving evidence into nursing
practice
‹ Define research
‹ Discuss the contribution of research to EBP
‹ Categorize types of research
‹ Distinguish between quantitative and qualitative research approaches
‹ Describe the sections found in research articles
‹ Describe the cycle of scientific development
‹ Identify historical occurrences that shaped the development of nursing as a
science
‹ Identify factors that will continue to move nursing forward as a science
‹ Discuss what future trends may influence how nurses use evidence to improve
the quality of patient care
‹ Identify five unethical studies involving the violation of the rights of human
subjects
KEY TERMS
abstract
applied research
barriers
basic research
cycle of scientific development
67
deductive reasoning
descriptive research
discussion section
early adopters
empirical evidence
evidence-based practice (EBP)
explanatory research
inductive reasoning
innovation
introduction
Jewish Chronic Disease Hospital study
laggards
list of references
methods section
model of diffusion of innovations
Nazi experiments
Nuremberg Code
predictive research
pyramid of evidence
qualitative research
quantitative research
replication study
research
research utilization
results section
review of literature
theoretical framework
68
theory
Tuskegee study
Willowbrook studies
It is not uncommon for students to question the need to study a textbook such as this.
To many students, it seems much more exciting and important to be with patients in
various settings. It is often hard for beginning practitioners to appreciate the value
of learning the research process and the importance of evidence in providing
patient care. To appreciate the importance of evidence, imagine that a family
member required nursing care. Would it not be much more desirable to have care
based on evidence rather than on tradition, trial and error, or an educated guess? To
be competent, a nurse must have the ability to provide care based on evidence. A
journey through this textbook will assist you with developing your skills and talents
for providing patients with care based on evidence so that the best possible
outcomes can be achieved.
1.1 EBP: What Is It?
At the end of this section, you will be able to:
‹ Define evidence-based practice (EBP)
‹ List sources of evidence for nursing practice
‹ Identify barriers to the adoption of EBP and pinpoint strategies to overcome
them
‹ Explain how the process of diffusion facilitates moving evidence into nursing
practice
Overview of EBP
When examining the literature about evidence-based practice (EBP), one will find
a variety of definitions. Most definitions include three components: research-based
information, clinical expertise, and patient preferences. Ingersoll’s (2000)
definition succinctly captures the essence of EBP, defining it as “the conscientious,
explicit, and judicious use of theory-derived, research-based information in making
decisions about care delivery to individuals or groups of patients and in
consideration of individual needs and preferences” (p. 152). What does this mean?
EBP is a process involving the examination and application of research findings or
other reliable evidence that has been integrated with scientific theories. For nurses
69
to participate in this process, they must use their critical thinking skills to review
research publications and other sources of information. After the information is
evaluated, nurses use their clinical decision-making skills to apply evidence to
patient care. As in all nursing care, patient preferences and needs are the basis of
care decisions and therefore essential to EBP.
e vide nce -bas e d practice (EBP): Practice based on the best available evidence, patient preferences, and
clinical judgment
FYI
Nurses’ unique perspective on patient care obliges nurses to build their own body of evidence through
scientific research. There are a variety of sources of evidence for nursing research, some of which build a
stronger case than others do.
EBP has its roots in medicine. Archie Cochrane, a British epidemiologist,
admonished the medical profession for not critically examining evidence
(Cochrane, 1971). He contended that individuals should pay only for health care
based on scientific evidence (Melnyk & Fineout-Overholt, 2011), and he believed
that random clinical trials were the “gold standard” for generating reliable and
valid evidence. He suggested that rigorous, systematic reviews of research from a
variety of disciplines be conducted to inform practice and policy making. As a
result of his innovative idea, the Cochrane Center established a collaboration
“dedicated to making up-to-date, accurate information about the effects of health
care readily available worldwide. It [the Cochrane Center] produces and
disseminates systematic reviews of healthcare interventions and promotes the
search for evidence in the form of clinical trials and other studies of interventions”
(Cochrane Collaboration, n.d.). Others built on Dr. Cochrane’s philosophy, and the
definition of EBP in medicine evolved to include clinical judgment and patient
preferences (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Straus,
Glasziou, Richardson, & Haynes, 2011).
During this time, nursing was heavily involved in trying to apply research
findings to practice, a process known as research utilization. This process
involves changing practice from the results of a single research study (Barnsteiner
& Prevost, 2002). Nursing innovators recognized that shifting from this model to an
EBP framework would be more likely to improve patient outcomes and provide
more cost-effective methods of care (Ingersoll, 2000; Levin, Fineout-Overholt,
Melnyk, Barnes, & Vetter, 2011; Melnyk, 1999; Schifalacqua, Mamula, & Mason,
2011; Youngblut & Brooten, 2001). Why? Many nursing questions cannot be
answered by a single study, and human conditions are not always amenable to
clinical trials. Also, the research utilization process does not place value on the
importance of clinical decision making, nor is it noted for being patient focused.
70
re s e arch utilization: Changing practice based on the results of a single research study
CRITICAL THINKING EXERCISE 1-1
© Jules_Kitano/ShutterStock, Inc.
Look carefully at the steps in each EBP model cited in Table 1-1. Are you reminded of a similar process?
These nursing innovators recognized that the EBP framework allows for
consideration of other sources of evidence relevant to nursing practice.
There are many different models for EBP. Three models that are especially
well known in nursing are shown in Table 1-1. While each is unique, they have
commonalities. For example, each one begins with a question or need for the
identification of acquiring knowledge about a question. All involve appraisal of
evidence and making a decision about how to use evidence. These models conclude
by closing the loop through evaluation to determine that the practice change is
actually meeting the expected outcomes.
Sources of Evidence
Over the years, a variety of sources of evidence has provided information for
nursing practice. Although it would be nice to claim that all nursing practice is
based on substantial and reliable evidence, this is not the case. Evidence derived
from tradition, authority, trial and error, personal experiences, intuition, borrowed
evidence, and scientific research are all used to guide nursing practice. Just as you
know from your own life, some sources are not as dependable as others.
TABLE 1-1 Models of EBP
ACE Star Model of
Knowledge
Transformation
Iowa Model of EBP
Model of Diffusion of
Innovations
1. Discovery
research
1. Ask clinical question 1. Acquisition of
knowledge
2. Evidence
summary
2. Search literature 2. Persuasion
3. Translation to 3. Critically appraise
71
guidelines evidence
4. Practice
integration
4. Implement practice
change
4. Implementation
5. Process, outcome
evaluation
5. Evaluate 5. Confirmation
Stevens (2012) Titler et al. (2001) Rogers (2003)
Tradition has long been an accepted basis for information. Consider this: Why
are vital signs taken routinely every 4 hours on patients who are clinically stable?
The rationale for many nursing interventions commonly practiced is grounded in the
phrase “This is the way we have always done it.” Nurses can be so entrenched in
practice traditions that they fail to ask questions that could lead to changes based in
evidence. Consistent use of tradition as a basis for practice limits effective
problem solving and fails to consider individual needs and preferences.
How often have you heard the phrase “Because I said so”? This is an example
of authority. Various sources of authority, such as books, articles, web pages, and
individuals and groups, are perceived as being meaningful sources of reliable
information; yet, in reality, the information provided may be based in personal
experience or tradition rather than scientific evidence. Authority has a place in
nursing practice as long as nurses ascertain the legitimacy of the information
provided.
Trial and error is another source of evidence. Although we all use this
approach in our everyday problem solving, it is often not the preferred approach
for delivering nursing care. Because trial and error is not based on a systematic
scientific approach, patient outcomes may not be a direct result of the intervention.
For example, in long-term care the treatment of decubitus ulcers is often based on
this haphazard approach. Nurses frequently try a variety of approaches to heal
ulcers. After some time, they settle on one approach that is more often than not
effective. This approach can lead to reduced critical thinking and wasted time and
resources.
Nurses often make decisions about patient care based on their personal
experiences. Although previous experience can help to build confidence and hone
skills, experiences are biased by perceptions and values that are frequently
influenced by tradition, authority, and trial and error. Personal intuition has also
been identified as a source of evidence. It is not always clear what is meant by
intuition and how it contributes to nursing practice. Intuition is defined as “quick
perception of truth without conscious attention or reasoning” (Read et al., 2005, p.
72
668). Whereas on very rare occasions a “gut feeling” may be reliable, most patients
would prefer health care that is based on stronger evidence. Thus, intuition is not
one of the most advantageous sources of evidence for driving patient care decisions
because nurses are expected to use logical reasoning as critical thinkers and
clinical decision makers.
Because of the holistic perspective used in nursing and the collaboration that
occurs with other healthcare providers, it is not uncommon for nurses to borrow
evidence from other disciplines. For example, pediatric nurses rely heavily on
theories of development as a basis for nursing interventions. Borrowed evidence
can be useful because it fills gaps that exist in nursing science and provides a basis
on which to build new evidence; it can be a stronger type of evidence than are
sources not based on theory and science. When nurses use borrowed evidence, it is
important for them to consider the fit of the evidence with the nursing phenomenon.
Because nursing offers a unique perspective on patient care, nurses cannot rely
solely on borrowed evidence and must build their own body of evidence through
scientific research. Scientific research is considered to yield the best source of
evidence. Nurses can use many different research methods to describe, explain, and
predict phenomena that are central to nursing care. To have an EBP, whenever
possible nurses must emphasize the use of theory-derived, research-based
information over the use of evidence obtained through tradition, authority, trial and
error, personal experience, and intuition.
the ory: A set of concepts linked through propositions to explain a phenomenon
Not all scientific research is equal. Some types of studies are designed in ways
that yield results that nurses can use with confidence. For example, experiments are
considered more strongly designed than are studies that use surveys. When multiple
studies have been conducted about a particular topic, the findings of the studies can
be combined into a synthesis. Syntheses provide results that can be used with even
more confidence. To rank evidence from strongest to weakest, nurses refer to the
pyramid of evidence. You will find the need to frequently refer to this figure as you
learn about appraising evidence and research designs.
pyramid of e vide nce : A model showing how evidence can be categorized from strong to weak
Adopting an Evidence-Based Practice
One would think that when there is compelling scientific evidence, findings would
quickly and efficiently transition to practice. However, most often this is not the
case. Many barriers complicate the integration of findings into practice. In fact, it
can take as many as 200 years for an innovation to become a standard of care.
73
Consider the history of controlling scurvy in the British Navy.
barrie rs : Factors that limit or prevent change
In the early days of long sea voyages, scurvy killed more sailors than did warfare, accidents, and other
causes. In 1601 an English sea captain, James Lancaster, conducted an experiment to evaluate the
effectiveness of lemon juice in preventing scurvy. He commanded four ships that sailed from England
on a voyage to India. Three teaspoonfuls of lemon juice were served every day to the sailors in one of
his four ships. These men stayed healthy. The other three ships constituted Lancaster’s “control group,”
as their sailors were not given any lemon juice. On the other three ships, by the halfway point in the
journey, 110 out of 278 sailors had died from scurvy.
The results were so clear that one would have expected the British Navy to promptly adopt citrus
juice for scurvy prevention on all ships. But it did not become accepted practice. In 1747, about 150
years later, James Lind, a British Navy physician who knew of Lancaster’s results, carried out another
experiment on the HMS Salisbury. To each scurvy patient on this ship, Lind prescribed either two
oranges and one lemon, or one of five other supplements. The scurvy patients who got the citrus fruits
were cured in a few days and were able to help Dr. Lind care for the other patients.
Certainly, with this further solid evidence of the ability of citrus fruits to combat scurvy, one would
expect the British Navy to have quickly adopted this innovation for all ships’ crews on long sea voyages.
Yet it took another 48 years for this to become standard practice, and scurvy was finally wiped out.
Why were the authorities so slow to adopt the idea of citrus for scurvy prevention? Other
competing remedies for scurvy were also being proposed, and each cure had its champions. For
example, the highly respected Captain Cook reported that during his Pacific voyages there was no
evidence that citrus fruits cured scurvy. In contrast, the experimental work by Dr. Lind, who was not a
prominent figure in the field of naval medicine, did not get much attention. This leads one to wonder if
the British Navy was typically hesitant to adopt new innovations. But, while it resisted scurvy prevention
for years, other innovations, such as new ships and new guns, were readily accepted. (Adapted with the
permission of Simon & Schuster Publishing Group from the Free Press edition of DIFFUSION OF
INNOVATIONS, 5th Edition by Everett M. Rodgers. Copyright ©1995, 2003 by Everett M. Rodgers.
Copyright © 1962, 1971, 1983 by The Free Press. All rights reserved.)
Even when the benefits and advantages of an innovation have been made
evident, adoption can be slow to occur. Even today, studies demonstrate that nurses
do not use nursing research in their practice. In 2005, Pravikoff, Tanner, and Pierce
conducted a large survey of registered nurses (RNs) from across the United States.
Of the clinical nurses who responded to the survey, more than 54% were not
familiar with the term EBP. The typical source of information for 67% of these
nurses was a colleague. Alarmingly, 58% of the respondents had never used
research articles to support clinical practice. Only 18% had ever used a hospital
library. Additionally, 77% had never received instruction in the use of electronic
resources. In contrast, a survey conducted at a Magnet hospital found that 96% of
nurses were aware that EBP was being implemented at their institution (White-
Williams et al., 2013). Although this shows a significant improvement over 7 years,
one must keep in mind that the inclusion of only a Magnet facility may present a
bias because to earn Magnet Recognition, EBP must be inherent in the organization.
innovation: Something new or novel
74
CRITICAL THINKING EXERCISE 1-2
© Jules_Kitano/ShutterStock, Inc.
Consider your last clinical experience. How much was your practice based on scientific research? What
other sources of evidence did you use? Divide a circle into sections (like a pie chart) to show how much
influence each of the sources of evidence had on the patient care you provided.
Overcoming Barriers
Studies demonstrate that the reasons nurses do not draw on research are related to
individual and organizational factors. Individual factors are those characteristics
that are inherent to the nurse. Organizational factors are related to administration,
resources, facilities, and culture of the system. Major barriers to nurses using
research findings at the point of care are nurses not valuing research, nurses being
resistant to change, and lack of time and resources to obtain evidence (Shivnan,
2011). In addition, the communication gap between researcher and clinician
(Brown, 1995; Paris, Callahan, & Pierson, 2011), organizational culture, and the
inability of individuals to evaluate nursing research have been identified as
barriers by registered nurses (Carroll et al., 1997; Funk, Champagne, Wiese, &
Tornquist, 1991; Kajermo, Nordstrom, Krusebrant, & Bjorvell, 2000; Majid et al.,
2011; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012; Solomons &
Spross, 2011; Van Patter Gale & Schaffer, 2009), healthcare administrators (Funk,
Champagne, Tornquist, & Wiese, 1995), and oncology nursing staff (Rutledge,
Ropka, Greene, Nail, & Mooney, 1998).
Strategies that do not overcome these barriers do little to promote EBP. To
overcome barriers related to individual factors, strategies need to be aimed at
instilling an appreciation for EBP, increasing knowledge, developing necessary
skills, and changing behaviors. Strategies to overcome organizational barriers must
be directed toward creating and maintaining an environment where EBP can
flourish. Research has focused on strategies to overcome both individual and
organizational factors to bring about change (Aitken et al., 2011; Fitzsimons &
Cooper, 2012; Hauck, Winsett, & Kuric, 2013; Melnyk, Fineout-Overholt,
Giggleman, & Cruz, 2010; Ogiehor-Enoma, Taqueban, & Anosike, 2010;
Pennington, Moscatel, Dacar, & Johnson, 2010; Reicherter, Gordes, Glickman, &
Hakim, 2013; Valente, 2010). Practical strategies for successfully overcoming these
barriers are summarized in Table 1-2.
TABLE 1-2 Strategies for Overcoming Barriers to Adopting
75
an EBP
Barrier Strategy
Lack of time
Devote 15 minutes per day to reading evidence related to
a clinical problem.
Sign up for emails that offer summaries of research
studies in your area of interest.
Use a team approach to equitably distribute the workload
among members.
Bookmark websites that have clinical guidelines to
promote faster retrieval of information.
Evaluate available technologies (i.e., tablets) to create
time-saving systems that allow quick and convenient
retrieval of information at the bedside.
Negotiate release time from patient care duties to collect,
read, and share information about relevant clinical
problems.
Search for already established clinical guidelines because
they provide synthesis of existing research.
Lack of value placed on
research in practice
Make a list of reasons why healthcare providers should
value research, and use this list as a springboard for
discussions with colleagues.
Invite nurse researchers to share why they are passionate
about their work.
When disagreements arise about a policy or protocol, find
an article that supports your position and share it with
others.
When selecting a work environment, ask about the
organizational commitment to EBP.
Link measurement of quality indicators to EBP.
Participate in EBP activities to demonstrate
professionalism that can be rewarded through promotions
or merit raises.
Provide recognition during National Nurses Week for
individuals involved in EBP projects.
Lack of knowledge
about EBP and research
Take a course or attend a continuing education offering on
EBP.
Invite a faculty member to a unit meeting to discuss EBP.
Consult with advanced practice nurses.
Attend conferences where clinical research is presented
and talk with presenters about their studies.
Volunteer to serve on committees that set policies and
protocols.
76
Create a mentoring program to bring novice and
experienced nurses together.
Lack of technological
skills to find evidence
Consult with a librarian about how to access databases
and retrieve articles.
Learn to bookmark important websites that are sources of
clinical guidelines. Commit to acquiring computer skills.
Lack of resources to
access evidence
Write a proposal for funds to support access to online
databases and journals.
Collaborate with a nursing program for access to
resources. Investigate funding possibilities from others
(i.e., pharmaceutical companies, grants).
Lack of ability to read
research
Organize a journal club where nurses meet regularly to
discuss the evidence about a specific clinical problem.
Write down questions about an article and ask an
advanced practice nurse to read the article and assist in
answering the questions.
Clarify unfamiliar terms by looking them up in a dictionary
or research textbook.
Use one familiar critique format when reading research.
Identify clinical problems and share them with nurse
researchers.
Participate in ongoing unit-based studies.
Subscribe to journals that provide uncomplicated
explanations of research studies.
Resistance to change
Listen to people’s concerns about change.
When considering an EBP project, select one that interests
the staff, has a high priority, is likely to be successful, and
has baseline data.
Mobilize talented individuals to act as change agents.
Create a means to reward individuals who provide
leadership during change.
Lack of organizational
support for EBP
Link organizational priorities with EBP to reduce cost and
increase efficiency.
Recruit administrators who value EBP.
Form coalitions with other healthcare providers to increase
the base of support for EBP.
Use EBP to meet accreditation standards or gain
recognition (i.e., Magnet Recognition).
To overcome barriers to using research findings in practice, it can be helpful to
use a model to assist in understanding how new ideas come to be accepted
77
practice. The model of diffusion of innovations (Rogers, 2003) has been used in
the nursing literature for this purpose (Barta, 1995; Carroll et al., 1997; Schmidt &
Brown, 2007; Van Patter Gale & Schaffer, 2009). You are already familiar with the
concept of diffusion. From studying chemistry you know that diffusion involves the
movement of molecules from areas of higher concentration to areas of lower
concentration. In the same way, innovative nursing practices frequently begin in a
small number of institutions and eventually spread or diffuse, becoming standard
practice everywhere. The model includes four major concepts: innovation,
communication, time, and social system. Rogers (2003) defines diffusion as “the
process by which (1) an innovation (2) is communicated through certain channels
(3) over time (4) among the members of a social system” (p. 11). An innovation is
an idea, practice, or object that is perceived as new by an individual or other unit
of adoption. Before adopting an innovation, individuals seek information about its
advantages and disadvantages.
mode l of diffus ion of innovations : Model to assist in understanding how new ideas come to be accepted
practice
Initially, only a minimal number of individuals, known as early adopters,
embrace the innovation. With time, early adopters who are opinion leaders, through
their interpersonal networks, become instrumental as the diffusion progresses
through the social system. Those individuals who are slow or who fail to adopt the
innovation are known as laggards. In the scurvy example, it took about 200 years
for the innovation to diffuse throughout the British Navy. You may also be surprised
to see how long it has taken other things we take for granted to diffuse throughout
American households (Table 1-3).
e arly adopte rs : Individuals who are the first to embrace an innovation
laggards : Individuals who are slow or fail to adopt an innovation
TABLE 1-3 Spread of Products to a Quarter of the
Population
Product Year Invented Years to Spread
Electricity 1873 48
Telephone 1876 35
Automobile 1896 55
Airplane 1903 64
78
Radio 1906 22
Television 1926 26
VCR 1952 34
Microwave oven 1953 30
PC 1975 16
Cellular phone 1983 13
Internet 1991 7
Source: Data from Leading Edge Forum (2011).
CRITICAL THINKING EXERCISE 1-3
© Jules_Kitano/ShutterStock, Inc.
In the scurvy example, identify communication channels and social system barriers to the adoption of citrus
fruits as a treatment for scurvy. Now, consider how the model of diffusion of innovations could have been
applied to this situation. How could the physicians have overcome the barriers you identified and convinced
others to become early adopters so that citrus became accepted practice for the treatment of scurvy?
TEST YOUR KNOWLEDGE 1-1
1. Which of the following is not a component of the definition of EBP?
a. Clinical expertise
b. Nursing research
c. Organizational culture
d. Patient preferences
2. To promote EBP, which of the following strategies must be addressed? (Select all that apply.)
a. Lack of commitment to EBP
b. Lack of computer skills
c. Lack of time
d. Lack of value placed on research in practice
How did you do? 1. c; 2. a, b, c, d
79
1.2 What Is Nursing Research?
At the end of this section, you will be able to:
‹ Define research
‹ Discuss the contribution of research to EBP
‹ Categorize types of research
‹ Distinguish between quantitative and qualitative research approaches
‹ Describe the sections found in research articles
Research is a planned and systematic activity that leads to new knowledge
and/or the discovery of solutions to problems or questions (Polit & Beck, 2011).
Simply stated, research means to search again. But the search must be deliberate
and organized as relevant questions are examined. It is essential that established
steps be followed.
re s e arch: Systematic study that leads to new knowledge and/or solutions to problems or questions
Following a systematic approach (Table 1-4) is more likely to yield results that
can be used with confidence. Through research, scientists aim to describe, explain,
and predict phenomena. But isn’t science supposed to prove that things are true?
Sometimes you may hear or read the phrase “research proves”; however, the use of
the word prove is inaccurate. Research findings support a particular approach or
view because the possibility of error exists in every research study. This
underscores why a planned, systematic approach is necessary and why replication
studies are important.
re plication s tudie s : Repeated studies to obtain similar results
Nurses use research to generate new knowledge or to validate and refine
existing knowledge that directly or indirectly influences nursing practice. In nursing
research, the phenomena of interest are persons, health, nursing, and environment.
Nurses study patient outcomes, attitudes of nurses, effectiveness of administrative
policy, and teaching strategies in nursing education. Nursing research contributes to
the development and refinement of theory. But most important, as a baccalaureate-
prepared nurse, you will use research as a foundation for EBP. Without research,
nursing practice would be based on tradition, authority, trial and error, personal
experiences, intuition, and borrowed evidence. This is why you must have the skills
to read, evaluate, and apply nursing research so that as an early adopter you can be
instrumental in moving an innovation to the point of care.
80
FYI
Research can be categorized as descriptive, explanatory, or predictive; basic or applied; and quantitative or
qualitative. Nursing research concerns persons, health, nursing practice, and environment and can be used to
generate new knowledge or to validate and refine existing knowledge that directly or indirectly influences
nursing practice.
TABLE 1-4 Steps of the Research Process
1. Identify the research question.
2. Conduct a review of the literature.
3. Identify a theoretical framework.
4. Select a research design.
5. Implement the study.
6. Analyze data.
7. Draw conclusions.
8. Disseminate findings.
Types of Research
A variety of terms is used to describe the research conducted by scientists.
Research can be categorized as descriptive, explanatory, or predictive; basic or
applied; and quantitative or qualitative. These categories are not necessarily
mutually exclusive. For example, a study may be descriptive, applied, and
qualitative. Although this sounds complicated, when you understand the definitions,
it will become clear.
de s criptive re s e arch: A category of research that is concerned with providing accurate descriptions of
phenomena
e xplanatory re s e arch: Research concerned with identifying relationships among phenomena
pre dictive re s e arch: Research that forecasts precise relationships between dimensions of phenomena or
differences between groups
bas ic re s e arch: Research to gain knowledge for the sake of gaining knowledge; bench research
applie d re s e arch: Research to discover knowledge that will solve a clinical problem
quantitative re s e arch: Research that uses numbers to obtain precise measurements
81
qualitative re s e arch: Research that uses words to describe human behaviors
One way to classify research is by its aims. Descriptive research answers
“What is it?” This category of research is concerned with providing accurate
descriptions and can involve observation of a phenomenon in its natural setting.
The goal of the explanatory category is to identify the relationships a phenomenon
has with individuals, groups, situations, or events. Explanatory studies address why
or how phenomena are related. Predictive research aims to forecast precise
relationships between dimensions of phenomena or differences between groups.
This category of research addresses when the phenomena will occur. Table 1-5
provides an example of how these different types helped nurses to better understand
the phenomenon of pain during chest tube removal.
Another way to classify research is to consider whether findings can be used to
solve real-world problems. Basic research, sometimes known as bench research,
seeks to gain knowledge for the sake of gaining that knowledge. This knowledge
may or may not become applicable to practical issues or situations. It may be years
before a discovery becomes useful when it is combined with other discoveries. For
example, vitamin K was studied for the sake of learning more about its properties.
Years later, the knowledge gained about its mechanism of action during coagulation
formed the foundation for vitamin K becoming an accepted treatment for bleeding
disorders. In contrast, the aim of applied research is to discover knowledge that
will solve a clinical problem. The findings typically have immediate application to
bring about changes in practice, education, or administration.
Quantitative and qualitative are terms that are also used to distinguish among
types of research. Philosophical approach, research questions, designs, and data all
provide clues to assist you in differentiating between these two methods of
classification. Quantitative research views the world as objective. This implies
that researchers can separate themselves from phenomena being studied. The focus
is on collecting empirical evidence, in other words, evidence gathered through the
five senses. Researchers quantify observations by using numbers to obtain precise
measurements that can later be statistically analyzed. Many quantitative studies test
hypotheses. In contrast, the premise of qualitative research is that the world is not
objective. There can be multiple realities because the context of the situation is
different for each person and can change with time. The emphasis is on verbal
descriptions that explain human behaviors. In this type of research, the focus is on
providing a detailed description of the meanings people give to their experiences.
Table 1-6 provides a comparison of these two approaches.
e mpirical e vide nce : Evidence that is verifiable by experience through the five senses or experiment
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TABLE 1-5 An Example of Building Knowledge in Nursing
Science: Pain and Chest Tube Removal (CTR)
Study Aim of
Research
Findings
Gift, Bolgiano, &
Cunningham (1991) Describe
Individuals reported burning pain and
pulling with CTR. Women reported pain
more frequently than men did.
Puntillo (1994) Describe
Compared CTR pain with endotracheal
suctioning. Patients reported less pain
with suctioning than with CTR. “Sharp”
was the most frequent adjective for CTR
pain.
Carson, Barton,
Morrison, & Tribble
(1994)
Explain
Patients were assigned to one of four
groups for treatment with pain
medications: IV morphine, IV morphine
and subfascial lidocaine, IV morphine
and subfascial normal saline solution, and
subfascial lidocaine. There were no
significant differences in pain alleviation.
Puntillo (1996) Predict
Patients were assigned to either placebo
normal saline interpleural injection or
bupivacaine interpleural injection. There
was no significant difference in pain
reports.
Houston & Jesurum
(1999)
Explain
Examined effect of Quick Release
Technique (QRT), a form of relaxation
using a breathing technique, during CTR.
Patients were randomly assigned to either
an analgesic-only group or an analgesic
with QRT. Combination of QRT with
analgesic was not more effective than
was analgesic alone in reducing pain.
Patients were randomly assigned to one
of four combinations of pharmacological
and nonpharmacological interventions to
reduce pain: 4 mg IV morphine with
procedural information, 30 mg IV
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Puntillo & Ley (2004) Predict ketorolac and procedural information, 4
mg IV morphine with procedural and
sensory information, and 30 mg IV
ketorolac with procedural and sensory
information. There were no significant
differences among the groups regarding
pain intensity, pain distress, or sedation
levels.
Friesner, Curry, &
Moddeman (2006)
Predict
A group of adults who had undergone
coronary artery bypass used a slow deep-
breathing relaxation exercise with opioid
analgesia. Their pain ratings were
compared to a group using opioids only.
There was a significant reduction in pain
ratings for the patients who used the
breathing exercise combined with opioids.
Demir & Khorsbid
(2010)
Predict
Cardiac patients were randomly assigned
to a group that received ice and analgesia,
a group that received warmth and
analgesia, or a group that received only
analgesia. Patients who received the
application of ice reported significantly
less pain than did patients from the other
two groups.
Ertuğ & Űlker (2011) Predict
Patients were randomly assigned to either
an experimental group that received cold
prior to CTR or a control group that had
no intervention for pain management.
Patients receiving cold reported
significantly less pain than did those in
the control group.
Note: CTR = chest tube removal.
Another important point about quantitative and qualitative approaches is that
there are two styles of reasoning associated with them. Deductive reasoning,
primarily linked with quantitative research, is reasoning that moves from the
general to the particular. For example, researchers use a theory to help them reason
out a hunch. If the researcher believes that the position of the body affects
circulation, then the researcher could deduce that blood pressure readings taken
while lying down will be different from those measured while standing. In contrast,
inductive reasoning involves reasoning that moves from the particular to the
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general and is associated with qualitative approaches. By using inductive
reasoning, researchers can take particular ideas and express an overall general
summary about the phenomenon (Figure 1-1).
de ductive re as oning: Thinking that moves from the general to the particular
inductive re as oning: Thinking that moves from the particular to the general
What Makes Up a Research Article?
The development of EBP requires careful attention to research already published.
Therefore, it is essential for nurses to identify research studies from among the
many other types of articles included in the literature. The trick is knowing what
sections are contained in a research article.
Typically, an abstract is the first section of a research article and is usually
limited to 100–150 words. The purpose of the abstract is to provide an overview
of the study, but the presence of an abstract does not necessarily mean that an article
is a research study. Because abstracts can frequently be found online, it is usually
helpful to read them before printing or requesting a copy of the article. Careful
attention to abstracts can avoid wasted time and effort retrieving articles that are
not applicable to the clinical question.
abs tract: The first section of a research article that provides an overview of the study
TABLE 1-6 Comparisons of Quantitative and Qualitative
Approaches
Attribute Quantitative Qualitative
Philosophical
perspective
One reality that can be
objectively viewed by the
researcher
Multiple realities that are
subjective, occurring within the
context of the situation
Type of reasoning Primarily deductive Primarily inductive
Role of researcher Controlled and structured Participative and ongoing
Strategies
Control and manipulation of
situations
Analysis of numbers with
statistical tests
Larger number of subjects
Naturalistic; allows situations to
unfold without interference
Analysis of words to identify
themes
Smaller numbers of participants
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Possible designs
Nonexperimental
Correlational
Quasi-experimental
Experimental
Phenomenological
Ethnographic
Grounded Theory
Historical
The introduction, which follows the abstract, contains a statement of the
problem and a purpose statement. The problem statement identifies the problem in a
broad and general way. For example, a problem statement may read, “falls in
hospitalized patients can increase length of stay.” Authors usually provide
background information and statistics about the problem to convince readers that
the problem is significant. The background information provided should set the
stage for the purpose statement, which describes what was examined in the study.
For example, a purpose statement may read, “the purpose of this study was to
examine the relationship between time of evening medication administration and
time of falls.” A good introduction convinces readers that the study was worthy of
being conducted.
introduction: Part of a research article that states the problem and purpose
The third section is the review of literature. An unbiased, comprehensive,
synthesized description of relevant, previously published studies should be
presented. For each study included in the review, the purpose, sample, design, and
significant findings are discussed. The review should focus on the most recent work
in the field but may include older citations if they are considered to be landmark
studies. A complete citation is provided for each article so that readers can retrieve
the articles if desired. A well-written literature review concludes with a summary
of what is known about the problem and identifies gaps in the knowledge base to
show readers how the study adds to existing knowledge.
re vie w of lite rature : An unbiased, comprehensive, synthesized description of relevant previously published
studies
FIGURE 1-1 Ways of Reasoning
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The research article should include a discussion of the theoretical framework,
which may be in a separate section or combined with the review of literature. A
theoretical framework often describes the relationships among general concepts
and provides linkages to what is being measured in the study. Authors frequently
use a model or diagram to explain their theoretical framework.
the ore tical frame work: The structure of a study that links the theory concepts to the study variables; a section
of a research article that describes the theory used
A major portion of a research article is the methods section, which includes a
discussion about study design, sample, and data collection. In most cases, authors
explicitly describe the type of design they selected to answer the research question.
In this section, it is important for the authors to describe the target population and
explain how the sample was obtained. Procedures for collecting data, including the
types of measures used, should also be outlined. Throughout this section, authors
provide rationale for decisions made regarding how the study was implemented.
me thods s e ction: Major portion of a research article that describes the study design, sample, and data
collection
Readers frequently consider the results section to be the most difficult to
understand. Here, authors describe the methods they used to analyze their data, and
the characteristics of the sample are reported. In quantitative studies, data tables
are frequently included for interpretation, and authors indicate which findings were
significant and which were not. In qualitative studies, authors present themes that
are supported by quotes from participants. After reading the results section, the
reader should be confident that the researchers selected the appropriate analysis for
the data collected.
re s ults s e ction: Component of a research article that reports the methods used to analyze data and
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characteristics of the sample
The body of a research article concludes with a discussion section. Authors
provide an interpretation of the results and discuss how the findings extend the
body of knowledge. Results should be linked to the review of the literature and
theoretical framework. The authors discuss the limitations of the study design and
sometimes suggest possible solutions to address them in future studies. Implications
for practice, research, and education are proposed. Often it is helpful to read this
section after reading the abstract and introduction because it provides clarity by
giving readers an idea of what is to come.
dis cus s ion s e ction: Portion of a research article where interpretation of the results and how the findings
extend the body of knowledge are discussed
The article concludes with the list of references that are cited in the article.
While styles vary, many journals adhere to the guidelines provided in the
Publication Manual of the American Psychological Association. Because it is
often helpful to refer to the original works listed in the reference section, it is wise
for readers to obtain a copy of the entire article, including the reference list.
lis t of re fe re nce s : Publication information for each article cited in a research report
TEST YOUR KNOWLEDGE 1-2
True/False
1. When reading a quantitative research article, you would expect to see words being analyzed as
data.
2. The purpose of research is to prove something is true.
3. It is possible for a descriptive, qualitative study to be applied to practice.
How did you do? 1. F; 2. F; 3. T
1.3 How Has Nursing Evolved as a
Science?
At the end of this section, you will be able to:
‹ Describe the cycle of scientific development
‹ Identify historical occurrences that shaped the development of nursing as a
science
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Nursing has been described as both an art and a science. Historically, the emphasis
was more on the art than the science. But as nursing has developed, the emphasis
has shifted. We propose that nursing is the artful use of science to promote the
health and well-being of individuals, families, and communities. Thus, nursing is
based on scientific evidence that provides the framework for practice. The art of
nursing is the blending of science with caring to create a therapeutic relationship in
which holistic care is delivered. The profession of nursing is entering a new era in
which the emphasis is on EBP, therefore reaffirming the importance of science in
nursing.
Cycle of Scientific Development
To fully appreciate nursing as a science, an understanding of the history of research
in nursing is necessary. Although a grasp of history is important, it can be confusing
when one focuses on a list of events and dates to memorize. Instead, by focusing on
the what and why of historical occurrences instead of the when, the evolution of
nursing as a science will be more clear.
Nursing has developed in a similar fashion to other sciences. Figure 1-2 depicts
the cycle of scientific development. Scientists begin by developing grand theories
to explain phenomena. A grand theory is a broad generalization that describes,
explains, and predicts occurrences that take place around us. Research is then
conducted to test these theories and to discover new knowledge. Conferences and
publications result from the need to disseminate research findings. Findings are
applied to patient care, resulting in changes in practice, and are used to refine
established theories and propose new ones. This cycle repeats, building the science
as new discoveries are made. Political and social factors are central to the cycle in
that they channel research priorities, funding, and opportunities for dissemination of
findings.
cycle of s cie ntific de ve lopme nt: A model of the scientific process
FIGURE 1-2 Cycle of Scientific Development
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A Glimpse of the Past
Before 1900
Florence Nightingale is considered by most to be the first nurse researcher. One
could say that, as an innovator, she was the first nurse to create an EBP. Through the
systematic collection and analysis of data, she identified factors that contributed to
the high morbidity and mortality rates of British soldiers during the Crimean War
(1853–1856). Health reforms based on her evidence significantly reduced these
rates. Her observations during the war led her to theorize that environmental factors
were critical influences on the health of individuals. In 1859, she disseminated her
ideas in Notes on Nursing: What It Is, and What It Is Not (1859/1946), which
continues to be in print today. Even though Nightingale was an innovator in nursing
research, 40 years passed before nursing research reemerged as relevant to nursing
practice.
1900–1929
During the first quarter of the 20th century, the focus of nursing research was
closely aligned with the social and political climate. Women were empowered by
the suffragette movement; thus their interest in higher education increased. Nursing
education became the focus of nursing research. The work of nursing leaders such
as Lavinia Dock, Mary Adelaide Nutting, Isabel Hampton Robb, and Lillian Wald
was instrumental in reforming nursing education. Similarly, the Goldmark Report
(1923) identified many inadequacies in nursing education and recommended that
advanced educational preparation for nurses was essential. As a result, Yale
University School of Nursing became the first university-based nursing program in
the United States. Also during this time, the first nursing doctoral program in
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education was started at Teachers College at Columbia University (1924). These
events are important because aligning programs of nursing with universities
provided the environment for the generation and dissemination of nursing research.
During this era, nursing was prominent in community health, addressing clinical
problems such as pneumonia, infant mortality, and blindness. Because nursing
research was still in its infancy, descriptive studies focusing on morbidity and
mortality rates of these problems were typically conducted. The first nursing
journal, American Journal of Nursing, was published (1900) and the American
Nurses Association was established (1912). As a result, nursing was organized and
promoted as a profession.
FYI
In the early 1900s, nursing research was primarily focused on education preparation.
1930–1949
The time from 1930 to 1949 was influenced by the Great Depression, which was
followed by World War II. During the Depression, families did not have money to
provide a university education for their children. Consequently, university-based
nursing education did not flourish, and nursing research did not advance. As a
result of the war, the demand for nurses was so great that nursing education
continued to take place primarily in hospital-based diploma programs because this
was the quickest way to prepare individuals for the workforce. Nurses continued to
focus their research on educational issues, and their studies began to be published
in the American Journal of Nursing. At the close of this era, the Brown Report
(1948) was published. Like the Goldmark Report published 25 years earlier, the
Brown Report recommended that nurses be educated in university settings. These
events illustrate how the social system can impede the diffusion of an innovation as
accepted practice.
1950–1969
In the 1950s, significant events occurred that advanced the science of nursing. The
innovation of moving nursing education into universities began to become accepted.
Through the work of the Western Interstate Commission for Higher Education
(1957), nursing research began to be incorporated into graduate curricula, which
provided a structure for the advancement of nursing science. Several nursing
research centers, including the Institute of Research and Service in Nursing
Education at Teachers College (1953), the American Nurses Foundation (1955), the
Walter Reed Institute of Research (1957), and the National League for Nursing
Research for Studies Service (1959), were established. The availability of funds
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from government and private foundations increased awards for nursing research
grants and predoctoral fellowships.
Also during the 1950s, the focus of nursing research shifted from nursing
education to issues such as the role of the nurse in the healthcare setting and
characteristics of the ideal nurse. Early nursing theories described the nurse–patient
relationship (Peplau, 1952) and categorized nursing activity according to human
needs (Henderson, 1966). To accommodate the growth of nursing science, journals
were needed to disseminate findings. In response, Nursing Research (1952) and
Nursing Outlook (1953) were published, and the Cumulative Index to Nursing
Literature (CINL) became more prominent.
The scholarly work done by nurses during the 1960s propelled nursing science
to a new level. Nursing’s major organizations began to call for a shift to research
that focused on clinical problems and clinical outcomes. Nurse researchers began
to develop grand nursing theories in an attempt to explain the relationships among
nursing, health, persons, and environment (King, 1964, 1968; Levine, 1967; Orem,
1971; Rogers, 1963; Roy, 1971). As in the evolution of any science, nursing began
to conduct research to test these theories. Because of the volume of nursing
scholarship, new avenues for dissemination of information became necessary.
Conferences for the sole purpose of exposing nurses to theory and research were
organized. For example, in 1965 the American Nurses Association began to
sponsor nursing research conferences. Worldwide dissemination became possible
with the addition of international journals, such as the International Journal of
Nursing Research (1963), thus increasing the interest in nursing research.
1970–1989
The hallmark of the 1970s and 1980s was the increased focus on the application of
nursing research. The Lysaught Report (1970) confirmed that research focusing on
clinical problems was essential but that research on nursing education was still
indicated. It was recommended that findings from studies on nursing education be
used to improve nursing curricula. During this era, the number of nurses with
earned doctorates significantly increased as did the availability of funding for
research fellowships. The scholarship generated by these doctoral-prepared nurses
increased the demand for additional journals. Journals, such as Advances in
Nursing Science (1978), Research in Nursing and Health (1978), and Western
Journal of Nursing Research (1979), contained nursing research reports and
articles about theoretical and practice issues of nursing. In 1977, CINL expanded
its scope to include allied health journals, thus changing its name to the Cumulative
Index to Nursing and Allied Health Literature (CINAHL), which allowed
individuals in other disciplines to be exposed to nursing research.
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On the national scene, the ethical implications of research involving human
subjects were given much attention. In 1973, the first regulations to protect human
subjects were proposed by the Department of Health, Education, and Welfare. The
formation of institutional review boards to approve all studies was an important
result of this regulation. Work regarding ethics in research continued throughout the
decade with publication of the Belmont Report (1979). This report identified
ethical principles that are foundational for the ethical treatment of individuals
participating in studies funded by the federal government. Because the focus of
nursing research on clinical problems involving patients was growing, nursing
research was held to the same standards as other clinical research. Thus, the
protection of human subjects became an important issue for nurse researchers.
Despite the abundance of research produced during the 1960s and 1970s, little
change occurred in practice. Because nurses recognized a gap between research
and practice, the emphasis in the 1980s was on closing this gap. The term research
utilization was coined to describe the application of nursing research to practice.
Activities to move nursing science forward included the Conduct and Utilization of
Research in Nursing Project. Through this project, current research findings were
disseminated to practicing nurses, organizational changes were facilitated, and
collaborative clinical research was supported.
The social and political climate of the 1980s included a major change in the
financing of health care with the introduction of diagnosis-related groups (DRGs).
As a result, significant changes in the way health care was reimbursed occurred.
Nurse researchers began to respond to the social and political demand for cost
containment by conducting studies on the cost-effectiveness of nursing care.
Another important social and political influence on nursing research was the
establishment of the National Center for Nursing Research (NCNR) at the National
Institutes of Health (NIH) in 1986. This was significant because nursing was
awarded a place among other sciences, such as medicine, for guaranteed federal
funding.
Activities that took place in the 1980s are consistent with the maturing of
nursing as a science. As the body of knowledge grew, specialty organizations
popped up enabling individuals to share their expertise in various clinical areas. In
addition, the demand for journals in which to publish research continued, and
Applied Nursing Research (1988), Scholarly Inquiry for Nursing Practice (1987),
Nursing Science Quarterly (1988), and Annual Review of Nursing Research
(1983) were started. In 1984, the CINAHL database became electronic. As nursing
researchers became more sophisticated in the use of research methods, they
embraced approaches new to nursing, such as qualitative methods. New theories
(Benner, 1984; Leininger, 1985; Watson, 1979) that used caring as an important
concept were especially amenable to emerging research methods.
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1990–1999
In the 1990s, organizations began setting research agendas compatible with the
social and political climate. For example, public concerns about the inequities of
healthcare delivery were at the forefront. Priorities for nursing research included
access to health care, issues of diversity, patient outcomes, and the goals of Healthy
People 2000. Because nursing research was gaining respect for its contributions to
patient care, opportunities for interdisciplinary research became available. In
1993, the NCNR was promoted to full institute status within NIH and was renamed
the National Institute of Nursing Research. This was significant because the change
in status afforded a larger budget that enabled more nurses to conduct federally
funded research. Furthermore, with increased funding, nurse researchers designed
more complex studies and began to build programs of research by engaging in a
series of studies on a single topic.
The knowledge explosion created by technological advances vastly influenced
nursing research. Electronic databases provided rapid access for retrieval of
nursing literature, and in 1995, CINAHL became accessible to individuals over the
Internet. Through email, nursing researchers were able to communicate quickly
with colleagues. Software programs to organize and analyze data became readily
available, allowing researchers to run more sophisticated analyses. Practice
guidelines, from organizations such as the Centers for Disease Control and
Prevention, were easily obtained on the Internet. The Online Journal of Knowledge
Synthesis for Nursing (1993) was the first journal to take advantage of this
technology by offering its content in an electronic format.
In previous eras, the focus was on the application of findings from a single
study to nursing practice. In the early to mid-1990s, the emphasis was on research
utilization. The Iowa model of nursing utilization (Titler et al., 1994) and the Stetler
model for research utilization (Stetler, 1994) were introduced to facilitate the
movement of findings from one research study into nursing practice. In the late
1990s, it became apparent that multiple sources of evidence were desirable for
making practice changes. Thus, EBP gained popularity over research utilization,
and these models were adapted to fit with the EBP movement (Stetler, 2003; Titler
et al., 2001).
2000–2009
In the new millennium, nursing research continued to be influenced by social and
political factors. Healthcare reform in the United States, although considered a
political priority, remained elusive throughout the decade. Although the H.R. 3962
—Affordable Health Care for America Act—was passed, significant changes had
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yet to be implemented.
Globalization became an important influential factor during this decade. With
the ease of retrieving information came the ability to share research findings
internationally. Nurses were able to access articles about research conducted in a
variety of other countries. Nurses in other countries became more equipped to
conduct research as well. Sigma Theta Tau International significantly broadened its
membership to include more chapters in other countries. Globalization also raised
new concerns that provided nurses with opportunities for research.
During this decade, a renewed focus centered on patient safety and outcomes.
The American Nurses Association was instrumental in creating the National
Database of Nursing Quality Indicators (NDNQI). The purpose of this database is
to collect and evaluate unit-specific nurse-sensitive data from hospitals in the
United States. Participating facilities receive unit-level comparative data reports to
use for quality improvement purposes. Refer to Table 1-7 for a listing of the current
NDNQI measures. Many of these measures are used by hospitals that have received
Magnet Recognition for nursing excellence.
Another significant accomplishment during this time was the mapping of human
genes. Conducted by the Human Genome Project (HGP), an international research
effort to sequence and map all of the genes—together known as the genome—was
completed in 2003. As a result, knowledge about genetics was integrated into
nursing education. Genetic-related research became a high priority for nursing and
other health professions.
Another challenge faced in the new millennium was a nursing shortage. Topics
such as nurse–patient ratios and interventions to decrease length of stay became
priorities for research. Other changes occurred in nursing education. The use of
technology for distance learning became more prominent as a way to educate
nurses. Additionally, the Doctor of Nursing Practice (DNP) degree was
recommended as the minimal educational requirement for those entering advanced
practice nursing. Nursing programs across the country began to offer DNP degrees.
Nurses who are prepared at the doctoral level and practice in clinical settings can
serve as leaders in EBP.
2010 to the Present
Since 2010, changes related to the Affordable Health Care for America Act have
begun to be implemented. Thus, nurses will be able to glean potential research
questions as changes in health care come about. For example, nurses can study the
impact of even shorter hospital stays on readmission rates. As care moves away
from hospitals to alternative settings, research will be needed to determine the
effects of these changes on patient outcomes.
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TABLE 1-7 2013 NDNQI Measures
Nursing Staff Skill Mix
Nursing Hours per Patient Day
Assault/Injury Rates
Catheter-Associated Urinary Tract Infection Rate
Central Line–Associated Bloodstream Infection Rate
Fall/Injury Rates
Hospital/Unit Acquired Pressure Ulcer Rates
Nurse Turnover Rate
Pain Assessment/Intervention/Reassessment Cycles Completed
Peripheral IV Infiltration Rate
Physical Restraint Prevalence
RN Education/Certification
RN Survey
Practice Environment Scale
Job Satisfaction
Ventilator-Associated Pneumonia Rate
Source: Adapted from ANA (2013).
Globalization continues to be an important social factor in health care. For
example, globalization contributes to an increasing threat of pandemic. Nurses are
in an excellent position to study ways to effectively prevent the spread of diseases
and to contribute to the implementation of strategies to care for infected
populations.
The electronic medical record (EMR) is fast becoming standard in health care.
Concerns about the protection of personal information are paramount. Additionally,
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linking EBP to EMRs will evolve. For example, when patient data are entered into
the EMR, a message may appear suggesting practice guidelines based on the best
evidence.
CRITICAL THINKING EXERCISE 1-4
© Jules_Kitano/ShutterStock, Inc.
Ten years from now nursing students will study how historical occurrences have shaped the evolution of
nursing as a science. Discuss four current events that will be considered to have influenced the development
of nursing science.
TEST YOUR KNOWLEDGE 1-3
True/False
1. Nursing research popular in the 1950s involved the study of nursing students.
2. Grand nursing theories were first introduced in the 1980s.
3. In the 1980s, DRGs were a driving force because they focused nursing research on cost-
effectiveness.
4. Technological advances created a knowledge explosion that has vastly influenced nursing
research.
5. Each historical era contributed to the development of nursing science.
How did you do? 1. T; 2. F; 3. T; 4. T; 5. T
1.4 What Lies Ahead?
At the end of this section, you will be able to:
‹ Identify factors that will continue to move nursing forward as a science
‹ Discuss what future trends may influence how nurses use evidence to improve
the quality of patient care
Factors similar to those that have propelled nursing research forward through
history will continue to be influential into the future. In the 21st century, nursing
research will grow in importance as EBP becomes more widely established and
patient outcomes come under increased scrutiny. Nursing research agendas will
continue to be driven by social and political influences.
The cycle of scientific development must continue in order to expand the body
of nursing knowledge and to recognize nurses for their contributions to health care.
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Middle range and practice theories that are more useful in clinical settings need to
be developed. Nursing research must include studies that replicate previous studies
with different populations to confirm prior findings. Studies that demonstrate
nursing’s contribution to positive health outcomes will be especially important. A
commitment to the continued preparation of nurses as scientists is vital to achieve
excellence in nursing research. It will be increasingly important for nurses to
advocate for monies and to draw on new funding sources. Interdisciplinary and
international research will continue to be important as complex health problems are
addressed. Technology will continue to offer new ways to communicate research
findings to a broader audience, thereby improving diffusion of innovations.
Research topics that are most likely to be priorities are listed in Table 1-8.
Nursing will continue to be challenged to bridge the gap between research and
practice. EBP offers the greatest hope of moving research findings to the point of
care. Nursing education must prepare nurses to appreciate the importance of basing
patient care on evidence. Educators need to create innovative strategies that teach
students to identify clinical problems, use technology to retrieve evidence, read and
analyze research, weigh evidence, and implement change (Schmidt & Brown,
2007). Nurses must accept responsibility for creating their own EBP and
collaborating with others to improve patient care.
TABLE 1-8 Nursing Research Priorities
Bioterrorism
Chronic illness
Cultural and ethnic considerations
End-of-life/palliative care
Genetics
Gerontology
Healthcare delivery systems
Health disparities
Health promotion
HIV/AIDS
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Management of pandemics/natural disasters
Mental health
Nursing informatics
Patient outcomes/quality of care
Safe administration of medications
Symptom management
Nurses who work in clinical settings and who are prepared at the doctoral level
are especially well positioned to move EBP forward. Healthcare facilities are
expected to embrace EBP to achieve Magnet Recognition. International
collaborations, such as the Joanna Briggs Institute, are essential so that when best
practices are identified they can easily be shared.
FYI
The Doctor of Nursing Practice degree is the recommended educational requirement for those entering
advanced practice nursing. Nurses who are prepared at the doctoral level and who practice in clinical
settings can serve as leaders in EBP.
The Challenge
Make a commitment to be an innovator when it comes to EBP! You are already
well on your way to having the knowledge and skills needed to overcome barriers
that laggards often cite as reasons for not adopting EBP. As you study this text,
don’t go through the pages just to pass an exam. Learn the material so you can carry
it with you throughout your career. To fulfill your commitment, with your next
clinical assignment, adopt one or two of the strategies suggested in Table 1-1. Over
the course of your career, your actions will convince laggards that EBP really does
create excellence in patient care.
CRITICAL THINKING EXERCISE 1-5
© Jules_Kitano/ShutterStock, Inc.
Recall a question you encountered during your last clinical experience. How might you have answered that
question using an EBP approach?
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TEST YOUR KNOWLEDGE 1-4
1. How can nurses who use EBP best be described?
a. As change agents
b. As early adopters
c. As innovators
d. As laggards
True/False
2. As the cycle of science continues, more middle range and practice theories will emerge that will
be useful in clinical settings.
How did you do? 1. b; 2. T
1.5 Keeping It Ethical
At the end of this section, you will be able to:
‹ Identify five unethical studies involving the violation of the rights of human
subjects
Scientific research has made significant contributions to the good of society and the
health of individuals, but these contributions have not come without cost. In the
past, studies have been conducted without regard for the rights of human subjects. It
is surprising to learn that even after national and international guidelines were
established, unethical scientific research continued. Four major studies involved
the violation of the rights of human subjects: (1) the Nazi experiments, (2) the
Tuskegee study, (3) the Jewish Chronic Disease Hospital study, and (4) the
Willowbrook studies. In addition, falsification and fabrication of data by the “Red
Wine Researcher” provide another example of misconduct.
During World War II, physicians conducted medical studies on prisoners in
Nazi concentration camps (NIH Office of Extramural Research, 2011). Most of the
Nazi experiments were aimed at determining the limits of human endurance and
learning ways to treat medical problems faced by the German armed forces. For
example, physicians exposed prisoners of war to mustard gas, made them drink
seawater, and exposed them to high-altitude experiments. People were frozen or
nearly frozen to death so that physicians could study the body’s response to
hypothermia. The researchers infected prisoners with diseases so that they could
follow the natural course of disease processes. Physicians also continued Hitler’s
genocide program by sterilizing Jewish, Polish, and Russian prisoners through X-
ray and castration. The War Crimes Tribunal at Nuremberg indicted 23 physicians,
100
many of whom were leading members of the German medical community. They
were found guilty for their willing participation in conducting “crimes against
humanity.” Seven physicians were sentenced to death, and the remaining 16 were
imprisoned. As a result, the Nuremberg Code, a section in the written verdict,
outlined what constitutes acceptable medical research and forms the basis of
international codes of ethical conduct. The experiments conducted were so horrific
that debate continues about whether the findings from these Nazi studies, or other
unethical studies, should be published or even used (Luna, 1997; McDonald, 1985;
Miller & Rosenstein, 2002), and professional organizations, such as the American
Medical Association (AMA), have published position papers about this dilemma
(AMA, 1998).
Nazi e xpe rime nts : An example of unethical research using human subjects during World War II
Nure mbe rg Code : Ethical code of conduct for research that uses human subjects
In the 1930s, the Tuskegee study was initiated to examine the natural course of
untreated syphilis (NIH Office of Extramural Research, 2011). In this study
conducted by the U.S. Public Health Service, black men from Tuskegee, Alabama,
were recruited to participate. Informed consent was not obtained, and many of the
volunteers were led to believe that procedures, such as spinal taps, were free
special medical care. Three hundred ninety-nine men with syphilis were compared
to 201 men who did not have syphilis. Within 6 years, it was apparent that many
more of the infected men had complications compared with the uninfected men, and
by 10 years, the death rate was twice as high in the infected men as compared with
the uninfected men. Even when penicillin was found to be effective for the
treatment of syphilis in the 1940s, the study continued until 1972, and subjects were
neither informed about nor offered treatment with penicillin.
Tus ke ge e s tudy: An unethical study about syphilis in which subjects were denied treatment so that the effects
of the disease could be studied
FYI
In the past, research was conducted with human subjects who were not fully informed of the purpose and/or
methods of the study. Today, studies must be reviewed to ensure that human subjects are protected.
In 1963, the Jewish Chronic Disease Hospital study began and involved the
injection of foreign, live cancer cells into hospitalized patients with chronic
diseases (NIH Office of Extramural Research, 2011). The purpose of the study was
to examine whether the body’s inability to reject cancer cells was due to cancer or
the presence of a debilitating chronic illness. Because earlier studies indicated that
injected cancer cells were rejected, researchers hypothesized that debilitated
101
patients would reject the cancer cells at a substantially slower rate than healthy
participants did. When discussing the study with potential subjects, researchers
failed to inform them about the injection of cancer cells because researchers did not
want to frighten them. Although researchers obtained oral consent, they did not
document the consent, claiming the documentation was unnecessary because it was
a standard of care to perform much more dangerous procedures without consent
forms. Researchers also failed to inform physicians caring for the patients about the
study. At a review conducted by the Board of Regents of the State University of
New York, researchers were found guilty of scientific misconduct, including fraud
and deceit.
Je wis h Chronic Dis e as e Hos pital s tudy: Unethical study involving injection of cancer cells into subjects
without their consent
CRITICAL THINKING EXERCISE 1-6
© Jules_Kitano/ShutterStock, Inc.
Do you think that the findings from unethical studies should be published? Why or why not?
Also in the 1960s, a series of studies was conducted to observe the natural
course of infectious hepatitis by deliberately infecting children admitted to the
Willowbrook State School, an institution for children with mental disabilities (NIH
Office of Extramural Research, 2011). During the Willowbrook studies,
administrators claimed overcrowded conditions and stopped admitting patients;
however, children could be admitted to the facility if they participated in the
hepatitis program. Because at that time facilities to care for children with mental
disabilities were few, many parents found they were unable to obtain care for their
children and fell victim to being coerced to allow their children to participate in
the study.
Willowbrook s tudie s : An unethical study involving coercion of parents to allow their children to participate in
the study in exchange for admission to a long-term care facility
Unfortunately, ethical violations are not a thing of the past. In 2008, a 3-year
investigation was launched into claims of scientific misconduct at the University of
Connecticut (Callaway, 2012). Dr. Das studied the beneficial health effects of red
wine and other foods on cardiac health and longevity. He was found guilty of
falsifying data on more than two dozen papers and grant applications. This type of
behavior creates public distrust of research findings and can also inhibit
researchers’ ability to recruit subjects.
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TEST YOUR KNOWLEDGE 1-5
Match the following.
1. Nazi medical experiments a. Infected subjects with cancer cells
2. Tuskegee study b. Coerced parents to allow children into study
3. Jewish Chronic Disease Hospital study c. Exposed subjects to cold
4. Willowbrook studies d. Falsified and fabricated data
5. “Red Wine Researcher” e. Failed to treat subjects with penicillin
How did you do? 1. c; 2. e; 3. a; 4. b; 5. d
RAPID REVIEW
» EBP involves: (1) practice grounded in research evidence integrated with theory,
(2) clinician expertise, and (3) patient preferences.
» Tradition, authority, trial and error, personal experiences, intuition, borrowed
evidence, and scientific research are sources of evidence.
» Individual and organizational barriers can prevent adoption of EBP.
» Innovations are adopted by the diffusion of the innovation over time through
communication channels among the members of a social system.
» Research is a planned and systematic activity that leads to new knowledge and/or
the discovery of solutions to problems or questions.
» Scientific research offers the best evidence for nursing practice.
» Nurses use the pyramid of evidence to rank evidence from strongest to weakest.
» Research can be categorized as descriptive, explanatory, or predictive; basic or
applied; and quantitative or qualitative.
» By analyzing words, qualitative research focuses on the meanings individuals
give to their experiences. Quantitative research views the world as objective
and focuses on obtaining precise measurements that are later analyzed.
» Most research articles include an abstract, introduction, review of literature,
theoretical framework, and methods, results, and discussion sections, and they
conclude with a list of references.
» The cycle of scientific development involves theory, research, dissemination, and
application. Social and political factors are central to the cycle.
103
» The cycle of scientific development can be seen operating in each historical era.
» Social and political factors will continue to influence nursing research.
» For nurses to use EBP to improve patient care, they must be committed to being
early adopters of innovations.
» NDNQI is a national database that involves measurement and reporting of
nursing-sensitive outcomes.
» Four studies are recognized for their gross violation of human rights: Nazi
medical experiments, the Tuskegee study, the Jewish Chronic Disease Hospital
study, and the Willowbrook studies. A fifth study, known as the “red wine
researcher,” involved falsification of fabrication of data.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Sign into a database for nursing literature (i.e., CINAHL, ProQuest, PubMed). For this chapter, you will
need to obtain the following two articles:
Pipe, T. B., Kelly, A., LeBrun, G., Schmidt, D., Atherton, P., & Robinson, C. (2008). A prospective
descriptive study exploring hope, spiritual well-being, and quality of life in hospitalized patients.
MEDSURG Nursing, 17, 247–257.
Flanagan, J. M., Carroll, D. L., & Hamilton, G. A. (2010). The long-term lived experience of patients
with implantable cardioverter defibrillators. MEDSURG Nursing, 19, 113–119.
One of these articles used qualitative methods, and the other used quantitative methods. Identify which is
which. After you have done that, for each article identify the various sections that make up a research
article. You may want to share these articles with nurses during your next clinical experience and consider
ways the recommendations can be incorporated into practice.
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CHAPTER 2
109
Using Evidence Through
Collaboration to Promote Excellence
in Nursing Practice
Emily Griffin and Marita G. Titler
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Discuss contributions to evidence-based practice (EBP) nurses practicing in
various roles have made
‹ Examine organizational strategies that facilitate EBP
‹ Describe regional resources that foster collaborative EBP
‹ Identify national resources committed to EBP
‹ List international organizations that are committed to the promotion of EBP
‹ Discuss international and national initiatives designed to promote ethical
conduct
‹ Describe the rights that must be protected and the three ethical principles that
must be upheld when conducting research
‹ Explain the composition and functions of institutional review boards (IRBs) at
the organizational level
‹ Discuss the nurse’s role as patient advocate in research situations
KEY TERMS
autonomous
Belmont Report
beneficence
Declaration of Helsinki
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exempt
expedited review
full review
human rights
individual nurse level
informed consent
institutional review boards
international level
justice
minimal risk
model of EBP levels of collaboration
national level
obligations
organizational level
regional level
research imperative
respect for persons
therapeutic imperative
translational research model
2.1 The Five Levels of Collaboration
At the end of this section, you will be able to:
‹ Discuss contributions to EBP nurses practicing in various roles have made
‹ Examine organizational strategies that facilitate EBP
‹ Describe regional resources that foster collaborative EBP
‹ Identify national resources committed to EBP
‹ List international organizations that are committed to the promotion of EBP
In the late 1800s, Florence Nightingale followed many of the principles of
111
evidence-based practice (EBP). Principles of EBP have been present for many
years; however, until recently this process was not called EBP nor was EBP fully
acknowledged as having an important impact on patient care. Development of a
culture of EBP is under way in nursing through collaborative efforts by nurses and
healthcare organizations, as well as by regional, national, and international entities.
Collaboration is critical for success with EBP, and Figure 2-1 illustrates the model
of EBP levels of collaboration. Nurses need to understand how they can maximize
their collaborative efforts at all five levels.
mode l of EBP le ve ls of collaboration: A model explaining how five levels are intertwined to contribute to
EBP
FIGURE 2-1 Model of EBP Levels of Collaboration
FYI
A culture of EBP has emerged in nursing through collaborative efforts by nurses and healthcare
organizations, as well as by regional, national, and international entities. Nurses need to collaborate at these
five levels.
In the model, the five levels are intertwined with one another. An international
entity can be a resource for staff nurses, and nurses can reciprocate and contribute
to EBP nationally and internationally. Nurses or organizations may use regional-
level resources to help move EBP projects forward. In return, nurses or
organizations assist regional or national resources to advance EBP. For example, a
staff nurse may use the Joanna Briggs Institute to find evidence to support an EBP
project. When the project is complete, the staff nurse disseminates her work by
publishing the project and presenting at an annual Sigma Theta Tau International
(STTI) EBP conference. At the conference, the nurse educates other nurses so that
best practices can be adopted at their organizations.
112
Individual Nurse Level
At the individual nurse level, nurses play an integral role in advancing EBP.
Although it takes a team approach to be successful with EBP, each nurse has a
unique set of skills to contribute that helps to advance EBP. Identifying clinical
issues, education approaches, and implementation strategies is an example of
contributions that nurses can make to the team. Nurses can assume various roles for
the team such as project leader, opinion leader, and mentor.
individual nurs e le ve l: Practice changes that can be implemented by an individual nurse
Staff nurses are an important link between research and the point of care. They
are clinical experts and know how to access unit resources. They can contribute by
problem solving, collaborating with the team, and acting as change champions.
Essential for implementation, staff nurses are often the adopters of the EBP change.
They can be designated as group leaders to help with planning and troubleshooting
during the implementation phase (Cullen & Adams, 2012).
Because staff nurses are integral to EBP, many organizations provide
performance criteria for promoting best practices. For example, performance
criteria for staff nurses may include critical thinking, continual questioning of
practice, participating in making EBP practice changes, serving as leaders of
change in their site of care delivery, and participating in evaluating evidence-based
changes in practice (Titler, 2014; see Table 2-1).
Nurse managers are also essential to EBP. Their aim is to “get their units on
board” with practice changes. They help to set unit expectations by discussing
projects with staff and other healthcare providers. Managers facilitate progress by
rewarding nurses involved in EBP and assisting noncompliant nurses to improve
their performances. “The nurse manager’s commitment is critical to project success
and can make a significant impact on project outcomes” (Cullen, 2006, p. 471).
Advanced practice nurses (APNs) are EBP experts who facilitate appraisal and
synthesis of the literature for the purpose of improving nursing practice. They often
are mentors and are thus important to the advancement of EBP in the clinical setting
(Shirey, 2006). They help with problem solving, planning, leading, and coaching.
As clinical experts, APNs are ideally positioned to be opinion leaders and change
champions. Opinion leaders are experts in their fields who facilitate adoption of an
innovation through modeling and peer influence. Their sphere of influence is broad,
usually encompassing several units or departments (Doumit, Gattellari, Grimshaw,
& O’Brien, 2007). Change champions are also experts in their fields and facilitate
change through persistence. They often work with a core group of nurses who are
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also working toward making EBP changes. To promote consistent practice changes,
this core group of nurses should include nurses across different shifts.
FYI
APNs are ideally positioned to be opinion leaders and change champions. To promote and facilitate
consistent practice changes, this core group of nurses should include nurses across different shifts.
TABLE 2-1 Sample EBP Performance Criteria for Nursing
Roles
Staff Nurse (RN)
Questions current practices
Participates in implementing changes in practice based on evidence
Participates as a member of an EBP project team
Reads evidence related to practice
Participates in quality improvement (QI) initiatives
Suggests resolutions for clinical issues based on evidence
Nurse Manager (NM)
Creates a microsystem that fosters critical thinking
Challenges staff to seek out evidence to resolve clinical issues and improve care
Role models EBP
Uses evidence to guide operations and management decisions
Uses performance criteria about EBP in evaluation of staff
Advanced Practice Nurse (APN)
Serves as coach and mentor in EBP
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Facilitates locating evidence
Synthesizes evidence for practice
Uses evidence to write/modify practice standards
Role models use of evidence in practice
Facilitates system changes to support use of EBP
Nurse Executive
Ensures the governance reflects EBP if initiated in councils and committees
Assigns accountability for EBP
Ensures explicit articulation of organizational and department commitment to EBP
Modifies mission and vision to include EBP language
Provides resources to support EBP by direct care providers
Articulates value of EBP to chief executive officer and governing board
Role models EBP in administrative decision making
Hires and retains NMs and APNs with knowledge and skills in EBP
Provides learning environment for EBP
Uses evidence in leadership decisions
Source: Adapted from Titler, M. (2014). Developing an evidence-based practice. In G. LoBiondo-Wood
& J. Haber (Eds.), Nursing research: Methods and critical appraisal for evidence-based practice
(8th ed., pp. 418–440). St. Louis, MO: Mosby Elsevier.
Nurse executives are responsible for establishing the culture for EBP. They
create a culture in which making evidence-based decisions and changing practice
are valued. It is important for nursing leaders to create a vision that includes EBP
and to identify methods to sustain this vision. This can include celebrating
successes or providing individual recognition during public forums (Cullen &
Adams, 2012). Shirey (2006) states that nurse leaders are expected to work to
maximize the capabilities of the staff and to partner with key professional
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organizations with goals to advance EBP.
Table 2-1 provides examples of performance criteria that may be expected at
the individual nurse level (Titler, 2014). It is important to remember that each nurse
is part of a team that is moving EBP forward. Specific advantages of teamwork
include division of workload, comprehensive problem solving, building “buy-in,”
and expanding expertise. Overall, teamwork builds a more comprehensive plan for
EBP.
FYI
Librarians are important resources for EBP, making them critical partners. They are experts in searching
databases such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and
PubMed, and many healthcare librarians specialize in searching for evidence in nursing and medicine.
Organizational Level
National initiatives and accrediting bodies support EBP and urge healthcare
systems to base patient care on evidence. At the organizational level, healthcare
systems are finding increased interest from nurses who want to practice from a
research base, need time to explore EBP, and desire to develop excellence in the
profession. “The goal of achieving excellence requires development of an
organizational capacity, culture, and vision for evidence-based practice” (Cullen,
Greiner, Greiner, Bombei, & Comried, 2005, p. 127).
organizational le ve l: When nurses in an organization effect practice changes
Healthcare organizations with a vision of providing excellence in nursing need
an infrastructure that accommodates EBP. As organizations restructure to focus on
EBP, they embrace a culture of EBP. This culture sets a tone so that nurses know
what is valued within the organization. One method for developing this culture is
adding value statements about EBP to organizational mission or vision statements.
For example, at the University of Iowa Hospitals and Clinics (UIHC), the mission
statement is “to provide high quality patient care based on our strong commitments
to practice, education, research, innovation, and collaboration” (UIHC, 2013). This
statement outlines expectations for nursing care at this organization.
Other factors that build a culture for EBP include setting performance
expectations for individual nurses, integrating EBP into governance structures, and
providing recognition and rewards for involvement in EBP. To help build
organizational capacity for EBP, it is recommended that responsibility be
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designated to at least one committee (Cullen et al., 2005). One recommendation is
to create four committees: an EBP steering committee, an EBP committee, a
specialty focus team, and a nursing policy and procedure committee. The EBP
steering committee oversees the other three committees, allocates the resources,
and provides support and direction for the work involved with adopting EBP
(Hudson, 2005).
At the organizational level, the focus is not only on developing a capacity for
EBP to take place but also on facilitating the adoption of individual EBP protocols.
As social systems, organizations can facilitate or impede change. The translational
research model (Figure 2-2), which is based on Rogers’s model of diffusion of
innovations (Rogers, 2003), provides specific strategies that organizations can use
to improve adoption of an evidence-based innovation (Titler, 2014; Titler &
Everett, 2001). Components of this model describe how characteristics of the
innovation, communication process, social system, and users lead to the adoption of
innovations. Organizational characteristics that influence the use of EBP include
expectations that policies are evidence based, access to clinical researchers,
authority to change practice, and support from peers, administrators, and other
disciplines (Titler & Everett, 2001).
trans lational re s e arch mode l: A model that provides specific strategies organizations can use to improve
adoption of an evidence-based innovation
As social systems, organizations can use four specific interventions described
in this model to promote excellence in nursing and move EBP forward. These
interventions include modifying policies and standards, modifying medical record
forms, ensuring senior administrators are educated and provide support, and
orienting new staff members.
The first intervention is for organizations to include EBP within policies and
standards (Titler & Everett, 2001). Policies should be based on evidence. For
example, the UIHC developed a schema for rating the type of evidence for each
statement within a policy. To indicate the type of evidence available, each statement
is assigned an R, N, E, or L, which stands for research article, national guideline,
expert opinion, or literature review, respectively. At the end of the policy, full
citations are provided for each piece of evidence cited in the policy. Staff nurses,
nurse managers, and APNs serve on committees to develop policies and
procedures and collaborate to see them implemented.
Modifying medical record forms or electronic documentation, the second
intervention, is an excellent way to help integrate evidence into care (Titler &
Everett, 2001). Reassessment of pain after an intervention is an example of a
recommended best practice that practitioners might not always follow. As a way to
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increase compliance with this standard of care, a medical record form or electronic
documentation field could be modified to include a place for nurses to document
pain reassessment. Similarly, a clinical reminder can be set up within some
computerized documentation systems to prompt nurses to reassess patient pain
levels.
The third intervention recommended involves supporting education of senior
administrators (Titler & Everett, 2001). It is important for leaders to receive
frequent updates on EBP activities within the organization. Updates could be given
through email or as a narrative summary or through rounds with a project team. It is
essential for senior administrators to develop the vision and the organizational
culture, and they need to be kept up-to-date with changes that are being made.
Keeping nurse leaders updated enhances the EBP culture while keeping the
organization accountable.
FIGURE 2-2 Translational Research Model
*Based on Rogers’s model of Diffusion of Innovation.
Source: Titler, M.G., & Everett, L.Q. (2001). Translating Research Into Practice: Considerations for
Clinical Care Investigators. Critical Care Nursing Clinics of North America, 13(4), 587–604.
Reproduced with permission from Maria G. Titler, PhD, RN, FAAN; for permission to use and/or
reproduce the model, please contact Dr. Titler.
The fourth intervention that a social system can implement involves orienting
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new staff and travel staff (Titler & Everett, 2001). The orientation should send a
message that EBP is valued at the organization. New staff members should be made
aware of how policies and standards are developed in the organization so they can
participate in the process.
It is imperative to find a model that is clear to those using the model and that
matches the organization’s values. Many models continue to be developed and
adapted to fit an organization. For example, Schaffer, Sandau, and Diedrick (2013)
reviewed several models, such as the ACE Star Model of Knowledge
Transformation and the Iowa model of EBP, that can be used within an organization
to facilitate EBP.
Regional Level
At the regional level, collaboration is very important for the advancement of EBP.
Using the skills of a local librarian, collaborating with a local program of nursing,
and using resources from regional centers of excellence are examples of using
regional collaboration.
re gional le ve l: When nurses from a large geographic area collaborate to change practice
It is critical for nurses to partner with a local librarian when trying to find
evidence. Many healthcare librarians specialize in searching for evidence in
nursing and medicine. Librarians are an important resource for EBP because they
are experts in searching databases such as CINAHL, PubMed, and Ovid (DiCenso,
2003). At the University of Iowa, the health sciences library has a program called
“housecalls” in which librarians call on individual researchers in their offices to
facilitate a literature search.
Programs of nursing are another regional resource available for collaboration.
The expertise of faculty can help nurses find, synthesize, and appraise the evidence.
Some hospital systems match staff nurses with students or professors to appraise
literature. Nursing professors can join organizational committees such as research
committees, evidence-based planning committees, or quality outcomes committees.
CRITICAL THINKING EXERCISE 2-1
© Jules_Kitano/ShutterStock, Inc.
Consider the facilities where you have been for clinical experiences. Which facilities appear to have
embraced EBP? Why do you think that is the case? How are individual nurses involved?
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Quality improvement committees or programs provide another opportunity for
collaboration. These committees might be groups from within or outside the
hospital setting. For instance, a unit-based committee might be formed to address
infection rates. Examples of groups operating outside the hospital setting are a
workgroup for fall prevention and a childhood obesity task force. Communities
continue to develop and expand these types of workgroups, which often include
nurses, public health employees, community members, parents, and other involved
individuals. Okihiro, Pillen, Ancog, Inda, and Sehgal (2013) reported about a
community collaborative project to improve childhood obesity. They used the
chronic care model and its adaptation, the obesity care model, to guide the
collaboration between primary healthcare, community-based, and public health
approaches to support self-management. Evidence-based strategies included
changing clinic personnel to include a dietician and pediatric clinical psychologist.
The dietician met with children during their wellness visits. The authors also
aligned the electronic medical record with obesity management best practice
guidelines. The Department of Pediatrics and university provided research
resources, infrastructure for training, and salary support. This EBP project shows
how regional resources can be maximized to improve patient outcomes.
Shirey (2006) identified four EBP regional resource centers of excellence (see
Table 2-2). These regional centers provide resources for nurses and organizations
incorporating best practices. Resources include toolkits, intensive training
programs, conferences, and specific guidelines that are available for purchase.
Most of these centers of excellence provide experts who are available by phone
and email to answer questions and guide nurses and organizations through the EBP
process.
TABLE 2-2 Regional Resource Centers of Excellence
Regional
Resource
Center
Region Website
University of North
Carolina at Chapel
Hill
Eastern
http://www.shepscenter.unc.edu/programs-
projects/
evidence-based-practice-center/
https://nursingandhealth.asu.edu/
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http://www.shepscenter.unc.edu/programs-projects/evidence-based-practice-center/
https://nursingandhealth.asu.edu/evidence-based-practice/center-advancement-evidence-based-practice-about-us?destination=node/3694
Arizona State
University at Tempe Western
evidence-based-practice/center-
advancement-evidence-
based-practice-about-us?
destination=node/3694
University of Iowa
Hospitals and Clinics
at Iowa City
Midwestern
http://www.nursing.uiowa.edu/excellence/
evidence-based-practice-guidelines
University of Texas at
San Antonio
Southern http://www.acestar.uthscsa.edu/acestar-
model.asp
National Level
On the national level, several entities have made considerable contributions to
nursing research and EBP. The Agency for Healthcare Research and Quality
(AHRQ; http://www.ahrq.gov) launched an initiative in 1997 to establish EBP
centers around the United States. These centers review scientific literature about
specific topics and publish technology assessments and evidence reports. The
National Guideline Clearinghouse (NGC) is another initiative of AHRQ that
maintains a comprehensive database of EBP guidelines. The NGC website
(http://www.guideline.gov/) provides abstracts of practice guidelines and access to
full-text publications. The National Institute of Nursing Research (NINR) has also
significantly contributed to the development of nursing research. NINR is a federal
agency that allocates funds for clinical and basic research and research training
(NINR, n.d.). Funded areas of research are based on social and political factors
involving health and illness across the life span. Nursing research generated as a
result of NINR funding is disseminated for the purpose of improving patient
outcomes.
national le ve l: Collaboration among nurses throughout the country to effect practice changes
Specialty nursing societies, such as the Oncology Nursing Society (ONS) and
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), are
other examples of national organizations that facilitate the generation,
dissemination, and use of new knowledge. ONS has an EBP area on its website
(https://www.ons.org/practice-resources/pep) that provides information for starting
an EBP project, topic reviews, and a toolkit with more resources. AWHONN
regularly publishes EBP guidelines in its journal and on the website
(http://www.awhonn.org/awhonn/index.do). The American Society of
PeriAnesthesia Nurses provides position statements, standards of care, and forums
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http://www.nursing.uiowa.edu/excellence/evidence-based-practice-guidelines
http://www.acestar.uthscsa.edu/acestar-model.asp
http://www.ahrq.gov
http://www.guideline.gov/
https://www.ons.org/practice-resources/pep
http://www.awhonn.org/awhonn/index.do
in which to post questions and discussions to encourage collaboration (see
http://www.aspan.org/).
The National Nursing Practice Network (NNPN; http://www.nnpnetwork.org)
is committed to the promotion and implementation of EBP through a collaborative
model designed to encourage shared learning and participation. The mission of the
NNPN is to foster exceptional healthcare outcomes, advance professional nursing
practice through application of evidence, support nursing leadership development
for EBP, and increase understanding of mechanisms and strategies that foster the
use of evidence. The vision of the NNPN is to be a national exemplar of nursing
practice excellence, innovation, translation science, and promotion of EBP.
The American Nurses Credentialing Center (ANCC) has developed the Magnet
Recognition Program to recognize healthcare organizations that provide nursing
excellence. This program includes 14 forces of magnetism that are criteria for
organizations to become nationally recognized as Magnet Recognition Program
healthcare facilities. Initiatives involving nursing research and EBP must be present
to earn Magnet Recognition. For example, the organization must be able to
demonstrate a culture that embraces EBP and nursing research. Structures and
processes such as committees, resources, and release time for research endeavors
must be evident. Nurses in direct care are expected to be involved in EBP, quality
assurance, and nursing research. This national recognition has increased awareness
about the importance of EBP at the individual nurse and organizational levels
(ANCC, 2013).
National associations, such as the American Heart Association (AHA) and the
American Diabetes Association (ADA), continue to expand to provide patients and
healthcare professionals with evidence-based guidelines and clinic practice
recommendations. Many of these associations or foundations have a disease-
specific focus. Other examples of national associations or foundations include the
Crohn’s and Colitis Foundation of America, the American Lung Association, and
the Asthma and Allergy Foundation.
Healthcare professionals can also find national evidence-based point-of-care
resources such as DynaMed and Up to Date. A part of EBSCO, DynaMed
(https://dynamed.ebscohost.com/about/about-us) is a company that provides the
CINAHL database, which offers clinical references for nurses, physicians,
pharmacists, physical therapists, and other healthcare professionals. Up to Date
(http://www.uptodate.com/home/about-us), a Wolters Kluwer Health product, also
provides point-of-care solutions for the healthcare industry. The Institute of
Medicine brief report discusses the importance of decision support and point-of-
care tools (Smith, Saunders, Stuckhardt, & McGinnis, 2012). The authors of the
report suggest that these tools be developed, accessible, and evidence-based
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http://www.aspan.org/
http://www.nnpnetwork.org
https://dynamed.ebscohost.com/about/about-us
http://www.uptodate.com/home/about-us
through research organizations, advocacy organizations, and professional specialty
societies, as well as emphasized within education programs. National
collaboration continues to expand, and nurses can use these evidence-based
recommendations at the point of care.
International Level
Efforts to enhance EBP are also conducted at the international level. Dr. Archie
Cochrane (1971) criticized the medical profession for not providing systematic
reviews of evidence from existing studies. In response to this criticism, the
Cochrane Center was established 20 years later in Oxford, England. One year after
that, the Cochrane Collaboration was established. This international not-for-profit
organization is dedicated to making up-to-date, accurate healthcare information
available worldwide (see http://www.cochrane.org/). The purpose of this
establishment is to offer healthcare providers current systematic reviews of
medical interventions and treatments. These summary reports are essential because
mass media and the Internet provide an abundance of information, making it
difficult for practitioners to stay current.
inte rnational le ve l: Changes that result from collaboration among nurses from different countries
STTI is a leader in the development and dissemination of knowledge to
improve nursing practice (see http://www.nursingsociety.org). This organization
has published a position statement on evidence-based nursing and strives to
provide nurses with the most current comprehensive resources to assist them with
translating evidence into nursing research, education, administration, policy, and
practice. STTI presents awards to honor nurses who have demonstrated excellence
in research and EBP. For example, the Founder’s Award is given for excellence in
research. Several specific research awards for research dissemination in nursing
and research utilization are also given.
The Joanna Briggs Institute is an international research and development unit of
the Royal Adelaide Hospital, which is located in Adelaide, South Australia (see
http://www.joannabriggs.org). The institute was established in 1995 and became
fully operational in 1996. It aims to improve the effectiveness of nursing practice
and healthcare outcomes. Some initiatives include conducting systematic reviews,
collaborating with expert researchers to facilitate development of practice
information sheets, and designing, promoting, and delivering short courses about
EBP.
TEST YOUR KNOWLEDGE 2-1
Match the following entities to the corresponding level of collaboration they
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http://www.cochrane.org/
http://www.nursingsociety.org
http://www.joannabriggs.org
provide:
1. APN a. Individual nurse level
2. Joanna Briggs Institute b. Organizational level
3. Policy committee c. Regional level
4. AHRQ d. National level
5. Librarian e. International level
6. NINR
7. Staff nurse
How did you do? 1. a; 2. e; 3. b; 4. d; 5. c; 6. d; 7. a
2.2 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss international and national initiatives designed to promote ethical
conduct
‹ Describe the rights that must be protected and the three ethical principles that
must be upheld when conducting research
‹ Explain the composition and functions of IRBs at the organizational level
‹ Discuss the nurse’s role as patient advocate in research situations
Ethical research exists because international, national, organizational, and
individual factors are in place to protect the rights of individuals. Without these
factors, scientific studies that violate human rights, such as the Nazi experiments,
could proceed unchecked. Many factors of ethical research, which evolved in
response to unethical scientific conduct, are aimed at protecting human rights.
Human rights are “freedoms, to which all humans are entitled, often held to
include the right to life and liberty, freedom of thought and expression, and equality
before the law” (Houghton Mifflin, 2007). Rights cannot be claimed unless they are
justified in the eyes of another individual or group of individuals (Haber, 2006).
When individuals have rights, others have obligations, that is, they are required to
act in particular ways. This means that when nursing research is being conducted,
subjects participating in studies have rights, and all nurses are obligated to protect
those rights.
human rights : Freedoms to which all humans are entitled
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obligations : Requirements to act in particular ways
International and National Factors: Guidelines for
Conducting Ethical Research
One of the earliest international responses to unethical scientific conduct was the
Nuremberg Code. This code was contained in the written verdict at the trial of the
German Nazi physicians accused of torturing prisoners during medical experiments.
Writers of the Nuremberg Code (Table 2-3) identified that voluntary consent was
absolutely necessary for participation in research. Research that avoided harm,
produced results that benefited society, and allowed participants to withdraw at
will was deemed ethical. The Nuremberg Code became the standard for other
codes of conduct.
TABLE 2-3 Articles of the Nuremberg Code
1. The voluntary consent of the human subject is absolutely essential.
2. The experiment should be such as to yield fruitful results for the good of
society, unprocurable by other methods or means of study, and not random and
unnecessary in nature.
3. The experiment should be so designed and based on the results of animal
experimentation and a knowledge of the natural history of the disease or other
problem under study that the anticipated results will justify the performance of
the experiment.
4. The experiment should be so conducted as to avoid all unnecessary
physical and mental suffering and injury.
5. No experiment should be conducted where there is an a priori reason to
believe that death or disabling injury will occur; except, perhaps, in those
experiments where the experimental physicians also serve as subjects.
6. The degree of risk to be taken should never exceed that determined by the
humanitarian importance of the problem to be solved by the experiment.
7. Proper preparations should be made and adequate facilities provided to
protect the experimental subject against even remote possibilities of injury,
disability, or death.
8. The experiment should be conducted only by scientifically qualified
persons. The highest degree of skill and care should be required through all
125
stages of the experiment of those who conduct or engage in the experiment.
9. During the course of the experiment the human subject should be at liberty
to bring the experiment to an end if he has reached the physical or mental state
where continuation of the experiment seemed to him to be impossible.
10. During the course of the experiment the scientist in charge must be prepared to
terminate the experiment at any stage, if he has probably [sic] cause to believe,
in the exercise of the good faith, superior skill and careful judgment required of
him that a continuation of the experiment is likely to result in injury, disability, or
death to the experimental subject.
Source: Office for Human Research Protections. (1993). Appendix 6 (pp. 7–8). In IRB guidebook .
Retrieved from http://www.hhs.gov/ohrp/archive/irb/irb_guidebook.htm
Another example of an international standard is the Declaration of Helsinki,
which was adopted by the World Medical Association (WMA) in 1964. Last
amended in 2013, the declaration provides guidelines for physicians conducting
biomedical research (WMA, 2013). Informed consent is considered to be the
hallmark requirement for the conduct of ethical research (National Cancer Institute,
n.d.). The 32 articles and two clarifications included in the document address
issues such as protecting the health of all patients, obtaining informed consent, and
conducting research with the aim of benefiting science and society (WMA, 2013).
The Declaration of Helsinki offers more specific detail about what constitutes
ethical scientific research than does the Nuremberg Code.
De claration of He ls inki: An international standard providing physician guidelines for conducting biomedical
research
informe d cons e nt: An ethical practice requiring researchers to obtain voluntary participation by subjects after
subjects have been informed of possible risks and benefits
Like the WMA, the American Nurses Association (ANA) was ahead of the
federal government in establishing codes of scientific conduct. In 1968, The Nurse
in Research: ANA Guidelines on Ethical Values was approved by the ANA board
of directors (Haber, 2006). ANA established the Commission on Nursing Research,
whose report emphasized the rights of human subjects in three ways: (1) right to
freedom from harm, (2) right to privacy and dignity, and (3) right to anonymity.
ANA (1985) published six ethical guidelines for nurses (Table 2-4). As a result of
these guidelines, all nurses are charged with the responsibility of protecting the
rights of all subjects in their care. Similar guidelines have also been created by
professional nursing organizations (Ketefian, Bays, Draucker, Herrick, & Lee,
2002).
TABLE 2-4 ANA Guidelines for Protecting the Rights of
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http://www.hhs.gov/ohrp/archive/irb/irb_guidebook.htm
Human Subjects
Rights/Guidelines Obligations
Right to Self-
Determination
Employers must inform nurses in writing if participating as a
subject in research is a condition of employment.
Potential subjects must be advised of risks and benefits of
participation.
Right to Freedom
from Risk or
Harm
Nurses must ensure freedom from harm.
Researchers must monitor vulnerable or captive subjects to
reduce potential risk of injury.
Scope of
Application
All nurses must ensure that all human subjects enjoy protection
of their rights.
Responsibilities to
Support
Knowledge
Development
All nurses must support the development of scientific
knowledge.
Informed Consent Nurses must ensure that informed consent from potential
subjects (or legal guardians) protects right to self-determination.
Participation on
IRB
Nurses should support inclusion of nurses on IRB.
Nurses have an obligation to serve on IRB.
Source: Adapted from American Nurses Association. (1985). Guidelines for nurses in clinical and
other research. Kansas City, MO: Author.
Not until the 1970s were federal guidelines about the ethical treatment of human
subjects formulated (National Cancer Institute, n.d.). In 1973, the Department of
Health, Education, and Welfare published the first set of proposed regulations about
the protection of human rights. One of the most important regulations to emerge was
the mandated implementation of institutional review boards to review and
approve all studies. The National Commission for the Protection of Human
Subjects of Biomedical and Behavioral Research was established in 1974 when the
National Research Act was passed. One of the first charges to the commission was
to identify basic ethical principles that are foundational to the conduct of ethical
scientific research involving human subjects. The commission was also charged
with developing guidelines to ensure that medical research was conducted in a
manner consistent with the principles the commission identified. The result was the
127
Belmont Report, issued in 1979. In the report, three major principles were
identified: (1) respect for persons, (2) beneficence, and (3) justice. These same
principles provide the foundation for present codes of conduct in many disciplines
that conduct research with human subjects.
ins titutional re vie w boards : Committees that review research proposals to determine whether research is
ethical
Be lmont Re port: A report outlining three major principles (respect for persons, beneficence, and justice)
foundational for the conduct of ethical research with human subjects
Respect for Persons
In the Belmont Report (U.S. Department of Health, Education, and Welfare, 1979),
respect for persons is based on two ethical convictions. The first conviction is that
individuals should be treated as autonomous, that is, having the ability to make
decisions. An autonomous person can deliberate about personal goals and act in
accordance with those goals. Nurses are obligated to show respect for the
autonomy of others. When they elicit and act upon the opinions of others, nurses are
fulfilling their obligations. The second conviction related to the ethical principle of
respect for persons is the recognition that persons with diminished autonomy are
entitled to protection. Individuals with diminished autonomy, often referred to as
vulnerable, include children, individuals with mental disabilities, and prisoners.
Some past research studies have violated this right. During the Nazi experiments,
individuals were not allowed to refuse participation. In the Jewish Chronic
Disease Hospital study, subjects were not able to make deliberate decisions
because the information about the injection of cancer cells was not shared.
Researchers conducting the Willowbrook studies did not allow parents free choice,
but rather they used admission to the facility in return for enrolling children in the
study.
re s pe ct for pe rs ons : Principle that individuals should be treated as autonomous and that those with diminished
autonomy are entitled to protection
autonomous : Having the ability to make decisions
FYI
The primary mechanism in place for the protection of human subjects at the organizational level (i.e.,
hospitals, nursing homes, and universities) is the IRB.
128
Beneficence
Beneficence is the principle of doing good. In the Belmont Report, two rules were
formulated: (1) to do no harm, and (2) to maximize possible benefits and minimize
possible harm (U.S. Department of Health, Education, and Welfare, 1979).
Individuals may face risk of harm while participating in research because in order
to learn what is harmful, subjects risk being harmed. Therefore, researchers are
obligated to identify and reduce possible risks as much as possible. Furthermore,
the risks must be justified in light of the possible benefits that may result from the
research. The principle of beneficence was not upheld in a number of earlier
studies. In the Willowbrook studies, injection of live hepatitis virus created a
monumental risk for harm that was not justified by the researchers’ rationale that
children were at risk for infection because they were institutionalized. Furthermore,
learning about the natural course of the disease was not an outcome that could be
justified by the high risk for harm. Individuals were also harmed in the Tuskegee
studies. Men with syphilis were not offered penicillin even when it was known that
penicillin was an effective treatment.
be ne fice nce : The principle of doing good
CRITICAL THINKING EXERCISE 2-2
© Jules_Kitano/ShutterStock, Inc.
Which vulnerable groups of individuals were targeted in the Jewish Chronic Disease Hospital study and the
Willowbrook studies? Can you think of other groups of individuals who may be at risk for unjust selection?
Justice
The principle of justice is concerned with equity or fairness in the distribution of
burdens and benefits. In this third principle identified in the Belmont Report, the
main consideration is that individuals ought to be treated equally (U.S. Department
of Health, Education, and Welfare, 1979). Nurses and other healthcare providers
are obligated to ensure that some groups of subjects, such as ethnic minorities or
institutionalized individuals, are not selected for studies because they are easily
available or in compromised positions. Individuals cannot be denied treatment
because they decline to participate in research. Subjects cannot receive less than
the standard of care. Furthermore, outcomes of publicly funded research need to be
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reported. Unfair treatment of individuals has been a problem in past studies. In the
Tuskegee study, black men were singled out and were not provided standard care.
In the Jewish Chronic Disease Hospital study and the Willowbrook studies,
vulnerable subjects were targeted.
jus tice : The principle of equity or fairness in the distribution of burdens and benefits
Organizational Factors: The IRB
There are also mechanisms in place for the protection of human subjects at the
organizational level. The primary mechanism is the IRB. Although the structure and
functions of IRBs are federally mandated, organizations are held accountable.
Hospitals, nursing homes, and universities commonly have established IRBs
because these organizations typically have employees conducting research.
Organizations without established IRBs or organizations with established IRBs that
do not hold researchers accountable for upholding ethical standards are not eligible
for federal funds to conduct research. Furthermore, conducting research without
IRB approval is illegal. In 1991, a statutory framework was enacted, and these
laws resulted in standards set forth in the Code of Federal Regulations 45 C.F.R. 46
(National Cancer Institute, n.d.). IRBs do not review research involving animals,
food and drug testing, and other kinds of research not involving human subjects.
Components and areas of concern that are reviewed by the IRB are listed in Table
2-5.
Federal guidelines stipulate membership of the IRB (National Cancer Institute,
n.d.; U.S. Department of Health, Education, and Welfare, 1979). The organization
that establishes the IRB appoints or invites members to participate. Members are
selected because they have knowledge of and experience working with people of
vulnerable populations because the major purpose of the IRB is to protect the rights
of vulnerable populations. Members must also have knowledge of the research
process and the ethical and legal regulations of research. IRBs must have a
minimum of five members. Members’ expertise must vary because all members
cannot practice in the same discipline. At least one member of the IRB must be
employed in a scientific area; at least one member, often a clergy member residing
in the community, must be employed in a nonscientific area. At least one member
must have no affiliation with the organization and no family member affiliated with
the organization. Membership must include both men and women. When conflicts of
interest arise, conflicted members must not participate in the review. For example,
when a researcher who is a member of the IRB submits a proposal, that researcher
is excused from the deliberations about that specific study. Each IRB has a
chairperson who is accountable for leading the IRB and who can make decisions
about how applications are reviewed.
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TABLE 2-5 Components and Areas of Concern Appraised by
IRBs
Component Areas of Concern
Risk/benefit analysis
Are possible risks and benefits identified, evaluated, and
described?
Are risks greater than minimal risk?
Have attempts been made to minimize risks?
Will the risk/benefit ratio be reassessed as the study
progresses?
Are subjects receiving less than the standard of care?
Informed consent
Does the study involve vulnerable subjects?
Is the language appropriate for the subjects?
Who will explain the study to potential subjects?
Do subjects need to be reinformed about the purpose of the
study periodically?
Is a waiver of consent justified?
Selection of subjects
Does the burden of participating in research fall (most likely)
on those who will benefit from the findings?
Does the research require using the proposed population?
Are there groups of people who will be more susceptible to
risk?
Have vulnerable subjects been overprotected?
Privacy and
confidentiality
Does the research involve intrusion?
How will information be kept private?
Should permission be sought for records?
Should documentation of consent be waived to protect
confidentiality?
Are procedures compliant with Health Insurance Portability
and Accountability Act (HIPAA) rules?
Monitoring and
observation
How will data be recorded and maintained?
Who will have access to the data?
Can information be provided to the IRB should unexpected
results be discovered?
Additional
Are recruitment procedures designed to ensure that informed
consent is given freely?
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safeguards Does the nature of the disease or behavioral issue permit free
consent?
Incentives for
participation
Are offered incentives reasonable?
Should the IRB monitor subject recruitment to ensure that
coercion is not a problem?
Continuing review
Are the actual risks and benefits as anticipated? Has any
subject been seriously harmed?
Have any unforeseen accidents or problems occurred?
Source: Data from IRB Guidebook/HHS.
There are two kinds of review: full and expedited. A full review is necessary
when a proposed research study involves vulnerable populations or when risks are
not minimal. A proposal might be eligible for an expedited review when the
research study poses minimal risk to human subjects (U.S. Department of Health,
Education, and Welfare, 1979). Minimal risk means that the probability and
magnitude of harm or discomfort anticipated in the research are not greater in and
of themselves than those ordinarily encountered in daily life or during the
performance of routine physical or psychological examinations or tests.
full re vie w: A type of review by an institutional review board that requires all members of the board to
participate; an IRB conducts a full review if there is potential risk to human subjects
e xpe dite d re vie w: A type of review by an institutional review board that can occur quickly; an IRB may
conduct an expedited review if there is minimal risk to human subjects
minimal ris k: The probability and magnitude of harm from participating in a research study are not greater than
those encountered in daily life
Prior to the review meeting, members of the IRB read the proposals in need of
a full review, and then convene to discuss whether each study’s protocols meet the
requirements of the Code of Federal Regulations (Table 2-6). Members vote on
whether or not to approve each study and might make recommendations for changes
to researchers. Proposals of studies qualifying for expedited review are read by the
chairperson of the IRB, who confirms that expedited review is appropriate and
determines whether the standards of the Code of Federal Regulations are being met.
Examples of research qualifying for expedited review include the following:
» Collecting hair and nail clippings
» Collecting excreta and external secretions
» Recording data on subjects 18 years or older using noninvasive routine clinical
procedures
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» Making voice recordings
» Studying existing documents, data, records, and specimens
Certain low-risk studies can be considered exempt from obtaining consent from
individuals. These studies still need IRB approval. There are six exempt categories
of research (Table 2-7). These exemptions do not apply to prisoners, pregnant
women, fetuses, newborns, and most children (National Cancer Institute, n.d.).
Researchers should never assume that their proposals qualify for exempt status, but
rather they must follow the policies specified by their organizations. Most policies
require that another person, usually the IRB chairperson, review proposals to
ensure that they qualify for exempt status.
e xe mpt: Certain studies may be low enough risk not to require consent from individuals
TABLE 2-6 Key Points of the Code of Federal Regulations
1. Risks to subjects are minimized.
2. The risks to subjects are reasonable in relation to anticipated benefits.
3. The selection of subjects is equitable.
4. Informed consent must be sought from potential subjects or their legal
guardians.
5. Informed consent must be properly documented.
6. When appropriate, research plans monitor data collection to ensure subject
safety.
7. When appropriate, privacy of subjects and confidentiality of data are
maintained.
8. Safeguards must be in place when subjects are vulnerable to coercion.
Source: Data from National Cancer Institute (n.d.).
TABLE 2-7 Six Categories of Exempt Research
1. Research conducted in established or commonly accepted educational
settings, involving normal educational practices.
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2. Research involving the use of educational tests (i.e., cognitive, diagnostic,
aptitude, achievement), survey procedures, interview procedures, or observation
of public behavior, unless:
a. Information obtained is recorded in such a manner that human participants
can be identified, directly or through identifiers linked to them.
b. Any disclosure of the human participant’s responses outside the research
could reasonably place the participant at risk of criminal or civil liability or be
damaging to the participant’s financial standing, employability, or reputation.
3. Research involving the use of educational tests (i.e., cognitive, diagnostic,
aptitude, achievement), survey procedures, interview procedures, or observation
of public behavior that is not exempt under item (2) of this list, if:
a. The participants are elected or appointed public officials or candidates for
public office.
b. Federal statute(s) require(s) without exception that the confidentiality of the
personally identifiable information be maintained throughout the research and
thereafter.
4. Research involving the collection or study of existing data, documents,
records, pathological specimens, or diagnostic specimens, if these sources are
publicly available or the information is recorded by the researcher in such a
manner that participants cannot be identified, directly or through identifiers
linked to them.
5. Research and demonstration projects conducted by or subject to the
approval of federal department or agency heads and designed to study, evaluate,
or otherwise examine public health benefit or service programs.
6. Taste and food-quality evaluation and consumer acceptance studies.
Source: Data from National Cancer Institute (n.d.).
It is becoming more common for IRBs to require EBP projects to be reviewed,
especially when personal data, for example, demographic information or patient
outcomes, are to be collected. Because interest in EBP is growing, data from such
projects are being shared at conferences and in publications. Sometimes nurses do
not consider the possibility of publicly sharing their findings until the end of a
project, but at this point, it may be unethical to present findings, especially if
personal data were collected without consent. Therefore, it is wise for nurses who
are initiating EBP projects to obtain IRB approval prior to implementing data
collection even when they do not anticipate sharing findings publicly.
CRITICAL THINKING EXERCISE 2-3
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© Jules_Kitano/ShutterStock, Inc.
A physician comes to the unit and states that she is working in the lab and needs some blood to run a lab test
for her research study. The physician asks the nurse to assist with drawing some blood. The physician and
nurse enter the room of one of the physician’s patients. Without a parent present, the physician asks the 17-
year-old patient if she can draw the patient’s blood. The adolescent seems reluctant but agrees to the
procedure. The physician and nurse draw the blood, and the physician leaves the unit without documenting
the procedure. The nurse feels uncomfortable and talks with the charge nurse about the situation. Which
ethical principles are violated in this situation? How did the nurse fail to act as a patient advocate? What
should the nurse have done to protect the rights of the adolescent? What should the charge nurse
recommend?
In many organizations, other factors ensure that research is ethical. Many
hospitals also have nursing research committees that review research proposals.
These committees are usually composed of staff nurses, nurse managers, APNs, and
the director of nursing research if there is such a person in the organization.
Individual Factors: Nurses as Patient Advocates
Individual nurses are accountable for ensuring that the rights of subjects are
protected. ANA has charged nurses to be patient advocates. Thus, nurses must be
familiar with international, national, and organizational standards to be effective in
their role as patient advocate. Nurses must be able to distinguish between advocacy
and science. Nurses have both a duty to care and duty to advance nursing
knowledge. This means that the research imperative must be weighed against the
therapeutic imperative. When there is doubt, the therapeutic imperative must take
precedence over the research imperative. Nurses can act as patient advocates in a
variety of ways. Nurses should be certain that subjects receive treatment that meets
the standard of care and that subjects choose freely to participate in research.
Ensuring that HIPAA guidelines are followed when data are collected advocates
for the privacy of patients and confidentiality of information. When subjects
express the desire to withdraw from a study, nurses can assist by contacting the
researcher. If nurses observe unethical behaviors, they should report these
violations to the chairperson of the IRB at their institution. Nurses can also
contribute by participating on IRBs and nursing research committees.
re s e arch impe rative : An ethical rule stating that nurses should advance the body of knowledge
the rape utic impe rative : An ethical rule stating that nurses should perform actions that benefit the patient
TEST YOUR KNOWLEDGE 2-2
True/False
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1. Informed consent is the hallmark of the Declaration of Helsinki.
2. The Belmont Report identified four ethical principles: respect for persons, nonmaleficence,
beneficence, and justice.
3. IRB approval must be obtained for studies involving animals, foods, or drugs.
4. A qualitative study of adults that only involves tape recording interviews would likely receive an
expedited review.
5. When there is a conflict, the therapeutic imperative takes precedence over the research
imperative.
How did you do? 1. T; 2. F; 3. F; 4. T; 5. T
It is imperative that nurses recognize that IRB approval does not guarantee that
ethical dilemmas will not arise. Unanticipated events can lead to unethical conduct,
whether intentional or unintentional. Nurses must use their own ethical frameworks
to judge whether their actions, or the actions of others, are in the best interest of
patients and nursing science.
RAPID REVIEW
» The model of EBP collaboration has five levels: individual nurse level,
organizational level, regional level, national level, and international level.
» Nurses, in a variety of roles, contribute to creating EBP. They can identify
clinical problems, participate in EBP changes, serve as change agents or
opinion leaders, and establish a vision for the organization.
» Organizational factors that build a culture for EBP include setting performance
expectations for individual nurses, integrating EBP into governance structures,
and providing recognition and rewards for involvement in EBP.
» Interventions that social systems can use to promote excellence in nursing and
move EBP forward include modifying policies and standards, modifying
medical record forms, educating senior administrators and garnering their
support, and orienting new staff members.
» Regional interventions include using skills of a local librarian, collaborating with
a local program of nursing, and using resources from regional centers.
» Many national and international entities have made considerable contributions to
nursing research and EBP.
» The Nuremberg Code and the Declaration of Helsinki are international guidelines
aimed at protecting the rights of human subjects.
» Federal laws have been enacted to protect subjects who participate in research.
National organizations have created codes of conduct for researchers.
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» The Belmont Report identified three ethical principles for guiding research:
respect for persons, beneficence, and justice.
» IRBs are federally mandated organizational structures that review research
proposals to ensure that the rights of human subjects are protected. Nursing
research committees can also be involved in the protection of human subjects.
» Nurses are expected to act as patient advocates by ensuring that their patients’
rights are upheld. Nurses are also expected to facilitate the development of
scientific knowledge in nursing.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
The National Cancer Institute offers a free web-based course about protecting the rights of human subjects.
Many researchers complete this tutorial as a requirement for obtaining federal funds. Visit the National
Cancer Institute website at http://phrp.nihtraining.com/users/login.php. Sign in, take the tutorial, and print
your certificate. Successfully completing the tutorial means that you can qualify to be a research assistant
over the next 2 years!
REFERENCES
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MO: Author.
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Cochrane, A. L. (1971). Effectiveness and efficiency. Random reflections on health services. Abingdon,
Berks, United Kingdom: Nuffield Provincial Hospitals Trust.
Cullen, L. (2006). Evidence-based practice: Strategies for nursing leaders. In D. Huber (Ed.), Leadership and
nursing care management (3rd ed., pp. 461–478). Philadelphia, PA: Saunders Elsevier.
Cullen, L., & Adams, S. (2012). Planning for implementation of evidence-based practice. Journal of Nursing
Administration, 42(4), 222–230.
Cullen, L., Greiner, J., Greiner, J., Bombei, C., & Comried, L. (2005). Excellence in evidence-based practice:
Organizational and unit exemplars. Critical Care Nursing Clinics of North America, 17, 127–142.
DiCenso, A. (2003). Evidence-based nursing practice: How to get there from here. Nursing Leadership, 16(4),
20–26.
Doumit, G., Gattellari, M., Grimshaw, J., & O’Brien, M. A. (2007). Local opinion leaders: Effects on
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doi:10.1002/14651858.CD000125.pub3
Haber, J. (2006). Legal and ethical issues. In G. LoBiondo-Wood & J. Haber (Eds.), Nursing research:
Methods and critical appraisal for evidence-based practice (6th ed., pp. 295–321). St. Louis, MO:
Mosby.
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Hudson, K. (2005). From research to practice on the Magnet pathway. Nursing Management, 36(3), 33–37.
Ketefian, S., Bays, C., Draucker, C., Herrick, L., & Lee, R. K. (2002). Guidelines for scientific integrity (2nd
ed.). Wheat Ridge, CO: Midwest Nursing Research Society.
National Cancer Institute. (n.d.). Human participant protections education for research teams. Retrieved
from http://phrp.nihtraining.com/users/login.php
National Institute of Nursing Research. (n.d.). Changing practice, changing lives: 10 landmark nursing
research studies. Retrieved from http://www.ninr.nih.gov/sites/www.ninr.nih.gov/
files/10-landmark-nursing-research-studies
Office for Human Research Protections. (1993). IRB guidebook . Retrieved from
http://www.hhs.gov/ohrp/archive/irb/irb_guidebook.htm
Okihiro, M., Pillen, M., Ancog, C., Inda, C., & Sehgal, V. (2013). Implementing the obesity care model at a
community health center in Hawaii to address childhood obesity. Journal of Health Care for the Poor and
Underserved, 24(2), 1–11.
Rogers, E. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Schaffer, M., Sandau, K., & Diedrick, L. (2013). Evidence-based practice models for organizational change:
Overview and practical applications. Journal of Advanced Nursing, 69(5), 1197–1209.
Shirey, M. (2006). Evidence-based practice: How nurse leaders can facilitate innovation. Nursing
Administration Quarterly, 30, 252–265.
Smith, M., Saunders, R., Stuckhardt, L., & McGinnis, J. M. (Eds.). (2012, September). Best care at lower cost:
The path to continuously learning health care in America (Institute of Medicine Brief Report, pp. 1–4).
Washington, DC: National Academies Press.
Titler, M. (2014). Developing an evidence-based practice. In G. LoBiondo-Wood & J. Haber (Eds.), Nursing
research: Methods and critical appraisal for evidence-based practice (8th ed., pp. 418–440). St. Louis,
MO: Mosby Elsevier.
Titler, M., & Everett, L. (2001). Translating research into practice: Considerations for critical care investigators.
Critical Care Nursing Clinics of North America, 13, 587–604.
University of Iowa Hospitals and Clinics. (2013). Nursing at Iowa: Mission and vision. Retrieved from
http://www.uihealthcare.org/otherservices.aspx?id=236220
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guidelines for the protection of human subjects of research. Retrieved from
http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
World Medical Association. (2013). World Medical Association declaration of Helsinki: Ethical principles for
medical research involving human subjects. Retrieved from
http://www.wma.net/en/20activities/10ethics/10helsinki/
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http://phrp.nihtraining.com/users/login.php
http://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/10-landmark-nursing-research-studies
http://www.hhs.gov/ohrp/archive/irb/irb_guidebook.htm
http://www.uihealthcare.org/otherservices.aspx?id=236220
http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
http://www.wma.net/en/20activities/10ethics/10helsinki/
Acquisition of Knowledge
UNIT 2
Questioning the efficacy of practice
lends itself to the discovery of
innovations.
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CHAPTER 3
Identifying Research Questions
Susie Adams
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Discuss ways research problems are identified
‹ Describe relationships among the purpose statement, the research problems,
and the research question
‹ Differentiate among associative, causal, simple, complex, nondirectional,
directional, null, and research hypotheses
‹ Use criteria to appraise research questions
‹ Identify independent and dependent variables
‹ Define mediators, moderators, and confounding variables
‹ Compare the purposes of research questions and evidence-based practice
(EBP) questions
‹ Describe the PICOT method
‹ Discuss ethical issues associated with the development of research and EBP
questions
KEY TERMS
associative relationship
case studies
causal relationship
complex hypothesis
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confounding variables
covary
dependent variable
directional hypothesis
empirical testing
extraneous variables
generalize
hypotheses
hypothesis testing
independent variable
mediators
moderators
nondirectional hypothesis
null hypothesis
PICOT model
pilot
problem statement
purpose statement
replication
research hypothesis
research problem
research question
research topic
simple hypothesis
statistical hypothesis
systematic reviews
3.1 How Clinical Problems Guide
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Research Questions
At the end of this section you will be able to:
‹ Discuss ways research problems are identified
‹ Describe relationships among the purpose statement, the research problems,
and the research question
The primary goals for conducting nursing research are to generate new knowledge
that has wide application to promote positive health outcomes for a particular
patient population, enhance the overall quality and cost-effectiveness of care,
improve the healthcare delivery system, and validate the credibility of the nursing
profession through evidence-based practice (EBP). Determining what problems to
study, framing research questions, and developing research hypotheses are often the
most challenging aspects of the research process. Where does one begin?
Identifying Nursing Research Problems
An infinite number of nursing problems merit investigation. The challenge is to
narrow the focus of problems so they are clinically relevant and can be answered
through empirical testing. Figure 3-1 shows the logical flow for narrowing a
nursing research problem. A research problem is an area of concern when there is
a gap in knowledge that requires a solution that can be described, explained, or
predicted to improve nursing practice (Norwood, 2000). Research problems are
identified through a variety of sources: personal clinical experience, professional
literature, current nursing theories, previous research, and national initiatives.
Nursing, like all healthcare professions, is constantly seeking ways to improve
clinical outcomes and promote health across the life span.
re s e arch proble m: Area of concern when there is a gap in knowledge that requires a solution
FYI
Using research to fill a gap in knowledge that requires a solution can improve clinical outcomes and promote
health across the life span. Research problems are identified through a variety of sources: personal clinical
experience, professional literature, current nursing theories, previous research, and national initiatives.
FIGURE 3-1 Narrowing the Research Question
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Clinical Experience
Experience most often leads nurses to question whether there is a better approach
to a clinical procedure or situation. Clinical curiosity and a desire to improve
patient care can be the most important motivators to begin further inquiry that
ultimately shapes research studies. Discussions with nursing colleagues regarding
their clinical experiences and practice approaches can identify mutual clinical
problems. Such discussions may stimulate shared interest for inquiry into best
practice approaches for a specific clinical problem.
Professional Literature
Consulting the professional literature is another way to identify research problems.
Journal clubs provide an approach to investigate clinical problems identified at the
practice level. Internet search engines and databases such as Google Scholar
(http://scholar.google.com/), PubMed (http://www.ncbi.nlm.nih.gov/pmc/), and
PsycINFO (http://www.apa.org/pubs/databases/psycinfo/index.aspx) provide
access to scholarly literature across many disciplines and sources including books,
abstracts, articles, and dissertations. Refinement of Internet search skills to extract
relevant professional literature can be learned through online tutorials and formal
classes and can be assisted by public or university research librarians. Reading,
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http://scholar.google.com/
http://www.ncbi.nlm.nih.gov/pmc/
http://www.apa.org/pubs/databases/psycinfo/index.aspx
sharing, and discussing clinical articles from professional journals typically lead to
further inquiry into the clinical research literature.
Previous Research
Identifying and reading research articles on particular clinical problems help
nurses to understand the current knowledge about the topic. Reading research
articles also reveals gaps about what is known or has not been tested or adequately
evaluated. For example, there is a gap when nurses are not using a new clinical
approach or intervention yielding better clinical results than the traditional
intervention does. A gap would also exist if there have been only one or two case
studies reported in the literature. A gap may become apparent when the study
design, method, measures, and outcomes apply to a small or limited sample.
Traditionally, new interventions are tested with a small number of subjects in pilot
studies before testing with larger samples. These types of studies begin to fill
knowledge gaps. Whether this same intervention will result in a positive outcome
in a more culturally diverse population, different age group, or different geographic
sample merits investigation. This type of research is called replication studies.
Finding that multiple studies have obtained similar positive results increases the
extent to which one can generalize or apply findings to a wider population.
cas e s tudie s : A description of a single or novel event; a unique methodology used in qualitative research that
may also be considered a design or strategy for data collection
pilot: A small study to test a new intervention with a small number of subjects before testing with larger
samples; adopting an innovation on a trial basis
re plication: Repeated studies to obtain similar results
ge ne ralize : Applying findings from a sample to a wider population
With the proliferation of professional journals across disciplines, it is no longer
feasible to read all the published information on any given healthcare topic. A
search of the literature about a narrowly focused clinical problem may yield dozens
of relevant articles. Articles presenting a synthesis of several articles about a
clinical topic, called systematic reviews, usually make gaps in the literature more
apparent.
s ys te matic re vie ws : A rigorous and systematic synthesis of research findings about a clinical problem
Current Nursing Theories
The earliest nursing theories, called grand theories, organized knowledge and
explained phenomena about the nature and goals of nursing related to four key
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elements: the person or recipient of care; the environment, including both internal
and external conditions; health, reflecting the degree of wellness or illness of the
person; and nursing, reflecting the actions and characteristics of the person giving
care. These grand theories each provide a set of concepts, definitions,
relationships, assumptions, and propositions that articulate a systematic view of
phenomena with the intent of describing, explaining, and/or predicting interactions
and outcomes. Peplau’s (1952) interpersonal relations theory, Orem’s (2001) self-
care deficit theory, Roy’s (1970) adaptation model, Rogers’s (1980) science of
unitary beings, Newman’s (1986) theory of health as expanding consciousness, and
Parse’s (1981, 1992) theory of human becoming are all examples of grand nursing
theories with general concepts and propositions that broadly describe nursing.
Developing studies that empirically test a specific nursing theory is challenging,
and most grand nursing theories or models have few studies that validate major
theoretical concepts. For example, Peplau’s (1952) interpersonal relations theory
has been widely cited in clinical papers; yet, only a few studies actually explore
and test nurse–patient relationship factors derived from this theory (Forchuk, 1994,
1995; Forchuk & Reynolds, 2001). These types of studies are more likely to be
initiated by experienced researchers who are well versed in theory construction
and the measurement of concepts. However, beginning researchers may have
opportunities to participate as members of a research team engaged in testing a
nursing theory, thereby gaining valuable conceptual knowledge and pragmatic
research skills as they develop their own programs of research.
Middle range theories are narrower in scope and provide a bridge from grand
theories to a testable theory with a limited number of variables that describe,
explain, and predict outcomes of interest in nursing practice. Middle range theories
can have diverse testable applications that contribute to a growing body of EBP.
Kolcaba’s (1994) theory of holistic comfort is one example of a middle range
theory that has generated testing in a variety of clinical settings. Kolcaba’s theory
posits basic assumptions that human beings (1) have holistic responses to complex
stimuli, (2) desire comfort as a holistic outcome that is relevant to nursing care, and
(3) strive to meet, or have met, basic comfort needs. Kolcaba (1992, 1994)
described three states of comfort (relief, ease, and transcendence) within four
contexts of care (physical, psychospiritual, social, and environmental). Koehn
(2000) applied Kolcaba’s theory to comfort within a labor and delivery setting.
Kolcaba and DiMarco (2005) applied the theory on pediatric inpatient units. March
and McCormack (2009) have most recently modified Kolcaba’s theory, to apply
institution-wide, to guide nursing care and evaluate patient outcomes on overall
comfort and satisfaction with nursing care. Other well-known middle range nursing
theories include Mercer’s (1986) maternal role attainment theory, Pender’s (1997)
theory of health promotion, and Resnick’s theory of self-efficacy (Resnick & Nigg,
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2003). The University of San Diego maintains a useful website on nursing theorists
at http://www.sandiego.edu/nursing/research/nursing_theory_research.php.
National Initiatives
A number of U.S. government agencies routinely identify major health problems and
establish national research priorities. These include the U.S. Surgeon General’s
Office (http://surgeongeneral.gov/) and the National Institutes of Health
(http://www.nih.gov/) and their member institutes (http://www.nih.gov/icd/), such
as the National Institute of Nursing Research (http://www.ninr.nih.gov/) and the
National Institute of Mental Health (http://www.nimh.nih.gov/index.shtml/).
The U.S. Department of Health and Human Services (USDHHS) convenes the
Secretary’s Advisory Committee on National Health Promotion and Disease
Prevention Objectives for 2020 (Advisory Committee) to produce
recommendations regarding the development and implementation of Healthy People
2020. The 12 members on the Advisory Committee are nationally known experts in
public health who, together with its subcommittees, produce recommendations for
the Healthy People guidelines and implementation
(http://www.healthypeople.gov/2020/default.aspx). The web portal not only
outlines the 10-year priorities to improve the health and health care of the nation
but also maintains database information accessible to health services researchers.
The Agency for Healthcare Research and Quality (AHRQ) works to improve
delivery and coordination of primary care services to meet the need for high-
quality, safe, effective, and efficient clinical prevention and chronic disease care
(http://www.ahrq.gov/). Ongoing initiatives by AHRQ include healthcare data
collection, cost and utilization statistics and reports, EBP guidelines clearinghouse,
and information portals for the public, policymakers, healthcare providers, and
researchers. Recent AHRQ initiatives have directed funding for patient-centered
outcomes research (PCOR). With the January 2014 implementation of the
Affordable Health Care for America Act, AHRQ will continue to gather
information on healthcare outcomes and costs and be an important source of
determining integrated models of healthcare delivery across the United States.
National research agendas identify areas of health concerns with significant
implications for the general public, such as access to affordable health care,
childhood obesity, oral health in children, health disparities in minority
populations, cardiovascular disease in women, mental health and substance use
disorders, genomics, disease prevention, and integration of primary care and
behavioral health services. Collectively, national agencies identify areas with high
priority for federal research funding to evaluate both prevention and intervention
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http://www.sandiego.edu/nursing/research/nursing_theory_research.php
http://surgeongeneral.gov/
http://www.nih.gov/
http://www.nih.gov/icd/
http://www.ninr.nih.gov/
http://www.nimh.nih.gov/index.shtml/
http://www.healthypeople.gov/2020/default.aspx
http://www.ahrq.gov/
healthcare strategies. Nursing research studies derived from such national research
agendas typically have greater opportunities for federal funding.
Narrowing the Problem of Interest
A clinical problem of interest is sometimes called the research topic. Because
clinical problems tend to be quite broad in scope, it is essential to narrow the
scope to design studies that are manageable. When narrowing clinical problems, it
is important to consider several factors. Having a strong interest and passion for a
clinical problem is vital because even a pilot study requires the investment of
considerable time and effort. Sustained motivation is needed to see a study through
to completion. The problem selected for the study needs to be of clinical
significance so it adds to the body of nursing knowledge. Consideration should be
given to whether the problem affects a large number of people; whether the
outcomes will improve the care or quality of life for individuals, families, or
groups; and whether findings will be applicable in a practice environment.
Additional considerations include feasibility in terms of time, research expertise,
available resources, access to subjects, and ethical considerations for research
subjects.
re s e arch topic: A clinical problem of interest
When developing research questions about clinical problems, one must
consider whether the problem can be answered by the research process of
empirical testing. Some questions are inherently philosophical in nature and cannot
be answered by a research study. Questions that pose a moral choice are questions
for philosophical inquiry and public policy deliberation. For example, stem cell
research is a current clinical topic that may offer new solutions to a broad range of
genetically linked disorders. The question, “Should stem cell research be limited to
current strains, and should access to fetal stem cells be prohibited?” poses an
ethical and philosophical question. However, reframing the question as “What are
the attitudes of patients with Parkinson’s disease and their family members toward
research that could involve stem cells injected into brain tissue to generate
myelinated neurons to reduce Parkinsonian tremors?” makes it empirically testable.
Research questions must always be framed in a manner that can be empirically
tested within ethical boundaries.
Even when questions can be framed for empirical testing, one must further
consider whether the question can be answered by existing knowledge or through
basic problem-solving skills. For example, “Can stem cells be safely transplanted
via injection into human bone marrow to treat leukemia?” is an EBP question that
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can be answered through consulting current literature (Laughlin & Lazarus, 2003).
At an earlier time, this posed a researchable question, but that question has
subsequently been answered. It is critical to investigate current literature because it
would be a waste of resources to conduct research when knowledge already exists.
Some questions may be answered through basic problem solving. For example, the
question “What is the best method to reduce fall risks among elderly clients served
by a home healthcare agency?” could be addressed through a continuous quality
improvement process. Initial and periodic fall risk assessments could be developed
and compared with ongoing monitoring to track falls. Questions included in the fall
risk assessment might be modified as data are obtained about client medications,
cognitive function, and home conditions associated with falls and how to reduce
these risks.
Problem Solving, Nursing Process, and Research
Process
It is helpful to recognize the similarities and differences among the problem-solving
process, nursing process, and research process. All three use abstract, critical
thinking, and complex reasoning to identify new information, discover
relationships, and make predictions about phenomena (Burns & Grove, 2009). All
involve the scientific method of observation, data collection, problem
identification, implementation of a solution, and evaluation of results. These
processes are iterative, that is, continual refinement of knowledge occurs as the
process is repeated.
Primary differences among the problem-solving process, nursing process, and
research process are in their foci, purposes, and outcomes (Burns & Grove, 2009).
The focus of the problem-solving process is on a specific goal in a particular
setting for the purpose of generating the best solution to achieve the goal. The focus
of the nursing process is on a specific patient care problem using assessment,
nursing diagnosis, planning, implementation, and evaluation. The goal of the nursing
process is to plan and direct care for a particular patient, family, or group of
patients. The outcome is the improvement of health for a particular patient or
family. In contrast, the research process has a broad focus drawing on knowledge
from nursing and other disciplines. Rigorous application of scientific methods is
used, and findings are disseminated through presentations and publications. The
purpose of the research process is to generate new knowledge that has wide
application to promote positive health outcomes for a particular patient population,
enhance the overall quality and cost-effectiveness of care, and improve the
healthcare delivery system.
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Developing Problem Statements
Problem statements are derived from a research problem that has been identified as
a situation that is unsatisfactory and requires further description, explanation, or a
solution (Norwood, 2000). The problem statement formally identifies what
problem is being addressed in the study. A problem statement must include the
scope of the research problem, the specific population of interest, the independent
and dependent variables, and the goal or question the study intends to answer
(Gillis & Jackson, 2002). Additionally, the problem statement should implicitly or
explicitly indicate that the proposed study is ethical, feasible, and of significant
interest to nursing (Nieswiadomy, 2008). Table 3-1 contains criteria nurses can use
to evaluate problem statements. The research purpose and research questions
logically flow from problem statements. The purpose statement is derived from
the problem statement and indicates the aim of the study. The research question
flows from the problem statement and study purpose, and often it is the
interrogatory form of the problem statement. Examples illustrating the differences
among the problem statement, the purpose of a study, and the research question are
presented in Box 3-1.
proble m s tate me nt: A formal statement describing the problem addressed in the study
purpos e s tate me nt: A statement indicating the aim of the study
re s e arch que s tion: An interrogatory statement describing the variables and population of the research study
Some researchers use the problem statement and research question
interchangeably. The difference is the use of a declarative or an interrogatory
sentence. The research problem when stated in the interrogative form is called the
research question. Other researchers frame the problem statement in a broader
manner that generates several research questions, as in the example in Box 3-1. Not
all research studies include both a formal problem statement and a research
question, but the research question can be implied from the problem statement.
TABLE 3-1 Criteria for Evaluating Problem Statements
1. Problem (or purpose) statement is clear and concise.
2. Problem statement is written as a declarative statement or a formal
question (interrogatory).
3. Population of interest is clearly described.
4. Independent and dependent variables are identified.
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5. Empirical data can be derived for the variables in the population of interest.
6. Indication that study is ethical.
7. Indication that study is feasible.
8. Indication that study is clinically significant and relevant to nursing practice.
BOX 3-1
Examples of Problem Statements, Purpose Statements, and Research
Questions
Problem statement: The use of alcohol by college freshmen contributes to alcohol-related injuries
and emergency department visits at a state university.
Purpose statement: To determine if brief screening and nursing intervention for alcohol use during
freshmen orientation reduces self-reported alcohol use, alcohol-related injuries, and emergency
department visits among college freshmen at a state university.
Research question 1: Is there a difference in self-reported alcohol use between college freshmen
who receive brief screening and nursing intervention for alcohol use during fall orientation and the
previous class of freshmen students who did not receive brief screening and nursing intervention?
Research question 2: Is there a difference in alcohol-related injuries and emergency department
visits between college freshmen who receive brief screening and nursing intervention for alcohol use
during fall orientation and the previous class of freshmen students who did not receive brief
screening and nursing intervention?
TEST YOUR KNOWLEDGE 3-1
1. Which of the following can be used to identify researchable problems? (Select all that apply.)
a. Current nursing theories
b. Personal clinical experiences
c. Philosophical questions
d. National initiatives
2. In an article, a nurse reads the following statement: This study aims to examine the effect of
guided imagery on postoperative pain in adults. This statement is an example of a:
a. problem statement.
b. research question.
c. purpose statement.
d. hypothesis.
How did you do? 1. a, b, d; 2. c
3.2 Developing Hypotheses
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At the end of this section, you will be able to:
‹ Differentiate among associative, causal, simple, complex, nondirectional,
directional, null, and research hypotheses
‹ Use criteria to appraise research questions
‹ Identify independent and dependent variables
‹ Define mediators, moderators, and confounding variables
Study hypotheses are formal statements regarding the expected or predicted
relationship between two or more variables in a specific population. They are
derived from either the problem statement or the research question. Some studies
do not have formally stated hypotheses; yet, the hypothesis can be implied from the
research question. Hypotheses include independent and dependent variables that
are directly linked to the problem statement and research question; predict the
relationship between the independent and dependent variables in a specific
population; and define the variables in a manner so that empirical data can be
gathered to test the predicted relationship between variables. Additionally,
hypotheses need to be ethical, feasible, and relevant to nursing research practice.
Criteria to evaluate hypotheses are outlined in Table 3-2.
hypothe s e s : Formal statements of the expected or predicted relationship among two or more variables
TABLE 3-2 Criteria for Evaluating Hypotheses and Research
Questions
1. Does the study have an explicit hypothesis (or hypotheses)? Or does the
study present a research question(s)?
2. Hypotheses are written in concise, present-tense, declarative statements
that are directly linked to the study problem.
3. For studies with an identified theoretical framework, each hypothesis is
derived from the framework.
4. Each hypothesis clearly identifies the population and at least two variables
that can be measured and empirically tested.
5. Each hypothesis will state one directional relationship between two
variables, or a rationale will be stated for a nondirectional hypothesis.
6. For studies that present research questions (rather than hypotheses), the
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research questions are concise, clear, and specific.
7. Studies with research questions meet similar criteria to studies testing
hypotheses with a clearly identified population, measurable variables, and
theoretical framework.
Types of Hypotheses
Hypotheses can be categorized in four broad ways: (1) associative versus causal,
(2) simple versus complex, (3) nondirectional versus directional, and (4) null
versus research. Hypotheses can fit into more than one category. For example, a
researcher can state a simple, directional research hypothesis. Sometimes multiple
independent and dependent variables can be included in a hypothesis.
Associative Versus Causal Hypotheses
Relationships identified in hypotheses are either associative or causal. Variables
that have an associative relationship (Figure 3-2A) occur or exist together in the
real world so that when one variable changes, the other variable changes. In an
associative relationship, the two variables may change, or covary. When two
variables covary in the same direction, a positive (Figure 3-2B) correlation results.
For example, as people age, measures of blood pressure increase normally. There
is a positive correlation between age and blood pressure. When variables vary in
opposite directions, they are known as negative or inverse relationships (Figure 3-
2C). The degree to which variables change may or may not be equal or
proportional. This is different from a causal relationship in which one variable,
the independent variable, is thought to cause or determine the presence of the other
variable, the dependent variable (Figure 3-2D). One must be cautious not to
misinterpret an associative relationship as one that is causal because association
does not equal causation.
as s ociative re lations hip: A type of relationship such that when one variable changes, the other variable
changes
covary: When change in one variable is associated with change in another variable.
caus al re lations hip: When one variable determines the presence or change in another variable
FYI
Hypotheses can be categorized in four broad ways: (1) associative versus causal, (2) simple versus complex,
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(3) nondirectional versus directional, and (4) null versus research, though they can fit into more than one
category. Hypotheses need to be ethical, feasible, and relevant to nursing research practice.
FIGURE 3-2 Associative and Causal Relationships
Simple Versus Complex Hypotheses
A simple hypothesis states or describes the relationship, associative or causal,
between two variables. A simple associative hypothesis would state that variable X
is related to variable Y (Figure 3-2A). A simple causal hypothesis would state that
one independent variable is causally related to one dependent variable (Figure 3-
2D). A complex hypothesis predicts the relationships, either associative or causal,
among three or more variables. For example, multiple independent variables may
act in a causal relationship to produce one or more dependent variables (Figure 3-
2E). One independent variable may act in a causal fashion to produce multiple
dependent variables (Figure 3-2F). Similar statements and illustrations could be
made for associative relationships among three or more variables.
s imple hypothe s is : A hypothesis describing the relationship among two variables
comple x hypothe s is : A hypothesis describing the relationships among three or more variables
Nondirectional Versus Directional Hypotheses
Sometimes researchers have hunches about the direction that variables may take.
Other times they may not. A nondirectional hypothesis is one that states that a
relationship exists between two variables, but it does not predict the direction or
nature of the relationship (Figure 3-2A). When no clear direction between the
variables has been identified in clinical practice, natural observation of
phenomena, relevant nursing theories, or existing clinical or research literature,
then no clear prediction can be hypothesized. Nondirectional hypotheses are
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commonly used in exploratory and descriptive studies. Common nondirectional
descriptors include terms such as associated, correlated, or related. When a
nondirectional hypothesis is used, a rationale is included in the problem statement
explaining why a directional relationship cannot be predicted between the
variables. In contrast, a directional hypothesis states the nature or direction of the
relationship between two or more variables (Figure 3-2B–F). This type of
hypothesis is based on nursing theories, observed phenomena, clinical experience,
and existing clinical and research literature. Directional hypotheses are used to
predict relationships between two or more variables. Common directional
descriptors include terms such as increase, decrease, less, more, smaller, and
greater. Directional hypotheses can also be categorized as associative or causal,
simple or complex.
nondire ctional hypothe s is : Statement of the relationship among two variables that does not predict the
direction of the relationship
dire ctional hypothe s is : Statement describing the direction of a relationship among two or more variables
Null Hypotheses Versus Research Hypotheses
The fourth category of hypotheses includes the null hypothesis (H0), which is also
commonly called the statistical hypothesis. The null hypothesis states that there is
no relationship between two variables, and statistical testing is used to either
accept or reject this statement. Conversely, the research hypothesis (H1) states that
a relationship exists between two or more variables. These relationships can be
described and categorized as associative or causal, simple or complex,
nondirectional or directional. Hypothesis testing or empirical testing involves the
collection of objectively measurable data that are gathered through the five senses
to confirm or refute a hypothesis. Table 3-3 offers examples of how hypotheses can
be worded.
null hypothe s is : A hypothesis stating that there is no relationship between the variables; the statistical
hypothesis
s tatis tical hypothe s is : A hypothesis stating that there is no relationship among the variables; null hypothesis
re s e arch hypothe s is : A hypothesis indicating that a relationship among two or more variables exists
hypothe s is te s ting: Collection of objectively measurable data that are gathered through the five senses to
confirm or refute a hypothesis; empirical testing; a test for construct validity
e mpirical te s ting: Collection of objectively measurable data that are gathered through the five senses to
confirm or refute a hypothesis; hypothesis testing
CRITICAL THINKING EXERCISE 3-1
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© Jules_Kitano/ShutterStock, Inc.
A common problem in the newborn nursery is that infants undergoing circumcision show decreases in body
temperature following the procedure. A nurse researcher is interested in studying the effect of a warming
tray on the body temperature of infants undergoing circumcisions. Write a research question, associative
hypothesis, directional hypothesis, and null hypothesis that would be appropriate for this study.
TABLE 3-3 Examples of Hypotheses for the Research
Question: What Is the Relationship Between Self-Esteem and
Adherence to a Diabetic Diet in Adolescents with Type 1
Diabetes?
Type of
Hypothesis
Hypothesis Statement
Associative
There is a relationship between the amount of self-esteem
and adherence to a diabetic diet in adolescents with type
1diabetes.
Causal Increased amounts of self-esteem increase adherence to a
diabetic diet in adolescents with type 1 diabetes.
Simple Increased amounts of self-esteem increase adherence to a
diabetic diet in adolescents with type 1 diabetes.
Complex
Increased amounts of self-esteem increase adherence to
diabetic diet and insulin administration in adolescents with
type 1 diabetes.
Nondirectional
There is an association between the amount of self-esteem
and adherence to a diabetic diet in adolescents with type 1
diabetes.
Directional Increased amounts of self-esteem increase adherence to a
diabetic diet in adolescents with type 1 diabetes.
Null
There is no relationship between the amount of self-
esteem and adherence to a diabetic diet in adolescents
with type 1 diabetes.
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Research
Increased amounts of self-esteem increase adherence to a
diabetic diet in adolescents with type 1 diabetes.
What Is a Variable?
To understand hypothesis testing, it is important to understand the nature of
variables. Variables may be phenomena that can be directly measured, such as
pulse rate, blood pressure, respiratory rate, red blood cell count, antibody titer,
thyroid stimulating hormone, or salivary cortisol level. Variables may also be
qualities, properties, or characteristics of people, groups, or objects, for example,
sociodemographic characteristics, intelligence, social support, and self-esteem.
Because these qualities, properties, and characteristics are not directly observable,
they are measured indirectly using questionnaires and scales. Variables may also be
derived from abstract concepts such as depression, anxiety, grieving, and quality of
life, which require some indirect type of measurement. There is an entire body of
research dedicated to the development and testing of variables used to measure
such abstract concepts. The Beck Depression Inventory (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961), the Hamilton Anxiety Scale (Hamilton, 1959), and the
Holmes and Rahe Social Readjustment Rating Scale (Holmes & Rahe, 1967) are
several examples of ways to measure variables associated with abstract concepts.
Regardless of whether a variable is one that can be directly measured or
requires some form of indirect measurement, variables are also categorized as
independent, dependent, and confounding variables. The independent variable,
commonly labeled the X variable, is the variable that influences the dependent
variable or outcome. In experimental studies it is the intervention or treatment that
is manipulated by the researcher. The dependent variable, commonly labeled the Y
variable, is the variable or outcome that is influenced by the independent variable.
inde pe nde nt variable : Variable that influences the dependent variable or outcome; intervention or treatment
that is manipulated by the researcher; X variable
de pe nde nt variable : Outcome or variable that is influenced by the independent variable; Y variable
Mediators and moderators are intervening variables that affect the association
between an independent variable and a dependent or outcome variable. A mediator
is an intervening variable that is necessary to complete a cause-effect link between
an independent and dependent variable. Mediators account for how or why two
variables are strongly associated. There may be a single mediating variable or a
series of sequential mediating variables between the independent and dependent
variables (Baron & Kenny, 1986; Bennett, 2000; Kraus et al., 2010). For example,
an exercise program for older adults that evaluates a number of physical activity
outcomes would need to consider a variety of mediating variables such as social
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support, perceived physical competence, or behavior change strategies. A
moderator is an interaction variable that affects the direction and/or strength of the
relationship between the independent variable and the outcome variable. In the
example of an exercise program for older adults on physical activity outcomes,
gender is a modifier that explains differences if the effects were greater for men
than for women. This is typically recognized as an interaction between gender and
the exercise program (Bauman, Sallis, Dzewaltowski, & Owen, 2002). See Figure
3-3.
me diators : Extraneous variables that come between the independent and dependent variables
mode rators : Extraneous variables that affect the relationship among the independent and dependent variables
Confounding variables, or extraneous variables, commonly labeled C, are
factors that distort or interfere with the relationship between the independent and
dependent variables. The confounding variable predicts the outcome variable, but it
is also associated with the independent variable. Sometimes a confounding
variable is known before a study begins; other times a confounding variable is
identified while the study is being conducted or after the study is completed. If a
confounding variable is known in advance, the researcher may try to use strategies
to minimize or eliminate the effect of these variables. Another way to control for
confounding variables is to use specific statistical tests to adjust for their effects.
Using the example of the exercise program for older adults on physical activity
outcomes, age may confound the relationship between the exercise program and
program outcomes. Older people may be less physically active, which is
associated with the outcome, and older people may be less likely to engage in a
physical exercise program, which is associated with the intervention or
independent variable. The confounder influences the association between the
exercise program and the physical activity outcomes, thus distorting the actual
strength of the effects (Bauman et al., 2002).
confounding variable s or e xtrane ous variable s : Factors that interfere with the relationship between the
independent and dependent variables; Z variable
FIGURE 3-3 Mediators, Moderators, and Confounders
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Source: Data from Bennett, J.A., (2000), Research in Nursing & Health, 23, 415–420.
Symbols are used to express the relationships between independent and
dependent variables and mediators, moderators, or confounders. The direction of
the “causal arrows” is important. If the intervention or independent variable
“causes” the confounder (the causal direction X→C), this represents a mediator. In
contrast, a confounder acts on the independent variable (C→X) and/or the
dependent variable (C→Y). A mediator does not act on the variable, but rather acts
on the relationship between the independent and dependent variables (see Figure 3-
3).
TEST YOUR KNOWLEDGE 3-2
Indicate which of the following terms best describes hypotheses 1–3 below:
a. associative
b. causal
c. simple
d. complex
e. directional
f. nondirectional
g. null
h. research
i. research question
1. Age, number of medical diagnoses, and number of medications affect the incidence of falls in
older adults.
2. There is no relationship between seatbelt use and head injury in auto accidents.
3. Does consuming one glass of red wine daily reduce the incidence of heart disease in middle-aged
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men?
4. Hypothesis: Scores on the Beck Depression Inventory will be lower in women who take yoga
classes than in women who do not. What is the independent variable?
a. Score on Beck Depression Inventory
b. Yoga ability
c. Women
d. Type of participation in yoga
How did you do? 1. a, d, f, h; 2. c, g; 3. i; 4. d
3.3 Formulating EBP Questions
At the end of this section, you will be able to:
‹ Compare the purposes of research questions and EBP questions
‹ Describe the PICOT method
Although research and EBP both involve questions, their purposes are quite
different. The primary purpose of nursing research is to generate new knowledge,
and the purpose of EBP is to make decisions about patient care based on the best
current evidence gathered from a systematic problem-solving approach. EBP
incorporates a systematic search for evidence and a critical appraisal of the
findings with clinical expertise and the patient’s and family’s values and
preferences to provide the best patient care (Melnyk & Fineout-Overholt, 2011).
Clinical curiosity motivates nurses and other healthcare providers to identify
choices available for a particular patient to determine the best course of treatment.
Given the burgeoning amount of new healthcare products, drugs, procedures,
alternative medicine approaches, and the emerging information on risks, benefits,
and efficacy of these products, procedures, and interventions, healthcare providers
will be continually required to judiciously find the right evidence to make informed
treatment care decisions in a time-efficient manner. In EBP, questions are generated
in a manner slightly different from how research questions are generated. One
widely used model in EBP is the PICOT model. Clinical questions for specific
patient problems are identified so that healthcare providers can find clinically
relevant information using Internet search engines and databases (Higgins & Green,
2011). The mnemonic PICOT stands for the following five components:
PICOT mode l: A model in EBP used to formulate EBP questions; the acronym stands for patient population,
intervention of interest, comparison of interest, outcome of interest, and time frame used to formulate EBP
P = Patient population or patient condition of interest
I = Intervention of interest
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C = Comparison of interest
O = Outcome of interest
T = Time (this element is not always included)
The patient population or patient condition needs to be carefully delineated so
that the search for evidence yields relevant information and prevents retrieval of
too broad or off-target information. During information retrieval, it is important to
keep in mind that findings may not be generalizable to a specific patient. For
example, a teaching strategy that is successful with children may not be successful
with adolescents.
FYI
Nurses must consider patient preferences when making practice decisions, as well as take limited resources
into consideration by selecting questions that are broad in scope and that can be completed. Priority should
be given to studies that have the potential to generate significant contributions to patient outcomes.
FYI
The primary purpose of nursing research is to generate new knowledge, and the purpose of EBP is to make
decisions about patient care based on the best current evidence gathered through a systematic problem-
solving approach.
In the PICOT model, the intervention of interest requires similar delineation to
yield focused, relevant information. When conducting a literature search, consider
the main intervention or treatment, diagnostic test, procedure, or exposure. Also
consider any factors that may influence the prognosis such as age, gender, ethnicity,
coexisting conditions, and exposures to risk factors such as cigarette smoke,
asbestos, or other toxins.
The comparison of interest can be a comparison with another intervention or
treatment. The intervention of interest can also be compared to the standard of care.
It is best to select the main alternative to the proposed intervention. For example, is
the issue about whether to implement a new treatment for sacral decubital ulcers in
immobile elderly nursing home patients? An approach to answer this question
would be to compare the patient outcomes with the new treatment and the usual
standard of care.
The outcome of interest is the desired accomplishment, measurement, or
improvement as a result of the selected intervention or treatment approach. It is
important to identify clear outcome measures to evaluate the efficacy of the
intervention with the identified comparison. In the previous example, the outcome
of decubital healing could be determined by measuring diameter and depth of ulcer,
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type and amount of drainage, formation of new tissue, and ulcer closure. Specifying
the desired outcome measures further refines the literature search. Once the
components of the PICOT question have been identified, a statement can be written.
Box 3-2 includes a resource for developing EBP questions using the PICOT model.
BOX 3-2
Resource for Developing EBP Questions Using the PICOT Model
Sonoma University provides a resource for developing a PICOT question
(http://www.sonoma.edu/users/k/koshar/n300/PICOs.html). Be sure to check out the link to the PICOT and
Search Query Worksheet.
CRITICAL THINKING EXERCISE 3-2
© Jules_Kitano/ShutterStock, Inc.
Consider how you would describe a group of patients similar to your specific patient. Include important
patient characteristics, primary problem or disease, and any coexisting conditions. If age, gender, race,
ethnicity, or other characteristics are relevant to the diagnosis or treatment, then those factors also need to
be included.
TEST YOUR KNOWLEDGE 3-3
True/False
1. There are no differences between research questions and EBP questions.
2. The PICOT model is useful when considering EBP questions.
3. The standard of care or alternate interventions can be used as comparisons of interest in the
PICOT model.
How did you do? 1. F; 2. T; 3. T
3.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss ethical issues associated with the development of research and EBP
questions
Although there are not very many ethical issues involved with the development of
research and EBP questions, the issues that exist are important. First and foremost,
nurses must be certain that research questions posed can be answered while
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http://www.sonoma.edu/users/k/koshar/n300/PICOs.html
respecting the rights of human subjects. For example, it would be unethical to leave
wounds untreated to determine how much time it takes for a stage IV ulcer to
develop because that intervention is less than the standard of care. Nurses must also
keep in mind that EBP is not based solely on evidence. Regardless of answers that
are found to questions, nurses must consider patient preferences when making
practice decisions.
Researchers must also be aware that resources are limited. Problems that are
broad in scope should be selected. Priority should be given to studies that have the
potential to generate significant contributions to patient outcomes. It is also
important to address questions that can be seen through to completion. Selecting
problems that are of interest makes it easier for one to invest the time, energy, and
resources necessary to finish a study. Nurses need to recognize the difference
between ethical questions and researchable questions. Although ethical questions
do not lend themselves to research methods, discussion about them can make
important contributions to nursing knowledge.
TEST YOUR KNOWLEDGE 3-4
1. Which ethical issues are associated with the development of research questions? (Select all that
apply.)
a. Limited resources
b. Respecting human rights
c. Interests of the researcher
d. Patient preferences
How did you do? 1. a, b, c, d
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
So that you can better understand EBP, throughout the remainder of the book you will be guided through a
series of exercises designed to involve you in the EBP process. The clinical problem used in this exercise is
medication errors. Students will search for articles on their own; however, there will be instructions within
this text’s digital resources. As you progress through the process, you will critique the evidence and decide
which best practice to recommend. You will also design a policy and evaluate outcomes. By actively
engaging in this exercise, you will be well prepared to be a leader who successfully moves evidence to the
point of care.
162
Imagine you are assigned to a committee in your facility. The committee has been charged with determining
best practices for reducing medication errors. To become familiar with the magnitude of this problem, visit
the report brief, “Preventing Medication Errors,” published by the Institute of Medicine (2006; see
http://www.iom.edu/~/media/Files/Report%20Files/
2006/Preventing-Medication-Errors-Quality-Chasm-
Series/medicationerrorsnew.ashx). After reading the report, formulate possible PICOT questions for the
committee.
RAPID REVIEW
» Identifying clinical practice and research questions is a critical skill for nurses
and healthcare providers.
» A research problem is an area of concern where there is a gap in knowledge.
These are identified through personal clinical experience, professional
literature, current practice theories, previous research, and national initiatives.
» To narrow the problem of interest, it is best to select a problem that is of interest,
can be answered by empirical testing, has not already been answered, or cannot
be answered through basic problem-solving skills.
» Problem statements identify what the study is about, while purpose statements
indicate why the study is being conducted.
» Research questions are interrogatory statements that flow from the problem
statement.
» Hypotheses are formal statements regarding the expected or predicted
relationships between two or more variables in a specific population.
Hypotheses can be associative, causal, simple, complex, nondirectional,
directional, null, and research.
» Variables can be measured directly or indirectly.
» The independent variable, X, influences the dependent variable, Y, or outcome. In
experimental studies, the intervention is the independent variable.
» The dependent variable is the outcome that is influenced by the independent
variable.
» Mediators, moderators, and confounding variables are factors that interfere with
relationships between independent and dependent variables.
» The purpose of research questions is to generate new knowledge, while the
purpose of EBP questions is to make decisions about patient care.
» The PICOT model is commonly used to formulate EBP questions. PICOT stands
for patient population, intervention of interest, comparison of interest, outcome
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http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.ashx
of interest, and time.
» Ethical considerations associated with research questions involve formulating
questions that are answered by studies that respect the rights of human subjects,
are feasible, and are of interest.
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165
CHAPTER 4
Finding Sources of Evidence
Patricia Mileham
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Explain why performing a quality literature review is an essential skill for
nursing students, researchers, and nurses
‹ Differentiate between searching for evidence and literature in lay and
professional sources
‹ Explain the scientific literature publication cycle
‹ Differentiate between primary and secondary sources
‹ Identify different types of articles found in the literature
‹ Characterize the four major types of reviews
‹ Identify and use a variety of sources, both within and outside of the field of
nursing, as appropriate
‹ Explain how the sources are structured
‹ Distinguish between the different sources’ content, in both topic or subject
matter and in format
‹ Perform various types of searches using basic and advanced source tools and
search techniques
‹ List four databases where scholarly literature of disciplines is indexed
‹ Consider the ethical presentation and application of evidence
KEY TERMS
Boolean operators
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call number
CINAHL
citation chasing
controlled vocabularies
electronic indexes
exploding
grey literature
indexes
integrative review
interlibrary loan
journal
keyword
magazine
meta-analyses
narrative reviews
nesting
peer review
periodical
plagiarism
popular literature
positional operators
precision
primary sources
print index
qualification
recall
record
scholarly literature
scientific literature publication cycle
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search field
secondary sources
stopwords
subject headings
subject searching
systematic reviews
trade literature
truncation
wildcards
4.1 Purpose of Finding Evidence
At the end of this section, you will be able to:
‹ Explain why performing a quality literature review is an essential skill for
nursing students, researchers, and nurses
‹ Differentiate between searching for evidence and literature in lay and
professional sources
Most often, your first introduction to the literature review is tied to writing an
academic paper. The focus of your papers as an undergraduate student is usually
one of gathering information on a topic and perhaps sharing a resulting opinion
about the findings. The literature review provides a consideration of what has been
studied previously. For researchers, the literature review identifies gaps in the
current research, highlights areas of needed change, increases awareness about
practice, and helps sharpen and focus a research question. Because of the
increasing emphasis on evidence-based practice (EBP), nurses must develop
abilities to perform literature reviews to increase knowledge about a specific topic
and provide the basis for an informed, professional opinion to champion EBP in
clinical settings.
Knowing how to search for, access, and evaluate information is as important to
your successful practice tomorrow as it is to earning a good grade on an academic
paper today. In an insightful editorial directed to nursing faculty, Christie, Hamill,
and Power (2012) specifically detailed the contextual support students should be
provided in learning about research: “The educator has a key role in supporting and
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guiding students in: the nature of research-evidence (authority), the type of research
required in clinical practice (relevance), the potential power of research to
transform, and improve practice (utility)” (p. 2792).
Lander (2005) further details the ties between research and EBP by delineating
competencies nursing students should possess to complete this connection
themselves:
They need to know what sources of information are reliable and credible and how to gain access to
them. They need some specific skills that enable them to comprehend designs and specific design
issues. They need to know how to differentiate poor quality from good quality reports of studies,
systematic reviews, and clinical guidelines. They need an approach for assessing the value of an
intervention for clinical practice. Above all, they need access to computers and technical resources. (p.
300)
These are competencies needed to perform quality literature reviews, not just an
academic exercise left behind when your diploma is in hand.
FYI
Research questions and practice considerations must be based on informed, ethical opinions resulting from
consideration of evidence that is currently available. This requires a detailed review of the literature.
Whether you are performing a literature review for the 1st, 15th, or 50th time,
consider it a part of your practice worth doing well every time. Just as patients are
assessed before treatment recommendations are made, literature reviews are
assessments of topics before the research or practice continues. Whether the
literature review is part of an EBP proposal in your workplace, a research question
in your graduate studies, or an academic paper as an undergraduate, the process is
the same. Depending on the situation, search complexity and access to resources
may be different; however, the procedural steps and attention to quality work
remain the same. This is because the desired outcome stays the same: Research
questions or practice considerations must be based on informed, ethical opinions
resulting from consideration of evidence that is currently available.
With ever-increasing amounts of information available via the Internet and the
proliferation of journal and monograph materials, skilled literature review
practices have never been more necessary. Although it is well known that anyone
can publish anything on the Internet, today’s more sophisticated tools, such as wikis
and blogs, increase the challenge of evaluating the validity of information.
Information of all types travels rapidly from source to source. This results in
mixing hoaxes, urban legends, and other types of misinformation along with
accurate and reliable information. Nurses face this situation not only as information
consumers but also as patient advocates. Patients are bombarded with information
as well. Their desire to be knowledgeable about their illnesses and health care
often makes them even more vulnerable to misinformation. Most patients do not
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have the knowledge base nurses have to evaluate information and make informed
decisions. As Gilmour, Scott, and Huntington (2008) note:
Nurses in our study were concerned about the quality of Internet health information, judged by criteria
such as the use of research-based evidence, evidence of peer review, named authors and currency of
information. Their evaluative practices were in sharp contrast to the findings by Fox (2006) that 75% of
public health information-seeker respondents (n = 2928) checked the source and date only sometimes at
best. (p. 27)
Books such as The Patient Safety Perspective: Health Information and
Resources Online and in Print (Burt, 2013), The Knowledgeable Patient:
Communication and Participation in Health (Hill & Cochrane Collection, 2011),
Health Technology Literacy: A Transdisciplinary Framework for Consumer-
Oriented Practice (Jordan-Marsh, 2011), and Surviving Health Care: A Manual
for Patients and Their Families (Kimbrough Kushner, 2010) provide nurses with
an insightful understanding of the structure and use of healthcare resources
available on the Internet. Resources such as these position nurses to assist patients
with obtaining accurate information.
Nurses have an ethical responsibility to skillfully use all tools and resources
available. Not everything is, or will ever be, available electronically. Nurses
should be aware of and use print materials that are still current and viable.
Conversely, because not all electronic resources based on print resources are
comprehensive and some contain older or archival information, research questions
can take reviewers back to older print journals or indexes.
inde xe s : A listing of electronic or print resources
Many reputable government, organizational, and educational resources are
available on the Internet (sites that are free and accessible to all), such as
Valparaiso University Christopher Center Library’s Nursing Libguide: Evidence-
Based Practice Resource (http://libguides.valpo.edu/content.php?
pid=42078&sid=337662) and the University of Washington Health Sciences
Library’s Evidence-Based Practice LibGuide
(http://libguides.hsl.washington.edu/ebp). There are also many restricted resources,
such as literature databases (often paid for by a school or hospital) and resources
within organizational sites available only to members. These restricted resources
usually contain professional literature that has been compiled, sorted, indexed, and
made available. Content in these resources is written for professional colleagues,
not for the lay person or the consumer. It is not unreasonable to expect nurses to be
well versed in both the professional and lay perspectives, using professional
resources to keep current about practice while also helping patients as consumers
of health care.
Access to academic, health sciences, or hospital library resources is vital to
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http://libguides.valpo.edu/content.php?pid=42078&sid=337662
http://libguides.hsl.washington.edu/ebp
quality literature review. Because each library and database has its own best
practice procedures, initial time spent orienting with an expert about these systems
is worthwhile. Just as nursing faculty are subject content experts, librarians are
searching and system experts.
TEST YOUR KNOWLEDGE 4-1
1. Learning to perform a quality literature review is essential for which of the following reasons?
(Select all that apply.)
a. Lays the foundation for writing quality undergraduate academic papers
b. Identifies gaps in current research
c. Provides the basis for making best practice decisions
d. Develops skills necessary for lifelong learning
True/False
2. All sources retrieved from the Internet are applicable to EBP.
3. Access to computers and technical resources is critical to link research to EBP.
4. Librarians are searching and system experts.
5. All useful resources on the Web are free and accessible to all.
How did you do? 1. a, b, c, d; 2. F; 3. T; 4. T; 5. F
4.2 Types of Evidence
At the end of this section, you will be able to:
‹ Explain the scientific literature publication cycle
‹ Differentiate between primary and secondary sources
‹ Identify different types of articles found in the literature
‹ Characterize the four major types of reviews
Not all information is created equal, nor is it presented in the same manner. Being
able to identify various types of information and sources is fundamental to starting a
successful literature review search.
Scientific Literature Publication Cycle
It is helpful first to consider the scientific literature publication cycle to make
searching easier (University of Washington Libraries, 1999). As shown in Figure 4-
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1, the cycle generally begins with the idea and the research itself, which is
available only informally through raw data reports, grant proposals, and perhaps
as-yet-unpublished conference papers. At the next point, when researchers are
confident in the findings and their presentations, information is prepared for
dissemination as professional, scholarly papers. Papers judged to be of high quality
about studies using sound research methods are accepted by editors of scholarly
journals and indexed in literature indexes and databases so that others may find
them when conducting literature searches. After this point, papers, or information
contained within them, move into a more generalized publication format where they
may be summarized or compiled with other like-topic papers. They are typically
published in reviews or magazines directed toward a wider, less professionally
focused audience. Finally, if findings are considered noteworthy, they may be cited
in textbooks or reference materials, such as encyclopedias or bibliographies.
s cie ntific lite rature publication cycle : A model describing how research becomes disseminated in
publications
FIGURE 4-1 The Scientific Publication Cycle
Keeping the scientific literature publication cycle in mind, you might now
realize that when looking for the most current, authoritative information on a topic,
you should be checking the published, scholarly literature. If the goal is to compare
evidence, systematic reviews are a useful way to locate similar topics quickly. By
keeping in mind the publication dates of the studies contained in the systematic
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review, you can complete the search by searching for evidence published during
time spans not covered by the systematic review.
Making Sense of Types of Evidence in the Literature
Evidence in the literature can be categorized in a variety of ways. Nurses find that
understanding the terms associated with these categories is helpful when making
decisions about evidence. Evidence can be categorized as: (1) primary or
secondary, (2) peer reviewed or not peer reviewed, and (3) scholarly, trade, or
popular.
Primary and Secondary Sources
Primary sources present original information by the person or people responsible
for creating it. Paintings, speeches, diary entries, autobiographies, and interviews
are some common examples. In the world of research, however, primary sources
are the journal articles, book chapters, dissertations, or conference proceedings
written by the people involved in the original research. Primary sources always
provide full references to other works cited within the paper. Secondary sources
are the resulting commentaries, summaries, reviews, or interpretations of primary
sources. Always written after primary sources are presented, and often written by
those not involved in the original work, secondary sources can provide new
insights or historical perspectives not previously available. Some common
secondary sources are textbooks, systematic reviews, biographies, and general
magazines. Secondary sources often do not cite the work of others.
primary s ource s : Original information presented by the person or people responsible for creating it
s e condary s ource s : Commentaries, summaries, reviews, or interpretations of primary sources; often written by
those not involved in the original work
For example, an original research paper on Internet use by patients with
diabetes was published in the scholarly journal Nursing Research. This publication
of the paper is considered to be a primary source. Several weeks later, Newsweek
published a more general article about the effect of the Internet on patient
education. In this article, results from the original paper published in Nursing
Research were mentioned along with a short quote. This article constitutes a
secondary source about the original research conducted. Sometimes it is important
to eliminate secondary sources because of the bias inherent when someone other
than the original researcher provides the information. When creating EBP, nurses
should always read primary sources and draw their own conclusions.
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Peer-Reviewed and Refereed Sources
Research and empirical papers published as primary sources in scholarly literature
undergo rigorous evaluation by experts and editors, which is known as peer review
or refereed judging. Subject significance, methods, and conclusions are judged by
peer reviewers. When papers meet established criteria, they are accepted for
publication. This process is designed to ensure high quality of published works and
enables readers who are not experts about the topic to have confidence in what is
being presented.
pe e r re vie w: When experts and editors rigorously evaluate a manuscript submitted for publication
Scholarly, Trade, and Popular Literature Categories
Distinguishing between different types of information categories can help determine
the type of information contained within them. There are generally three broad
categories: scholarly, trade, and popular literature. Scholarly works are written
and edited by professionals in the discipline for other colleagues. They are the
vehicles for publication of original research, focus on narrow topics within the
discipline, and are often filled with discipline-specific vocabulary. For example,
the Journal of Nursing Scholarship, published by Sigma Theta Tau International, is
a scholarly journal. Trade publications are also written for professionals within a
discipline but are written with a more casual tone. They contain information related
to professional development, products, practices, or trends in the discipline.
American Journal of Nursing and RN Magazine are examples of trade
publications. Popular literature is written to inform or entertain the general public.
The writing level is very basic, and graphics often get as much space as the text.
For example, Prevention is a source of information about health that is written for
the general public.
s cholarly lite rature : Works written and edited by professionals in the discipline for other colleagues
trade lite rature : Works written for professionals in a discipline using a more casual tone than used in scholarly
literature
popular lite rature : Works written to inform or entertain the general public
Periodicals, Journals, and Magazines
Few terms used in libraries cause more confusion than these three: periodicals,
journals, and magazines. Although some people use these terms as synonyms, it is
best to understand the differences between these terms and to use them correctly.
Periodical is the broadest term of the three and indicates a resource that is
published periodically, usually on a set schedule. In many libraries, periodical is
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the term used to designate these types of publications as a collection. Both journals
and magazines are designated as periodicals. Journal is the term used to indicate
resources of a scholarly or professional nature. Magazine indicates a resource
targeted for the general reading audience, most often in the popular works category.
When you have difficulty distinguishing among these three types of resources, a
quick consultation with a librarian or a search of a library website for information
about this topic can be helpful.
pe riodical: A resource that is published on a set schedule
journal: A scholarly or professional resource
magazine : A resource targeted to the general reading audience
Understanding Types of Reviews
Before the electronic information age, researchers developed ways to keep up-to-
date by creating early forms of reviews to summarize information. Because of the
increased volume of information being made available as a result of information
technology, there is some cause for concern. Hawker, Payne, Kerr, Hardey, and
Powell (2002) make the concern clear:
Both reviews and the results of primary research are now being used as bases for health care
decisions. However, despite this expansion, the quality of literature reviews varies widely, particularly
across academic disciplines, and the standard of some published reviews remains poor (Evans &
Kowanko, 2000). If reviews are to be considered as evidence and seen as research in their own right,
then it follows that the rigor that is expected of primary research must also be applied to literature
reviews. (pp. 1284–1285)
Consider the implications of a poorly conducted summary when contrasting the
academic and clinical settings. When literature reviews conducted for academic
papers lack precision and quality searching, the results often lead to a lower grade.
Likewise, when nurses consider decisions about EBP, a poorly conducted literature
review may negatively affect patient care.
FYI
Different types of sources provide different levels of quality information. It is nurses’ responsibility to be
able to distinguish among the different types of sources: primary or secondary, peer reviewed or not peer
reviewed, and scholarly, trade, or popular.
Reviews can be conducted in a variety of ways. In an article that has become
definitive in this field, Whittemore (2005) detailed differences among the major
types of reviews. Echoing concerns of Hawker and colleagues (2002), Whittemore
also noted that the “literature search stage is a critical element to conducting a
quality research review because incomplete and biased searches result in an
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inadequate database for the review and the potential for faulty conclusions” (p. 58).
To make good decisions about best practice, nurses should familiarize themselves
with the major types of reviews: narrative, integrative, meta-analysis, and
systematic.
Narrative Reviews
Narrative reviews are the most traditional type of review, thus the most familiar.
These kinds of reviews are frequently found in trade publications. Because writers
judge which works to include and exclude, narrative reviews are subjective. These
reviews are often based on only the common or uncommon elements of the various
works, and writers are not particularly concerned with widely varying research
methods, designs, or settings. For example, the review of literature section in most
published articles is a traditional narrative review.
narrative re vie ws : Reviews based on common or uncommon elements of works without concern for research
methods, designs, or settings; traditional literature review
Integrative Reviews
Jackson (1980) defined an integrative review as “generalizations about substantive
issues from a set of studies directly bearing on those issues” (p. 438). Integrative
reviews are scholarly papers that synthesize published studies and articles to
answer questions about phenomena of interest. They are typically found in peer-
reviewed professional publications. Ganong (1987) is credited with clarifying the
steps of conducting integrative reviews in nursing. Ganong’s article provided a grid
layout that many find useful as a tool to track and compile data from various
research papers. Components of the grid include methods, theories, and empirical
findings of the reviewed papers. These grids are often included in published
integrative reviews. Whittemore (2005) noted that an advantage to integrative
reviews “is the ability to combine data from different types of research designs and
include theoretical, as well as, empirical literature” (p. 57). In other words,
integrative reviews do not need to include works that use the same designs or
research methods.
inte grative re vie w: A scholarly paper that synthesizes published studies to answer questions about phenomena
of interest
Meta-Analyses
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Meta-analyses combine results of studies into a measurable format and statistically
estimate the effects of proposed interventions. Often, individual studies about an
intervention fail to show statistical significance. But when the results from multiple
studies are combined in one large analysis, results may show that the intervention is
beneficial (Crombie & Davies, 2009). For example, suppose there are 10 studies
about the effect of yoga on blood pressure, but none of the studies showed that yoga
reduced blood pressure. However, when the results are pooled, data analysis
showed statistical significance; then, it could be concluded that yoga can reduce
blood pressure. Unlike in an integrative review, meta-analyses include works that
are similar or identical so that statistical comparisons can be made. Another
difference between these two types of reviews is that meta-analyses include both
published and unpublished works. Evans and Kowanko (2000) surmised that meta-
analysis reviews grew from narrative reviews when the increasing amounts of
numerical data grew too cumbersome. According to Whittemore (2005), meta-
analyses are especially useful as sources of evidence when large randomized trials
are not feasible.
me ta-analys e s : A scholarly paper that combines results of studies, both published and unpublished, into a
measurable format and statistically estimates the effects of proposed interventions
Systematic Reviews
Systematic reviews combine elements of the three previously discussed methods.
These are “scientific tools which are used to summarize and communicate the
results and implications of otherwise unmanageable quantities of research” (Evans
& Kowanko, 2000, p. 35). Articles included in systematic reviews all address the
same clinical problem. “A well-specified clinical question, use of the best
available evidence, explicit methods, and an exhaustive search for relevant primary
studies are hallmarks of this method” (Whittemore, 2005, p. 58). Systematic
reviews adhere to strict eligibility criteria so that bias can be minimized and
reliable conclusions can be made (Higgins & Green, 2011). Systematic reviews,
combined with other types of guidelines, are sources that can be helpful in
situations when evidence is needed quickly. A brief editorial by Cowell (2012)
provides a comparative overview of these types of reviews as well as ways in
which to assess the quality of such reviews.
s ys te matic re vie ws : Rigorous and systematic syntheses of research findings about a clinical problem
TEST YOUR KNOWLEDGE 4-2
1. Put the following points of the scientific literature publication cycle in order.
177
a. Finding cited in textbook
b. Paper accepted for publication in scholarly journal
c. Idea for research identified
d. Article cited in indexes in databases
e. Findings included in magazine article
2. Which of the following are primary sources? (Select all that apply.)
a. Biography
b. Systematic review
c. Research article
d. Dissertation
3. Which of the following journals are considered scholarly journals? (Select all that apply.)
a. Nursing Research
b. RN Magazine
c. American Journal of Nursing
d. Journal of Nursing Scholarship
4. What is a review that synthesizes only published articles to answer questions about phenomena of
interest?
a. Narrative review
b. Integrative review
c. Meta-analysis
d. Systematic review
How did you do? 1. c, b, d, e, a; 2. c, d; 3. a, d; 4. b
4.3 How Sources Are Organized
At the end of this section, you will be able to:
‹ Identify and use a variety of sources, both within and outside of the field of
nursing, as appropriate
‹ Explain how the sources are structured
‹ Distinguish between the different sources’ content, in both topic or subject
matter and in format
Consider your first clinical experience with a patient. Before that experience, you
were educated about various aspects of patient care and equipment. No one just
handed you a stethoscope and a blood pressure cuff and wished you luck. Most
likely, you first read about the various procedures, learned what to expect in typical
situations, and then practiced in a laboratory setting. Learning to search for
information can be approached in a similar way. Gaining insight about how
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information resources are structured, what their contents contain, and what search
techniques work best increase your skill and efficiency.
Many factors come into play when conducting a search of the literature. What
interests you about the topic should determine the depth and breadth of the search,
which sources to search, and the dates of publication to include. Immediate access
to sources being sought is not always possible. Sometimes it may take several
weeks to acquire sources, while other sources may be unobtainable. Knowing this
encourages implementing strategies to ensure that you are able to meet deadlines.
FYI
To create an EBP, nurses must be aware of information retrieval options. Librarians are an excellent
resource for becoming an effective researcher.
After the research question is developed, the researcher is ready to proceed
through the steps of the literature review process. Using selected search words and
terms based on the topic, the researcher searches databases, organizes search
results, locates full content of the materials, and evaluates the evidence for its
usefulness. Being aware of these steps focuses attention on the process and results.
When information applicable to the subject has been gathered, it is important to
keep in mind that the process might not be finished. It is not usual for individuals to
quit at this point, satisfied that the information they have gathered will somehow
work within their needs. Carefully reviewing obtained materials to ensure that they
are appropriate can save time and money. Reexamine the original focus and search
strategy to ensure that the information obtained is indeed useful. If it is not,
determine where the search was flawed and decide whether a new search is
necessary.
Finally, make sure that the information gathered is scholarly. Information should
be written by knowledgeable authors, published by respected sources, and be
appropriately current. The content of information should always be evaluated,
appraised on criteria such as intended audience, depth of coverage, objectivity, and
related reviews. When you are unsure of the credibility of information, nursing
faculty or librarians can provide guidance.
Consult with an Information Resources Expert
Working with a librarian is guaranteed to save you time. Using a systematic review
to support their claim, Weightman and Williamson (2005) noted that “there is
evidence that library services can lead to time savings for healthcare professionals
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and, thus, to cost savings and healthcare benefits” (p. 5). Few others on a campus
or in a healthcare institution know as much about information structure, storage,
retrieval, and evaluation as librarians do. Most academic libraries have subject-
specialty librarians for specific disciplines, and at health sciences libraries, new
roles are emerging that make librarians more specialized (Cooper & Crum, 2013).
Whereas reference desk inquiries are appropriate for general questions, an
appointment with a subject-specialty librarian is the best way to obtain specific
information in a shorter amount of time.
Impactful use of librarians and library resources isn’t limited to academic study. In 1992, hospital
librarians in Rochester, New York, initiated what has since become known as “The Rochester Study” in
their quest to assess whether or not having a hospital library impacts patient care. “It demonstrated that
in the eyes of the information users (in this case, physicians) that library services were valued and that
the provided information was seen as making a positive difference in patient care. The Rochester study
has been heavily cited, achieving a prominent influence in the field, not only among librarians, but also in
the medical literature.” (Dunn, Brewer, Marshall, & Sollenberger, 2009, p. 308)
Systematic reviews and other studies, such as “The Health Information Literacy
Project,” continue to consider and evaluate the value of library use and resources in
positively influencing patient care.
To create an EBP, nurses must be aware of information retrieval options.
Hospitals often support library resources and a librarian. Academic or health
sciences libraries, especially at state-funded institutions, may allow community
members access to their holdings. Academic libraries are especially useful because
they have strong collections in the scholarly literature, while public libraries have
more consumer-oriented materials.
Looking at the Structure of Sources
When information sources are organized using basic principles of consistent record
formatting and field labels, searchers can rely on finding similar information each
time they perform the same search, even if new information has been added to the
system. For example, if the keyword anxiety is entered into a database, the searcher
would expect the search to yield information such as author, title of article, year of
publication, and the abstract each time the keyword is entered. Each time anxiety is
entered, the same sources should be seen. If any new sources have been added to
the database since the previous search, these should also appear.
Considering familiar organizational structures of sources will help in
understanding more complex systems. Perhaps the first organizational system you
ever learned was the alphabet. Children in kindergarten learn to line up in
alphabetical order according to their last names. They do not line up according to
height or hair color because those system labels are not as straightforward and
consistent as the alphabet is. The phone book is another example of a structure for
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organizing information. The white pages are arranged in alphabetical order. This is
a very effective way to organize information when one knows the name of the
business one is seeking. The yellow pages offer another organizational structure for
searching. Subject listings in the yellow pages were created so that if one knows
the type of business, but not its name, the information can be found. The key to using
the yellow pages, though, is to know exactly what terms the creators used for the
subject areas. For example, if you need a haircut, would you use “hair,” “barber,”
or “beauty shop” as a keyword? Although this example might seem very elementary
right now, understanding how the phone book is organized will be beneficial when
considering the most common types of electronic searches.
Structures can also be designed to organize physical objects. For example, in
bookstores, books are organized in subject areas around the store, and within each
area, they are perhaps grouped into subcategories and shelved by the author’s last
name. Libraries are arranged in the same manner, but, because there are many more
books to organize, a consistent number or letter/number combination system is
used. Most public and school libraries use the Dewey decimal system, while most
academic libraries in the United States use the Library of Congress system. Many
health sciences libraries use the National Library of Medicine system. Here too,
when the books are in their general subject areas, they are then categorized into
smaller subcategories and shelved according to the author’s last name. In the
library system, every item has its own unique call number according to its subject
area and author’s last name. No other item will have that same number. Familiarity
with the system and knowing which system the library uses makes searching for
sources more efficient.
call numbe r: Unique identification number assigned to items in a library by subject and author name
Knowing general call numbers of a subject can also expedite searches for items
in a library collection. For example, in academic libraries using the Library of
Congress method, medical books are located within the R area shelves and nursing
books are on the RT shelves. Further knowledge of what subjects the numbers
connote can lead to more detailed browsing, such as knowing that the nursing
research texts’ section is RT 81.5, while writings about nursing history are on the
RT 31 shelves. Call numbers for specific books are easily found through searching
the library’s catalog.
Although the structure used in libraries is quite efficient for locating sources,
confusion can occur when sources can be classified in more than one way.
Information on a specific topic might be scattered throughout the collection. For
example, in a search for sources on the topic of ethical practices and how they
relate to health care, it is helpful to browse multiple areas, such as nursing ethics,
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medical philosophy, medical ethics, law of the United States, and medical
legislation.
Other structures aid in finding information. For example, the table of contents in
a book helps readers find information located within the text without having to read
every single page. The table of contents narrows the search from hundreds of pages
to perhaps 20 or 30 pages. The search can be narrowed even further by using the
index, which provides a very detailed listing of subjects contained in the book. The
index can narrow the search to a few pages.
The concept of indexes has proved to be a very useful structure to assist
researchers with finding scholarly articles and reports. Prior to the electronic age,
printed indexes of professional literature covering only the information in one
particular discipline provided listings of all information produced in that discipline
in a specific time span. For nursing, the most recognized and used print index was
started in the 1940s and was known as the Cumulative Index to Nursing and Allied
Health Literature. Today, nurses use the electronic version known as CINAHL.
Electronic indexes are most commonly referred to as databases.
print inde x: Printed listing of electronic or print resources
CINAHL: Cumulative Index to Nursing and Allied Health Literature; database for nursing and health-
related literature
e le ctronic inde xe s : Electronic listings of electronic or print resources
In the print indexes, information is organized three ways: author listings, title
listings, and subject listings. In early print indexes, subject listings offered a new
organizational structure. Publishers of the indexes began to choose keywords that
would always represent the subject regardless of the words used by authors. For
example, the term heart attack is always listed as “myocardial infarction.” The
consistent use of keywords provided a solid foundation for the electronic searching
conducted today.
With the advent of electronic resources and the Internet, another type of
searching became possible. Searching does not need to be limited to keywords
because entire bodies of text can be searched. This is known as keyword searching.
This type of searching in electronic databases allows searching for the author’s
words, not the subject terms assigned by the database publisher. Keyword
searching is not without its challenges. For example, the word diet as it is used by
the general public usually is defined as a meal plan to lose weight. Healthcare
professionals typically use the word diet to refer to meal plans that are therapeutic
for patients. When conducting a keyword search, entering “diet” will achieve
different results depending on the source. Keyword searches also provide results
that are exactly what the searcher intends, or not, depending on how the word is
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used in the text. The source searched does not know the searcher’s intent; it only
knows what term has been entered.
ke yword: A word used to search electronic databases; a significant word from a title or document used as an
index to content
As electronic search options and resources increase and become integral to
today’s practice, journal publishers and librarians collaborate to create methods of
assisting authors in promoting their articles and researchers in finding them. Grant
(2010) detailed the creation of keyword lists, resources that are becoming
especially useful when searching for scholarly works on the open Internet. The
piece also provides a quick glimpse of the publishing methods of a journal in which
submitted articles are reviewed for accuracy and quality while the publisher adds
content-rich data that in turn increases findability of articles for keyword searching.
Using authoritative keyword lists can save time, whether on the open Internet or
when using an institution’s databases.
The Internet, while an accessible source of abundant information, has a very
unorganized and inconsistent structure. Tools that are comparable to those used in
electronic databases are being developed to support Internet searching. Google
Scholar and the advanced search options for Google and other Internet search
systems give users specific search options, such as searching for phrases, broad
subject areas, and document types. As with all organizational structures, knowing
how to use the tool results in more productive searches.
Being aware of these simple facts can facilitate searching in indexes and
databases. As mentioned earlier, not all electronic resources that were once in print
format are comprehensive in their coverage. They may go back in the literature only
20 to 25 years. Foundational or key studies could be missed if they were conducted
prior to the date the electronic database began. Keep in mind the frequency with
which the database is updated. For example, a database updated monthly will not
yield a new search on a daily basis. Searches can be programmed to be performed
regularly so that new literature is identified when it is added to the database.
Practicing this as a student prepares you to find evidence for implementing best
practice.
Databases: The Same but Different
There are variations in databases just as there are variations in the human body. In
healthy people there are variations in height, weight, age, and appearance, but
overall their organ systems perform in the same manner. Databases also vary in
appearance (color, graphics, results display) even though content is the same or
very similar. Understanding how a search strategy works in one database can be
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helpful in understanding how to use another database. If the results of a database
search are unsatisfactory, the help feature can offer guidance. Also, it is important
to be sure that your topic area fits with the database. For example, when you look
for information about anxiety, there may be more citations in a database such as
PsycINFO compared to CINAHL (McGrath, Brown, & Samra, 2012).
The fact that not all databases are provided by the same information vendor can
be a source of confusion. Consider the many different fast food restaurants that offer
variations of the hamburger. Each company touts a special bun, sauce, or grade of
hamburger. In the same way, vendors who provide access to the same databases do
so in various manners. Companies such as EBSCOhost, Ovid, SilverPlatter,
Elsevier, and Thomson Gale purchase database content from the original creator
and sell the content with their own design, search options, and date ranges. For
example, suppose you are using CINAHL in the EBSCOhost system and a friend at
another institution is using it through the Ovid system. Although the content and
search strategies the two of you use will be similar, your resulting searches and
appearance of the screens will be very different.
Another cause of confusion for users and librarians alike is that content may
change in a database. These changes are caused by interactions among vendors and
journal publishers who provide the articles. Sources available in full text one day
may be found in a citation-only option the next. When this happens, it may not be the
result of errors made while searching. Talking to a librarian may resolve the
situation and result in obtaining the information desired.
Topic and Subject Matter
Information about scholarly literature of disciplines is collected and indexed in
subject-specific databases, such as CINAHL. Not much, if any, popular-content
works are contained in these databases. Additionally, information about works yet
to be published, called grey literature, includes unpublished reports, conference
papers, and grant proposals. Grey literature is often indicative of upcoming hot
topics in the field. Databases can also cite professional information, such as
organizational guidelines, editorial essays, and letters to the editor. For example,
commentaries on author works that have generated controversy can be useful
sources.
gre y lite rature : Unpublished reports, conference papers, and grant proposals
General content databases offer a mix of scholarly, trade, and popular works.
Professional journals, popular magazines, newspapers, and industry bulletins may
all be part of the search results (unless you limit the search accordingly). These
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databases are helpful for gathering information on current news events, government
reports, and healthcare topics from the consumer point of view.
Databases also contain citations useful to patient education. In the healthcare
literature, distinctions are made between consumer health materials and patient
education materials. Consumer health materials are general articles about topics
such as maintaining a healthy lifestyle. Patient education materials are items
designed to assist patients in making informed decisions regarding their medical
care. Nurses are often asked to decipher what patients hear in the news and to refer
consumers to additional, reliable information sources.
Format
In print and electronic information sources, the basic building block is called a
record. Each piece of information contained in the record has been entered into
what is referred to as a search field, which makes electronic searching possible.
Each record minimally consists of a citation of information and a record number.
Citations provide author name, title, publication date, and, depending on the type of
item, publisher information and page numbers. Citations are the minimal amount of
information needed to locate items, and they contain information required for a
reference list. Record numbers, similar to call numbers for books, are numbers
assigned by the information source and are unique to each record.
re cord: Basic building block in an electronic or print database
s e arch fie ld: Where each piece of information contained in the record is entered
Depending on the information source, other fields of information may be
available for the citation. Subject terms and subject headings are often listed. An
abstract may be included and is helpful to quickly determine the item’s content.
Sometimes references cited in the item are also included in the format. Reference
information can be helpful for locating other relevant information. Other fields
might be added to the record, such as text language, type of publication, or
designation of whether the research is evidence based or peer reviewed. Whereas
all databases offer citations, these come in three formats: citation only, citation with
full content, or a mix of both. Because print indexes are citation only, an additional
step is required to obtain the full content. Most electronic information sources are
mixed. Very few databases provide only full-content records, and they are the
exception rather than the rule. Because librarians understand the need to have full
content available as easily as possible, systems have been created to meet that
need. These systems basically tie citations in one database to full content available
in other databases or to print resources within the library. If a hyperlink in the
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record is available to link to full content, no additional step is needed.
s ubje ct he adings : A set of controlled vocabulary used to classify materials; organization of databases
according to topic
When items are not available in full content within any database or within
library print holdings, a copy of the item can be retrieved through the interlibrary
loan system. For your convenience, most records provide a hyperlink to
interlibrary loan request forms so that requests can be made immediately when you
determine that an item is not available locally. Most of the time, this service is
subsidized by the library and is available at no cost. Because it usually takes 7 to
10 days after making a request to receive materials, it is prudent to begin searches
well before deadlines. Journal articles are usually copied and sent to the requester
to keep. Books, videos, and other such items are sent on loan and must be returned
to the lending library. Because each library’s procedure is slightly different, it is
important to understand how to request materials prior to needing this service. You
might not receive everything requested because copyright issues, limited numbers
of available copies, and other restrictions can affect requests.
inte rlibrary loan: A service whereby libraries provide items in their collections to each other upon request;
lending of items through a network of libraries
TEST YOUR KNOWLEDGE 4-3
True/False
1. All libraries use the same system for organizing their collections.
2. Tables of contents and indexes can be useful to narrow searches for evidence.
3. Knowing key terms used in an index can facilitate effective searches.
How did you do? 1. F; 2. T; 3. T
4.4 How to Search for Evidence
At the end of this section, you will be able to:
‹ Perform various types of searches using basic and advanced source tools and
search techniques
‹ List four databases where scholarly literature of disciplines is indexed
Access to Content: Tools and Techniques
There are three types of access to information: free access, access paid by an
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institution, and access paid by an individual. Most electronic sources provided by
the U.S. government are free access. Most libraries grant free access to their
holdings to those physically present. If the item is available for borrowing, a
library card is needed to check out the item. Although these services are provided
to patrons for free, the library is paying the costs. Nurses can often access
resources for free at their places of work. Like libraries, the healthcare
organization is charged to provide the services. Regardless, access to electronic
sources is being paid for by someone. For example, a nurse who is self-employed
may have to subscribe as an individual to access CINAHL.
FYI
Knowing a variety of search techniques—such as use of keywords, Boolean operators, and truncation—is
essential to effective research, while accessing the most reliable databases ensures EBP.
General Search Strategies
Searching for evidence does take time, but knowing the organization of the system
and doing a search correctly can improve efficiency (Cleary, Hunt, & Horsfall,
2009; McGrath et al., 2012). Novice searchers often begin by searching for a
specific type of document, such as a nursing research article reporting outcomes of
an experimental study. Although it is good to have an idea of the evidence that you
would like to find, do not discount other evidence uncovered during the search.
Sometimes a continuing education article that mentions a particular study or a
literature review in an article on a related topic may provide sources not found
through other methods of searching.
Another helpful strategy to locate evidence is to build searches both backward
and forward in time. This is sometimes called citation chasing. For example, a
nurse locates a single article about community preparations for bioterrorism. The
nurse examines the references listed to determine whether other sources on this
topic seem to stand out as foundational or noteworthy. If so, the nurse obtains these
sources and proceeds to appraise their reference lists as well. This strategy is an
effective way to search previous literature and often identifies the articles that were
first published about the topic. Forward searching strategies are made possible by
electronic databases. For example, the nurse enters information for a single article
and uses a hyperlink option “times cited in this database.” This link connects to
other documents that have cited that article since its publication.
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citation chas ing: Using a reference list to identify sources of evidence
Hints for Searching Print Indexes
Because of the convenience of electronic resources, most individuals are
unfamiliar with print indexes. Typically, print indexes are used to search for older
literature that has not been indexed in electronic databases. Therefore, perhaps the
best strategy when using print indexes is to ask a librarian for help. Librarians are
familiar with the sources and know which sources will be most useful. Because
older print resources are primarily organized by time, usually in spans of a year or
two, knowing the years to search can help immensely. Keeping in mind that search
terms change over time is also important when using print indexes. For example,
whereas “patient education” is the correct subject term today, if searching records
created before 1988, the correct term is “health education, information services.”
Hints for Searching Electronic Databases
Parameters of recall and precision provide conceptual baselines for refining search
strategies in electronic databases. The successful integration of these parameters
results in retrieved records that more closely match the desired focus and number
of sources.
Recall describes the broad “catch” of retrieved records. Those records, usually
high in number, display a wide range of what has been classified as related
records. Recall is a strategy best used when the information being sought is
uniquely detailed, a new topic or procedure, or has not been widely written about
in the literature. Gathering a large number of records ensures that the information
needed is somewhere within them, even though many of the records retrieved will
not be relevant.
re call: A strategy used to search for the number of records retrieved with a keyword; the broad “catch” of
retrieved records
Precision is a search strategy that narrows the parameters of the search. When
a search term displays a precise retrieval, the records are usually smaller in
number but more closely matched to the entered search terms. This search strategy
is best when the information being sought has been written about in a number of
authoritative sources by a number of knowledgeable people. The search can be
narrowed without undue concern about the loss of some relevant records because it
is likely that the search contained needed information in the retrieved records.
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pre cis ion: A search strategy that narrows the parameters of the search
An effective technique, especially for novices whose skills are not yet finely
tuned, is to combine these search strategies. Beginning with a recall strategy
retrieves many records. Following with precision search strategies narrows the
field of the originally recalled records.
Basic Searches: Using Keywords
Selecting key terms is critical for achieving successful results when searching for
evidence. A good place to begin identifying key terms is the PICOT question
(PICOT stands for patient population, intervention of interest, comparison of
interest, outcome of interest, and time frame; McGrath et al., 2012). For example,
consider the PICOT question, “Does practicing yoga three times a week reduce
blood pressure in older adult?” By using the parts of the PICOT question, one can
see that concepts such as yoga, blood pressure, and older adults can form the basis
for keywords.
There are two basic types of search queries when searching electronic
databases: keyword and controlled vocabulary (discussed in the next section). Each
has its own benefits and constraints, but the key to successful searching is knowing
which type of query to use. Because the Internet is easy to use, bad search habits
have resulted. Internet search engines are eager to please and therefore usually
produce results for the entered search term. However, the results often include
unrelated items, or the definition of terms may not match, the websites identified
may be of dubious quality, or perhaps a misspelled search term retrieves matches
from others who have misspelled words the same way. Electronic databases hold
searchers to a higher level of use. For example, correct spelling really counts.
When words are misspelled, databases reply with “zero results retrieved.” With the
use of good search habits, databases can offer consistency in searching, reliability
of information found, and access to information not available on the open Internet.
Keyword searching allows you to enter a search term that best describes a topic
as it is used in information source records (Cleary et al., 2009). Although this
search strategy retrieves related records, searches also need to include synonyms
and variations of the search term to ensure that all relevant records are retrieved.
For example, in a search for information about newborns and their mothers, a
keyword search using the terms “bonding” and “attachment” would be necessary.
Keyword searches are often best for searching full-text or citation records. In most
databases, keyword searching also considers words in the title, content notes, and
author fields of each item’s record.
Search tools are used to refine keyword searches. While the underlying
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concepts of these tools remain constant across various applications and resources,
some electronic databases do not support all of them, or their symbols may be
slightly different. To make the best use of powerful search strategies, it is essential
to check the database’s help files to make sure the tools are available and that the
chosen symbols are entered correctly.
Search operators, also known as Boolean operators, are words that specify the
relationship between two or more search terms. Search terms can be linked in a
number of ways using the terms and, or, and not.
Boole an ope rators : Words, such as and, or, and not, that specify the relationship between search terms
Using “and” narrows a search. Both of the search terms entered must be found
somewhere in the record, though not necessarily in the same place. For example,
terms may be a part of an author’s name and part of a title. In most databases, the
Boolean operation of “and” is automatically used when two or more keywords are
entered. For example, a nurse is searching for information about eating disorders.
Entering the keywords “anorexia” and “bulimia” will return only records
containing both terms.
Using the Boolean operation of “or” broadens a search. When using this
approach, either search term must be found somewhere in the record. This is
especially helpful when searching synonyms or words with various forms. Unlike
electronic databases, most Internet search engines default to the “or” operation
when two or more keywords are entered. This explains why a search can retrieve
so many irrelevant records. For example, a search strategy of “anorexia or bulimia”
returns records that contain either one or both terms.
Searches can be narrowed by using the Boolean operation of “not.” Using this
operation, a record can be retrieved only if the first search term is present and the
second search term is not present. In the example of eating disorders, entering
keywords “anorexia not bulimia” returns results that contain only anorexia.
Search operators can also be used with Internet search engines. It is essential to
check the help files of the search engine. Some search engines require that the
search operators be typed in all capital letters, some accept two of the three
operators and not the other, and some require the combination “and not” for the
“not” operator.
Another helpful strategy when conducting basic searches is truncation, which
is the ability to retrieve records of search terms that share a common root. In each
database, a symbol of some sort is placed at the end of the group of letters forming
the root search term. The symbol is usually an asterisk, but sometimes a colon, a
question mark, a dollar sign, or a pound sign might be used. Check the help files to
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see which symbol is used in the database. Using the longest root possible increases
the accuracy of the search. For example, instead of entering all of the terms “nurse,”
“nurses,” and “nursing” in a search, truncation would replace all three with
“nurs*”. The challenge with truncation, however, is that it is often surprising to find
how many words share common roots. In this example, records that include nursery
and nursing home are also retrieved.
truncation: A search strategy that uses a symbol at the end of a group of letters that form the root search term
The use of wildcards is another strategy that involves substituting symbols for
one or more letters in a search term. Many databases use the question mark as a
wildcard. The help section provides information about how wildcards are used.
For example, instead of entering both “woman” and “women” as search terms, use
the wildcard entry “wom?n” instead.
wildcards : Symbols substituted for one or more letters in a search term
Nesting, or grouping, is a strategy best used when a search contains two or
more Boolean operators. Parentheses, and sometimes quotation marks, are used to
indicate which search terms are grouped together. Just as in elementary algebra
problems, the information within the parentheses is processed first and then applied
to the information outside the parentheses. Another way to use nesting is to place
the parentheses around a phrase or proper noun to instruct the database to search
for the terms exactly as entered. For example, if searching for information about the
use of herbal remedies, entering “(herbal remedies)” would generate records about
this topic. Nesting is becoming a useful option with many Internet search tools and
databases.
ne s ting: A strategy best used when a search contains two or more Boolean operators
In most databases, the first screen allows searchers to apply limits to fields
being searched within records, thereby filtering searches from the very start. Limits
can be set for fields such as search term, language, publication type, and
publication date. Limiting a set after an initial search creates a new, narrower list
of records drawn from the original set of records. In some databases, it is possible
to apply consecutive limits, which further narrows each subset.
Stopwords are words that are so commonly used in records that they are a
hindrance to accurate record retrieval. These words are usually articles of speech,
conjunctions, and pronouns. Although database searching has been programmed to
ignore stopwords, some databases still show “failed search” when stopwords are
used. Although stopwords can vary among databases, the most common ones to
avoid are a, an, and, for, in, of, the, this, and to.
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s topwords : Words, such as a, the, and in, that are so commonly used that they can hinder accurate record
retrieval
Advanced Searches: Controlled Vocabulary
Controlled vocabularies are standardized, hierarchical lists that have been
designated to represent major subject concepts and conditions contained within a
database. For a moment, consider the hashtags that you may be familiar with from
Twitter, Instagram, or Facebook. People posting comments and photos use hashtags
so that searches can retrieve items with matching content. This is basically the same
conceptual idea behind controlled vocabularies. Whereas hashtags are chosen by
those posting the photo or information, controlled vocabularies are created by those
who manage the intellectual content of the index or database.
controlle d vocabularie s : Standardized hierarchical lists that represent major subjects within a database
Vocabularies usually change from database to database. The hierarchical nature
of the lists benefits search strategies by allowing broad concepts to be narrowed in
a manner that stays consistent within that framework. CINAHL’s list is called
CINAHL Headings. MEDLINE and the Cochrane Library use Medical Subject
Headings (MeSH). Before items are added to a database, subject matter is
determined. Specific terms that apply to the determined subjects are chosen from
the standardized list, regardless of the terminology used by authors. This approach
provides a consistent method for retrieving the records even when different
terminology is used in the text. For example, the term heart attack is always listed
as “myocardial infarction” within a controlled vocabulary structure. Using
controlled vocabulary searching is called subject searching. Unless otherwise
noted, only records that match exactly to the terms as they were entered are
displayed. The challenge is to determine which term is being used to represent the
subject matter that is being sought.
s ubje ct s e arching: Searching databases using controlled vocabulary
It is possible to find standardized lists used in databases to determine the best
terms to use. In most databases, terms are hyperlinked for ease of use. Do not
assume that a keyword in one database is the same one to use in another database.
For example, a search conducted in the PsycINFO database may use a different
subject term than a search conducted in the MEDLINE database would use, even
though both are science-related databases. When this happens, the search “fails”
and the searcher is mistakenly led to believe that the second database contains no
information on the topic.
Exploding is one of the most powerful techniques for searching subject
192
headings. When a subject term is exploded, the database is instructed to search all
the records indexed to that term as well as any terms that are in a related, narrower
category. For example, exploding the search term “headache” in a CINAHL search
results in a search that includes the terms “rebound headache” and “vascular
headache.” Exploding can dramatically increase the number of records generated
by the search. Most health sciences databases support this technique.
e xploding: Technique for searching subject headings that identifies all records indexed to that term
One of the benefits of knowing both keyword and subject searching is that they
can be combined to increase the effectiveness and efficiency of the search.
Qualification and positional operators are more advanced keyword techniques that
can be very powerful when used in combination with subject searching.
Qualification designates which fields are to be searched in the record. The most
common ways to limit searches are by author (au), title (ti), subject (su), publisher,
and publication date. Placement of the punctuation can be important when using
limiting search terms. These options may be available only using the advanced
search methods in databases.
qualification: Limiting fields of search, commonly using limits such as author, title, or subject
The proximity of search terms to one another can be specified using positional
operators. The most commonly used are “adj” (adjacent), “near,” and “same.”
Usually, “adj” and “near” can be grouped with a number to specify the number of
words that can appear between search terms. “Same” designates that the search
terms are found in the same field of the record such as the title or the abstract.
Because order is not designated with “same,” search terms will not necessarily be
next to one another. When using this technique, it is best to check the help section
for instructions.
pos itional ope rators : Terms that specify the number of words that can appear between search terms
Best Sources for EBP
Both print and electronic resources contain useful information to answer EBP
questions. Many useful encyclopedias, handbooks, guides, and care plan manuals
are available in print-only format. Asking a librarian for details on the collection
can provide valuable insight. Electronic sources offer a mix of scholarly, trade, and
popular works. Professional journals, popular magazines, newspapers, and industry
bulletins may all be part of the search results.
193
The three most commonly found general databases are Academic Search
Complete, Expanded Academic ASAP, and LexisNexis Academic. The first two
databases contain very similar content and have a higher percentage of scholarly
work than does LexisNexis Academic. LexisNexis Academic is all full content and
offers a wider range of news, business, and legal sources than do the other two
databases. In subject-specific databases, scholarly literature of professions and
disciplines is indexed. Table 4-1 provides categorization and general information
about subject-specific databases that are extremely useful when creating EBP. The
URL is provided for access to additional information, but if the database is
proprietary, it does not provide access to the content. Access may be available
through local libraries or places of employment.
TABLE 4-1 Subject-Specific Databases
CINAHL http://www.ebscohost.
com/cinahl/
CINAHL is the premier
database covering the areas of
nursing and allied health. Online
coverage is usually
comprehensive back to 1982
with monthly updates. This
proprietary site URL is for
information only. Check with
your institution’s library to
determine whether you have
subscriber access and through
which vendor.
MEDLINE via
PubMed
Health
http://www.ncbi.nlm.
nih.gov/pubmed/
Providing coverage of
MEDLINE and other medical
sciences and biomedical
literature back to the 1950s,
PubMed is a service of the U.S.
National Library of Medicine,
with free access on the Internet
to more than 17 million
citations. This link is to the free
version available on the
Internet; your library might
provide access to other vendor-
created versions that provide a
familiar search environment and
then also link directly to library
resources (and it is called
MEDLINE, not PubMed).
194
http://www.ebscohost.com/cinahl/
http://www.ncbi.nlm.nih.gov/pubmed/
PubMed
Clinical Queries
http://www.ncbi.nlm.nih.
gov/pubmed/clinical
The Clinical Queries search
supports specialized PubMed
queries for clinicians in areas of
clinical studies, systematic
reviews, and medical genetics.
Joanna Briggs
Institute EBP
Database
http://www.ovid.com/
webapp/wcs/stores/
servlet/product_Joanna-
Briggs-Institute-EBP-
Database_13051_-1_13151_
Prod-11299
The institute was established in
1996 to offer collaboration in
EBP with healthcare
professionals and researchers
across the professional
continuum in more than 40
countries. JBI is considered one
of the foundational providers of
EBP information. This
proprietary site URL is for
information only. Check with
your institution’s library to
determine whether you have
subscriber access.
The Cochrane
Collaboration
and Library
http://www.thecochranelibrary.com
An international not-for-profit
organization, the collaboration
seeks to provide timely, up-to-
date research evidence. Not a
physical entity, the Cochrane
Library is a database collection,
providing access to systematic
reviews, controlled trials,
methodology registry,
technology assessment, and
more. DARE (Database of
Abstracts of Reviews of
Effects) is also part of the
library. This proprietary site
URL is for information only.
Check with your institution’s
library to determine whether
you have subscriber access.
Google Scholar allows you to
use the familiarity of Google to
search the Internet in an
interdisciplinary way. Citation
results are scholarly in nature
and direct you to full content if
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http://www.ncbi.nlm.nih.gov/pubmed/clinical
http://www.ovid.com/webapp/wcs/stores/servlet/product_Joanna-Briggs-Institute-EBP-Database_13051_-1_13151_Prod-11299
http://www.thecochranelibrary.com
Google Scholar http://scholar.google.com/ it is available on the Internet.
Google Scholar also partners
with libraries to set up linking
with their full-content resources.
Your librarian can tell you
whether this is possible in your
system.
After evidence has been gathered, materials must be appraised for their
integrity and applicability. Sources chosen by your library, a respected professional
organization, or a reputable government agency have already been through an
evaluation process. Most individuals struggle with evaluating other Internet
sources. A couple of general guidelines can serve you well:
» If you have any doubts at all about the information, do not use it. Or, minimally,
verify it elsewhere in a reputable source.
» Ask your nursing faculty or librarian for insight on the situation. Chances are your
discussion can clarify your concerns, and as often happens in a discussion of
this type, your decision will become apparent.
Librarians create guides to assist users in accessing locally available subscription
resources as well as critically evaluated open Internet resources. For example, a
categorized listing of recommended sites for other guidelines, systematic reviews,
clinical trials, and “free” EBP resources is available through Valparaiso University
(http://libguides.valpo.edu/content.php?pid=42078&sid=337662). Table 4-2
provides recommendations of other EBP sources.
TABLE 4-2 Recommended Sources About EBP
Clinical Practice Guidelines
‹ Agency for Healthcare Research and Quality (AHRQ)
(http://www.ahrq.gov/clinic/cpgsix.htm)
‹ National Guideline Clearinghouse (http://www.guideline.gov/)
‹ Oncology Nursing Society (ONS) PEP: Putting Evidence into Practice
(http://ons.org/Research/PEP)
‹ Registered Nurses’ Association of Ontario (RNAO) (http://rnao.ca/bpg)
‹ Royal College of Nursing
(http://www.rcn.org.uk/development/practice/clinicalguidelines)
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http://scholar.google.com/
http://libguides.valpo.edu/content.php?pid=42078&sid=337662
http://www.ahrq.gov/clinic/cpgsix.htm
http://www.guideline.gov/
http://ons.org/Research/PEP
http://rnao.ca/bpg
http://www.rcn.org.uk/development/practice/clinicalguidelines
Systematic Reviews and Other Synopses/Syntheses of Evidence
‹ Agency for Healthcare Research and Quality (AHRQ) EPC Evidence-Based
Reports (http://www.ahrq.gov/research/findings/evidence-
based-reports/index.html)
‹ British Medical Journal (BMJ) Clinical Evidence
(http://clinicalevidence.bmj.com/ceweb/index.jsp)
‹ PubMed Clinical Queries
(http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml)
‹ TRIP Database (http://www.tripdatabase.com/)
‹ University of York Centre for Reviews and Dissemination
(http://www.york.ac.uk/inst/crd/)
Clinical Trials
‹ ClinicalTrials.gov (http://clinicaltrials.gov/ct/gui)
‹ MedlinePlus: Clinical Trials
(http://www.nlm.nih.gov/medlineplus/clinicaltrials.html)
Other EBP Sources
‹ American Nurses Association (ANA) Evidence-Based Care Research Toolkit
(http://www.nursingworld.org/Research-Toolkit)
‹ Centre for Evidence Based Medicine (http://www.cebm.net/index.aspx?o=1023)
‹ Evidence-Based Nursing (http://ebn.bmj.com/)
‹ National Institute of Nursing Research (http://www.ninr.nih.gov/)
‹ National Quality Measures Clearinghouse (http://www.qualitymeasures.ahrq.gov/)
‹ University of Washington Health Sciences Library EBP guide
(http://libguides.hsl.washington.edu/ebp)
‹ Virginia Henderson Global Nursing e-Repository
(http://www.nursinglibrary.org/vhl/)
CRITICAL THINKING EXERCISE 4-1
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http://www.ahrq.gov/research/findings/evidence-based-reports/index.html
http://clinicalevidence.bmj.com/ceweb/index.jsp
http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
http://www.tripdatabase.com/
http://www.york.ac.uk/inst/crd/
http://ClinicalTrials.gov
http://clinicaltrials.gov/ct/gui
http://www.nlm.nih.gov/medlineplus/clinicaltrials.html
http://www.nursingworld.org/Research-Toolkit
http://www.cebm.net/index.aspx?o=1023
http://ebn.bmj.com/
http://www.ninr.nih.gov/
http://www.qualitymeasures.ahrq.gov/
http://libguides.hsl.washington.edu/ebp
http://www.nursinglibrary.org/vhl/
© Jules_Kitano/ShutterStock, Inc.
Which of the following two articles would you recommend to your unit supervisor for changing practice?
Explain why you would make this recommendation. One article contains general referrals to the foremost
authorities on the topic, and five research studies are cited. The second article contains a summative review
of research conducted by authorities in the field, various application scenarios for different institutions, and a
comprehensive reference list.
Many guides and resources that help evaluate Internet materials are available in
local libraries. Evaluating sources is not as simple as just using a checklist. As
noted previously in this chapter, Gilmour and colleagues (2008) stressed that
nurses need to be able to assist patients with their healthcare-information-seeking
behaviors. In a qualitative study, Cader (2013) identified six evaluative tasks for
nurses when evaluating WWW/Internet resources:
» Assessing user-friendliness of web pages
» Assessing the outlook of web pages
» Assessing authority of web pages
» Assessing relationship to nursing practice
» Appraising the nature of evidence
» Applying cross-checking strategies
In other words, if you discover a piece of evidence that is not confirmed in any
other sources and is never mentioned as new, foundational, or ground-breaking, the
information may be questionable. The complexity and amount of healthcare-related
information available to both professionals and patients are staggering. Nursing
professionals will do well to assess such information in a consistent and contextual
manner, much as the practice followed in patient assessment.
Formulating a Search Strategy
Creating a plan for searching by combining the suggestions offered in this chapter
about where and how to search is wise. Begin by planning the order of databases
that will be searched and the key terms that will be used. Keeping notes of the
search is recommended, especially because key terms may vary between databases
(McGrath et al., 2012). Good notes can be invaluable when there is a need to
search in another database.
Searches are rarely completed in one sitting (McGrath et al., 2012); thus
referring to notes during subsequent sessions can save time by avoiding
duplication. Time can also be used efficiently by saving the search results and
having an account for items obtained through interlibrary loan. It is also possible to
198
set up an automatic, periodic search whereby alerts are sent directly to your
account.
TEST YOUR KNOWLEDGE 4-4
Match the following:
1. Boolean operator a. ?
2. Wildcard b. Near, same, and adj
3. Stopwords c. Or, and, and not
4. Qualification d. au, ti, or su
5. Positional operator e. for, this, and to
How did you do? 1. c; 2. a; 3. e; 4. d; 5. b
4.5 Keeping It Ethical
At the end of this section, you will be able to:
‹ Consider the ethical presentation and application of evidence
The phrase “give credit where credit is due” is familiar to most individuals. Few
places more stringently apply the concept of attribution than the university setting
does. For those new to academic writing, the reference list and citing of sources
within papers are confusing and are often considered purposeless tasks imposed by
the professor. Often, the citation of references is the last thing done when deadlines
are approaching. Consequently, not much thought is given to the importance of
attributing information to appropriate sources.
Citations of sources provide acknowledgments of others’ ideas and
contributions to the subject. Ideas are owned by those individuals who first wrote
about them. For example, when you submit a paper to a professor, you have created
a piece of original work. No one else has written about the topic in quite the same
way, used the same sources in the same way, or drawn conclusions in the same
way.
It is considered plagiarism to use another’s work without giving proper credit.
Plagiarism occurs when ideas from others are used without proper documentation
(Horrom, 2012). Intentionally passing off the work of others as your own is
unethical. Unintentional plagiarism reflects poor scholarship and laziness. Either
way, plagiarism can be illegal because copyright laws may be violated (Horrom,
199
2012). A simple rule to avoid plagiarism is: If you have read it, heard it, or viewed
it and want to include it, cite it. If the thought, wording, or graphic is not your
original work, cite the source. Because plagiarism is considered a serious violation
of ethical standards, penalties can be severe. Plagiarism is easy to avoid by
providing proper citations.
plagiaris m: The use of another’s work without giving proper credit
Things get a little less clear when it comes to paraphrasing the work of others.
This is when unintentional plagiarism can occur, even by the most conscientious
students. There are examples of both direct quotes and paraphrasing in this chapter.
Paraphrasing can be identified by noting the citation for the author names and
publication dates. Depending on the sentence construction, paraphrasing either
precedes or follows those indicators. Paraphrasing can be very challenging. If you
have difficulty with this technique, use direct quotes or seek assistance from your
school’s writing center.
Using the common knowledge test can help determine whether a citation is
required. Like paraphrasing, over time you will become more comfortable with
this. As you become more knowledgeable about accepted facts in nursing, you will
be able to recognize common knowledge situations. Another simple rule is: If you
have to look it up, cite it. For example, it is common knowledge that antibiotics are
used to treat infections. But if information is presented about a new antibiotic that is
not well known, a citation would be required. It is better to err on the side of
caution and write a paper with too many citations than to accidentally plagiarize.
There are several strategies one can use to avoid plagiarism. One major way is
not to cut and paste content from the original source (Horrom, 2012). By avoiding
cut and paste, writers are more likely to put ideas into their own words. Another
way to avoid plagiarism is to ensure that all sources are cited appropriately.
Following style guidelines, such as APA (from the American Psychological
Association) or MLA (from the Modern Language Association), helps to eliminate
plagiarism. Checking your paper with plagiarism detection software is another way
to ensure that ideas are expressed in your own words.
Your authority as a writer in the discipline is increased when you give proper
credit to the work of others. Practiced professionals often skim a reference list to
see if foundational studies are included, and if not, they may disregard the paper.
By placing your original thoughts within the context of others who are already
known and respected, you are continuing the scholarly conversation from your
perspective. Given the increase in undergraduate research, your contributions could
provide a new insight that results in being cited by others.
Citation formatting is not just busywork to add stress to the task of completing a
200
paper. Just as providing the proper information in search fields increases
consistency and reliability in searching, providing citation information that is
correct and in the right format increases the reliability and ease of locating those
sources if desired. Providing the correct citation information allows your work to
serve as a conduit for those who are citation chasing.
FYI
Keeping the review of the literature ethical requires giving full credit to sources, which entails keeping
accurate citations.
TEST YOUR KNOWLEDGE 4-5
1. How can plagiarism be avoided? (Select all that apply.)
a. By using quotations with proper citations
b. By paraphrasing the work of others
c. By erring on the side of caution
d. By cutting and pasting from websites
How did you do? 1. a, b, c
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Members of the EBP committee have searched the literature and compiled a list of articles. As a committee
member, you have agreed to retrieve these articles and distribute copies to all committee members. In the
first column of the table provided here is a list of the citations. In the second column are search terms and
limiters to help you search.
Citation Search Terms (Limiters)
Anthony, K., Wiencek, C., Bauer, C., Daly, B., &
Anthony, M. K. (2010). No interruptions please. Impact of
a no interruption zone on medication safety in intensive
care units. Critical Care Nurse, 30(3), 21–29.
Anthony (author) “no
interruptions” (all fields)
201
Ausserhofer, D., Schubert, M., Desmedt, M., Blegen, M.
A., DeGeest, S., & Schwendimann, R. (2013). The
association of patient safety climate and nurse-related
organizational factors with selected patient outcomes: A
cross-sectional survey. International Journal of Nursing
Studies, 50, 240–252.
Ausserhofer (author) Schubert
(author) “safety climate” (title)
Biron, A. D., Loiselle, C. G., & Lavoie-Tremblay, M.
(2009). Work interruptions and their contribution to
medication errors: An evidence review. World Views on
Evidence-Based Nursing, 6, 70–86.
Biron (author) “evidence
review” (all fields)
Cohen, H., & Shastay, D. (2008). Getting to the root of
medication errors. Nursing, 38(12), 39–49.
Cohen (author) Shastay
(author) 2008 (publication
date)
Flanagan, J. M., Carroll, D. L., & Hamilton, G. A. (2010).
The long-term lived experience of patients with
implantable cardioverter defibrillators. MEDSURG
Nursing, 19, 113–119.
“lived experience” (title)
“implantable cardioverter
defibrillators” (title)
Flynn, L., Liang, Y., Dickson, G. L., Xie, M., & Suh, D.
(2013). Nurses’ practice environments, error interpretation
practices, and inpatient medication errors. Journal of
Nursing Scholarship, 44(2), 180–186.
Flynn (author) Liang (author)
“Journal of Nursing
Scholarship” (publication
name)
Kliger, J., Blegen, M. A., Gootee, D., & O’Neil, E.
(2009). Empowering frontline nurses: A structured
intervention enables nurses to improve medication
administration accuracy. Joint Commission Journal on
Quality and Patient Safety, 35, 604–612.
Kliger (author) Gootee (author)
Pipe, T. B., Kelly, A., LeBrun, G., Schmidt, D., Atherton,
P., & Robinson, C. (2008). A prospective descriptive
study exploring hope, spiritual well-being, and quality of
life in hospitalized patients. MEDSURG Nursing, 17, 247–
257.
Pipe (author) “hope” (all
fields) “spiritual well-being” (all
fields)
Rich, V. L. (2005). How we think about medication errors:
A model and a charge for nurses. American Journal of
Nursing, 105(3 Suppl.), 10–11.
Rich (author) “model” (title)
“American Journal of Nursing”
(publication name)
Schwappach, D. L. B., Hochreutener, M. A., & Wernli,
M. (2010). Oncology nurses’ perceptions about involving
patients in the prevention of chemotherapy administration
errors. Oncology Nursing Forum, 37, E84–E91.
Schwappach (author)
“oncology” (all fields)
“qualitative” (all fields)
202
Tomietto, M., Sartor, A., Mazzocoli, E., & Palese, A.
(2012). Paradoxical effects of a hospital-based, multi-
intervention programme aimed at reducing medication
round interruptions. Journal of Nursing Management,
20(3), 335–343.
Tomietto (all fields)
To retrieve these articles, you will need to sign into a database for nursing
literature (i.e., CINAHL, Proquest, PubMed). Once you have signed in, enter a
search term in a blank box that appears. Then, using the drop-down menu, enter the
limiter that is suggested for that search term. Here is an example from CINAHL to
show you how to enter the search terms and limiters for the first article by Anthony,
Wiencek, Bauer, Daly, and Anthony (2010).
Source: Courtesy of EBSCO Host, http://www.ebscohost.com/
When you obtain the article, it is helpful to save it as a PDF file. As you save
each article, it is wise to name the file using the name of the first author followed
by the year of publication. For example, the first article could be saved as
“Anthony (2010) .” Naming files in this manner will save you time and
frustration later when you want to find a particular article referenced in Apply
What You Have Learned. Continue this process for the remaining articles shown in
the table.
There are two other pieces of evidence that the committee wants to review.
These cannot be obtained through the databases suggested above. The citation for
203
http://www.ebscohost.com/
the first of the two pieces of evidence is:
Murphy, K. (2006, October 31). What pilots can teach hospitals about patient
safety. New York Times. Retrieved from
http://www.nytimes.com/2006/10/31/health/31safe.html?
ex=1319950800&en=a64123f3e689ea9f&ei=5088
&partner=rssnyt&emc=rss
You can obtain this article by entering the URL listed in the citation. Or you can
enter the phrase “what pilots can teach hospitals about patient safety” into a search
engine such as Google or Bing.
The second citation is as follows:
Xue, Y. (2013), Medication errors: Double checking. Joanna Briggs Institute.
Retrieved from http://ovidsp.tx.ovid.com/sp-3.10.0b/ovidweb.cgi?&
S=NJCIFPGFJODDKDEKNCNKIAOBGLKBAA00&
Link+Set=S.sh.21%7c1%7csl_190
To obtain this, you will need to access JBI through your library’s subscription.
Once at the website, you can enter the search terms “medication errors double
checking” as shown here:
Source: Courtesy of Wolters Kluwer Healh
Once you have searched for the item, it will appear at the top of the list. To obtain
the summary, click on the link “JBI Database PDF.” The summary will open in full-
text mode.
204
http://www.nytimes.com/2006/10/31/health/31safe.html?ex=1319950800&en=a64123f3e689ea9f&ei=5088&partner=rssnyt&emc=rss
http://ovidsp.tx.ovid.com/sp-3.10.0b/ovidweb.cgi?&S=NJCIFPGFJODDKDEKNCNKIAOBGLKBAA00&Link+Set=S.sh.21%7c1%7csl_190
The next task is to read and analyze each piece of evidence. The committee has
decided to use a grid to organize and summarize the evidence so that the
information is presented in a consistent and succinct format. This is helpful because
trends can easily be identified and gaps in the knowledge base are made apparent.
Organizing the review with a grid is a positive strategy to overcome the barrier of
lack of time because it reduces the need to repeatedly sort through articles during
future discussions. Also, within this text’s digital resources, you will find a grid to
use for this exercise. Two articles (Cohen & Shastay, 2008; Tomietto, Sartor,
Mazzocoli, & Palese, 2012) are summarized as an example.
Read Kliger, Blegen, Gootee, and O’Neil (2009). Enter information about this
article into the first two columns. In column 1, use APA format, like in the example,
because this is the most commonly used style for nursing publications.
RAPID REVIEW
» Today’s work environment requires that nurses be adept at gathering and
appraising evidence for clinical practice and assisting patients with healthcare
information needs.
» Literature reviews provide syntheses of current research and scholarly literature.
A well-done literature review can provide support for EBP.
» An understanding of the scientific literature publication cycle provides a basis for
making decisions about the most current information on a topic.
» Primary sources are original sources of information presented by the people who
created them. Secondary sources are resulting commentaries, summaries,
reviews, or interpretations of primary sources.
» Many research journals involve peer review.
» There are many ways to categorize sources. Scholarly, trade, and popular
literature is one way. Another categorizing system involves periodicals,
journals, and magazines.
» There are four types of review: narrative, integrative, meta-analysis, and
systematic.
» Understanding how sources are structured can simplify a search of the literature.
» Sources can be identified through both print indexes and electronic databases.
Topics, subject matter, and format may vary but all include citation information.
» Helpful strategies to use when conducting a search include citation chasing,
measurements of recall and precision, keyword and controlled vocabulary
205
searches, Boolean operators, truncation, wildcards, nesting, limits, stopwords,
exploding, qualification, and positional operators.
» Databases can be either general content sources or subject-specific content
sources. CINAHL is nursing’s premier subject-specific database.
» By interacting with professional literature through writing, creating literature
reviews, and conducting research, nurses are part of the scholarly conversation
taking place within their discipline. Correct attribution of others’ original work,
as well as proper construction of citations, demonstrates the ethical sense of
responsibility and professionalism.
REFERENCES
Burt, H. A. (2013). The patient safety perspective: Health information and resources online and in print.
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Cader, R. (2013). Judging nursing information on the World Wide Web. Computers, Informatics, Nursing,
31(2), 66–73.
Christie, J., Hamill, C., & Power, J. (2012). How can we maximize nursing students’ learning about research
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Cleary, M., Hunt, G. E., & Horsfall, J. (2009). Conducting efficient literature searches: Strategies for mental
health nurses. Journal of Psychosocial Nursing and Mental Health Services, 47(11), 34–41.
Cohen, H., & Shastay, D. (2008). Getting to the root of medication errors. Nursing, 38(12), 39–49.
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http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/meta-an
Dunn, K., Brewer, K., Marshall, J., & Sollenberger, J. (2009). Measuring the value and impact of health sciences
libraries: Planning an update and replication of the Rochester study. Journal of the Medical Library
Association, 97(4), 308–312.
Evans, D., & Kowanko, I. (2000). Literature reviews: Evolution of a research methodology. Australian Journal
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CHAPTER 5
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Linking Theory, Research, and
Practice
Elsabeth Jensen
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Define the terms theory and research as they relate to the practice of nursing
‹ Distinguish between conceptual and empirical definitions
‹ Describe how theory and research influence each other in a professional
discipline
‹ Apply the language of the discipline in describing the relevance of linking
theory, research, and practice in nursing
‹ Discuss how honoring prior work ethically builds nursing knowledge
KEY TERMS
concepts
conceptual definitions
construct
empirical indicators
metaparadigm
model
operational definitions
proposition
theoretical framework
theory
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5.1 How Are Theory, Research, and
Practice Related?
At the end of this section, you will be able to:
‹ Define the terms theory and research as they relate to the practice of nursing
‹ Distinguish between conceptual and empirical definitions
‹ Describe how theory and research influence each other in a professional
discipline
‹ Apply the language of the discipline in describing the relevance of linking
theory, research, and practice in nursing
“The bringing together or nexus of nursing theory, practice and research creates a
true integration of knowledge designed to support the service to clients and the
health of society” (Butcher, 2006, p. 112). In the profession of nursing, theories and
research provide an essential foundation for practice and exist to serve the goals of
practice. At the same time, practice is the source of the questions to be addressed
by research. The relationships between theory, research, and practice are
reciprocal in that each informs the other in the development of disciplinary
knowledge. Practice is also the testing ground for theory, where only those theories
found helpful to practice survive and evolve. Practice is also a source for new
theories. In the same way, the disciplinary knowledge that is nursing knowledge is
also dynamic and evolving. As students prepare for practice as nurses, it is easy for
them to believe that what is being learned is sound and should never be questioned.
Learning to ask good questions and developing a critical mind are essential. A
curious mind is invaluable in the pursuit of providing the best nursing service
possible.
Knowledge is not static, but rather it develops out of asking questions and
seeking answers. Learning to ask good questions is as essential as learning how to
find good answers.
FYI
Knowledge is not static, but rather it develops out of asking questions and seeking answers. Learning to ask
good questions is as essential as learning how to find good answers.
Understanding Theory, Research, and Practice from a
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Practice Perspective
There are terms applicable when discussing theory, research, and practice.
Understanding these terms allows nurses to communicate ideas effectively with
other members of the healthcare team to develop an evidence-based practice.
The Special Language of Theory
A theory is a set of concepts linked through propositions to provide an explanation
of a phenomenon. Nursing theories are belief systems that guide practice (Parse,
2006). Theory provides the lens through which nurses view clients. In any
discipline there is usually one model that defines it at any point in time (Butcher,
2006). Currently in nursing, the concepts of person, environment, health, and
nursing are the focus of the development of disciplinary knowledge (Fawcett, 1984;
Graham, 2003). These four concepts have been present from the time of Nightingale
(1859/1969). Nurses have many formal nursing theories available from which to
choose. Although it is beyond the scope of this chapter to describe them, it is
important for students and nurses to study them because they represent the many
ways that nursing practice can be approached.
the ory: A set of concepts linked through propositions to explain a phenomenon
Using theory in practice provides a framework to nurses as they assess and
provide care. The study of theory introduces a new language that is specific to
nursing. Fawcett and Downs (1992) are considered to be authorities on the study of
theory and research. As mentioned earlier, the concepts that are core to nursing are
person, environment, health, and nursing. These are known as the metaparadigm of
nursing. The concepts are very broad, and each nursing theory provides definitions
for how they are used in that model. Concepts are the words or phrases that convey
a unique idea or mental image that is relevant to the theory. For example, Hildegard
Peplau (1952) defined health as the forward movement of personality, whereas
Martha Rogers (1970) defined health as being what the person says it is, that is to
say, individuals define health for themselves, and nurses need to know what that
definition is for each person. As another example, Nightingale defined environment
as everything outside the person, whereas Rogers defined environment as being
integral with the person. These are different views and lead to some differences in
the focus of practice of nurses guided by each of these theories.
me taparadigm: Four broad concepts core to nursing: person, environment, health, and nursing
conce pts : Words or phrases that convey a unique idea that is relevant to a theory
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CRITICAL THINKING EXERCISE 5-1
© Jules_Kitano/ShutterStock, Inc.
In your nursing program, how are the concepts of the metaparadigm defined? Is there a model or theory that
is used?
Concepts are individual building blocks joined together in statements to create
propositions. A proposition is a statement about the relationship between two or
more concepts. For example, Nightingale (1859/1969) linked a concept from the
environment, sunlight, to the concept of health when she wrote:
propos ition: A statement about the relationship between two or more concepts
It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is
their need of light … not only light, but direct sunlight they want…. People think the effect is upon the
spirits only…. we must admit that light has quite as real and tangible effects upon the human body. (p.
84)
Nightingale’s proposition is that exposure to sunlight promotes healing and
recovery in the person. Knowing this, nurses will expose people to sunlight to
promote health.
Another important word in the language of theory is construct. A construct is a
property that is neither directly nor indirectly observed. It is a word or phrase to
communicate a specific, key idea to others. One example of a construct is social
support. Social support cannot actually be seen, but it can be inferred through
assessment of other observable attributes. To assess social support, nurses could
count the number of people in a patient’s circle of family and friends or could ask
patients about their perceptions of the support they receive.
cons truct: A word or phrase used to communicate a specific key idea to others
The Importance of Testing Theory
Nurses look to research to develop and test ideas that may be useful and also look
to researchers to address practice questions for which there are no answers.
Nursing researchers are responsible for developing and testing knowledge to guide
nursing practice (Butcher, 2006). There are important distinctions to note in order
to understand what is and what is not nursing research. Nursing research is research
that provides results that are relevant for practice, either at the level of basic
research or at the level of applied research. Some researchers claim their work is
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nursing research because the researcher is a nurse or because the researcher
studied nurses. But it is the focus on nursing practice that defines nursing research.
The mere fact that the research was conducted by a nurse or that nurses were
studied does not necessarily qualify the research as nursing research. Historically,
and even today, approaches to practice are often based on “professional opinion”
when research is absent. Case Example 5-1 provides such a historical illustration.
It also demonstrates the value of systematically studying the effects of interventions.
CASE EXAMPLE 5-1
Early Me thods of Re s us citation: An Example of Practice Bas e d on Unte s te d The ory
Throughout the past century, nursing students have been taught how to resuscitate patients who stop
breathing. As early as 1912, students were taught a variety of methods for providing artificial respiration. It
was theorized that moving air in and out of the lungs would be effective. One of these techniques was
designed for resuscitating infants. Byrd‘s Method of Infant Resuscitation (Goodnow, 1919) directed the
nurse to hold the infant‘s legs in one hand, and the head and back in the other. The nurse would then double
the child over by pressing the head and the knees against the chest. Then the nurse would extend the knees
to undouble the child. This would be repeated, but “not too rapidly” (Goodnow, 1919, p. 305). At intervals,
the nurse would dip the child into a mustard bath in the hope that this would also stimulate respiration. The
nurse would continue this until help arrived.
Other methods of artificial respiration taught included Sylvester‘s method for adults (Goodnow, 1919). The
patient was placed flat on his back. The nurse would grasp the patient‘s elbows and press them close to his
sides, pushing in the ribs to expel air from the chest. The arms would then be slowly pulled over the head,
allowing the chest to expand. The arms would be lowered to put pressure on the chest, and the cycle was
then repeated. This was to be done at the rate of 18 to 20 cycles per minute.
By 1939, postmortem examinations after unsuccessful resuscitations showed veins to be engorged while the
arteries were empty (Harmer & Henderson, 1942). Although this evidence indicated other factors needed to
be considered, resuscitation techniques continued to focus only on the respiratory system. The same
methods of resuscitation that were in use in 1919 were still being taught in 1942. Although students were still
being taught the Sylvester method, they were also learning the new “Schäfer method” (Harmer &
Henderson, 1942, p. 9401). This method involved placing the patient in a prone position. The nurse would
straddle the thighs, facing the patient‘s head, and alternatively apply and remove pressure to the thorax.
Eventually, it was noted that what was believed to be best practice was not effective. Results of postmortem
examinations indicated that something was missing in the techniques, and therefore research was begun to
determine best practice. Today, nursing students are taught cardiopulmonary resuscitation techniques based
on updated research and theories.
This case example clearly illustrates how knowledge changes over time and
how ineffective practices are replaced with innovations. What is considered to be
state-of-the-art practice at one time is replaced when new knowledge based on
evidence emerges. Understanding the cycle of science compels nurses to continue
learning throughout their careers to avoid becoming laggards. This case also
underscores the importance of ordinary observations in the field of practice. In this
case example, postmortem observations pointed to the need for another, sounder
approach to resuscitation. This case also illustrates how slowly innovations are
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adopted, even with evidence that a current practice is unsound.
Another area of nursing that has seen many changes over time is wound care.
Daunton, Kothari, Smith, and Steele (2012) reviewed the approaches to wound
care from 2500 BC to the present. One can see that some old approaches may have
been on the right track, such as ancient Egyptians putting moldy bread into a wound
(we now know bread mold can be a source of penicillin). Other approaches, such
as the use of dry gauze, also have long roots but are now falling out of favor. For
example, removal of dry gauze from the wound damages the tissue, slowing
healing; the move is now toward use of newer products and less frequent dressing
changes. Kohr (2001) demonstrated both effectiveness in practice and efficiency in
cost reductions in the use of these new approaches in a practice setting.
FYI
Nursing research provides results that are relevant to and expand or enhance practice. For research to be
considered nursing research, the focus is on nursing practice rather than that the research happens to be
conducted by a nurse.
The Special Language of Research
It is important to understand the special language associated with research (Fawcett
& Downs, 1992). Research can be either deductive or inductive. It can be
quantitative, qualitative, or a combination of both approaches. Regardless of the
approach used, theory provides a framework for the design.
Deductive research typically involves quantitative designs and begins by
deriving testable ideas from theories (Case Example 5-2). Reports of deductive
research describe the theoretical assumptions used to guide the study in the
introduction section. Reports also include a critical review of previous research
that both supports and refutes aspects of the theory. Because theories are abstract in
nature, there is a language of research that corresponds to the language of theory.
Unlike terms associated with theory, the language of research refers to the
empirical, or that which can be observed.
Researchers cannot measure concepts; however, they can measure variables. A
variable is an observation that can be measured by assigning a number to each
dimension. For example, a researcher may choose to study the abstract concept of
health by measuring the empirical variable of number of acquired upper respiratory
infections per year. A hypothesis is a special type of proposition that can be tested
empirically. There should be a theoretical basis for hypotheses. For example, to
test Nightingale’s (1859/1969) observations, a nurse may wish to test the
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relationship between exposure to sunlight and number of acquired upper respiratory
infections per year in people receiving nursing care. The stated hypothesis could be
that there is a relationship between exposure to sunlight and the number of acquired
upper respiratory infections per year. The researcher would statistically test the
null hypothesis that exposure to sunlight does not affect the acquisition of upper
respiratory infections.
CASE EXAMPLE 5-2
Nightingale ‘s Work to Re duce De ath Rate s During War: An Example of The ory and De ductive
Re s e arch
Nightingale theorized that five factors were essential for promoting health: pure or fresh air, pure water,
efficient drainage, cleanliness, and light—especially direct sunlight (Nightingale, 1859/1969). Through the
application of her theory about what was required for the sick to recover, the death rate at Barrack Hospital
during the Crimean War dropped from 42% to 2.2% in the first 6 months after her arrival. Nightingale was
able to document this through the use of statistics (Strachey, 1918). Through careful collection and tracking
of data, she was able to confirm that nursing interventions based on her theory were effective. Nightingale
remains the first known quantitative researcher in nursing. Her work is an excellent example of developing
theory, applying theory to practice, and finding support and validation through systematic research.
Statistical methods are such that a hypothesis, and by extension, a theory, is
never proved. Hypotheses can only be supported. A theory holds only until
evidence comes forward to refute it (Johnson, 1983). This is a hard concept for
students to grasp because the logic of building knowledge by rejecting opposite
ideas seems backward. This is one reason why research can be slow and
painstaking.
Using deduction, researchers formulate hypotheses based on clear definitions of
concepts and variables. Often, formulating hypotheses coincides with stating
definitions. There are two kinds of definitions: conceptual and operational.
Conceptual definitions are the definitions of concepts contained in the theory that
is being used. These definitions sound like those found in dictionaries. Operational
definitions are definitions that explicitly state how the variable will be measured
or operationalized. For example, using Nightingale’s theory (1859/1969), the
conceptual definition of health would be the absence of disease. A researcher could
operationalize health as the number of self-reported upper respiratory infections
per year. Environment was defined as everything outside the person (Nightingale,
1859/1969); this is the conceptual definition. The number of hours a person is in the
light of the sun is an operational definition of environment. Defining concepts and
variables allows researchers to collect quantitative data and apply statistics to
learn about the phenomenon of interest.
conce ptual de finitions : Definitions of concepts contained in a theory that sound like dictionary definitions
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ope rational de finitions : Definitions that explicitly state how the variable will be measured or operationalized;
empirical definitions
Operational definitions can vary across studies because there are many
different ways to measure any given concept. In the example, exposure to sunlight
could also be measured using an instrument that would provide a value for the
intensity of sunlight over a period of time. The researcher would need to decide
whether exposure to sunlight through a glass window is appropriate or whether
exposure needs to be unobstructed by glass. The instruments used to measure the
amount of time exposed to sunlight and the method of recording the number of self-
reported acquired upper respiratory infections would be considered the empirical
indicators of the variables being studied.
e mpirical indicators : Measures of the variables being studied
When researchers formulate their plans of research, they use theories to create
theoretical frameworks. A theoretical framework provides the structure for the
study by linking the abstract to the empirical. Sometimes researchers depict their
frameworks using a model, which is essentially a pictorial representation of the
concepts and their interrelationships.
the ore tical frame work: The structure of a study that links the theory concepts to the study variables; a section
of a research article that describes the theory used
mode l: Pictorial representation of concepts and their interrelationships
Inductive research is used to develop theory and is usually qualitative.
Researchers typically begin data collection before reading the literature to avoid
biasing the data collection process. When reporting inductive research, authors use
quotations to highlight key points of the theory that has emerged. An example of
how a theory can be developed inductively using one particular qualitative method
follows (Case Example 5-3).
CASE EXAMPLE 5-3
Unde rs tanding and He lping De pre s s e d Wome n: An Example of The ory and Inductive Re s e arch
Schreiber, a clinical nurse specialist, noticed that twice as many women as men suffered from depression.
She found little in the way of nursing research that could help her care for these women. In order to better
understand the recovery process for these women, she used a grounded theory approach (Glaser & Strauss,
1969) to guide her work (Schreiber, 1996). A sample of 21 women who had recovered from depression was
interviewed for the study. Schreiber identified that women need to tell their story, and “seek understanding,”
in order to proceed to the stage of “cluing in,” which is a stage of recovery. By identifying stages of
recovery and formulating a theory about the process of recovery, specific nursing interventions were able to
be identified. For example, implications for nursing practice include recognizing the importance of facilitating
women telling their stories.
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There are also researchers who use both qualitative and quantitative methods in
the same study. Studies can also have both deductive and inductive elements. The
development of the transitional discharge model in mental health is an example of
this mixing of methods and approaches (Forchuk & Brown, 1989; Forchuk, Chan, et
al., 1998; Forchuk, Jewell, Schofield, Sircelj, & Valledor, 1998; Forchuk, Martin,
Chan, & Jensen, 2005).
Case Example 5-4 illustrates how researchers might use multiple approaches
when addressing clinical questions. It also demonstrates that it takes more than one
study to build knowledge. Work replicated in Scotland with similar positive results
(Reynolds et al., 2004) lends further support to the transitional discharge model for
mental health.
CASE EXAMPLE 5-4
A Transitional Discharge Model for Mental Health: An Example of Theory
and Research Using Mixed Methods
As an advanced practice nurse in a tertiary care mental health setting, Forchuk noted that more clients
left the unit because of death than by discharge. Those who had been discharged were often readmitted
within a month of leaving the hospital. Her challenge was to find a way to help discharged clients return to
the community and successfully remain there. She worked systematically with staff, clients, family
members, and former clients in the community to discover what interventions might be helpful. From these
efforts, it became clear that patients were discharged to an environment where all of their relationships were
within a community in which they felt alone and isolated. This conclusion was reached inductively.
Because no nursing theory could be found to effectively explain the observations, Forchuk began developing
a model to explain successful discharge of mental health clients. The model combined continuing staff
support from professionals who had established therapeutic relationships with the clients with peer support
from former users of mental health services who had successfully transitioned to the community.
Professionals continued interactions with clients until the clients established a working relationship with the
community. The model was piloted and the results were impressive (Forchuk & Brown, 1989). All nine
clients discharged during the study year were successful in their return to the community, reducing the cost
of their care (Forchuk, Chan, et al., 1998; Forchuk, Jewell, et al., 1998; Schofield et al., 1997). Both
quantitative and qualitative measures were used to collect data. As a result of the pilot, funding for a large
clinical trial to test the model in an experimental study was obtained (Forchuk et al., 2005).
Theory in Practice
The American Nurses Association (ANA) has defined the practice of nursing as the
“protection, promotion, and optimization of health and abilities, prevention of
illness, injury, alleviation of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, communities, and
populations” (ANA, 2003, p. 6). From the early days of the profession, students
217
have been taught that a scientific attitude and method of work combined with
“experience, trained senses, a mind trained to think, and the necessary
characteristics of patience, accuracy, open-mindedness, truthfulness, persistence,
and industry” (Harmer, 1933, p. 47) are essential components of good practice.
Harmer goes on to say, “Each time this habit of looking, listening, feeling, or
thinking is repeated it is strengthened until the habit of observation is firmly
established” (p. 47). This still holds true today. Benner (1984) studied nurses in
practice and concluded that to become an expert nurse one has to practice nursing a
minimum of 5 years. There are no shortcuts to becoming an expert in one’s field.
The development of knowledge and skill takes time and work. As nurses encounter
new situations, learning takes place. Nursing knowledge develops and is refined as
nurses practice (Waterman, Webb, & Williams, 1995). In this way, nurses adapt
theories to fit their practices. Unfortunately, much that is learned about theory
during practice remains with the nurse because nurses rarely share their practice
expertise through conference presentations and publications. The discipline will be
enriched when nurses engage more formally in disseminating their knowledge about
theory in practice.
CRITICAL THINKING EXERCISE 5-2
© Jules_Kitano/ShutterStock, Inc.
A nurse on a surgical floor observes that several new approaches are being used to dress wounds. She
observes that some methods appear to promote healing faster than others do. While reviewing the research
literature, she is unable to locate any research about the dressings she is using. How might she go about
testing her theory that some methods are better than others? Can this be done deductively, inductively, or
using mixed methods? Are any theories presently available related to wound healing, and if so, where might
she locate these? What concepts might be important in forming the question?
The Relationships Among Theory, Research, and
Practice
Practice relies on research and theory and also provides the questions that require
more work by theorists and researchers. Each informs and supports the other in the
application and development of nursing knowledge. When the relationships among
theory, research, and practice are in harmony, the discipline is best served,
ultimately resulting in better patient outcomes (Maas, 2006). The relationships are
dynamic and flow in all directions. Practice informs and is informed by theory
development as well as research. Research and theory development inform and are
informed by each other (see Figure 5-1). Inclusion of practitioner perspectives,
experiences, and insights in education helps students to understand how theory and
218
research are applied to practice and informed by it (Chan, Chan, & Liu, 2012).
FIGURE 5-1 The Relationships of Theory, Research, and
Practice
The literature continues to reflect that in the nursing profession there is tension
about the relationships among theory, research, and practice (McCrae, 2012). Too
often theorists, researchers, and nurses work in isolation from each other. Some see
research as serving to develop theory that should then drive practice (Mitchell,
1997), while others see theory as driving research that should then drive practice
(Billings & Kowalski, 2006). Still others see practice as informing and being
informed by research and theory (Schmelzer, 2006). As Butcher (2006) pointed out,
practicing nurses focus on unique individuals, researchers focus on systematically
collecting knowledge about samples and populations, and theorists focus on
abstract and general concepts and their interrelationships. Understanding the
different perspectives of each of these groups in knowledge building shows their
activities to be complementary.
At a micro level, each nurse engages in research and theory development. For
example, each patient encounter can be considered a study with one subject.
Assessment can serve as data collection involving both quantitative and qualitative
data, and the plan of care emerges from the analysis. The result is a theory of what
will work for this person. The theory is tested as care is delivered, and if positive
outcomes are achieved, the theory is validated. If outcomes are not positive, the
theory is refuted and a new theory is created, resulting in a revised plan of care.
Learning from each patient encounter is applied to new encounters. Case by case,
the nurse learns about both the unique and universal characteristics of individuals.
CRITICAL THINKING EXERCISE 5-3
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© Jules_Kitano/ShutterStock, Inc.
Reflect on your most recent patient encounter. When you assessed your patient, what theoretical
assumptions guided your data collection? Were there questions you had about nursing needs or health
circumstance that puzzled you? How did you go about addressing these questions? How might you go about
that in the future? Who might you involve in addressing questions? What did you do that worked when
providing care for this patient? Would you use the approach with another patient? Why or why not?
Researchers engage in a similar process, but from a different perspective.
Nursing researchers systematically study individuals in groups, or in samples
representing larger populations, to uncover knowledge about universal
characteristics of individuals as these apply to people’s health. Knowledge from
research assists nurses to choose interventions that have a known probability of
success. Although research findings help nurses predict what will be successful for
the majority of individuals, outcomes cannot be predicted for an individual. When
an individual does not respond like the majority of people does, a nurse will rely
more on clinical judgment and patient preferences.
Like researchers, theorists also work at a macro level building knowledge that
can be universally applied. Theory provides understanding and guidance to the
practice of nursing. It also provides language for describing nursing’s work.
It is clear from the debate in the literature that nurses, researchers, and theorists
can work more closely together and that such partnerships will be very fruitful for
the development of nursing knowledge. Schmelzer (2006) encouraged nurses to
collaborate with researchers to find answers for practice problems. Waterman and
associates (1995) also supported closer working relationships among nurses,
researchers, and theorists. It is quite reasonable for nurses to be members of formal
research teams as content experts. Another way to increase collaboration is for
more researchers and theorists to engage in practice.
TEST YOUR KNOWLEDGE 5-1
Fill in the blanks:
1. A concept at the abstract level is comparable to a ________________ at the operational level.
2. A ________________ at the abstract level is comparable to a hypothesis at the operational
level.
3. Quantitative research typically ________________ theory, whereas qualitative research
typically ________________ theory.
True/False
4. Theory, research, and practice should be developed in isolation.
5. Nurses are encouraged to collaborate with researchers and theorists to expand nursing
knowledge.
6. Concepts of the metaparadigm of nursing include nursing, health, disease, social interaction, and
persons.
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How did you do? 1. variable; 2. proposition; 3. tests, builds; 4. F; 5. T; 6. F
5.2 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss how honoring prior work ethically builds nursing knowledge
FYI
Credit must be given for ideas built on earlier work as well as for new ideas generated by challenging old
ideas.
Students of any discipline are taught the body of knowledge that has been built over
time, including the origins of the ideas that comprise that body of knowledge. As
individuals contribute to the body of knowledge, credit should be given to those on
whose work they are building.
Knowledge in a discipline is built in small steps that in time mark a long and
fruitful journey of discovery. When reading the works of nurses, researchers, and
theorists, students of the discipline should be able to trace the evolution of ideas.
Credit must be given for ideas built on earlier work as well as for new ideas
generated by challenging old ideas. This trail can be followed by examining
references and reading the work of those who made earlier contributions. Sadly,
nurses have been poor at leaving such a trail. Few theorists cite the nurses who
influenced their thinking. For example, Peplau (1952) gives credit to Adler, a
psychologist, for influencing her thinking, but she makes no mention of nurses who
may have influenced her despite the fact that she published for nurses practicing in
mental health areas. Likewise, Rogers (1970) does not credit the sources of her
nursing knowledge even though she published a model for nurses in all settings. In
other cases, an author may state that an idea came from another individual but does
not provide a reference, or an author may use a secondary source for a quotation
when a primary source is available. Failure to honor the work of others creates
problems for nurses trying to understand the evolution of nursing knowledge and
practice.
Here is a very good example of how the knowledge train can get derailed.
McCrae (2012) credited Virginia Henderson as publishing the first definition of
nursing as “to attend to the functional needs of patients.” McCrae sited the 1955
version of the text Henderson coauthored with Bertha Harmer. However, the credit
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for this definition really should go to Harmer. Harmer had first published this
definition as a sole author in 1925 and had clearly linked her work to Nightingale’s
work.
Nursing is rooted in the needs of humanity and is founded on the ideal of service. Its object is not only to
cure the sick and heal the wounded but to bring health and ease, rest and comfort to mind and body, to
shelter, nourish, and protect and to minister to all those who are helpless or handicapped, young, aged or
immature. Its object is to prevent disease and to preserve health. (Harmer, 1925, p. 3)
Not until 1942 when Harmer brought in Henderson to take over her work was
Henderson associated with this definition (Harmer & Henderson, 1942). A much
later edition by these two authors from 1955 is where McCrae in 2012 obtained her
citation. This example shows the importance of following the knowledge trail with
curiosity and diligence in order to truly understand the foundations of current
nursing knowledge. Honoring the work of earlier nurses honors the profession
itself, and all who are part of it.
When studying the writings of nurses who are contributors to disciplinary
knowledge, it is important to look for the foundation of their ideas. Where
information about these ideas is lacking, nurses should critically appraise claims
that the work is a legitimate part of the disciplinary knowledge of nursing. To write
as a contributor to the disciplinary body of knowledge without giving proper credit
to those who provided the basis for the ideas is not just poor or dishonest practice
but is unethical and, in fact, plagiarism.
FYI
To write as a contributor to the disciplinary body of knowledge without giving credit to those who provided
the basis for the ideas is not just poor practice but is unethical and, in fact, plagiarism.
TEST YOUR KNOWLEDGE 5-2
True/False
1. In the discipline of nursing, it is easy to follow how knowledge has developed because theorists
have carefully provided citations for their ideas.
2. Giving credit to those who provide the basis for ideas is ethical practice.
How did you do? 1. F; 2. T
RAPID REVIEW
» Theories are sets of concepts linked by propositions that explain phenomena.
They provide a belief system to guide practice.
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» Concepts are words or phrases conveying unique ideas or mental images. They
are the building blocks of theories.
» The metaparadigm of nursing has four concepts: person, health, environment, and
nursing.
» Propositions are statements describing relationships between two or more
concepts.
» Constructs are properties that are inferred because they cannot be directly
observed.
» Variables describe how concepts will be measured at the empirical level, and
hypotheses are propositions that can be tested empirically.
» Concepts, propositions, variables, and hypotheses form theoretical frameworks
that provide structure for research studies. Models are pictorial representations
of theoretical frameworks.
» Conceptual definitions are like definitions found in dictionaries and are abstract
in nature. Operational definitions specify how variables will be measured.
Empirical indicators are the instruments used to measure variables.
» Deductive quantitative research is typically used to test theory, whereas inductive
qualitative research can be used to build theory. Mixed methods can also
contribute to the development of theory.
» In practice, nursing knowledge is developed and refined through patient
encounters.
» The relationships of theory, research, and practice are dynamic and
complementary.
» In practice, nurses learn about unique and universal characteristics of individuals.
Researchers use systematic study to discover knowledge about universal
characteristics of people. Theorists build knowledge that can be universally
applied.
» The ethical practice of honoring the work of others creates a trail whereby nurses
can follow the building of nursing knowledge.
APPLY WHAT YOU HAVE LEARNED
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© Lisovskaya Natalia/ShutterStock, Inc.
An evidence-based practice committee member tells you she has found an article (Rich, 2005) that uses a
theoretical framework. She is excited about this and would like the committee to consider how this model
might be useful to its work. As the chairperson, you are responsible for facilitating discussion. To prepare,
you read the article and consider how this model could be used as a framework for designing interventions
that reduce medication errors. Be sure to enter information about this article into the first and second
columns of your grid within this text‘s digital resources.
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of Continuing Education in Nursing, 37, 248–249.
Butcher, H. (2006). Integrating nursing theory, nursing research, and nursing practice. In P. S. Cowen & S.
Moorhead (Eds.), Current issues in nursing (pp. 112–122). St. Louis, MO: Mosby.
Chan, E. A., Chan, K., & Liu, Y. W. J. (2012). A triadic interplay between academics, practitioners and students
in the nursing theory and practice dialectic. Journal of Advanced Nursing, 68(5), 1038–1049.
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management. Wound Practice and Research, 20(4), 174–186.
Fawcett, J. (1984). The metaparadigm of nursing: Current status and future refinements. Image: Journal of
Nursing Scholarship, 16, 84–87.
Fawcett, J., & Downs, F. S. (1992). The relationship of theory and research (2nd ed.). Philadelphia, PA:
Davis.
Forchuk, C., & Brown, B. (1989). Establishing a nurse–client relationship. Journal of Psychosocial Nursing,
27(2), 30–34.
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discharge process. Canadian Nurse, 94(3), 22–26.
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therapeutic relationships. Journal of Psychiatric and Mental Health Nursing, 5, 197–202.
Forchuk, C., Martin, M. L., Chan, Y. L., & Jensen, E. (2005). Therapeutic relationships: From psychiatric
hospital to community. Journal of Psychiatric and Mental Health Nursing, 12, 556–564.
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Graham, I. W. (2003). The relationship of nursing theory to practice and research within the British context:
Identifying a way forward. Nursing Science Quarterly, 16, 346–350.
Harmer, B. (1925). Textbook of the principles and practice of nursing. New York, NY: Macmillan.
Harmer, B. (1933). Textbook of the principles and practice of nursing (2nd ed.). New York, NY: Macmillan.
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Harmer, B., & Henderson, V. (1942). Textbook of the principles and practice of nursing (4th ed.). New
York, NY: Macmillan.
Johnson, M. (1983). Some aspects of the relation between theory and research in nursing. Journal of
Advanced Nursing, 8(1), 21–28.
Kohr, R. (2001). Moist healing versus wet-to-dry [Standard protocol for chronic wounds]. Canadian Nurse,
97(1), 17–19.
Maas, M. L. (2006). What is nursing, and why do we ask? In P. S. Cowen & S. Moorhead (Eds.), Current
issues in nursing (pp. 5–10). St. Louis, MO: Mosby.
McCrae, N. (2012). Whither nursing models? The value of nursing theory in the context of evidence-based
practice and multidisciplinary health care. Journal of Advanced Nursing, 68(1), 222–229.
Mitchell, G. J. (1997). Questioning evidence-based practice for nursing. Nursing Science Quarterly, 10, 154–
155.
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published 1859)
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discharge model for psychiatric patients. Journal of Psychiatric and Mental Health Nursing, 11, 82–88.
Rich, V. L. (2005). How we think about medication errors: A model and a charge for nurses. American Journal
of Nursing, 105(3 Suppl.), 10–11.
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Schmelzer, M. (2006). Personal reflections about the theory–research–practice connection. Gastroenterology
Nursing, 29, 489–491.
Schofield, R., Valledor, T., Sircelj, M., Forchuk, C., Jewell, J., & Woodcox, V. (1997). Evaluation of bridging
institution and housing—a joint consumer care provider initiative. Journal of Psychosocial Nursing, 35, 9–
14.
Schreiber, R. (1996). Understanding and helping depressed women. Archives of Psychiatric Nursing, 10, 165–
175.
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Waterman, H., Webb, C., & Williams, A. (1995). Parallels and contradictions in the theory and practice of action
research and nursing. Journal of Advanced Nursing, 22, 779–784.
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Persuasion
UNIT 3
Persuasion is the art of using facts to
promote change.
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CHAPTER 6
Key Principles of Quantitative Designs
Rosalind M. Peters
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Explain the relationships among the study purpose, literature review, research
questions or hypotheses, study framework, and the study design
‹ Define key concepts relevant to quantitative research designs including
experimental, nonexperimental, causality, probability, control, manipulation,
bias, randomization, between-subjects, within-subjects, and study validity
‹ List elements to be considered when appraising quantitative designs
‹ Define the two types of validity
‹ Describe seven threats to internal validity
‹ Describe five threats to external validity
‹ Identify strategies used to reduce threats to internal and external validity
‹ Differentiate the time dimension of data collection across retrospective, cross-
sectional, and longitudinal and prospective designs
‹ Discuss ethical issues related to internal and external validity
KEY TERMS
attrition rate
between-groups design
bias
case-control
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causality
cohort comparison
construct validity
control
crossover designs
cross-sectional
double-blind experimental designs
effects of selection
ex post facto
external validity
extraneous variables
follow-up
Hawthorne effect
history
instrumentation
interaction of treatment and history
interaction of treatment and setting
interaction of treatment with selection of subjects
internal validity
longitudinal designs
manipulation
maturation
mortality
panel designs
probability
prospective designs
random assignment
random sampling
randomization
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reactivity
retrospective designs
selection bias
statistical conclusion validity
study validity
testing
trend
type II error
within-groups design
6.1 Chart the Course: Selecting the Best
Design
At the end of the section, you will be able to:
‹ Explain the relationships among the study purpose, literature review, research
questions or hypotheses, study framework, and the study design
‹ Define key concepts relevant to quantitative research designs including
experimental, nonexperimental, causality, probability, control, manipulation,
bias, randomization, between-subjects, within-subjects, and study validity
‹ List elements to be considered when appraising quantitative designs
You will see the term research design used two different ways. Many people use
the term broadly to encompass multiple aspects of the research process including
the sampling plan, data collection procedures, implementation strategies, and data
analysis. In this context, the broad use of the term implies the overall method of the
research study. Another way the term can be used is to refer to the specific plan or
blueprint that will be used to meet the stated purpose of the study. When you
evaluate the appropriateness of the research design, it is important to realize that
the design is not developed in a vacuum. Instead, it should reflect an integration of
the theoretical and empirical literature that was presented in the review of the
literature section of the study. This section usually ends by identifying a gap in
current knowledge about the phenomenon of interest. The purpose of the proposed
study should be to fill some portion of that gap in knowledge with the research
questions or hypotheses determining what specific new knowledge will be
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generated. The research design should flow from the stated purpose and provide a
plan that can answer the research questions and test the stated hypotheses.
FYI
An appropriate research design reflects an integration of the theoretical and empirical literature that was
presented in the review of the literature section of the study.
Quantitative designs used to examine relationships among variables are
categorized as experimental or nonexperimental. These designs can be used to meet
four key purposes. Experimental designs are used for the purpose of examining
causality. Nonexperimental designs can be used for the purposes of describing a
phenomenon in detail, explaining relationships and differences among variables,
and predicting relationships and differences among variables. The major difference
between nonexperimental and experimental designs is the role of the researcher. In
experimental designs, researchers actively manipulate the independent variable
(IV), sometimes known as the causal variable, to determine its effect on the
dependent variable (DV), or outcome variable. Experimental designs also involve
randomization and the use of a control group whose results can be compared to the
group receiving the experimental intervention. Quasi-experimental designs also
involve the manipulation of the IV but lack either randomization or a control group.
In nonexperimental designs, researchers are observers noting the occurrence of the
variables of interest and trying to determine relationships and differences. Other
quantitative designs are used to address methodological issues such as instrument
development or in the case of meta-analyses to examine outcomes across a number
of studies.
As you appraise an article for the quality of the study presented, you should find
that there is a logical flow of information presented. Information from the literature
reviewed and discussion of the study framework should lead you to agree that the
study is needed, that the purpose is appropriate given the literature presented, and
that the planned design will be able to generate quantitative information to address
the stated research questions and hypotheses.
Understanding Key Concepts in Quantitative Designs
Best practice means that nurses must have confidence in the evidence that they are
applying to patient care. Having confidence in findings requires that nurses be able
to critically appraise quantitative studies before applying findings to practice.
Therefore, understanding key concepts and principles related to the design of
quantitative studies is necessary.
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Causality and Probability
Causality refers to the relationship that exists between a cause and its effect. The
cause has the ability or power to produce a specific effect. The assumption is made
that the cause precedes the effect. Being able to determine causality requires that
the variables of interest are studied in chronological order: the causal variable, or
IV, has to occur prior to the occurrence of the DV, or the effect. From a research
perspective, causality is the belief that researchers, using stringent controls, can
manipulate a cause to produce the effect or result that can be repeated.
Experimental designs are used to examine causality, with researchers manipulating
the IV while observing its effect on the DV. When working with people, nurse
researchers recognize that there are multiple factors that can contribute to an
outcome. Rarely do nurses deal with problems that have only one cause and one
effect. When outcomes have many causes, it is known as multicausality. Therefore,
it is important to consider multicausality when evaluating research designs.
Because it is possible that there are multiple, interrelated factors causing an
outcome, it is important for researchers to try to identify and control for as many of
those factors as possible. When appraising research studies, nurses need to
familiarize themselves with the variables included in the study and evaluate the
discussion section of the study report to determine whether researchers identified
other possible causes for the results. Table 6-1 outlines points that should be
considered when appraising quantitative designs.
caus ality: The relationship between a cause and its effect
Closely related to the idea of multicausality is the idea of probability. Again,
because nursing is a human science rather than a basic science, such as biology or
chemistry, nurse researchers are unlikely to be able to assert with absolute certainty
that the IV caused the effect in the DV. Instead, research related to human health and
functioning results in assertions of probability or how likely it is that the change in
the DV was caused by the IV. Probability assertions leave open the possibility that
there are other causes and factors affecting the result seen in the DV.
probability: Likelihood or chance that an event will occur in a situation
TABLE 6-1 Elements to Consider When Appraising
Quantitative Designs
What type of quantitative design is being used?
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Can causality be inferred?
Did researchers use the highest level of design possible to answer the research
questions?
What strategies did the researcher use to control for the effects of extraneous
variables?
What threats to internal and external validity might be present, and were any
strategies used to reduce them?
Were there any ethical concerns about the design?
Control, Manipulation, and Bias
Control refers to the ability to manipulate, regulate, or statistically adjust for the
multitude of factors that can influence the DV. Control is necessary to make
assertions about cause and effect. Manipulation is an important aspect of control
in experimental designs and refers to the ability of researchers to control the IV.
The IV is considered to be the intervention, or treatment, that is being tested in an
experimental study. The intervention may be physiological, psychological,
behavioral, educational, or a combination of these.
control: Ability to manipulate, regulate, or statistically adjust for factors that can affect the dependent variable
manipulation: The ability of researchers to control the independent variable
For example, a researcher hypothesizes that educational interventions will
result in increased condom use among sexually active teens and wants to test a
newly developed computer-based intervention. The researcher manipulates the IV,
the educational intervention, by determining what content will be included, how it
will be delivered, in what environment it will be delivered, and who will receive
it. The researcher in this example would then compare preintervention condom
usage with postintervention usage. The researcher also could compare the
difference in condom usage between the intervention group and a control group. In
health-related experimental designs, the control group of subjects usually receives
the standard of care but does not get the intervention. The control group of teens, in
this example, would participate in the traditional sex education classes offered in
their school but would not be able to access the computer-based program.
However, because factors other than education can affect condom use, the
researcher also needs to control for these extraneous or confounding factors.
Extraneous variables are those that confound, or confuse, the effect of the IV
on the DV. Researchers can control for extraneous variables through careful
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selection of participants, use of consistent data collection procedures,
randomization, or use of certain statistical tests. Examples of confounding variables
in the example might be the age of the teen, religious beliefs, self-efficacy for
resisting peer pressure, cost of condoms, ease of purchasing them, and whether or
not the teen has a current sexual partner. Without careful control of extraneous
variables, bias can be introduced into the study.
e xtrane ous variable s : Factors that interfere with the relationship between the independent and dependent
variables; confounding variable; Z variable
Bias results when extraneous variables influence and distort the relationship
between the IV and the DV so that the findings are not really reflecting the true
relationship. For example, if the study included students without a current sexual
partner, it would be highly likely that the intervention would result in no significant
difference in condom use. This lack of difference might be attributed to the
intervention being ineffective when it is actually caused by the fact that the teen is
not currently engaging in sexual activity requiring a condom. Researchers control
for this type of bias by clearly specifying criteria required for subjects to be
included in a study. After subjects are enrolled in a study, it is important for
researchers to control how the study is actually conducted. This includes
controlling the environment in which the study is conducted, providing consistency
in how interventions are delivered, and collecting data in a careful and consistent
manner. For example, asking students to report their condom use during an
interview where others might hear their responses could bias the results because
students may not feel comfortable responding truthfully. A better way to obtain this
information may be to have students complete a self-report of their condom use on
an anonymous questionnaire.
bias : When extraneous variables influence the relationship between the independent and dependent variables
Randomization
Randomization is an effective way to control extraneous variables. Randomization
can occur either with random sampling of the subjects to be studied or by random
assignment of subjects to intervention or control group. Random sampling means
that all people in the population of interest have the same probability of being
selected to be included in the study. This occurs infrequently in health-related
research because researchers usually do not have the time or money to randomly
sample all people who could potentially participate. For example, it would be very
difficult to randomly sample sexually active teens from around the country. Instead,
in this example the researcher would most likely use a convenience sample of
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students from high schools within the area. The researcher would then randomly
assign the students into the intervention and the control groups. Random
assignment means that all subjects in the sample (not the population) have an equal
chance of being assigned to either the treatment or the control group. Random
assignment increases the likelihood that extraneous variables that may affect the DV
will be equally distributed between the two groups. Using random assignment
allows researchers to be more confident that the IV rather than the extraneous
variables caused the effect on the DV. Although researchers may be very careful
about selecting representative samples and using random assignment to groups to
control for extraneous variables, these techniques do not guarantee that extraneous
variables will be equally distributed between the two groups. When groups are
different, researchers need to apply certain statistical tests to control for the effect
of extraneous variables on the DV.
randomization: The selection, assignment, or arrangement of elements by chance
random s ampling: Technique for selecting elements whereby each has the same chance of being selected
random as s ignme nt: Assignment technique in which subjects have an equal chance of being in either the
treatment or the control group
Between-Groups and Within-Groups
Quantitative studies often are designed for the purpose of making comparisons
either by comparing different groups of subjects or by comparing the same subject
at different points in time. Studies developed to compare two different groups of
subjects use a between-groups design. For example, a researcher who is studying
condom use among adolescents may wish to know the practices of high school
juniors and seniors as well as college freshmen and sophomores. The researcher
could make comparisons among these four groups about the frequency of condom
use.
be twe e n-groups de s ign: Study design where two groups of subjects can be compared
Although comparisons among diverse subjects are important, there may be other
situations when researchers are more interested in making comparisons within the
same subject. For example, a researcher is interested in the effect of music therapy
on patients’ levels of pain. Using a within-groups design, the researcher would
measure the subjects’ levels of pain before the intervention, conduct the
intervention, and then measure pain levels after the intervention. By comparing the
subjects’ pain scores before and after the intervention, the researcher is able to
determine the effectiveness of music therapy as a pain relief measure.
within-groups de s ign: Comparisons are made about the same subjects at two or more points in time or on two
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or more measures
TEST YOUR KNOWLEDGE 6-1
1. When designing a study, which of the following should the researcher consider? (Select all that
apply.)
a. Research question
b. Review of the literature
c. Theoretical framework
d. Study purpose
2. Which of the following is not a purpose of nonexperimental designs?
a. Describe phenomenon
b. Explain relationships
c. Predict relationships
d. Examine causality
3. What is the researcher’s ability to manipulate or regulate extraneous variables known as?
a. Control
b. Manipulation
c. Bias
d. Probability
4. When a researcher assigns subjects to groups by tossing a coin, the researcher is using which
technique?
a. Random selection
b. Random assignment
c. Bias
d. Within-groups design
How did you do? 1. a, b, c, d; 2. d; 3. a; 4. b
Researchers can combine between-groups and within-groups designs within the
same study to compare the effectiveness of more than one intervention. In the pain
example, the researcher might offer music therapy as an intervention to one group of
subjects and relaxation therapy as another intervention to a different group of
subjects. The researcher could analyze the within-groups results to determine the
level to which each intervention reduced pain, and the researcher could compare
between-groups results to determine whether there was a difference in the amount
of pain relief provided by the music and relaxation.
6.2 What Is Validity?
At the end of this section, you will be able to:
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‹ Define the two types of validity
‹ Describe seven threats to internal validity
‹ Describe five threats to external validity
‹ Identify strategies used to reduce threats to internal and external validity
Exerting control over extraneous variables affecting the DV is one important factor
to ensure valid results. Study validity refers to the ability to accept results as
logical, reasonable, and justifiable based on the evidence presented. Validity is
sometimes described as the truth or accuracy of the results. Evaluating the quality
of quantitative evidence requires nurses to identify potential threats to validity,
evaluate the seriousness of those threats, and determine whether results are valid
for application to patient care. Threats are forces that can change the results of
studies. Campbell and Stanley (1966) identified two major types of validity:
internal and external (see Table 6-2). Internal and external validity were originally
developed to evaluate cause-and-effect relationships, making them most relevant
for experimental designs. However, validity should be considered with all
quantitative designs. It is important when appraising research articles to identify
threats and consider how these threats may have influenced the relationship
between the IV and DV or the interpretation of results.
s tudy validity: Ability to accept results as logical, reasonable, and justifiable based on the evidence presented
Internal Validity
Internal validity is the degree to which one can conclude that it was the IV, not
extraneous variables, that produced the change in the DV (Cook & Campbell,
1979). To establish internal validity, researchers must demonstrate that results
obtained were caused by the IV. Seven common threats to internal validity include
selection bias, history, maturation, testing, instrumentation, mortality, and statistical
conclusion validity.
inte rnal validity: The degree to which one can conclude that the independent variable produced changes in the
dependent variable
TABLE 6-2 Summary of Design Threats
Threats to Internal Threats to External Validity
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Validity Threats to External Validity
‹ Selection bias
‹ History
‹ Maturation
‹ Testing
‹ Instrumentation
‹ Mortality
‹ Statistical conclusion validity
‹ Construct validity
– Bias
– Confounding
– Reactivity
‹ Effects of selection
‹ Interaction of treatment and selection of
subjects
‹ Interaction of treatment and setting
‹ Interaction of treatment and history
Selection Bias
Selection bias occurs when the change in the DV is a result of differences in the
characteristics of subjects before they entered a study rather than a result of the IV.
Suppose a researcher wants to compare the effectiveness of group teaching to one-
on-one teaching. At the hospital where the study is being conducted, patients are
allowed to choose the kind of teaching they want. It is possible that people who
select group teaching are different on some characteristics from those who select
one-on-one teaching. Selection bias can be minimized somewhat by the use of
random assignment to groups.
s e le ction bias : A threat to internal validity when the change in the dependent variable is a result of the
characteristics of the subjects before they entered a study
History
The threat of history occurs when the DV may have been influenced by some event
other than the IV that occurred during the course of the study. In the example of
condom use, it might be difficult to attribute increased use of condoms to the
computer intervention if during the same time as the study was being conducted
MTV or VH1 aired public service announcements encouraging safe sex practices.
In such a situation, it is difficult for the researcher to know whether the IV or the
increased awareness from television produced the change in the DV. The threat of
history could have been decreased by including a control group that was exposed to
237
his tory: A threat to internal validity when the dependent variable is influenced by an event that occurred during
the study
FYI
Evaluating the quality of quantitative evidence requires nurses to identify potential threats to validity, evaluate
the seriousness of those threats, and determine whether results are valid for application to patient care. The
two primary types of validity are internal validity and external validity.
Maturation
Over the course of a study, subjects may change either by growing or becoming
more mature. This is known as the threat of maturation. Changes such as these are
more likely to influence the DV when a study continues over time. For example, if
subjects during the study on condom use came of age to obtain a driver’s license
and get a job, it would be difficult to determine whether an increase in condom use
was a result of the IV or of the subjects’ increased ease of purchasing condoms for
use. A control group may help limit this threat to internal validity.
maturation: A threat to internal validity when subjects change by growing or maturing
Testing
The threat of testing occurs when a pretest influences the way subjects respond on
a posttest. Repeated testing can cause familiarity with the test itself, and answers
may reflect subjects’ abilities to remember how questions were answered
previously rather than reflecting current knowledge and beliefs.
te s ting: A threat to internal validity when a pretest influences the way subjects respond on a posttest
Instrumentation
When there are changes made in the way variables are measured, the threat of
instrumentation can occur. For example, in a study measuring blood pressure, if
the original measurement is taken using an aneroid sphygmomanometer but later
measurements are taken using an automated device, it makes it difficult to determine
whether any change in blood pressure readings is a result of the IV or the change in
238
measurements are taken using an automated device, it makes it difficult to determine
whether any change in blood pressure readings is a result of the IV or the change in
devices. Another potential instrumentation threat arises when data are collected by
observation or interview using different data collectors. To control for this threat,
researchers need to ensure all data collectors are comprehensively trained.
Researchers also evaluate interrater reliability to determine the degree of
consistency among individuals collecting data.
ins trume ntation: A threat to internal validity when there are inconsistencies in data collection
Mortality
Mortality refers to the loss of subjects before the study is completed. Loss of
subjects may be a threat to internal validity if there is a difference in the
characteristics of the subjects who dropped out compared to those who completed
the study. Internal validity is also threatened when there is a difference in the loss
of subjects between the experimental and control groups. Mortality tends to
increase the longer a study lasts. In health-related research, emotional states such as
depression and anxiety, as well as physical states such as fatigue, may influence
dropout rates. When appraising a study for the threat of mortality, it is important to
compare the number of subjects who entered the study with the number of subjects
in the final sample. In a research article, the term attrition rate refers to the
dropout rate. If the attrition rate is high, the author of the article should provide an
analysis and explanation for the dropout rate.
mortality: A threat to internal validity when there is a loss of subjects before the study is completed; attrition
rate
attrition rate : Dropout rate; loss of subjects before the study is completed; threat of mortality
Statistical Conclusion Validity
Statistical conclusion validity refers to the confidence one has that the results of
the statistical analysis accurately reflect the true relationship between the IV and
DV. This does not happen when researchers make a type II error. Type II errors
occur when researchers inaccurately conclude that there is no relationship between
the IV and DV when an actual relationship does exist. A type II error is more likely
to occur when the sample size is small. Often large samples are needed in order to
detect the effect of the IV on the DV. Low reliability of the measures is another
factor that can interfere with researchers’ abilities to draw accurate conclusions
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information presented in the methods section that details the reliability of
instruments. Researchers can control for low reliability of the measures by using
well-established and well-designed instruments.
s tatis tical conclus ion validity: The degree that the results of the statistical analysis reflect the true relationship
among the independent and dependent variables
type II e rror: When researchers inaccurately conclude that there is no relationship among the independent and
dependent variables when an actual relationship does exist; when the researcher accepts the null hypothesis
when it should have been rejected
External Validity
External validity refers to the degree to which the results of the study can be
generalized to other subjects, settings, and times (Cook & Campbell, 1979). There
are five major threats to external validity. Construct validity is concerned with
whether the instruments are really measuring the theoretical concepts under
investigation. Other threats to external validity include threats related to selection
of subjects for the study and ones that occur because of interactions between the IV
and the subjects, the setting, or history.
e xte rnal validity: The degree to which the results of the study can be generalized to other subjects, settings,
and times
CRITICAL THINKING EXERCISE 6-1
© Jules_Kitano/ShutterStock, Inc.
A researcher is interested in studying the effect of hearing loss on self-esteem in adolescents attending
grades 6–12. What threats to internal validity should the researcher address? What controls could the
researcher use to minimize these threats?
Construct Validity
Construct validity is an important consideration when evaluating external validity.
Assessing construct validity allows researchers to determine whether instruments
are actually measuring the theoretical cause or effect concepts that are intended to
be measured. A threat of construct validity can lead to bias or unintentional
confounding of the results.
cons truct validity: A threat to external validity when the instrument does not accurately measure the
theoretical concepts
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cons truct validity: A threat to external validity when the instrument does not accurately measure the
theoretical concepts
Bias refers to a systematic error in subject selection, measurement of variables,
or analysis. For example, a researcher is studying the effect of anger on blood
pressure; however, the instrument used to measure anger contains some items that
might also reflect depression. The relationship between anger and blood pressure
is biased because the instrument measures two different theoretical concepts.
Therefore, the researcher would be unable to determine whether changes in blood
pressure were a result of anger or depression. When appraising an article for
threats to construct validity, it is important for readers to consider information
presented in the methods section of the article. This section should contain
information on the reliability of the instrument used and details on how the validity
of the instrument was established.
Confounding means there is a possible error in interpretation of the results
(Cook & Campbell, 1979). This can occur when experimental controls do not
allow the researcher to eliminate possible alternative explanations for the
relationship between the IV (cause variable) and the DV (effect variable). Subject
reactivity and experimenter reactivity are two examples of unintentional
confounding.
Subject reactivity means that sometimes subjects are influenced by participating
in a study. Changes noted in the DV can be a result of subject reactivity and not a
result of the IV. This is known as the Hawthorne effect. The Hawthorne effect was
first recognized in studies done at the Western Electric Corporation’s Hawthorne
plant (Mayo, 1933). One of the studies attempted to determine whether changing the
amount of lighting (IV) in the work environment changed worker productivity (DV).
In this study, productivity increased regardless of changes made to lighting. Thus,
one explanation was that increased lighting caused increased productivity as was
hypothesized, but that interpretation did not explain why productivity increased in
the control group. An alternative explanation for this result was that the increased
productivity occurred not because of changes in illumination but because the
employees in both groups knew they were being studied. Therefore, the effect of the
IV on the DV was confounded by the subjects’ behavior. The behavior of subjects
in a study may be affected by their personal values, their desires to please the
experimenter or provide the results the experimenter wants, and congruence of the
study with subjects’ personal interests and goals.
re activity: The influence of participating in a study on the responses of subjects; Hawthorne effect
Hawthorne e ffe ct: Subjects’ behaviors may be affected by personal values or desires to please the
experimenter; reactivity
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© Jules_Kitano/ShutterStock, Inc.
Have you ever participated in a research study? Do you think your behaviors were different because you
knew you were being studied?
Experimenter reactivity is another type of reactivity that threatens external
validity. When researchers have expected or desired outcomes in mind, they may
inadvertently affect how interventions are conducted and how they interact with
subjects. For example, a researcher may be friendlier to subjects in the
experimental group than to subjects in the control group. As a result, subjects in the
experimental group may perceive involvement in the study more positively than do
subjects in the control group.
Double-blind experimental designs have been used in health research to
control for threats of reactivity. In double-blind studies, neither subjects nor
individuals administering the treatments know whether subjects are receiving
experimental interventions or standard of care. This design is fairly common in
drug studies where a placebo pill can be manufactured to appear exactly like the
drug being studied.
double -blind e xpe rime ntal de s igns : Studies in which subjects and researchers are unaware whether subjects
are receiving experimental interventions or standard of care
Effects of Selection
Because researchers most often study samples rather than an entire population,
representativeness of the sample is essential. If the sample does not represent the
population, effects of selection limit whether study can be generalized to the
population. For example, a researcher is interviewing mothers. Because interviews
are being conducted only during the day and no child care is provided, individuals
who work during the day or who have small children are less likely to participate
in this study. Consequently, researchers would not be able to generalize to all
mothers but only to mothers who do not work during the day and mothers without
young children.
e ffe cts of s e le ction: Threats to external validity when the sample does not represent the population
Interaction of Treatment and Selection of Subjects
Because external validity is concerned with generalizing to other individuals, it is
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Because external validity is concerned with generalizing to other individuals, it is
only natural to ask, “Will this IV affect other people in the same way?” The
interaction of treatment with selection of subjects must be considered (Cook &
Campbell, 1979). This requires consideration of the difference between the
accessible population and the target population of interest (Kempthorne, 1961). In
the condom use example, the target population is all sexually active teens. The
accessible population is the group of teens from which the researcher is actually
able to obtain a sample of subjects. So, if the computer-based intervention is found
to be effective in increasing condom use in a sample of students from a Midwestern
suburban high school, how generalizable are those findings to teens living in urban
centers in the West or rural areas of the South?
inte raction of tre atme nt with s e le ction of s ubje cts : A threat to external validity where the independent
variable might not affect individuals the same way
Interaction of Treatment and Setting
Sometimes an interaction of treatment and setting can affect external validity.
This interaction is concerned with whether results from an intervention conducted
in one setting can be generalized to another setting where the same intervention is
used. If the study on condom use was conducted with teens waiting to be seen in a
family planning clinic, can the findings from that study be generalized to teens in a
high school setting?
inte raction of tre atme nt and s e tting: A threat to external validity when an intervention conducted in one
setting cannot be generalized to a different setting
TEST YOUR KNOWLEDGE 6-2
1. What is the degree to which the results of studies can be generalized to other individuals, settings,
or time called?
a. External validity
b. Construct validity
c. Internal validity
d. Statistical conclusion validity
2. During a study examining nurses’ job satisfaction, the union decides to hold a strike. This is which
type of threat to internal validity?
a. Selection bias
b. Mortality
c. History
d. Testing
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be on their best behavior when guests are present in the classroom. What is the greatest threat to
external validity?
a. Construct validity
b. Hawthorne effect
c. Selection
d. Interaction of treatment setting
How did you do? 1. a; 2. c; 3. b
Interaction of Treatment and History
Interactions of treatment and history can also occur. This threat is concerned
with how the effects from the intervention might be changed by events occurring in
the past or in the future. For example, if the researcher found that the computer-
based intervention increased condom use, would those results be generalizable to
the future if a cure for HIV were to be discovered?
inte raction of tre atme nt and his tory: A threat to external validity when historical events affect the
intervention
6.3 Categorizing Designs According to
Time
At the end of this section, you will be able to:
‹ Differentiate the time dimension of data collection across retrospective, cross-
sectional, and longitudinal and prospective designs
Evaluating the strength of the evidence obtained with quantitative designs includes
evaluating the timing of data collection. The time dimension of a study may be
classified as retrospective, cross-sectional, and longitudinal or prospective.
Retrospective Designs
Retrospective designs may also be referred to as ex post facto, which means after
the fact. When designing retrospective studies, researchers start with the DV and
look back in time to determine possible causative factors. Retrospective designs
are considered to be after the fact because the DV has already occurred, which
means that the IV cannot be manipulated and subjects cannot be randomly assigned.
Thus, retrospective designs are never experimental in nature.
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re tros pe ctive de s igns : Research designs when researchers look back in time to determine possible causative
factors; ex post facto
e x pos t facto: Research design in which researchers look back in time to determine possible causative factors;
retrospective research design
Retrospective designs are often used in epidemiological studies. For example,
causes of AIDS were discovered by researchers who started noticing an unusual
increase in the number of cases of Kaposi’s sarcoma occurring in young men (Gallo
& Montagnier, 2003). By taking careful histories, researchers were able to look
back in time to determine behaviors and risk factors common to men who
developed AIDS. Behaviors were compared with behaviors of men who did not
have the disease. This type of retrospective study is called a case-control study
because researchers started with a group of people who already had the disease.
Identifying smoking as a cause of lung cancer also resulted from examining
retrospective data. In both of these examples, retrospective designs were
appropriate because it would have been unethical for researchers to deliberately
expose subjects to either the HIV virus or tobacco smoke.
cas e -control: A type of retrospective study in which researchers begin with a group of people who already had
the disease; studies that compare two groups: those who have a specific condition and those who do not have
the condition
When conducting quality control studies, researchers often use retrospective
designs. In these types of studies, researchers may want to gather information about
an organization’s status related to a patient problem such as falls. Chart audits can
be done to determine the number of falls that occurred in the past 6 months.
Information can be gathered on patients who have fallen to identify potential
causative factors such as age, diagnoses, units where falls occurred, and staffing
levels at the time of falls. Thus, retrospective studies can provide important data
using nonexperimental designs. However, because retrospective designs are not
experimental, a disadvantage is that researchers cannot say definitively that the IV
caused the DV. Instead, researchers can conclude that there is an increased
likelihood or probability that the IV caused the outcome in the DV.
Cross-Sectional Designs
Cross-sectional studies are nonexperimental designs that researchers use to gather
data from a group of subjects at only one point in time. Cross-sectional designs
provide a snapshot by collecting data about the IV and DV at the same time.
Because data are collected at one time, it is difficult to establish cause and effect
using cross-sectional designs. For example, a researcher is studying the effect of
self-efficacy on condom use in adolescents. If a cross-sectional design is used, it
would be difficult to determine whether increased self-efficacy caused increased
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condom use or increased condom use resulted in a sense of increased self-efficacy.
cros s -s e ctional: Nonexperimental design used to gather data from a group of subjects at only one point in time;
study design to measure exposure and disease as each exists in a population or representative sample at one
specific point of time
Use of a strong theoretical framework can guide the researcher when
speculating about the relationships of the variables being studied with a cross-
sectional design. It is important not to confuse cross-sectional studies with other
designs. For example, a researcher who is interested in subjects’ cardiovascular
responses to stress may start by measuring blood pressures, exposing subjects to a
stressful video clip, and then remeasuring blood pressures during and immediately
after the video. Although data are collected in the immediate present, data about the
IV and DV are not collected at the same point in time. Therefore, this is an example
of an experimental design rather than a cross-sectional design.
Cohort comparison studies are a specific type of nonexperimental cross-
sectional design where more than one group of subjects is studied at the same point
in time. Cohort comparison designs allow researchers to draw conclusions about
variables over time even though data were collected at only one point in time. In
the example of condom use, a cohort design could be used to study the factors
associated with condom use among high school freshmen as well as high school
sophomores, juniors, and seniors. The variables related to condom use in each
group could be analyzed and compared to see if the same variables applied across
the groups or to find out at which grade level the variables changed. Because
following the same subjects as they progress through high school would take 4
years, gathering data from different subjects at each grade saves time. The
advantages of cross-sectional designs are that they are easier to manage and are
more economical. Because data are collected only one time from each subject, the
threats of mortality, maturation, and testing are minimized. A limitation of cross-
sectional designs is that it is difficult for researchers to make claims about cause
and effect.
cohort comparis on: Nonexperimental cross-sectional design in which more than one group is studied at the
same time so that conclusions about a variable over time can be drawn without spending as much time
Longitudinal Designs
Longitudinal designs are used to gather data about subjects at more than one point
in time. These may be either experimental or nonexperimental designs. Longitudinal
designs are sometimes called prospective designs, which are studies that begin in
the present and end in the future. Nonexperimental, prospective designs are
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commonly used in epidemiological studies where researchers begin by identifying
presumed causes and then follow subjects into the future to determine whether the
hypothesized effects actually occur.
longitudinal de s igns : Designs used to gather data about subjects at more than one point in time
pros pe ctive de s igns : Studies over time with presumed causes that follow subjects to determine whether the
hypothesized effects actually occur
In panel designs, the same subjects are used to provide data at multiple points
in time. The observational study component of the well-known Women’s Health
Initiative (WHI) is an example of a prospective, nonexperimental, panel design
(National Heart, Lung, and Blood Institute [NHLBI], 2013). In the WHI,
researchers funded by the NHLBI gathered data over an 8-year period from
postmenopausal women between 50 and 79 years of age. The purpose of the study
was to determine reliable estimates of the extent to which known risk factors
predict heart disease, cancer, and fractures in older women. Women who joined the
panel study were asked at different points in time to provide data about their health
behaviors. They were not required to change any of their health habits—only to
report them.
pane l de s ign: Longitudinal design where the same subjects, drawn from the general population, provide data at
multiple points in time
Trend studies use nonexperimental designs to gather data about the variables of
interest from different samples from the target population across time. An example
of this is the Youth Risk Behavior Surveillance System (YRBSS) conducted by the
Centers for Disease Control and Prevention
(http://www.cdc.gov/HealthyYouth/yrbs). Since 1992, the YRBSS has surveyed
representative samples of students in grades 9–12. Repeated every 2 years, surveys
provide data regarding the prevalence of risk behaviors among high school
students. By using different samples of teens, researchers are able to determine
whether the rates of risky behaviors are increasing, decreasing, or staying the same
over time.
tre nd: A type of longitudinal design to gather data from different samples across time
FYI
Several research designs allow researchers to track data over time. These include retrospective designs and
longitudinal designs.
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http://www.cdc.gov/HealthyYouth/yrbs
Another type of longitudinal design is the follow-up study. Researchers use this
design to follow subjects into the future. These may be either experimental or
nonexperimental designs. Nonexperimental follow-up studies differ from panel
studies in that the samples are not drawn from the general population (e.g., not from
all postmenopausal women or all teens in high school), but instead samples are
selected because they have a specific characteristic or condition that researchers
are interested in studying. An example of a nonexperimental follow-up design is a
study involving the breastfeeding behaviors of new mothers. The researcher would
select a sample of new mothers and follow them for a period of months to
determine variables associated with their continuing or discontinuing breastfeeding.
follow-up: A longitudinal design used to follow subjects, selected for a specific characteristic or condition, into
the future
Follow-up studies may also be experimental in design. A researcher may design
a supportive educational intervention to increase new mothers’ confidence in
breastfeeding. The researcher would randomly assign mothers to either the new
educational intervention group or the standard of care group. Mothers would be
followed over the next few months to determine whether the educational
intervention made a difference in the length of time that mothers breastfed their
infants. The hormone replacement component of the WHI Clinical Trial and
Observational Study (http://www.nhlbi.nih.gov/whi/ctos.htm) is another example of
an experimental follow-up study. In this study, women were randomly assigned to
either a treatment or placebo group and then followed for 8 years to determine the
effect of hormone replacement therapy on the prevention of coronary heart disease
and osteoporotic fractures.
Crossover designs are a type of longitudinal study in which subjects receive
more than one experimental treatment and are then followed over time. Subjects act
as their own control group. Researchers manipulate the IV by randomizing the order
in which the treatments are provided. An example of a crossover design is one in
which the researcher is interested in determining whether relaxation techniques or
exercise has a greater effect on reducing blood pressure. Some subjects would be
randomly assigned to receive training in relaxation techniques first while others
would be given instructions about exercise first. As subjects enter the study,
baseline measures of blood pressure would be obtained. They would then do either
the exercise or relaxation procedures for a set time period and would have their
blood pressure measured at different points in time. Subjects would then be asked
to stop the intervention and resume their normal habits while blood pressures are
measured again. At a later time, subjects would receive instructions about the
experimental treatment they had not done initially. Again, subjects would be
followed for a set period of time with their blood pressures being measured. At the
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http://www.nhlbi.nih.gov/whi/ctos.htm
end of the study, the researcher would be able to determine which intervention
produced the greatest reduction in blood pressures. One problem with crossover
studies, however, is the possibility of a carryover effect. Even though subjects are
asked to stop performing the first intervention, sometimes they may continue to use
it during the second phase of the study.
cros s ove r de s igns : Experimental designs that use two or more treatments; subjects receive treatments in
random order
Gathering data at multiple points in time does not necessarily make a study
longitudinal. Usually the term longitudinal is reserved for studies in which data are
gathered over extended periods of time rather than in just a few hours or days. In
some nursing situations, data may be repeatedly gathered but only for a relatively
short period of time. For example, a researcher is studying the effects of music
therapy on blood pressure of patients who are admitted to the intensive care unit.
Although blood pressure is measured every hour for a 24-hour period, this study
would not be described as a longitudinal study.
Longitudinal designs provide important information about the chronological
relationships that exist between the IV and DV by determining changes over time.
Another advantage is that this type of design can be used to test cause and effect.
One disadvantage of longitudinal studies is their cost in following subjects over an
extended period of time. The threat of mortality is increased; thus, researchers need
to make special plans to encourage subjects to complete the studies. Maturation is
another threat inherent in longitudinal designs because changes of subjects are
inevitable. Because longitudinal studies involve repeated measurements, the threat
of testing is often increased.
TEST YOUR KNOWLEDGE 6-3
True/False
1. In retrospective designs, also known as ex post facto designs, the researcher manipulates the IV.
2. Cohort comparison studies can save time because more than one group of subjects is studied.
3. The threat of mortality is greater in cross-sectional designs than in longitudinal designs.
4. Any study that involves collecting data at multiple points in time is a longitudinal study.
How did you do? 1. F; 2. T; 3. F; 4. F
6.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss ethical issues related to internal and external validity
249
Researchers are obligated to conduct well-constructed studies. If a study does not
have adequate controls in place, then the researcher has wasted valuable resources
such as time, money, and subject volunteerism. Furthermore, failure to control
threats to study validity jeopardizes the integrity of the findings. When findings are
flawed, patient safety could be affected when practice is changed based on the
evidence. Researchers should make every effort to implement strategies that
enhance control and manipulation while reducing bias.
Implementing strategies needs to be balanced with protecting the rights of
human subjects. For example, when individuals are recruited for a study that
involves two or more groups, they often express a desire to choose their group
assignment. Allowing subjects to select their group assignment introduces the threat
of selection bias. Most researchers would opt to randomly assign subjects to
groups to reduce this threat. Therefore, it would be important for the researcher to
inform subjects during the recruitment process that they will not be allowed to
choose their own groups. Doing so allows individuals to make informed decisions
about participating.
FYI
Researchers are obligated to conduct well-constructed studies. If a study does not have adequate controls in
place, then the researcher has wasted valuable resources such as time, money, and subject volunteerism.
TEST YOUR KNOWLEDGE 6-4
True/False
1. Researchers should design studies that are easy for subjects to participate in regardless of how
much control over extraneous variables is achieved.
2. Nursing’s body of knowledge is dependent on the quality of research findings that are
disseminated.
How did you do? 1. F; 2. T
RAPID REVIEW
» Quantitative designs are used to describe phenomena, explain relationships,
predict relationships, and explain causality.
» Nurses must consider elements of design when appraising quantitative studies.
» There are three major categories of quantitative designs: experimental, quasi-
250
experimental, and nonexperimental.
» Causality refers to a relationship that exists between a cause and its effect. The IV
must occur prior to the DV in order to claim a cause-and-effect relationship.
Because outcomes can have multiple causes, probability assertions leave open
the possibility for multicausality.
» In quantitative designs, researchers control, manipulate, and randomize to control
for extraneous variables.
» Randomization is used in two ways to control for extraneous variables. Random
sampling is the process of selecting a sample whereby each element in the
population has an equal chance of being selected. Random assignment to groups
means that all subjects in the sample have an equal chance of being assigned to
either the intervention or control group.
» Researchers use within-groups designs to examine how subjects in the same
group change over time. Between-groups designs involve comparisons of
subjects of one group to subjects in another group.
» There are two major types of validity: internal and external. Internal validity is
the degree to which one can conclude that it was the IV, not extraneous
variables, that produced the change in the DV. External validity refers to the
confidence one has that findings can be generalized across different types of
people, settings, and times.
» There are seven threats to internal validity: selection bias, history, maturation,
testing, instrumentation, mortality, and statistical conclusion validity.
» There are five threats to external validity: construct validity, selection, interaction
of treatment and selection of subjects, interaction of treatment and setting, and
interaction of treatment and history.
» Quantitative studies can be classified as follows according to the timing of data
collection: retrospective, cross-sectional, longitudinal, and prospective.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Consider the designs used by Anthony, Wiencek, Bauer, Daly, & Anthony (2010) and Kliger, Blegen,
251
Gootee, and O’Neil (2009). Identify any threats to internal and external validity of these studies. Discuss
strategies researchers used to minimize these threats.
REFERENCES
Anthony, K., Wiencek, C., Bauer, C., Daly, B., & Anthony, M. K. (2010). No interruptions please. Impact of a
no interruption zone on medication safety in intensive care units. Critical Care Nurse, 30(3), 21–29.
Campbell, D. T., & Stanley, J. C. (1966). Experimental and quasi-experimental designs for research.
Chicago, IL: Rand McNally.
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis issues for field
settings. Boston, MA: Houghton Mifflin.
Gallo, R. C., & Montagnier, L. (2003). The discovery of HIV as the cause of AIDS. New England Journal of
Medicine, 349, 2283–2285.
Kempthorne, O. (1961). The design and analysis of experiments with some reference to education research. In
R. O. Collier & S. M. Elan (Eds.), Research design and analysis (pp. 97–126). Bloomington, IN: Phi Delta
Kappa.
Kliger, J., Blegen, M. A., Gootee, D., & O’Neil, E. (2009). Empowering frontline nurses: A structured
intervention enables nurses to improve medication administration accuracy. Joint Commission Journal on
Quality and Patient Safety, 35, 604–612.
Mayo, E. (1933). The social problems of an industrial civilization. New York, NY: Macmillan.
National Heart, Lung, and Blood Institute. (2013). Women’s health initiative. Retrieved from
http://www.nhlbi.nih.gov/whi/index.html
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http://www.nhlbi.nih.gov/whi/index.html
CHAPTER 7
253
Quantitative Designs: Using Numbers
to Provide Evidence
Rosalind M. Peters
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Explain the three essential components of experimental designs
‹ Identify major experimental designs
‹ Discuss the advantages and disadvantages of various experimental designs
‹ Discuss the key difference between quasi-experimental and experimental
designs
‹ Identify major quasi-experimental designs
‹ Discuss the advantages and disadvantages of various quasi-experimental
designs
‹ Describe the purpose of nonexperimental designs
‹ Identify major nonexperimental quantitative designs
‹ Discuss the advantages and disadvantages of various nonexperimental designs
‹ Define translational research, community-based participatory action research,
and health services research
‹ Discuss ethical issues related to quantitative designs
KEY TERMS
community-based participatory action research
comparative designs
correlational designs
covary
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crossover designs
descriptive correlational designs
descriptive designs
experimental designs
exploratory designs
factorial designs
health services research
model testing
multiple experimental groups designs
nonequivalent control group pretest-posttest design
nonequivalent-groups posttest-only designs
nonexperimental designs
one-group posttest-only designs
predictive correlational design
preexperimental
quasi-experimental designs
Solomon fourgroup design
survey designs
time series design
translational research
two-group posttest-only designs
two-group pretest-posttest design
7.1 Experimental Designs
At the end of this section, you will be able to:
‹ Explain the three essential components of experimental designs
‹ Identify major experimental designs
‹ Discuss the advantages and disadvantages of various experimental designs
255
Quantitative designs can provide evidence that describe a phenomenon, explain
relationships and differences among variables, predict relationships and
differences among variables, or determine causality (Campbell & Stanley, 1966;
Cook & Campbell, 1979). Experimental designs provide the best evidence for
claiming that a cause-and-effect relationship exists. This type of design often
includes the terms pretest and posttest. These terms refer to the point in time when
data collection is taking place. Sometimes these are labeled “before” and “after”
designs because pretest means data are collected prior to or before the intervention
group receives the treatment, and posttest refers to data collected after the
intervention is completed. Experimental designs look for differences between
treated and untreated subjects. Therefore, there must be a minimum of two groups.
To be considered a true experimental design, three features must be present:
randomization, control, and manipulation.
e xpe rime ntal de s igns : Designs involving random assignment to groups and manipulation of the independent
variable
CRITICAL THINKING EXERCISE 7-1
© Jules_Kitano/ShutterStock, Inc.
Remember an experiment you conducted in your chemistry class. Identify the three essential components of
an experiment and tell how each was accounted for in your example.
Essential Components of Experimental
Designs
Randomization in experimental designs is used in two ways. One way requires
researchers to randomly select subjects from the target population. The other way is
to randomly assign subjects to groups. Because random selection of the sample
usually is not possible in nursing research, random assignment to groups is
considered to be sufficient to meet the criterion of randomization for an experiment.
The second component of experimental designs is control, which is related to
randomization. A control group, for comparison to the experimental group, is one
strategy researchers use to control for extraneous variables. In addition to a control
group, other ways researchers control for extraneous variables are by exerting the
highest level of control over the selection of subjects, the definitions of the
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variables, and the environment in which the experiment is conducted.
Manipulation is the third essential component. Researchers must be able to
manipulate the independent variable (IV) for a design to be considered
experimental. This is accomplished by consistently administering the intervention.
True Experimental Designs
When creating an evidence-based practice (EBP), experimental designs are most
valued. When appraising quantitative research studies, you may see the term
randomized controlled trial (RCT), a term used to describe an experimental study
that is conducted in healthcare settings. The RCT designation refers to the fact that
the study is “clinical” in nature rather than a specific type of design. Regardless of
the specific experimental design used, RCTs are characterized by the following
considerations: (1) they involve a large number of subjects, often from diverse
geographic areas; (2) there are strict guidelines for including subjects in a study;
(3) subjects are randomly assigned to either the intervention or control group; (4)
subjects in each group must be comparable (equivalent) on key characteristics at
baseline; (5) the intervention is consistently implemented to all subjects in the
experimental group following a very rigidly defined protocol for implementation;
and (6) all subjects in both groups are measured on the dependent variable (DV)
using the same method of measurement at the same points in time.
FYI
Experimental designs look for differences between treated and untreated subjects. The untreated group is
the control group.
There are six types of true experimental designs commonly reported in the
scientific literature. These include: (1) two-group pretest-posttest, (2) two-group
posttest-only, (3) Solomon fourgroup, (4) multiple experimental groups, (5)
factorial, and (6) crossover designs.
Two-Group Pretest-Posttest Designs
The two-group pretest-posttest design is considered to be the “classic”
experimental design. Subjects are randomized to either the experimental group
receiving the intervention or the control group. They are measured before and after
the intervention is implemented (see Table 7-1). This design allows researchers to
examine within-subjects results as well as between-subjects results. For example, a
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researcher wants to test a new teaching strategy for diabetic patients. Patients in a
diabetic clinic are randomly assigned to either the computerized learning module
group or the standard of care group. Knowledge about diabetes is measured before
and after teaching for all subjects. One way the researcher can determine the
efficacy of the intervention is to compare the pretest and posttest scores of subjects
in the intervention group to see if learning occurred. Another way to evaluate the
intervention would be to compare posttest scores from the two groups to determine
whether one teaching method increased posttest scores more than another did.
two-group pre te s t-pos tte s t de s ign: Subjects are randomly assigned to the experimental or control group and
are measured before and after the intervention; classic or true experiment
TABLE 7-1 Experimental Designs
A potential disadvantage of the two-group pretest-posttest design is that threats
to internal validity are introduced from repeated testing. In the previous example,
the threat of testing could be reduced by providing subjects with alternate forms of
the diabetic knowledge test. Mortality is another threat because subjects are
measured more than once and some subjects may drop out before the study is
completed. Also, if the intervention or data collection is burdensome, subjects may
be more likely to withdraw from studies.
Two-Group Posttest-Only Designs
In experimental two-group posttest-only designs, researchers randomly assign
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subjects to either an intervention group or a control group. In nursing studies, the
intervention is conducted with the experimental group (see Table 7-1), while the
control group receives the usual standard of care. After the intervention is
completed, the DV is measured at the same point in time in both groups. This type
of design is used when it is not possible or practical to measure the DV before the
intervention is implemented. For example, a researcher is interested in examining
the effect of music therapy on pain levels of patients undergoing invasive
procedures. Because patients have no pain prior to invasive procedures, it would
be impossible to determine whether the intervention decreased levels of pain.
Therefore, the only way a researcher can determine whether music therapy
effectively reduced pain would be to use a between-subjects design. Pain levels
from subjects who used music therapy would be compared to the pain levels of
subjects who did not. Because subjects are measured only once, threats of testing
and mortality are minimized. A disadvantage of the two-group posttest-only design
is that it is susceptible to the threats of selection bias. One cannot assume that the
two groups are equivalent, because there was no measurement at baseline.
Selection bias should be minimized because subjects are randomly assigned to
groups. The characteristics of subjects that might affect the DV should be equally
distributed between the two groups through the use of random assignment.
two-group pos tte s t-only de s igns : Experimental designs when subjects are randomly assigned to an
experimental or control group and measured after the intervention
Solomon FourGroup Designs
As the name implies, there are four groups of subjects involved in the Solomon
fourgroup design. Two groups of subjects receive the intervention, and two groups
of subjects receive the usual standard of care or a placebo. One experimental group
and one control group are measured before and after the intervention, while the
other experimental and control groups are measured only after the intervention (see
Table 7-1). Researchers select this fourgroup design over the two-group pretest-
posttest design to reduce the threat of testing. This design is also superior to the
two-group posttest-only design because selection bias is minimized. Consider the
diabetic teaching intervention example again. Suppose the researcher is concerned
that subjects will learn information by taking the diabetic knowledge test. By
adding two more groups that do not take the pretest, the researcher can compare
posttest scores from subjects who took the pretest to scores of subjects who did not
take the pretest. If testing is a threat, the researcher can expect that the pretest
groups will have higher posttest scores than those who did not take the pretest.
Solomon fourgroup de s ign: An experimental design with four groups—some receive the intervention, others
serve as controls; some are measured before and after, others are measured only after the intervention
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Although the Solomon fourgroup design is a strong design, it has limitations.
Because there are more groups, sample sizes must be large. This means that
subjects must be available, recruitment of subjects will take longer, and costs will
be increased.
Multiple Experimental Groups Designs
It is possible for researchers to use either the posttest alone or the pretest-posttest
design with multiple experimental groups designs. To conduct this type of study,
researchers would have multiple experimental groups and one control group. In the
example of interventions to reduce pain during invasive procedures, the researcher
might be interested in testing two different interventions. The researcher could
randomly assign subjects to experimental group 1, which would receive music
therapy. Other subjects would be randomly assigned to experimental group 2,
where they would receive therapeutic touch. Other subjects would be randomly
assigned to the control group for the usual standard of care. The advantage of the
multiple-groups design is that it allows researchers to compare the effect of
different interventions on the DV. A major disadvantage of this design is that a large
number of subjects is needed to detect differences across multiple groups.
multiple e xpe rime ntal groups de s igns : Experimental designs using two or more experimental groups with
one control group
Factorial Designs
In the previously discussed designs, only one intervention has been manipulated.
Even in multiple-groups experiments, each experimental group receives only one
intervention. Factorial designs allow researchers to manipulate more than one
intervention during the same experiment. Researchers may compare multiple
interventions (e.g., music and therapeutic touch combined) or multiple levels of
interventions (e.g., music with therapeutic touch for 10 minutes, 15 minutes, or 20
minutes). For example, a researcher is interested in increasing self-care behaviors
of people with high blood pressure. The researcher hypothesizes that home visits
and an interactive website will be effective in lowering blood pressures. Two
experiments could be used to test each intervention separately, or a factorial design
could be used to test both interventions separately, while testing the effects of a
combined intervention for controlling high blood pressures. Table 7-2 depicts the 2
× 2 factorial design for this example. Note that there are three intervention groups
(home visit alone, website alone, and combined home visit and website) and one
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control group that receives neither the home visits nor the interactive website.
factorial de s igns : Experimental designs allowing researchers to manipulate more than one intervention
Because of its complex nature and sophisticated data analysis, more
experienced researchers tend to use this type of design. Like Solomon fourgroup
designs, sample sizes need to be large because there are a minimum of four groups.
However, time and effort are saved by not having to conduct multiple studies.
Crossover Designs
In the discussion of longitudinal designs, crossover designs were mentioned.
Although only one group of subjects is used, crossover designs include the three
essential components of an experiment (see Table 7-1). Independent variables are
manipulated by the researcher, and the order in which the interventions are
administered to subjects is randomized. Because subjects serve as their own
control group, the criterion of control is met because it is assumed that each subject
will remain stable on the extraneous variables during the study.
cros s ove r de s igns : Experimental designs that use two or more treatments; subjects receive treatments in a
random order
Smaller sample sizes are needed because only one group of subjects is
required, and subjects serve as their own controls. A disadvantage is that subjects
may continue to engage in the first intervention after moving to the second.
TABLE 7-2 Factorial Design
TEST YOUR KNOWLEDGE 7-1
True/False
1. All experiments must include a minimum of three groups of subjects.
2. The Solomon fourgroup design is more effective at controlling for the threat of testing than is the
two-group pretest-posttest design.
3. In a factorial design, only one group of subjects is required because they act as their own control.
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4. Patients who are not in the intervention group must receive the usual standard of care.
How did you do? 1. F; 2. T; 3. F; 4. T
7.2 Quasi-Experimental Designs
At the end of this section, you will be able to:
‹ Discuss the key difference between quasi-experimental and experimental
designs
‹ Identify major quasi-experimental designs
‹ Discuss the advantages and disadvantages of various quasi-experimental
designs
Quasi-experimental designs are similar to experimental designs in that they
involve manipulation of the IV, but they do not meet one of the other essential
components of experimental designs (Campbell & Stanley, 1966; Cook &
Campbell, 1979). They either lack randomization or a control group, which makes
claims of cause and effect weaker than in experimental designs. Because of this,
studies using quasi-experimental designs are ranked lower as sources of evidence
than are studies using experimental designs. However, there are many situations
involving the study of human health when it is not feasible or ethical to conduct an
experiment. Therefore, quasi-experimental designs serve an important function in
providing beginning evidence of causality. There are three commonly used quasi-
experimental designs: (1) nonequivalent control group pretest-posttest, (2) time
series, and (3) preexperimental designs (see Table 7-3).
quas i-e xpe rime ntal de s igns : Research designs involving the manipulation of the independent variable but
lacking either random assignment to groups or a control group
TABLE 7-3 Quasi-Experimental Designs
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Nonequivalent Control Group Pretest-Posttest Designs
The nonequivalent control group pretest-posttest design differs from the classic
experimental design in that researchers are unable to randomly assign subjects to
groups. Because researchers are unable to randomize in these designs, the
nonintervention group is referred to as a comparison group rather than a control
group. Researchers are able to measure both groups on the DV prior to and after the
intervention (see Table 7-3). For example, the faculty of a nursing college is
considering changing a nursing research course offered to junior students. In one
semester, a professor administers a pretest measuring knowledge about nursing
research. The professor then teaches the course content in the usual lecture style. At
the end of the semester, the final exam is used as a posttest to measure students’
knowledge of research. The next semester, another group of students enter the
research course. They are given the same pretest, but the instruction is online with
no class lectures. At the end of the semester, the same comprehensive final exam is
administered. The faculty would then be able to compare students’ knowledge pre-
and postintervention and make a determination regarding the effect of the different
teaching methods on students’ knowledge about research. Because students were
unable to be randomly assigned to a teaching method, this is not an experimental
design. Without randomization, it is possible that the students are not equivalent on
important factors that may affect how they learned the course materials. This
contributes to selection bias and weakens the design. Threats to internal validity as
a result of testing, maturation, and mortality can exist.
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none quivale nt control group pre te s t-pos tte s t de s ign: A quasi-experimental design where two groups are
measured before and after an intervention
Time Series Designs
The second most common quasi-experimental design is the time series design.
This type of design may be used when neither randomization nor a comparison
group is possible. Researchers may opt to study one group over a prolonged period
of time prior to administering the intervention and then make multiple observations
after the intervention is conducted. For example, the faculty decides to change the
pass rate on exams from 75% to 80%. They could compare the number of student
nurses passing at 75% for four semesters to the number who pass at 80% over four
semesters. Although many factors contribute to pass rates among student nurses,
following the data for an extended period of time helps faculty to determine the
effect of a policy change.
time s e rie s de s ign: A quasi-experimental design where one group is measured prior to administering the
intervention and then multiple times after the intervention
Preexperimental Designs
One-group posttest-only and nonequivalent-groups posttest-only designs are
often referred to as preexperimental rather than quasi-experimental. The
difference between pre-and quasi-experimental designs is that quasi-experimental
designs, while lacking some elements of an experiment, use other strategies to
control for extraneous variables. With preexperimental studies, many threats to
internal validity can be found because these are posttest-only designs. An example
of a one-group posttest-only study is when a researcher implements an educational
intervention to teach new mothers the benefits of breastfeeding. After the
intervention, the mothers’ knowledge of breastfeeding was tested. Without a pretest
to determine the mothers’ previous knowledge and without any information about
their prior history of breastfeeding, it would be almost impossible to determine
what effect the intervention had on the breastfeeding outcome. One-group posttest-
only designs provide a low level of evidence, and no change in nursing practice
should be made based on this type of design.
one -group pos tte s t-only de s ign: A preexperimental design involving one group and a posttest with little
control over extraneous variables
none quivale nt-groups pos tte s t-only de s ign: A preexperimental design involving two groups measured after
an intervention with little control for extraneous variables
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pre e xpe rime ntal: A posttest-only design that involves manipulation of the independent variable but lacks
control for extraneous variables
Adding a comparison group slightly increases the quality of evidence found in
posttest-only designs. A nonequivalent-groups posttest-only design involves
manipulation of the IV and two or more groups of subjects who are compared on
the DV. For example, a researcher works in an agency where the policy is that all
new mothers will receive the breastfeeding educational intervention. Because
randomization of mothers is not possible, the researcher decides to compare
breastfeeding knowledge of mothers from a hospital requiring the educational
intervention to breastfeeding knowledge of mothers from a hospital that does not
offer that intervention. Because this is a nonequivalent-groups posttest-only design,
it is impossible for the researcher to have any information about breastfeeding
knowledge of the mothers in either group prior to the intervention. It is impossible
to determine the equivalence of the two groups because the researcher does not
have any pretest information. If the results of the study indicated that the mothers in
the intervention group knew more about breastfeeding than the mothers in the
comparison group, can the researcher conclude that the intervention was the cause
of the increased knowledge? It is possible there were other factors, such as
previous positive experiences with breastfeeding, increased family support, and
encouragement to breastfeed by nursing staff, that were more influential in
determining the results. Given that there could be many threats to internal validity,
nurses should be cautious about changing practice based on data from
preexperimental designs.
FYI
Quasi-experimental designs lack an essential component of experimental designs. There are several types
including nonequivalent control group pretest-posttest, time series, and preexperimental designs.
TEST YOUR KNOWLEDGE 7-2
1. Quasi-experimental designs include which of the following essential components?
a. Randomization, control group, and manipulation of the IV
b. Randomization and control group
c. Manipulation of the IV
d. Randomization and manipulation of the IV
2. Experimental designs have control groups. Quasi-experimental designs have which of the
following?
a. Control groups
b. Comparison groups
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c. Extraneous groups
d. Peer groups
3. Rank the evidence generated from the following designs from lowest to highest.
a. Experimental designs
b. Nonequivalent control group pretest-posttest
c. One-group posttest-only
d. Nonequivalent-groups posttest-only
How did you do? 1. c; 2. b; 3. c, d, b, a
7.3 Nonexperimental Designs
At the end of this section, you will be able to:
‹ Describe the purpose of nonexperimental designs
‹ Identify major nonexperimental quantitative designs
‹ Discuss the advantages and disadvantages of various nonexperimental designs
Although experimental designs are considered to provide the strongest quantitative
evidence, that is not the only type of evidence needed for nursing practice. Nurses
are concerned with the whole person in interaction with the environment, and as
such, they need information that is not always available from experimental studies.
Information about personal phenomena such as patients’ thoughts, beliefs, and
subjective experiences, especially related to health care, is often most
appropriately obtained using either qualitative or quantitative nonexperimental
designs, which are descriptive in nature (Campbell & Stanley, 1966; Cook &
Campbell, 1979). Nonexperimental designs also are important when there is little
information known about a particular phenomenon, when it would be unethical to
manipulate the independent variable, or when it is not practical to conduct an
experiment (e.g., lack of resources or excessive burden to the subjects). The
primary difference between nonexperimental and other quantitative designs is that
researchers do not actively manipulate the IV. Even though the IV is not being
manipulated, it is important for quantitative researchers to exert as much control as
possible to avoid threats to internal and external validity. Researchers still need to
protect against bias when conducting these quantitative studies. Bias can be
controlled with carefully selecting the sample, having an adequate sample size to
ensure sufficient statistical power, clearly defining conceptual and operational
variables, using reliable and valid instruments to measure the variables of interest,
and exerting control over the conditions under which the data will be collected.
none xpe rime ntal de s igns : Research designs that lack manipulation of the independent variable and random
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assignment
Nonexperimental designs can be used for the purposes of: (1) describing a
phenomenon in detail, (2) explaining relationships and differences among
variables, and (3) predicting relationships and differences among variables.
Because the IV is not manipulated, researchers using quantitative nonexperimental
designs cannot make claims about cause and effect. Although nonexperimental
designs can be categorized in many ways, they fall into two general categories:
descriptive and correlational.
FYI
Nonexperimental designs are descriptive in nature and can be used to describe phenomena in detail, explain
differences among variables, and predict relationships and differences among variables.
Descriptive Designs
The purpose of descriptive designs is to describe in detail a phenomenon of
interest. Descriptive designs provide a picture of a situation as it is naturally
happening without manipulation of any of the variables. This type of design allows
researchers to identify and document the different characteristics of phenomena and
describe the frequency with which they occur. Because there is no manipulation of
variables and no attempt to establish causality, the terms IV and DV should not be
used with descriptive designs. Instead, the term research variable is more
appropriate. Researchers use descriptive designs for a variety of purposes. These
designs are often used to assess current practice. They can also be used in the early
stages of theory development. Conceptual and operational definitions of the
variables and possible theoretical relationships among the variables can emerge
from descriptive studies. Although most descriptive designs tend to be cross-
sectional, they can be conducted in any of the time dimensions as discussed
previously.
de s criptive de s igns : Designs that provide a picture of a situation as it is naturally happening without
manipulation of any of the variables
Descriptive designs are often called by a variety of names, such as exploratory,
comparative, and survey designs. The term exploratory is used because
descriptive designs are used when little is known about a phenomenon, so
exploration is required. For example, an exploratory design could be used to
determine factors associated with nurses’ willingness to discuss sexual concerns
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with their patients. The term comparative is used if the purpose of the study is to
describe phenomena by comparing two or more groups or two or more variables.
For example, a researcher could use this type of design to describe nurses’
willingness to discuss sexual concerns with patients and compare oncology nurses
to cardiology nurses. Another approach a researcher might take could be to study
oncology nurses and compare their willingness to discuss sexual concerns with
patients to variables such as the nurses’ ages, levels of education, and years of
experience. The term survey is used to indicate that data are obtained through
subjects’ self-report about variables such as their attitudes, perceptions, and
behaviors. Surveys and questionnaires are popular methods used to collect
descriptive data. They can be completed face to face, through the mail, online, or
through telephone interviews.
e xploratory de s igns : Nonexperimental design type used when little is known about a phenomenon
comparative de s igns : Descriptive design type that compares two or more groups or variables
s urve y de s igns : Descriptive design type involving data obtained through subjects’ self-report
A well-controlled descriptive study offers a number of advantages over other
types of quantitative designs. Descriptive designs have flexibility in the methods
that can be used to collect data, often leading to more rapid collection of data and
cost savings. The major disadvantage of this type of design is the inability to
establish causality.
Correlational Designs
Correlational designs are used when researchers are interested in establishing
relationships between two or more variables. When reviewing the evidence from
correlational studies, it is important for nurses to remember that correlation does
not prove causality. Because correlational designs do not involve manipulation of
the IV, no causal statements can be made. For example, for some individuals there
is a correlation between their symptoms of arthritis and changes in the weather.
Before a change in weather, individuals may experience joint pain. However, one
cannot conclude that joint pain causes the weather to change even though there is a
strong correlation between the two phenomena. The best way to interpret a
correlation is to understand that correlations simply mean that the variables covary
—that is, when there is a change in one variable, there will be an associated change
in the other. Evaluating statistical data provides information about the strength of
the relationship, the direction of the relationship (positive or negative), and
whether the relationship is statistically significant. There are three types of
correlational designs commonly reported in the literature: (1) descriptive
correlational, (2) predictive correlational, and (3) model-testing.
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corre lational de s igns : Nonexperimental designs used to study relationships among two or more variables
covary: When change in one variable is associated with change in another variable
Descriptive Correlational Designs
Descriptive correlational designs build on comparative descriptive designs.
Comparative descriptive designs simply describe the phenomena as they occur in
two or more groups or among two or more variables associated with the
phenomena. Descriptive correlational designs are used when researchers are
interested in explaining the degree and characteristics of relationships that exist
among the variables or groups. For example, in the case of nurses’ willingness to
discuss sexual concerns with their patients, the researcher can use a descriptive
correlational design to determine the extent to which level of education or years of
experience is related to the nurses’ comfort with discussing sexual issues.
de s criptive corre lational de s igns : Correlational design type used to explain the relationship among the
variables or groups using a nondirectional hypothesis
Predictive Correlational Designs
Sometimes there is insufficient empirical or theoretical literature for researchers to
assume the degree or direction of the relationships among the variables.
Researchers use descriptive correlational designs to test nondirectional hypotheses.
Like descriptive studies, there is no IV or DV, and the variables are simply referred
to as “research” variables. In other situations, researchers have sufficient evidence
to predict the expected direction of relationships that will be found among the
variables. When this is the case, a predictive correlational design is used.
Researchers hypothesize which variables are predictors and which are outcomes.
Although researchers may be able to predict a statistically significant relationship,
the design is still correlational and causality cannot be assumed. Therefore, even
though it is common to see the terms IV and DV used with this type of design, this is
not technically correct. The variables should be referred to as predictor and
outcome.
pre dictive corre lational de s ign: Correlational design when researchers hypothesize which variables are
predictors or outcomes
There are two major aims of predictive designs. First, and most commonly seen
in nursing, researchers attempt to determine the amount of variance in an outcome
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variable that can be explained by multiple predictor variables. For example, a
researcher is interested in determining which factors are most likely to predict the
quality of life (QOL) in patients receiving dialysis treatments. The researcher could
conduct a study to determine the relationship between the hypothesized predictor
variables of emotional distress, functional status, marital status, employment status,
age, and length of time on dialysis. The researcher could then use statistical tests to
determine the amount of variance in QOL scores that could be predicted by this
group of predictor variables. Suppose the researcher finds that emotional distress
accounts for a large portion of QOL scores, and employment status accounts for
only a small portion of QOL scores. Using this evidence to determine best practice,
nurses should recognize that interventions directed toward alleviating emotional
distress would have a greater influence on dialysis patients’ perceptions of QOL
than would interventions directed toward altering employment status.
Sometimes researchers want to know how accurately a group of predictor
variables can determine group membership. Determining group membership is the
second aim of predictive correlational designs. For example, this type of design
could be used if a researcher wanted to determine to what degree the predictor
variables of age, self-efficacy, level of education, and level of general stress
predict whether a woman will smoke during pregnancy. Data will allow the
researcher to calculate the odds that a woman will be a smoker versus the odds that
she will be a nonsmoker. The outcome variable is the group membership because
women are either predicted to be in the group of smokers or in the group of
nonsmokers. Although correlational studies are considered to produce a lower
level of evidence, odds ratios are growing in popularity as a way to inform
practice.
Model-Testing Correlational Designs
A third type of correlational design is model testing. Researchers use this type of
design to test a hypothesized theoretical model. All related variables are identified,
and specific hypothesized relationships are stated. Researchers create graphic
representations or paths to show the relationships among the variables. For
example, Figure 7-1 is a graphic resulting from a study (Tomake, Morales-Monks,
& Shamaley, 2013) conducted to determine the relationships among variables
related to alcohol problems in college students. Statistical analysis is done to test
all of the relationships at one time. The analysis determines how well the data
collected actually “fit” the hypothesized model. The better the fit of the model to the
analysis, the more likely it is that the predicted theoretical relationships are true in
reality.
mode l te s ting: Correlational design to test a hypothesized theoretical model; causal modeling or path analysis
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Often the term causal modeling is used for model-testing designs, but this is
misleading. Although model-testing designs provide a rigorous test of predicted
relationships among multiple variables based on theory, they can only provide a
suggestion of causality, not true evidence of causality. Modeltesting and predictive
designs, although they establish predictive links between variables, do not allow
researchers to say that variable X causes variable Y. True causality can be
established only with an experimental design. However, because in nursing it is
often unethical to manipulate IVs, model-testing designs provide the strongest
nonexperimental evidence regarding the relationships among variables.
FIGURE 7-1 Diagram of a Structural Equation Model
Source: Reproduced from Tomaka, J., Morales-Monks, S., & Shamaley, A. G. (2013). Stress and
coping mediate relationships between contingent and global self-esteem and alcohol-related problems
among college drinkers. Stress and Health, 29(3), 205–213.
TEST YOUR KNOWLEDGE 7-3
True/False
1. In nonexperimental designs, researchers manipulate the IV to determine cause-and-effect
relationships.
2. Nonexperimental designs can be used to develop and test theories.
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3. The purposes of nonexperimental designs are to describe, explain, and predict relationships.
4. Descriptive data are usually cross-sectional and can be collected through surveys and
questionnaires.
5. Researchers use correlations to determine if there are differences between two groups.
How did you do? 1. F; 2. T; 3. T; 4. T; 5. F
7.4 Specific Uses for Quantitative Designs
At the end of this section, you will be able to:
‹ Define translational research, community-based participatory action research,
and health services research
Quantitative designs are often used in translational research, community-based
participatory action research, and health services research. Because there are
commonalities among these types of research, a study may fit in more than one of
these categories.
Translational research “transforms scientific findings or discoveries from
basic laboratory, clinical, or population studies into new clinical tools, processes,
or applications” (Grady, 2010, p. 164). There are two areas of translation: one
involves moving knowledge from basic, laboratory research into clinical studies;
and the second involves translating best practices identified in those clinical trials
to adoption in the broader community. The purpose of this type of research is to link
basic research to the point of care, ultimately improving patient outcomes.
trans lational re s e arch: Research for the purpose of linking research findings to the point of care
Like EBP, translational research is the study of how nurses and other healthcare
providers can apply scientific findings to address real clinical problems (Grady,
2010; Woolf, 2008). Recall the cycle of scientific development. Translational
research occurs when research findings are disseminated and subsequently applied.
For example, if a cure for the common cold were discovered through basic
research, translational research could be used to determine the best way to
distribute the treatment to individuals. Application of findings provides feedback
for further development of theory and research. For example, if the cure is
distributed and side effects are identified, additional research may be indicated to
improve the product.
FYI
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Quantitative designs are often used to answer research questions involving translational research,
community-based participatory action research, and health services research.
Funding for translational research is increasing because of the recognition that
failure to adopt new innovations thwarts the cycle of science. The Agency for
Healthcare Research and Quality (AHRQ), committed to the support of
translational research, is the federal agency accountable for disseminating research
findings for clinical decision making (AHRQ, 2013).
An alternative to traditional research approaches is community-based
participatory action research (CBPAR; Schmittdiel, Grumbach, & Selby, 2010).
CBPAR is based on a philosophy that when users of research are involved from the
start of the research process, findings that are practical and relevant to community
needs are more likely to result. Critical principles for CBPAR include engaging in
collaborative, equitable partnerships; building on resources and goals present in
the community; creating long-term sustainable partnerships; and using dynamic
processes where ideas flow between researchers and community members
(Schmittdiel et al., 2010). CBPAR aims to combine knowledge from community
members and researchers with a goal for action and social change to improve
community health and often reduce health disparities (National Institutes of Health,
Office of Behavioral and Social Sciences Research, 2013).
community-bas e d participatory action re s e arch: Active involvement of community members throughout the
research process
For example, if nurses wanted to improve the health of immigrants in an urban
area using a CBPAR model, the nurses would first meet with community leaders to
determine the needs, priorities, strengths, and desired outcomes. The research team
and community members would mutually agree upon the purpose and methods to be
used. By working together, they could create an intervention that fit with the
community’s culture and would be sustainable when the research was completed.
However, CBPAR, if done with marginalized or vulnerable populations such as
immigrants, may present ethical issues during the research process that may not
have been identified during the institutional review board review process.
Researchers need to be sensitive to those issues and address them when reporting
findings (Campbell-Page & Shaw-Ridley, 2013).
CRITICAL THINKING EXERCISE 7-2
© Jules_Kitano/ShutterStock, Inc.
A researcher is interested in studying the effect of different medications on the pain of fractures in children
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admitted to the emergency department. The researcher wants to compare intravenous morphine, oral
ibuprofen, and oral acetaminophen with codeine. What kind of design do you think the researcher should
use? Why?
The goals of health services research are to determine strategies to effectively
organize, manage, finance, and deliver high-quality care. Research topics include
ways to reduce medical errors and improve patient safety (AHRQ, n.d.). Studies
often involve multidisciplinary teams. For example, a study might be conducted to
determine how Internet communications can be used to connect healthcare
providers practicing in rural areas to specialists around the world.
he alth s e rvice s re s e arch: Research involving phenomena, such as cost, political factors, and culture, related to
the delivery of health care
TEST YOUR KNOWLEDGE 7-4
1. A researcher is conducting a study to determine whether a radio advertisement about the
importance of early detection for colorectal cancer increases the attendance of middle-aged men at a
free screening. Which type of research is this an example of? (Select all that apply.)
a. Basic research
b. Community-based participatory action research
c. Health services research
d. Translational research
How did you do? 1. c, d
7.5 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss ethical issues related to quantitative designs
When researchers plan studies using quantitative designs, they must incorporate
mechanisms to safeguard the rights of subjects. In nursing and other health research,
no subject can receive less than what is considered to be the usual standard of care.
Even if subjects withdraw from studies, they must continue to receive standard
care. Providing standard care protects subjects’ rights to fair treatment. For
example, in a study testing the effects of several educational programs on patient
outcomes, it would be unethical for subjects in the control group to receive no
education because the usual standard of care is to provide all patients with
education about their care. When studies involve the use of placebos, decisions
about their use must be scrutinized carefully because it is unethical to withhold
treatment while testing a new intervention.
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To protect the autonomy of individuals, they must be made aware of the benefits
and risks of participating in a study so that they can make informed decisions about
participating. All institutional review boards require that a description of benefits
and risks be provided on consent forms. Most researchers also provide verbal
explanations of the benefits and risks when recruiting subjects.
When designing quantitative studies, researchers must assess the associated
benefits and risks of any intervention or test that they plan to use. To protect
subjects from harm, the goal is to maximize the benefits while minimizing the risks.
For example, suppose a researcher is testing radiation doses in women with breast
cancer. Ideally, the researcher should select the dose of radiation that obtains the
desired effect with the least amount of side effects. It would be unethical to
irradiate women with unusually large doses of radiation, even though it could be
hypothesized that larger doses are more effective, because there are known
complications associated with high doses. Consideration must be given to potential
psychological harm as well. For example, suppose a researcher plans to interview
women shortly after their miscarriages. Because miscarriage is an emotional
incident for most women, the researcher must use sensitive language in consent
forms and during interviews. Referring to the product of conception as a baby may
cause undue emotional stress for some subjects.
In some studies, the risk of harm remains high regardless of strategies
incorporated by researchers. For example, a researcher is testing a new medication
for a serious condition. Regardless of whether subjects are assigned to the control
or experimental groups, they are at risk for harm. When it is identified that one
treatment is better than another, all subjects should be offered the best intervention.
At times, unanticipated adverse reactions to interventions occur. When researchers
discover that subjects are having adverse reactions, they should report the reactions
immediately. Careful consideration should be given to discontinuing a study if this
occurs.
FYI
When designing quantitative studies, researchers must assess the associated benefits and risks of any
intervention or test that they plan to use. To protect subjects from harm, the goal is to maximize the benefits
while minimizing the risks.
Researchers have an obligation to minimize subject burden—that is, to place as
few demands as possible on subjects. For example, a researcher is studying the
effects of diet on cholesterol. Careful consideration should be given to the length of
the study and the number of times subjects need to have blood samples drawn. If
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subjects perceive their participation in a study to be too burdensome, there is
greater likelihood that they will not complete the study.
Although it is important to exert control to reduce threats to validity,
researchers must ensure that strategies used are sensitive to the rights of subjects.
When recruiting subjects, care must be taken to follow selection criteria to reduce
selection bias. Sometimes subjects express a desire to be placed in a particular
treatment group. Researchers cannot be swayed by these requests, and they must
adhere to protocols about assigning subjects to groups. When subjects are enrolled
in studies, it can be tempting to coerce subjects to remain in a study to limit threats
related to mortality, but this is unethical. Subjects must feel free to withdraw at any
time without consequences.
TEST YOUR KNOWLEDGE 7-5
Which of the following situations is unethical?
1. A researcher tells a subject that he will not receive as high quality care if he withdraws from the
study.
2. A research assistant carefully explains in English, without using an interpreter, the benefits and
risks of being in a study to a woman who speaks only Spanish.
3. After discovering that subjects are experiencing adverse reactions to an intervention, researchers
agree to discontinue the study.
How did you do? 1. Unethical; 2. Unethical; 3. Ethical
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
You‘ve come a long way in your understanding of how evidence is applied to practice. You are now ready to
enter information about the designs used in Anthony, Wiencek, Bauer, Daly, and Anthony (2010) and Kliger,
Blegen, Gootee, and O‘Neil (2009) into the design column of your grid, which is available within the digital
resources that accompany this book. Look at the examples and note how the types of designs are listed.
Indicate the IVs and DVs if applicable.
RAPID REVIEW
» Experimental designs provide the best evidence of cause-and-effect relationships.
These types of designs must include three features: randomization, control, and
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manipulation. There are six types of experimental designs: two-group pretest-
posttest, two-group posttest-only, Solomon fourgroup, multiple-experimental
groups, factorial, and crossover designs.
» Quasi-experimental designs involve manipulation of the IV but do not meet one of
the other criteria for experimental designs. Three common quasi-experimental
designs are nonequivalent control group pretest-posttest, time series, and
preexperimental designs.
» In nonexperimental designs, the IV is not manipulated; therefore, cause and effect
cannot be established. These types of designs are used to explore phenomena
when the information is scant. Descriptive designs and correlational designs are
two major types of nonexperimental designs.
» Researchers must consider maintaining standards of care and the benefits and
risks of study participation when designing quantitative studies.
» Quantitative designs can be used in translational research, community-based
participatory action research, and health services research.
REFERENCES
Agency for Healthcare Research and Quality. (n.d.). Quality and patient safety. Retrieved from
http://www.ahrq.gov/qual/
Agency for Healthcare Research and Quality. (2013, December). AHRQ profile. Retrieved from
http://www.ahrq.gov/about/profile.htm
Anthony, K., Wiencek, C., Bauer, C., Daly, B., & Anthony, M. K. (2010). No interruptions please. Impact of a
no interruption zone on medication safety in the intensive care units. Critical Care Nurse, 30(3), 21–29.
Campbell, D. T., & Stanley, J. C. (1966). Experimental and quasi-experimental designs for research.
Chicago, IL: Rand McNally.
Campbell-Page, R. M., & Shaw-Ridley, M. (2013). Managing ethical dilemmas in community-based participatory
research with vulnerable populations. Health Promotion Practice, 14, 485–490.
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis issues for field
settings. Boston, MA: Houghton Mifflin.
Grady, P. A. (2010). Translational research and nursing science. Nursing Outlook , 58, 164–166.
Kliger, J., Blegen, M. A., Gootee, D., & O‘Neil, E. (2009). Empowering frontline nurses: A structured
intervention enables nurses to improve medication administration accuracy. Joint Commission Journal on
Quality and Patient Safety, 35, 604–612.
National Institutes of Health, Office of Behavioral and Social Sciences Research. (2013). Community-based
participatory research. Retrieved from http://obssr.od.nih.gov/scientific_areas/methodology/
community_based_participatory_research/
Schmittdiel, J. A., Grumbach, K., & Selby, J. V. (2010). System-based participatory research in health care: An
approach for sustainable translational research and quality improvement. Annals of Family Medicine, 8,
256–259.
Tomaka, J., Morales-Monks, S., & Shamaley, A. G. (2013). Stress and coping mediate relationships between
contingent and global self-esteem and alcohol-related problems among college drinkers. Stress and Health,
277
http://www.ahrq.gov/qual/
http://www.ahrq.gov/about/profile.htm
http://obssr.od.nih.gov/scientific_areas/methodology/community_based_participatory_research/
29(3), 205–213.
Woolf, S. H. (2008). The meaning of translational research and why it matters. Journal of the American
Medical Association, 299(2), 211–213.
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CHAPTER 8
279
Epidemiologic Designs: Using Data to
Understand Populations
Amy C. Cory
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Define epidemiology
‹ Describe the use of epidemiology in nursing practice
‹ Discuss infectious disease using the epidemiologic triangle
‹ Describe transmission
‹ Describe the steps to an outbreak investigation
‹ Describe count data, ratios, proportions, and rates
‹ Define and compute prevalence
‹ Define and compute incidence
‹ Explain descriptive characteristics of person, place, and time when examining
the distribution of disease in a population ‹ Describe descriptive study
designs, including case reports and series, ecologic studies, and cross-
sectional studies ‹ Construct a 2 × 2 data table
‹ Calculate a prevalence ratio for a cross-sectional study design
‹ Describe analytic study designs, including case-control studies, cohort studies,
and intervention studies ‹ Calculate an odds ratio for a case-control study
design
‹ Calculate relative risk for a cohort study design
‹ Define screening
‹ Calculate sensitivity, specificity, and positive predictive value
‹ Explain the relationship between sensitivity and specificity
‹ Describe the use of epidemiologic designs in evaluating health outcomes and
health services in evidence-based practice ‹ List ethical concerns related to
epidemiology
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KEY TERMS
aggregate data
analytic epidemiology
case-control
case reports or series
cohort studies
count data
cross-sectional
descriptive epidemiology
determinants
distribution
ecologic fallacy
ecologic studies
endemic
epidemic
epidemiology
etiology
exposure
false negative
false positive
incidence
intervention study
odds ratio
pandemic
period prevalence
point prevalence
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positive predictive value
prevalence
proportion
rate
ratio
relative risk
screening
sensitivity
specificity
temporal ambiguit
8.1 Epidemiology and Nursing
At the end of this section, you will be able to:
‹ Define epidemiology
‹ Describe the use of epidemiology in nursing practice
Epidemiology is the study of the distribution and determinants of disease in human
populations. Distribution describes the pattern of disease occurrence in and among
populations or subgroups. Determinants are factors that are “capable of bringing a
change in health” (Friis & Sellers, 2009, p. 6). Determinants can be preventative or
causal. For example, immunizations are a method of preventing disease in
populations, while H1N1 is an infectious agent that causes influenza. Epidemiology
is based on two fundamental assumptions: (1) disease does not occur at random,
and (2) the determinants of disease can be identified through systematic
investigation of populations or subgroups within populations (Hennekens & Buring,
1987).
e pide miology: The study of distribution and determinants of disease in human populations dis tribution: The
pattern of disease occurrence in and among populations or subgroups de te rminants : Factors that are capable
of bringing a change in health
The word epidemiology is derived from the Latin prefix of epi meaning “upon,”
the root demos, meaning “the people,” and the suffix logos, meaning “the study of.”
Although epidemiology dates back to Hippocrates, the father of medicine, John
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Snow is considered the modern father of epidemiology as a result of his
investigations into the 1854 cholera epidemic in London.
Epidemiologic principles provide the foundation for public health and are
useful for supporting evidence-based practice. Principles of epidemiology are used
to determine the effect and extent of disease in a population. Knowing these
determinations is important for decision making regarding prevention, treatment,
control, and research of disease in populations. Epidemiology is used to describe
the natural history of disease and to identify the etiology, or cause of disease.
Epidemiology is used in surveillance of disease. Disease surveillance is used to
monitor the distribution of disease and evaluate the effectiveness of prevention and
control programs.
e tiology: The cause of disease
There are two types of epidemiologic investigations: descriptive and analytic.
Descriptive epidemiology examines the distribution of disease in a population in
terms of person, place, and time. The purpose of descriptive epidemiology is to
identify subgroups that may have the highest risk of disease or the outcome of
interest. Epidemiologists also use this approach to find clues about the potential
causes of disease and to generate hypotheses about the relationship between
exposures and outcomes. Analytic epidemiology is used to investigate the
determinants of disease. Differing from descriptive epidemiology, analytic
epidemiology is hypothesis testing and is used to determine the etiology of disease
or health-related outcomes. Special types of statistics are used to determine
associations among determinants of disease.
de s criptive e pide miology: Examination of the distribution of disease in a population in terms of person, place,
and time analytic e pide miology: Investigation of the determinants of disease
Epidemiology is an exciting field by which nurses use CSI-like skills to
investigate patterns of disease to best determine contributing factors with the goal
of improving health outcomes. For example, a nurse in the pediatric intensive care
unit might ask, “What factors are contributing to the increase in gunshot wounds in
September as compared to March?” A family nurse practitioner might ask, “Why
are more children affected by asthma in one county as compared with children in a
neighboring county?” A nurse scientist might ask, “Why are women who cook over
open flames more at risk for upper respiratory infections as compared to women
who cook with gas or electricity?” By understanding findings from epidemiologic
studies that result from questions such as these, nurses can identify strategies to
improve health outcomes. Nurses can then implement various strategies to
determine best practice.
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TEST YOUR KNOWLEDGE 8-1
Indicate whether the following statements are true or false:
1. Epidemiology is the study of disease in populations rather than in individuals.
2. Descriptive epidemiology is used to investigate the determinants of disease.
How did you do? 1. T; 2. F
8.2 Infectious Diseases and Outbreak
Investigations
By the end of this section, you will be able to:
‹ Discuss infectious disease using the epidemiologic triangle
‹ Describe transmission
‹ Describe the steps to an outbreak investigation
Because epidemiology is the study of the distribution and determinants of disease in
human populations, epidemiologists are by nature concerned with infectious
diseases. Their goal is to control infectious diseases and to eradicate them when
possible. Endemic diseases, which are diseases that are localized to a particular
geographic area, are controlled to prevent epidemics or pandemics. Eradication of
a disease occurs when the infectious agent no longer exists in the human population.
For a disease to be eradicated, there needs to be 3 years of data to support that the
population is disease free with no newly occurring cases. Smallpox is the only
disease that has been eradicated.
FYI
Epidemiologic principles provide the foundation for public health and are useful for supporting evidence-
based practice. They are used to determine the effect and extent of disease in a population. Knowing these
determinations is important for decision making regarding prevention, treatment, control, and research of
disease in populations.
Epidemiologists view disease through the lens of the epidemiologic triangle
(see Figure 8-1). The host is the human, the agent is the organism, and the
environment is the world in which we live. Each one of these components
contributes to the control of infectious diseases.
To better understand and control infectious diseases, nurses must understand the
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transmission cycle. Transmission of disease occurs through both direct and indirect
mechanisms. Direct transmission occurs from person to person; indirect
transmission occurs through vehicles (e.g., water, food), vectors (e.g., mosquitoes),
and airborne mechanisms (e.g., droplet, dust).
The purpose of an outbreak investigation is to stop the transmission of disease
from the environment to the host, the host to the agent, or the agent to the
environment. For example, the cycle of transmission of disease from the
environment to the host can be stopped through hand washing, water chlorination,
and food safety. The cycle of transmission of disease from the host to the agent can
be broken with immunizations, isolation, and treatment. Finally, the cycle of
transmission from agent to the environment can be stopped with insect and vector
controls. In an outbreak investigation, nurses can follow steps to prevent further
transmission of disease (see Table 8-1).
FYI
Epidemiologists view disease through the lens of the epidemiologic triangle: The host is the human, the agent
is the organism, and the environment is the world in which we live.
FIGURE 8-1 The Epidemiologic Triangle
TABLE 8-1 Steps of an Outbreak Investigation
1. Research the disease.
2. Verify the existence of an outbreak.
3. Verify the diagnosis.
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4. Define and identify cases.
5. Describe the data in terms of person, place, and time.
6. Develop hypotheses.
7. Test the hypotheses.
8. Implement measures to control the outbreak and prevent further
occurrences.
Source: Modified from CDC (2004).
CRITICAL THINKING EXERCISE 8-1
© Jules_Kitano/ShutterStock, Inc.
When you watch the news, what kinds of outbreaks are reported? Are any of these concerns for college
students? Have you encountered patients diagnosed with a disease associated with an outbreak?
TEST YOUR KNOWLEDGE 8-2
1. All of the following are components of the epidemiologic triangle except: a. agent
b. environment
c. host
d. population
How did you do? 1. d
8.3 Measures of Disease Frequency
At the end of this section, you will be able to:
‹ Describe count data, ratios, proportions, and rates
‹ Define and compute prevalence
‹ Define and compute incidence
Measures of disease frequency are used to quantify health outcomes to describe and
compare populations. Several types of epidemiologic measures are used to
calculate disease frequency. These include count data, ratios, proportions, and
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rates.
Epidemiologic Measures
The simplest measure used is count data. Count data refer to the raw number of
health phenomena under investigation and would include health events such as
births, cases of a disease, and deaths. Count data are not particularly useful when
comparing populations of different sizes. For example, a country with a large
population will have more births than will a country with a small population
regardless of other factors associated with birth rate.
count data: The raw number of health phenomena under investigation in epidemiology
When populations differ in size, epidemiologists use ratios to compare and
contrast health outcomes across populations. A ratio describes a mathematical
relationship between two numbers. The formula is a/b, and the numerator and the
denominator do not necessarily have to have a specified association. For example,
of 1,000 patients with acute myocardial infarction (AMI), 600 were male and 400
were female. The sex ratio for AMIs is
ratio: The highest level of measurement that involves numeric values that begin with an absolute zero and have
equal intervals; in epidemiology a mathematical relationship between two numbers
Proportions and rates are all types of ratios. A proportion is a type of ratio in
which the numerator is included in the denominator. The formula for calculating a
proportion is a/a + b multiplied by 1,000. In a proportion, the numerator and
denominator have an association. The numerator is the number of cases, deaths, or
events, and the denominator is the population being studied. Proportions are used in
epidemiology to describe measures such as prevalence, cumulative incidence, case
fatality rates, and attack rates. For example, of 300,000 children, 3,800 were
diagnosed with an autism spectrum disorder and 296,200 were not. The proportion
for children diagnosed with autism spectrum disorders is
proportion: A type of ratio where the numerator is included in the denominator
The proportion of autism spectrum disorder in this population of children is 12.66
per 1,000 children.
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FYI
Prevalence describes the number of existing cases of disease in a population. It is an indicator of the extent
of a health problem in a population and is used for planning healthcare needs for communities.
A rate is a measure of disease frequency in a defined population over a
specified period of time. Rates are used in epidemiology to describe measures such
as incidence density, crude mortality rates, and fertility rates. When calculating
rate, the numerator is the number of people affected and the denominator is the
entire population. For example, of 6,182 babies born in Lake County in 2011, 52
babies died before reaching their first birthday. The infant mortality rate in 2011
was
rate : A measure of disease frequency in a defined population over a specified period of time
Prevalence and Incidence
In epidemiology two important rates are reported. These rates are named
prevalence and incidence, and they describe the extent to which a disease is present
in a population.
Prevalence describes the number of existing cases of disease in a population. It
is an indicator of the extent of a health problem in a population and is used for
planning healthcare needs for communities. Prevalence may be expressed as a
number, percentage, proportion, or rate. Prevalence rate per 100,000 at a specified
time is
pre vale nce : The number of existing cases of disease present in the population
For example, in 2011, of the 82,692,308 people younger than age 20 years, 215,000
people had diabetes. The prevalence of diabetes in the United States in 2011 in this
age group was
There are two different terms used to describe prevalence. Point prevalence
describes the number of existing cases of disease in a population at a particular
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point in time. For example, one might calculate the point prevalence of flu on a
college campus today and then compare that to the point prevalence of flu on the
same day in the previous year. Period prevalence denotes the number of existing
cases of disease in a population during a specified period of time. The time period
might be a week, a month, a year, or a number of years. For example, nurses at a
campus health center may calculate the period prevalence of flu from the previous
year’s flu season to make decisions about how many flu shots to purchase for the
current year.
point pre vale nce : The number of existing cases of disease in a population at a particular point in time pe riod
pre vale nce : The number of existing cases of disease in a population during a specified period of time
FYI
Incidence rate is a measure of disease occurrence and is used for investigating the causes of disease.
Nurses use incidence rates to investigate risk of disease in populations or subgroups.
Incidence describes the number of new cases of a disease in a population
during a specified period of time. Incidence rate is a measure of disease occurrence
and is used for investigating the causes of disease. Nurses use incidence rates to
investigate risk of disease in populations or subgroups related to many factors such
as age, gender, occupation, and exposures. Incidence is calculated by dividing the
number of new cases that occur during a time period by the number of individuals
who are at risk. Incidence rates involve a multiplier (i.e., 1,000 or 100,000) that is
relevant to the phenomenon.
incide nce : The number of new cases of a disease in a population during a specified period of time
In 2010, of the 6,483,802 people living in Indiana, there were 81 confirmed cases
of Lyme disease. The incidence of Lyme disease in Indiana in 2010 was
TEST YOUR KNOWLEDGE 8-3
Match the following:
1. Count data a. measure of disease frequency in a defined
population over a specified period of time
2. Incidence b. the number of existing cases of disease in a
population
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3. Prevalence c. the raw number of health phenomena under
investigation
4. Rate d. the number of new cases of disease in a
population
How did you do? 1. c; 2. d; 3. b; 4. a
8.4 Descriptive Epidemiology
By the end of this section, you will be able to:
‹ Explain descriptive characteristics of person, place, and time when examining
the distribution of disease in a population
The purpose of descriptive epidemiology is to identify subgroups in populations
that may have the highest risk for a specific disease or outcome. Descriptive
epidemiology is used to find clues about potential causes of disease so that nurses
can generate hypotheses about the relationship between different exposures and
diseases or other health-related outcomes. Descriptive epidemiology is used to
measure disease frequency by person, place, and time to determine why disease
occurs more frequently under certain conditions.
FYI
Descriptive epidemiology is used to find clues about potential causes of disease so that nurses can generate
hypotheses about the relationship between different exposures and diseases or other health-related
outcomes.
Person
Many descriptive characteristics of the person are factors that contribute to the
frequency of diseases and health-related outcomes (see Table 8-2).
For example, nurses know that life expectancy varies with sex. Other
characteristics such as race and ethnicity contribute to life expectancy. Consider the
average life expectancy in the United States for 2011. For all races and both sexes,
life expectancy was 78.7 years. But there are variations in life expectancy
depending on race. For example, Hispanic females have a life expectancy of 83.7
years compared to non-Hispanic white females whose life expectancy is 81.1
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years, while non-Hispanic black females have a shorter life expectancy at 77.8
years (Centers for Disease Control and Prevention [CDC], 2012b).
Place
A second way to examine descriptive characteristics is by place. These also
contribute to the frequency of disease or other health-related outcome (see Table 8-
3).
TABLE 8-2 Examples of Descriptive Characteristics by
Person
Age Alcohol
Diet/Exercise Education
Ethnicity Genetic markers
Marital status Occupation
Parity Race
Religion Sex
Smoking Socioeconomic status
TABLE 8-3 Examples of Descriptive Characteristics by Place
Altitude City
Country County
Distance from exposure site Latitude
Pollution Rainfall
Rural State
Sunlight Urban
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Zip code
For example, obesity is an epidemic in the United States. The frequency of
obesity can be examined by state to identify patterns, also called spatial clustering
(see Figure 8-2). Nurses will note that in the south and in some midwestern states
the prevalence of adult obesity is reported to be between 30% and 35% (CDC,
2013a).
Time
A third way that descriptive epidemiology is used is to investigate by time. Several
temporal factors contribute to disease frequency and other health-related outcomes
(see Table 8-4). Trends can be secular, cyclical, or short term.
FIGURE 8-2 Prevalence of Self-Reported Obesity Among
U.S. Adults
Source: Reproduced from Overweight and Obesity/CDC (2013a).
TABLE 8-4 Examples of Descriptive Characteristics by Time
Secular
• Trends over years
Cyclical
• Seasonal trends
Short-term changes
• Epidemics
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Secular trends, changes in disease patterns that occur over a long period of
time, are often difficult to interpret but can yield important information. For
example, the CDC has trended diabetes over decades. The incidence of diabetes in
adults, aged 18 to 79 years, in the United States has more than tripled from 493,000
in 1980 to more than1.5 million in 2011 (CDC, 2012a).
Cyclical trends, changes in disease patterns that are often predictable and that
recur over time, are seen more readily in health care, particularly as they relate to
infectious diseases. A common infectious disease with a seasonal trend is
influenza. The CDC trends positive influenza test results reported each week.
Figure 8-3 shows that during the 2011–2012 influenza season, positive influenza
test results peaked during the 10th to 12th week of 2012 (CDC, 2012c).
Finally, the frequency of diseases may also be described by short-term trends,
which are brief, unexpected changes in disease distribution. Short-term changes
include epidemics and pandemics. To understand epidemic and pandemic, it is
important first to understand the definition of endemic. Endemic describes the
expected occurrence of a particular disease within a community or population.
Epidemic is a widespread occurrence of a disease in a community or population
that is in excess of what is expected. Pandemic is an epidemic that has spread
worldwide. For example, in 2012 and 2013, Japan experienced an epidemic of
rubella.
e nde mic: The expected occurrence of a particular disease within a community or population e pide mic: A
widespread occurrence of a disease in a community or population that is in excess of what is expected
pande mic: Epidemic that has spread worldwide
FIGURE 8-3 Influenza Positive Tests Reported to CDC by
U.S. WHO/NREVSS Collaborating Laboratories, National
Summary, 2011-2012
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Source: Reproduced from FluView/CDC (2012c).
Until the early 2000s, rubella was endemic in Japan, with periodic epidemics approximately every 5
years and seasonal increases in the spring and summer. The number of reported rubella cases remained
at record low levels until 2010 [n = 87], and in 2011 [n = 378], a few outbreaks were reported in the
workplace among adult males. In 2012, the number of rubella cases sharply increased to 2,392, with the
rise in cases continuing into 2013. From January 1 to May 1, 2013, a total of 5,442 rubella cases were
reported. (CDC, 2013b) These data demonstrated short-term trends in the number of reported cases of
the rubella virus in Japan that were in excess of normal expectancy. As a result, health officials deemed
that Japan was experiencing a nationwide rubella epidemic (CDC, 2013b). As a result of these findings,
Japan initiated a country-wide education and immunization campaign focused on households with
pregnant women to further protect this population from contracting rubella because of the risks to the
unborn child (CDC, 2013b).
TEST YOUR KNOWLEDGE 8-4
1. Diseases that occur over long periods of time are known as: a. cyclical changes.
b. intermittent trends.
c. secular trends.
d. short-term trends.
2. Diseases that spread around the world are known as:
a. endemic.
b. epidemic.
c. international outbreak.
d. pandemic.
How did you do? 1. c; 2. d
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8.5 Descriptive Study Designs
By the end of this section, you will be able to:
‹ Describe descriptive study designs, including case reports and series, ecologic
studies, and cross-sectional studies ‹ Construct a 2 × 2 data table
‹ Calculate a prevalence ratio for a cross-sectional study design
Descriptive study designs are hypothesis-generating and are used to examine
different types of phenomena. These studies include case reports or series, ecologic
studies, and cross-sectional studies.
FYI
Researchers use descriptive study designs to generate hypotheses to examine different types of phenomena.
These types of studies include case reports or series, ecologic studies, and cross-sectional studies.
Case Reports or Series
Case reports or series are used to describe rare diseases or outcomes. The
purpose of these studies is generally to describe new diseases, explain a change in
disease patterns, or alert the healthcare community to unusual signs and symptoms
in an individual patient (case report) or rare findings among a few patients (case
series). Here is an example of a case series:
cas e re ports or s e rie s : Epidemiologic reports used to describe rare diseases or outcomes
In the period October 1980–May 1981, 5 young men, all active homosexuals, were treated for biopsy-
confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of
the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalo-virus (CMV)
infection and candidal mucosal infection…. The diagnosis of Pneumocystis pneumonia was confirmed
for all 5 patients antemortem by closed or open lung biopsy. The patients did not know each other and
had no known common contacts or knowledge of sexual partners who had had similar illnesses. Two of
the 5 reported having frequent homosexual contacts with various partners. All 5 reported using inhalant
drugs, and 1 reported parenteral drug abuse. Three patients had profoundly depressed in vitro
proliferative responses to mitogens and antigens. Lymphocyte studies were not performed on the other
2 patients. (AIDS.gov, n.d.) This edition of the MMWR was the first official report of what later
became known as the AIDS epidemic (AIDS.gov, n.d.).
The advantage of case reports is that this design can be used to describe
unusual signs and symptoms so that healthcare providers may be able to identify
commonalities among patients when a new disease appears in a population. Case
reports also can be helpful in identifying when a current disease mutates. The
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http://AIDS.gov
http://AIDS.gov
disadvantage of case reports is the lack of a comparison group. Without a
comparison group, there is no mechanism to test hypotheses.
Ecologic Studies
Correlational studies are used when the unit of analysis is a population, not an
individual, and are known as ecologic studies. These studies are used to compare a
summary measure of disease frequency across summary measures of exposure.
Merriam-Webster defines exposure as “the condition of being subject to some
effect or influence.” As a result, the nurse is evaluating group-level rates of disease
and exposures. When data from individuals are reported as group information, they
are said to be aggregate data. For example, suppose a nursing administrator has to
report salaries for staff nurses. Rather than telling each individual’s salary, the
nurse administrator would aggregate the data and report the average salary by unit
or by shift. Reporting aggregate data in this manner preserves confidentiality.
e cologic s tudie s : Correlational studies that are population-based rather than individual-based e xpos ure :
Contact with a disease or disease-producing agent aggre gate data: Data collected from individuals that are
grouped to represent a population
Ecologic studies can be used to compare distribution and determinants of
diseases across many different population units such as states, counties, zip codes,
and even schools. For example, epidemiologists can use this type of design to make
comparisons about disease frequency or death rates for different countries or to
compare food consumption or exercise patterns in different states. Another example
is a nurse examining the relationship between childhood obesity and physical
education classes. By plotting the average weights and average number of hours
students spent in physical education classes by schools, a nurse could determine the
association between childhood obesity and physical education classes among
schools.
Ecologic studies offer many advantages. They are expedient and relatively
inexpensive because they often rely on secondary data, which are data that have
already been collected. Ecologic studies can be used to examine a broad range of
exposures and diseases. They are useful when generating hypotheses and may even
be used to evaluate the effectiveness of population-level interventions, such as
immunizations, smoking bans, and seat belts.
Ecologic studies have disadvantages as well. The single greatest disadvantage
is that the nurse is unable to link exposure to disease with specific individuals. For
example, in the study of childhood obesity and physical education classes, the nurse
is unable to determine whether the student who participated the least number of
hours in physical education classes is obese. Another disadvantage is when the
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pattern demonstrated in the population data is not the same as the pattern shown in
the individual data. To take this example further, suppose the nurse finds an
association between aggregate data of students’ weights and aggregate data of hours
spent in physical education classes in the schools she assessed. Based on this
information, the nurse might assume that obese children spend fewer hours in
physical education classes. However, if the nurse were to look at individual student
data, the nurse would find that there is no association between weight and hours
spent in physical education classes. When an observation is made at the group level
and nurses make inferences at the individual level, it is known as the ecologic
fallacy. Another disadvantage of ecologic studies includes situations when there
are differences in data collection systems, disease definitions, treatment modalities,
and survival across population units. These differences can make comparisons
difficult and sometimes inappropriate. Also, inability to control for confounding
variables and inability to determine whether the exposure truly occurred before the
disease, called temporal ambiguity, can compromise the findings.
e cologic fallacy: When false assumptions are made about individuals based on aggregated data and
associations from populations te mporal ambiguity: The inability to control for confounding variables and the
inability to determine whether the exposure truly occurred before the disease
Cross-Sectional Studies
Cross-sectional studies, also called prevalence studies, measure exposure and
disease as each exists in a defined population, or representative sample, at one
specific point in time. These studies provide a snapshot of the current health status
and behaviors, or exposures, of the population. Cross-sectional studies measure the
prevalence of exposure and disease; therefore, the measure of association for
cross-sectional studies is the prevalence ratio (PR). The PR estimates the
magnitude of the association between the exposure and the disease. The PR does
not inform the nurse that the exposure causes the disease because these data are
collected at the same time.
cros s -s e ctional: Nonexperimental design used to gather data from a group of subjects at only one point in time;
study design used to measure exposure and disease as each exists in a population or representative sample at
one specific point in time
It is important to review how data are organized in epidemiology. Data are put
into a 2 × 2 table, also known as a contingency table. The 2 × 2 table categorizes
subjects in a study based on exposure and disease status, where A equals the
number of people with both the exposure and disease; B equals the number of
people with the exposure, but not the disease; C equals the number of people with
the disease, but not the exposure; and D equals the number of people with neither
the disease nor the exposure. It is very important always to place the same
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information in the same cell; otherwise, the calculation will be incorrect.
For example, the Texas Department of Health sent a questionnaire to 1,000
adults to inquire about their blood pressure and exercise patterns. Analysis of the
surveys showed that 100 cases of hypertension (HTN) were reported among those
who exercise more than three times per week, while 400 cases of HTN were found
among those who reported no exercise. Of the 500 cases without HTN, 300
reported exercising more than three times per week and 200 reported no exercise.
These data were entered into a 2 × 2 table as shown here.
Using these data, a PR was calculated using the following formula:
In this study, the exposure of exercising more than three times per week provided a
protective effect for HTN. With protective effects, the PR is subtracted from 1 and
multiplied by 100 to derive the percentage of the reduced risk. People who
exercised more than three times per week were 63% (1 − 0.37 = 0.63 × 100 =
63%) less likely to have HTN as compared to those people who did not exercise at
all.
Cross-sectional studies have advantages and disadvantages. Cross-sectional
studies can be used to explain current exposures and diseases in a given population.
These studies are efficient and relatively inexpensive. They can also be used to
examine a number of different phenomena, including behaviors, symptoms,
diseases, and health status. The investigator is not limited to a single exposure and
disease but can examine multiple exposures and diseases simultaneously. The
major disadvantage of cross-sectional studies is temporal ambiguity. Because data
about exposure and disease status are collected at the same time, an investigator is
unable to ascertain if the exposure preceded the disease. Another disadvantage
exists because cross-sectional studies measure prevalence. Because prevalence is
a function of incidence and duration of time, it is difficult to distinguish
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determinants of the cause of the disease from determinants of survival with the
disease. As a result, with a cross-sectional design, the investigator is not able to
determine whether the specific exposures caused the specific diseases.
TEST YOUR KNOWLEDGE 8-5
Calculate the PR for the following 2 × 2 table
How did you do? PR = 6.02
8.6 Analytic Study Designs
By the end of this section, you will be able to:
‹ Describe analytic study designs, including case-control studies, cohort studies,
and intervention studies ‹ Calculate an odds ratio for a case-control study
design
‹ Calculate relative risk for a cohort study design
FYI
Researchers use analytic study designs to test hypotheses and to test the association between exposure and
disease. These types of studies include case-control studies, cohort studies, and intervention studies.
Analytic study designs are hypothesis-testing and are used to test the association
between exposure and disease. These studies include case-control studies, cohort
studies, and intervention studies.
Case-Control Studies
Case-control studies are designed to sample a group of people with and a group of
people without the disease or the outcome measure being studied. Individuals are
asked to recall their past exposures to risk factors associated with the disease.
Because individuals are recalling their past, these designs are retrospective
designs. Individuals who have the disease are known as cases. Those individuals
who do not have the disease of interest but who are at risk for developing the
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disease are known as controls. Cases are often asked to recall exposures up to 1
year prior to diagnosis. Controls are asked about their history of exposures up to
the point of entry into the study.
cas e -control: A type of retrospective study in which researchers begin with a group of people who already
have the disease; studies that compare two groups: those who have a specific condition and those who do not
have the condition
In a case-control study, the investigator compares the probability of exposure
for persons who have the disease to the probability of exposure for persons who do
not have disease. The statistical test used for a case-control study is the odds ratio
(OR). For example, the Mississippi Department of Health was interested in
examining the relationship between smoking and heart disease. Investigators
examined medical records at Jackson County Hospital and invited 500 patients who
had experienced an AMI to join the case-control study. Then they contacted 500
people from Jackson County who did not have a history of heart disease but who
were similar to the cases in all other demographic areas. The investigators asked
the cases to recall their exposures 1 year prior to diagnosis and asked the controls
to recall their exposures up to the date of the interview. The investigators found that
400 of the cases were current smokers compared to 150 controls who were
smokers. In a 2 × 2 table, the data are expressed as follows:
odds ratio: The statistic reported when epidemiologists conduct a case-control study
The investigators, using the 1,000 participants, calculated an OR using the
following formula:
The value of an OR is interpreted by comparing it to 1.0. When an OR is equal
to 1.0, the probability of disease among the exposed and the nonexposed is
identical; therefore, there is no association between the exposure and the disease.
When an OR is greater than 1.0, there is a greater probability of disease among the
exposed; therefore, there is an association between the exposure and the disease.
An OR of less than 1.0 indicates there is decreased probability of disease among
the exposed or a protective effect. In this example, the value of 9.33 shows that
there is an association between smoking and having an AMI. Individuals who
smoke were 9.33 times more likely to have an AMI compared to those who did not
smoke.
Case-control studies can be advantageous. They are expedient, require a small
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sample size, and are relatively inexpensive. Case-control studies are used to
examine rare diseases and situations that involve individuals who have had many
exposures. Another advantage is that the risk of attrition is low because participants
are asked to recall exposures and thus do not leave the study.
Case-control studies have disadvantages as well. They cannot measure
incidence. These designs are able to examine only one disease rather than many.
The design is not conducive to measuring rare exposures. Because of the
retrospective design, recall bias is a threat. This bias can be especially significant
when cases are searching for a reason to explain why they acquired the disease.
They may be more likely to report potential causes and risk factors as well as
exposures that may not have happened to them.
Cohort Studies
Cohort studies are natural experiments. One famous cohort study is the Nurses’
Health Study that began in 1976. The primary goal of this study was to examine diet
and lifestyle risk factors and their associations with cancer, heart disease, and other
chronic diseases. The study was initiated in 1976 with 120,000 female nurses
between the ages of 30 and 55 years. The population of the study was ethnically
and racially diverse, although all had a higher education than the general population
of women. Now in its third version, nurses continue to be followed and outcomes
have been added (Nurses’ Health Study, n.d.).
cohort s tudie s : Quasi-experimental studies using two or more groups; epidemiologic designs in which subjects
are selected based on their exposure to a determinant
Unlike case-control studies where individuals are selected based on the
presence or absence of disease, in cohort studies individuals are selected based on
their exposure. The investigator selects a sample group that is representative of the
target population. Once the sample has been selected, the investigator assigns
individuals to groups based on their exposure status. Exposure status is
hypothesized to be positively or negatively associated with risk of disease.
Investigators can use either prospective or retrospective designs. Prospective
designs follow individuals from the time they enroll in the study until they develop
the disease. When investigators use retrospective designs, they determine a
historical exposure and then follow the sample forward to the present time to
determine whether the disease is present.
In a cohort study, the investigator compares the probability of disease in
individuals who are exposed to the probability of disease in individuals who are
not exposed. The statistical test used for a cohort study is relative risk (RR). For
example, consider the Mississippi Department of Health study that was previously
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described. Investigators were interested in examining the relationship between
heart disease and smoking. In the previous example of a case-control study, the
investigators sought individuals who had AMIs. In contrast, when using a cohort
design, investigators select individuals based on whether or not they smoke.
Therefore, medical records at Jackson County Hospital were examined and 1,000
patients were invited to join the cohort study. Of the 1,000 patients, investigators
found 550 patients who smoked, and 450 patients who did not have a history of
smoking but who were similar to the smokers in all other demographic areas. They
followed these individuals to see who did and did not have an AMI. Of the 550
patients who smoked, 400 patients developed an AMI compared to only 100
patients who never smoked developing an AMI. These data are recorded in the 2 ×
2 table as follows:
re lative ris k: The statistic reported by epidemiologists when they conduct a cohort study
An RR was calculated using the following formula:
The interpretation of an RR is the same as an OR. An RR equal to 1.0 indicates the
probability of disease among the exposed and the nonexposed is identical;
therefore, there is no association. An RR greater than 1.0 indicates there is a
greater probability of disease among the exposed; therefore, there is an association.
An RR less than 1.0 indicates there is decreased probability of disease among the
exposed or a protective effect. For this example, the RR value indicates that
smokers were 3.27 times more likely to have an AMI compared to nonsmokers.
Cohort studies are advantageous because they can be used to measure incidence
and to study many outcomes. Generally, cohort studies are quite large, so they are a
good design to study rare exposures and can readily establish that an exposure
preceded the disease. Cohort studies are less vulnerable to recall bias.
Cohort studies have disadvantages as well. They tend to be expensive because
of the need for a large sample size and their longitudinal nature. They require a
significant amount of time depending on the disease of interest and are impractical
for rare outcomes. Because cohort studies are longitudinal, the threat of mortality is
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significant because subjects drop out, move, or even die during the course of the
study. Exposures during the course of a cohort study may change. For example, a
person may begin a study smoking two packs per day but during the study may cut
back to half a pack per day or quit smoking entirely. These changes can be
controlled if the investigator measures exposures more frequently throughout the
study rather than simply at baseline.
Intervention Studies
A third design commonly used in epidemiology is an intervention study. The key
feature of this design is that the investigator manipulates the exposure of interest
and then assigns subjects to one or more exposure groups, including a placebo or a
group receiving the standard of care. Like experimental designs, an intervention
study has the hallmark feature of random assignment of individuals into treatment
groups. Randomization is used to control for the effects of confounding variables.
Like cohort studies, the statistical test used for intervention studies is the RR.
inte rve ntion s tudy: In epidemiology, a study that has a treatment that can be manipulated by the researcher
There are advantages and disadvantages of intervention studies. The advantages
include control over the exposure, randomization to control for potential
confounding variables, and blinding to reduce bias. Some disadvantages associated
with intervention studies are costs and time. The study subjects may experience the
Hawthorne effect. Because intervention studies are often time-consuming, subjects
may become noncompliant or withdraw from the study, which biases outcomes. For
ethical reasons, not all exposures are able to be manipulated, and therefore this
design would not be appropriate.
CRITICAL THINKING EXERCISE 8-2
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In your clinical experience, have you encountered any reports of incidence or prevalence? How about OR
or RR?
TEST YOUR KNOWLEDGE 8-6
Match the following:
1. Case-control study a. OR
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2. Cohort study b. RR
How did you do? 1. OR; 2. RR
8.7 Screening
By the end of this section, you will be able to:
‹ Define screening
‹ Calculate sensitivity, specificity, and positive predictive value
‹ Explain the relationship between sensitivity and specificity
In epidemiology, screening involves testing people without known disease to
determine whether they have a disease. Screening is not a diagnostic tool. It is used
to reduce morbidity and mortality in a population. Early detection of disease
allows for early entry into the healthcare system with the idea that early treatment
will lead to more favorable outcomes. For example, newborns are routinely
screened for a variety of genetic diseases, such as phenylketonuria (PKU) and
sickle cell disease.
s cre e ning: Testing people without known disease to determine whether they have a disease; used to reduce
morbidity and mortality in populations
In articles involving screenings, it is important to assess the validity of a
screening test. Investigators often report measures for sensitivity, specificity, and
positive predictive value of the test. Sensitivity describes the ability of the test to
correctly identify people with the disease by positive test results. Specificity
describes the ability of the test to correctly identify people without the disease by
negative results. Positive predictive value is the probability that a person who
screens positive actually has the disease.
s e ns itivity: The ability of the test to correctly identify people with the disease by positive test results
s pe cificity: The ability of the test to correctly identify people without the disease by negative results pos itive
pre dictive value : The probability that a person who screens positive actually has the disease
To calculate sensitivity, specificity, and positive predictive value, investigators
use a variation of the 2 × 2 table as follows:
Disease No Disease
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Positive Screen True positives (TP) False positives (FP)
Negative Screen False negatives (FN) True negatives (TN)
Sensitivity measures the accuracy of the test for identifying who has the disease (TP
and FN) and is calculated as follows:
Specificity measures the accuracy of the test for identifying who does not have the
disease (FP and TN) and is calculated as follows:
Positive predictive value measures the proportion of positive screening test results
that correctly identifies those patients who actually have the disease and is
calculated as follows:
So, what does this mean? If the sensitivity of a test is 80%, then the screening
will correctly identify 80% of the people who have the disease. In other words,
80% of the people who have the disease will test positive, while 20% of the
people who are screened will be missed, which is known as a falsenegative result.
If the specificity of a test is 95%, then the screening will correctly identify 95% of
the people who do not have the disease and 5% of the people without the disease
will have a false-positive result. A false-positive result means that individuals are
told that they have the disease when in reality they do not.
fals e ne gative : When a screening gives a negative result despite the presence of the disease fals e pos itive :
When a screening gives a positive result even though the disease is not present
These principles are evident in the reported estimates about mammography. The
American College of Preventive Medicine (ACPM) and the U.S. Preventive
Services Task Force reported estimates for the sensitivity and specificity for
mammography. For all women, sensitivity estimates range from 75% to 95% with
specificity ranging from 90% to 97% (Ferrini, Mannino, Ramsdell, & Hill, 1996;
U.S. Preventive Services Task Force, 2009). Positive predictive value for
mammography was also distributed by age. For women younger than 50 years of
age, the positive predictive value was about 20% compared to a range of 60% to
80% in women 50 to 69 years of age (Ferrini et al., 1996). With the positive
predictive value for mammography being 20% in women younger than age 50
years, then 20% of the women in this age group who screened positive for breast
cancer during mammography actually have breast cancer. If the positive predictive
value for mammography was 70% in women 50 to 69 years of age, then 70% of the
women in this age group who screened positive for breast cancer during
mammography actually have breast cancer. Therefore, mammography is better at
detecting breast cancer in older women than in younger women.
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FYI
Screening involves testing people without known disease to determine whether they have a disease. It is not
a diagnostic tool but can be used to reduce morbidity and mortality in a population. Early detection of disease
allows for early entry into the healthcare system with the idea that early treatment leads to more favorable
outcomes.
It is important to ascertain the psychological and financial costs to the
population for the consequences of falsenegative and false-positive screening
results. Falsenegative screening results can lead to further progression of disease
without treatment until symptoms become more apparent or the patient is
rescreened. False-positive screening results have psychological effects as well as
potential medical risks and inherent financial costs associated with further
diagnostic assessment because individuals are receiving follow-up care for
diseases they do not have. As a result, decisions must be made when establishing
guidelines for positive and negative results in screenings. These decisions are
based on the perceived costs of false-positive or falsenegative screening test
results.
CRITICAL THINKING EXERCISE 8-3
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Suppose you were told that your stool smear for occult blood was positive. The physician orders a
colonoscopy for you. After the procedure, you are told that your colon is healthy and that the smear must
have produced a false-positive result. How would you feel about this situation?
TEST YOUR KNOWLEDGE 8-7
Indicate whether the following statements are true or false.
1. Screenings are done even when there is no treatment for the disease being screened.
2. Sensitivity describes the ability of the test to correctly identify people without the disease by
negative results.
3. As sensitivity of a test increases, specificity of the test decreases.
4. A false positive is when individuals are told they have the disease when in reality they do not.
How did you do? 1. F; 2. F; 3. T; 4. T
8.8 Evaluating Health Outcomes and
Services
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By the end of this section, you will be able to:
‹ Describe the use of epidemiologic designs in evaluating health outcomes and
health services in evidence-based practice
Epidemiologic designs provide sound methodology for nurses to investigate
patterns of disease to best determine contributing factors to improve health
outcomes and services. Nurses can measure the frequency of disease in clinics,
hospitals, and communities and describe diseases by person, place, and time. They
can examine the cost-benefit of screening initiatives by examining the sensitivity,
specificity, and positive predictive value of screening tests. Outbreaks can be
investigated when there appears to be an excess of disease. By analyzing best
practice with case-control and cohort studies, nurses can evaluate evidence-based
practice interventions using epidemiologic designs and measures.
TEST YOUR KNOWLEDGE 8-8
1. Diseases can be described by all of the following except:
a. dimension.
b. person.
c. place.
d. time.
How did you do? 1. a
8.9 Keeping It Ethical
At the end of this section, you will be able to:
‹ List ethical concerns related to epidemiology
Ethical concerns in epidemiology are similar to those associated with quantitative
designs. For ethical reasons, not all exposures can be manipulated in intervention
studies. For example, it would be highly unethical for an investigator to assign
individuals to a smoking intervention knowing the inherent risks associated with
this behavior.
Risk-benefit ratios must be carefully considered while conducting intervention
studies. Investigators must make informed decisions regarding the potential need to
terminate a study if either the risks or benefits become clearer during the course of
the study.
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Risk-benefit must also be considered when setting guidelines for screenings.
Screening individuals without the ability to provide follow-up is unethical for two
reasons. First, screening conditions for which there is no treatment is a waste of
time and money. Furthermore, undue stress may result for individuals who are made
aware of untreatable conditions. Additionally, this can also result in needless false
positives and false negatives. Best practice dictates that nurses must be wise
consumers of limited healthcare resources and sensitive to the impact that
misdiagnosis can have on the mental health of individuals.
TEST YOUR KNOWLEDGE 8-9
Indicate whether the following statements are true or false.
1. There are no ethical concerns related to false negatives.
2. It would be unethical to expose individuals to asbestos to study the disease pattern.
How did you do? 1. F; 2. T
RAPID REVIEW
» Epidemiology is the study of disease in populations.
» Nurses use epidemiology to determine the effect and extent of disease in a
population.
» The epidemiologic triangle consists of agent, environment, and host. If one
relationship can be altered, then the spread of infectious disease can be reduced
or eliminated.
» Direct transmission of disease is spread person to person. Indirect transmission
involves vehicles, vectors, and airborne mechanisms.
» When an outbreak occurs, nurses can follow eight steps to prevent further
transmission of disease.
» Epidemiology involves data that can be expressed as count data, ratios,
proportions, and rates.
» Prevalence is the number of existing cases of disease that are present in the
population.
» Incidence is the number of new cases of disease that are present in the population
during a specified period of time.
» Characteristics of person, place, and time are important when examining the
distribution of disease in a population.
» Descriptive study designs include case reports, ecologic studies, and cross-
308
sectional studies.
» Epidemiologic data are often expressed in a 2 × 2 data table that compares the
exposed and unexposed cases to whether or not a disease is present.
» Epidemiologists calculate a PR when they use a cross-sectional study design.
» Analytic study designs include case-control studies, cohort studies, and
intervention studies.
» Epidemiologists calculate an OR for a case-control study design. They calculate
an RR when conducting a cohort study.
» Screenings are tests to identify symptoms of disease and are not diagnostic.
Screenings involve testing people without known disease to determine whether
they have a disease. They are used to reduce morbidity and mortality in a
population.
» Sensitivity, specificity, and positive predictive value are measures used to
describe the validity of a screening test.
» When the sensitivity of a test increases, the specificity of the test will decrease.
When the sensitivity decreases, specificity will be increased.
» Epidemiologic designs can be used to investigate patterns of disease and evaluate
cost-benefit of screening initiatives.
» False-positive and falsenegative results from screenings can have ethical
implications related to psychological and financial costs.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Your committee has found an article by Ausserhofer, Schubert, Desmedt, Blegen, DeGeest, and
Schwendimann (2013). These researchers used a cross-sectional survey to examine the patient-safety
climate and nurse-related organizational factors. Look on page 248 to see a table showing the relationship
between organizational variables and seven patient outcomes using ORs. Which nurse variable is associated
with medication errors? (Hint. Look for the adjusted OR that is greater than 1.0.) How can these results be
used to justify adequate staffing levels of nurses?
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http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm
http://www.cdc.gov/nchs/data/databriefs/db115.htm
http://www.cdc.gov/flu/weekly/weeklyarchives2011-2012/weekly39.htm
http://www.cdc.gov/obesity/data/adult.html
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a1.htm?s_cid=mm6223a1_w
http://c.ymcdn.com/sites/www.acpm.org/resource/resmgr/policy-files/polstmt_breast
http://www.channing.harvard.edu/nhs/?page_id=70
http://www.uspreventiveservicestaskforce.org/uspstf09/breastcancer/brcanrs.htm
CHAPTER 9
311
Qualitative Designs: Using Words to
Provide Evidence
Kristen L. Mauk
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Define qualitative research
‹ Describe sampling techniques in qualitative research
‹ Discuss the three major sources of qualitative data
‹ Explain analysis and interpretation methods with qualitative data
‹ Describe techniques used to meet the four elements of evaluation
‹ Distinguish among the four major types of qualitative research
‹ Discuss the philosophical underpinnings of four major types of qualitative
research
‹ Explain the focus of phenomenological inquiry
‹ Give an example of grounded theory used in nursing
‹ Name a major nurse contributor to the advancement of ethnographic research
‹ List two hypothetical examples of historical research in nursing
‹ Discuss how qualitative studies can be used to create evidence-based practice
(EBP)
‹ Discuss ethical considerations that are unique to qualitative methods
KEY TERMS
audit trail
bracketing
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case studies
confirmability
credibility
data reduction
data saturation
dependability
emic
ethnography
ethnonursing
ethnoscience
etic
fieldwork
focus groups
gatekeeper
grounded theory
historical
informants
key informants
lived experience
member checks
memoing
participant observation
participants
peer debriefing
persistent observation
phenomenology
purposive
referential adequacy
snowball sampling
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strategic sampling
transferability
9.1 What Is Qualitative Research?
At the end of this section, you will be able to:
‹ Define qualitative research
‹ Describe sampling techniques in qualitative research
‹ Discuss the three major sources of qualitative data
‹ Explain analysis and interpretation methods with qualitative data
‹ Describe techniques used to meet the four elements of evaluation
Qualitative research was first used by disciplines such as the social and
psychological sciences. It is used to answer questions related to the hows and whys
of behavior that are not easily explained through quantitative methods, to
investigate topics about which little is known, or to generate theory. Nursing,
although using qualitative research since the 1970s, has only recently begun to
embrace qualitative methods as an equally valuable means to explore certain topics
while advancing the science and providing foundational evidence for best practice.
Unfortunately, in the evidence-based practice (EBP) process, qualitative research
is still considered to be far less compelling than quantitative research is because of
the subjective nature of data analysis and interpretation.
In contrast to quantitative research, qualitative research focuses on words
instead of numbers, on understanding and giving meaning to a phenomenon or an
event. Data often stem from telling stories, describing events, analyzing case
studies, and examining context, all of which emphasize words versus numbers and
statistics (Anthony & Jack, 2009). Qualitative research is more exploratory and
inductive, while quantitative research aims to reach conclusions by deduction and
hypothesis testing. In deciding whether qualitative methods would be appropriate to
the topic being studied, Patton (2003) suggested a checklist such as the one found in
Table 9-1.
With qualitative studies, researchers often discover those important aspects of
inquiry that would be easily missed if the researchers had relied completely on
quantitative data. Qualitative research is often the most appropriate method of
inquiry for subjects that have been scarcely studied and for those topics about
which the researcher wishes to obtain a different viewpoint. For example, if a
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nurse was interested in exploring the healthcare practices of a culture different from
his or her own, and one that had not been referenced in the research literature, a
type of qualitative research method would be the logical place to begin. The nurse
would not expect to be able to develop an appropriate questionnaire or instrument
to measure healthcare practices in a culture about which nothing had been
previously written or studied. So, qualitative methods are useful to answer
descriptive and exploratory questions.
TABLE 9-1 Example of a Qualitative Evaluation Checklist
1. Determine the extent to which qualitative methods are appropriate given the
evaluation’s purposes and intended uses.
2. Determine which general strategic themes of qualitative inquiry will guide
the evaluation. Determine qualitative design strategies, data collection options,
and analysis approaches based on the evaluation’s purpose.
3. Determine which qualitative evaluation applications are especially
appropriate given the evaluation’s purpose and priorities.
4. Make major design decisions so that the design answers important
evaluation questions for intended users. Consider design options, and choose
those most appropriate for the evaluation’s purposes.
5. When field work is part of the evaluation, determine how to approach field
work.
6. When open-ended interviewing is part of the evaluation, determine how to
approach the interviews.
7. Design the evaluation with careful attention to ethical issues.
8. Anticipate analysis—design the evaluation data collection to facilitate
analysis.
9. Analyze the data so that the qualitative findings are clear and credible and
they address the relevant and priority evaluation questions and issues.
10. Focus the qualitative evaluation report.
Source: Patton, M. Q. (2003). Qualitative evaluation checklist. Retrieved on
November 21, 2013 from http://citeseerx.ist.psu.edu/viewdoc/summary?
doi=10.1.1.135.8668.
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http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.135.8668
The Basics of Qualitative Research
Before nurses can apply findings from qualitative studies to nursing practice, they
must have the ability to critically appraise and evaluate qualitative studies.
Understanding the basics of sampling, collecting data, analyzing and interpreting
data, and evaluating findings is necessary so that nurses can ensure that qualitative
evidence is trustworthy.
Sampling
In qualitative research, the volunteers who participate in a study are called
participants rather than subjects. Participants are also known as informants. The
sampling method used is purposive rather than random, which is preferred in
quantitative methods, because in qualitative methods, the researchers wish to obtain
information from specific persons who could provide inside information about the
subject being studied. Such people are sometimes referred to as key informants
because they have intimate knowledge of the subject being investigated and are
willing and able to share this with the researcher. A purposive sample is one
selected intentionally, yet it includes volunteers who are willing to tell their stories.
participants : Individuals in a qualitative study; informants
informants : Individuals in a qualitative study; participants
purpos ive : Sampling method to recruit specific persons who could provide inside information
ke y informants : Individuals who have intimate knowledge of a subject and are willing to share it with the
researcher
Another type of sampling often used alone or in combination with purposive is
called snowball sampling. This refers to the accumulation of participants based on
word of mouth or referrals from other participants. For example, if a researcher
interviewed a participant in his home and he mentioned that he attended a support
group with others who might wish to talk with the researcher, this referral to the
support group could be an additional source of participants for the study. If those in
the support group suggest others who might be included in the study, the number of
participants snowballs by referrals from the existing sample. Qualitative
researchers often find this to be an effective way to identify key informants.
s nowball s ampling: Recruitment of participants based on word of mouth or referrals from other participants
The number of participants in a qualitative research study is also different from
the numbers involved in quantitative methods. Generally, a smaller number is
involved (often 6 to 10 participants in many studies). Instead of being determined
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by the number of variables the researchers might include in a quantitative study, in
qualitative designs sample size is determined by the information being provided by
the participants. Data collection stops when no new information is being obtained
and repetition of information is consistently heard. This is called data saturation.
data s aturation: In qualitative research, the time when no new information is being obtained and repetition of
information is consistently heard
FYI
Researchers in nursing have only recently begun to embrace qualitative methods as equal in value to
quantitative research to advance the science and provide foundational evidence for best practice. However,
qualitative research is still gaining acceptance in the EBP process because of the subjective nature of data
analysis and interpretation.
Collecting Data
There are three main sources of data in qualitative research: (1) in-depth
interviews, (2) direct observation, and (3) artifacts such as written documents,
photographs, and physical objects. Each of these sources of data provides rich
information for researchers. The data come from fieldwork, which is a term used to
describe the time researchers spend interacting with participants through
interviews, observations, and sessions during which detailed records are created.
These records include field notes, methodological logs, and reflective journals.
Field notes include notations made before, during, and after contacts with
participants to record observations about such details as the participant’s mood,
environment, and others in the setting. Methodological logs are used to document
the researcher’s decisions about the study, such as changing an interview question
or coding data. Researchers also use a reflective journal to record personal
feelings and insights as studies progress. These records are important mechanisms
for keeping the researcher true to the data. The researcher must continually refer
back to the data in these records as analysis and interpretation progress.
fie ldwork: The time researchers spend interacting with participants through interviews, observations, and
detailed records
The interview is often the key source of data in qualitative research. Generally,
interview questions are open ended, allowing the participant to respond freely and
provide the most information possible. The researcher may use an unstructured
interview and then follow up with questions as the informant leads. However, most
researchers compile a set of questions that arise from the literature review or
previous interviews, and these questions guide the discussion with interview
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participants. The skill of the researcher as an interviewer is important in qualitative
research. A common saying is “in qualitative inquiry the researcher is the
instrument” (Patton, 1990, p. 14). This means that the qualitative researcher should
be skilled in the art of communication and be able to pick up on key words,
phrases, thoughts, or ideas informants mention during the interview. Researchers
use themselves as tools to solicit information from key informants to obtain the
most accurate and useful data for the study.
Researchers should avoid common pitfalls of qualitative research (Easton,
McComish, & Greenberg, 2000). They should pay attention to seemingly simple
details such as bringing backup batteries for the tape recorder, having plenty of
space on the video recorder to complete an interview that runs longer than
expected, being sure there is a power source available if using electricity, and the
like. A quiet place where the interview can be conducted without interruption is
essential. The investigators must anticipate every problem and have a plan in place.
The normal interruptions of daily life make it difficult enough to conduct an
interview, even without common problems interfering.
Recruiting volunteers who are willing to be interviewed can present a
challenge. Nurse scientists may find participants by advertising in newspapers or
newsletters, visiting support groups, using the media such as television or radio,
posting fliers in places where potential participants might be, or partnering with a
healthcare facility that services patients who may volunteer. For example, a nurse
who wishes to recruit older people for a study about their attitudes toward living
arrangements might find participants in independent living homes, church groups,
senior centers, long-term care facilities, inter-generational care centers, and even
the grocery store. In addition, snowball sampling may work well with this
population. Whichever method of recruiting participants is used, it is essential that
the researcher maintain integrity, obtain informed consent, and have institutional
review board (IRB) approval to protect the rights of participants and maintain
scientific rigor.
Interviews are generally audio-or videotaped as unobtrusively as possible. The
interview must be sufficiently long to allow participants to share all essential
information. A typical interview may last between 30 and 90 minutes. Open-ended
responses and direct quotations are basic sources of data. The researcher also
keeps notes during or immediately after the interview to record thoughts, ideas, and
reflection on the interview itself. This provides additional contextual data from
which to view the results.
The researcher continuously compares information obtained from various
interviews, documents, or other sources. Unlike in quantitative research, the
interview questions may even change over time as the researcher collects
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additional data that prompt exploration in other directions. The researcher must
keep in mind that the purpose of the interview is to obtain as much pertinent
information as possible about the phenomenon being studied and that the person
with this information is the participant.
After an interview is complete, it is transcribed verbatim and printed for
review. Simple mistakes during transcription can change the meaning of a phrase,
even making it read the opposite of what the participant actually said. Although
most researchers have support personnel who assist with transcribing, if the
transcriber is unfamiliar with the jargon or slang used by the participant, common
errors can occur. The researcher is ultimately responsible for the tapes being
correctly transcribed. Researchers typically read over the line-by-line
transcriptions many times prior to analysis and interpretation. When researchers
use software to help with data analysis, they must also be careful to continually
revisit the data throughout all stages of analysis. Waiting until later stages of data
analysis to perform queries in the software program can result in inconsistencies in
the results (Bergin, 2011).
Participant observation is the term most often used to describe the role of the
researcher in qualitative data collection (Spradley, 1979). Entire books have been
written on this subject because of its importance to the data collection process. The
researcher is not merely an observer but also a participant during data collection.
Because researchers are considered to be tools for obtaining information, they
cannot be merely a detached observer in most cases. For example, a nurse scientist
studying how prostate cancer survivors cope with urinary incontinence after
surgery might choose to sit in on a support group for these patients. As a participant
observer, the nurse might ask questions of the group while keeping notes on patient
interactions and the main topics of concern. The nurse would be a part of the
support group for that day rather than a nonparticipating attendee. The members of
that support group may even later become key informants to the nurse’s study of this
subject. The role of participant observer takes on an even greater meaning if the
researcher has personally experienced the phenomenon being studied. In the
preceding case, if the researcher had experienced surgery for prostate cancer and
suffered the complication of urinary incontinence, he might participate within such
a group at a deeper level. In such a case, however, the researcher must be careful
not to allow the bias of personal experience to cloud the results that arise from the
data collected from others.
participant obs e rvation: Role of the researcher in qualitative methods when the researcher is not only an
observer but also a participant during data collection
Artifacts provide an additional source of data in qualitative research. This is
particularly true in historical research when the main source of data is
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governmental reports, journals, books, memos, photographs, letters, or diaries. It is
important for researchers to remember when using these sources that they can
provide only a snapshot in time. Furthermore, the researcher must determine the
authenticity of these sources of evidence. There is always room for discussion
about the interpretation of findings (Marshall & Rossman, 2011).
Analyzing and Interpreting Data
Although data analysis techniques may vary somewhat depending on the type of
qualitative method used, some general comments can be made. Data analysis in
qualitative research involves description, data reduction, analysis, and
interpretation. Unlike quantitative methods where analysis occurs only after data
collection is completed, qualitative data analysis occurs as data are collected.
Immersion refers to the data collection process in which the researcher
“lives” with the data over time. The researcher should constantly reflect on the data
and make comparisons with existing data as new information is obtained. Reading
and rereading the text that has been transcribed verbatim are essential. The
researcher should live with the data for a significant time, comparing every piece
of data with the others.
Researchers use a technique called memoing to record ideas that come to them
as they live with data. Researchers must keep paper and pencil or their tape
recorder handy because ideas may occur at any moment. It is important to memo
ideas as they occur because it is difficult to re-create them after a period of time.
Researchers use self-reflection to explore personal feelings and experiences to
minimize their biases. This is important because analysis and interpretation are
inherently subjective in qualitative research. Bracketing is a strategy used by
researchers to set aside their personal interpretations to avoid bias.
me moing: A technique used in qualitative research to record ideas that come to researchers as they live with
the data
bracke ting: A strategy used by qualitative researchers to set aside personal interpretations to avoid bias
Data reduction occurs when the researcher begins to simplify the large
amounts of data obtained from interviews and/or other sources. Terms, ideas, or
quotations from transcribed interviews are identified to help the researcher focus
on the common themes and patterns that will emerge. The researcher attaches
meanings to certain portions of the data that seem to best represent what the
majority of participants have reported. Data segments may be coded and indexed by
identifying categories in the data. Repeated words or common ideas are noted.
Computer software may be of great assistance in managing these data and helping to
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assign codes, numbers, colors, or other distinguishing marks to sets of data as the
researcher attempts to group the data into meaningful segments.
data re duction: The simplification of large amounts of data obtained from qualitative interviews or other
sources
After the data have been reduced in some fashion, the researcher identifies
themes, patterns, and relationships. Essential to analysis and interpretation is that
the themes, categories, or patterns that are ultimately chosen to represent the data
do just that—represent what most of the participants in the study said. In qualitative
research, one must be “true to the data” and build in continuous checks and
rechecks to be certain that the labels assigned to various themes or patterns reflect
what participants have told the researcher. Often, words used by the study
participants form the basis for categories assigned.
The final phase of managing the data is interpretation. Interpretation is critical
because it brings the message of the participants to the public for reading and
application. The researcher uses interpretation to provide meanings that can be
used in EBP. Interpretation is open to subjectivity because it is likely that no two
researchers would interpret the meaning of the data in exactly the same way.
Cassidy (2013) cautioned qualitative researchers to beware of hubris, defined as
overconfidence and exuberance for one’s interpretations of the data that could
potentially influence or cloud the accuracy of conceptual development. However, in
spite of the inherent difficulties of defending the results and analysis of qualitative
research, Sandelowski (2010) concluded that “qualitative descriptive research is
still interpretive” (p. 79). To establish scientific rigor, other nurse scientists should
be able to follow the paper trail and the researcher’s analysis and to agree that the
interpretation and results reported are true to the data obtained from the
participants.
FYI
The interview is frequently used as the key source of data in qualitative research. Interview questions are
generally open ended, allowing the participant to respond freely and provide the most information possible so
that there is an abundance of data from which to draw interpretations.
In some types of qualitative research, theory development is an expected
outcome. In this case, the researcher must identify concepts and find links or
relationships among them to form a theory. The theory is then shared with
participants to ensure that it reflects or captures what they experienced or felt.
Remember that theories just provide a blueprint or framework from which to view
a phenomenon and that they need to be tested and refined.
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Evaluation
Guidelines have been established for evaluating qualitative research. Because
qualitative methods are so different from quantitative methods, terms such as
validity and reliability are not useful.
However, checklists have been developed to help evaluate the results of
qualitative research (Boeije, van Wesel, & Alisic, 2011; Patton, 2003). Lincoln and
Guba (1985) provided what remains the standard for evaluation of qualitative
research. There are four essential elements of evaluation: credibility,
transferability, dependability, and confirmability. Credibility is the qualitative
equivalent of validity in quantitative research. It refers to the truth or believability
of the findings (Leininger, 1985). Credibility is established through many strategies
that are built into qualitative research. Strategies include persistent observation,
peer debriefing, referential adequacy, and member checks.
cre dibility: One of four criteria for establishing a trustworthy qualitative study; refers to the truth or believability
of findings
trans fe rability: One of four criteria for a trustworthy qualitative study that relates to whether findings from one
study can be transferred to a similar context; application of findings to a different situation
de pe ndability: One of four criteria for a trustworthy qualitative study that relates to consistency in the findings
over time; auditability; findings are reflective of data
confirmability: One of four criteria for a trustworthy qualitative study that relates to the rigorous attempts to be
objective and the maintenance of audit trails to document the research process; findings can be substantiated by
participants
pe rs is te nt obs e rvation: When the researcher has spent sufficient quality time with participants while
attempting to describe and capture the essence of the phenomenon
pe e r de brie fing: A technique used in qualitative research in which the researcher enlists the help of another
person, who is a peer, to discuss the data and findings
re fe re ntial ade quacy: A technique used in qualitative research in which multiple sources of data are compared
and the findings hold true
me mbe r che cks : A strategy used in qualitative studies when the researcher goes back to participants and
shares the results with them to ensure the findings reflect what participants said
Persistent observation means that the researcher has spent a good deal of
quality time with the participants while attempting to describe and capture the
essence of the phenomenon being studied. The nature of qualitative research
requires prolonged engagement. Thus, it is not considered to be a quick form of
research.
Peer debriefing is when the researcher enlists the help of another person who is
educationally prepared at a similar level to the researcher and who would be
considered a peer. Throughout the study the researcher meets on at least several
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occasions with the peer debriefer, who has consented to assume this role. The
researcher and peer debriefer discuss the data and findings, as well as the
researcher’s reflections, feelings, and struggles. The peer debriefer provides
another pair of eyes to examine the consistency of the researcher’s interpretation of
the data, thus holding the researcher accountable during this process. This is an
excellent strategy for new researchers, particularly doctoral students, in that it
provides support as well as validation for the student.
Referential adequacy and member checks are additional ways to establish
credibility of qualitative research (Lincoln & Guba, 1985). Referential adequacy is
satisfied when a researcher can refer to other sources of data, such as photos or
journals, for comparison and have the results hold true when referencing these other
data. Member checks involve the researcher going back to study participants either
during or after the study, or both, and sharing the results with them to be sure that
the end product reflects what the participants said.
Transferability relates to whether the findings from one study can be transferred
to a similar context. The goal of qualitative research is to understand a particular
phenomenon (Leininger, 1985) rather than generalizing to a population as in
quantitative methods. Transferability is accomplished through techniques such as
eliciting thick descriptions, executing adequate sampling, and achieving data
saturation. Thick descriptions involve rich, written comments and narrative related
to the situation being studied. Journals and mementos that help to enlighten the
process can be kept. Deep and detailed description is needed to establish the
scientific rigor of the study. Therefore, researchers must maintain an audit trail that
can demonstrate the researcher’s decision making throughout the study. Adequate
sampling means that the researcher took enough time to be sure that data saturation
was reached. That is, enough subjects were interviewed so that consistent patterns
and themes emerged prior to stopping data collection. When no new information is
being obtained, data saturation is said to have been achieved.
audit trail: The documentation of the research process and researcher’s decision making in qualitative studies
The criterion of dependability is satisfied when the researcher has established
sufficient audit and paper trails through accurate and detailed journaling and logs.
Record keeping and reflective writing are essential in this type of research. Other
people, such as peer debriefers, should be able to look at the researcher’s writings
and see that the theory or results accurately reflect the data.
Confirmability means that the researcher made rigorous attempts to be objective
and that audit trails were kept to document the research process. Evaluating
interview questions to ensure that they are open ended and not leading is important
for ensuring confirmability. The reader must be satisfied that the researcher has
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revealed that data were confirmed with the participants through member checks.
The researcher’s written records should reveal a detailed review of the data,
careful analysis and coding, and detailed logs and field notes.
CRITICAL THINKING EXERCISE 9-1
© Jules_Kitano/ShutterStock, Inc.
Which of the three types of data collection would you use to answer each of the following questions? How
would you defend your choice of data collection method for each of these items? Would a combination of
methods be appropriate for any of the questions below? If so, why?
1. What factors influence a student nurse’s decision in choosing his or her first job after graduation?
2. How did Florence Nightingale choose elements to focus on when she began to formalize nursing
as a profession?
3. What influences whether a nurse reports a medication error to his or her supervisor?
TEST YOUR KNOWLEDGE 9-1
1. Which of the following terms are associated with qualitative sampling? (Select all that apply.)
a. snowball
b. random
c. purposive
d. subjects
2. Which of the following are techniques for maintaining scientific rigor in qualitative studies?
(Select all that apply.)
a. achieving saturation
b. thick descriptions
c. peer debriefing
d. generalizing to populations
How did you do? 1. a, c; 2. a, b, c
9.2 The Four Major Types of Qualitative
Research
At the end of this section, you will be able to:
‹ Distinguish among the four major types of qualitative research
‹ Discuss the philosophical underpinnings of four major types of qualitative
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research
‹ Explain the focus of phenomenological inquiry
‹ Give an example of grounded theory used in nursing
‹ Name a major nurse contributor to the advancement of ethnographic research
‹ List two hypothetical examples of historical research in nursing
‹ Discuss how qualitative studies can be used to create evidence-based practice
There are four major types of qualitative research: phenomenology, grounded
theory, ethnography, and historical. Each of these types of research has
distinguishing characteristics, so it is important for a researcher to select a method
appropriate to the question. Table 9-2 provides a comparison of these four major
types.
phe nome nology: A type of qualitative research that describes the lived experience to achieve understanding of
an experience from the perspective of the participants
grounde d the ory: A type of qualitative research that examines the process of a phenomenon and culminates in
the generation of a theory
e thnography: A type of qualitative research that describes a culture
his torical: A type of qualitative research used to examine events or people to explain and understand the past to
guide the present and future
TABLE 9-2 Comparisons of Qualitative Methods
Type of
Qualitative
Research
Focus
Example
Question
Phenomenology Lived experience
What is the lived
experience of a woman
dying from breast cancer?
Grounded theory Process
What is the process of
recovery following breast
cancer?
Ethnography Culture
What are the self-breast-
exam practices of
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Amerasian women?
Historical The past
What were the ancient
Romans’ basic beliefs
regarding diseases of the
breast?
Phenomenological Research: Studying the Lived
Experience
Phenomenology is the method used when one wishes to study lived experience. The
general question being asked is, “What is the meaning of…?” The goal is to
achieve understanding of an experience from the perspective of the participants.
live d e xpe rie nce : The perspective of an individual who has experienced the phenomenon
Philosophical Underpinnings
Phenomenology has its roots in the human sciences. Edward Husserl and Martin
Heidegger were philosophers whose work inspired current phenomenology.
Husserl was a German philosopher credited with moving from naturalistic science
to philosophical reduction by separating the researcher’s preconceived notions to
reveal a true lived experience. “Husserl’s phenomenology emphasized a way of
coming to know through the actual experience of a phenomenon (experiential
epistemology) with a goal of describing the experience of the phenomenon. Thus
methodology inspired by Husserl is often called description methodology”
(Converse, 2012, p. 29).
Heidegger’s philosophy was influential in the development of the use of
phenomenology in nursing today. He supported the idea that the researcher needs to
know about the history of an individual in order to have proper context for
investigation. Heidegger (1962) believed “that the meaning of being is an important
way of understanding human existence” (Pratt, 2012, p. 12). The concepts of “time”
and “being” were essential to helping researchers have a context to explore the
lived experience of others. Phenomenology focuses on the human experience and
causes the nurse to ask why a particular phenomenon has occurred. In addition,
Heidegger saw nurses’ experience as a valuable part of the research process.
“When conducting research using the Heideggerian perspective, researchers can
draw on their backgrounds as nurses” (Pratt, 2012, p. 13).
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Method
Using purposive sampling, phenomenological studies more than likely will have
small sample sizes, depending on the phenomenon being studied. For example, in
Su and Chen’s (2006) study of women terminating treatment after in vitro failure,
the sample size was 24. Women were selected from a common area and clinics
because they were likely to have shared similar experiences. Case studies can also
provide a description of the lived experience. For example, Marshall, Kitson, and
Zeitz (2012) examined the views about patient-centered care based on 10 patients
on a surgical unit in Australia. The case study was a unit of persons with like
experiences. It is important to keep in mind that one person’s experience may be
unique and not totally reflective of the experiences of others.
cas e s tudie s : A description of a single or novel event; a unique methodology used in qualitative research that
may also be considered a design or strategy for data collection
Data Collection and Management
Most of the data for phenomenological research are obtained from fieldwork,
particularly interviews with people who have experienced the phenomenon being
examined. Marshall and Rossman (2011) described phenomenological interviewing
as an in-depth type of interviewing that discovers how experiences are put together
to develop a worldview. Interviews are transcribed verbatim and read multiple
times by the researchers. Significant statements are identified; items are coded and
analyzed for themes and patterns. Statements may link together to form common
themes. The researcher identifies broad themes with categories and subcategories
that are consistent among participants. There may be several core themes or one
broad theme with associated categories.
Benner (1984) described three interpretive research steps of phenomenology:
thematic analysis, analyzing exemplars, and identifying paradigms. During thematic
analysis, the reasons, feelings, and thoughts of participants are explored. Meanings
of the categories are analyzed and integrated into a theme or themes. Step 2
involves analyzing exemplars. This is when researchers repeatedly read data for
possible new categories, corrections of thematic or categoric assignments, and
analysis of differences among the data. Last, according to Benner, the researcher
identifies paradigms, checking the themes and categories to be sure that they are
representative of the responses from all participants.
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FYI
There are four major types of qualitative research: phenomenology, grounded theory, ethnography, and
historical. These types are used frequently in nursing because they fit with the types of questions that nurses
ask. These types have well-established philosophical underpinnings and methods.
Examples of Nursing Research Using Phenomenology
There are many examples of nursing research using phenomenology. Some of the
better-known nursing theories coming from this type of research are Parse’s (1991)
theory of human becoming and Watson’s (1989) theory of human caring. Probably
the best-known research of this type is Benner’s (1984) work From Novice to
Expert in which she identified five stages of nursing competence that are still used
to guide practice. Dr. Benner based her work on dialogue with nurses who were
interviewed individually or in small groups. Her research offers examples of
excellence in nursing practice and a framework demonstrating the development of
nurses as they move through five stages: novice, advanced beginner, competent,
proficient, and expert. This is indeed an example of how qualitative research
translates into EBP as nurses all over the world study ways in which nurses
develop into expert clinicians. In many healthcare facilities, professional
promotion and clinical ladders are based on this model.
Lapidus-Graham (2012) examined the lived experiences of nursing students
who participated in a student nurse organization. The sample was 15 nursing
students who had graduated from schools in Long Island. The themes that emerged
from the data were “(1) leadership: communication, collaboration and resolving
conflict; (2) mentoring and mutual support; (3) empowerment and ability to change
practice; (4) professionalism; (5) sense of teamwork; and (6) accountability and
responsibility” (p. 4). The author concluded that student nurse associations (SNAs)
were important to the development of future nurses and that instructors should
integrate SNA activities into the existing curricula to foster leadership behaviors.
Grounded Theory Research: Creating Theory Through
Induction
Grounded theory is the method of choice when the researcher wants to discover the
process of something. The general question being asked is, “What is the process
of…?” This method is most commonly used in areas where there is little or no
previous research. The grounded theory method was originated by Glaser and
Strauss in 1967 when they looked at the way people approach the process of dying.
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The researchers specified a systematic set of procedures that is used to inductively
create a theory that is grounded in the data about a phenomenon (Strauss & Corbin,
1990). These theories can be useful in explaining and predicting phenomena
(Glaser & Strauss, 1967).
Philosophical Underpinnings
Grounded theory was developed as a way of conceptualizing research information.
Although grounded theory was developed by two social scientists, Glaser and
Strauss (1967), its philosophical underpinnings are from a variety of paradigms,
including positivism, postpositivism, and constructivism. Positivism focuses on
deductive reasoning and logical thinking, suggesting that the world is ordered in an
organized fashion. Postpositivism contends that true reality may exist, but we can
never truly know it. The constructivist view is that the researcher and the inquiry
are linked. This suggests that humans do not truly discover knowledge, but rather
they create or construct it through their interactions (Hall, Griffiths, & McKenna,
2013). One can clearly see the influence of each of the epistemologies on the
development of grounded theory.
Method
A few characteristics make grounded theory different from other qualitative
methods. The most important difference concerns the review of literature. In most
research methods, an extensive review of literature is done prior to beginning the
study to shed light on the phenomenon in question and identify gaps in the literature.
In grounded theory, just enough literature is examined to identify the gaps in the
literature, but a more extensive review of literature is done only after the research
is completed (Glaser, 1978). The purpose of this approach is to avoid bias because
a grounded theory must emerge from the data and never be forced by preconceived
notions. Writing in a reflective journal is an effective strategy for raising self-
awareness, thus reducing bias. After the theory has been generated, a thorough
review of the literature is done, and the researcher compares the theory with other
research. This is known as comparative analysis, and Glaser and Strauss (1967)
listed the following steps: (1) obtaining accurate evidence, (2) making empirical
generalizations, (3) specifying a concept, (4) verifying theory, and (5) generating
theory. Grounded theory is dynamic and subject to change as new data become
available. One could almost say that a grounded theory is never really finished but
that it can be constantly validated and refined.
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Data Collection and Management
Data are gathered mainly through interviews. As with other qualitative methods, the
face-to-face interviews are video-or audiotaped and are conducted using open-
ended questions. The researcher keeps detailed field notes and methodological logs
to record observations and reflections. The interview questions may become more
focused as the study progresses so the researcher can discover the major processes
taking place.
Another unique aspect of grounded theory is that researchers may use the
literature as data. Both the technical and nontechnical literature can be used for this
purpose (Glaser, 1992; Strauss & Corbin, 1990). Technical literature includes
research reports or theoretical/philosophical papers of a scholarly nature.
Nontechnical literature may include biographies, diaries, reports, newsletters, and
records. Literature could be used as primary data or to supplement data gathered
from interviews.
There is no set sample size for grounded theory. The researcher obtains data
until data saturation is reached. This may be as few as 10 interviews or more than
double that, depending on the data obtained. The use of focus groups, a strategy
often employed in qualitative research, lends itself well to grounded theory. Focus
groups are useful to generate ideas and help formulate interview questions to be
used later with key informants. Generally, a focus group consists of six to eight
people with a common interest but who do not know each other well. The
researcher may act as a facilitator by using open-ended questions to begin the
discussion and guide the group to provide sought-after information. Or the
researcher may be a participant observer in a focus group, such as attending a
breast cancer support group to gain insight. Focus groups have the added benefit of
being an excellent way to identify key informants for one-on-one interviews later
(Easton, 1999b).
focus groups : A strategy to obtain data from a small group of people using interview questions
Another difference between grounded theory and other qualitative methods is
the use of constant comparison. Comparisons are continuously made among the
data. In this way, both data gathering and analysis occur somewhat simultaneously.
The researcher records ideas, thoughts, possible emerging themes and patterns,
questions for follow-up, and potential categories for data coding. As data are
coded and clustered, the researcher continues to explore commonalities as
interviewing and data collection continue. Negative case examples and conflicting
information are also noted. All of these data form the basis for the final categories
that are generated to reflect the process described by participants. As more
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interviews are conducted, the emerging theory is confirmed and refined as the
researcher asks more focused questions (Cooney, 2011). In addition, new
subconcepts may be added or deleted to further refine the categories identified.
Examples of Nursing Research Using Grounded
Theory
Folden (1994) used a grounded theory approach to describe how stroke survivors
managed multiple functional deficits produced by stroke. The process was labeled
“ensuring forward progress” (p. 81). Folden indicated that each person defined
recovery “as the accomplishment of personal goals” (p. 81). Her findings were
consistent with other findings in the stroke literature at the time, adding credibility
to her work. Although Folden’s work added much to nursing knowledge about
stroke, the published articles stopped short of proposing a complete theory with
assumptions and relational statements.
Using the same population, stroke survivors, Mauk, who published earlier as
Easton, sought to answer the question: What is the process of stroke recovery?
(Easton, 1999a). From her research, a grounded theory emerged for poststroke
recovery that was labeled the poststroke journey: from agonizing to owning. Mauk
used writings and videotapes from stroke survivors to identify concepts and
generate a theory. She then conducted face-to-face interviews with 18 stroke
survivors to refine the theory. The end result of this grounded theory research
showed that stroke survivors reported six major phases in the process of recovery:
agonizing, fantasizing, realizing, blending, framing, and owning (Mauk, 2001,
2006). Nursing interventions targeted to each phase of recovery are being
developed and explored but have yet to be tested.
More recently, Gallagher (2011) developed a grounded theory that focused on
the emotional process of stroke recovery. In a sample of 9 stroke survivors, she
found three key themes related to emotional recovery: “1) recognizing that stroke
will not go away, 2) choosing to work on recovery, 3) working on being normal”
(p. 24). Interestingly, many of these themes are similar to what Mauk found in
examining the overall process of stroke recovery.
These three studies illustrate that grounded theory can be used by nurses to
explore a phenomenon about which little is known. In the previous examples, the
process of stroke recovery was one that had to be discovered from survivors
themselves. Theories can be used to develop practice guidelines. By listening to,
documenting, and explaining the process that patients go through, nurses can
provide better care because they are sensitized to patients’ situations.
Ethnographic Research: Understanding Culture
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Spradley (1979), considered to be a leading expert in ethnography, defined the
method as “the work of describing a culture” (p. 3). He further stated that instead of
just studying people, ethnography involves learning from people. Spradley (1980)
suggested three basic aspects of human experience that researchers needed to
discover: cultural behavior (what people do), cultural knowledge (what people
know), and cultural artifacts (what people make and use). “The goal of inquiry is
rounded, not segmented understanding. It is comprehensive in intent” (Hughes,
1992, p. 443). Ethnographic research involves studying groups and making
collective observations. It is the method of choice for studying cultures.
Additional related methods that grew out of ethnography, ethnoscience and
ethnonursing, warrant mention here. Ethnoscience is a method used in
anthropology to discover nursing knowledge. Ethnonursing is the systematic study
and classification of nursing care beliefs, values, and practices in a particular
culture (Leininger, 1985; Welch, 2002). Cultural representatives share knowledge
acquired through their language, experiences, beliefs, and value systems regarding
nursing phenomena such as care, health, and environment. Because the focus is on
nursing, studies using these methods are usually not as broad in scope and depth as
studies conducted to explain an entire culture. Therefore, obtaining information may
not require one to live in the culture for an extended period of time. These methods
were used by Madeleine Leininger (1985), founder of transcultural nursing.
Leininger, a noted professor and prolific author and theorist, earned a doctorate in
cultural and social anthropology, which influenced her research related to nursing.
She derived her theory of culture care diversity and universality from work in
anthropology and nursing. Leininger firmly believed that quantitative methods had
limited use in studying cultures and health and that ethnographic methods provided
the clearest information when researching other cultures.
e thnos cie nce : A method used in anthropology to discover nursing knowledge
e thnonurs ing: Systematic study and classification of nursing care beliefs, values, and practices in a particular
culture
Philosophical Underpinnings
Ethnography, whether general or focused, grew out of the idea that researchers
learn about people by learning from them (Roper & Shapira, 2000). Ethnography
originated from the discipline of anthropology with social scientists such as
Margaret Mead. However, early ethnographers were often considered
“professional strangers” (Cruz & Higginbottom, 2013, p. 37), unwanted by the
people whom they studied, and whose writings often mispresented the culture and
beliefs of the people because of the influence of the day’s political loyalties. The
philosophical roots of ethnography are in naturalism, which emphasizes or focuses
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on setting and environment of subjects. Participant observation is still considered a
key method in ethnography, though many researchers have used more broad
qualitative methods to conduct ethnographic research. Today, ethnography is used
by nurse researchers not only to study other cultures but also to study specific areas
or “cultures” in nursing such as nurse triaging in the emergency room (Fry, 2012).
Method
A few techniques distinguish ethnographic research from the other methods
previously discussed in this chapter. Because participant observation is a key
strategy in this type of research, gaining access to a group, particularly if it is one to
which the researcher is not attached, has unique challenges. Gaining access to a
particular group often requires that the researcher go through a gatekeeper. This is
a person who facilitates the entry of the researcher into the particular group being
studied. For example, if a Caucasian researcher wished to study the culture of a
particular tribe of Native Americans, the researcher might first need to identify a
person from that tribe who would invite the researcher to be a participant observer
because it is highly unlikely that the researcher would gain access without
assistance. The gatekeeper is generally a person with some authority in the group.
gate ke e pe r: Person who facilitates or hinders entry of the researcher into a particular group or setting
When obtaining information from key informants, the researcher strives to
discover the emic perspective, or the informant’s perspective (i.e., the “inside”
scoop; Boyle, 1994). Conversely, the researcher has an etic, or outside,
perspective. In ethnography, discovering the emic perspective is essential. The
researcher needs to record and observe both what key informants say and what they
do, looking for consistencies or inconsistencies between the emic and etic
perspectives.
e mic: The insider’s or participant’s perspective
e tic: The outsider’s perspective; the perspective of the researcher
Data Collection and Management
Researchers using ethnographic methods study people in their natural environments
over long periods of time to gain a comprehensive view of the culture (Leininger,
1995). There is direct personal involvement with the study of participants over
time, usually several months to years (Boyle, 1994). This method takes prolonged
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engagement and patience.
Along with participant observation, the researcher conducts in-depth interviews
with key informants. As with any method that uses interviews, the skill of the
researcher largely influences the quality and credibility of the results. Interviews
should begin with open-ended questions that allow the informant to provide as
much information as possible and that support the grand tour question, or the major
question that the researcher is trying to answer.
Spradley (1979) believed that the ethnographic interview should be like sharing
a friendly conversation. He identified three important elements to the interview: (1)
explicit purpose, (2) ethnographic explanations, and (3) ethnographic questions.
First, the researcher must make the purpose of the interview perfectly clear and
gradually take the lead in directing the questions and conversations to discover the
knowledge of the informant. Throughout interviews the researcher must also give
repeated explanations to the informant about information that needs to be obtained.
Informants may need to be reminded to speak from their own perspective and not
“translate” for the researcher. Interviews are usually conducted over weeks during
numerous encounters so that the researcher can gradually guide the informant
toward providing relevant information. Spradley listed more than 30 kinds of
ethnographic questions that could be used during an interview (see Table 9-3).
Easygoing conversation should be interspersed with questions that the researcher
wishes to have answered.
TABLE 9-3 Examples of Ethnographic Questions
Type of
Question
Focus Example
Descriptive Sample of language Could you describe a typical day
at the mill?
Structural How participants
organize
What are all the activities you do
at the mill?
Contrast
For a participant to
explain differences or
relationships
You mentioned earlier that ____
is a habit that only a “millrat”
does. Would a ____ do that?
Would ____ do that? Who
wouldn’t do that?
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Source: Adapted from Spradley (1979).
One can see from this style of interviewing that the researcher needs to gain
skill through practice and experience to be able to conduct such interviews
effectively. Table 9-4 summarizes some key points for ethnographic interviewing.
In this method, as with many others, keeping detailed field notes is essential along
with in-depth ethnographic interviews. The researcher should also collect artifacts
or symbols of the culture, employ maps and diagrams, and obtain family trees and
the like to help understand the culture. The importance of language cannot be
overemphasized. Words convey various meanings in context, so the meanings of
words and the situations in which they are used are essential to record and
understand. Body language, vocal inflection, and tone in the context of the situation
should be recorded and analyzed. Slang or jargon should be noted and explored.
TABLE 9-4 Suggestions for Ethnographic Interviewing
Explain the purpose of the interview clearly.
Obtain informed consent and ensure confidentiality and anonymity.
Gain entry into the culture through a gatekeeper.
Identify key informants.
Develop a rapport with the participants.
Practice and study techniques related to ethnographic interviewing.
Allow sufficient time for prolonged engagement to observe and participate in the
culture.
Keep detailed field notes, records, and reflective journals.
Collect significant artifacts.
Keep in mind the grand tour question.
When interviewing, begin with open-ended questions and progress to more focused
questions over time and in repeated interviews.
Be sure all equipment is working and that you have a plan for malfunctions of tape
recorders, etc.
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Keep interviews conversational and friendly even when trying to elicit specific
information.
Pay special attention to the language of the participants and the use of key words.
Clarify the meanings of terms using contrast questions.
Constantly compare and contrast data with each other during the collection process.
Record all interviews and transcribe them verbatim.
Be true to the data.
Source: Adapted from Spradley (1979).
As with grounded theory, the constant comparison method is often used so that
data collection and data analysis may occur somewhat simultaneously. Thick
descriptions are used in each area of data collection. The researcher may log an
example of a typical day within the group, focus on specific unique events, or
develop a story with a plot and characters (Marshall & Rossman, 2011). Several
logs or journals may be kept to organize data and observations.
The data are coded and grouped according to their meanings. Patterns and
categories are identified. When presenting the findings, the researcher often uses a
more personal reporting style. Researchers must strive to have objectivity when
analyzing and interpreting the data (Fetterman, 2010). Bias can occur as a result of
the closeness that the researcher typically gains with the culture when living among
the people. The ultimate goal is to present a detailed picture of a culture that an
outsider could read to obtain a better understanding and gain empathy for a specific
group. Ethnographic research is an excellent way to increase sensitivity to those
whose culture is different from researchers’ and readers’.
Examples of Nursing Research Using Ethnography
Nurses have used ethnography in many unique ways to understand cultures related
to health or the health practices of other cultures (Roper & Shapira, 2000). For
example, Rosenbaum (1990) used Leininger’s theory of culture care as a
framework to uncover the cultural care needed for older Greek Canadian widows.
The sample contained 12 key informants and 30 general informants, and the
researcher collected data using participant observation and interviews. Rosenbaum
found that for these widows, health meant a state of well-being, ability to perform
activities in their role, and avoidance of pain and illness. These findings could
stimulate future nursing interventions for EBP related to caring for widows in this
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culture and perhaps others.
Another example of nurses using ethnography is a study by Shambley-Ebron and
Boyle (2006) that explored self-care and mothering in African American women
with HIV/AIDS. The researchers studied 10 African American mothers and found
themes related to disabling relationships, strong mothering, and redefining self-
care, with a cultural theme of creating a life of meaning. The researchers concluded
that their study pointed out the strengths of African American women and helped to
generate theory that will promote better care for this population.
In a meta-ethnography about older persons’ views on risk for falls, the
researchers selected 11 qualitative articles from 7 databases to gain a conceptual
understanding about how elders view falls and their needs for fall prevention
interventions. Researchers examined the culture of falls in elderly adults. The
researchers found six key concepts that explained how older adults appraised their
risk for falls and how they coped with fall risk interventions. The six key concepts
identified were: (1) beyond personal control, (2) rationalizing, (3) salience, (4) life
change and identity, (5) taking control, and (6) self-management (McInnes, Seers, &
Tutton, 2011). By synthesizing findings using meta-ethnography, the researchers
were able to identify a culture unique to older adults who experience falls.
Street (1992) conducted a study that became a book titled Inside Nursing: A
Critical Ethnography of Clinical Nursing Practice. She studied nurses and the
culture of nursing at a large hospital in Australia. Street’s background was social
theory and feminism rather than nursing. Nonetheless, her work provided great
insight into the politics, power struggles, and frustrations reported by nurses that
challenged the traditional view of nursing at the time.
These studies demonstrate that culture does not have to be merely defined in
terms of one’s ethnic group, but that culture embodies the feelings, beliefs, attitudes,
values, and behaviors of a group of people and ethnography can be conducted on a
variety of topics in different settings. Today’s nurse researchers “would be well-
served by describing specific cultural patterns in order to develop targeted
interventions to best meet increasingly diverse patient needs” (Oliffe, 2005, p.
397).
Historical Research: Learning from the Past
Historical research is based on documentation of sources that are used to
retrospectively examine events or people. “Historical methods are concerned with
uncovering and generating evidence and with interpreting that evidence in the
historical context in which it was created” (Fealy, Kelly, & Watson, 2013, p.
1882). The questions being asked are “Who are we?” “Where did we come from?”
“Why did we do this?” “How did we get to this point?” The goal of this type of
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research is to explain and understand the past with the hope of guiding the present
and future.
Philosophical Underpinnings
The philosophy of historical nursing research is grounded in the idea that historical
documents and recordings can be used as research data. In 1948, Professor Allan
Nevis described “the oral history method as the process of recording the expressed
memories of the authorized persons” (Firouzkouhi, Zargham-Boroujeni, Nouraei,
Yousefi, & Holmes, 2013, p. 226). This method has been useful in qualitative
research because it allows persons to share their mementos, feelings, diaries,
photographs, and other data with researchers to learn more about a phenomenon.
Historical studies have been defined as studies containing narratives using
rigorous historical methods and/or studies that synthesize previous historical
knowledge (Fealy et al., 2013). In examining the history of nursing through
published articles in the Journal of Advanced Nursing from 1976 to 2011, the
authors believed that “for a discipline like nursing, the relevance of historical
scholarship is its ability to demonstrate the particular and distinct contribution that
nursing has made to society through its role in the development of systems of health
care” (Fealy et al., 2013, p. 1882).
Method
One unique type of sampling used in this method is called strategic sampling. This
is when the researcher locates a small group of people who were either witnesses
to or participants in the phenomenon being studied. In such a sample, often no
restrictions on age or gender are made except as delineated by the phenomenon
being studied. There is no set sample size, but an accumulation of facts continues
until no new data are obtainable. For example, Harmon (2005) studied nursing in a
state hospital between 1950 and 1965. This researcher used oral history methods to
describe the experiences of eight American nurses who worked in psychiatric
hospitals before and during the introduction of antipsychotic medications.
s trate gic s ampling: Sampling in historical research to locate a small group of people who were either
witnesses of or participants in the phenomenon being studied
Data Collection and Management
The major sources of data in historical research are eyewitness accounts and
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documentation. Although interviews with participants are possible, participants
would be reflecting on past events, and data would be based on their recollections.
A common criticism of the method is that data may not always be reliable because
data are based on the memories of the participants. Accurate and detailed
documentation on the part of the researcher is needed to maximize credibility. Some
of the documentation sources that nurses might use in historical research include
government reports, professional journals, oral evidence, books, memos,
photographs, letters, newsletters, newspapers, diaries, journals, videos, films,
official publications, written responses to surveys, and memorabilia.
After the researcher has obtained all sources of data, including the verbatim
transcription of personal accounts or oral histories, central themes are identified
from “disciplined reflection” (Galvin, Todres, & Richardson, 2005, p. 3). The
analysis and interpretation should be logical and easy to follow, flowing smoothly
from the data. Most historical research tells a story of events over time. The
usefulness to nursing lies in allowing the past to illuminate and positively influence
the future. The following examples of historical research in nursing provide
thought-provoking ways nurses can examine the evidence on which we base our
practice.
Examples of Nursing Research Using Historical
Research
Lusk (2005), one of the proponents of nurses using historical research, used this
method to study nurses who cared for patients with cancer between 1920 and 1950.
She used primary sources from U.S. archives, nursing procedure books, annual
reports, and even minutes from meetings. Her secondary sources included textbooks
and journal articles. Lusk chronicled the development of cancer as a specialty in
nursing and revealed the discomfort nurses experienced when hiding a cancer
diagnosis from patients.
The Careful Nursing Philosophy, a model for professional nursing, was derived
from historical research. The author (Meehan, 2012) derived a model from
examining the practices of 19th-century Irish nurses. Twelve Irish nurses were
appointed to work closely with Florence Nightingale to develop a system for
nursing that became widely used in Europe. Using historical nursing research as a
method, the author used content analysis of historical documents to discover the
thinking and practice of these early nurses. Meehan’s (2006) work on this model
spanned many years, and she developed a practice model based on an in-depth
scrutiny and thematic analysis of historical writings in context. Her results revealed
4 major concepts with 18 dimensions. The major concepts for practice were
“therapeutic milieu, practice competence and excellence, management of practice
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and influence in health systems and professional authority” (Meehan, 2012, p.
2905). Meehan believed that our present nursing system could be improved and
enhanced by revisiting our successful roots within these four major areas. This
research shows how identifying past behavior can be used as a basis to inform
decisions about nursing practice in the present and future.
CRITICAL THINKING EXERCISE 9-2
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Consider a time when you may have been exposed to a new culture. What were the emic perspectives?
How did these compare to your etic perspectives?
TEST YOUR KNOWLEDGE 9-2
1. Which method would you choose to answer the question, What process do older adults use when
they quit smoking?
a. ethnography
b. historical
c. phenomenology
d. grounded theory
2. Match the following terms with one of the four types of qualitative methods
a. constant comparison
b. strategic sampling
c. lived experience
d. emic
How did you do? 1. d; 2. a. b. c. d.
9.3 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss ethical considerations that are unique to qualitative methods
Qualitative researchers are held to the same ethical standards as are researchers
using other methods. Participants have the same rights as individuals who volunteer
for research involving quantitative measures. Researchers must obtain informed
consent, protect privacy, allow volunteers to withdraw from the study at any time,
and avoid harm to individuals who participate. Because of their noninvasive
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nature, most qualitative studies qualify for exempt status from the institutional
review board review.
Some ethical considerations, however, are unique to qualitative research. These
considerations fall into two major categories: those that have to do with the
relationship between the researcher and participant and those that involve
procedures to handle the data.
CRITICAL THINKING EXERCISE 9-3
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Review Table 9-2. Devise one research question for each of the four methods that could be answered by
appropriately applying phenomenological, grounded theory, ethnographic, or historical research.
When conducting qualitative research, the researcher spends a prolonged time
in contact with participants, and relationships are formed. It is not uncommon for
researchers and participants to move from a formal (stranger) relationship to one
that is more personal (friend) (Leininger, 1985, 1995). For example, a participant
may share information in the context of a friendship, never expecting it to be study
data. Other consequences of prolonged engagement may include the difficulty of
ensuring ongoing informed consent or allowing a participant to withdraw from the
study if indicated. Another dilemma can occur when the subject matter is emotional
for participants. They may become upset and begin to cry during an interview while
sharing their experiences. When this occurs, the appropriate response for the
researcher is to ask if the tape recorder should be turned off until the participant
regains composure. Researchers must examine the appropriateness of responding
with therapeutic use of self versus maintaining the role of researcher. In addition,
researchers must avoid taking advantage of a friendship. For example, the
researcher may be tempted to prolong the length of an interview past the agreed-
upon time or to ask for a second interview when this was not included in the
original plan. Researchers are obligated to report suspicions of abuse, neglect, or
criminal activity if this is revealed. Therefore, it is essential that the consent form
indicates to participants that this is the case.
Spradley (1979) listed ethical principles that must be considered when working
with participants. These are summarized in Table 9-5. Some important strategies
must be implemented when handling qualitative data to safeguard participants’
rights. When audiotapes are transcribed, all identifying information such as name,
address, place of employment, and phone numbers must be replaced with fictitious
information. Participants are often assigned gender-appropriate code names that
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progress alphabetically. Audio-and videotapes must be treated as confidential and
kept secured until the conclusion of the study when they are destroyed. If a
participant withdraws from the study, the researcher may still use the data,
provided that the participant agrees to this. A unique feature of qualitative research
is that sharing findings with participants is expected as part of the research process.
It is appropriate to share categories, themes, and theories with participants;
however, transcripts, audio-and videotapes, and participant names must never be
shared.
FYI
Some ethical considerations are unique to qualitative research. These fall into two major categories: the
relationship between the researcher and participant and the procedures to handle the data.
TABLE 9-5 Ethical Principles for Consideration with
Participants
Protect the participants’ rights and interests.
Put participants’ interests first.
Clearly communicate the goals of the research.
Obtain informed consent.
Ensure privacy.
Avoid exploitation.
Share results and reports.
Source: Adapted from Spradley (1980).
TEST YOUR KNOWLEDGE 9-3
Indicate whether the following statements are true or false:
1. Qualitative researchers do not have to adhere to the usual protection of human subjects because
most studies are noninvasive.
2. Qualitative findings must be shared with participants.
3. When a nurse researcher suspects abuse, it is unethical to report it because this information was
obtained during a research interview.
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4. Fictitious names should be used when transcribing data so that actual participants remain
unknown to others.
How did you do? 1. F; 2. T; 3. F; 4. T
APPLY WHAT YOU HAVE LEARNED
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The committee has found one qualitative study about medication errors. Read Schwappach, Hochreutener,
and Wernli (2010) and enter information into the first two columns and complete the design column of the
grid within this text’s digital resources as you have done previously for other articles. As you complete this
exercise, consider whether the following were consistent with what you learned in the chapter:
Sampling method and size
Data collection methods
Analysis and interpretation
Strategies used to maintain scientific rigor
Ethical considerations
RAPID REVIEW
» Qualitative research focuses on words instead of numbers to give meaning to a
phenomenon or events.
» Qualitative research uses induction to inquire about topics with little evidence
and/or to develop a theory.
» Individuals who volunteer for qualitative studies are known as participants.
Purposive sampling is used to obtain a sample.
» Sampling continues until data saturation is achieved. Typically, sample sizes are
small in qualitative studies.
» The three main sources of data in qualitative research are in-depth interviews,
direct observation, and artifacts.
» Data come from fieldwork and can involve participant observation.
» Analysis and interpretation are conducted simultaneously with data collection.
» The four essential elements of evaluation are credibility, transferability,
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dependability, and confirmability.
» Strategies to maintain scientific rigor include bracketing, persistent observation,
peer debriefing, referential adequacy, member checks, and audit trails.
» The four major types of qualitative research are phenomenology, grounded theory,
ethnography, and historical.
» Phenomenology describes the lived experience and has provided the foundation
for some nursing theories.
» Grounded theory uses constant comparison to create theories about processes.
» Ethnography is the method of choice when studying a culture. Ethnoscience and
ethnonursing are methods used to study cultural interpretations of nursing
phenomena such as care, health, and environment.
» The emic perspective provides the “inside” scoop, while the etic perspective is
the outsider’s viewpoint.
» Historical research examines past events or people with the purpose of guiding
the present and future. Strategic sampling can be used to obtain participants.
» Findings from qualitative studies contribute to EBP by sensitizing nurses to
patient experiences and providing theories to explain various processes.
» Qualitative researchers are held to the same ethical standards as are researchers
using other methods; however, some unique ethical considerations are
associated with qualitative methods.
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http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.135.8668
CHAPTER 10
Collecting Evidence
Jan Dougherty
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Identify factors that should be considered when planning for data collection
‹ Discuss reasons for piloting data collection
‹ Describe various methods to measure and collect quantitative data
‹ Discuss advantages and disadvantages to data collection methods
‹ Identify levels of measurement
‹ Examine strategies used to address issues associated with quantitative data
collection methods
‹ Identify types of random and systematic measurement errors
‹ Define validity and reliability
‹ Name strategies that researchers use to establish reliability and validity of
various measures
‹ Recognize questions used to appraise quantitative data collection methods
‹ Identify the researcher as the most important data collection instrument
‹ Describe various methods used to collect qualitative data
‹ Discuss the advantages and disadvantages of qualitative data collection
methods
‹ Recognize questions used to appraise qualitative data collection methods
‹ Discuss the importance of protecting human subjects during data collection
KEY TERMS
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alternate form
case studies
categorical data
concurrent validity
construct validity
content validity
continuous data
convergent testing
correlation coefficient
criterion-related validity
Cronbach’s alpha
dichotomous
direct observations
divergent testing
equivalence
face validity
factor analysis
focus groups
hypothesis testing
internal consistency
interrater reliability
interval
interviews
item to total correlation
known group testing
Kuder-Richardson coefficient
levels of measurement
Likert scales
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measurement error
methodological
multitrait-multimethod testing
nominal
observation
ordinal
parallel form
physiological measures
predictive validity
psychometrics
questionnaires
random error
ratio
reliability
scales
split-half reliability
stability
systematic error
test-retest reliability
unstructured observations
validity
visual analog scale
10.1 Data Collection: Planning and
Piloting
At the end of this section, you will be able to:
‹ Identify factors that should be considered when planning for data collection
‹ Discuss reasons for piloting data collection
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Data collection is a key component in all research studies. Just as it is essential to
use a theoretical or conceptual model to ask the important research questions, there
must be a solid plan for collecting and managing the data to study and ultimately to
answer research questions. Many nurses may be intimidated as they read the
methods section of a research article. Words describing study designs, such as
double-blind, quasi-experimental, and ethnography, can be overwhelming for
those with limited research background. Additionally, terms discussing reliability,
validity, and level of significance may further intimidate or overwhelm nurses
(Granger et al., 2013). Many readers may be tempted to skim this information or to
bypass it completely. However, because practice decisions will be made based on
the findings of the data, it is important for nurses to be able to understand and
critically evaluate methods used by researchers. Accurate data collection methods
are more likely to yield valid findings. These findings provide or support the
evidence that nurses can trust when making evidence-based practice (EBP)
decisions. In EBP, quantitative studies are considered to produce the strongest
evidence. Yet, in health care, many clinical and cultural phenomena are better
studied using qualitative research. Many nursing and health research studies draw
upon both quantitative and qualitative measures. In both types of methods, it is
imperative that the same rigor be employed when collecting data.
Planning for Data Collection
Researchers are often very excited to begin collecting data. Most often they have
spent months working on their overall framework and/or research questions and
have organized pertinent literature to further support the study at hand. They have
also carefully selected and developed data collection methods. This requires that
researchers detail the data collection plan from the time consent from subjects is
obtained to the actual completion of the data collection period. A timeline should
be included along with a comprehensive budget that accounts for costs such as
salaries of research staff, mileage, meals, data collection materials and
instrumentation, fees related to the recruitment of subjects, and data input and
interpretation. A plan for how data will be managed should also be included. A
haphazard approach to collecting data, planning the timeline and budget, and
managing data can lead to serious problems for researchers. Therefore, when
appraising research studies, it is important for nurses to carefully read and
determine whether the data collection methods support the framework and are
appropriate for the study questions. If appropriate data collection methods are not
used, the findings can easily be challenged and the evidence may not support the
desired changes in practice (Havens, 2001).
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FYI
Nurses must have a solid plan for collecting and managing data, because these methods will be evaluated
before practice decisions are made based on the findings of the data. Accurate data collection methods are
more likely to yield valid findings that provide or support the evidence nurses can trust when making EBP
decisions.
Researchers begin by determining the type of data that need to be collected.
This includes when and how data will be collected, who will collect the data, and
what type of data collection methods, devices, or instruments will be used. Many
factors affect data collection. Such factors may include availability and access to
preexisting instruments, mobile devices (including personal digital assistants
[PDAs], tablets, phones, laptops, or netbooks) or data collection sites, personnel
needed to collect data, the amount of data to be collected, and the sample size.
Budget considerations are key because researchers are accountable to stay within
the planned budget. Data collection can be one of the most costly parts of
conducting a research project. With the growing use of technology for data
collection, the researcher must also consider the capabilities of mobile devices
such as connectivity, mobility, and software compatibility. Care must also be taken
to secure data (Drayton, 2013).
Piloting Data Collection Methods
Many researchers conduct a pilot study using a scaled-back version of the data
collection method. This is very helpful to evaluate the instruments, devices, and
process so that unexpected problems can be identified. Additionally, a pilot study
helps confirm the study’s feasibility and allows for revisions to be made.
Researchers do not want to get midway into projects only to find that the
instruments are flawed, the projected sample size is unachievable, a need for
additional research assistants arises, or the study cannot be completed within the
budget. All of these issues can cause serious problems and ultimately jeopardize
the study.
TEST YOUR KNOWLEDGE 10-1
1. Factors to consider when planning data collection include which of the following? (Select all that
apply.)
a. time frame
b. budget
c. training of personnel
d. availability of preprinted questionnaires
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2. A pilot:
a. is a small version of the study
b. confirms feasibility of the study
c. critiques the conclusions from a study
d. is the small stipend that subjects receive for participating in a study
How did you do? 1. a, b, c, d; 2. a, b
10.2 Collecting Quantitative Data
At the end of this section, you will be able to:
‹ Describe various methods to measure and collect quantitative data
‹ Discuss advantages and disadvantages to data collection methods
‹ Identify levels of measurement
‹ Examine strategies used to address issues associated with quantitative data
collection methods
Collecting Numbers
Quantitative methods are used to test stated hypotheses and call for researchers to
use formal, objective, and systematic procedures and instruments that produce
numerical data (Havens, 2001). Data from quantitative studies are the highest level
of evidence on which clinicians can base EBP decisions. For example, studies
involving meta-analyses of multiple randomized controlled trials (RCTs) are
considered to be the strongest level of evidence, whereas those based on case
reports and opinions of experts and authorities are considered to be the lowest
level of evidence (Myers & Meccariello, 2006). In quantitative studies, research
questions and hypotheses are derived from theories. The study design reflects the
objectives of the study. Researchers must decide how each variable will be
operationalized and what types of data will need to be gathered. The main methods
used in quantitative research include questionnaires, observation, scales, and
physiological measures. Table 10-1 provides an overview of data collection
methods that are associated with various quantitative research designs.
FYI
Regardless of how the data are collected, researchers must consider a variety of issues to ensure a high-
quality study. Interrater reliability must also be established when more than one person is involved in making
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observations.
Questionnaires
Questionnaires are commonly used in quantitative research and can provide an
inexpensive way to gather numerical data from a potentially large number of
respondents. Although questionnaires may be inexpensive to administer, when
compared to other data collection methods, they can be expensive in terms of
design time and interpretation. It is essential that each question is monitored for
clarity, sensitivity to the respondent, reading level, and absence of bias (Sinkowitz-
Cochran, 2013).
que s tionnaire s : Printed instruments used to gather numerical data
TABLE 10-1 Quantitative Research Designs and Data
Collection Methods
Quantitative Research
Design
Data Collection Methods
Exploratory/descriptive
(answers what questions; describes
frequency of occurrence)
Questionnaire
Scales
Correlational
(examines relationships among variables)
Questionnaire
Scales
Biophysiological
Quasi-experimental
(examines why certain effects occur)
Questionnaire
Scales
Biophysiological
Experimental/clinical trial
(examines causes of certain effects)
Questionnaire
Scales
Biophysiological
The formatting and length of the questionnaire are important details. The
questionnaire should include only essential questions because shorter
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questionnaires are more likely to be completed. Whenever possible, the questions
using numbered answers should be either circled or checked and should use a
consistent pattern throughout (Figure 10-1). There should be a balance between
positive and negative questions to decrease biased responses in subjects
(Sinkowitz-Cochran, 2013). Each research subject is assigned a research
identification number that should be on each page of the questionnaire in case the
pages get separated.
Questionnaires can be administered in person; on computers and hand-held
devices; and via telephone, interactive voice response, mail, and, increasingly,
email. Confidentiality is necessary to ensure that respondents not only participate in
the study but also answer questions honestly and without fear of reprisal. It is
desirable to have a good response rate, which is the percentage of questionnaires
that are returned. Return rates can be increased when a cover letter is included. The
cover letter can provide an explanation or brief description of the purpose of the
research because respondents may be more likely to participate if they perceive
benefit to self or society. The letter can also provide some brief instructions about
how to complete the survey (Meadows, 2003).
E-questionnaires are growing in popularity and may be used as a strategy to
enhance response rates (Hunter, 2012). Low response rates can lead to bias
because samples may not be representative. A variety of factors can influence
whether subjects complete a questionnaire. Not all subjects are able to respond to
questionnaires. For example, young children, people who are blind, and many
elders who are frail or cognitively impaired may have difficulty completing
questionnaires. Questionnaires that are long, hard to understand, or time consuming
are not likely to be completed. Using appropriate colors, fonts, and white space can
improve the likelihood that individuals will complete a questionnaire. Thanking
respondents for their participation at the end of the questionnaire/survey is
important, along with providing them contact information if they have additional
questions/concerns (Meadows, 2003).
FIGURE 10-1 Example of Easy, Consistent Survey Design
Observation
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Structured observations provide a way to quantify an explicit feature of the
phenomenon under observation. For example, a researcher could count the number
of people who wash their hands after using a public restroom. Researchers serve as
objective observers and follow systematic methods using specific directions during
a scheduled period of time. In the hand washing example, the researcher may
observe individuals during dinner time at a popular restaurant. Not only do
researchers outline what observations are made but they also note how
observations are recorded and coded. The researcher in this example may record
tallies under three columns: no hand washing, water only, or soap and water.
Establishing a detailed protocol is extremely important if researchers use research
assistants.
obs e rvation: A technique to gather data
Scales
Scales are used to assign a numeric value or score along a continuum. They are
frequently incorporated into a questionnaire or interview. Numerous types of scales
have been developed to measure social and psychological concepts specific to
nursing. Researchers choose scales based on the scales’ ability to measure
identified concepts. Ideally, it is best to choose scales that have already been
tested. If a scale does not exist, researchers can develop and test a new scale
(Meadows, 2003). Scales can be designed to measure either a single or
multidimensional concept. For example, the Marwit-Meuser Caregiver Grief
Inventory is a 50-item multidimensional scale that measures grief reactions by
current caregivers of people with progressive dementias (Marwit & Meuser,
2002). Because three subscales compose the total grief score, it is a
multidimensional scale. Each subscale measures a specific part of the caregiving
experience as detailed in the Caregiver Grief Model (Meuser & Marwit, 2001).
s cale s : Used to assign a numeric value or score a continuum
You may already be familiar with Likert scales, which are frequently used to
collect data. A Likert scale consists of statements placed on a continuum of seven
points and to which respondents indicate whether they agree or disagree. Seven
points allow for a neutral opinion. Some researchers find a neutral response hard to
interpret. Therefore, researchers may adapt the scale to eliminate the neutral point
by having an even number of points. Scales containing fewer than seven points are
known as Likert-type scales (see Figure 10-2).
Like rt s cale s : Ordinal-level scales containing seven points on an agree or disagree continuum
355
Another type of scale is the visual analog scale (VAS) (see Figure 10-3).
Researchers use this type of scale to measure the intensity of sensations and
feelings. The VAS is a 100-mm line that is anchored on each end with words or
symbols. Subjects mark a line across the VAS to indicate the intensity of their
feelings or attitudes along the continuum represented. In nursing, VAS scales are
frequently used to collect data about pain, fatigue, quality of life, and health status.
This type of scale can be completed easily and quickly and is understood by most
people. To score the VAS, researchers measure the distance of the mark from the
end of the scale in millimeters. Usually the low end of the scale is used as the zero
point.
vis ual analog s cale (VAS): Ratio-level scale of a 100-mm line anchored on each end with words or symbols
FIGURE 10-2 Example of Likert-Type Scale
FIGURE 10-3 Example of a VAS to Measure Pain
CRITICAL THINKING EXERCISE 10-1
© Jules_Kitano/ShutterStock, Inc.
A nurse researcher is interested in testing an intervention on the quality of life of individuals with lung
cancer. What methods do you think the nurse researcher should use to collect data?
Physiological Measures
Physiological measures provide a wide range of biological, chemical, and
microbiological data. Measures of blood pressure, cardiac output, and weight are
examples of biological variables. Chemical measures include electrolytes,
hormones, and cholesterol, while microbiological measures include the bacterial
356
counts obtained from urine and blood cultures. There are many advantages to using
these objective measures because they tend to be accurate. Some physiological data
are typically accessible in most healthcare settings, allowing for ease of data
collection with minimal or no cost to the researcher. Researchers must specify
measurement protocols that include specific equipment used for measurement,
frequency and methods for calibration of equipment, training for data collectors,
specific times to obtain measurements, procedures for measuring and recording
data, and any special storage or handling considerations (Merchant & Mateo,
1993).
phys iological me as ure s : Data obtained from biological, chemical, and microbiological phenomena
Issues in Quantitative Data Collection
Regardless of how the data are collected, researchers must consider a variety of
issues to ensure a high-quality study. They must have a written plan that outlines the
process for data collection, particularly when additional data collectors are
employed. Research assistants must be trained to collect data in a very consistent
manner (i.e., instruments should be administered in the same order for all subjects,
in the same context and setting, using the same set of directions). Interrater
reliability must also be established when more than one person is involved in
making observations. Interrater reliability is the extent to which two or more
individual raters agree. Although it is necessary for multiple observers or raters to
achieve interrater reliability, this may slow the process of observational methods.
Interrater reliability should be monitored periodically throughout the study to
increase the degree of confidence in the data (Casey, 2006). Researchers may
choose to prepare a code book to organize the raw data prior to collection and to
assign numerical values to data obtained during data collection. For example,
researchers may assign a numerical value of 1 to females and 2 to males (Wolf,
2003).
Data collection plans should detail a time frame. It is not uncommon for
researchers to encounter unplanned obstacles when gathering data. Frequently data
collection requires at least twice as long as the researcher anticipates. Issues such
as slow enrollment of consented subjects, heavy workloads, and staff turnover are
common causes of delay. Plans should include strategies to manage attrition of
subjects as a result of death, dropout, or relocation. Plans also must address
decisions about missing data. For example, subjects may fail or refuse to respond
to particular questions.
Many studies are funded by federal grants, state grants, or private foundation
357
monies. A budget is necessary to consider all of the factors involved in data
collection, including any delays that may be anticipated. Time extensions may be
requested by researchers because of delay, and this subsequently requires
researchers to account for any changes in budgeting. If the project is cut back as a
result of delays or exceeding the budget, the research can be seriously
compromised (Anastasi, Capili, Kim, & Chung, 2005).
Levels of Measurement
Measurement is the process of assigning numbers using a set of rules. Four
categories are used to describe measurements: nominal, ordinal, interval, and
ratio. These categories are more commonly known as levels of measurement.
When researchers collect data, they must know which level of measurement is used
to select appropriate statistical tests for analyzing data (Trochim, 2000).
nominal: The lowest level of measurement whereby data are categorized simply into groups; categorical data
ordinal: A continuum of numeric values where the intervals are not meant to be equal
inte rval: A continuum of numeric values with equal intervals that lacks an absolute zero
ratio: The highest level of measurement that involves numeric values that begin with an absolute zero and have
equal intervals; in epidemiology a mathematical relationship between two numbers
le ve ls of me as ure me nt: A system of classifying measurements according to a hierarchy of measurement and
the type of statistical tests that is appropriate; levels are nominal, ordinal, interval, and ratio
Nurses must be able to identify levels of measurement correctly to appraise
evidence. Nominal measurement is the weakest level of measurement. The word
nominal is derived from the word name. Researchers use nominal measurement to
classify or categorize variables, also referred to as categorical data. The numbers
assigned to each category are just labels and do not indicate any value. For
example, responses of “yes” and “no” on a survey are often assigned numbers 1 and
2. The value of these numbers has no meaning because one cannot claim that a “no”
response is higher than a “yes” response. The arbitrary numbers are assigned for
the purpose of coding, recording, and entering data for collection and analysis.
Questionnaires often utilize nominal measures to record a variety of categorical
data and/or closedended questions with fixed responses such as gender, race, and
diagnosis (see Figure 10-4). Dichotomous is the term used when there are only
two possible fixed responses, such as true or false, yes or no, and male or female.
cate gorical data: Lowest level of measurement where by data are categorized simply into groups; nominal data
dichotomous : Nominal measurement when only two possible fixed responses exist such as yes or no
Ordinal measurement represents the second lowest level of measurement. A
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continuum of numeric values is used with small numbers representing lower levels
on the continuum and larger numbers representing higher values. However, although
the values are ordered or ranked, the intervals are not meant to be equal. For
example, in a marathon the distance and time among those who finish in first,
second, and third are not equal; however, there is value to the number assigned.
Many questionnaires and scales use ordinal measurements. Figure 10-5 provides
examples of ordinal measures.
FIGURE 10-4 Examples of Nominal Level Measurement
FIGURE 10-5 Examples of Ordinal Level Measurement
Interval measurement is a third level of measurement and uses a continuum of
numeric values, also known as continuous data. At this level, the values have
meaning and the intervals are equal. On interval scales, the zero point is arbitrary
and not absolute. The zero is not an indication of the true absence of something. The
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best example of this is the Celsius scale. When measuring temperature in Celsius, 0
does not mean the absence of temperature. In fact, it is quite cold. Other examples
of interval scores include intelligence measures, personality measures, and manual
muscle testing.
continuous data: Interval-or ratio-level data that use a continuum of numeric values with equal intervals
Continuous data are also collected using ratio measurement, which is the
highest level of measurement and uses a continuum of numeric values with equal
intervals and a zero point that is absolute. Age, weight, height, and income are good
examples of this type of measurement. VAS also provides ratio measurement along
with many other biochemical and physiological measures.
TEST YOUR KNOWLEDGE 10-2
1. Which of the following are advantages that questionnaires have over interviews? (Select all that
apply.)
a. Take less time to administer
b. Provide for anonymity
c. Allow for more in-depth responses
d. Minimize socially desirable responses
2. Which of the following are physiological measures? (Select all that apply.)
a. blood pressure
b. grades on an exam
c. digoxin levels
d. Mini-Mental State Examination
3. Match the terms:
a. Nominal 1. intake and output measurement
b. Ordinal 2. pH of urine
c. Interval 3. type of cancer
d. Ratio 4. strength of contractions (mild, moderate, strong)
How did you do? 1. a, b, d; 2. a, c; 3. 1, d; 2, c; 3, a; 4, b
10.3 Validity and Reliability
At the end of this section, you will be able to:
‹ Identify types of random and systematic measurement errors
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‹ Define validity and reliability
‹ Name strategies that researchers use to establish reliability and validity of
various measures
‹ Recognize questions used to appraise quantitative data collection methods
Measurement Error
Although it may seem that creating surveys and instruments is easy, researchers
actually spend a significant amount of time designing them. They do this to reduce
measurement error so that they know the measurements provide a true reflection
of the sample characteristics. In any measurement, the goal is for the observed
measurement to be as close to the true measurement as possible. The equation O =
T + E illustrates this concept. O stands for the observed score. This is the actual
number or value that is obtained from the instrument regarding the characteristic. T
stands for the true score, the actual amount of the characteristic. If O = T, there
would be a perfect instrument, but this is never the case because error (E) is
always present during measurements. Error can be either random error or
systematic error. Random error is error that occurs by chance. It is difficult for
researchers to control for random error because it results from transient factors.
Random error can be attributed to subject factors, instrumentation variations, or
environmental factors. For example, have you ever made the mistake of answering
a test question by filling in the wrong bubble? Although you knew the correct
answer, something occurred that caused a mistake. In this example, the observed
score (your test score) indicates that you did not know the content, whereas your
true score would indicate otherwise.
me as ure me nt e rror: The difference between the true score and the observed score
random e rror: Error that occurs by chance during measurement
s ys te matic e rror: Error that occurs in the same way with each measurement
CRITICAL THINKING EXERCISE 10-2
© Jules_Kitano/ShutterStock, Inc.
What if you were to take an exam two times? The first time would be in a comfortable room sitting at a
desk in a nice chair. The second time you are expected to stand with a clipboard in a hot, stuffy room.
Which observed score is likely to be closer to your true score? Why?
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Systematic error occurs when the same kind of error occurs repeatedly. Also
known as consistent error, it can result from subject, instrumentation, and
environmental factors. For example, a researcher measures body temperatures after
an intervention. The researcher assumes that the electronic thermometer is
measuring accurately; however, the device has not recently been calibrated. Body
temperatures are being reported a half degree lower than the actual temperatures.
Because every temperature measured is affected, this is systematic error.
If there is error in all measurement, how do researchers know when instruments
are useful? Instruments can be tested using a variety of strategies to identify error.
Researchers conduct methodological studies to test instruments. The nursing
literature, as well as literature from other disciplines, contains such reports.
Another term, psychometrics, is also associated with instrument testing.
Psychometrics refers to the development of measures for psychological attributes.
me thodological: Studies for the purpose of creating and testing new instruments
ps ychome trics : The development of instruments to measure psychological attributes
Validity
When selecting an instrument, researchers must first ask themselves if it is valid.
Validity refers to the degree an instrument measures what it is supposed to measure.
A valid instrument reflects the characteristics or concept that is being measured.
For example, a researcher might want to measure the amount of fear patients have
prior to surgery. The researcher would need to carefully select an instrument that
measures fear, and not anxiety, which is a similar but different concept. There are
three kinds of validity: content validity, criterion-related validity, and construct
validity (Table 10-2).
validity: The degree that an instrument measures what it is supposed to measure
conte nt validity: A kind of validity to ensure that the instrument measures the concept; a test in which experts
on the topic are asked to judge each item on an instrument by assigning a rating to determine its fit with the
concept being measured
crite rion-re late d validity: Degree to which the observed score and the true score are related
cons truct validity: A threat to external validity when the instrument does not accurately measure the
theoretical concepts
Content validity is established when researchers know that the instrument
measures the concept intended to be measured. This requires that researchers
clearly define the concept being studied to ensure that the selected instrument fits.
Researchers test for content validity in two ways: face validity and content
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validity. Both methods involve letting others examine the instruments. When
researchers try to obtain face validity, they ask colleagues or subjects to examine an
instrument and indicate whether the instrument appears to measure the concept.
Face validity is less desirable than content validity because face validity uses an
intuitive approach. To establish content validity, researchers give an instrument to a
panel consisting of experts on the concept. The experts judge the instrument by
rating each item for the degree to which it reflects the concept being measured.
After researchers receive feedback from the panel, they make adjustments to the
instrument. Items that receive high ratings are kept, and items with low ratings are
altered or eliminated. For example, when Beyer, Denyes, and Villarruel (1992)
developed a pediatric photographic pain scale, they asked children, rather than
adults, to rank pictures of a child experiencing pain. Children placed the pictures in
order from no pain to most pain. Researchers found consensus among children
regarding some photographs and eliminated others when children disagreed about
the amount of pain being expressed.
face validity: A test for content validity when colleagues or subjects examine an instrument and are asked
whether it appears to measure the concept
TABLE 10-2 Validity: Does the Instrument Accurately
Measure What It Is Supposed to Measure?
Type Test Description
Content validity: Is the
content representative of
the content domain
under study?
Content validity
Experts on the topic are asked to
judge each item on an instrument
by assigning a rating to determine
its fit with the concept being
measured.
Face validity
Colleagues or subjects examine
an instrument and are asked
whether it appears to measure
the concept.
Criterion-related validity:
To what degree are the
“observed score” and
the “true score” related?
Concurrent validity
New instrument is administered
at the same time as an
instrument known to be valid.
Scores of the two instruments
are compared. Strong positive
correlations indicate good
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validity.
Predictive
New instrument is given at two
different times and scores are
correlated. Strong positive
correlations indicate good
validity.
Construct validity: To
what extent does the
instrument measure the
theoretical construct or
trait?
Hypothesis testing
Hypotheses derived from
theories are tested with the new
instrument.
Convergent
New instrument is administered
at the same time as an
instrument known to be valid.
Scores of the two instruments
are compared. Strong, positive
correlations indicate good
validity.
Divergent
New instrument is administered
at the same time as an
instrument measuring the
opposite of the concept. Scores
of the two instruments are
compared. Strong negative
correlations indicate good
validity.
Multitrait-multimethod
New instrument, established
instrument of same concept, and
established instrument of
opposite concept are given at the
same time. Strong positive and
negative correlations indicate
good validity.
Known groups
New instrument is administered
to individuals known to be high
or low on the characteristic being
measured.
Factor analysis Statistical approach to identify
items that group together.
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Criterion-related validity is concerned with the degree to which the observed
score and the true score are related. Researchers test for criterion-related validity
in two ways: concurrent validity and predictive validity. Concurrent validity is
tested when researchers simultaneously administer two different instruments
measuring the same concept. Usually, the new instrument being developed is
compared to an instrument already shown to be valid. Researchers use correlations
to compare scores from the two instruments. High correlations indicate agreement
between the instruments, whereas low correlations indicate that the instruments are
measuring different concepts. Predictive validity refers to whether a current score
is correlated with a score obtained in the future. For example, suppose that a class
of sophomore nursing students completed an instrument measuring critical thinking
today, and they will complete the instrument again 1 month from now. If the
instrument has good criterion-related validity, their scores will be correlated.
concurre nt validity: A test for criterion-related validity when a new instrument is administered at the same
time as an instrument known to be valid; scores of the two instruments are compared, and strong positive
correlations indicate good validity
pre dictive validity: Test for criterion-related validity where a new instrument is given at two different times
and scores are correlated; strong positive correlations indicate good validity
Construct validity focuses on theory. Constructs are theoretical concepts that
are tested empirically. When researchers test for construct validity, they ask how
well the instrument measures a theoretical concept. Because establishing construct
validity requires empirical testing, more sophisticated strategies implemented over
a longer period of time are needed. There are a number of ways to determine
construct validity: hypothesis testing, convergent testing, divergent testing,
multitrait-multimethod testing, known group testing, and factor analysis.
hypothe s is te s ting: Collection of objectively measurable data that are gathered through the five senses to
confirm or refute a hypothesis; empirical testing; a test for construct validity
conve rge nt te s ting: A test for construct validity in which new instruments are administered at the same time
as an instrument known to be valid; scores of the two instruments are compared, and strong, positive correlations
indicate good validity
dive rge nt te s ting: Test for construct validity in which new instruments are administered at the same time as an
instrument measuring the opposite of the concept; scores of the two instruments are compared, and strong
negative correlations indicate good validity
multitrait-multime thod te s ting: Test for construct validity in which a new instrument, established instrument
of the same concept, and established instrument of the opposite concept are given at the same time; strong
positive and negative correlations indicate good validity
known group te s ting: A test for construct validity in which new instruments are administered to individuals
known to be high or low on the characteristic being measured
factor analys is : A test for construct validity that is a statistical approach to identify items that group together
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For hypothesis testing, researchers use theories to make predictions about the
concept being measured. Data are gathered, and a determination is made as to
whether the findings support the hypothesis. In the study by Beyer et al. (1992), the
authors hypothesized that pain scores would be highest on the day of the surgical
procedure and then gradually decrease. They found that scores were highest on the
operative day and gradually decreased over the course of the hospital stay. The
construct validity of the Oucher, a children’s pain scale, was supported because
data were consistent with predicted pain patterns.
When researchers use two or more instruments to measure the same theoretical
component, they are testing for convergent validity. Convergent validity focuses on
how the observed scores compare to one another. For example, Beyer et al. (1992)
compared the Oucher to a VAS pain scale. Pain ratings were highly correlated, thus
establishing convergent validity. Divergent validity testing involves comparing
scores from two or more instruments that measure different theoretical constructs.
In this strategy, it is not unusual for researchers to compare opposites, for example,
depression and happiness. In this situation, negative correlations support construct
validity. When convergent testing and divergent testing are combined, researchers
are using a strategy known as multitrait-multimethod. This approach is especially
helpful to reduce systematic error.
Another way to test for construct validity is to use the known group approach.
Instruments are administered to individuals known to be high or low on the
characteristic being measured. Researchers expect that there will be significantly
different scores between the high group and the low group. Beyer et al. (1992)
tested known groups by comparing pain scores for children who had experienced
extensive surgical procedures with pain scores for children who had minor surgical
procedures. Children who had spinal fusions reported significantly higher pain
scores using the Oucher than did children who had a cardiac catheterization.
Most concepts have more than one dimension. These dimensions are known as
factors. Researchers use factor analysis, a statistical approach, to identify questions
that group around different factors. Thus, items that group together as one factor
have high correlations. These items may or may not highly correlate with items
around a different factor. Questions that do not fit are altered or eliminated.
Because factor analyses require complex, simultaneous computations of
correlations, computers are needed.
Reliability
Instruments are considered to be reliable when researchers obtain consistent
measurements over time. Reliability must be considered in relation to validity. An
instrument can be reliable but not valid. If you weighed yourself 10 times in a row
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on your bathroom scale this morning, you would expect the scale to show the same
weight each time. You would conclude that the scale is reliable. If you are anxious
about your weight, you cannot conclude that the scale measured your level of
anxiety. Whereas the scale is a valid instrument to measure your weight, it is not a
valid instrument to measure your anxiety even though the scale was shown to be
reliable. Estimates of reliability are usually presented in the form of a correlation
coefficient, with +1.00 indicating a perfect reliability and 0.00 reflecting the
absence of reliability. Typically, reliability coefficients of 0.80 and above are
acceptable for well-established instruments, whereas reliability coefficients of
0.70 and above are acceptable for newly developed instruments (Griffin-Sobel,
2003).
re liability: Obtaining consistent measurements over time
corre lation coe fficie nt: An estimate, ranging from 0.00 to +1.00, that indicates the reliability of an instrument;
a statistic used to describe the relationship between two variables
When testing instruments for reliability, researchers are interested in three
attributes: stability, equivalence, and internal consistency. Instruments are stable
when the same scores are obtained with repeated measures under the same
circumstances (as in the bathroom scale example). An instrument is said to be
equivalent when there is agreement between alternate forms or alternate raters.
Internal consistency, also known as homogeneity, exists when all items on a
questionnaire measure the same concept. Seven ways are commonly used to test
instruments for reliability. They are test-retest reliability, parallel or alternate
form, interrater reliability, split-half reliability, item to total correlation,
Kuder-Richardson coefficient, and Cronbach’s alpha (Table 10-3).
s tability: An attribute of reliability when instruments render the same scores with repeated measures under the
same circumstances
e quivale nce : An attribute of reliability in which there is agreement between alternate forms of an instrument or
alternate raters
inte rnal cons is te ncy: An attribute of reliability when all items on an instrument measure the same concept
te s t-re te s t re liability: A test for instrument reliability when new instruments are given at two different times
under the same conditions; scores are correlated, and strong positive correlations indicate good reliability
paralle l form: A test for instrument reliability in which two different versions of new instruments are given.
Scores are correlated, and strong positive correlations indicate good reliability; also known as alternate form
alte rnate form: A test for instrument reliability in which two different versions of new instruments are given.
Scores are correlated, and strong positive correlations indicate good reliability; also known as parallel form
inte rrate r re liability: A test for instrument reliability when two observers measure the same event. Scores are
correlated, and strong positive correlations indicate good reliability
s plit-half re liability: A test for instrument reliability in which the items are divided to form two instruments.
Both instruments are given and the halves are compared using the Spearman-Brown formula
ite m to total corre lation: A test for instrument reliability in which each item is correlated to the total score;
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reliable items have strong correlations with the total score
Kude r-Richards on coe fficie nt: A test for instrument reliability for use with dichotomous items; all items are
simultaneously compared using a computer
Cronbach’s alpha: A test for instrument reliability used with interval or ratio items; all items are simultaneously
compared using a computer
Test-retest reliability determines stability by administering the instrument to the
same subjects under the same conditions at two different times. Scores are used to
calculate a Pearson r, a type of correlation coefficient. Parallel or alternate form
testing is used to test for both stability and equivalence. Researchers create parallel
forms by altering the wording or layout of items. Because the forms are similar,
researchers expect high positive correlations. For example, Beyer et al. (1992)
compared a pocket-sized Oucher with a poster-sized Oucher and obtained similar
pain ratings.
Interrater reliability also tests for equivalence. This method is used when
instruments record observations. A common way to determine interrater reliability
is to have two observers score the same event. Ratings are compared, and if the
ratings are similar, the instrument is considered to have strong reliability. Another
way to establish interrater reliability is to have one individual make multiple
observations over time.
TABLE 10-3 Reliability: Does the Instrument Yield the Same
Results on Repeated Measurements?
Type What Is Determined? Description
Test-retest Stability
New instrument is given at two
different times under the same
conditions. Scores are correlated.
Strong positive correlations
indicate good reliability.
Parallel or alternate Stability Equivalence
New instrument is given in two
different versions. Scores are
correlated. Strong positive
correlations indicate good
reliability.
Two observers measure the
same event. Scores are
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Interrater reliability Equivalence correlated. Strong positive
correlations indicate good
reliability.
Split-half Internal consistency
The items are divided to form
two instruments. Both
instruments are given and the
halves are compared using the
Spearman-Brown formula.
Item to total Internal consistency
Each item is correlated to the
total score. Reliable items have
strong correlations with the total
score.
Kuder-Richardson
coefficient
Internal consistency
Used with dichotomous items. A
computer is used to
simultaneously compare all
items.
Cronbach’s alpha Internal consistency
Used with interval or ratio items.
A computer is used to
simultaneously compare all
items.
Sometimes, researchers divide the items on a questionnaire in half to make two
versions, a technique known as split-half reliability. Researchers use the
Spearman-Brown formula to compare the two halves. Split-half testing is used to
establish internal consistency. Item to total calculations are also used to test for
internal consistency. Each item on the instrument is compared to the total score
obtained. Strong items have high correlations with the total score. Items with low
correlations to the total score are examined, and decisions are made to change or
eliminate them. When the level of measurement is dichotomous, researchers
determine internal consistency using the Kuder-Richardson coefficient (K-20). This
correlation compares all items at the same time. Cronbach’s alpha is the most
common method used by nursing researchers to assess internal consistency. This
method can be used when data are interval level or higher. Like the Kuder-
Richardson, all items are compared simultaneously to obtain a single correlation
(Trochim, 2000). Computer software is required to perform these sophisticated
tests.
As nurses appraise the methods section of any research article, it is important to
consider the issues of validity and reliability (Roberts & Priest, 2006) before
making practice decisions. The report should contain information about the validity
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and reliability of each instrument used. References for the original development of
the instruments should be provided. Occasionally researchers include instruments
in articles that allow readers to observe how the questions align with the concepts
that were being measured.
Appraising Data Collection in Quantitative Studies
When reading the methods section of any research article, nurses should determine
that each instrument is described and the reliability and validity are reported. The
level of measurement should be noted for each variable measured. Nurses should
also appraise whether instruments represent the concepts and variables being
operationalized. Interventions should be detailed so that nurses know what was
done in the research. If a pilot was done prior to the study, its instruments,
interventions, and findings should be presented. If subjects are grouped, the author
should describe how grouping was accomplished.
Many quantitative studies fall short of significant findings if there are holes in
the methods section. If the instruments do not adequately measure the concepts or
variables, or if they lack validity and reliability, the study may be flawed
(Ioannidis, 2005). Table 10-4 lists questions that nurses should consider when
appraising the methods section.
TEST YOUR KNOWLEDGE 10-3
True/False
1. Validity is concerned with an instrument obtaining accurate and repeatable measures.
2. Content validity is established by having a panel of experts review the instruments.
3. Face validity is the strongest method to establish validity.
4. Equivalence, internal consistency, and stability are tested to ensure instrument reliability.
5. An instrument with a reported Cronbach’s alpha of .65 has good reliability.
How did you do? 1. F; 2. T; 3. F; 4. T; 5. F
TABLE 10-4 Assessing the Quality of Quantitative Data
Collection Methods
What are the variables being measured?
Does the data collection method fit with the study variables?
What is the intervention?
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Is there sufficient detail given about the intervention and the control group?
Was the setting described?
What steps were taken to minimize measurement error?
What instruments are used? Were validity and reliability discussed for each
instrument?
Was the level of measurement considered?
Were there any difficulties with enrollment, attrition, or missing data?
10.4 Collecting Qualitative Data
At the end of this section, you will be able to:
‹ Identify the researcher as the most important data collection instrument
‹ Describe various methods used to collect qualitative data
‹ Discuss the advantages and disadvantages of qualitative data collection
methods
‹ Recognize questions used to appraise qualitative data collection methods
Collecting Words
In recent years, the use of qualitative methods has become more common in health
services research, resulting in an increase in publication of these studies in
healthcare journals (Sandelowski, 2004). Qualitative researchers collect data that
are in-depth and descriptive in order to understand the phenomena being studied.
The methods allow participants to express their thoughts and describe their actions
and intentions in their own words. The researcher is the most important data
collection instrument (Miller, 2010). Researchers gather qualitative data through
questionnaires, interviews, focus groups, case studies, and direct observations.
Table 10-5 lists data collection strategies associated with the four major qualitative
methods.
inte rvie ws : A method for collecting data in person or over the telephone
focus groups : A strategy to obtain data from a small group of people using interview questions
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cas e s tudie s : A description of a single or novel event
dire ct obs e rvations : Observing phenomena using the five senses; capturing information by watching
participants
Questionnaires
Questionnaires are frequently used to collect qualitative data from individuals or
groups of participants. The questionnaire is typically a list of written questions that
can be self-administered. It can also be administered using the Internet or can be
read to the participant by the data collector. Questionnaires can use open-ended
questions, closedended questions, or both. Open-ended questions are used to elicit
statements without providing a fixed answer. An example of an open-ended
question is, “Tell about your experience as a caregiver for a person with
Parkinson’s disease.” Closedended questions offer fixed choices that must be
selected. For example, a closedended question may ask participants to respond
“yes” or “no” to a list of questions. Thoughtful consideration should be given to
wording questions in a clear and concise manner. A sufficient number of questions
must be included so that accurate descriptions can be obtained. The font size should
be large enough for easy reading.
TABLE 10-5 Qualitative Research Methods and Instruments
Method Instrument/Tool
Phenomenology
In-depth interviews
Diaries
Artwork
Grounded theory
Observations
Open-ended question interviews with individuals
or small groups
Ethnography
Participant and direct observations
Open-ended question interviews
Diagrams
Documents
Photographs
Open-ended question interviews
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Historical
Interviews
Documents
Photographs
Artifacts
The advantages of questionnaires are that they are usually easy to administer,
can provide a wealth of data, and are relatively inexpensive. They can provide
anonymity when desired; however, researchers cannot ensure that intended
participants actually answered the questions. The sample may be limited to literate
participants when individuals are expected to self-administer the questionnaire.
Interviews
The one-on-one nature of interviews makes them more personal than self-
administered questionnaires are, and researchers are able to probe more deeply
with follow-up questions. Interviews can be conducted in person or over the
telephone. Structured interviews emphasize obtaining answers based on carefully
predetermined questions. For some qualitative methods, an in-depth interview
guide is used that does not follow this structured form. Rather, a general or “grand
tour” question is asked, and a dialogue between the researcher and the participant
unfolds, leading to more detailed information. Interviews are frequently tape
recorded so they can be transcribed word for word at a later date. Researchers
must take care to minimize distractions and interruptions to allow participants to
focus on the topic. Although interviews provide the opportunity to clarify questions
and answers, they are more expensive and take more time to conduct than
questionnaires do. Because anonymity is impossible to achieve, participants may
be inclined to answer in socially desirable ways. Face-to-face interviews provide
an opportunity for researchers to assess nonverbal communication and the context
in which the interview occurs. Self-reported data, whether obtained from
questionnaires or interviews, provide a rich source of information. Additionally,
response rates are generally high for participants who are willing to express their
opinions.
Focus Groups
Focus groups are small groups composed of usually less than 12 participants
(Beyea & Nicoll, 2000). Participants are brought together to explore attitudes and
thoughts about a particular subject. Through group interaction, insights are often
gained that may not have emerged through individual interviews. When focus
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groups are used, researchers must identify and define the objectives of the focus
group. A facilitator guides the group process by stating ground rules, objectives,
and questions. This role is essential to keep participants comfortable and the group
process flowing and on track. Facilitators must be skilled at involving all
participants and ensuring that the conversation is not monopolized by one or two
individuals. It is recommended that the researcher not be the facilitator of the group
but rather an observer who can listen, take notes, and ask specific follow-up
questions.
Focus group participants must represent the intended population identified by
the researcher. An adequate number of participants should be represented because
participants are not randomly selected. They should be notified in advance
regarding the date, time, and location of the focus group. Focus group sessions are
usually audiotaped and involve a note taker. Approximately 60 to 90 minutes are
given to ask no more than 10 structured questions. Following the session, the data
are transcribed and analyzed to look for trends and patterns.
There are both advantages and disadvantages to using focus groups. This data
collection method is an economical way to bring participants together to gather
information. Often participants selected for focus groups are pleased to offer their
answers, opinions, and insights about the objectives identified for the group.
However, participants must feel secure about the topic. For example, a researcher
investigating the attitudes of nurses about employment practices may be wise to put
nursing managers in separate focus groups from staff nurses. Like other qualitative
methods, the transcription and analysis may be costly and time consuming (Curtis &
Redmon, 2007).
Case Studies
Case studies are often used to gain an understanding of the circumstances around a
rare or sentinel health event. A group of individuals involved in the situation is
brought together to analyze and draw conclusions about the event. Researchers use
this method to examine participants’ behaviors and decision making. Although this
method may be used less in research, it is an important method in quality
improvement programs in almost every healthcare setting. For example, healthcare
providers may convene when a major error is made such as amputating the wrong
limb. Circumstances of the situation are examined and strategies to ensure that this
type of error is avoided are identified.
Observation
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Observations are another type of qualitative data collection method and must be
consistent with the aims of the study (Casey, 2006). Researchers capture
information in the natural and often unstructured setting either by being present or
by recording on videotape to view at a later time. Unstructured observations use
an inductive approach. Phenomena of interest are allowed to emerge over time as
observations are being made. Researchers may be both observers and participants.
Participants are aware of the researchers’ roles and the research taking place, but
researchers are also participants to gain insiders’ perspectives about the
phenomena (Casey, 2006).
uns tructure d obs e rvations : A method of data collection associated with qualitative research in which
phenomena of interest are allowed to emerge over time as observations are made
Researchers usually make observations in settings where research projects take
place. Observations can be expensive and time consuming. When more than one
individual is involved in making observations, the observers should confer
occasionally to make sure that data are being collected in the same manner. The
presence of researchers may alter behaviors that are observed. Therefore,
researchers may need to spend additional time in the setting so that participants feel
more comfortable and the behaviors that are observed are more likely to be typical
(Casey, 2006).
FYI
When selecting an instrument, researchers must first ask themselves if it is valid—whether it reflects the
characteristics or concept that is being measured. There are three kinds of validity: content validity, criterion-
related validity, and construct validity.
Preparing to Go into the Field
After consent has been obtained from participants and researchers go into the field
to collect data, they should be prepared with additional materials and anticipate
needs that may arise. Researchers should go prepared with additional consent
forms in case additional participants are identified, participant information sheets
that explain the study, stamped self-addressed return envelopes, and additional
interview guides. Because field notes are essential in qualitative research methods,
it is helpful to have notebooks with extra pens and pencils available. If interviews
are being conducted, extra tape recorders, additional batteries, and audiotapes need
to be available as backups. Likewise, if video is being used for observations, extra
video cameras, additional batteries, and extra videotapes should be available.
When mobile devices are utilized, it is imperative to be sure wireless access is
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available if required. The device should be fully charged, and/or charging
capability should be available. Additionally, when using devices, it is imperative
that a secure network be used so that others cannot access the information that is
being entered. When compensation is given to participants, researchers should be
prepared with monetary and nonmonetary rewards (Ripley, Macrina, Markowitz, &
Gennings, 2010).
Appraising Data Collection in Qualitative Studies
As nurses read and interpret evidence from qualitative studies, it is essential that
they determine whether data collection methods are appropriate. Table 10-6
outlines critical questions that can be used to appraise data collection methods of
qualitative research. Data collection methods should be congruent with the research
question. For example, when appraising an ethnographic study, the reader must ask
whether a broad question is clearly stated. This question may become more focused
as time is spent in the field and the researcher identifies emerging themes. Do
emerging questions make sense to participants and therefore accurately reflect what
participants are saying? Does the particular group or do individuals in the study
sample represent the experiences into which the researcher hopes to gain insight?
The sample of the study should also be assessed. The setting should be adequately
described so that readers can determine whether the findings relate to other
settings. Readers need to ask if a systematic method or procedure for data
collection was described so that others could replicate the study and if enough data
were collected to reach saturation. Greenhalgh and Taylor (1997) recommended
that readers ask, “Have I been given enough information about the methods used?”
and “Are these methods a sensible and adequate way of addressing the research
question?” (p. 742).
CRITICAL THINKING EXERCISE 10-3
© Jules_Kitano/ShutterStock, Inc.
Recall the last time you performed a physical assessment on a client. What type of data were you able to
gather through interview? Through observation? What open-ended questions did you use? What
closedended questions did you use?
FYI
As nurses read and interpret evidence from qualitative studies, it is essential that they determine whether
data collection methods are appropriate. Data collection methods should be congruent with the research
question.
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TABLE 10-6 Appraising Data Collection Methods in
Qualitative Studies
Where was the setting of the study?
What was the rationale for choosing the setting?
Who were the participants and what were their roles and characteristics?
Why were they chosen?
What data collection methods were used?
What role did the researcher adopt within the setting?
Who collected the data and were they qualified for their roles?
How were data collectors trained? Was the training adequate?
Was the process of the fieldwork adequately reported?
How did the event unfold?
Was data collection continued until saturation was achieved?
Were the researchers’ assumptions or biases acknowledged?
TEST YOUR KNOWLEDGE 10-4
1. Which of the following statements is true regarding the collection of qualitative data?
a. Questionnaires are an economical way to collect anonymous data.
b. Researchers can probe for more data when using questionnaires than when using interviews.
c. Focus groups can be led by anyone interested in the subject.
d. Researchers should never interact with individuals they are observing.
2. Which of the following should nurses consider when appraising qualitative data collection
methods? (Select all that apply.)
a. The cost of the study
b. The setting of the study
c. The ages of the data collectors
d. The role of the researcher
How did you do? 1. a; 2. b, d
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10.5 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss the importance of protecting human subjects during data collection
Protecting human subjects is essential throughout the data collection process. In
healthcare research, subjects or participants are considered to be more vulnerable
because of alterations in health status. Dilemmas can arise when advocating for the
rights of individuals conflicts with the need to promote nursing science. It is not
uncommon for nurses to find themselves caring for individuals involved in research
studies; therefore, it is helpful for nurses to understand some basic safeguards.
Prior to data collection, informed consent must be obtained. One of the
fundamental responsibilities of researchers is to make sure each person understands
the nature of the research project and the implications of participating. Potential
research participants should not be given too much hope that the intervention will
benefit them because this could influence their decisions to participate. Individuals,
or the proxy decision makers, must be able to freely decide whether to participate.
They must be assured that they can withdraw from the study at any time without fear
of reprisal. If nurses determine that potential subjects are not fully informed or lack
understanding, they have an obligation to notify primary investigators. If proxy
decision makers are involved in informed consent, nurses should determine that
decisions are in the best interest of participants (Dunn et al., 2013).
FYI
One of the fundamental responsibilities of researchers is to make sure each person understands the nature
of the research project and the implications of participating. Potential research participants should not be
given too much hope that the intervention will benefit them because this could influence their decisions to
participate.
Sometimes research studies raise sensitive issues among nurses who feel
protective of their patients. Nurses may be reluctant to identify and recruit subjects
or may collect only partial data. For example, Moody and McMillan (2002)
reported that hospice nurses shielded their patients from a study even though the
study was supported by the hospice administrative staff. Only 60 patient–caregiver
dyads were enrolled despite there being 475 eligible patients. It was noted that
many nurses believed that patients who were in the final stage of life should not be
disturbed.
RCTs also create dilemmas for nurses because subjects are randomized into
treatment and control groups. Nurses must accept that randomization occurs to
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better understand the differences between groups, particularly when it is not known
if treatments are beneficial. In blinded studies, nurses should not speculate with
subjects or their families about the intervention. When nurses are informed of
RCTs, they are more likely to assist researchers in recruiting, enrolling, and
retaining participants (Anastasi et al., 2005; Roll et al., 2013).
The Internet is an accepted source of data and method used to collect data;
therefore, it is important for nurses to be aware of some ethical considerations,
namely, privacy and confidentiality. Because Internet communications leave a trail
of archived records, privacy and confidentiality might be threatened. There is
growing debate about whether information on the Internet is private or public. If the
site is considered to be public, researchers may use information without obtaining
informed consent (Ahern, 2005). There is mounting concern that data collected via
the Internet could be sold to others, posing threats to individuals who are willing to
meet via the Internet and share health-related experiences. When online methods
are used, individuals should access the Internet via a secure site and use usernames
and passwords. Security issues must be monitored continuously throughout the data
collection process, and researchers also need to update and upgrade security
measures frequently (Im & Chee, 2006). It is essential that researchers protect any
personal data or IP addresses and comply with the Health Insurance Portability and
Accountability Act (HIPAA).
Regardless of how data are collected, researchers must implement strategies to
keep data secure. Attention to data collection methods is imperative to prevent
error. Researchers should not feel pressured to falsify or fabricate data because
there are statistical methods to address missing data. Security measures must be in
place to ensure that only authorized individuals have access to data. For example,
data should be kept in secured computer files that require passwords to access.
Codes, rather than names of subjects, must be used on data collection instruments
such as questionnaires and laboratory reports to ensure anonymity. Raw data should
be stored in locked cabinets, and audiotapes should be destroyed after they are
transcribed.
TEST YOUR KNOWLEDGE 10-5
True/False
1. When collecting data via the Internet, the rights of human subjects can be ignored because the
Web is a public domain.
2. Nurses should not speculate about the treatments subjects receive in a blinded RCT.
3. Data collection instruments should have codes rather than subject names to ensure anonymity.
How did you do? 1. F; 2. T; 3. T
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APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Read the article by Flynn, Liang, Dixon, Xie, and Suh (2012) and note the methods used for data collection.
Also consider the other articles that you have read. Fill in the measurement column on your grid within this
text’s digital resources by indicating the instruments that were used to collect quantitative data. For the
qualitative study, indicate the method used to obtain data. For the articles that are not data based, indicate
“not applicable” in the column. Examples are provided.
RAPID REVIEW
» Data collection takes a significant amount of time and resources when conducting
research. Pilot studies can help identify unexpected problems.
» Quantitative data collection methods involve measurements that gather numbers.
» Questionnaires, observation, scales, and physiological measures are data
collection methods used in quantitative studies.
» There are four levels of measurement: nominal, ordinal, interval, and ratio.
Statistical tests used in data analysis are selected based on the level of
measurement.
» All measurement contains error. There are two types of error: random and
systematic.
» Validity refers to whether an instrument measures what it should be measuring.
There are three kinds of validity: content validity, criterion-related validity, and
construct validity.
» Reliability refers to the accuracy and consistency of an instrument. Reliable
instruments have stability, equivalence, and internal consistency.
» A correlation coefficient of 0.70 or greater indicates that an instrument has good
reliability. Cronbach’s alpha is one correlation coefficient that is commonly
reported for interval and ratio data.
» The purpose of qualitative data collection is to collect words.
» The researcher is the most important data collection instrument in qualitative data
collection. Researchers use questionnaires, interviews, focus groups, case
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studies, and observation to collect qualitative data.
» Protecting human subjects is an important aspect of all research studies and one
in which nurses play a key role.
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http://dx.doi.org/10.1155/2013/183984
CHAPTER 11
Using Samples to Provide Evidence
Ann H. White
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Identify the basic concepts associated with sampling
‹ Differentiate between probability and nonprobability samples
‹ Describe various sampling methods
‹ Identify quantitative and qualitative research sampling strategies
‹ Discuss factors that should be considered when determining sample size
‹ Describe strategies that enhance the recruitment and retention of subjects
‹ Identify factors related to sampling that must be considered when appraising
studies for evidence-based practice
‹ Describe ethical considerations related to sampling
KEY TERMS
accessible population
anonymity
assent
attrition rate
cluster sampling
coercion
confidentiality
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convenience sampling
data saturation
effect size
elements
exclusion criteria
heterogeneous
homogeneity
inclusion criteria
informed consent
network sampling
nonprobability sampling
population
power analysis
probability sampling
purposive sampling
quota sampling
randomization
representativeness
sample
sampling bias
sampling error
sampling frame
sampling interval
sampling plan
significance level
simple random sampling
snowball sampling
stratified random sampling
subjects
384
systematic random sampling
target population
theoretical sampling
vulnerable population
11.1 Fundamentals of Sampling
At the end of this section, you will be able to:
‹ Identify the basic concepts associated with sampling
Nurses make decisions every day and are using the best evidence from research as
one method to guide these decisions (Hopp, 2012). The ultimate goal of evidence-
based practice (EBP) is high-quality health care with beneficial outcomes (Hall &
Roussel, 2014). Collecting evidence to change clinical practice by identifying
relevant nursing research on clinical topics is critical. After research studies are
identified, nurses must appraise whether the research is valid and relevant to
clinical practice. One consideration when appraising evidence is to determine
whether the sample and the sampling method were appropriately selected for the
study.
Learning the Terms
When designing a research study, researchers must define the population as
specified in the research question. A population is the entire group of elements that
meet study criteria (Fawcett & Garity, 2009). Elements, also called population
units, are the basic unit of the population and may be people, events, experiences,
or behaviors (Fawcett & Garity, 2009). When elements are people, they are
referred to as subjects. After determining the population of interest, researchers
must create a sampling plan that includes the size of the sample, who will be
eligible to be in the study, how individuals will be selected, and how they will be
recruited (Bloom & Trice, 2011). It is not economical, feasible, and time efficient
to include all possible subjects in a study. An alternative is to identify a select
group of subjects that is representative of all eligible subjects. These individuals
constitute the sample.
population: The entire group of elements that meet study inclusion criteria
385
e le me nts : Basic unit of the population such as individuals, events, experiences, or behaviors
s ubje cts : Individuals who participate in studies, typically studies using a quantitative design
s ampling plan: Plan to determine how the sample will be selected and recruited
s ample : A select group of subjects that is representative of all eligible subjects
To obtain the sample needed for the study, researchers must identify the target
population, which is defined as all elements that meet the study criteria. For
example, if a researcher is conducting a study on individuals ages 13–17 who have
type 1 diabetes, then every single adolescent who has type 1 diabetes and who is
13–17 years of age would be included in the target population. The researcher may
choose to narrow the scope of the study by defining the target population as a more
specific group of subjects. For example, the target population could be defined as
adolescents 13–17 years of age with type 1 diabetes whose care is managed by a
local diabetic clinic. The researcher determines the target population based on the
purpose of the study, the design, and the type of data collection being planned
(Fawcett & Garity, 2009).
targe t population: All elements that meet the study inclusion criteria
After the target population is defined, researchers identify the accessible
population, which is the group of elements to which the researcher has reasonable
access. Typically, the accessible population is a smaller group than the target
population; however, in some cases it may be the same group. In the previous
example of adolescent diabetics who received care in one local clinic, the sample
target population and accessible population may be the same. Regardless,
researchers select subjects from the accessible population (see Figure 11-1).
acce s s ible population: The group of elements to which the researcher has reasonable access
FIGURE 11-1 Relationship of Sample to Population
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CRITICAL THINKING EXERCISE 11-1
© Jules_Kitano/ShutterStock, Inc.
The next time you use the term sample or population, pause and consider whether you have used the term
correctly. Were you referring to the individuals who participated in a study or were you referring to the
group of individuals to whom the findings would be generalized? Listen to how others use these terms. Are
they using them correctly?
Learning these terms means using them correctly when appraising research
studies. Frequently, individuals use the words population and sample
interchangeably, which is incorrect. The term sample is used appropriately when
one discusses the elements of a study. The term population is used appropriately
when one is generalizing findings to all possible elements (Bloom & Trice, 2011).
FYI
In order to collect evidence that changes clinical practice, nurses must identify and appraise research that is
relevant to clinical practice. Key to this appraisal is determining that the sample and the sampling method are
appropriate for the study and generalizable. Confidence in generalizability can be increased if samples
accurately represent the target population.
The Hallmark of a Sample: Representativeness
Researchers place much importance on representativeness. This means obtaining
representative samples so that results of studies can be generalized to target
populations (Albert, O’Connor, & Buelow, 2012). Generalizability, also referred to
387
as external validity, is the applicability of study findings to target populations.
There is greater concern for generalizability in quantitative research studies than in
qualitative studies. Generalizabilty of study findings is a critical factor in EBP. As
nurses identify and read research studies to determine best practice, they must
determine whether results of the studies are applicable to patients in their
organizations. Confidence in generalizability can be increased if samples
accurately represent the target population. This means that the elements of a sample
must possess characteristics similar to the elements composing the target
population. Melnyk & Cole (2011) identified a four-step method to ensure that
samples are representative of target populations (see Table 11-1). By following this
process, the potential for obtaining a representative sample is high. When the
population, target population, accessible population, and sample are similar, the
sample can be said to be representative.
re pre s e ntative ne s s : The degree to which elements of the sample are like elements in the population
Inclusion criteria are used to determine subjects to be included in the sample.
Researchers identify characteristics that each element must possess to be included
in the sample. Inclusion criteria are guided by the research question and careful
identification of the target and accessible populations. For example, in the study of
adolescent diabetics, the researcher would first identify the essential
characteristics or inclusion criteria for the target population. These characteristics
could include age, a diagnosis of type 1 diabetes, receiving care at a local diabetic
clinic, and ability to speak English. Researchers often report inclusion criteria to
clearly identify the subjects of the study.
inclus ion crite ria: Characteristics that each element must possess to be included in the sample
TABLE 11-1 Four Steps to Ensure Representative Samples
1. Define and clearly articulate the target population for the study by listing all
of the essential characteristics of the target population or eligibility criteria for
inclusion in the study.
2. Identify the population the researcher has access to for the study, taking
care to verify that the accessible population closely resembles the target
population by using the same eligibility criteria.
3. Develop a method to approach the accessible population. Some researchers
refer to this as a sampling frame. The sampling frame is a practical method used
to gain access to the population that is readily available to the researcher.
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4. Select subjects from the accessible population to include in the sample.
Source: Adapted from Melnyk & Cole (2011).
Researchers may also designate exclusion criteria, which are characteristics
of elements that will not be included in a sample. The use of exclusion criteria may
decrease the risks of certain characteristics influencing the results of a study
(Bloom & Trice, 2011). For example, the researcher wants to study coping in
adolescents with type 1 diabetes. Individuals having another chronic disease such
as asthma may be excluded from the study. The researcher may believe that having
another chronic disease is an extraneous variable that could affect coping. If
researchers choose to set exclusion criteria, the criteria must be clearly delineated,
and researchers must have valid explanations to support the reasons for the
exclusions.
e xclus ion crite ria: Characteristics of elements that will not be included in the sample
Inclusion and exclusion criteria are also important to appraise when
considering evidence. When criteria are explicit, nurses can determine whether
results are applicable to the clinical practice topic being considered. Clearly
defined inclusion and exclusion criteria tend to improve studies because the
precision of sample selection is enhanced. This precision leads to stronger
evidence when looking at research relevant to clinical practice (Bloom & Trice,
2011).
TEST YOUR KNOWLEDGE 11-1
Match the following:
1. Population a. The elements included in a study
2. Target population b. All elements that meet a well-defined set of
criteria
3. Accessible population c. Degree to which the sample reflects the
population
4. Sample d. Characteristics that eliminate elements from a
study
5. Inclusion criteria e. A population that meets sampling criteria
6. Exclusion criteria f. Basic unit of the population
7. Representativeness g. Population from which a researcher can sample
8. Element h. Characteristics of elements in a study
How did you do? 1. b; 2. e; 3. g; 4. a; 5. h; 6. d; 7. c; 8. f
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When samples are not representative of target populations, the potential for
sampling errors and bias is increased. Sampling error occurs when subjects in a
study do not adequately represent the population. In most instances, sampling error
is a result of small sample size that could not adequately represent all of the
elements of the target population. Sampling bias occurs when the sample includes
elements that over-or underrepresent characteristics when compared to elements in
the target population. This is a threat to the external validity of the study or how the
study can be generalized and reported to reflect the target population.
s ampling e rror: Error resulting when elements in the sample do not adequately represent the population
s ampling bias : A threat to external validity when a sample includes elements that over-or underrepresent
characteristics when compared to elements in the target population
11.2 Sampling Methods
At the end of this section, you will be able to:
‹ Differentiate between probability and nonprobability samples
‹ Describe various sampling methods
‹ Identify quantitative and qualitative research sampling strategies
Once inclusion criteria have been determined, researchers identify a method to
select subjects for the sample. Researchers can use several sampling methods to
select subjects. These methods are divided into two categories: probability and
nonprobability sampling.
Probability Sampling Methods
When researchers use probability sampling, every element in the accessible
population has an equal chance of being selected for inclusion in the study. Three
conditions must be met in probability sampling. First, an accessible population
must be identifiable. Next, the researcher must create a sampling frame, that is, a
list of all possible elements in the accessible population. Finally, random selection
must be used to choose elements from the sampling frame. The use of
randomization is important because it reduces the threat of selection bias. The
probability that the characteristics of elements in the sample will be similar to
elements of the population is increased (Graff, 2014; Stevens, 2011). There are
four probability sampling methods: simple random sampling, stratified random
sampling, cluster sampling, and systematic random sampling.
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probability s ampling: Sampling method in which elements in the accessible population have an equal chance of
being selected for inclusion in the study
s ampling frame : A list of all possible elements in the accessible population
randomization: The selection, assignment, or arrangement of elements by chance
Each of the four probability sampling methods has advantages and
disadvantages. Researchers should select a method based on the purpose of the
research, the research question, and the research design. Table 11-2 provides an
overview of the assumptions, potential bias, and representativeness of probability
sampling methods.
Simple Random Sampling
Simple random sampling involves randomly selecting elements from the
accessible population and is considered by some authorities to be the most
effective method to obtain a representative sample. If the accessible population is
small, simple random sampling may be as easy as drawing names. For example, if
the accessible population is 25 nursing students and the researcher needs 10
students for the study, the name of each student could be placed in a container. The
first name is drawn and recorded as a potential participant. The name is returned to
the container and this process continues until 10 student names have been selected.
Should one of the selected students decline to participate in the study, another name
would be selected in the same manner.
s imple random s ampling: Randomly selecting elements from the accessible population
TABLE 11-2 Overview of Probability Sampling Methods
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Source: Adapted from Grove, Burns, and Gray (2013) and Polit and Beck (2014).
FYI
Researchers can use several sampling methods to select subjects. The methods can be divided into two
categories: probability and nonprobability sampling. Researchers should select a method based on the
purpose of the research, the research question, and the research design.
When the accessible population is large, it may be easier for researchers to use
a random numbers table. Such a table contains columns of digits (see Table 11-3).
Each element in the sampling frame is assigned a number. The researcher points to
a number on the random numbers table to begin the selection process. The
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researcher then proceeds through the table either horizontally, vertically, or
diagonally. Numbers are selected until the desired sample size is achieved.
Elements corresponding to the numbers selected form the sample. For example, in a
study to determine student interest in creating a smoke-free campus, the accessible
population is 5,500 undergraduate and graduate students. The researcher secures a
list of all students enrolled in the university and assigns each name on the list a
number. It has been determined that a sample of 200 students is necessary to
achieve representativeness. After selecting the start point, the researcher selects
additional elements by proceeding vertically through the columns until 200 subjects
are selected. Computer programs are also available that select a random sample,
and these programs are frequently used when the researcher is using a large sample.
TABLE 11-3 Table of Random Numbers
Stratified Random Sampling
Stratified random sampling involves selecting elements from a population that
has been divided into groups or strata. Researchers identify characteristics that they
want to stratify. These determinations are frequently based on what is already
known about the phenomenon being studied. For example, findings show that boys
and girls respond differently to pain. Therefore, a researcher may want to stratify
subjects on the variable of sex to ensure that they have enough boys and girls to
393
make comparisons.
s tratifie d random s ampling: Selecting elements from an accessible population that has been divided into
groups or strata
Strata must be mutually exclusive. This means that each element can be put into
one and only one stratum (Grove, Burns, & Gray, 2013). For example, if the sample
is stratified according to gender, subjects can be categorized only as a boy or a girl.
These strata are mutually exclusive because subjects cannot fit into both categories.
After strata are established, researchers assign each element from the accessible
population to a stratum. Participants are then randomly selected from each stratum.
For example, the researcher may want to study nursing student attitudes toward
treatment of pain. Because there are significantly fewer male than female nursing
students, the researcher needs to account for gender disparity in the study. If less
than 10% of the accessible population is male, the researcher uses stratified
random sampling so that 10% of the sample is male. After strata are determined,
subjects are randomly selected from each stratum.
One advantage to stratified random sampling is that sampling error can be
reduced because elements are selected by strata that are known to represent the
population. Representative samples increase the likelihood that findings can be
generalized to the population. Stratifying can also decrease data collection time and
costs of collecting data (Grove et al., 2013). However, care must be taken when
using this method. Each stratum must have a sufficient number of elements. In the
preceding example, if 50 males are needed to constitute 10% of the sample, there
must be at least 50 males in the accessible population.
Cluster Sampling
Cluster sampling is also known as multistaging sampling. Cluster sampling is an
effective and efficient method to collect data from large populations. A manageable
sample is obtained by randomly selecting elements from larger to smaller clusters
or subsets of a population. First, researchers identify all elements that could be
included in a study. Then they determine logical subsets of the populations using
random selection techniques. The participants are then randomly selected within
those groups. For example, a researcher wants to study baccalaureate nursing
education in the United States. Using cluster sampling, the researcher first randomly
selects 10 states that will be included in the study. Then all baccalaureate nursing
programs in each of the 10 states are identified. The researcher then randomly
selects three schools from each state and obtains the names of baccalaureate
students enrolled in each of the programs selected. Sampling is concluded by
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randomly selecting 30% of the names on each list.
clus te r s ampling: Random sampling method of selecting elements from larger to smaller subsets of an
accessible population; multistaging sampling
Although cluster sampling is an effective method to sample large populations,
there are limitations. In the preceding example, suppose the researcher decided to
select 50 students from each program rather than selecting 30%. This could result
in oversampling of students from small programs and undersampling of students
from large programs. Selecting a percentage of students provides a more
representative sample.
Systematic Random Sampling
A fourth type of probability sampling is systematic random sampling. In this
method, researchers select subjects by creating a numbered list of elements and
then selecting every kth element. Sometimes every odd-or even-numbered element
may be chosen. To determine the sampling interval, researchers must know two
things: the desired size of the sample and the size of the sampling frame. The
formula for determining sample interval is as follows (Grove et al., 2013):
s ys te matic random s ampling: Sampling method in which every k th element is selected from a numbered list
of all elements in the accessible population; the starting point on the list is randomly selected
s ampling inte rval: The interval (k ) between each element selected when using systematic random sampling
For example, a researcher desires to study infant feeding patterns and has access to
a well-baby clinic. At this clinic, 300 infants are registered as patients. The
researcher needs 20 subjects for the study. Using systematic sampling, the
researcher would obtain a list of names of all infants seen in the clinic and assign
each name a number. The sampling interval would be calculated by dividing 300 by
20, which equals 15. After randomly selecting a starting point on the list, every
15th (kth) name would be invited to participate in the study.
Sampling bias may be introduced with this method. This method should not be
used if there is a pattern inherent in the list of elements. For example, if every 10th
name on the list is a baby with formula intolerance, these infants would either be
over-or undersampled, resulting in a biased sample.
CRITICAL THINKING EXERCISE 11-2
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© Jules_Kitano/ShutterStock, Inc.
Suppose you are on a task force at your university. The task force needs to survey students about attitudes
toward adopting a smoke-free campus. What are the advantages and disadvantages to using each of the
probability sampling methods?
Nonprobability Sampling Methods
A second category of sampling methods is nonprobability sampling. These
methods do not require random selection of elements and therefore are less likely
to be representative of the target population. Researchers use nonprobability
sampling methods when a sampling frame cannot be determined. Because
randomization is not used, the threat of selection bias is increased; therefore,
samples selected using nonprobability are likely to be less representative than are
samples selected using probability methods. The researcher should make every
effort to create a representative sample and clearly describe the method of
sampling for the reader (Houser, 2011; Melnyk & Cole, 2011). There are four
nonprobability sampling methods: convenience, quota, purposive, and theoretical.
Table 11-4 provides an overview of nonprobability sampling methods.
nonprobability s ampling: Sampling methods that do not require random selection of elements
Convenience Sampling
In convenience sampling, also known as accidental sampling, researchers select
elements for inclusion in the sample because they are easy to access. For example,
a researcher desires to conduct a study of patients with type 2 diabetes presenting
for treatment at an emergency department. Because the researcher cannot predict
which diabetic patients will use the emergency department over the course of the
study, it is impossible for the researcher to create a sampling frame and randomly
select subjects. Therefore, the researcher elects to use a convenience sample that
includes all patients with type 2 diabetes who seek care at the emergency
department.
conve nie nce s ampling: Nonprobability sampling method in which elements are selected because they are easy
to access
Although sampling bias is a concern with this method, strategies can be used to
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control for bias. Comparing demographic data from individuals in the sample to
population demographics can help researchers determine whether the sample is
representative. Researchers should present a thorough description of the
convenience sample in the study results and compare it to the target population. A
careful explanation of why and how the sample was selected allows nurses to
determine the potential for sampling bias and whether study findings should be used
as evidence for clinical practice.
TABLE 11-4 Overview of Nonprobability Sampling
Source: Adapted from Grove, Burns, and Gary (2013) and Polit and Beck (2014).
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Quota Sampling
When researchers sample from strata without randomly selecting elements, they are
using quota sampling. Like stratified random sampling, researchers select strata
based on what is already known about the phenomenon being studied. The desired
number, or quota, needed to fill each stratum should be proportionate to the
population to obtain a representative sample.
The difference between quota sampling and stratified random sampling is the
use of random selection. In quota sampling, elements are conveniently selected
from each strata rather than being randomly selected. For example, in a study about
how age is related to success in nursing programs, a researcher could stratify
according to age by creating three age groups: 18–22, 23–30, and older than 30.
Suppose 80% of nursing students are ages 18–22, 15% are ages 23–30, and 5% are
older than age 30. If the researcher needs a sample size of 100, the sampling would
continue until 80 students between the ages of 18 and 22 years, 15 students between
the ages of 23 and 30 years, and 5 students older than age 30 had been recruited. By
establishing proportional quotas that mirror the nursing student population, the
researcher is more likely to obtain a representative sample.
quota s ampling: Nonprobability sampling method involving selection of elements from an accessible population
that has been divided into groups or strata
Convenience and quota sampling are predominantly used in quantitative
research studies. They are frequently used because it is often difficult in nursing
research to determine a sampling frame in advance of a study. They also are less
time consuming and less costly than probability sampling methods. The ability to
generalize results to the target population depends heavily on the appropriateness
of the sampling method used.
Purposive Sampling
Purposive sampling, which is a nonprobability sampling method, is used in
qualitative studies. Sampling methods used in qualitative research must be
appropriate to allow researchers to gain insight into the experience or event being
studied. There is less focus on the results of the study being generalized to the target
population, and more emphasis is placed on the interpretation and understanding of
the event or experience, including relevant contextual factors being studied
(Leeman & Sandelowski, 2012). Researchers use purposive sampling in qualitative
research to select a distinct group of individuals who either have lived the
experience or have expertise in the event or experience being studied. In qualitative
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studies, individuals in the sample are referred to as participants. For example,
researchers investigating the lived experience of women younger than the age of 25
years who have survived a liver transplant would use purposive sampling. Because
the focus of the study is so specific, the researcher can hand select women who
meet the inclusion criteria. Researchers must carefully document the process used
to select subjects.
purpos ive s ampling: Nonprobability sampling method used in qualitative studies to select a distinct group of
individuals who either have lived the experience or have expertise in the event or experience being studied;
sampling method to recruit specific persons who could provide inside information
When obtaining a purposive sample, researchers often use what is known as
snowball sampling, or network sampling. When using this approach, an initial
participant who meets the study criteria is identified. This participant then
identifies other individuals who meet the criteria for inclusion in the study. To
protect confidentiality, researchers must ascertain from the referring participant that
it is permissible to contact suggested potential participants. When using snowball
sampling, researchers assume that individuals will identify others who are similar
to themselves. Snowball sampling is a useful method to identify participants who
would otherwise be difficult for the researchers to find. Suppose a researcher is
investigating the lived experience of young women with eating disorders. By first
identifying a small group of women who meet the criteria and then asking them to
identify other young women that they know, researchers can find a larger number of
potential participants.
s nowball s ampling: Recruitment of participants based on word of mouth or referrals from other participants
ne twork s ampling: Recruitment of participants based on word of mouth or referrals from other participants;
snowball sampling
TEST YOUR KNOWLEDGE 11-2
1. A researcher desires to study the effect of a memory game on older adults’ abilities to recall a
short-term task list. The researcher randomly selects 20 elders from a list of residents at a local nursing
home. The sampling method used is
a. convenience sampling
b. quota sampling
c. simple random sampling
d. purposive sampling
2. Which of the following sampling methods involves randomization? (Select all that apply.)
a. systematic sampling
b. snowball sampling
c. stratified random sampling
d. cluster sampling
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3. To use random sampling, a researcher must know the
a. sampling frame
b. characteristics of the population
c. exclusion criteria
d. sampling interval
How did you do? 1. c; 2. a, c, d; 3. a
Theoretical Sampling
Another sampling method, used specifically in grounded theory, is theoretical
sampling. When using this sampling method, researchers collect data from an
initial group of participants. After conducting some preliminary analyses of data,
researchers identify additional participants for inclusion in the sample (Fawcett &
Garity, 2009).
the ore tical s ampling: Nonprobability sampling method used in grounded theory to collect data from an initial
group of participants
11.3 Sample Size: Does It Matter?
At the end of this section, you will be able to:
‹ Discuss factors that should be considered when determining sample size
‹ Describe strategies that enhance the recruitment and retention of subjects
‹ Identify factors related to sampling that must be considered when appraising
studies for evidence-based practice
Determining Sample Size
After the sampling method is identified, researchers must decide how large a
sample is needed. Various factors determine sample sizes for quantitative and
qualitative studies. In either type of design, the sample size must be sufficient to
adequately support the research purpose and design of the study. Homogeneity of
the population is one factor that needs to be considered when determining sample
size in quantitative studies. Homogeneity refers to the degree to which elements are
homogenous or similar (Bloom & Trice, 2011). If a population has a number of
common characteristics, the sample size does not need to be as large as a more
heterogeneous, or diverse, population.
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homoge ne ity: The degree to which elements are similar or homogenous
he te roge ne ous : The degree to which elements are diverse or not alike
Another factor to consider when determining sample size is the purpose of the
study and what is being studied. If the focus of the study is narrow, the sample may
not need to be as large as a sample for a very broadly focused study. A study
investigating eating habits of fifth graders is very broad and would require a large
sample. A study on eating habits of fifth graders who have diabetes is narrower in
focus; thus, the number of subjects needed for the study may be smaller.
Another factor that researchers need to consider when conducting quantitative
studies is attrition rate, also known as dropout rate. Typically, there will be
subjects who agree to participate in a study and, for whatever reason, do not
complete the study. Attrition is a threat to internal validity, and the researcher
should attempt to create a study design that minimizes loss of subjects. One method
to address attrition is to increase the number of subjects in the sample so that even
with losing subjects, the researcher will have a sufficient sample size for the
research study (Albert et al., 2012).
attrition rate : Dropout rate; loss of subjects before a study is completed; threat of mortality
The design of the study also influences decisions about sample size. The
number of variables being investigated is an important factor. Typically, the greater
the number of variables being tested in a study, the larger the sample size needed to
detect changes in the variables. The sensitivity of instruments used to collect data
also affects the sample size. A very precise instrument typically requires fewer
subjects than does a less precise instrument (Bloom & Trice, 2011). In addition,
decisions about sample size are influenced by practical matters such as cost,
convenience, and feasibility.
There is one accepted rule for determining sample size when using quantitative
research designs (Bloom & Trice, 2011). The rule of 30 is used by many
quantitative researchers (Grove et al., 2013). This rule states that in order to have a
sufficient sample size to adequately represent the target population, there needs to
be a minimum of 30 subjects in each group being studied. For example, in an
experiment using a control group and an intervention group, a sample size of 60
would be indicated. The rule of 30 should be considered the minimal number of
subjects in each group.
A more powerful and accurate method to determine sample size for quantitative
studies is to conduct a power analysis. A power analysis is a statistical method
used to determine the acceptable sample size to detect the true effect or difference
in the outcome variable (Houser, 2011). When nurses read that a power analysis
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was conducted and used correctly, they can have greater assurance that the sample
size was appropriate for the study and be confident applying the findings to the
target population (Polit & Beck, 2014).
powe r analys is : A statistical method to determine the acceptable sample size that will best detect the true
effect of the independent variable
Two factors must be established to conduct a power analysis: significance level
and effect size. The significance level is the alpha level established prior to the
beginning of the investigation. A vast majority of nursing researchers use p = .05 as
the significance level. The effect size is an estimate of how large a difference will
be observed between the groups (Hayat, 2013). When researchers expect that the
effect size is large, fewer subjects are needed to detect differences between the
groups. If the effect of an intervention is small, a larger sample is needed to
statistically demonstrate that the intervention was effective. A review of relevant
literature on the research topic can assist the researchers in identifying the effect
size (Albert et al., 2012).
s ignificance le ve l: The alpha level established before the beginning of a study
e ffe ct s ize : An estimate of how large a difference will be observed between the groups
There are also factors that determine sample sizes in qualitative studies. These
factors include the scope of the study, the phenomenon being investigated, the
quality of data collected, and the study design. The size of the sample is sufficient
when qualitative researchers achieve data saturation. Saturation means that
collecting data from additional participants adds no new information to what has
already been collected (Fawcett & Garity, 2009). Researchers should provide
information about sample selection so that nurses can make determinations about
the adequacy of the sample. Because the focus is on the data collected, the richness
of data, and the researchers’ conclusions, qualitative studies tend to have smaller
samples than quantitative studies do.
data s aturation: In qualitative research, the time when no new information is being obtained and repetition of
information is consistently heard
Recruitment and Retention of Subjects
Effective recruitment and retention of subjects are imperative to the credibility of
research studies. Failure to attend to recruitment and retention details can critically
affect the size of samples. Initial contacts made by researchers may determine
whether subjects will participate and remain in the study. Because researchers may
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have only one opportunity to encourage participation, information should be
professional, informative, and culturally sensitive for the accessible population.
Flyers, letters, and advertisements are all methods used to recruit subjects.
Decisions about recruitment strategies are based on cost, predicted success,
and appropriateness for the accessible population. Recruitment materials should
include a brief description of the study purpose, inclusion criteria, and information
explaining how to enroll in the study. It is helpful to indicate in recruitment
materials if incentives are being offered for participation. Researchers should
determine reasons that subjects elect not to participate in studies. Being cognizant
of who is not participating in a study should be included in the discussion of the
results because selection bias affects generalizability of the results. Even with
mailed, anonymous questionnaires, researchers may discover, by trending
demographic data, similarities among subjects who did not respond. Researchers
should be aware that certain age groups, socioeconomic groups, or ethnic groups
may be underrepresented.
It is important to retain subjects after they have been recruited to participate in
a study. Strategies to reduce threats of mortality can be effective in reducing subject
attrition. Reasons why subjects withdraw from studies should be monitored, and
conditions causing subjects to withdraw should be modified if possible.
FYI
Various factors determine sample sizes for quantitative and qualitative studies, including homogeneity or
diversity of the population, purpose of the study, focus of the study, design of the study, and number of
variables being investigated. Sample size must be sufficient to adequately support each of these factors.
Considerations for EBP
It is imperative that nurses use the best possible evidence to make decisions about
clinical practice. When considering research studies for EBP, nurses must critically
appraise whether samples represent target populations. Nurses should expect
detailed accounts of sampling methods, sample sizes, and recruitment and retention
strategies. When critically appraising studies, nurses should look for discussion
about power analyses in quantitative studies and data saturation in qualitative
studies. By carefully examining attributes of samples and sampling methods, nurses
can make decisions about the applicability of findings to clinical practice (Hopp,
2012).
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CRITICAL THINKING EXERCISE 11-3
© Jules_Kitano/ShutterStock, Inc.
Suppose you are in charge of designing recruitment materials for a study examining Hispanic mothers’
attitudes toward breastfeeding. What factors would need to be considered when designing these materials?
TEST YOUR KNOWLEDGE 11-3
True/False
1. Attrition has little effect on the generalizability of study findings.
2. The best way to determine sample size for a quantitative study is through power analysis.
3. A study involving three groups needs a minimum of 30 subjects.
4. A group with elements having similar attributes would be considered heterogeneous.
5. Characteristics of the accessible population should be considered when creating recruitment
materials.
How did you do? 1. F; 2. T; 3. F; 4. F; 5. T
11.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ Describe ethical considerations related to sampling
Individuals who participate in research have fundamental rights that must be
protected. The American Nurses Association (ANA) code of ethics and human
rights guidelines direct researchers to protect the rights of each and every subject
(ANA, 2001). The ANA code addresses five human rights that mandate protection
when conducting research. These rights include the right to anonymity and/or
confidentiality, the right to self-determination, the right to privacy, the right to fair
treatment, and the right to protection from discomfort and harm.
Researchers have a responsibility to protect all subjects, especially those who
are considered to be in a vulnerable population. Children, pregnant women, the
unborn, frail elderly, prisoners, and individuals with some level of mental
incapacity are considered to be members of vulnerable populations. In some
situations, factors such as ethnicity, gender, socioeconomic status, education, and
language may create potential vulnerability for certain subjects (Polit & Beck,
2014).
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vulne rable population: A special group of people needing protection because of members’ limited ability to
provide informed consent or because of their risk for coercion
To ensure subject protection, researchers maintain anonymity and
confidentiality. Anonymity means keeping the names of the subjects separated from
the data so that no one, not even the researcher, knows their identities. In some
studies, it is not possible for subjects to remain anonymous. In these situations,
confidentiality must be protected. Confidentiality refers to protecting subjects’
identities. One way identities are protected is to keep a master list with the names
of subjects and the codes assigned to the data collected. The list is locked away
from other data and destroyed after all data are collected. The principal researcher
or designee should be the only person who has the list of names and code numbers.
Another way to ensure confidentiality is by reporting results as group data, not as
individual data. Actions such as these are in accordance with the ANA code of
ethics and human rights guidelines (ANA, 2001), as well as the Health Insurance
Portability and Accountability Act (HIPAA) guidelines.
anonymity: Keeping the names of subjects separate from data so that no one, not even the researcher, knows
subjects’ identities; concealing the identity of subjects, even from the researcher
confide ntiality: The protection of subjects’ identities from everyone except the researcher
CRITICAL THINKING EXERCISE 11-4
© Jules_Kitano/ShutterStock, Inc.
Check out the Health Insurance Portability and Accountability Act (HIPAA) regulations at
http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html. How do these guidelines provide direction to
researchers about protecting confidentiality of subjects?
Another major responsibility of researchers is maintaining subjects’ rights to
self-determination by obtaining informed consent. Prior to beginning a research
study, institutional review board (IRB) approval must be obtained. This board
consists of individuals who review research proposals to ensure that research is
conducted in an ethical manner and that the rights of subjects are not violated. The
IRB pays particular attention to the process of informed consent and ensures that
mandatory content is included in consent forms. See Table 11-5 for a list of
essential components of consent forms.
informe d cons e nt: An ethical practice requiring researchers to obtain voluntary participation by subjects after
subjects have been informed of possible risks and benefits
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http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html
TABLE 11-5 Mandatory Components of Consent Forms
Title of study
Invitation to participate in the research study
Participation is voluntary
Basis for subject selection
Purpose of study
Explanation of procedures
Benefits and risks
Alternatives to participation
Financial obligations/compensation
Confidentiality assurance
HIPAA disclosure
Subject withdrawal without penalty or consequences
Offer to answer questions
Consent statement
Identification of researchers
Source: Adapted from Code of Federal Regulations: Protection of Human Subjects (2009).
FYI
When inviting subjects to participate in studies, researchers must obtain informed consent, with particular
regard for vulnerable populations. With children, nurses should obtain assent. Nurses should also maintain
anonymity and confidentiality as well as avoid coercion when sampling.
Subjects must be informed that they may choose to participate or not participate
in the study and that they may withdraw at any time without harm or consequences.
There must be a clear and concise explanation of the study and what subjects will
be asked to do in the study. There should also be a discussion of the potential
benefits and risks of participation in the study. If there are monetary benefits, there
must be a description of the amount of money participants will receive and what is
required to receive that monetary amount. If there are risks to subjects, those risks
must be clearly detailed and include any physical, emotional, spiritual, economic,
social, or legal risks.
There are other factors to consider when obtaining informed consent. Informed
consents should be written in simple language. If subjects cannot read, forms should
be read to potential subjects. For subjects who speak English as a second language,
consent forms should be read by an interpreter or written in the subjects’ native
language. Subjects should have sufficient time to carefully think about whether or
not to participate. Both subjects and researchers must sign consent forms after
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researchers assure subjects that participation is voluntary. Consent forms should not
be kept with data; this protects subjects’ confidentiality. A copy of the signed form
should also be given to subjects.
There can be some unique circumstances for obtaining informed consent. For
example, if there is minimal risk associated with participation in the study, the IRB
may not require the signing of consent forms. Rather, it may be required that a
statement indicating that completion and submission of the survey imply that the
subject is giving informed consent. With vulnerable populations, the researcher
needs to have clearly stated guidelines as to how the informed consent will be
obtained (Polit & Beck, 2014).
One reason that considerable attention is given to the process of obtaining
informed consent is that it is unethical for subjects to feel coerced into participating
in research. Coercion is the threat of harm or the offer of an excessive reward with
the intent to force an individual to participate in a research study. Healthcare
providers must be extremely careful when conducting clinical research to ensure
that patients do not feel coerced into participating in studies. Patients may feel
particularly vulnerable if they decline participation because they may fear that
treatment may be withheld (Polit & Beck, 2014). Coercion can also be a factor in
studies involving nursing education. Faculty who conduct research involving
nursing students must be careful that students do not feel coerced into participating
and must recognize the power faculty has over students when assigning grades.
coe rcion: The threat of harm or the offer of an excessive reward with the intent to force an individual to
participate in a research study
Children, because they are minors, cannot give consent to participate in
research; however, researchers are obligated to obtain assent when possible.
Children may have difficulty understanding what a study involves, and they may
agree to participate to please adults. Typically, children 7 years of age and older
must give oral assent, while children 12 years and older must sign an assent form.
Regardless of the age, parents or legal guardians must sign consent forms.
as s e nt: Permission given by children to participate in research
TEST YOUR KNOWLEDGE 11-4
Indicate whether the following actions are ethical or unethical.
1. Allowing a subject who does not speak English to sign a consent form without providing an
interpreter.
2. Allowing a nursing administrator to see group data from surveys conducted in the organization.
3. Keeping a folder for every subject that contains a signed consent form and raw data.
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4. Providing subjects with money to reimburse their travel expenses to the data collection site.
5. Promising health care for life to individuals if they choose to participate in a study.
How did you do? 1. Unethical; 2. Ethical; 3. Unethical; 4. Ethical; 5. Unethical
Despite the importance placed on adherence to IRB guidelines and informed
consent, there usually is little discussion about the process used to ensure that
subjects’ rights were not violated. In research articles, authors typically state that
IRB approval was obtained and that the rights of subjects were protected. When
such a statement is made, nurses can assume that ethical principles were upheld.
Sampling methods and how subjects are selected and protected through the IRB
process are critical components in nursing research. The nurse evaluating nursing
research for best evidence to influence clinical practice must understand the
implications of the entire research process.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
As your committee has progressed in its assignment to identify strategies that reduce medication errors, you
have been challenged to apply research principles for the purpose of establishing best practices. The next
step is to review your articles, paying particular attention to details about the sample. Fill in the sample
column on your grid within this text’s digital resources by including details such as sample characteristics,
sampling method, and size. Consult the examples already done.
RAPID REVIEW
» Sampling methods are determined by the research purpose and the research
design.
» There are two major types of sampling: probability and nonprobability.
» Probability sampling and selected nonprobability sampling are used in
quantitative research. Fundamental to probability sampling, but not
nonprobability sampling, is random selection of subjects.
» Probability sampling methods include simple random sampling, stratified random
sampling, cluster sampling, and systematic random sampling.
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» Nonprobability sampling methods include convenience sampling, quota sampling,
purposive sampling, and theoretical sampling.
» In quantitative research, the goal of sampling is to select a representative sample
by identifying subjects that reflect the same characteristics as the population.
» The more representative the sample, the more confidence there is generalizing to
the population.
» Nonprobability sampling is used in qualitative research.
» Sample size is determined by homogeneity of the population, purpose of the study,
attrition rate, design, number of variables being investigated, and the sensitivity
of instruments used.
» Power analysis is used to calculate the minimal number of subjects required in a
quantitative study.
» Sample size for qualitative research continues until saturation is achieved.
» When making decisions about EBP, critical appraisal of the sampling method and
sample size is desirable.
» Researchers must attend to many factors to ensure that the rights of subjects are
protected. Researchers must ensure that informed consent is obtained and that
individuals choose freely, without coercion, to participate in studies.
» Vulnerable populations must be especially protected by researchers.
REFERENCES
Albert, N., O’Connor, P., & Buelow, J. (2012). How many subjects do I need in my research sample? Clinical
Nurse Specialist, 26(2), 302–304.
American Nurses Association. (2001). Code of ethics for nurses with interpretative statements. Washington,
DC: Author.
Bloom, K. C., & Trice, L. B. (2011). Sampling. In C. Boswell & S. Cannon (Eds.), Introduction to nursing
research: Incorporating evidence based practice (2nd ed., pp. 145–163). Sudbury, MA: Jones & Bartlett
Learning.
Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-based nursing practice. Philadelphia, PA:
F. A. Davis.
Graff, J. C. (2014). Mixed methods research. In H. Hall & L. Roussel (Eds.), Evidence-based practice: An
integrative approach to research, administration, and practice (pp. 45–64). Burlington, MA: Jones &
Bartlett Learning.
Grove, S., Burns, N., & Gray, J. (2013). The practice of nursing research: Conduct, critique and utilization
(7th ed.). St. Louis, MO: Elsevier Saunders.
Hall, H., & Roussel, L. (2014). Interdisciplinary collaboration and the integration of evidence-based practice. In
H. Hall & L. Roussel (Eds.), Evidence-based practice: An integrative approach to research,
administration, and practice (pp. xxi–xxvi). Burlington, MA: Jones & Bartlett Learning.
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Hayat, M. (2013). Understanding sample size determination in nursing research. Western Journal of Nursing
Research, 35(7), 943–956.
Hopp, L. (2012). Professional nursing and evidence-based practice. In L. Hopp & L. Rittenmeyer (Eds.),
Introduction to evidence-based practice: A practical guide for nursing (pp. 2–11). Philadelphia, PA: F.
A. Davis.
Houser, J. (2011). Nursing research: Reading, using and creating evidence. Sudbury, MA: Jones & Bartlett
Learning.
Leeman, J., & Sandelowski, M. (2012). Practice-based evidence and qualitative inquiry. Journal of Nursing
Scholarship, 44(2), 171–179.
Melnyk, B. M., & Cole, R. (2011). Generating evidence through quantitative research. In B. Melnyk & E.
Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare (2nd ed., pp. 397–434).
Philadelphia, PA: Lippincott Williams & Wilkins.
Polit, D., & Beck, C. T. (2014). Essentials of nursing research: Appraising evidence for nursing practice.
Philadelphia, PA: Lippincott Williams & Wilkins.
Stevens, K. (2011). Critically appraising knowledge for clinical decision making. In B. Melnyk & E. Fineout-
Overholt (Eds.), Evidence-based practice in nursing and healthcare (2nd ed., pp. 73–80). Philadelphia,
PA: Lippincott Williams & Wilkins.
U.S. Department of Health and Human Services. (2009). Code of Federal Regulations. Title 45: Public welfare.
Part 46: Protection of human subjects. Retrieved from
http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html
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http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html
CHAPTER 12
Other Sources of Evidence
Cynthia L. Russell
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ List the 5 Ss in the pyramid of evidence
‹ Discuss the types and purposes of other sources of evidence
‹ List interdisciplinary databases that can provide evidence for practice
‹ Use the 5 Ss to locate evidence in a logical fashion
‹ Discuss one ethical dilemma when using other sources of evidence
KEY TERMS
case studies
concept analyses
integrative review
meta-analysis
meta-synthesis
nonpropositional knowledge
practice guidelines
propositional knowledge
studies
summaries
synopses
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syntheses
systematic review
systems
traditional literature review
12.1 The Pyramid of Evidence: The 5 Ss
At the end of this section, you will be able to:
‹ List the 5 Ss in the pyramid of evidence
‹ Discuss the types and purposes of other sources of evidence
Nursing is both an art and a science. We learn and practice nursing by using both
propositional knowledge and nonpropositional knowledge. Propositional
knowledge is the science of nursing, or knowledge that is “formal, explicit, derived
from research and scholarship and concerned with generalisability” (Rycroft-
Malone et al., 2004, p. 83). For example, the knowledge we gain from research
studies is propositional knowledge. Nonpropositional knowledge is the art of
nursing, or knowledge that is “informal, implicit and derived primarily through
practice” (Rycroft-Malone et al., 2004, p. 83). When we learn to prepare adhesive
tape before dressing a wound, we are gaining nonpropositional knowledge. Both of
these ways of knowing must come from many sources, be critically evaluated by
experts, and be integrated into the evidence that guides nursing practice.
propos itional knowle dge : The science of nursing or knowledge that is obtained from research and scholarship
nonpropos itional knowle dge : The art of nursing or knowledge that is obtained through practice
An organizing framework to explain the importance and contribution of various
levels of information to evidence-based healthcare delivery has been developed
(Haynes, 2006). The framework is organized in a pyramid with five levels,
including studies, syntheses, synopses, summaries, and systems (see Figure 12-
1). These levels are known as the 5 Ss (Haynes, 2006). Research studies form the
base of the pyramid. The use of research studies as one source of evidence has
been presented previously. Additional types of evidence that form this bottom layer
of the pyramid include case studies and concept analyses. Haynes identifies other
layers of the information pyramid moving upward. These levels are syntheses or
systematic reviews, synopses or brief evidence-based journal abstracts, summaries
such as evidence-based textbooks, and finally systems such as computerized
decision support systems.
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s tudie s : A level in the pyramid of evidence that contains quantitative and qualitative studies, case studies, and
concept analyses
s ynthe s e s : A level in the pyramid of evidence containing evidence to present a whole depiction of a
phenomenon
s ynops e s : A level in the pyramid of evidence containing brief descriptions of evidence
s ummarie s : A level in the pyramid of evidence containing detailed descriptions of evidence
s ys te ms : A level in the pyramid of evidence involving electronic medical records integrated with practice
guidelines
cas e s tudie s : A description of a single or novel event; a unique methodology used in qualitative research that
may also be considered a design or strategy for data collection
conce pt analys e s : Scholarly papers that explore the attributes and characteristics of a concept
FIGURE 12-1 Pyramid of Evidence
Source: Adapted from Haynes (2006).
The First S: Studies
The case study report contributes to nursing’s body of knowledge; it can expand and
generalize theory, represent a typical case, and provide great detail about a
phenomenon for which little information is known (Yin, 2013). A case study
enhances our understanding of clinical care and clinical decision making,
specifically the process of care for a particular case (Aitken & Marshall, 2007).
Yin (2013) notes that a case study “is an empirical inquiry that investigates a
contemporary phenomenon within its real-life context, especially when the
boundaries between the phenomenon and context are not clearly evident” (p. 13).
Sandelowski (2011) provides an expanded definition, stating that “case studies are
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singular combinations of diverse arrays of methodological approaches directed
toward maintaining empirical intimacy with the one or more temporally and
spatially defined objects researchers construct and target for study” (p. 153). What
does this mean? In nursing, case studies are frequently used to report the story of
one patient, including details such as diagnosis, nursing care, and influential
environmental factors. The case study report provides enough detail so that the
reader feels informed about that particular situation.
The case study approach, which originated from sociology, informs nurses
about phenomena through the information that it provides. Case studies can be
exploratory, but they are typically descriptive or explanatory and answer research
questions that ask “how” or “why” (Yin, 2013). The selection of a case or cases for
study is based on the cases’ representativeness of a particular situation. Cases may
also be selected for their potential to describe or explain a theory.
Case studies involve direct observation of the situation and are best used as a
research approach when studying events that are currently happening and when the
researcher has little or no control over these events. Yin (2013) notes that “the case
study’s unique strength is its ability to deal with a full variety of evidence–
documents, artifacts, interviews, and observations” (p. 8). A case study typically
includes an introduction that focuses on the area of clinical practice and provides a
review of the literature about the current knowledge in the area (Aitken &
Marshall, 2007). The introduction can also present a description about a unique
case and include information such as history, care, and outcomes. Aitken and
Marshall note “the discussion should provide a critique of the care in the context of
the known literature, including commentary on care that was not effective and
exploration of possible reasons for this” (p. 132). Implications for practice and
recommendations for future research should be included.
Just like for research studies, the merit of the case study must be evaluated to
determine its contribution to the evidence. Table 12-1 lists criteria for evaluating a
case study. Although the findings from case studies are not regarded as highly as
findings from research studies are, in some instances case study findings can
provide insight and understanding when little evidence is available, thus
contributing to the body of knowledge in a specific clinical area. For example,
when a novel innovation is implemented, a case study may be the only published
information about the innovation.
Other sources of evidence in the first S of the pyramid are concept analyses.
Rogers and Knafl (2000) defined concepts as being “formed by the identification of
characteristics common to a class of objects or phenomena and the abstraction and
clustering of these characteristics, along with some means of expression (most often
a word)” (p. 78). For example, pain is an important concept in patient care. One
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way to define pain is an uncomfortable feeling, but this definition is problematic
because it is too broad and other concepts, such as itching, could be defined the
same way. Therefore, concepts must be described, understood, and communicated
so they can be used for building theory (Risjord, 2009).
TABLE 12-1 Criteria for Evaluating a Case Study
Does the introduction focus on a specific area of practice?
Is the purpose of the case study appropriate?
Does the background literature clearly indicate a literature gap that this case study
fills?
Are multiple sources of evidence from the literature included?
If appropriate, is a theoretical framework presented for the case study?
Is the case history presented clearly?
Is the process of clinical care clearly described?
Are outcomes identified?
Are all appropriate history, process, and outcome elements included?
Does the discussion address the case in the context of what is known, offering
rationale for successful and unsuccessful outcomes?
Are appropriate implications for practice provided?
Are specific suggestions for future research delineated?
Is the case study presented clearly?
Is the case study presented logically?
CRITICAL THINKING EXERCISE 12-1
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Consider the last time that you read a case study. How did the study enhance your understanding of the
situation? How did the case study strengthen your theory about an issue? How did it clarify clinical
processes and outcomes for you?
FYI
An organizing framework, or pyramid of evidence, explains the importance and contribution of various levels
of information to evidence-based healthcare delivery. The pyramid of evidence has five levels, known as the
5 Ss: studies, syntheses, synopses, summaries, and systems.
Concept analyses provide for the exploration of the attributes and
characteristics of a concept (Walker & Avant, 2010). Specific steps for concept
analyses have been described (Walker & Avant, 2010). Understanding these steps
can assist nurses in evaluating concept analyses for application to theories and
evidence-based practice (EBP). The author of the concept analysis should begin by
clearly stating the aims of the analysis. The contribution of the concept analysis to
research and practice should be clearly described. Assumptions made about the
concept may also be presented and may assist in understanding the perspective of
the author’s analysis. Possible uses of the concept should be presented, including
definitions and descriptions found in all types of literature. Related and
interchangeable concepts may also be described. This further assists in clarifying
the concept being studied. After this, the author can state specific characteristics of
the concept, known as defining attributes. Antecedents, or conditions that must
precede the concept, are also presented. For example, a person must have
functioning neurons to feel pain. Next, the consequences, or outcomes, of the
concept should be discussed.
The most interesting part of the concept analysis is the presentation of various
cases. In the pain example, one case describes pain, another may describe itching,
and yet another may describe pleasure. These cases represent, almost represent,
and do not represent the concept. Critiquing the rigor with which the author has
approached the concept analysis report is of utmost importance in determining the
contribution of the report to evidence. When the author has carefully and
thoughtfully followed the concept analysis steps, the results and implications for
practice and research can contribute to the development of evidence.
FYI
Within the 5 Ss are several types of evidence, including case studies, concept analyses, metasyntheses,
systematic reviews, traditional literature reviews, integrative reviews, metaanalyses, practice guidelines, and
abstracts.
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CRITICAL THINKING EXERCISE 12-2
© Jules_Kitano/ShutterStock, Inc.
Read a concept analysis article on a concept that is of interest to you. How does the report increase your
understanding of the concept? Describe how the concept analysis report helped you clarify the “edges” of
the concept.
Although qualitative findings are considered lower-level evidence, they do
provide the patient perspective for EBP. Metasynthesis is the analysis of a group
of qualitative studies. Finfgeld (2003) noted the goal is “to produce a new and
integrative interpretation of findings that is more substantive than those resulting
from individual investigations” (p. 894). Metasynthesis involves breaking down
findings, examining them, discovering essential features, and finally transforming
the essential features into a new, integrated whole.
me ta-s ynthe s is : A systematic review that contains only qualitative studies; a scholarly paper that combines
results from qualitative studies
The Second S: Syntheses
Syntheses integrate various pieces of evidence to present a whole depiction of a
phenomenon. A systematic review is a common type of synthesis found in nursing.
It is a rigorously conducted process of obtaining and reviewing the literature to
answer preestablished theoretical or practice questions. The word systematic is the
key to understanding the nature and intent of a systematic review. According to the
Encarta dictionary, systematic means “done methodically or carried out in a
methodological and organized manner.”
s ys te matic re vie w: A rigorous and systematic synthesis of research findings about a clinical problem
The Cochrane Library (2013) stated, “A systematic review attempts to identify,
appraise and synthesize all the empirical evidence that meets prespecified
eligibility criteria to answer a given research question.” A systematic review of the
literature includes both a systematic approach to obtaining the literature and a
systematic approach to conducting the review of the literature after it is obtained.
“Researchers conducting systematic reviews use explicit methods aimed at
minimizing bias, in order to produce more reliable findings that can be used to
inform decision making” (Cochrane Library, 2013).
Understanding the critical steps to these processes assists in evaluating the
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quality of a systematic review. The Cochrane Library offers specific guidelines for
conducting systematic reviews. There are three types of Cochrane systematic
reviews: (1) intervention reviews to assess the benefits and harms of interventions
used in health care and health policy, (2) diagnostic test accuracy reviews to assess
how well a diagnostic test performs in diagnosing and detecting a particular
disease, and (3) methodology reviews to address issues relevant to how systematic
reviews and clinical trials are conducted and reported. The Cochrane Handbook
for Systematic Reviews of Interventions and the Cochrane Handbook for
Diagnostic Test Accuracy Reviews offer specific guidance for these reviews.
Before beginning the systematic review process, the author of the review
clarifies the problem and the questions to be answered (Cochrane Library, 2013;
Cooper, 1998). Questions that can be answered by a systematic review include:
What is the state of the theoretical knowledge in this area? What are the
methodological gaps in the current studies? What is the impact of interventions on
patient outcomes from these studies? What should be the focus of the next research
study? and How are two bodies of literature related or unrelated? Because the
systematic review can assist in answering many types of questions, the author must
define what variables and/or concepts are important to the problem or question.
Furthermore, the author may also identify the relationships between variables if
these relationships are important to the problem being investigated.
The author must decide what kinds of studies to include in the systematic
review. Therefore, inclusion and exclusion criteria must be established based on
the problem and question to be answered. For example, if the question relates to a
particular age group, then research reports that include only that particular age
group would be included in the systematic review. If studies with a particular
design are the target, for example, a randomized controlled trial, then only reports
with this design would be included. The inclusion and exclusion criteria must
logically flow from the problem and questions.
After the problem and question to be answered by the systematic review are
clarified and the inclusion and exclusion criteria are identified, the author obtains
relevant literature (Cooper, 1998). This begins the data collection phase of the
systematic review. Through an exhaustive process, both published and unpublished
literature is sought for the review. Because most published studies have significant
findings, including unpublished literature helps to decrease bias. Computerized
databases are searched, including Cumulative Index to Nursing and Allied Health
Literature (CINAHL), MEDLINE, Psyc INFO, Health-STAR, the Cochrane
Library, Google Scholar, and Dissertation Abstracts Online. Keywords are used to
query the databases. Additional computerized databases may also be used,
depending on the selected topic. For example, if the author were conducting a
systematic review on a topic related to geriatric nursing, the Age Line Database
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would be included.
The author of the review should consult with expert health science information
specialists during the search. These specialists can locate more studies than less
experienced researchers can (Conn, Valentine, Cooper, & Rantz, 2003; Cook,
Guyatt, & Ryan, 1993). The author must also search for additional published
literature through the ancestry approach. This strategy is completed when the
reference lists of articles are carefully reviewed for any additional articles that are
pertinent to the review. Hand searches of journals in which other eligible articles
have been found should also be completed. Locating all pertinent research reports
is critical to enhancing external validity of the systematic review. External validity
is the ability to generalize the findings from a study, in this case a systematic
review, to another situation (e.g., clinical practice).
The next phase of the systematic review involves evaluation of the literature
(Cooper, 1998). Each piece of literature can be conceptualized as a subject, much
like a subject in primary research. Each piece of literature is evaluated for its
contribution to the problem and posed questions. A typical approach for data
evaluation involves a data collection tool similar to the grid within this text’s
digital resources that you are developing in the Apply What You Have Learned
exercise. A table such as this is often created, where each evaluation criterion is
listed and data that are extracted from each report are placed into the format.
Depending on the question to be answered by the systematic review, data
evaluation may include gathering author, year, study purpose, research
question/hypothesis, variables studied, sample size, sample age, setting, research
design, research instruments used to measure each variable, instrument
psychometrics, procedures used for data collection, and study results.
The next phase of the systematic review process is data (Cooper, 1998). This
stage is defined as “reducing the separate data collection points collected by the
inquirer into a unified statement about the research problem” (Cooper, 1998, p.
104). The goal of the systematic review determines the data analysis approach
used. On one hand, reviews of concepts, definitions, and methods are best
summarized qualitatively. On the other hand, if the body of reports is still relatively
small and quantitative results are reported, then descriptive statistics can be
applied to the group of studies.
The final step of the systematic review is interpretation of the data and
dissemination of the results (Cooper, 1998). The stated results should flow
logically from the data presented in the systematic review. The problem and
research questions should be answered from the data. Systematic reviews are
written using a format similar to that used in primary research reports, including the
introduction, methods, results, and discussion. Most often a table of the data
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collected from each study is included in the systematic review article.
There are two additional types of syntheses that are less rigorous than
systematic reviews. These include the traditional literature review and the
integrative review. A traditional literature review differs from a systematic review
because when a literature review is conducted, the author typically does not go to
the extreme lengths of obtaining all possible literature on a topic. When conducting
a traditional literature review, the author may include only literature that supports a
particular point, excluding reports that have conflicting findings. Nurses are very
familiar with the traditional literature review because this is the type of paper they
wrote for many of their nursing courses.
traditional lite rature re vie w: Article based on common or uncommon elements of works with little concern
for research methods, designs, or settings; narrative literature review
inte grative re vie w: A scholarly paper that synthesizes published studies to answer questions about phenomena
of interest
CRITICAL THINKING EXERCISE 12-3
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Locate a systematic review of the literature that addresses a topic pertinent to your patients. Evaluate the
rigor of the study using the information presented in Table 12-1. How will you use the results of the
systematic review to enhance the evidence that you use to provide the best care possible?
Integrative reviews are more rigorous than traditional literature reviews are but
not as rigorous as systematic reviews are. Authors of integrative reviews seek only
published reports, whereas systematic reviewers use a more rigorous method of
obtaining both published and unpublished reports. Authors follow very methodical
approaches for both types of reviews. Because the scope of integrative reviews is
narrower, the findings are less likely to have external validity than are the findings
from a systematic review.
When the body of reports is large and homogenous, a meta-analysis can be
conducted. Meta-analysis is a statistical procedure that involves quantitatively
pooling data from a group of independent studies that have studied the same or
similar clinical problems using the same or similar research methods (Cooper,
Hedges, & Valentine, 2009). A pooled estimate of effect, called effect size (ES),
and a confidence interval (CI) are calculated. Effect size estimates the strength of
the relationship between two variables, and a confidence interval shows the
reliability of the estimate, in this case, effect size (Cooper et al., 2009).
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me ta-analys is : A scholarly paper that combines results of studies, both published and unpublished, into a
measurable format and statistically estimates the effects of proposed interventions
Network meta-analysis, also known as multiple treatments meta-analysis or
mixed treatment comparison meta-analysis, is a method used to assess the
comparative effectiveness of experimental treatment among similar patient
populations that have not been compared directly in a randomized clinical trial.
Unlike traditional metaanalyses, which summarize the results of trials that have
evaluated the same treatment/placebo combination, network metaanalyses compare
the results from two or more studies that have one treatment in common (Academy
Health, 2013; Bafeta, Trinquart, Seror, & Ravaud, 2013; Cipriani, Higgins,
Geddes, & Salanti, 2013; Lumley, 2002). Unlike the systematic review, the author
obtains both published and unpublished evidence. Authors may even contact
researchers for their data to perform the analysis. Metaanalyses are critical because
information may be used to guide clinical practice decision making and direct the
development of future research strategies (Moore, 2012).
The Preferred Reporting Items for Systematic Reviews and MetaAnalyses
(PRISMA) guidelines were created to help authors improve the reporting of
systematic reviews and metaanalyses (Moher, Liberati, Tetzlaff, & Altman, 2009).
PRISMA consists of a 27-item checklist and a flow diagram. For each checklist
item, this document contains an example of good reporting, a rationale for its
inclusion, and supporting evidence, including references, whenever possible.
In nursing and other practice disciplines, an important kind of synthesis is
practice guidelines. They are “systematically developed statements to assist
practitioner and patient decisions about appropriate health care for specific clinical
circumstances” (Institute of Medicine [IOM], 1990, p. 8). These guidelines are
systematically created by a group of experienced experts and key affected persons
who read, critique, and prioritize the pertinent evidence. Practice guidelines have
been introduced into practice for several reasons. These consensus
recommendations are developed for use in practice to improve patient and system
outcomes. These tools seek to reduce variations in practice, resulting in more
consistent care delivery by those who use the guidelines. Guidelines also enhance
efficient use of resources, which frequently results in reducing the cost of care
delivery. Guidelines should have the following characteristics (IOM, 1990):
practice guide line s : Systematically developed statements to assist healthcare providers with making
appropriate decisions about health care for specific clinical circumstances
» Validity
» Reliability/reproducibility
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» Clinical applicability
» Clinical flexibility
» Clarity
Nursing practice guidelines can be found at the Registered Nurses’ Association
of Ontario Nursing Best Practice Guidelines Program (http://www.rnao.org), the
National Guideline Clearinghouse (http://www.guideline.gov), and the Royal
College of Nursing (http://www.rcn.org.uk). Clinical practice guidelines may also
be written and made available to educate and enhance decision making for the
public. The guidelines can be very helpful to the layperson who is faced with
making choices about health care.
CRITICAL THINKING EXERCISE 12-4
© Jules_Kitano/ShutterStock, Inc.
Locate a nursing clinical guideline and explore the process that was used to develop the guideline. How do
you think the guideline changes practice patterns?
Understanding the process of clinical practice guideline development can assist
nurses in evaluating the merit of clinical practice guidelines. Depending on the area
of practice, the team of experts may be multidisciplinary in nature. Guidelines are
typically focused on patient problems that involve many disciplines working
toward similar patient goals. Practice guidelines may be created locally, nationally,
or internationally. Often they are developed by professional organizations or
federal agencies. Examples include the Gerontological Nursing Interventions
Research Center (http://www.nursing.uiowa.edu/excellence/evidence-based-
practice-guidelines), the Association of Women’s Health, Obstetric and Neonatal
Nurses (http://www.awhonn.org/awhonn/), the American Pain Society
(http://www.ampainsoc.org), and the Oncology Nursing Society
(http://www.ons.org). Systematic reviews of the literature are frequently used to
assist a group of experts with integrating the larger body of literature pertinent to
the practice guideline development. If current systematic reviews of the literature
are not available, the experts must use the rigorous systematic review process for
assimilating the body of literature to create practice guidelines.
As new evidence is generated from primary research reports, systematic
reviews of the literature and practice guidelines must be revised and updated. The
Agency for Healthcare Research and Quality (AHRQ, 2007) has developed a
series of questions that can be used to guide systematic review updates. As the
number of guidelines has increased, guideline syntheses are
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http://www.rnao.org
http://www.guideline.gov
http://www.rcn.org.uk
http://www.nursing.uiowa.edu/excellence/evidence-based-practice-guidelines
http://www.awhonn.org/awhonn/
Ampainsoc – Amplified Performance, Alleviate Injury & Network Socially
http://www.ons.org
systematic comparisons of selected guidelines that address similar topic areas. Key elements of each
synthesis include a discussion of areas of agreement and difference, the major recommendations and
the corresponding strength of evidence and recommendation rating schemes, and a comparison of
guideline methodologies. Also presented are the source(s) of funding, the benefits/harms of
implementing the guideline recommendations, and any associated contraindications. (AHRQ, 2013)
The Third S: Synopses
A synopsis is a brief description of evidence. Abstracts obtained through CINAHL
and MEDLINE are essentially synopses. A variety of evidence-based journals have
emerged that provide synopses of valid and clinically useful studies (DiCenso et
al., 2005; Melnyk & Fineout-Overholt, 2011; Straus, Glasziou, Richardson, &
Haynes, 2011). Although most of these require subscriptions, many websites allow
guests access to some full-text articles. The medication alerts nurses may receive
on their personal digital assistants (PDAs) as updates to the drug book are another
example of synopses.
The Fourth S: Summaries
Integrative summaries are addressed in the fourth level of the pyramid of evidence
(Haynes, 2006). These can be found at several summary services such as BMJ
Clinical Evidence (http://www.clinicalevidence.com/ceweb/index.jsp), the
AHRQ’s National Guideline Clearinghouse (http://www.guideline.gov), and
Physicians’ Information and Education Resource (American College of Physicians,
n.d.; Haynes, 2006).
The Fifth S: Systems
If you deliver nursing care in a healthcare organization that has an integrated
computerized decision support system, you have the system in place to implement
evidence-based care (Haynes, 2006). This system model uses an electronic
medical record that has integrated practice guidelines with patients’ specific
characteristics. Most healthcare providers do not practice in such an advanced
healthcare system. Imagine a future when you would open the electronic medical
record and receive pop-ups (like when surfing the Web) that you could click on to
link to synopses of evidence that pertain to your patient.
TEST YOUR KNOWLEDGE 12-1
1. Which of the following are considered to be at the bottom of the pyramid of evidence?
a. metaanalyses
b. concept analyses
c. synopses
d. systems
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http://www.clinicalevidence.com/ceweb/index.jsp
http://www.guideline.gov
2. The systematic review involves which of the following? (Select all that apply.)
a. methodical review of the literature
b. obtaining published and unpublished sources
c. creating a grid for summarizing data collection
d. establishing inclusion criteria
How did you do? 1. b; 2. a, b, c, d
12.2 Using the Pyramid for Evidence-
Based Practice
At the end of this section, you will be able to:
‹ List interdisciplinary databases that can provide evidence for practice
‹ Use the 5 Ss to locate evidence in a logical fashion
Because the purpose of EBP is to answer clinical questions, and the goal is to
efficiently find information, nurses should begin the search for information at the
top of the pyramid and work down the various levels. The best option is having a
system already in place that brings the information to the nurse. However, because
such systems are not very common, the next best source of evidence is integrative
summaries. If you are unable to locate summaries of the evidence, you should
attempt to locate synopses of the evidence in Evidence-Based Nursing
(http://ebn.bmjjournals.com) or another selected evidence-based journal. If you are
unable to find what you need there, you should look for systematic and other types
of reviews of the literature. The Cochrane Library (http://www.cochrane.org) is a
good place to begin. When none of these are available, you must rely on individual
studies, case studies, and concept analyses. Table 12-2 presents a multidisciplinary
list of online resources that can assist in accessing all levels of evidence.
FYI
Because the purpose of EBP is to answer clinical questions, and the goal is to efficiently find information,
nurses should begin the search for information at the top of the pyramid and work down the various levels.
The best option is having a system already in place that brings the information to the medical record.
TABLE 12-2 Databases to Search for Evidence
Age ncy for He althcare Re s e arch and Quality (AHRQ)
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http://ebn.bmjjournals.com
http://www.cochrane.org
http://www.ahrq.gov
AHRQ works with 12 Evidence-Based Practice Centers that develop evidence reports and technology
assessments on topics relevant to clinical, social science/behavioral, economic, and other healthcare
organization and delivery topics. Professional societies, health plans, insurers, employers, and patient
groups can nominate topics. AHRQ sponsors a National Guideline Clearinghouse at
http://www.guideline.gov.
Ame rican Colle ge of Phys icians Smart Me dicine S M (ACP Smart Me dicine S M)
http://smartmedicine.acponline.org/index.aspx?jhp
ACP Smart MedicineSM provides evidence-based guidance to improve clinical care. Topics include
diseases, screening and prevention, complementary/alternative medicine, ethical/legal issues, procedures,
quality measures, and drug resources.
BMJ Clinical Evidence
http://www.clinicalevidence.com/ceweb/index.jsp
BMJ Clinical Evidence presents summaries that address common or important clinical conditions seen in
primary and hospital care and benefits and harms of preventive and therapeutic interventions. A rigorous
process of developing the summaries is described. Drug safety alerts and links to national guidelines are
included.
DynaMed
http://www.ebscohost.com/dynamed/
DynaMed provides clinically organized summaries of nearly 1,800 evidence-based topics for use at the
point of care via the Internet and/or PDA.
Evidence-Based Medicine
http://ebm.bmj.com/
Evidence-Based Medicine presents abstracts of international medical journals with commentary on its
clinical application to primary medicine.
Evidence-Based Nursing
http://ebn.bmj.com/
Evidence-Based Nursing presents abstracts of selected research with an expert commentary on its
clinical application.
First Consult
http://www.firstconsult.com/php/440744608-113/home.html
First Consult supports clinical decision making by providing concise, readable summaries of evidence that
relates to patient care.
He alth Se rvice s /Te chnology As s e s s me nt Te xt
http://www.ncbi.nlm.nih.gov/books/NBK16710/
The Health Services/Technology Assessment Text is a free, Web-based resource of full-text documents
including guidelines that provide health information and support healthcare decision making for
healthcare providers, health service researchers, policymakers, payers, consumers, and the information
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http://www.ahrq.gov
http://www.guideline.gov
http://smartmedicine.acponline.org/index.aspx?jhp
http://www.clinicalevidence.com/ceweb/index.jsp
http://www.ebscohost.com/dynamed/
http://ebm.bmj.com/
http://ebn.bmj.com/
http://www.firstconsult.com/php/440744608-113/home.html
http://www.ncbi.nlm.nih.gov/books/NBK16710/
professionals who serve these groups.
InfoPOEMs
http://www.infopoems.com/index.cfm
InfoPOEMs (Patient-Oriented Evidence that Matters) is a searchable database from the Journal of
Family Practice. POEMs are summaries similar to ACP Journal Club articles in methodology and
format that are targeted at family practitioners.
Joanna Briggs Institute
http://www.joannabriggs.org/
The Joanna Briggs Institute is an International Research and Development Unit of Royal Adelaide
Hospital and an Affiliated Institute of the University of Adelaide that supports the development and
dissemination of international systematic reviews and summaries of best practices to consumers,
healthcare professionals, and all levels of the healthcare systems, governments, and service provider
units.
Physiotherapy Evidence Database
PEDro is the Physiotherapy Evidence Database, which was developed to provide rapid access to
bibliographic details and abstracts of randomized controlled trials, systematic reviews, and evidence-
based clinical practice guidelines in physiotherapy.
Primary Care Clinical Practice Guide line s
http://medicine.ucsf.edu/education/resed/ebm/practice_guidelines.html
This site, compiled by Peter Sam at the UCSF School of Medicine, includes all guidelines, evidence-
based, consensus, practice parameters, protocols, and other resources such as integrative studies,
metaanalyses, critically appraised topics, and review articles.
SUM Search
http://sumsearch.org/
SUM Search provides references to answer clinical questions about diagnosis, etiology, prognosis, and
therapy (plus physical findings, adverse treatment effects, and screening/prevention) by searching
sources such as Merck Manual, MEDLINE, National Guideline Clearinghouse from AHRQ, Database
of Abstracts of Reviews of Effects, and Pub Med.
The Cochrane Library
http://www.thecochranelibrary.com
The Cochrane Library provides systematic reviews related to clinical topics. The complete reviews are
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http://www.infopoems.com/index.cfm
http://www.joannabriggs.org/
http://medicine.ucsf.edu/education/resed/ebm/practice_guidelines.html
http://sumsearch.org/
http://www.thecochranelibrary.com
available by subscription, either on CD-ROM or via the Internet. Abstracts of the reviews are available
on the website.
The Guide to Community Pre ve ntive Se rvice s
http://www.thecommunityguide.org
The Guide to Community Preventive Services is a multidisciplinary, independent, nonfederal group that
develops evidence-based practice guidelines for community preventive services.
Trip Database
http://www.tripdatabase.com/index.html
The Trip Database supports evidence-based practice by presenting evidence summaries for healthcare
providers.
UpToDate
http://www.uptodate.com/
UpToDate provides evidence-based clinical information to a variety of clinicians on the Internet, on CD-
ROM, and on Pocket PC.
U.S. Pre ve ntive Se rvice s Tas k Force (USPSTF)
http://www.ahrq.gov/clinic/uspstfix.htm
The U.S. Preventive Services Task Force, sponsored by AHRQ, systematically reviews the evidence of
effectiveness of a wide range of clinical preventive services, including screening tests, counseling,
immunizations, and chemoprophylaxis.
CRITICAL THINKING EXERCISE 12-5
© Jules_Kitano/ShutterStock, Inc.
Consider each of the types of evidence and how to locate each type. How will you integrate the use of
these other sources of evidence into your practice?
TEST YOUR KNOWLEDGE 12-2
1. Put the following sources of evidence in order, beginning at the top of the pyramid of evidence.
a. synopses
b. systems
c. studies
d. summaries
e. syntheses
How did you do? 1. b, d, a, e, c
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http://www.thecommunityguide.org
http://www.tripdatabase.com/index.html
http://www.uptodate.com/
http://www.ahrq.gov/clinic/uspstfix.htm
FYI
Fortunately, few ethical dilemmas arise when considering use of evidence. When nurses find evidence that
can be applied to practice, they must consider changes carefully because lives are at stake; however, it is
unethical not to adopt practice guidelines when the evidence is clear.
12.3 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss one ethical dilemma when using other sources of evidence
Fortunately, few ethical dilemmas arise when considering use of evidence. Care
must be taken to label evidence correctly and to be true to the process of review.
Shortcuts should not be taken when searching for evidence, and attention to detail is
critical. On occasion, an author might mislabel the type of review conducted
because there are many commonalities. Authors sometimes generalize beyond the
scope of the evidence or ignore limitations of studies (Gambrill, 2011). It is
therefore important for nurses to critically read and be familiar with the various
types of review to determine the usefulness of the findings. Gambrill noted that
discretion must be used when choosing how to describe new ideas (e.g., accurately
or in a distorted form) and that original (rather than secondary) sources must be
read.
It is normal to become excited when finding evidence that can be applied to
practice. Such enthusiasm makes providing nursing care stimulating. On one hand,
practice changes must be considered carefully because lives are at stake. On the
other hand, it is unethical not to adopt practice guidelines when the evidence is
clear. Our nursing efforts must focus on providing the best care to achieve optimum
patient outcomes, with the least variation in practice, in a resource-conscientious
manner while integrating the evidence with patient preferences. Using other sources
of evidence upon which to base your nursing practice enhances your abilities to
achieve these goals.
TEST YOUR KNOWLEDGE 12-3
True/False
1. Nurses are ethically obligated to follow practice guidelines when evidence is clear.
2. Authors who publish their work in professional journals never draw conclusions beyond their
findings.
How did you do? 1. T; 2. F
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APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Your committee has found some additional articles. They are not reports about research studies, yet they
contain some very pertinent information about medication errors. The evidence summary by Xue (2013)
provides an overview of the evidence regarding the effect of double checking to prevent medication errors.
The systematic review by Biron, Loiselle, and Lavoie-Tremblay (2009) summarizes findings from several
international studies about medication errors. A very interesting strategy is presented in the Web-based
article by Murphy (2006). Read these articles and complete the grid within this text’s digital resources for
each of them. Look to the Rich (2005) article as an example.
RAPID REVIEW
» Propositional knowledge is the science of nursing, and nonpropositional
knowledge is the art of nursing.
» The pyramid of evidence is an organizing framework that explains the importance
of various levels of evidence. It uses the 5 Ss: studies, syntheses, synopses,
summaries, and systems.
» Syntheses include case studies, concept analyses, meta-synthesis systematic
reviews, traditional literature reviews, integrative reviews, and metaanalyses.
» Case studies provide great detail about phenomena for which little is known.
» Concept analyses are an example of a synthesis. Nurses use them to clarify
understanding about concepts that are important in patient care.
» Metasyntheses combine the results of multiple qualitative studies about the same
topic.
» Although all reviews require searching for evidence, the amount and kind of
evidence included vary among the types of reviews.
» Practice guidelines are developed by experts who systematically review the
literature and develop recommendations about patient care.
» Nurses can use synopses, summaries, and systems to efficiently obtain evidence
for practice.
» To avoid ethical dilemmas, nurses must critically read and be familiar with the
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various types of review to determine the usefulness of the findings.
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Decision
UNIT 4
Decisions about practice should always
be based on a careful appraisal of the
evidence.
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CHAPTER 13
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What Do the Quantitative Data Mean?
Rosalind M. Peters, Nola A. Schmidt, and Moira
Fearncombe
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Define statistics
‹ Differentiate between descriptive and inferential statistics
‹ Identify how frequencies can be graphically depicted
‹ Describe measures of central tendency and their uses
‹ Name patterns of data distribution correctly
‹ Describe measures of variability and their use
‹ Discuss the purpose of inferential statistical tests
‹ Explain how statistical testing is related to chance
‹ Distinguish between type I and type II errors
‹ Describe alpha levels commonly used in nursing research
‹ Match common notations with associated statistical tests
‹ Identify common statistical tests as parametric or nonparametric
‹ Describe tests used to determine statistically significant differences between
groups
‹ Discuss tests used to determine statistically significant differences among
variables
‹ Assign commonly used statistical tests to examples based on type of research
question and level of measurement
‹ Interpret data reported in statistical tables
‹ Differentiate between statistical significance and clinical significance
‹ Appraise data analysis sections of an article
‹ Discuss ethical considerations when conducting statistical analyses
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KEY TERMS
alpha level
amodal
analysis of variance
bimodal
bivariate analysis
Chi square
coefficient of variation
confidence intervals
correlated t test
correlation coefficients
degrees of freedom
descriptive statistics
direction
heterogeneous
homogenous
independent t test
inferential statistics
kurtosis
magnitude
mean
measures of central tendency
measures of variability
median
modality
mode
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multiple regression
multivariate analysis
negatively skewed
nonparametric
nonsignificant
normal distribution
parametric
Pearson’s r
percentage distributions
percentile
population parameters
position of the median
positively skewed
probability
range
Rule of 68–95–99.7
sample statistics
sampling distribution
sampling error
semiquartile range
skewed
standard deviation
statistically significant
statistics
Statistics
t statistic
tailedness
type I error
type II error
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unimodal
univariate analysis
z scores
At the end of this section, you will be able to:
‹ Define statistics
‹ Differentiate between descriptive and inferential statistics
13.1 Using Statistics to Describe the
Sample
Originally the term statistics referred to information about the government because
the word is derived from the Latin statisticum, meaning “of the state.” It was given
its numerical meaning in 1749 when Gottfried Achenwall, a German political
scientist, used the term to designate the analysis of data about the state (Harper,
2013). Currently, there are two meanings of the term statistics. Statistics, with a
capital S, is used to describe the branch of mathematics that collects, analyzes,
interprets, and presents numerical data in terms of samples and populations, while
statistics, with a lowercase s, is used to describe the numerical outcomes and the
probabilities derived from calculations on raw data.
Statis tics : The branch of mathematics that collects, analyzes, interprets, and presents numerical data in terms of
samples and populations
s tatis tics : The numerical outcomes and probabilities derived from calculations on raw data
When reporting the results of their study, researchers often present two types of
statistics: descriptive and inferential. Descriptive statistics deal with the collection
and presentation of data used to explain characteristics of variables found in a
sample. As its name implies, descriptive statistics describe, summarize, and
synthesize collected data. Calculations and information presented with descriptive
statistics must be accurate. Inferential statistics involve analysis of data as the
basis for predictions related to the phenomenon of interest. Inferential statistics are
used to make inferences or draw conclusions about a population based on a sample.
They are used to develop population parameters from the sample statistics. For
example, a researcher conducted a study on the efficiency of vitamin C in
preventing the common cold. Descriptive statistics would be used to report that
60% of subjects in the experimental group had fewer colds than did subjects
receiving the placebo. The researcher would then use inferential statistics to
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determine whether the difference in the number of colds between the two groups
was statistically significant. If it was, then it could be inferred that taking vitamin C
would be advantageous. Descriptive statistics are used to provide information
regarding univariate or bivariate analyses.
de s criptive s tatis tics : Collection and presentation of data that explain characteristics of variables found in the
sample
infe re ntial s tatis tics : Analysis of data as the basis for prediction related to the phenomenon of interest
population parame te rs : Characteristics of a population that are inferred from characteristics of a sample
s ample s tatis tics : Numerical data describing characteristics of the sample
Univariate analysis is conducted to present organized information about only
one variable at a time and includes information regarding frequency distributions,
measures of central tendency, shape of the distribution, and measures of variability,
sometimes known as dispersion. Bivariate analysis is performed to describe the
relationship between two variables that can be expressed in contingency tables or
with other statistical tests. Multivariate analysis is done when the researcher
wants to examine the relationship among three or more variables.
univariate analys is : The use of statistical tests to provide information about one variable
bivariate analys is : The use of statistics to describe the relationship between two variables
multivariate analys is : The use of statistics to describe the relationships among three or more variables
The results of descriptive analysis are frequently presented in table format, and
scientific notations are often used. Therefore, it may be helpful to review common
notations used in tables as shown in Table 13-1.
TABLE 13-1 Statistical Symbols for Descriptive Statistics
Symbol/Abbreviation Definition
f Frequency
M Mean
Mdn Median
n Number in subsample
N Total number in a sample
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% Percentage
SD Standard deviation
z A standard score
TEST YOUR KNOWLEDGE 13-1
1. To describe the frequency of the single variable myocardial infarction in adults ages 30–49, which
of the following could be used? (Select all that apply.)
a. descriptive statistics
b. inferential statistics
c. univariate analysis
d. bivariate analysis
How did you do? 1. a, c
FYI
There are two types of statistics: descriptive and inferential. Descriptive statistics describe, summarize, and
synthesize collected data, while inferential statistics involve analysis of data as the basis for predictions
related to the phenomenon of interest.
13.2 Using Frequencies to Describe
Samples
At the end of this section, you will be able to:
‹ Identify how frequencies can be graphically depicted
Information about the frequency, or how often, a variable is found to occur may be
presented as either ungrouped or grouped data. Ungrouped data are primarily used
to present nominal and ordinal data where the raw data represents some
characteristic of the variable. In contrast, with interval-and ratio-level data, the
raw data are collapsed (grouped) into smaller classifications to make the data
easier to interpret. Table 13-2 provides an example of how categorical data about a
sample may be presented in ungrouped format.
Ungrouped data are rarely presented when reporting on continuous variables
such as age, scores on scales, time, or physiological variables (e.g., temperature,
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blood pressure, cell counts). For example, if readers of an article were presented
with a set of ages for 20 different participants in the study, it would be difficult to
make sense of this raw data (see Table 13-3). However, if the numbers were
arranged in a frequency distribution and graphed, they would make much more
sense to the readers. Before a graph can be constructed, the researcher must create
a frequency distribution table. First, the raw data are sorted, usually in ascending
order. Next, the number of times each value occurs is tallied, and the frequency of
each event is recorded in the table. Table 13-3 shows how the raw data can be
organized to more clearly present the information. The table shows how raw data
are tallied and the resulting frequencies and percentages are recorded. The left-
hand side of the table shows the frequency with which individual age data occur.
Because all possible data points are presented, it is still somewhat difficult to
comprehend this presentation of the ungrouped data. The right-hand side of the table
shows a grouped frequency and percentage distribution with the ages grouped in 2-
year increments. It should be obvious that the grouped data are more meaningful
than either the raw or ungrouped data.
TABLE 13-2 Example of Categorical Data Presented in
Ungrouped Format
Variable n(P)
Gender
Men 14 (41)
Women 20 (59)
Race/Ethnicity
White/Caucasian 190 (76.0)
Black/African American 32 (12.8)
Hispanic/Latino 12 (4.8)
Native American/Eskimo 3 (1.2)
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Asian/Pacific Islander 2 (0.8)
No answer 11 (4.4)
Self-Care Behaviors
Current smoker 7 (18)
Alcohol > 1 drink/day 0 (0)
Exercise
No regular exercise 9 (27)
1–2 days/week 10 (29)
3–4 days/week 8 (24)
≥ 5 days/week 5 (15)
n = numbe r in group; P = pe rce nt
Although there are few fixed rules regarding how and when to group data, it is
imperative that there be no overlap of categories. Each group must have well-
defined lower and upper limits so that the groups are mutually exclusive, yet the
groups must include all data collected. For example, if the groupings in Table 13-3
had been 18–20 and 20–22, people who are 20 years old would have been counted
in both groups, and the statistics would have been compromised. Group size also
should be consistent. If the groups had been 18–20 (a 3-year span), 21–25 (a 4-year
span), and older than 25 (a 3-year span), then inaccurate analysis of data would
occur. Although grouping data might make it easier to understand, it also results in
some loss of information. The grouped data presented in Table 13-3 indicate that
30% of the subjects were between 20 and 21 years of age; however, there is no
way of knowing that most subjects (five of the six) were 21, and only one subject
was 20 years of age.
TABLE 13-3 Example of Frequency and Percentage
Distributions of Ages
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In addition to frequency distributions, percentage distributions are often used
to present descriptive statistics. A percentage distribution is calculated by dividing
the frequency of an event by the total number of events. For example, in Table 13-3
the three 18-year-old subjects in the study represent 15% of the total number of
subjects reported. Providing information about percentages is another way to group
data to make results more comprehensible and allow for easier comparisons with
other studies.
pe rce ntage dis tributions : Descriptive statistics used to group data to make results more comprehensible;
calculated by dividing the frequency of an event by the total number of events
After data are tallied and a frequency distribution is determined, data may be
converted to graphic form. Graphs provide a visual representation of data and often
make it easier to discern trends. The most common types of graphs are line charts,
bar graphs, pie charts, histograms, and scattergrams (or scatterplots). Figure 13-1
depicts two different ways to present the age data from Table 13-3.
FIGURE 13-1 Frequency Polygon and Histogram of Age
Data
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TEST YOUR KNOWLEDGE 13-2
True/False
1. Frequency distributions are an effective way to present inferential statistics.
2. Categories in grouped data must be mutually exclusive.
3. Percentages are often used to describe characteristics of samples.
4. The total number of subjects in a sample is represented by the symbol n.
How did you do? 1. F; 2. T; 3. T; 4. F
13.3 Measures of Central Tendency
At the end of this section, you will be able to:
‹ Describe measures of central tendency and their uses
Measures of central tendency offer another way to describe raw data. These
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measures provide information about the “typical” case to be found in the data. The
mean, median, and mode are the three terms most commonly used to describe the
tendency of data to cluster around the middle of the data set (i.e., “averages” for the
data). The mean and median are used to describe continuous-level data, while the
mode is used to describe both continuous-and nominal-level data. Because the
mean and median may be calculated values, they can be rounded to the nearest
number; however, the mode is never rounded because it is an actual data point.
me as ure s of ce ntral te nde ncy: Measures (e.g., mean, median, mode) that provide information about the
typical case found in the data
Mode
The mode is the easiest measure of central tendency to determine because it is the
most frequently occurring value in a data set. It is the highest tally when counting
and is the highest frequency in a distribution table. Modality refers to the number of
modes found in a data distribution. Data can be amodal (without a mode),
unimodal (with one mode), or bimodal (with two modes). There is no specific
term to indicate when data have more than two modes. The mode does not mean
that a data value occurs more than once in a frequency distribution because the
mode is an actual data point. The mode is not affected by the existence of any
extreme values in the data. Table 13-4 demonstrates how the change in just one data
point affects the modality of the data. In the age data presented in Table 13-3, note
that the ungrouped data are unimodal with the mode being 21. However, when the
data are grouped, they become bimodal with modes at 18–19 years as well as 20–
21 years of age (Table 13-5). It is easy to see the modes on the frequency polygon
and histogram in Figure 13-1 because the modes have the highest peaks and tallest
bars. The mode is considered to be an unstable measure of central tendency
because it tends to vary widely from one sample to the next. Given its instability,
the mode is rarely presented as the sole measure of central tendency.
mode : The most frequently occurring value in a data set
modality: The number of modes found in a data distribution
amodal: A data set that does not have a mode
unimodal: A data set with one mode, such as a normal distribution
bimodal: A data set with two modes
TABLE 13-4 Mode
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Data Points
Type of Mode
Location of
Mode
{0, 1, 2, 3} amodal N/A
{0, 1, 2, 2} unimodal 2
{1, 1, 2, 2} bimodal 1 and 2
{1, 1, 1, 2, 2} unimodal 1
{1, 1, 1, 2, 596} unimodal 1
Median
The median is the center of the data set. Just as the median of the road divides the
highway into two halves, the median of a data set divides data in half. If there are
an odd number of data points, the median is the middle value or the score where
exactly 50% of the data lie above the median and 50% of the data lie below it. If
there is an even number of values in the data set, the median is the average of the
two middle-most values and as such may be a number not actually found in the data
set. The median actually refers to the average position in the data, and it is
minimally affected by the existence of an outlier.
me dian: The point at the center of a data set
The position of the median is calculated by using the formula (n + 1)/2, where
n is the number of data values in the set. It is important to remember that this
formula gives only the position, and not the actual value, of the median. For
example, in a study describing the number of hours that five (n = 5) sedentary
subjects spent watching television last week, the following data were collected:
{4, 6, 3, 38, 6} hours. To determine the median, the researcher would perform a
number of easy steps.
pos ition of the me dian: Calculated by using the formula (n + 1)/2, where n is the number of data values in the
set
TABLE 13-5 Mode of Age Data for 20 Subjects
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FYI
The three most commonly used measures of central tendency are the mean, median, and mode. The mean
and median are used to describe continuous-level data, while the mode is used to describe both continuous-
and nominal-level data.
1. Sort the data: 3 4 6 6 38
2. Determine the median’s location. The median is at the (5 + 1)/2, or third,
position from either end.
3. Count over three places to find that the median is 6. In this example, 6 is also the
mode because it is the most frequently occurring value.
If the data set is changed to {3, 4, 6, 6}, then the position of the median would
be 2.5, or halfway between the second and third sorted data points. In this example,
the median is 5, and 6 is the mode. If the data set is changed again to include {3, 4,
6, 100}, the position of the median still will be 2.5, or halfway between the second
and third sorted data points, and the median remains 5. This example demonstrates
that the outlier value of 100 did not affect the median value. For this reason, the
median is generally used to describe average when there is an extreme value in the
data.
When data are grouped, the median is determined using cumulative frequencies.
In Table 13-6 age data are reported for 20 subjects. The median is located at (20 +
1)/2, the 10.5th position, and it is the average of the 10th and 11th data values. In
the ungrouped data, the median is 21 years old, while the grouped median is 20–21
years.
TABLE 13-6 Median of Age Data for 20 Subjects
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Mean
When people refer to an average, what they are really referring to is the mean. The
mean is calculated by adding all of the data values and then dividing by the total
number of values. The mean is the most commonly used measure of central
tendency. It is greatly affected by the existence of outliers because every value in
the data set is included in the calculation. The larger the sample size, the less an
outlier will affect the mean. For example, using the previous data example about
number of hours spent watching television, subjects reported watching 4, 6, 3, 38,
and 6 hours of television per week. Using these data, the mean is calculated to be
11.4 hours (57 / 5 = 11.4). However, 11.4 hours does not present a clear picture of
the amount of television watched by most subjects because the one extreme value of
38 hours skews the data. Because the mean is the measure of central tendency used
in many tests of statistical significance, it is imperative for researchers to evaluate
data for outliers before performing statistical analyses.
me an: The mathematical average calculated by adding all values and then dividing by the total number of values
When reading articles in which averages are used, nurses must carefully
examine the conclusions drawn. For example, suppose a nursing unit employs five
staff nurses and a nursing manager. Annual salaries of these employees are
$66,500, $66,500, $67,000, $68,000, and $69,000. The nursing manager earns
$133,000. During contract negotiations, nurses indicate that they need a raise. One
individual claims the “average” salary is $67,000 per year (median), while another
says the “average” salary is $66,500 (the mode). When confronted by the
administration, the nurse manager responds by saying the “average” salary is
actually $78,333.33 (mean). So, who is correct? In fact, they are all correct. They
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are just using different meanings of average. This example demonstrates how easy
it is to manipulate statistics and why careful attention must be given to the
interpretation of data being presented.
When appraising evidence, it is helpful to remember that the mean is the best
measure of central tendency if there are no extreme values, and the median is best if
there are extreme values. Because they are calculated, the mean and median are not
necessarily actual data values, whereas the mode must be an exact data point. The
mean and median are unique values (again, because they are calculated), but the
mode might be unique or might not exist at all, or there might be multiple modes.
The mean is greatly affected by extreme values, the median is marginally affected,
and the mode is not affected. The mean and median use continuous-level data
values for their calculations, while the mode can use either continuous-or nominal-
data values. The mean is the most stable in that if repeated samples were drawn
from the same population, the mean would vary less than either the median or the
mode would from sample to sample.
TEST YOUR KNOWLEDGE 13-3
1. The most frequent data value in a set of data is the
a. mean.
b. median.
c. mode.
d. average.
2. When data have no outliers, researchers prefer to report the
a. mean.
b. median.
c. mode.
d. magnitude.
How did you do? 1. c; 2. a
Because it is the most stable, the mean is most often used when computing other
statistics. The median is used when the center of a data set is desired, and the mode
is used to determine the most frequent case.
13.4 Distribution Patterns
At the end of this section, you will be able to:
‹ Name patterns of data distribution correctly
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Normal Distributions: Symmetrical Shapes
Measures of central tendencies are used to define distribution patterns. When the
distribution of the data is symmetrical (that is, when the two halves of the
distribution are folded over, they would be superimposed on each other and
therefore be unimodal), then the mean, median, and mode are equal. In this
situation, the data are considered to be normally distributed. A normal
distribution has a distinctive bell-shaped curve and is symmetric about the mean.
In Figure 13-2, note that the decreasing bars, or area under the curve, indicate that
the data cluster at the center and taper away from the mean. A number of human
traits, such as intelligence and height, are considered to be normally distributed in
the population.
normal dis tribution: Data representation with a distinctive bell-shaped curve, symmetric about the mean
FIGURE 13-2 Example of a Normal Distribution
When Data Are Not Normally Distributed
Often data do not fit a normal distribution and are considered to be asymmetric or
skewed. In asymmetric distributions, the peak of the data is not at the center of the
distribution, and one tail is longer than the other. Skewed distributions are usually
discussed in terms of their direction. If the longer tail is pointing to the left, the data
are considered to be negatively skewed (Figure 13-3). In this situation, the mean is
less than the median and mode. For example, a group of students take a test for
which all but one student studied. The one student, who did not study, scores very
low. This low score, because it is an outlier, affects the mean because the scores of
students who studied are high. This outlier contributes to a negatively skewed
distribution. The low score pulls down the mean and pulls with it the tail of the
distribution to the left. If the mean is greater than the median and mode, then the
data are positively skewed, pulling the tail to the right. For example, an instructor
gives a difficult test. Only one or two students scored high on the test. The rest of
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the students’ scores were low. Most students’ scores are lower than the mean
because the outliers affect the mean. The distribution of these scores is positively
skewed. The extremely high scores pull up the mean and pull the tail in a positive
direction toward the right (Figure 13-4).
s ke we d: An asymmetrical distribution of data
ne gative ly s ke we d: A distribution when the mean is less than the median and the mode; the longer tail is
pointing to the left
pos itive ly s ke we d: Distribution when the mean is greater than the median and the mode; the longer tail is
pointing to the right
FIGURE 13-3 Example of a Negatively Skewed Distribution
FIGURE 13-4 Example of a Positively Skewed Distribution
Attention should be given to how the data are spread, or dispersed, around the
mean. Just as school children or military personnel wear uniforms to be like each
other, uniform data have very little spread and look like each other. When there is
greater variation in data, a wider spread results. In graphic representations of data
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(see Figure 13-5), highly uniform data have a high peak and highly variable data
have a low peak. Kurtosis is the term used to describe the peakedness or flatness
of a data set.
kurtos is : The peakedness or flatness of a distribution of data
FIGURE 13-5 Example of Kurtosis
TEST YOUR KNOWLEDGE 13-4
True/False
1. If the tail of a distribution is skewed to the left, the data are negatively skewed.
2. In a normal distribution, the mean, median, and mode are the same value.
3. If data are highly uniform, a low peak will be observed in a graphic representation of the data.
How did you do? 1. T; 2. T; 3. F
13.5 Measures of Variability
At the end of this section, you will be able to:
‹ Describe measures of variability and their use
Measures of variability provide information regarding how different the data are
within a set. These can also be known as measures of dispersion because they
provide information about how data are dispersed around the mean. If the data are
very similar, there is little variability, and the data are considered to be
homogenous. If there is wide variation, the data are considered to be
heterogeneous. Common measures of variation include range, semiquartile range,
percentile, and standard deviation. z scores and variance are used to compare the
variability among data using different units of measure.
me as ure s of variability: Measures providing information about differences among data within a set; measures
of dispersion
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homoge nous : Elements that share many common characteristics
he te roge ne ous : The degree to which elements are diverse or not alike
TABLE 13-7 Example of Ranges of Income
Control Experimental
$30,000 $15,000
$38,000 $23,000
$42,000 $42,000
$57,000 $57,000
$73,000 $103,000
Range $43,000 $88,000
Range
A statistical range is the difference between the maximum and minimum values in a
data set. Because the range is very sample specific, it is considered to be an
unstable measure of variability. Table 13-7 shows the income reported for subjects
in the experimental and control groups of a study designed to evaluate health
literacy. The mean for both data sets is $48,000, and the medians are each $42,000.
However, the data are quite different because the data for the experimental group
are more heterogeneous than for the control group. The experimental group’s
income varies from a minimum of $15,000 to a maximum of $103,000, with a range
of $88,000. The control group’s income has a minimum of $30,000 and a maximum
of $73,000. Although salaries are still quite variable, they are more uniform than
the experimental group’s salaries because their range is $43,000. In data
comparisons, the smaller the range, the more uniform the data; the greater the range,
the more variable the data.
range : The difference between the maximum and minimum values in a data set
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FYI
The most commonly reported measure of variability, the standard deviation, is the measure of the average
deviations of a value from the mean in a given data set. Because standard deviations are based on the mean
of the data set, information collected using different measurement scales cannot be directly compared.
Semiquartile Range
Just as the median divides data into two halves, other values divide these halves in
half, meaning into quarters. The semiquartile range is the range of the middle 50%
of the data. Figure 13-6 illustrates the semiquartile range of the age data from a
previous example. The semiquartile range lies between the lower (first) and upper
(third) quartile of ages. The first quartile value is the median of the lower half of
the data set; one fourth of the data lies below the first quartile and three fourths of
the data lie above it. The third quartile value is the median of the upper half of the
data; three fourths of the data lie below the third quartile and one fourth of the data
lies above it. The semiquartile range is the difference between the third and first
quartile values and describes the middle half of a data distribution. In Figure 13-6,
note that 50% of the data lie between 19 and 22.5, and the range is 3.5.
s e miquartile range : The range of the middle 50% of the data
FIGURE 13-6 Semiquartile Range of Age Data
Percentile
A percentile is a measure of rank. Each percentile represents the percentage of
cases that a given value exceeds. The median is the 50th percentile, the first
quartile is the 25th percentile, and the third quartile is the 75th percentile score in a
given data set. For example, if a newborn baby boy’s weight is in the 39th
percentile, he weighs more than 39% of babies tested weigh but less than 61% of
the other babies.
pe rce ntile : A measure of rank representing the percentage of cases that a given value exceeds
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Standard Deviation
The most commonly reported measure of variability is the standard deviation,
which is based on deviations from the mean of the data. Whereas the mean is the
expectation value (the expected “average” of the data set), the standard deviation is
the measure of the average deviations of a value from the mean in a given data set.
Because it is a measure of deviation from the mean, a standard deviation should
always be reported whenever a mean is reported. Standard deviation is based on
the normal curve and is used to determine the number of data values that fall within
a specific interval in a normal distribution. Understanding the standard deviation
allows you to interpret an individual score in comparison with all other scores in
the data set. Recall the salary example presented earlier. The data were variable
because of the extreme ranges of salary values. Calculating a standard deviation
provides different information about variability. It is now apparent that the average
deviation from the mean for the experimental group is $34,842.50, which is more
than double that of the control group’s $17,073.37 deviation (see Table 13-8).
s tandard de viation: A measure of variability used to determine the number of data values falling within a
specific interval in a normal distribution
CRITICAL THINKING EXERCISE 13-1
© Jules_Kitano/ShutterStock, Inc.
Consider how your ACT or SAT scores were reported. What was your raw score? What was your
percentile? What do these data indicate about your performance on these tests?
TABLE 13-8 Standard Deviations of Income
Control Experimental
$30,000 $15,000
$38,000 $23,000
$42,000 $42,000
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$57,000 $57,000
$73,000 $103,000
SD $17,073.37 $34,842.50
Comparing Variability When Units of Measure Are
Different
Because standard deviations are based on the mean of the data set, information
collected using different measurement scales cannot be directly compared. For
example, the mean of a sample’s age is reported in years, whereas the mean of a
sample’s weight is reported in pounds. To make comparisons among unlike data
requires that all the data means be converted to standardized units called
standardized or z scores. z scores are then used to describe the distance a score is
away from the mean per standard deviation. A z score of 1.25 means that a data
value is 1.25 standard deviations above the mean. A z score of –2.53 means that a
data value is 2.53 standard deviations below the mean. Using the z score allows
researchers to compare results of age and weight.
z s core s : Standardized units used to compare data gathered using different measurement scales
The coefficient of variation is a percentage used to compare standard
deviations when the units of measure are different or when the means of the
distributions being compared are far apart. The coefficient of variation is computed
by dividing the standard deviation by the mean and recording the result as a
percentage. For example, if you were to compare age and income of a sample of
nurses, you could not use range or standard deviations to discuss the variables’
comparative spread because they are measured with different units. If the mean
salary for nurses is $66,000, with a standard deviation of $6,000 and the mean age
is 32 years, with a standard deviation of 4 years, the coefficient of variation for the
salary is 9.1%, and the coefficient of variation for age is 12.5%. Using the
coefficient of variation shows that age is more variable than salaries among this
group of nurses.
coe fficie nt of variation: A percentage used to compare standard deviations when the units of measure are
different or when the means of the distributions being compared are far apart
CRITICAL THINKING EXERCISE 13-2
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© Jules_Kitano/ShutterStock, Inc.
Do you have a professor who uses means and standard deviations, known as norm referencing, for grading
exams? What are the advantages to using this approach as opposed to straight scales for grading? What are
some disadvantages? Why would it be false to assume that having more questions on exams would be
advantageous to students when norm referencing is used?
Tailedness: The Rule of 68–95–99.7
The concept of tailedness is important to understand when reading statistical
reports. Recall that a normal distribution is one in which the mean, median, and
mode are all equal and the data are symmetrical. In discussing tailedness, the graph
of a normal distribution is depicted as a bell-shaped curve, centered about the mean
(x), with three standard deviations marked to the right (positive) and also to the left
(negative) (see Figure 13-7). Normal distributions are not shown beyond three
standard deviations in either direction because approximately 99.7% of the data
will lie within this range. Approximately 68% of all data in a normal curve lie
within one standard deviation of the mean, and 95% of the data lie within two
standard deviations of the mean. Thus, the Rule of 68–95–99.7 tells us that for
every sample, 99.7% of the data will fall within three standard deviations of the
mean. In Figure 13-8, note the symmetry about the mean for the standard deviations
as they are divided in half for each distribution percentage. For example, one
standard deviation contains 34% of the scores above and 34% of the scores below
the mean to total 68%; two standard deviations contain 34% plus 13.5% above and
below the mean to equal 95% of the scores. On a standard deviation graph, the
mean has a z score of zero. Other z-score percentages may be determined by using a
table showing the area under the curve data.
taile dne s s : The degree to which a tail in a distribution is pulled to the left or to the right
Rule of 68–95–99.7: Rule stating that for every sample 68% of the data will fall within one standard deviation
of the mean; 95% will fall within two standard deviations; 99.7% of the data will fall within three standard
deviations
FIGURE 13-7 Normal Distribution with Standard Deviations
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FIGURE 13-8 Standard Deviations and Percentage
Distribution
FIGURE 13-9 Percentile Rank Based on Normal Distribution
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Figure 13-9 shows that normal distributions may also be used to approximate
percentile ranks. Actual percentile values must always be determined by using a
normal distribution table to look up a given z score.
FIGURE 13-10 Standard Deviations of Age Data
The age data from previous examples do not approximate a normal distribution
because the mean, median, and mode are not equal. If, however, we used data that
were standardized with a mean of 23 and a standard deviation of 1.5 years, the
normal curve for these data would look like the graph in Figure 13-10. Sixty-eight
percent of these people would be between 21.5 and 24.5 years of age, and someone
26 years old would be in the 95th percentile.
Half of the people would be 23 years or older, while half would be younger
than 23 years.
Correlation Coefficients
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Bivariate analyses are performed to calculate correlation coefficients, which are
used to describe the relationship between two variables. Correlation coefficients
provide information regarding the degree to which variables are related.
Correlations are evaluated in terms of magnitude direction and sometimes
significance. Scatterplots of data can provide hints about direction and magnitude
of the correlation (Figure 13-11). Direction refers to the way the two variables
covary. A positive correlation occurs when an increase in one variable is
associated with an increase in another or when a decrease in one variable is
associated with a decrease in the other. For example, if a researcher found that as
weight increased so did systolic blood pressure, or if weight decreased so did
systolic blood pressure, a “positive” relationship between weight and blood
pressure exists. A negative correlation occurs when two variables covary
inversely; that is, when one decreases, the other increases. For example, as
exercise increases body weight decreases.
corre lation coe fficie nts : An estimate, ranging from 0.00 to +1.00, that indicates the reliability of an instrument;
statistic used to describe the relationship among two variables
dire ction: The way two variables covary
FIGURE 13-11 Scatterplots of Correlational Relationships
Magnitude refers to the strength of the relationship found to exist between two
variables. A correlation can range from a perfect positive correlation of 1.00 to a
perfect negative correlation of 1.00. A correlation of zero means that there is no
relationship between the two variables. It is generally accepted that correlations
ranging between .10 and .30 are considered to be weak, .30 and .50, moderate, and
greater than .50, strong; however, the final determination is based on the variables
being examined. It is important to remember that magnitude is not dependent on or
related to the direction of the correlation.
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magnitude : The strength of the relationship existing between two variables
TEST YOUR KNOWLEDGE 13-5
Match the following terms:
1. Range a. rank
2. Semiquartile range b. difference between maximum and minimum values
3. Percentile c. measure of the average deviations of a value from the
mean
4. Standard deviation d. percentage comparing standard deviations when units
of measure are different
5. z score e. range of the middle 50% of data
6. Coefficient of variation f. converted standard deviation to a standardized unit
How did you do? 1. b; 2. e; 3. a; 4. c; 5. f; 6. d
13.6 Inferential Statistics: Can the
Findings Be Applied to the Population?
At the end of this section, you will be able to:
‹ Discuss the purpose of inferential statistical tests
‹ Explain how statistical testing is related to chance
When to Use Inferential Statistics
First, samples are analyzed using descriptive statistics. Then, if appropriate,
inferential statistical tests can be conducted to: (1) make decisions about whether
findings can be applied to the population, or in other words, to make inferences
about the population based on the sample, and (2) test hypotheses. For some
studies, the use of inferential statistics is not appropriate, and their use depends on
the research questions being asked. Research questions that are descriptive would
not require inferential statistics. For example, the research question “How often do
nurses assess the use of herbal remedies by patients?” would best be answered by
using descriptive statistics, such as frequencies, means, and standard deviations.
Using parameter estimation to determine inferences to the population is less
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common in nursing research; however, this approach is becoming more popular
with the emphasis on evidence-based practice (EBP) in nursing and medicine
(Borenstein, 1997; Straus, Richardson, Glasziou, & Haynes, 2010). Most
frequently, these estimates are reported as confidence intervals (CIs). CIs are
ranges established around means that estimate the probability of being correct
(American College of Physicians—American Society of Internal Medicine, 2001;
Hoekstra, Johnson, & Kiers, 2012). In other words, CIs estimate the degree of
confidence one can have about the inferences. Researchers typically report
confidence levels of 95% or 99%.
confide nce inte rvals : Ranges established around means that estimate the probability of being correct
Use of inferential statistics to test hypotheses is best suited to research
questions or hypotheses that ask one of two broad questions:
» Is there a difference between the groups?
» Is there a relationship among the variables?
Most experimental and quasi-experimental designs involve questions asking if
there is a difference between the groups. For example, the use of inferential
statistics to test the hypothesis “Patients who have uninterrupted sleep cycles have
better wound healing than do patients who awaken throughout the night” would be
appropriate. Research questions or hypotheses that ask about relationships among
variables, such as “Is there a relationship between the number of hours of sleep and
a score on a memory exam?” can also be tested using inferential statistics.
When deciding which statistical tests to use to analyze data, researchers must
take into account many factors (Hayes, 1994). After considering whether the
research questions or hypotheses involve groups or variables, the next most
important factor researchers consider is the level of measurement. Whether
variables are nominal, ordinal, interval, or ratio is important because some tests
are appropriate for interval and ratio data but not for other levels of measurement.
Other factors that can influence selection of inferential statistical tests include
whether: (1) a probability sampling method was used, (2) the data are normally
distributed, and (3) there is potential confounding of the variables. Nurses should
keep in mind that the strongest inferences can be made when the level of
measurement is interval or ratio, a probability sampling method was used, the
sample size is adequate, and the data are normally distributed.
FYI
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Statistics enable nursing researchers to determine the probability that results are not a result of chance
alone.
It’s All About Chance
Regardless of the type of question being asked, the major unanswered question is:
What is the likelihood that the findings could have occurred by chance alone? For
example, suppose that you toss a coin 10 times, and each time it lands heads up.
Could that happen by chance? Absolutely. Now suppose you flip it another 10 times
and it lands with heads up every time. Although it is possible that a coin could land
heads up 20 times in a row, this would be a rare occurrence. Would you begin to
wonder if this were happening by chance or would you suspect that the coin is not
fair? How many times would you want to toss the coin before you conclude that the
coin is not fair?
Researchers ask the same types of questions when they analyze data using
inferential statistics. They ask, “What is the probability that the findings were a
result of chance?” Probability is the likelihood of the frequency of an event in
repeated trials under similar conditions. Probability is the percentage of times that
an event (e.g., “heads”) is likely to occur by chance alone. Probability is affected
by the concept of sampling error. Sampling error is the tendency for statistical
results to fluctuate from one sample to another. There is always a possibility of
errors in sampling, even when the samples are randomly selected. The
characteristics of any given sample are usually different from those of the
population. For example, suppose a fair coin was tossed 10 times for 10 different
trials. A tally of the results in Table 13-9 shows that the trials varied; but as
expected, more of the trials were nearer 50% heads than 100% heads.
probability: Likelihood or chance that an event will occur in a situation
s ampling e rror: Error resulting when elements in the sample do not adequately represent the population
TABLE 13-9 Coin Toss Example
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CRITICAL THINKING EXERCISE 13-3
© Jules_Kitano/ShutterStock, Inc.
When is there enough testing to make a decision?
Researchers determine whether the results were obtained by chance using
inferential statistical tests, sometimes known as tests of significance. Mathematical
calculations are performed, usually by computers, to obtain critical values. These
values are plotted on a normal distribution, and determinations of whether findings
are statistically significant or nonsignificant are made. Statistically significant
critical values fall in the tails of the normal distributions, usually three standard
deviations from the mean or where about only 0.3% of the data occur. Thus, when
critical values are in that area, researchers believe it is appropriate to claim that
the findings did not happen by chance.
s tatis tically s ignificant: When critical values fall in the tails of normal distributions; when findings did not
happen by chance alone
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nons ignificant: When results of the study could have occurred by chance; findings that support the null
hypothesis
TEST YOUR KNOWLEDGE 13-6
1. Inferential statistical tests are used to: (Select all that apply.)
a. make assumptions about the population.
b. describe the sample with means and standard deviations.
c. test hypotheses by asking if there are differences between the groups.
d. select a sample.
e. determine whether results occurred by chance.
How did you do? 1. a, c, e
13.7 Reducing Error When Deciding
About Hypotheses
At the end of this section, you will be able to:
‹ Distinguish between type I and type II errors
‹ Describe alpha levels commonly used in nursing research
Researchers do many things to reduce error so that nurses can have confidence in
findings. They reduce error by selecting designs that fit with research questions,
controlling the independent variable, carefully measuring variables, and reducing
threats to internal and external validity. They also take steps to reduce error when
deciding whether a research hypothesis is supported or not supported.
When making decisions about hypotheses, researchers keep several principles
in mind (Hayes, 1994). First, hypotheses are claims about the world. Second,
decisions are made about null hypotheses, not research hypotheses. The purpose of
inferential statistical tests is to determine whether the null hypothesis should be
accepted or rejected. Third, it is important to remember that no matter how well
errors are reduced or how powerful the findings are, nothing is ever proven. The
most that can be claimed is that a research hypothesis is either supported or
unsupported. Last, it is wise to understand that an empirical view is adopted and an
assumption is made that there is a single reality in the physical world and that
science can be used to discover the truth about reality.
FYI
Researchers attempt to reduce error so that nurses can have confidence in findings. Methods for reducing
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error include selecting designs that fit with research questions, controlling the independent variable, carefully
measuring variables, and reducing threats to internal and external validity.
For example, suppose a researcher is testing a new way to assess risk for skin
breakdown over the sacrum. The researcher hypothesizes that prior to the
presentation of redness, skin temperature will be increased. From an empirical
viewpoint, it is assumed that skin temperature, redness, and sacrum are real entities
and that in the real world one of four situations is true: prior to the appearance of
redness over the sacrum, the skin temperature will be increased, unchanged,
decreased, or varied. Now suppose that in the real world, the unknown truth is that
skin temperature does increase before redness appears over the sacrum. After
collecting and analyzing data, statistically significant results were obtained. The
researcher decides to reject the null hypothesis, that there will be no difference in
skin temperature before the appearance of redness, and the research hypothesis is
supported. In this instance, unknown to the researcher, an error was not made. The
claim of the original hypothesis, that skin temperature would be increased prior to
the appearance of sacral redness, matches what actually happens in the world. The
researcher rejected the null hypothesis, and it was indeed false. If nurses
accumulated additional supporting evidence, findings would make their way into
practice, and patients at risk for skin breakdown could be identified earlier.
Errors are avoided when researchers accept the null hypothesis when it is true.
Consider this variation of the preceding example. The researcher hypothesizes that
prior to the presentation of redness over the sacrum, skin temperature will be
increased; however, in the real world there is no change in skin temperature over
the sacrum prior to the appearance of redness. After collecting and analyzing data,
the researcher finds that calculations from inferential statistical tests are
nonsignificant and therefore the null hypothesis is supported. Although
disappointed, the researcher accepts the null hypothesis and unwittingly avoids
error because there is no temperature change in the real world. The goal of
hypothesis testing is to accept true claims and reject false ones.
Type I and Type II Errors
The goal is to avoid the two kinds of errors that can be made when making
decisions about null hypotheses. These errors are known as type I and type II
errors. A type I error occurs when the researcher rejects the null hypothesis when
it should have been accepted. In nursing, when the null hypothesis is wrongly
rejected, the usual result is that the researcher makes false claims about the
research hypothesis. Usually this means that the researcher claims that some
treatment works or some relationship exists, when in actuality that is not the case.
For example, in the previous examples, the researcher hypothesized that skin
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temperatures over the sacrum would be increased prior to the appearance of
redness. Now suppose that in the real world, there is no change in the temperature;
however, analysis of the data collected indicates that there is an increase of
temperature. In other words, the researcher has obtained statistically significant
results. This false finding could be the result of any number of errors, such as
sampling bias and measurement error. The false finding could have happened by
chance, just as it would be possible by chance to get 20 heads in a row when
tossing a fair coin. The researcher, unaware about what is true in the world, rejects
the null hypothesis based on the statistical analysis and claims that the research
hypothesis is supported. This is a type I error. If nurses adopt this finding into
practice, they will unnecessarily spend time measuring skin temperature because it
would provide no indication of risk. If the practice of measuring skin temperature
continued without evaluation of patient outcomes, it is possible that this type I error
would never be discovered.
type I e rror: When the researcher rejects the null hypothesis when it should have been accepted
A type II error occurs when researchers accept the null hypothesis when it
should have been rejected. In nursing, this type of error usually means that practice
does not change when it should be changed. The opportunity to implement an
effective treatment or claim the discovery of a relationship has been missed.
Consider this variation of the previous example. The researcher still hypothesizes
that sacral skin temperature is increased prior to the appearance of redness, and in
the real world this is true. The researcher completes the analysis, which has
statistically nonsignificant results. These nonsignificant results can be the result of
error or chance. Based on the statistical analysis, the researcher is forced to accept
the null hypothesis, unaware that the research hypothesis is true in the real world. A
type II error has occurred, and nurses miss an opportunity to predict which patients
are at risk for skin breakdown.
type II e rror: When the researcher inaccurately concludes that there is no relationship among the independent
and dependent variables when an actual relationship does exist; when the researcher accepts the null hypothesis
when it should have been rejected
CRITICAL THINKING EXERCISE 13-4
© Jules_Kitano/ShutterStock, Inc.
Individuals make decisions every day. They make decisions based on their assumptions about the world, only
to find out later that the assumptions were incorrect. Can you think of times when you have made a type I
error? What about a situation when a type II error was made?
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TABLE 13-10 Type I and Type II Errors
The Null Hypothesis Is True in
Real World
The Null Hypothesis Is
False in Real World
Researcher
Accepts the
Null
Hypothesis
No Error Type II Error
Researcher
Rejects the
Null
Hypothesis
Type I Error No Error
There are a few strategies for remembering type I and type II errors. One way is
through the graphic representation in Table 13-10. One axis of the table represents
whether the null hypothesis is true or false in the real world. The other axis
represents the two decisions that can be made by researchers about the null
hypothesis: to accept or to reject. The center boxes are then filled in as appropriate.
No errors are made when a decision to accept a null hypothesis is made when it is
true in the real world. Likewise, there is no error when a false null hypothesis is
rejected. A type I error is made when researchers, obtaining statistically significant
results, reject the null hypothesis when in fact it was true. A type II error occurs
when researchers fail to obtain statistically significant results, and thus they accept
the null hypothesis despite the fact that it is false. Another way to remember type I
and type II errors is to think of the acronym RAAR (Gillis & Jackson, 2002).
RAAR stands for the phrase: “Reject the null hypothesis when you should accept it,
and accept the null hypothesis when you should reject it.” The first two letters, RA,
stand for type I error. The second two letters, AR, stand for type II error.
Level of Significance: Adjusting the Risk of Making
Type I and Type II Errors
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In health care, type I errors are considered to be more serious than type II errors
are (Smith, 2012). It seems much more risky to claim that a treatment works when
in reality it does not than to miss the opportunity to claim that a treatment works.
For example, a researcher invents and tests a new device for measuring blood
sugar. If a type I error is made, the researcher claims that the new device works
when in reality it does not. Patients begin using the device, which inaccurately
measures blood sugar. Because nurses evaluate the implementation of this new
device, they eventually realize that the device is not effective as the researcher
claimed. The type I error could result in accusations of harming diabetics with a
fraudulent measuring device. Because patients who used the device might have
been harmed, they might want to sue the researcher. However, if a type II error is
made, the researcher throws away the device for measuring blood sugar even
though in reality it is superior to other devices. In this situation, the researcher
misses the opportunity to market the device and earn money, and diabetics miss the
opportunity to benefit from the measuring device. Although neither scenario is
desirable, most researchers would choose to miss the opportunity to make money
rather than to harm patients and risk the legal implications.
Researchers must make decisions about how much risk they are willing to
tolerate. When interventions are complex, expensive, invasive, or have many side
effects, such as a new procedure for cardiac surgery, researchers are usually less
willing to make type I errors. When interventions are simple, inexpensive, or
noninvasive, such as a new teaching method, the tolerance for a type I error is
increased.
Researchers use statistics to adjust the amount of risk involved in making type I
and type II errors. It is helpful to remember that type I and type II errors have an
inverse relationship. When type I error is increased, type II error is decreased.
Risks for these errors are adjusted by selecting the alpha level, which is the
probability of making a type I error. Alpha level is designated at the end of the tail
in a distribution (see Figure 13-12). In nursing research, the alpha levels are
usually either .05 or .01. In the figure, the placement of the alpha level shows how
type I and type II errors can be adjusted. In this example of a one-tailed test, the
area under the curve to the left of the alpha level represents the amount of type II
error. The area under the curve to the right of the line is the amount of type I error.
Notice that when the alpha level is larger, there is more space to the right of the line
than when the alpha level is smaller.
alpha le ve l: Probability of making a type I error; typically designated as .05 or .01 at the end of the tail in a
distribution
What are the implications of these alpha levels? When the alpha level is set at
.05, it is likely that 5 times out of 100, the researcher would make a type I error by
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wrongly rejecting the null hypothesis. When .01 is used for the alpha level, a
researcher would make a type I error only 1 time out of 100. Thus, alpha levels of
.05 increase type I errors while reducing type II errors. In general, although alpha
levels of .01 reduce type I errors, the likelihood of making a type II error increases.
In nursing, .05 is used more commonly than .01 is.
FIGURE 13-12 Placement of Alpha Level on Normal
Distribution
FIGURE 13-13 Relationship of Alpha Levels and Critical
Values
Although the mathematical difference between these alphas is miniscule, the
implications for decision making are great. Figure 13-13 provides an illustration of
how the acceptance or rejection of the null hypothesis is affected by the alpha level
selected. When conducting statistical tests to test hypotheses, suppose there is a
chance for three possible critical values. Note in Figure 13-13 that critical value
“A” falls to the left of both alpha levels. Regardless of the alpha level chosen, the
results will be statistically nonsignificant, and the null hypothesis will be accepted.
Critical value “B” falls to the right of both alpha levels. The results will be
statistically significant regardless of the alpha level selected. Now consider the
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position of critical value “C.” How would the decision about the null hypothesis be
affected by either of these two alphas? If the alpha level is set at .05, the critical
point would be significant and the null hypothesis would be rejected. However, if
an alpha level of .01 is selected, the critical point would be nonsignificant, and the
researcher would accept the null hypothesis. To avoid any temptation to select
alpha levels that bias decision making, researchers must always state their selected
alpha levels in the initial research proposal. Strong rationales for the one selected
must also be provided.
TEST YOUR KNOWLEDGE 13-7
1. When a researcher accepts the null hypothesis when it really should have been rejected, the
researcher: (Select all that apply.)
a. committed a type I error.
b. committed a type II error.
c. obtained significant results.
d. obtained nonsignificant results.
2. The most commonly used alpha level in nursing research is
a. .001.
b. .0001.
c. .005.
d. .05.
How did you do? 1. b, d; 2. d
13.8 Using Statistical Tests to Make
Inferences About Populations
At the end of this section, you will be able to:
‹ Match common notations with associated statistical tests
‹ Identify common statistical tests as parametric or nonparametric
‹ Describe tests used to determine statistically significant differences between
groups
‹ Discuss tests used to determine statistically significant differences among
variables
‹ Assign commonly used statistical tests to examples based on type of research
question and level of measurement
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The Language of Inferential Statistics
A unique language is used by statisticians to communicate statistical data. A variety
of terms and statistical symbols (Table 13-11) is associated with inferential
statistics. Statistical tests are frequently named after the individuals who devised
them, which can sometimes make the names seem arbitrary and hard to remember.
The following fundamental terms are ones with which nurses should become
familiar.
TABLE 13-11 Statistical Symbols for Inferential Statistics
Symbol/Abbreviation Definition
ANOVA Analysis of variance
df Degrees of freedom
F Fisher’s F ratio
ns Nonsignificant
p Probability
r Pearson product–moment correlation
R Multiple correlation
R2 Multiple correlation squared
t Computed value of t test
α Alpha; probability of type I error
β Beta; probability of type II error
∆ Delta; amount of change
Σ Sigma; sum or summation
X2 Chi square
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Parametric tests are used to make inferences about the population when
specific conditions have been met (Hayes, 1994; Plichta & Kelvin, 2013). These
conditions include: (1) use of probability sampling, (2) normal distribution of data,
(3) measurement of variables at the interval or ratio level, and (4) reduction of
error. For example, data collected using a visual analog scale would be analyzed
using parametric tests. These important conditions make parametric tests especially
powerful. When parametric tests are used, nurses can have high levels of
confidence about the conclusions made.
parame tric: Inferential statistical tests involving interval-or ratio-level data to make inferences about the
population
When all four conditions are not met, researchers must use less powerful tests
known as nonparametric tests. Nonparametric statistics are used for interval data
that do not have a normal distribution or for data that are nominal or ordinal in
nature. Because these tests are considered to be less powerful, the level of
confidence nurses have about making inferences about the population is not as
strong as when parametric tests are used.
nonparame tric: Inferential statistics involving nominal-or ordinal-level data to make inferences about the
population
Another term used when talking about statistics is degrees of freedom. Degrees
of freedom (df), based on the number of elements in a sample, are used to correct
for possible underestimation of population parameters when performing
mathematical equations. Specifically, degrees of freedom refers to the freedom of a
variable’s score to vary given the other existing variables’ score values and the sum
of these score values (df = N − 1) (Plichta & Kelvin, 2013). For example, suppose
a data set consists of four scores: 1, 4, 4, and 7. Before any of these scores were
collected, the researcher did not know what these scores would be. Each score was
free to vary. This means that each score was independent from the other scores.
Because there are four scores, there are four degrees of freedom. However, when
the mean is calculated, one degree of freedom is lost. This is because after the
mean is known, along with three of the scores, the fourth score is no longer free to
vary. The fourth score can be calculated, and only one value will be correct.
Therefore, the data set of four scores has three degrees of freedom, n − 1, because
one degree of freedom is lost. Many inferential statistics include degrees of
freedom in their calculations.
de gre e s of fre e dom: A statistical concept used to refer to the number of sample values that are free to vary; n
– 1
Another concept important in the language of inferential statistics is sampling
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distribution (Nieswiadomy, 2012; Plichta & Kelvin, 2013). In theory, an infinite
number of samples can be drawn from a population. Some samples are more likely
to be drawn than others are. For example, when sampling coin tosses, getting half
heads and half tails when tossing a coin 20 times is far more likely than is tossing
heads 20 times in a row. For many inferential tests, statisticians have calculated the
likelihood of obtaining different samples and reported them in tables. When
researchers perform certain inferential tests, they refer to these tables to find out
whether their results are likely or unlikely. Results that are unlikely to occur as a
result of chance are then considered to be statistically significant.
s ampling dis tribution: A theoretical distribution representing an infinite number of samples that can be drawn
from a population
Nurses commonly see a number of inferential tests in the literature. Although the
study of statistical tests can seem overwhelming to some individuals, to appraise
evidence it might not be necessary to fully understand why each test is conducted
and how the calculations are performed. Nurses should be able to discern that the
correct tests were used to analyze data. This can be determined by focusing on two
broad questions: (1) “What type of question is being asked by the researcher?” and
(2) “What is the level of measurement being used to measure the variables?” Some
inferential statistical tests commonly used in nursing research are listed in Table
13-12. Although it is beyond the scope of this text to elaborate on all the tests listed
in the table, information about some of the most common tests is worth
remembering. When answering questions about statistically significant differences
between groups, nurses should be familiar with Chi square, t tests, and analysis of
variance (ANOVA). They should also be familiar with Pearson’s r and multiple
regression, which are tests used to determine if there is a statistically significant
correlation among the variables.
TABLE 13-12 Inferential Tests Commonly Used in Nursing
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Note: ANOVA = analysis of variance; ANCOVA = analysis of covariance; MANOVA = multivariate
analysis of variance.
Testing for Differences Between Groups
As shown in Table 13-12, a variety of tests is used to analyze data for the purpose
of determining if there is a statistically significant difference between the groups.
When deciding which test to use, researchers must consider the number of groups to
be included in the analysis and at what level variables were measured. Pilot
studies frequently involve one group, whereas classic experiments and quasi-
experiments can include two or more groups. Before analyzing data, researchers
need to consider whether the groups are dependent or independent to select the
correct tests to perform. For example, suppose a researcher is studying perceptions
of health in married couples before and after a class about stress reduction. The
researcher tests both men and women who are married to one another. Because
individuals in a marriage have many characteristics in common, the data collected
should be analyzed using inferential tests for dependent groups. Data from designs
using subjects as their own controls, for example, measuring blood pressures
before and after exercise, are also treated as data from dependent groups. More
likely than not, researchers collect data from independent groups, for example, test
scores from two groups of diabetic patients.
The Chi Square Statistic
Chi square is a very commonly used statistic (Hayes, 1994; Plichta & Kelvin,
2013). Calculated when analyzing nominal and ordinal data, it is a nonparametric
test. One reason Chi square is used so often is because it is very useful for finding
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differences between the groups on demographic variables. For example, suppose
that a researcher is studying the effect of aromatherapy on blood pressure and
randomly assigns 200 individuals to one of two groups. The experimental group
contains 54 women and 46 men, while the control group has 46 women and 54 men.
By performing a Chi-square test, the researcher can determine whether the groups
are alike on the extraneous variable of gender. If the groups are not significantly
different on gender, it can be assumed that changes in blood pressure are more
likely a result of the intervention than of gender.
Chi s quare : A common statistic used to analyze nominal and ordinal data to find differences between groups
When Chi-square statistics are used, the frequencies that are observed during
the study are compared to the frequencies that would be expected to occur if the
null hypothesis were true. Observed and expected frequencies are entered into
contingency tables, and a Chi-square statistic is calculated. Using the calculated
Chi-square statistic, the degrees of freedom, and the alpha level, researchers
consult Chi-square tables to determine the critical value and judge whether the
critical value is statistically significant. In the literature, notations for Chi square,
such as X2 = 1.89, df = 1, p < .05, appear reported with degrees of freedom and
significance. Another reason Chi squares are frequently used is that they can be
calculated without the use of computers. However, the sample size must be
adequate because there must be at least five or more observed frequencies in each
cell of the table. If this minimum is not met, then a variation of the Chi square,
known as Fisher’s exact probability test, is used.
The t Statistic
The t statistic is another inferential statistical test that is frequently reported in
nursing research. Commonly known as the t test, or Student’s t test, this parametric
measure is used to determine whether there is a statistically significant difference
between two groups (Hayes, 1994; Plichta & Kelvin, 2013).
t s tatis tic: Inferential statistical test to determine whether a statistically significant difference between groups
exists
There are two variations of the t test. One variation, known as the correlated t
test or paired t test, is used when there are only two measurements taken on the
same person (one group) or when the groups are related. For example, a paired t
test would be used to assess for differences between subjects’ morning and evening
blood pressure readings. The other variation is known as an independent t test and
is used when data values vary independently from one another.
corre late d t te s t: A variation of the t test used when there is only one group or when groups are related; paired
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t test
inde pe nde nt t te s t: A variation of the t test used when data values vary independently from one another
In experimental and quasi-experimental designs, the t test is used to determine
whether the means of two groups are statistically different. Suppose a researcher is
measuring the effectiveness of applying ice for pain reduction in patients with a
new cast applied for fracture of the tibia. The mean pain intensity rating for the
experimental group, which received the ice application, is 5.6, whereas for the
control group, which did not get the ice, it is 6.0. As with a Chi-square test,
researchers calculate the t statistic and consult tables using the statistic, degrees of
freedom, and alpha levels to find the critical value. The critical value is obtained
and a decision about its statistical significance is made. In reports, the t test
information provided includes t, indicating the statistical test done, number of
degrees of freedom, actual t value obtained, and significance level, which is
reported in the following manner: t(2)= 2.54, p < .01.
Analysis of Variance
Analysis of variance (ANOVA) is used when the level of measurement is interval
or ratio and there are more than two groups or the variable of interest is measured
more than two times (Hayes, 1994; Plichta & Kelvin, 2013). The broad question
being answered is whether group means significantly differ from one another. Using
ANOVA allows researchers to compare a combination of pairs of means while
reducing the odds for a type I error. For example, suppose that a researcher is
testing three different styles of education with adolescents who have asthma: peer,
text messaging, and Web-based. There would be three different pairs of means to
compare: peer to text messaging, peer to Web-based, and text messaging to Web-
based. If t tests were conducted for each pair, the same null hypothesis would be
tested three times, increasing the risk of a type I error. By using an ANOVA,
researchers can compare the variations among the groups using one statistical test,
thereby reducing the chances of making a type I error.
analys is of variance : Inferential statistical test used when the level of measurement is interval or ratio and
more than two groups are being compared
ANOVA and t tests are very closely related. When testing only two groups, the
same mathematical answer would result whether an ANOVA or a t test were used.
Using ANOVA, researchers calculate the F statistic, which is based on the F
distribution using degrees of freedom. The greater the F statistic, the greater the
variation between the means of the groups. Tables of the F distributions and
degrees of freedom are also used. F = 4.65, df = 2, 50, p < .05 is an example of the
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notation that would be used to report an ANOVA. However, the F statistic indicates
only that the null hypothesis can be rejected because there is a difference between
the group means, but the F test alone does not tell which specific group differed.
Instead, researchers have to conduct post hoc tests to determine where the
significant difference occurred.
Two variations of ANOVA, analysis of covariance (ANCOVA) and multivariate
analysis of variance (MANOVA), are also used in nursing research. ANCOVA is
used to statistically control for known extraneous variables. For example, if a
researcher believes that level of education affects the amount learned by the
adolescents with asthma, the researcher may use ANCOVA to control for grade in
school. When researchers have more than one dependent variable, they used
MANOVA instead of ANOVA to analyze data.
Other Tests of Significance
Table 13-12 shows that a number of other inferential statistics can be used to
determine whether there are statistically significant differences between groups.
These include Kolmogorov-Smirnov test, sign test, Wilcoxin matched pairs test,
signed rank test, median test, and Mann-Whitney U test (Hayes, 1994; Plichta &
Kelvin, 2013). These tests are used when ordinal level data are involved; thus, they
are categorized as nonparametric tests. Tests are selected based on considerations
such as the number of groups being compared, the distribution pattern of the data
(normal or skewed), and other nuances that can be found in the data.
Testing for Relationships Among Variables
To find whether there are relationships among variables, a variety of statistical
tests is used to determine the significance of correlations (see Table 13-12).
Decisions about which statistical tests to use are based on whether there are two
variables or more than two variables. Consideration is also given to the level of
measurement used. Understanding how decisions are made allows nurses to
ascertain the quality of the findings.
Pearson’s r
When researchers pose hypotheses about the relationships among variables, they
are testing for the significance of the correlation coefficient. When two variables
are measured at the interval or ratio level, they calculate the Pearson’s r statistic,
also known as the Pearson product–moment correlation (Hayes, 1994; Plichta &
Kelvin, 2013). The degrees of freedom for this test are always N − 2, which means
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that the correlation coefficient can be affected by the sample size. It is possible for
a small correlation coefficient to be statistically significant when there is a large
sample. In the literature, the notation r = .62, p < .01 is used. This notation provides
three important pieces of information about the two variables. First, the variables
are related at a magnitude of .62, which is usually considered to be a moderate—or
moderately strong—relationship. Second, the two variables have a positive
relationship with each other because the value is positive. Third, the correlation is
statistically significant. A statistically significant correlation is one that is
significantly different from zero.
Pe ars on’s r: An inferential statistic used when two variables are measured at the interval or ratio level;
Pearson product–moment correlation
Small correlations can be statistically significant because it does not take much
variation to be significantly different from a correlation of zero (Nieswiadomy,
2012). Therefore, researchers can use a variation of Pearson’s r that determines the
percentage of variance shared by two variables, which provides more meaningful
information. By squaring the coefficient (r2), the overlap, or shared variance, is
computed. A helpful way to think about variance is to think of a pie chart. The
entire pie chart represents all the variables that can contribute to changes in the
dependent variable. Each r2 indicates how large a section of the pie chart that
variable earns. With this information, knowledge of one variable can be used to
predict the value of the other variable. For example, suppose that a correlation
coefficient of .23 was obtained for the variables self-esteem and weight gain.
Squaring .23 equals .0529. This is interpreted to mean that self-esteem accounts for
about 5% of weight gain. Thus, the researcher would know that other variables
must also contribute to weight gain.
Multiple Regression
A change in one variable is usually the result of many factors. Thus, when
researchers want to study the relationship of many independent variables on one
dependent variable, they use multiple regression analysis (Hayes, 1994; Plichta &
Kelvin, 2013). Calculations such as these have become much more sophisticated
with the use of computers because computers can perform simultaneous
calculations. Like Pearson’s r, multiple regression is used when variables are
measured at the interval or ratio level. For example, suppose a researcher wants to
determine which factors best predict an anorexic adolescent’s success at
maintaining a weight in the normal range. Independent variables might include self-
esteem, social support, anxiety, and locus of control. In this situation, a multiple
regression will be performed.
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multiple re gre s s ion: Inferential statistical test that describes the relationship of three or more variables
There are different approaches to performing multiple regression based on the
way in which the predictor variables are entered into the analysis. One common
approach to multiple regression is known as step-wise. This approach is used to
find the smallest number of independent variables that account for the greatest
proportion of variance in the outcome variable (Pedhazur, 1982). For example, in a
study of adolescents with anorexia, a researcher might find that self-esteem,
anxiety, and locus of control account for 24% of the variance in weight gain and
that social support does not make any significant difference in weight gain.
Researchers can use another approach to multiple regression know as hierarchical
regression. This approach is typically used when the importance of variables has
been specified in theories. For example, suppose it is proposed in a theory about
anorexia in adolescents that locus of control is the most important factor, followed
by self-esteem and then anxiety. Based on this theory, the researcher would be able
to specify the order the independent variables are to be entered into the equations.
As in step-wise multiple regression, the amount of variance that is significant is
reported.
Other Tests of Significance
Because all variables are not measured at interval and ratio levels, there are other
tests of significance that can determine whether changes in variables are significant
(Hayes, 1994; Plichta & Kelvin, 2013). When nominal data are involved, statistics
such as phi coefficients, point biserials, and contingency coefficients are reported.
Researchers use Kendall’s Tau, Spearman Rho, and discriminate function analysis
to analyze ordinal-level data. There are also very sophisticated methods for testing
and predicting the strength and direction of relationships among multiple variables.
These analytic methods, such as linear structural relationships or structural
equation modeling, are useful ways to use data to test theories.
TEST YOUR KNOWLEDGE 13-8
Match the following
1. Chi square a. uses the F statistic
2. t test b. tests for the significance of a correlation
between two variables
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3. ANOVA c. has independent and correlated variations
4. Pearson’s r d. tests the significance of relationships among
three or more variables
5. Multiple regression e. tests for differences between groups using
nonparametric data
6. A researcher is studying the relationship of the amount of time intensive care unit patients spend
lying on their backs and urine output. Which test would the researcher use to analyze the data?
a. Chi square
b. Pearson’s r
c. Phi coefficient
d. Multiple regression
How did you do? 1. e; 2. c; 3. a; 4. b; 5. d; 6. b
13.9 What Does All This Mean for EBP?
At the end of this section, you will be able to:
‹ Interpret data reported in statistical tables
‹ Differentiate between statistical significance and clinical significance
‹ Appraise data analysis sections of an article
When reading research articles, nurses must assume that mathematical calculations
were done accurately because raw data are not included. What nurses should
appraise is that the correct tests were performed. Table 13-12 is a helpful tool for
appraising the analysis sections of articles.
Nurses should also appraise data presented in tables to determine whether
conclusions drawn by researchers are supported by the findings. Although many
readers frequently skip over the tables when reading research articles, this is not a
good practice. The tables contain evidence on which practice changes can be made,
and for this reason they may be one of the most important components of the report.
Nurses need to acquire skill at reading and interpreting tables. Some hints for doing
so are presented in Table 13-13.
It is also important to differentiate between statistical significance and clinical
significance. For example, suppose a drug lowered cholesterol levels on average
from 195 to 178. Analysis indicated that this decrease was statistically significant;
however, because any cholesterol value below 200 is considered to be within
normal range, there is no clinical significance to this finding. In another example,
consider an experimental study involving guided imagery. Children in the guided
imagery group had average pain ratings of 4.2, while children in the control group
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had average pain ratings of 5.2. Although the difference between these means is not
statistically significant, it may be clinically significant to have pain ratings a whole
point lower. Furthermore, because guided imagery was noninvasive and
inexpensive and children reportedly enjoyed it, it might be worth incorporating as a
practice intervention. When appraising evidence, it is wise for nurses to keep in
mind that statistical significance and clinical significance are different.
FYI
Although many readers frequently skip over the tables when reading research articles, this is not a good
practice. Data presented in tables may contain evidence on which practice changes can be made, and thus
may be one of the most important components of a report.
TABLE 13-13 Tips for Reading Statistical Tables
Be familiar with symbols used.
Read the title of the table first.
Pay attention to the labels of columns and rows.
Observe when headings for subsamples and subscales are indented.
Follow columns carefully both horizontally and vertically.
Attend to significant findings.
Alpha levels are either reported with a notation or under the table with an asterisk
(*).
Pay attention to superscript or footnote markings.
Do not skip tables, because information can be clearer after studying a table.
Recognize that there can be typos and math errors.
Remember that subsamples may be omitted from the table (i.e., sample indicates
total subjects and number of women, leaving reader to calculate number of men).
TABLE 13-14 Questions for Appraising Analysis of Data
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1. What statistics were used to describe the characteristics of the sample? What statistics were
used to analyze the data that were collected? Were the statistics appropriate for the level of
measurement?
2. Were measures of central tendency provided? If so, which ones were used? Are they the
most appropriate? How sensitive to outliers is the measure reported?
3. Were measures of variation/dispersion provided? Were standard deviations reported for each
mean that was reported?
4. What was the distribution of the data? Were data normally distributed? Was skewness or
kurtosis discussed?
5. What statistics were used to determine differences between the groups? Were the results
significant?
6. What statistics were used to express relationships among variables of interest? What was the
magnitude and direction of the relationship? Was it significant?
7. Are all the hypotheses addressed in the analysis section of the report?
8. Is the selected level of significance appropriate for the purpose of the study and the types of
analyses being conducted?
9. Do the tables and graphs agree with the text? Are they precise and do they offer economy of
information?
10. Are the results understandable and presented objectively?
Appraising the results section of research reports can be challenging. An
understanding of the material presented in this chapter can assist you in meeting this
challenge. Table 13-14 lists questions that should be considered when evaluating
data analysis.
TEST YOUR KNOWLEDGE 13-9
True/False
1. Nurses should determine that researchers are using the correct statistical tests to analyze data.
2. Data contained in tables are an important source of evidence for practice.
3. All statistically significant findings have clinical significance.
4. Reading the table after the text is a helpful strategy that can improve comprehension of ideas.
How did you do? 1. T; 2. T; 3. F; 4. T
13.10 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss ethical considerations when conducting statistical analyses
All researchers hope that their hypotheses will be supported. Researchers develop
a passion for their topics that keeps them invested in their research. However,
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researchers must use care when analyzing data and selecting alpha levels. It is best
if decisions about which statistical tests to conduct and which alpha levels to use
are made prior to implementing the study. These decisions are usually presented,
with strong rationales for the decisions, in the proposal for the study. Although
there are situations when it is appropriate to conduct additional statistical tests, it is
unethical for researchers to “go fishing” for evidence to support their hypotheses.
Editors and research conference planners who review studies are faced with
making decisions about which studies warrant dissemination. Studies with
significant findings are much more likely to be accepted for presentation or
publication. Because nonsignificant findings have an important role in making
decisions about practice, decision makers, such as conference planners and journal
publishers, need to give more consideration to studies with nonsignificant findings.
Ignoring incidental findings that are pertinent to decision making is also
unethical. Incidental findings are findings that were not purposefully sought. A
dilemma can occur when an intervention is found to be effective, but incidental
findings, such as side effects or risks, are found to be associated with the
intervention. It is possible for researchers to report additional analyses comparing
risks and benefits. Reporting adverse effects is necessary so that professionals and
patients can make informed choices. Researchers should also report incidental
findings when findings have clinical significance or are interesting and indicate a
need for further research.
CRITICAL THINKING EXERCISE 13-5
© Jules_Kitano/ShutterStock, Inc.
Imagine that manuscripts for 10 different studies conducted about the effect of massage on the oxygen
saturation of infants in the neonatal intensive care unit are sent to a variety of journals. Only one study had
significant findings, and it was accepted for publication. If none of the other nine studies were accepted for
publication, what evidence would be available to nurses for EBP? How might practice be affected if all 10
studies were published?
TEST YOUR KNOWLEDGE 13-10
Which of the following are unethical?
1. Selecting an alpha of .05 so that the research hypothesis is supported when it would not be if the
alpha were set at .01.
2. Publishing articles about studies with nonsignificant findings.
3. Including information about incidental findings, especially when they involve side effects or risks.
How did you do? 1. Unethical; 2. Ethical; 3. Ethical
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APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
The committee is nearly done analyzing the evidence. Complete the results column of the grid within this
text’s digital resources for the various articles that use quantitative designs by indicating which strategies
were most effective in reducing medication errors. In some cases, it may be helpful to include some
important statistics. The other quantitative articles that the committee has been reading are already
completed.
RAPID REVIEW
» Statistics are used to describe numerical outcomes and the probabilities derived
from calculations on raw data.
» There are two types of statistics: descriptive and inferential. Descriptive
statistics explain characteristics of variables found in a sample. Inferential
statistics are the basis for predictions about the phenomenon.
» Univariate analysis involves only one variable at a time and includes frequency
distributions, measures of central tendency, shape of the distribution, and
measures of variability.
» Bivariate analysis is conducted to describe relationships between two variables.
» Frequencies may be grouped or ungrouped data describing how often a variable
is found to occur. Line charts, bar graphs, pie charts, histograms, and
scattergrams are ways frequencies can be depicted.
» The mode, median, and mean are measures of central tendency. In a normal
distribution, they are all the same value.
» A normal distribution is a bell-shaped curve that is symmetric around the mean.
Asymmetric distributions are known as skewed and have either positive or
negative directions.
» Data with little variability are considered to be homogenous, whereas data with
wide variations are considered to be heterogeneous.
» Measures of variability include the range, semiquartile range, percentile,
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standard deviation, z scores, and coefficient of variation.
» The Rule of 68–95–99.7 is a way of describing the percentage of scores falling
within specific standard deviations of the mean.
» Correlation coefficients are used to describe the relationship between two
variables.
» Inferential statistics are used to estimate population parameters and test
hypotheses.
» CIs describe the probability of being correct.
» When selecting which statistical tests to use, researchers must consider the type
of question being asked and the level of measurement. The null hypothesis is
statistically tested and is rejected when significant findings occur. Research
hypotheses are supported but never proven.
» Probability is the likelihood of a frequency of an event in similar trials under
similar conditions and indicates how probable it is that the results were
obtained by chance. Sampling error is the tendency for statistics to fluctuate
from one sample to another and forms the basis of probability.
» Type I errors occur when researchers reject the null hypothesis when it should
have been accepted. Type II errors occur when researchers accept the null
hypothesis when it should have been rejected.
» Alpha levels of either .05 or .01 are typically used in nursing research. Alpha
levels affect the amount of risk involved for making type I and type II errors.
» Parametric tests are more powerful than nonparametric tests are because they are
used with interval or ratio level data.
» To test for differences between groups, researchers can use Chi square, t test, and
ANOVA.
» To test for relationships among variables, Pearson’s r and multiple regression can
be used.
» To apply findings to EBP, nurses must be able to interpret statistical tables,
differentiate between clinical and statistical significance, and appraise data
analysis.
» To maintain ethical integrity, researchers should select statistical tests and alpha
levels in advance and report incidental findings. It is as important to
disseminate nonsignificant findings as it is to disseminate significant findings.
REFERENCES
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American College of Physicians—American Society of Internal Medicine. (2001). Primer on 95% confidence
intervals. Effective Clinical Practice, 4, 229–231. Retrieved from
http://www.vhpharmsci.com/decisionmaking/Therapeutic_
Decision_Making/Fundamentals_files/ACP%20Primer%20on%2095
%25%20confidence%20intervals
Borenstein, M. (1997). Hypothesis testing and effect size estimation in clinical trials. Annals of Allergy, Asthma,
and Immunology, 78, 5–11.
Gillis, A., & Jackson, W. (2002). Research for nurses: Methods and interpretation. Philadelphia, PA: F. A.
Davis.
Harper, D. (2013). Statistics. Online Etymology Dictionary. Retrieved from
http://www.etymonline.com/index.php?term=statistics
Hayes, W. L. (1994). Statistics. Boston, MA: Wadsworth.
Hoekstra, R., Johnson, A., & Kiers, H.A.L. (2012). Confidence intervals make a difference: Effects of showing
confidence intervals on inferential reasoning. Educational and Psychological Measurement, 72(6), 1039–
1052.
Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Upper Saddle River, NJ: Pearson
Education.
Pedhazur, E. J. (1982). Multiple regression in behavioral research: Explanation and prediction (2nd ed.).
Philadelphia, PA: Harcourt Brace.
Plichta, S. B., & Kelvin, E. (2013). Munro’s statistical methods for health care research (6th ed.). Philadelphia,
PA: Wolters Kluwer/Lippincott Williams & Wilkins.
Smith, C. J. (2012). Type I and type II errors: What are they and why do they matter? Phlebology, 27(4), 199–
200.
Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2010). Evidence-based medicine: How to
practice and teach EBM (4th ed.). Edinburgh, Scotland: Churchill Livingstone.
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http://www.vhpharmsci.com/decisionmaking/Therapeutic_Decision_Making/Fundamentals_files/ACP%20Primer%20on%2095%25%20confidence%20intervals
http://www.etymonline.com/index.php?term=statistics
CHAPTER 14
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What Do the Qualitative Data Mean?
Kristen L. Mauk
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Compare and contrast ways that qualitative data are analyzed
‹ Discuss the benefits of Computer Assisted Qualitative Data Analysis Software
to assist with managing qualitative data
‹ Describe how researchers draw conclusions from the data and verify them
‹ Recognize the common ways data are presented in reports
‹ State why qualitative research is evaluated differently from how quantitative
research is evaluated
‹ Define trustworthiness in terms of credibility, transferability, dependability,
and confirmability
‹ Describe strategies for evaluating qualitative research
‹ Describe key ethical issues in qualitative research
KEY TERMS
auditability
axial coding
coding
Computer Assisted Qualitative Data Analysis
Software (CAQDAS)
confessionist tales
confirmability
credibility
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data reduction
data saturation
dependability
impressionist tales
member checks
negative case analysis
open coding
peer debriefing
personal narrative
qualitative data analysis
realist tales
reflexivity
replicated
representativeness
transferability
triangulation
trustworthiness
14.1 Qualitative Data Analysis
At the end of this section, you will be able to:
‹ Compare and contrast ways that qualitative data are analyzed
‹ Discuss the benefits of Computer Assisted Qualitative Data Analysis Software
to assist with managing qualitative data
What Is Qualitative Data Analysis?
Qualitative data analysis is a much less straightforward process than quantitative
data analysis is. Using words versus numbers to explain phenomena is both more
subjective and more labor intensive. Qualitative data analysis has been described
as being “directed by few standardized guidelines” (Polit & Beck, 2012), and there
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are many acceptable methods to analyze the data. Sandelowski (1995) pointed out
that although data analysis and interpretation often occur simultaneously in
qualitative research, they should be considered distinct processes. “Qualitative
analysis is a means to knowledge production” (Sandelowski, 1995, p. 373) that
involves the breakdown, categorization, and prioritization of data into a useful
system. She described data analysis as having two major parts: getting a sense of
the whole and developing a system. According to Strauss and Corbin (1998), data
analysis is “the process of breaking down, examining, comparing, conceptualizing,
and categorizing data” (p. 57). Bogdan and Biklen (2006) described data analysis
in two stages: analysis (systematically arranging the data) and interpretation.
qualitative data analys is : The production of knowledge that results from analysis of words
FYI
Because qualitative data are made up of words rather than numbers, analyzing the data is less
straightforward, more subjective, and more labor intensive than analyzing quantitative data is. Qualitative
data analysis involves processes in which data are managed, organized, arranged, or prioritized.
Miles and Huberman (1994) defined qualitative analysis as having three
“concurrent flows of activity: data reduction, data display, and conclusion
drawing/verification” (p. 10). Although each of these definitions differs somewhat,
there is agreement that data analysis involves some type of process in which data
are managed, organized, arranged, or prioritized.
Unfortunately, qualitative research is still often viewed as less essential or of
less significance than quantitative research is. Certainly, it is usually ranked lower
on most hierarchies of evidence. Recent evidence suggests that despite the progress
in qualitative methods, published qualitative studies use methods inconsistently,
terminology is not uniform across studies, and rigor may still be lacking in some
studies (Ball, McLoughlin, & Darvill, 2011). Researchers can demonstrate rigor in
this type of research by addressing the evaluation strategies that will be discussed
in this chapter.
Managing the Data
Researchers begin analysis by examining data. Remember that qualitative
researchers may have mounds of data from numerous pages of transcribed
interviews and field notes. This large amount of data must be reduced or broken
into manageable units (Jacelon & O’Dell, 2005). Because the nature of qualitative
research is thick description, “the purpose of analysis is to organize the description
so that it is manageable” (Patton, 1990, p. 430). Remember that data gathering and
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analysis may be occurring simultaneously, with ideas and results enlightening
subsequent data collection and interaction with participants (Clissett, 2008).
Coding and Data Reduction
Line-by-line coding was historically a common way to begin data analysis and one
by which many new researchers learned about this process. It involves reading
transcripts line by line and attaching labels to each line. Coding is done to
categorize the data into groups. Line-by-line coding done by hand, as many novice
researchers do to gain practice, is tedious and frustrating work and not always as
fruitful as one would like. Stepping back and taking in the whole data set by
thorough reading and rereading prior to considering the grouping of data into
meaningful and manageable units should precede any type of systematic coding.
coding: Assignment of labels to each line of transcript in qualitative analysis
There are many ways to approach coding, or labeling. Some researchers use a
note card system with labels, filing key quotes under the basic codes, while others
handwrite codes into the margins in a complicated hierarchy according to a
codebook they have developed. Color coding is another option, as is the use of
computer software, but ultimately researchers come up with their own systems by
which to organize the data into manageable units.
Tesch (1990) believed that traditional hand coding resulted in more data instead
of less, and that data reduction is a better alternative. Miles and Huberman (1994)
stated that “data reduction refers to the process of selecting, focusing, simplifying,
abstracting, and transforming the data that appear in written-up field notes or
transcriptions” (p. 10). Data reduction is part of analysis, and the researcher must
make decisions about which data are most representative of the entire story being
told. As researchers choose which patterns or categories best present the most
essential chunks of the data, they become the tool for data analysis and
interpretation.
data re duction: The simplification of large amounts of data obtained from qualitative interviews or other
sources
There is no perfect process for coding data, and there is no wrong process
either. Jacelon and O’Dell (2005) maintained that “through the process of coding,
the researcher fractures that data and organizes it by the ideas contained within …
it is the knowledge and perceptions of the researcher that are used to identify the
ideas in the data” (p. 218). This is why the knowledge and skill of the qualitative
researcher take on such great significance and importance in qualitative research.
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Traditional open coding (Corbin & Strauss, 1990, 2008) is one way to
describe the first step in grouping the data into categories that seem logical.
Researchers should always leave an audit trail by keeping a log of their ongoing
thoughts and ideas about the naming and assigning of categories to the data so that
they can later examine why certain labels were chosen and others discarded. Axial
coding (Corbin & Strauss, 1990, 2008) takes the analysis process further and
requires researchers to compare the categories and labels, defining and exploring
relationships among them.
ope n coding: The grouping of qualitative data into categories that seem logical
axial coding: The analysis of categories and labels after completion of open coding
After the data have been organized by basic coding, Marshall and Rossman
(2011) suggest that the next step is to generate categories, themes, and patterns.
Researchers must search for categories of meaning that best express “relevant
themes, repeating ideas or language, and patterns of belief linking people and
settings.” Codes might be connected through a common theme. There might be
patterns across and within the themes. Researchers look at how codes overlap and
how themes and patterns emerge in relationship to each other. The analysis process
is done with the end result in mind: to stay true to the data and best represent the
story or phenomenon being studied.
After the data are categorized and themes emerge, researchers need to pull
everything together to paint a picture of the underlying truths revealed by the data.
This pulling together of the evidence into a meaningful report that can be
communicated to others is another challenge. As Sandelowski (1995) stated,
“Qualitative analysis also has artistic dimensions that are often inchoate and
incommunicable, involving playfulness, imaginativeness, and creativity” (p. 375).
The following examples were taken from interviews with stroke survivors
(Easton, 2001). The examples provide some raw data from which you can derive
some ideas or common threads. In the first example, what do you perceive? Are any
important concepts, ideas, or themes expressed? What was the participant trying to
convey?
Well I know one of the therapists, physical therapists here at the campus, uh, I talked to her about it and
then she says, oh, she says, it may never get all right. It was sorta a jolt for me. (p. 148)
Compare the next example with the previous and see whether you notice any
similarities or differences. If so, what are they? Are the different participants in
these interviews saying anything that might lead you to believe they had similar
experiences?
That, uh, you know, just get up and go do what you were gonna do. But that was just a flashing—and
then we realized that, uh, we can’t do that no more. (p. 148)
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Look at one more quote from yet another stroke survivor. Are there any
similarities between this participant’s ideas and those of the other two cited
previously? If so, what are they?
I was home probably, oh, I had been to the SOS meeting, and after listening and watching some of the
people there, I realized I may never get back everything. (p. 148)
In the previous examples, one might observe some common threads such as a
sense of loss or realizing that things may not be the same as before the stroke.
These snippets of data are examples of those that researchers might identify as
containing codes or ideas. Using the ideas found within the data as codes,
researchers compile lists of codes and then return to the data again and again to
categorize data into organized units. Remember that analysis occurs while data
collection is still in progress. When common ideas begin to emerge, the analysis
should be used to adapt future interviews and direct and focus the data collection
process. This entire process of data analysis and interpretation can be compared to
discovering and putting together the pieces of a puzzle to form a meaningful picture
that best represents the essence of the story told by the participants.
Sandelowski (1995) recommended some alternative strategies to traditional
coding for developing a system to manage the data. She suggested extracting the
facts and looking for story lines, topics, and content in addition to reduction of the
data. Facts are those items of data that are not subject to debate, that are “givens,”
and later may be important for establishing the context of the research. While
capturing the data in a systematic way, Sandelowski’s approach avoids line-by-line
coding. The aim is to think of the data as telling a story. Researchers approach the
data by trying to identify the main points of the story or the major idea.
Sandelowski suggested making a list that captures all the topics present in the data,
much like the major plot points in each scene of a play.
In a more recent work, Sandelowski, Leeman, Knafl, and Crandell (2013)
proposed a new method of data analysis and interpretation called data extraction.
Sandelowski and colleagues summarized this method by stating that “findings are
transformed into portable statements that anchor results to relevant information
about sample, source of information, time, comparative reference point, magnitude
and significance and study-specific conceptions of phenomena” (p. 1428). This
method allows for a more accurate contextual view of the data.
It is always best to try to use the language of the participants for formulating
labels for codes, themes, or patterns. Qualitative researchers, in efforts to remain
true to the data, select words that reflect the participants’ language and ideas, even
often using those native terms as key labels for the data. For example, in Easton’s
(2001) stroke survivor study, a major subconcept early in the stroke recovery
process was labeled the mirage of recovery, using a term coined by Veith (1988),
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an author of one of the books used in the theoretical development for the framework
of the study. Veith used this term in reference to the optimistic and unrealistic
assurances given to her by physicians that she would recover from her stroke with
no residual effects. The quotations in Table 14-1 are direct quotes from face-to-
face interviews with stroke survivors whose average time at the interview since
their stroke was 5 years. Do these quotes illustrate any similar ideas that may have
supported Easton’s label of the mirage of recovery?
TABLE 14-1 Quotes from Stroke Survivors
“I always expected it to go away.”
“I didn’t think it was going to be very bad. I thought it was just going to be a mild
stroke…. I thought I’d be recovered before I went home.”
“Even after 3 years, I can’t help but believe that, eh, your, that’s always a little
progress … and I can’t help but believe that it’s all gonna go away.”
“I always thought I would [recover]. I had a feeling that if I tried hard enough, I
could beat it.”
“I had a neurologist told me, he said 6 weeks … but then … he [another doctor]
said 9 months.”
“He [the doctor] said that this was all on the left side, and I should have complete
recovery, that’s what he said.”
Source: Reprinted from Geriatric Nursing 20(2), March–April 1999, Kristen L. Easton, The Post-
stroke Journey: From Agonizing to Owning, pp. 70–76, Copyright 1999, with permission from Elsevier.
Computer Software
Software can assist researchers in managing qualitative data. Just as statistical
software helps to manage and manipulate numbers, software for qualitative data
helps to manage multitudes of words. The software available today falls into
several categories that include word processing, text, analysis, grouping and
linking, and displaying relationships. The type of software researchers choose is
determined by what they intend to do with the data and how the data will be
displayed or managed.
Although software can be extremely helpful in managing large amounts of data,
it does not do the work of coding for the researcher. Qualitative researchers are
still responsible for analyzing and labeling the data. Software programs can help
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with the sorting and grouping of data so that researchers can view similar
statements or categories in a systematic way. This is often referred to as computer-
assisted qualitative data or qualitative data analysis software (Jacelon & O’Dell,
2005), or more currently it is known as Computer Assisted Qualitative Data
Analysis Software (CAQDAS) (University of Surrey, 2013). A basic word
processor, such as Microsoft Word, generally serves as the initial data entry
software. That is, the interviews or field notes are transcribed from audiotapes into
a word processing document. Such software itself is a useful tool and works well
for simple data analysis. However, if the study is large and will result in copious
amounts of data, it is wise to investigate the benefits of Computer Assisted
Qualitative Data Analysis Software (CAQDAS).
Compute r As s is te d Qualitative Data Analys is Software (CAQDAS): Computer software that assists in
the management, coding, grouping, and analysis of qualitative data
There are so many analysis programs on the market today that the University of
Surrey (2013) developed the CAQDAS project aimed to provide “practical
support, training and information in the use of a range of software programs
designed to assist qualitative data analysis” (para. 1). The CAQDAS networking
project also provides a forum for researchers to discuss qualitative issues with the
use of software and promotes discussion among researchers using qualitative
methods.
Software assists researchers to label statements within the transcriptions, group
them into categories, and then make interpretations or inferences. Some of the more
popular software packages include ATLAS.ti V5, HyperRESEARCH, QSR N6, and
MAXqda. These programs have enormous searching capabilities to help
researchers look through hundreds of pages of text to find items of specific data,
group data, and make charts and graphs, as well as many other features (University
of Surrey, 2014). Researchers must compare the features of each program and
decide which to use depending on the type of qualitative methods employed.
Qualitative researchers may also use a variety of tools or apps to manage data.
Information comparing various qualitative software programs can be obtained at
http://www.irss.unc.edu/content/pdf/CompChart2010-11 and
http://www.bu.edu/tech/support/desktop/
distribution/nvivo/comparison/.
Likewise, Ethnograph (Qualis Research, 2008) is a software program for the
analysis of text-based data that is highly regarded by qualitative researchers,
particularly those doing ethnography. Ethnograph was first introduced in 1985 and
has continued to be developed in various forms. The major categories in
Ethnograph 6.0 include creating and managing data files, coding data files, the
codebook, master list, family tree, and analytic writing. Ethnograph allows text-
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http://www.irss.unc.edu/content/pdf/CompChart2010-11
http://www.bu.edu/tech/support/desktop/distribution/nvivo/comparison/
based data to be imported directly and was one of the pioneer programs for
management and analysis of qualitative data.
Although software can be helpful, qualitative packages are generally
cumbersome to learn and require a commitment on the part of researchers to master
the software to maximize its usefulness. Data entry and coding are still time
consuming and tedious. The greatest benefit to such software is the ability to group,
compare, and contrast data more efficiently because of easier accessibility after all
data are entered. Software is also helpful when preparing written reports of the
data and selecting quotations or collapsing data for presentations, although some
researchers find that basic word processing software is sufficient for these
purposes.
TEST YOUR KNOWLEDGE 14-1
1. Put the following in the correct order:
a. Pull together evidence into a meaningful report
b. Code line by line
c. Transcribe interviews
d. Group coded data to generate categories, themes, and patterns
True/False
2. Computer software programs used to analyze qualitative data automatically generate themes
based on participants’ words.
3. There are many different strategies for coding data.
4. Analysis of data in qualitative research is done simultaneously with data collection.
How did you do? 1. c, b, d, a; 2. F; 3. T; 4. T
14.2 Qualitative Data Interpretation
At the end of this section, you will be able to:
‹ Describe how researchers draw conclusions from the data and verify them
‹ Recognize the common ways data are presented in reports
Sandelowski (1995) distinguished between analysis and interpretation of data by
stating:
In contrast, qualitative interpretation is the knowledge produced: the end-product of analysis where the
researcher construes or renders the analyzed data in such a way that something new is created that is
different from, yet faithful to, that data in its original form. (p. 372)
In other words, data analysis is the means to an end, with the final outcome
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being a useful piece of research that can be applied in practice. It is important for
researchers to be mindful of the language used to ensure that the message is
accessible and usable to a broad range of readers and so that strategies for the point
of care can be implemented (Sandelowski & Leeman, 2012). Thus, one could say
that the interpretation of qualitative data provides evidence for practice. This is the
evidence of words.
FYI
The interpretation of qualitative data should provide evidence for practice; the results of the study must be
reported with sufficient rigor and details about the methods used to establish trustworthiness of the findings
so that readers can have confidence that the results represent suggestions for best practice. There are three
common approaches to reporting qualitative data: realist tales, confessionist tales, and impressionist tales.
Drawing and Verifying Conclusions
As the data are being analyzed, researchers are also drawing some conclusions that
are continually tested and either modified, discarded, or verified. So, how does one
figure out what all the data and codes mean? How do researchers know that codes
they have chosen to use are correct? Table 14-2 lists five levels of qualitative data
(Jacelon & O’Dell, 2005; Kearney, 2001) that range from simple to most complex.
To address this question of what the data mean, one could start with the simplest
level of research analysis and merely describe the phenomenon. As the levels
progress to more complex, researchers become increasingly engaged in
exploration, explanation, and synthesis. Qualitative researchers should strive for a
product that meets level 5 in Table 14-2 and provides the most useful level of
information aimed at positively influencing nursing practice.
For practical purposes, Miles and Huberman (1994) suggested 13 tactics for
generating meaning from data. These are summarized in Table 14-3. Using
strategies such as these, qualitative researchers extract the most important points
from large amounts of data to form a logical conclusion.
To verify the conclusions drawn, Miles and Huberman (1994) suggested
several other strategies. These include checking for researcher effects or bias that
might have been introduced by the researcher’s presence among the participants.
Researchers must ask themselves if their presence may have influenced the
participants to act any differently, and if so, how? Researchers should also check
for representativeness. This means that researchers should challenge their
assumption that the participants included in a study indeed represent the group. In
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addition, all cases that do not fit the typical profile that emerged from the data
should be examined. These extreme or negative cases should be analyzed to see
why they are not represented by the researchers’ findings. Such exceptional cases
should be few and able to be logically explained.
re pre s e ntative ne s s : The degree to which elements of the sample are like elements in the population
Confirmation of a study’s findings is enhanced if the findings can be replicated.
This means that if another researcher can essentially do the same study with similar
results, this helps to validate the original researcher’s findings. Another strategy is
to get feedback from the study participants about how well the results represent
what they actually experienced. Having the participants themselves confirm the
findings of the study lends credibility to the results.
re plicate d: When another researcher has findings similar to a previous study
TABLE 14-2 Five Levels of Qualitative Data
Level of Data Summary
1. A priori framework
Data analyzed according to a preexisting
framework; lowest level of data; provides no new
knowledge
2. Descriptive
Researcher develops labels for data categories but
does not explicate relationships among the
categories; useful for devising lists of descriptors
on a topic
3. Developing a synthesis Researcher explains and explores relationships
among themes with logical integration
4. Increased complexity and
case variance
Researcher explains variations and negative case
examples of the research; a step beyond
developing a synthesis
5. A product that
comprehensively explains a
complex human phenomenon
The level of research that is considered to be the
gold standard; provides an explanation of a
phenomenon with depth and breadth as to
increase others’ understanding and advance the
science
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Source: Adapted from Jacelon & O’Dell (2005) and Kearney (2001).
TABLE 14-3 Strategies for Generating Meaning
Strategy Summary
Noting patterns, themes Items that “jump out” at you; commonalities
Seeing plausibility When categories make sense, feel right, fit
Clustering Clumping or grouping data into categories
Making metaphors Making comparisons with things that people
identify with
Counting Looking at number of times, recurrence
Making contrasts/comparisons Comparing cases with practical significance
Partitioning variables Unbundling variables as needed; separating
variables that should not be clumped together
Subsuming particulars into the
general
Asking whether a specific thing really stands
alone, or does it belong in a more general category
Factoring Identifying general themes to see which go
together
Noting relations among variables Describing the effects of one variable on another
and any relationships among concepts
Finding intervening variables Identifying the variables that go together only with
the help of an additional variable to facilitate
Building a logical chain of
evidence
Defining causal links that make logical sense when
viewed as a whole
Making conceptual/theoretical
coherence
Moving from constructs and interrelationships to
theories that can be predictive
Source: Adapted from Miles & Huberman (1994, pp. 245–262).
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Writing Reports
Another challenge of qualitative research is reporting the results. Traditional
formats for reporting quantitative research do not fit well with most qualitative
studies, and many authorities have suggested that qualitative reports focus much
more on detailed description and integration of the discussion of methods (Burnard,
2004; Dickie, 2003). A typical report of qualitative research would follow a format
similar to that presented in Table 14-4. Traditional reports contain an introduction,
explanation of the significance of the project, a review of the relevant literature,
description of methods, findings, discussion, and conclusions. However, there are
several ways in which qualitative research may be presented, and researchers
should carefully choose the strategy for presentation that best represents what they
are trying to convey. Thought should be given to creatively reporting findings if it
would enhance the ability of nurses to better apply the research in practice. That
said, the results of the study must be reported with sufficient rigor and details about
the methods used to establish trustworthiness of the findings so that readers can
have confidence that the results represent suggestions for best practice.
TABLE 14-4 Example of Standard Components of a
Qualitative Research Report
Title page
Abstract
Introduction
Aim or purpose of the study
Review of literature
Methods
Sample
Setting
Data collection methods
Data analysis methods
Findings or results
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Discussion
Nursing implications
Limitations of study
Conclusions
Questions that arose
Recommendations for future research
Although there are several ways to approach the reporting of qualitative data,
Van Manen (1988) identified three that are often referred to when considering how
to write the report: realist tales, confessionist tales, and impressionist tales.
Realist tales are the most common and were used by ethnographers such as
Margaret Mead (Marshall & Rossman, 2011). When using this approach,
researchers write a real-life account of the culture being studied and present it by
using a third-person voice, clearly separating researchers from the participants in
the study. The focus is on the many details about the group, and there is very little
description of methods. The researcher is almost invisible (Miles & Huberman,
1994). Scholarly journals or monographs are common places to publish this type of
writing. Peer-reviewed articles are standard and respected types of articles, but
they have been criticized for being dull and boring. Whatever strategy for reporting
the data is used, the discussion should always reflect the data and be true to the data
(Burnard, 2004).
re alis t tale s : A real-life account of the culture being studied presented in a third-person voice that clearly
separates researchers from participants
confe s s ionis t tale s : Qualitative researchers’ personal accounts that provide insight about data collection and
scientific rigor
impre s s ionis t tale s : Qualitative researchers’ storytelling and personal descriptions about the experiences of
conducting studies
Confessional tales are more personalized accounts in which the writer gives
insight into the process of data collection and shows the scientific rigor of the field
methods. The confessional tale is written from the researcher’s viewpoint with
personal authority and thick description (Van Manen, 1988).
Impressionist tales allow researchers to chronicle their experiences “in a type
of auto-ethnography” (Marshall & Rossman, 2011). Researchers speak more
personally about the experiences of conducting the study, and they are participant
observers versus disconnected realists. These reports are often more like
storytelling and help the reader relive the experience.
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Whichever voice researchers choose to use when reporting the results of the
study, the decision should be made with the goal of communicating results in the
most useful manner. Reports should be written with the audience in mind. If the
audience is nursing students, the focus will be different from a focus for registered
nurses who are working on their master’s degrees and different still if the readers
are interdisciplinary team members outside of nursing.
Patton (1990) stated that the most important aspect of reporting is focus. When
writing qualitative research reports, researchers must take care to include enough
detail but not too much so as to preclude the major purpose of communicating
useful, evidence-based information that influences practice. “Sufficient description
and direct quotations should be included to allow the reader to enter into the
situation and thoughts of the people represented in the report. Description should
stop short, however, of becoming trivial and mundane” (Patton, 1990, p. 430).
Sandelowski summarized her view by saying, “I think one of the hallmarks of a
good qualitative researcher is someone who writes in a very accessible way for
particular audiences” (Morse, 1994, p. 280).
Some differences in reporting formats among the four major types of qualitative
research should also be noted. In phenomenological research, researchers can use
realist tales, confessionist tales, or impressionist tales when writing. The choice
depends on the audience and certainly on the sample size. If the sample is small,
perhaps a storytelling approach would best convey the participants’ experiences.
The personal narrative, as a way of conveying the meaning of experiences, has
recently received increased attention. Gaydos (2005) suggested that nurses can use
their intuition to assist key informants who are ready to tell their stories in a type of
cocreation of a personal narrative by using memories and metaphors. “The
experience of creating a self story with a nurse can be healing, as the self story is
heard by a caring person, memories are understood in new ways, and the self story
is both confirmed and recreated” (Gaydos, 2005, p. 254). This may represent yet
another way to report information about lived experience.
pe rs onal narrative : A way of conveying the meaning of experiences through storytelling
Grounded theory, conversely, is often presented more traditionally because it
seeks to communicate a process that the researcher has discovered, lending itself to
a more detached, analytic mode of reporting. So, although one could use a variety
of voices in reporting qualitative data, it is key to focus the report to the audiences
and choose the best approach to communicate with that audience.
With ethnography, researchers often choose the realist voice, but perhaps the
impressionist tale would be better to describe information about a certain concept
with a different culture. For example, if a researcher was studying death and burial
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practices of an unknown tribe in the jungle, perhaps a storytelling approach would
be the most effective way to communicate the message learned from the research.
Henderson (2005) suggested that dramaturgy (a description of the scene or social
situation that is similar to a play) be included in field notes and reported in
conjunction with ethnography to better explain the societal context of social
activity.
CRITICAL THINKING EXERCISE 14-1
© Jules_Kitano/ShutterStock, Inc.
You have just finished helping with a qualitative research study on homeless people in the rural Midwest, in
which you assisted with data collection. The research team has discovered some essential health-related
information about the homeless people living in the vicinity of your university. The lead researcher asks your
opinion about how the research should be presented for publication. She wants the information to be
targeted to nurses and nursing students. How should the article be written for the target audience? What
suggestions would you make about the best way to present this information to students? How could
information be disseminated to promote evidence-based practice (EBP) or to improve the community
outreach efforts of your university?
In historical research, the typical voice is the realist because the data are
usually obtained from documents. Miller and Alvarado (2005) suggested that
documents could be used as commentary and as actors in qualitative research.
Reports using documents would include more talk and observation. Certainly, with
this approach, one might choose a different voice to present the results or at least
take a more creative approach to reporting.
TEST YOUR KNOWLEDGE 14-2
1. Which of the following are strategies for drawing and verifying conclusions? (Select all that
apply.)
a. checking for representativeness
b. ignoring negative cases
c. being sensitive to bias
d. confirming findings through replication
2. Match the following:
a. Real life account using third-person voice 1. realist tales
b. Speaking as a participant observer about the
experience
2. confessionist tales
c. Emphasizing scientific rigor in the method 3. impressionist tales
How did you do? 1. a, c, d; 2. a. 1, b. 3, c. 2
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14.3 Qualitative Data Evaluation
At the end of this section, you will be able to:
‹ State why qualitative research is evaluated differently from how quantitative
research is evaluated
‹ Define trustworthiness in terms of credibility, transferability, dependability,
and confirmability
‹ Describe strategies for evaluating qualitative research
Standards for Evaluating Qualitative Data
As with quantitative research, certain standard criteria are accepted for evaluating
qualitative studies. These were developed because quantitative criteria such as
internal validity, external validity, generalizability, reliability, and objectivity were
for evaluating numbers and did not fit well when evaluating words. It is expected
that qualitative studies be conducted with extreme rigor because of the potential for
subjectivity that is inherent in this type of research. In addition to addressing ethical
issues, such as informed consent and use of data, qualitative researchers are guided
by the requirements for establishing trustworthiness of the study. This is a more
difficult task when dealing with words and people than numbers and statistics.
Lincoln and Guba (1985) proposed a different set of criteria with unique
terminology that is appropriate for evaluation of qualitative research. These criteria
are still considered to be a gold standard to establish trustworthiness or rigor of a
study (Houghton, Casey, Shaw, & Murphy, 2013).
trus tworthine s s : The quality, authenticity, and truthfulness of findings from qualitative research
Establishing Trustworthiness
Trustworthiness refers to the quality, the authenticity, and the truthfulness of
findings in qualitative research. It relates to the degree of trust, or confidence,
readers have in the results. Trustworthiness can be established by meeting four
criteria (Lincoln & Guba, 1985): credibility, transferability, dependability, and
confirmability. Table 14-5 provides a summary of strategies for meeting these
criteria. By maintaining an audit trail, researchers can demonstrate whether these
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criteria are met. Auditability means that records maintained by the researcher can
be examined by others. For example, just like an auditor reviews financial records
to ensure ethical business practices are used, peer reviewers can evaluate
documents from qualitative studies to judge the trustworthiness of findings. When
another researcher can follow the audit trail, that researcher should arrive at the
same or similar conclusions. If contradictions about the conclusions exist, then the
trustworthiness of the study could be called into question.
cre dibility: One of four criteria for establishing a trustworthy qualitative study; refers to the truth or believability
of findings
trans fe rability: One of four criteria for a trustworthy qualitative study that relates to whether findings from one
study can be transferred to a similar context; application of findings to a different situation
de pe ndability: One of four criteria for a trustworthy qualitative study that relates to consistency in the findings
over time; auditability; findings are reflective of data
confirmability: One of four criteria for a trustworthy qualitative study that relates to the rigorous attempts to be
objective and the maintenance of audit trails to document the research process; findings can be substantiated by
participants
Credibility
Credibility in qualitative research is akin to internal validity in quantitative
research. To meet the criterion of credibility, the research must be shown to be
authentic and truthful. The results should make sense and be believable. There are
many strategies to help establish and evaluate credibility. Researchers should use
well-established research methods and describe them with sufficient detail so the
study can be replicated. If a similar study can show similar results using another
method, credibility is supported.
Good interviewing skills help to establish credibility of the data. Shenton
(2004) suggested that specific questions be asked of participants to ensure that they
are giving the truth and not misleading researchers during interviews. Likewise,
Kuper, Lingard, and Levinson (2008) recommended asking several key questions
when evaluating a qualitative research report. These included, “Was the sample
appropriate for the research question?” “Were data collected and analyzed
appropriately?” “Are the methods clear?” “Can the results be transferred to the
reader’s own setting?” and “Do the researchers address ethical considerations?”
auditability: When another researcher can clearly follow decisions made by the investigator, arriving at the
same or comparable conclusions
TABLE 14-5 Strategies to Establish Trustworthiness of a
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Study
Credibility
Use of well-established research methods
Use of random sampling methods when possible
Prolonged engagement
Persistent observation
Triangulation
Thick description
Detailed interviews
Questioning to prevent deliberate deception by informants
Data saturation
Peer debriefing
Peer critique
Member checks
Constant comparison
Negative case analysis
Reflexivity (reflective journaling)
Established expertise and appropriate experience of the researcher
Ability to relate previous research findings to the current study
Confirmability
Audit trail
Peer debriefing
Member checks
Acknowledgment of potential sources of bias
Self-reflection of the researcher evidenced by journals
Accurate record keeping of methods and procedures
Credibility and authenticity of the data
Dependability
Audit trail
Peer debriefing
Stability of observations over time
Multiple interviews
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Data saturation
Coding checks that show agreement
Uniformity of responses across subjects
Transferability
Clear explanation of the boundaries/limitations of the study
Description of the context of the study
Thick description
Deliberately trying to find negative case examples
Checking for representativeness of the data
Sources: Adapted from Houghton, Casey, Shaw, Murphy, et al. (2013), Lincoln & Guba (1985), Miles &
Huberman (1994), Sandelowski (1986), and Shenton (2004).
Data saturation, when no new information is being provided by participants,
should be achieved. When evaluating qualitative research for credibility, readers
should be able to see that researchers used peer debriefing to ensure that truth
emerged from the data. Peer debriefing provides researchers with another
professional’s opinion and views of the data. A peer who does the debriefing
should be at the same educational and positional levels as the researcher and
should be considered a colleague but not a supervisor or boss.
data s aturation: In qualitative research, the time when no new information is being obtained and repetition of
information is consistently heard
pe e r de brie fing: A technique used in qualitative research in which the researcher enlists the help of another
person, who is a peer, to discuss the data and findings
Using the constant comparison method, researchers may choose to do member
checks in which participants are asked to confirm the results as data collection
progresses. Another strategy, negative case analysis, includes analyzing cases that
do not seem to fit the patterns or categories that emerge and exploring the reasons
for this. Other strategies involve keeping a reflective journal that details thoughts
and ideas as they emerge and relating the research findings of others’ studies to
one’s own. In addition, researchers should have appropriate expertise, skills, and
established credentials to carry out the study. “The presence of the researcher is
integral and should be acknowledged” (Barham, 2013, para. 5). All of these
strategies are used to both establish and evaluate credibility.
me mbe r che cks : A strategy used in qualitative studies when the researcher goes back to participants and
shares the results with them to ensure the findings reflect what participants said
ne gative cas e analys is : A qualitative strategy involving the analysis of cases that do not fit patterns or
categories
Triangulation is another way to promote credibility of qualitative research.
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This strategy uses different research methods to gather and compare data. Two
ways that triangulation helps to establish credibility include confirming the data and
ensuring completeness of the data. So, if data gathered through various methods or
sources are found to be consistent, the credibility of the research is promoted
(Houghton et al., 2013). Additionally, reflexivity, or reflective journaling, also
promotes credibility of findings by demonstrating the researcher’s thoughts during
the entire process. The researcher records thoughts, ideas, and decisions during
data gathering and refers to them throughout the analysis and when developing
themes and deriving patterns from the data.
triangulation: Use of different research methods in qualitative research to gather and compare data
re fle xivity: Using a journal to record thoughts, ideas, and decisions during qualitative data gathering
Transferability
Transferability relates to external validity, generalizability, or fittingness of the data
(Miles & Huberman, 1994). Although the purpose of qualitative research is not
specifically to generalize, it is necessary to note the significance of the study with
relation to its importance in helping understand a phenomenon in different contexts
or situations. For example, a qualitative study uncovers themes about the lived
experience of waiting for a heart transplant. Nurses working with transplant
patients would need to consider whether these findings are transferable to
individuals waiting for another type of organ transplant. Certainly, if the findings of
a study are congruent with existing research or theoretical frameworks, this
supports transferability. Other strategies used to meet this criterion include
providing a clear explanation of the limitations of the study, giving thick
descriptions of the study context and setting, leaving a paper trail that can be
followed, checking that the data are representative in most cases, and making
suggestions for other settings to test the findings. In addition, if the study is
sufficiently described so that it can be replicated, transferability is supported.
Dependability
Dependability in qualitative research is similar to reliability in quantitative
research. This means that the study should be consistent over time and that enough
observations were made to show this consistency. Dependability is supported when
coding checks show that there is agreement within and among the concepts and
themes. When existing theories can be tied to new findings, dependability is
enhanced. Review by peers or colleagues, as with peer debriefing, also supports
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dependability. There should be a logical consistency between responses of
participants that carries over into the coding and analysis procedures. The audit
trail should show rigor of research method with multiple journals being used to
record thoughts, decisions, and reflections about the data and coding procedures.
FYI
The standard criteria accepted for evaluating quantitative data (internal validity, external validity,
generalizability, reliability, and objectivity) fit well for evaluating numbers, but not words, the basic unit of
qualitative data. Establishing the trustworthiness of qualitative data is particularly challenging because of the
potential for subjectivity that is inherent in this type of research; however, it can be achieved by meeting four
criteria: credibility, transferability, dependability, and confirmability.
Confirmability
Confirmability in qualitative research is most like objectivity in quantitative
research. Neutrality refers to the findings of the research versus the researcher
(Sandelowski, 1986). Some subjectivity is inherent in qualitative methods because
the researcher is the instrument for data gathering as well as analysis and
interpretation. It is when any potential biases are not recognized or accounted for
that confirmability may be in question. Member checks and peer debriefing may
help researchers remain true to the data. Methods of the study should be described
completely with an audit trail clearly detailing all aspects of the study. The self-
reflections of researchers should be recorded in journals. Record keeping must be
accurate. Data should make sense and appear to be real and authentic.
In summary, qualitative researchers should consciously address the four criteria
that are the standard for establishing trustworthiness. Nurse researchers should
review the strategies for meeting these criteria and build them into the research
plan. Journaling, good record keeping, recording detailed field notes with thick
descriptions, and recognizing sources of bias are essential to meet these criteria. In
addition, scientific and ethical standards for rigor in qualitative research must be
maintained to provide the best possible believability and trustworthiness for the
study.
CRITICAL THINKING EXERCISE 14-2
© Jules_Kitano/ShutterStock, Inc.
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Compare and contrast each of the four criteria of trustworthiness of a qualitative study with what you have
learned about the criteria for evaluating quantitative studies. How are they alike? How are they different?
What is your understanding of the reasons behind using different measures to evaluate qualitative versus
quantitative research?
TEST YOUR KNOWLEDGE 14-3
1. Which of the following are criteria for establishing trustworthiness? (Select all that apply.)
a. credibility
b. reliability
c. confirmability
d. inferability
2. Which of the following are techniques used by qualitative researchers? (Select all that apply.)
a. peer review
b. member checks
c. data saturation
d. audit trails
How did you do? 1. a, c; 2. b, c, d
14.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ Describe key ethical issues in qualitative research
Numerous ethical issues are inherent in qualitative research. Some issues arise
during the initial phases of planning a research study, and others arise during
implementation. Certain ethical issues are of note during data analysis,
interpretation, and evaluation. Miles and Huberman (1994), still considered a
standard resource for qualitative data analysis, recommended that specific ethical
issues be given particular attention. These are summarized in Table 14-6.
TABLE 14-6 Ethical Issues to Consider in Qualitative
Research
Issue Ask Yourself (Implications for Nursing)
Worthiness of the project Is this a worthwhile project to pursue? Does it have value?
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Worthiness of the project What will it add to nursing knowledge?
Competence boundaries
Am I adequately prepared to conduct this study? If not,
what would I need to become so, or whom can I get to
assist me?
Informed consent
Have I obtained informed consent from participants? Did I
explain the purpose, risks, and benefits of the study and
allow time for questions?
Benefits, costs, and
reciprocity
Does the cost/benefit ratio make sense? Is it fiscally
responsible?
Harm and risk Is there minimal harm or risk to participants? Have any
potential effects been explained to participants?
Honesty and trust Have I established trust and been honest with participants?
Privacy, confidentiality,
and anonymity
Have I received institutional review board approval? How
have I ensured privacy, confidentiality of responses, and
anonymity of participants will be maintained? Have I met
criteria for training in protection of human subjects?
Intervention and
advocacy
Do I advocate for the right when I observe wrong
behavior of other researchers? Can my subjects count on
me to put their interests above my own? Do I avoid any
real or perceived conflict of interest?
Research integrity and
quality
Do I adhere to accepted standards of practice and
embrace scientific integrity? Am I absolutely true to the
data to avoid fraud and deception in analysis? Have I
considered every aspect of evaluating trustworthiness of
the data?
Ownership of data and
conclusions
Have I clarified who owns my work and the results of it?
Who has access to the data, and have I protected the data,
and thus my subjects, sufficiently?
Use and misuse of
results
Have I taken adequate care to avoid interventions and
persuasion instead of remaining in the role of the
researcher? Have my findings been sufficiently described
so as not to be misinterpreted or misused by others for
their own purposes?
Have I examined all of the possible ethical dilemmas that
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Conflicts, dilemmas, and
trade-offs
analysis? Have I thought of my position related to these
possible dilemmas and how I would handle them? Have I
taken steps to avoid any possible conflict of interest
related to the study?
Source: Adapted and modified from Miles & Huberman (1994).
Many of the ethical issues posed in Table 14-6 can be addressed by
establishing trustworthiness of the research project. Researchers should be able to
defend and explain why a study is significant and describe what it adds to EBP.
Potential risks to participants should be carefully weighed against benefits, and
justifications for decisions should be made. Researchers should be competent to
carry out proposed studies and have the necessary skills and expertise to interpret
findings and convey them for use in practice.
Because qualitative research deals with unique human situations that are largely
interpreted by researchers, issues related to scientific rigor seem to be always
present. It is essential, then, that qualitative researchers take every care to ensure
anonymity and confidentiality of study participants. In sharing people’s words and
thoughts, the potential for inappropriate disclosure of personal information is
greater than in studies where numbers and statistics form the descriptions. Careful
explanations of how data will be used and how participants’ identities will be
protected must be given to participants. Researchers must make certain to honor
these obligations. Participants must be able to trust that if they share their innermost
thoughts with researchers, researchers will do what has been promised with regard
to protecting privacy and safeguarding personal data. Details of the study must be
carefully planned in advance so that even the smallest matter is not left to chance.
FYI
Certain ethical issues are of note during data analysis, interpretation, and evaluation; they can be addressed
by establishing trustworthiness of the research project. Researchers should be able to defend and explain
why a study is significant, describe what it adds to EBP, and carefully weigh potential risks to participants
against benefits.
Qualitative researchers have an inherent obligation and contract with
participants to use data in the way that has been specified, to analyze data with an
open mind, and to be true to the data when reporting findings. For example, when
using ethnography as a method, researchers must address challenges such as
avoiding bias when studying cultural groups different from their own and finding
how best to obtain informed consent among these groups (Lipson, 1994). The
American Anthropological Association (2004), in its statement on Ethnography and
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American Anthropological Association (2004), in its statement on Ethnography and
Institutional Review Boards, stated that “the ethnographer bears the responsibility
of ensuring that the participants are fully informed of the intent of the ethnographic
research, how the participants’ information contributes to the research, and the
anticipated risks and benefits the participants may expect to occur as a result of
their agreement to participate in the research” (p. 3).
When the research findings further nursing science and translate into better care
and outcomes for study participants, or those like them, then researchers can be
assured that an important task has been accomplished. If this goal is kept in mind
while maintaining the expected rigor of this type of research, researchers are much
less likely to violate ethical standards.
TEST YOUR KNOWLEDGE 14-4
True/False
1. Qualitative researchers do not need to obtain informed consent because they participate in the
process.
2. Qualitative researchers often assign code names to participants to protect participants’ privacy.
3. There is no harm or risk associated with participation in qualitative research because data are
typically collected through interviews.
How did you do? 1. F; 2. T; 3. F
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
The committee has almost completed entering information into the grid within this text’s digital resources.
Conclude the analysis by reporting the findings from the Schwappach, Hochreutener, and Wernli (2010)
article. Because this is a qualitative study, it is appropriate to indicate the themes in the results column.
RAPID REVIEW
» In qualitative research, data collection, data analysis, and data interpretation
often occur simultaneously.
» Data analysis involves coding data into manageable units. This can involve data
513
» Coded data are used to generate categories, themes, and patterns.
» Themes, using the language of the participants, paint a meaningful picture of the
phenomenon.
» Computer software programs, such as CAQDAS, can assist researchers in
organizing and managing data.
» Interpretations of qualitative data strive to produce a description of complex
phenomena.
» Qualitative research reports have a format different from quantitative reports.
Authors use one of three approaches: realist tales, confessionist tales, or
impressionist tales.
» Criteria used to evaluate quantitative studies cannot be applied when evaluating
qualitative studies. Qualitative studies are trustworthy when strategies have
been used to meet the criteria of credibility, transferability, dependability, and
confirmability.
» Maintaining confidentiality and protecting anonymity are especially important
when conducting qualitative studies. Researchers have an obligation to remain
true to the data during analysis and interpretation.
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involving patients in the prevention of chemotherapy administration errors. Oncology Nursing Forum, 37,
E84–E91.
Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for
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Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing
grounded theory. Thousand Oaks, CA: Sage.
Tesch, R. (1990). Qualitative research: Analysis types and software tools. New York, NY: Falmer Press.
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University of California Press.
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CHAPTER 15
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Weighing In on the Evidence
Carol O. Long
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Describe strategies that individuals use to reduce uncertainty when making
decisions
‹ Explain how findings from quantitative designs contribute to evidence
‹ Discuss characteristics that should be appraised when evaluating qualitative
and quantitative designs
‹ Rank pieces of evidence using a rating system
‹ Explain the development and use of clinical practice guidelines
‹ Discuss reasons why nurses should follow agency policies even when they
conflict with evidence
KEY TERMS
active rejection
adoption
AGREE II
case control studies
clinical practice guidelines
cohort studies
descriptive studies
evidence hierarchies
GRADE
levels of evidence
meta-analyses
passive rejection
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pilot
randomized controlled trials
rejection
systematic review
uncertainty
15.1 Deciding What to Do
At the end of this section, you will be able to:
‹ Describe strategies that individuals use to reduce uncertainty when making
decisions
Evidence-based nursing is the process whereby nurses make clinical decisions that
integrate the best available research with clinical relevance and incorporate the
patient’s preferences, values, and circumstances (University of Minnesota, n.d.).
This assumes that sufficient evidence or research is clinically relevant,
methodologically sound, and of scientific merit (Straus, Glasziou, Richardson, &
Haynes, 2011). Some practice decisions are made by a committee responsible for
overseeing policies and procedures in the clinical setting. Other decisions can be
made when circumstances warrant a timely decision. For example, a patient may
have an unusual complication that is not addressed by the current protocol.
Healthcare providers may collaborate after securing evidence about an innovative
treatment, and, after consulting with the patient, they may decide to implement it.
How do clinicians make decisions? There are really only two options:
adoption or rejection of the innovation. Individuals aim to select the option about
which they are the least uncertain. “Uncertainty is the degree to which a number of
alternatives are perceived with respect to the occurrence of an event and the
relative probability of these alternatives” (Rogers, 2003, p. 6). Individuals
typically adopt an innovation when uncertainty is reduced. When there is a
significant amount of uncertainty about a new innovation, individuals generally
reject adopting the innovation.
adoption: Applying an innovation to practice
re je ction: Decision not to adopt an innovation
unce rtainty: Degree to which alternatives are perceived relative to the occurrence of an event and the
probability of these alternatives
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FYI
Clinicians must decide to adopt or reject innovations through reducing the uncertainty of an innovation. One
strategy that individuals use to reduce uncertainty during the decision-making process is to try a portion of
the innovation or adopt the innovation on a trial basis, which is called a pilot.
Individuals use different strategies to reduce uncertainty during the decision-
making process (Rogers, 2003). Sometimes individuals may decide to try a portion
of the innovation or adopt the innovation on a trial basis, which is called a pilot.
For example, a new infusion pump may be piloted on one unit to determine its
efficiency before implementing the new model throughout the facility. In some
cases, a trial of a new idea by peers and their recommendations are sufficient to
affect a decision about adoption. Respected individuals are often asked to endorse
innovations as a marketing strategy. Offering free samples, a frequent practice
among pharmaceutical companies, is another strategy that can facilitate the adoption
of an innovation. Demonstrations can also be effective in furthering the adoption of
innovations.
pilot: A small study to test a new intervention with a small number of subjects before testing with larger
samples; adopting an innovation on a trial basis
There are two kinds of rejection: active and passive (Rogers, 2003). Just
because an innovation is adopted for a period of time, there are no guarantees that
rejection will not occur. Active rejection involves active decision making after a
pilot and purposefully deciding not to adopt the innovation. For example, in the
pilot testing of the new infusion pump, nurses reported that alarms sounded for no
reason, requiring more time to monitor infusions. Therefore, it was decided not to
adopt the new infusion pumps in the facility. Passive rejection is when there is no
consideration given to adopting the innovation. In essence, no decision is ever
made and old practices are continued.
active re je ction: Purposefully deciding not to adopt an innovation
pas s ive re je ction: Lack of consideration given to adopting an innovation; hence, old practices are continued
Culture plays an important role in the decision-making process. In some
cultures, it is common for decisions to be made collectively. For example, married
women in an Asian village attended a presentation by a government change agent
about intrauterine devices (IUDs). At the conclusion of the presentation, 18 women
voted to adopt this method of birth control. They immediately went to a nearby
clinic to have an IUD inserted (Rogers, 2003). In some cultures, such as
mainstream America, individual goals supersede the goals of the group and a vote
described above would be rare.
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TEST YOUR KNOWLEDGE 15-1
1. Which of the following strategies reduce uncertainty during decision making? (Select all that
apply.)
a. pilot testing
b. reviewing samples
c. listening to the opinions of peers
d. relying on intuition
How did you do? 1. a, b, c
15.2 Appraising the Evidence
At the end of this section, you will be able to:
‹ Explain how findings from quantitative designs contribute to evidence
‹ Discuss characteristics that should be appraised when evaluating qualitative
and quantitative designs
‹ Rank pieces of evidence using a rating system
Does the Study Provide Good Evidence?
Determining the relevance of the evidence requires skill in analyzing research
studies. These skills include techniques used for determining the strength,
significance, and relevance of the evidence. There are five steps for evaluating and
implementing evidence-based practice (EBP), which are listed and briefly
described in Table 15-1 (Straus, 2005). Although each step requires solid
analytical skills and application of good research methods, the steps are especially
important for weighing the evidence. When appraising, nurses need to ensure that
the first two steps, ask and acquire, were thoroughly executed.
TABLE 15-1 Five-Step Approach for Evidence-Based
Nursing Practice
Ask Identify the research question. Determine whether the
question is well constructed to elicit a response or solution.
Acquire Search the literature for preappraised evidence or
research. Secure the best evidence that is available.
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Appraise
Conduct a critical appraisal of the literature and studies.
Evaluate for validity and determine the applicability in
practice.
Apply Institute recommendations and findings and apply them to
nursing practice.
Assess Evaluate the application of the findings, outcomes, and
relevance to nursing practice.
Source: Adapted from Straus (2005).
After specific literature about the research question has been collected, a
rigorous evaluation is conducted. The mere fact that an individual study has been
published in a peer-reviewed journal does not ensure that the findings are sound
(Watson, 2012). During appraisal, the study design, how the research was
conducted, and the data analysis are all scrutinized to ensure that the study was
sound. Table 15-2 presents questions that should be considered when examining
individual studies.
Quantitative Designs
By this point, you are familiar with quantitative methods and are ready to learn to
apply your knowledge about research principles to make decisions about the
evidence. A critical appraisal of quantitative studies is necessary for nurses to
determine the validity, reliability, statistical significance, clinical importance, and
applicability of the findings (University of Alberta, 2008a).
When appraising meta-analyses, nurses should establish whether well-
designed studies that fit with the research question are included. Both published
and unpublished studies should be included. One must be confident that the
literature was systematically searched to obtain an adequate sample size. There
should be evidence that statistical findings from the studies were merged to identify
incongruencies and similarities of findings among the studies.
me ta-analys e s : Scholarly papers that combine results of studies, both published and unpublished, into a
measurable format and statistically estimate effects of proposed interventions
TABLE 15-2 Questions to Consider When Appraising
Nursing Studies
Introduction
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1. Does the introduction demonstrate the need for the study?
2. Is the problem clearly and concisely identified?
3. Is the problem presented with enough background material to acquaint the
reader with the importance of the problem?
4. Is the purpose of the study clearly stated?
5. Are the terms and variables relevant to the study clearly defined?
6. Are the assumptions clearly and simply stated?
7. If appropriate to the design, are hypotheses stated?
8. Does the study use a theoretical framework to guide its design?
Review of the Literature
1. Is the review of the literature (ROL) relevant to the problem?
2. Is the ROL adequate in terms of the range and scope of ideas, opinions,
and points of view relevant to the problem?
3. Is the ROL well organized and synthesized?
4. Does the ROL provide for critical appraisal of the contribution of each of
the major references?
5. Does the ROL conclude with a summary of the literature with implications
for the study?
6. Is the ROL adequately and correctly documented?
Methods
1. Is the research approach appropriate?
2. Was the protection of human subjects considered?
3. Are the details of data collection clearly and logically presented?
4. Are the instrument(s) appropriate for the study both in terms of the
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problem and the approach?
5. Are the instrument(s) described sufficiently in terms of content, structure,
validity, and reliability?
6. Is the population and the method for selecting the sample adequately
described?
7. Is the method for selection of the sample appropriate?
8. Is the sample size sufficient?
9. Is attrition of sample reported and explained?
10. Does the design have controls at an acceptable level for the threats to internal
validity?
11. What are the limits to generalizability in terms of external validity?
Results
1. Is the presentation of data clear?
2. Are the characteristics of the sample described?
3. Was the best method(s) of analysis selected?
4. Are the tables, charts, and graphs pertinent?
Discussion
1. Are the results based on the data presented?
2. Is the evidence sufficient to draw conclusions?
3. Are the results interpreted in the context of the problem/purpose,
hypothesis, and theoretical framework/literature reviewed?
4. Are the conclusions and generalizations clearly stated?
5. Are the limitations of the findings clearly delineated?
6. Are the generalizations within the scope of the findings or beyond the
findings?
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7. Does the study contribute to nursing knowledge?
Other kinds of studies that nurses are likely to appraise are randomized
controlled trials (RCT). RCT sometimes also stands for randomized clinical trials.
Studies of this type can be found in the nursing literature and are especially
important to the advancement of EBP. Studies showing that a treatment has a greater
effect, rather than studies showing a small effect, weigh more heavily in the
appraisal. Sample sizes are typically large, and often patients are recruited from
multiple sites. Studies are strengthened by using strategies such as blinded designs,
ensuring that interventions are controlled, and showing that patient groups were
similar at the beginning of the trial (University of Alberta, 2008b). Reviewers
should determine whether there is bias by using the five Cs approach for
evaluation: contamination, crossover, compliance, cointervention, and count, that
is, attrition (Attia & Page, 2001). Results should be readily applicable to patients
with similar clinical and demographic backgrounds.
randomize d controlle d trials : Experimental studies that typically involve large samples and are conducted in
multiple sites
Cohort studies, sometimes known as quasi-experimental studies, examine a
large sample of the population and observe changes in characteristics over time.
Like RCTs, there are two groups: one that receives the treatment and one that does
not. Then both groups are followed for a period of time related to the outcome of
interest. Cohort studies are considered to be less rigorous than RCTs are because
subjects are not randomly assigned to groups; therefore, the two groups may vary
on other characteristics, and the controls may be difficult to identify. Cohort studies
may be retrospective or prospective.
cohort s tudie s : Quasi-experimental studies using two or more groups; epidemiological designs in which
subjects are selected based on their exposure to a determinant
Case control studies compare two groups: those who have a specific condition
and those who do not have the condition. This type of research usually focuses on
rare disorders or disorders where there is considerable time between exposure or
treatment and the onset or change in outcome. In case control studies, fewer
subjects are needed than in cross-sectional studies. The disadvantages of case
control studies include the potential for confounding variables, bias (recall and
selection), and difficulty in selecting the control group.
cas e control s tudie s : A type of retrospective study in which researchers begin with a group of people who
already had the disease; studies that compare two groups: those who have a specific condition and those who do
not have the condition
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Descriptive studies aim to provide information about a phenomenon. They are
nonexperimental in design and most often lack an independent variable. They are
often used when little is known about the phenomenon. Correlational and survey
designs fall into this category of research. These types of studies may have large or
small samples, be cross-sectional or longitudinal, and typically report means,
standard deviations, and frequencies. Correlations are reported if the purpose of
the study is to determine relationships.
de s criptive s tudie s : Nonexperimental studies used to provide information about a phenomenon
Qualitative Designs
Qualitative nursing research provides a valuable contribution to building nursing
theory and understanding the practice of nursing. Qualitative studies have not been
highly regarded in the growing field of EBP. Traditionally, it has been difficult for
many individuals to accept qualitative findings because the criteria to determine
scientific rigor are so different from the criteria for quantitative methods. However,
the contributions of qualitative research should not be underestimated because
findings provide the patient perspective, which is an important component of EBP.
When nurses appraise qualitative studies, they should evaluate several
characteristics. The qualitative method selected should be appropriate for the
research question. Unlike quantitative research, samples tend to be small, and
nurses should determine that researchers report reaching saturation. Scientific rigor
should be maintained through orderly and detailed data collection. Strong evidence
is generated when analyses are systematic, rigorous, and auditable (Thorne, 2000).
Conclusions should be grounded in the data.
FYI
There are five steps for evaluating and implementing EBP: ask, acquire, appraise, apply, and assess. Nurses
need to examine all the evidence to make recommendations about practice changes.
Ranking the Evidence
Decisions should not be based on one piece of evidence. Nurses need to examine
all the evidence to make recommendations about practice changes. You may think
that this will be difficult to do; however, it is usually easier than appraising an
individual study. There are predetermined scales, known as evidence hierarchies,
that guide decisions for ranking studies. Because authors are typically very clear in
their descriptions of their studies, it is usually easy to rank the evidence correctly.
In EBP, there are a variety of ways to rate evidence. These rating systems have
been designed by professional organizations or expert panels. Figure 15-1 provides
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a rating system that is commonly used in nursing to make decisions about evidence
(Melnyk & Fineout-Overholt, 2011).
e vide nce hie rarchie s : Predetermined scales that guide decisions for ranking evidence; levels of evidence
Although the rating system in Figure 15-1 provides a commonly encountered
method for rating evidence, you will likely come across other useful rating scales.
Regardless of the scale selected, they all have in common ranking/rating systems to
stratify the evidence by quality. Several notable rating scales are presented so that
you can become familiar with alternative approaches.
Members of the Canadian Task Force on Preventive Health Care (CTFPHC)
were some of the first to generate levels of evidence (Centre for Evidence-Based
Medicine, 2013). The recommendations that typically accompany clinical practice
guidelines (CPGs) are graded by examining the risk versus the benefit and the
quality or strength of the evidence on which the information is derived. Reviewers
focus on decision making that supports evidence over consensus. Current efforts of
the CTFPHC center on preventive care and health policy with guidelines generated
for practitioners to use in clinical practice (CTFPHC, 2013).
le ve ls of e vide nce : Predetermined scales that guide decisions for ranking evidence; evidence hierarchies
FIGURE 15-1 Evidence Hierarchy
Source: Adapted from Melnyk and Fineout-Overholt (2011, p. 12).
First convened by the U.S. Public Health Service in 1984, the U.S. Preventive
Services Task Force (USPSTF) adopted the CTFPHC methodology. The USPSTF
is currently sponsored by the Agency for Healthcare Research and Quality
(AHRQ). AHRQ’s mission is to improve the quality, safety, efficiency, and
effectiveness of health care for all Americans. AHRQ provides administrative,
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research, technical, and communication support for the USPSTF. The USPSTF
evaluates scientific studies related to clinical preventive services and makes
recommendations based on explicit criteria, generally intended for use in
preventive care and the primary care setting. Recommendations provide
information about the evidence, allowing clinicians to make informed practice
decisions. The USPSTF grades the strength of the evidence from “A” (strongly
recommends), “B” (recommends), “C” (no recommendation for or against), “D”
(recommends against), or “I” (insufficient evidence to recommend for or against)
while considering a balance of benefit and harm for the preventive service
(USPSTF, 2013). Recognizing the diversity of rating systems, AHRQ identified
three relevant domains and elements for systems to grade the strength of the
evidence (USPSTF, 2008).
1. Quality: The aggregate of quality rating for individual studies, predicted on the
extent to which bias was minimized
2. Quantity: The magnitude of effect, numbers of studies, and sample size or power
3. Consistency: For any given topic, the extent to which similar findings are
reported using similar and different study designs
CRITICAL THINKING EXERCISE 15-1
© Jules_Kitano/ShutterStock, Inc.
Read the following description and determine how you would rank this study using the rating system in
Figure 15-1.
The purpose of this experimental study was to test the efficacy of two interventions for mothers and
their adolescents in delaying initiation of sexual intercourse for youth who are not sexually active and
encouraging the use of condoms among sexually active youth. Adolescents (N = 582) and their
mothers were randomly assigned to one of two groups (Dilorio et al., 2006).
AHRQ’s mission is to support quality of care and EBP, most notably through its
11 Evidence-based Practice Centers (EPCs) throughout the United States. The
EPCs are awarded 5-year contracts to review relevant scientific materials on
clinical, behavioral, organizational, and financial topics to produce evidence
reports and technology assessments (AHRQ, 2002, 2013). EPCs also conduct
research on methodology and systematic reviews, and evidence-based reports are
added to the AHRQ website on a regular basis (AHRQ, n.d.).
s ys te matic re vie ws : Rigorous and systematic syntheses of research findings about clinical problems
The Cochrane Collaboration, founded in 1993, is an international not-for-profit
528
organization that is dedicated to disseminating information about the effects of
health care worldwide. The Cochrane Collaboration has several resources at the
disposal of evidence-based practitioners, one of them being the Cochrane Database
of Systematic Reviews, published on a continuous basis from the Cochrane Library
(http://www.thecochranelibrary.com/view/0/index.html). The Cochrane
Collaboration is best known for its comprehensive evidence-based summaries
written in an easy-to-read style. Existing Cochrane Reviews are updated regularly,
keeping pace with the fast-paced healthcare environment.
The Joanna Briggs Institute (2011) is an international not-for-profit research
organization that is part of the School of Translational Science at the University of
Adelaide, South Australia. Its central mission is to evaluate health outcomes for the
client and community from an economic and clinical perspective. The institute also
focuses on the evaluation of research. It identifies topics for systematic review,
plans the review, and uses expert panels and reviewers to publish systematic
reviews. With more than 70 collaborating entities, the Joanna Briggs Institute has an
international presence, providing the best clinical evidence at the point of care.
Levels of evidence, ranked 1 through 4, are based on the following factors:
feasibility, appropriateness, meaningfulness, effectiveness, and economic evidence
currently known as FAME. The Joanna Briggs Institute (2011) uses these factors to
grade recommendations used in CPGs and gives them letter grades of A through E.
The institute has an array of resources to appraise the research evidence, assist in
the process of conducting a systematic review, and facilitate thematic analysis of
primary data.
Clearly, there are many evidence rating and grading schemes. There is
controversy about which scheme provides the best evaluation. Yet deciding on one
universal rating scheme may not be feasible. Grades of Recommendations,
Assessment, Development, and Evaluation, known as GRADE, has been an
international effort to develop a universal system of evaluation. The mission has
been to consolidate the forces of many reputable organizations and agencies, such
as AHRQ, the Centers for Disease Control and Prevention, the World Health
Organization, and many other professional societies within the United States and
abroad (http://www.gradeworkinggroup.org). GRADE is closely aligned with the
Cochrane Collaboration. The GRADE system ranks the strength and quality of
evidence into four levels: (1) high, (2) moderate, (3) low, and (4) very low. The
recommendation is either (1) strong or (2) weak. Criteria of the GRADE system
can be accessed at http://www.gradeworkinggroup.org/FAQ/index.htm. The
GRADE Working Group has developed a free software application that uses a
systematic approach to grade the evidence and create a summary table with the
findings.
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http://www.thecochranelibrary.com/view/0/index.html
http://www.gradeworkinggroup.org
http://www.gradeworkinggroup.org/FAQ/index.htm
GRADE: Grades of recommendations, assessment, development, and evaluation; international, universal system
for evaluating evidence
When weighing evidence, nurses may be involved in discussions that involve
determining the clinical significance of the findings (Straus et al., 2011). Questions
about diagnosis, therapy, prognosis, causation, harm, and etiology can be discussed.
Examples are provided in Table 15-3. It would not be unusual for the discussion to
include concepts such as relative risk, relative risk reduction, absolute risk
reduction, numbers needed to treat, and odds ratio. Definitions of these terms are
provided in Table 15-4. This content is included so that you can become familiar
with the terminology, not so that you become adept at performing calculations.
It should be noted that not all the rating systems discussed include a way to rank
qualitative studies. Melnyk (2004) noted that EBP must consider the inclusion of
qualitative studies when reviewing studies of merit, and those qualitative studies
should assume a step on the hierarchy ladder. The research findings that emerge
from qualitative research are valued because they incorporate the “patients’ voice
into evidence based process” (p. 142). As such, qualitative research deserves a
place in the hierarchy of evidence although it may not be considered equivalent to
quantitative research findings.
TABLE 15-3 Common Clinical Questions
Diagnosis Queries the selection and interpretation of diagnostic
tests
Therapy Examines therapeutic treatment(s) for healthcare
problems and their efficacy, cost, and potential harm
Prognosis Evaluates the course of treatment over time, any
complications, and overall prognosis
Causation/harm/etiology Looks at the causes of disease, including iatrogenic
causes, potential harm, and benefits
Other
Questions may be written related to prevention,
clinical examinations, cost, point of contact, or
patient/client data
Source: Adapted from Straus et al. (2011).
TABLE 15-4 Definitions of Clinically Significant Statistics
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Relative risk (RR) is the risk of the outcome in the treated group (Y) compared to
the risk in the control group (X). RR = Y / X
Relative risk reduction (RRR) is the percentage reduction in risk in the treated group
(Y) compared to the control group (X). RRR = 1 – Y / X × 100%
Absolute risk reduction (ARR) is the difference in risk between the control group
(X) and the treatment group (Y). ARR = X – Y
Numbers needed to treat (NNT) is the number of patients that must be treated over
a given period of time to prevent one adverse outcome. NNT = 1 / (X – Y)
Odds ratio (OR) is the odds of an experimental patient suffering an event compared
to a patient in the control group or the odds of risk.
Source: Adapted from Straus et al. (2011).
TEST YOUR KNOWLEDGE 15-2
1. Which of the following would be considered when appraising quantitative studies? (Select all that
apply.)
a. representativeness of the sample
b. trustworthiness
c. sample size
d. control over extraneous variables
2. Which of the following would be considered when appraising qualitative studies? (Select all that
apply.)
a. validity and reliability
b. audit trail
c. thick description
d. participants are experienced in the phenomenon
3. Place the following kinds of evidence in order from highest to lowest.
a. meta-analyses
b. case studies
c. RCTs
d. cohort studies
e. expert opinions
How did you do? 1. a, c, d; 2. b, c, d; 3. a, c, d, b, e
15.3 Clinical Practice Guidelines: Moving
Ratings and Recommendations into
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Practice
At the end of this section, you will be able to:
‹ Explain the development and use of clinical practice guidelines
Various professional associations and other clinical entities have developed
clinical practice guidelines to be used in practice settings. The National Guideline
Clearinghouse (NGC), under the auspices of the AHRQ and the U.S. Department of
Health and Human Services (http://www.guidelines.gov), hosts a myriad of these
documents. Nurses can purchase other guidelines through professional associations.
The NGC is a public resource for evidence-based practice guideline summaries
that provide inclusion criteria, attributes of the guideline, a glossary, the
classification scheme, and summary of the content development.
clinical practice guide line s : Recommendations based on evidence that serve as useful tools to direct clinical
practice
Most guidelines have a standard format and therefore provide similar
information. Most often they identify the names of the reviewers or development
team or a listing of the background of experts who served on the panel plus any
disclosures. The method of review is generally presented, such as the number of
citations, databases searched, and other means to capture relevant research and
secondary sources of interest. Panel members typically review findings and reach
consensus about best practice. Usually limitations of the review are listed, which
may include exclusions of certain topics tangential to the guidelines or issues that
were beyond the scope of the review, such as issues related to legal matters,
economics, or healthcare system issues. Recommendations by the panel members
form the basis of CPGs. Appendixes often contain the rating scales used to evaluate
the evidence, tables, and figures. Often a disclaimer is included that notes that
recommendations serve as guides and are not to be used in lieu of “critical thinking,
sound judgment, and clinical experience” (American Geriatrics Society, 2009, p.
1333).
Clinical practice guidelines are just that: guidelines. CPGs offer an evaluation
of the quality of the relevant scientific literature and an assessment of the likely
benefits and harms of a particular treatment (Institute of Medicine [IOM], 2011, p.
1). As such, they serve as useful tools to direct clinical practice. They typically
include all relevant process and outcome measures that would be indicated for the
average patient with a specific diagnosis or treatment problem. Guidelines provide
an easy-to-read consolidation of research findings. Algorithms or decision trees are
used in some guidelines to demonstrate a stepwise process for resolving a specific
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http://www.guidelines.gov
clinical problem. Although evidence-based CPGs specify good clinical practice,
healthcare providers may not be using them to their maximum potential. Clinicians,
patients, and healthcare systems stand to benefit when guidelines are easy to follow
and widely used.
Although guidelines may appear to be comprehensive, they do not include all of
the variables that clinicians encounter when managing patient conditions or
treatments. Guidelines are unable to address unique patient characteristics. Social,
psychological, emotional, spiritual, environmental, and biomedical factors are not
considered in the guidelines. Using guidelines can result in making generalizations
that can be problematic. Guidelines provide a general approach to clinical
management based on scientific evidence, but caution must be exercised when
applying them to individual patients.
FYI
Various professional associations and other clinical entities have developed CPGs to be used in practice
settings. CPGs will continue evolving because of the momentum generated by EBP, and they will become
more available because of the increased capacity to search the literature through computerization.
Heath (2005) warned about the use of CPGs as an “instrument of surveillance”
(p. 269), whether it is for financial reward, measures of quality, punitive action, or
ethical or legal considerations. Manipulation of guidelines for such purposes
should be considered carefully because their primary intent is to describe best
practice for the typical patient. Nurses must be aware that guidelines may also
contain bias and therefore must critically evaluate them. The IOM (2011)
recommended that CPGs need to be trustworthy or of high quality for healthcare
practitioners to improve decision making and effect quality outcomes. CPGs need
to show transparency in how recommendations are derived and rated, allowing for
external review and timely updating.
To remedy some of the concerns about bias, the Appraisal of Guidelines
Research and Evaluation (AGREE II) instrument was developed as part of an
international collaborative of researchers and policymakers. The instrument
provides a standard framework for the development and implementation of CPGs.
A checklist of 23 items across six different quality domains provides a useful tool
for the generation and evaluation of guidelines (AGREE Collaboration, 2009;
Table 15-5). The AGREE II instrument is generic and can be applied to all types of
CPGs. It is based on evidence-based geriatric nursing protocols (Levin & Jacobs,
2012). A tutorial is available to learn how to use the tool and is useful for teaching
EBP nursing in the classroom or clinical setting (Levin, Ferrara, & Vetter, 2012).
The instrument and tutorials can be accessed at http://www.agreetrust.org/resource-
centre/agree-ii-trainingtools/.
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http://www.agreetrust.org/resource-centre/agree-ii-trainingtools/
AGREE II: Appraisal of Guidelines Research and Evaluation; internationally developed instrument to evaluate
clinical practice guidelines
CPGs will continue evolving because of the momentum generated by EBP.
Evidence is more available because of the increased capacity to search the
literature. Computerization capabilities are allowing information from guidelines,
such as algorithms or decision tools, to be loaded into the personal digital
assistants of practicing nurses. Others, such as insurers, attorneys, and ethicists,
will be interested in guideline development.
CRITICAL THINKING EXERCISE 15-2
© Jules_Kitano/ShutterStock, Inc.
Think about your last clinical experience. What practice guidelines would have been helpful? Where might
you find these guidelines? Do you think the staff would be receptive to your using clinical guidelines on the
unit?
TABLE 15-5 Domains of Quality in the AGREE II
Instrument
Domain 1 Scope and purpose of the guidelines
Purpose, aims, clinical questions, and target population are
evaluated
Domain 2 Stakeholder involvement
Identifies the congruence of meeting the needs of the
intended users
Domain 3 Rigor of development
Evaluates the process of gathering and synthesizing the
evidence and how it was examined
Domain 4 Clarity and presentation
Evaluates the format and clearness of the guideline
Domain 5 Applicability
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Addresses the behavioral, cost, and organizational
consequences of applying the guideline
Domain 6 Editorial independence
Specification of possible conflicts of interest are
enumerated and the independence of the
recommendations
Source: Data from AGREE Collaboration (2009).
TEST YOUR KNOWLEDGE 15-3
True/False
1. Patient care must follow clinical guidelines exactly.
2. A panel of experts synthesizes evidence to make recommendations for clinical guidelines.
3. Nurses should evaluate clinical guidelines because they may be biased.
How did you do? 1. F; 2. T; 3. T
15.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss reasons why nurses should follow agency policies even when they
conflict with evidence
When weighing evidence, nurses need to remember that there are no perfect studies;
therefore, there are always limitations of the evidence. Even though systematic
reviews are highly regarded, they may not provide all the answers a researcher
would like to have or that the clinician might want to know. Evidence might support
a certain treatment or intervention, but one must remember that the literature might
not report all aspects that were tested. For example, the use of case reports might
reveal harm from a pharmaceutical agent, such as an adverse drug reaction. A
systematic review might ensue to appraise harmful consequences of the
pharmaceutical agent. However, because negative trials typically never make it to
publication, the information would not be uncovered during a systematic review.
Similarly, the evidence derived from research might be perceived to be ironclad,
without exception or deviation. This cannot be further from the truth. Clinicians
must examine the evidence within the context of the question, and consequently, the
answer that is revealed. Nurses must incorporate several sources of evidence at the
bedside: the individual patient experience, the clinical experience, and policy or
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cost considerations (Rycroft-Malone, 2003). Questions that nurses can ask are
(Straus et al., 2011):
» Are our patients enough like those in the study so that results can apply?
» Is the treatment feasible in our setting?
» What are the potential benefits and harms from the treatment for our patients?
» What are our patients’ values and expectations about the treatment and the
outcomes?
Generalizability is always a concern when deciding how to apply evidence to
practice. Application of evidence to practice relies on findings and
recommendations generated from samples. Individual patients may not have the
same characteristics as study subjects, and this raises concern for nurses when
considering the adoption and application of the evidence to the point of care.
Gray (2005) suggested that the path from the evidence to utilization in practice
can be value laden and raise ethical concerns. For example, recommendations for
specific diagnostic screenings, such as routine cancer testing for specific age
groups or genders, may be scientifically justified based on incidence and
prevalence rates and other population characteristics. In a perfect world of
unlimited resources, a full battery of cancer screening tests could begin at age 21
and be done annually thereafter. However, in the real world with limited resources
and potential harm from repeated screening, it would be difficult to justify this
standard of screening. Using resources for routine, comprehensive cancer screening
at age 21 would be considered foolish and wasteful. Clinical decisions are
ultimately derived from choices that are influenced by the needs and values of the
population. Even when practice is based on evidence, other factors might affect
clinical decision making.
An ethical dilemma may arise if agency policy conflicts with evidence. Nurses
who engage in activities that promote EBP, such as journal clubs and policy
committees, may find that even after diligently reviewing the evidence, practice
changes are not implemented. But for legal reasons, nurses need to follow agency
policy and act as change agents to effectively bring the evidence to the point of
care.
FYI
Nurses who engage in activities that promote EBP, such as journal clubs and policy committees, may find
that even after diligently reviewing the evidence, practice changes are not implemented. Nurses need to
follow agency policy and act as change agents to effectively bring the evidence to the point of care.
TEST YOUR KNOWLEDGE 15-4
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True/False
1. Decisions about clinical practice are based solely on evidence.
2. If a conflict exists between evidence and facility policy, the nurse should implement procedures
based on the evidence.
How did you do? 1. F; 2. F
RAPID REVIEW
» When weighing the evidence, clinicians can either adopt or reject an innovation.
Innovations are adopted when uncertainty is reduced.
» There are two kinds of rejection: active and passive.
» Appraisal involves reviewing the design, sampling methods, and data analysis.
» Quantitative designs must be appraised to ensure that appropriate conclusions are
drawn.
» Qualitative research is appraised for scientific rigor, systematic analysis, and
conclusions that are grounded in data.
» Evidence hierarchies provide a meaningful way to rank research studies based on
scientific rigor and the levels of evidence: CPGs, meta-analyses, systematic
reviews, RCTs, cohort studies, case control studies, descriptive studies,
qualitative studies, expert opinions, and case studies.
» A variety of professional organizations and clinical entities have developed
rating systems that provide a systematic way to rate risks, benefits, quality, and
strengths of the evidence. An international collaboration proposes to use the
GRADE system as a single standard.
» CPGs provide recommendations for practice based on a thorough review of
evidence conducted by expert panel members. Because CPGs might have bias,
the AGREE II instrument assists nurses in evaluating guidelines.
» Nurses must consider other factors aside from evidence that influence clinical
decision making.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
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The committee has been meeting regularly to analyze evidence and is now able to make recommendations
for best practice. Of course, if you were on an actual EBP committee, there would be much more evidence
about medication errors that you would need to consider. We have provided only a sample of evidence for
you in this exercise. When making a policy decision in clinical practice, you would need to consider all the
evidence. First, examine each study to determine whether the study is valid by considering the questions
presented in Table 15-2. Then use the rating system described in Figure 15-1 to assign each piece of
evidence a ranking. Make a decision about the evidence and write a nursing policy that you think will reduce
medication errors. Be sure to consider the feasibility (organizational and individual barriers) of your policy. A
template is included within this text’s digital resources that serves as an example of a format that can be
used to standardize the way policies are written in a healthcare facility. Use this template to record your
policy.
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http://www.ahrq.gov/research/findings/evidence-based-reports/index.html
Agency for Healthcare Research and Quality. (2002). Systems to rate the strength of scientific evidence
(Evidence Report/Technology Assessment No 47. AHRQ Pub. No. 02-E016). Retrieved from
http://archive.ahrq.gov/clinic/epcsums/strengthsum
Agency for Healthcare Research and Quality. (2013). Evidence-based practice centers (EPCs). Retrieved from
http://www.ahrq.gov/research/findings/evidence-based-reports/centers/index.html
AGREE Collaboration. (2009). Appraisal of guidelines for research and evaluation II (AGREE II)
instrument. Retrieved from http://www.agreetrust.org/wp-content/uploads/2013/
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item_Instrument_ENGLISH
American Geriatrics Society. (2009). The pharmaceutical management of persistent pain in older persons. AGS
Panel on Persistent Pain in Older Persons. Journal of the American Geriatrics Society, 57, 1331–1346.
Attia, J., & Page, J. (2001). A graphic framework for teaching critical appraisal of randomized controlled trials.
Evidence Based Medicine, 6, 68–69.
Canadian Task Force on Preventive Health Care. (2013). History. Retrieved from
http://canadiantaskforce.ca/about-us/history/
Centre for Evidence-Based Medicine. (2013). Oxford Centre for Evidence-based Medicine: Levels of evidence.
Retrieved from http://www.cebm.net/index.aspx?o=1025
Dilorio, C., Resnicow, K., McCarty, F., De, A. K., Dudley, W. N., Wang, D. T., & Denzmore, P. (2006). Keepin’
it R. E. A. L.! Results of a mother–adolescent HIV prevention program. Nursing Research, 55(1), 43–51.
Gray, J. A. (2005). Evidence-based and value-based healthcare. Evidence-based Healthcare and Public
Health, 9, 317–318.
Heath, I. (2005). The use and abuse of guidelines. Evidence-based Healthcare and Public Health, 9, 268–
269.
Institute of Medicine. (2011). Clinical practice guidelines we can trust. Washington, DC: Author.
Joanna Briggs Institute. (2011). Reviewers’ manual 2011 edition. Retrieved from
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ReviewersManual-2011 #page=5&zoom=auto,0,237
Levin, R. F., Ferrara, L., & Vetter, M. J. (2012). Evaluating clinical practice guidelines. In R. F. Levin & H. R.
Feldman (Eds.), Teaching evidence-based practice in nursing (2nd ed., pp. 133–137). New York, NY:
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Levin, R. F., & Jacobs, S. K. (2012). Developing and evaluating clinical practice guidelines: A systematic
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approach. In M. Boltz, E. Capezute, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing
protocols for best practice (4th ed., pp. 1–10). New York, NY: Springer.
Melnyk, B. M. (2004, Second Quarter). Evidence digest. Worldviews on Evidence-based Nursing, 142–145.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide
to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Rycroft-Malone, J. (2003). Consider the evidence. Nursing Standard, 17(45), 21.
Straus, S. E. (2005). Introduction to teaching evidence-based health care [PowerPoint presentation].
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Straus, S. E., Glasziou, P., Richardson, W. S., & Haynes, R. B. (2011). Evidence based medicine: How to
practice and teach it (4th ed.). Edinburgh, Scotland: Elsevier.
Thorne, S. (2000). Data analysis in qualitative research. Evidence Based Nursing, 3, 68–70.
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University of Alberta. (2008b). Therapy/prevention article appraisal guide. Retrieved from
http://www.ebm.med.ualberta.ca/Therapy.html
University of Minnesota. (n.d.). Evidence-based practice: An interprofessional tutorial. Retrieved from
https://www.lib.umn.edu/apps/instruction/ebp/
U.S. Preventive Services Task Force. (2008). Grade definitions. Retrieved from
http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm
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Watson, R. (2012). Peer review under the spotlight in the UK. Journal of Advanced Nursing, 68(4), 718–720.
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http://www.uspreventiveservicestaskforce.org/about.htm
Implementation
UNIT 5
Innovations are not helpful if they are
not adopted.
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CHAPTER 16
Transitioning Evidence to Practice
Maria Young
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Identify evidence-based practice (EBP) models
‹ Discuss barriers to application of evidence to practice
‹ Discuss strategies for creating change to support EBP
‹ Describe strategies for engaging others in change
‹ List Kotter’s eight phases of change
‹ Discuss dilemmas that can be encountered during change
KEY TERMS
barriers
change
change phases model
conduct and utilization of research in nursing (CURN)
cost-benefit ratio
disciplined clinical inquiry model
Iowa model for EBP to promote quality care
journal club
Nursing Quality Indicators
Stetler model
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16.1 Evidence-Based Practice Models to
Overcome Barriers
At the end of this section, you will be able to:
‹ Identify evidence-based practice (EBP) models
‹ Discuss barriers to application of evidence to practice
By now you should have an understanding of EBP. As you recall, trial and error,
educated guesses, and intuition are all useful in contributing to a nurse’s experience
that guides practice, but these processes or behaviors do little to provide the
stronger evidence needed to achieve positive patient outcomes. In today’s rapidly
changing, highly complex healthcare environment, patient outcomes based on
evidence provide the foundation for safe, quality patient care. So, how do we take
the evidence and apply it to the point of care? What EBP models have the potential
to increase our use of research to guide care? What are the barriers to applying
evidence to practice? What elements are necessary if nurses are to create a practice
culture that is committed to and supports evidence-based processes, policies, and
actions? Answers to these questions are examined in this chapter as well as
strategies to create an EBP setting.
Evidence-Based Practice Models
EBP is nothing new to nurses. Florence Nightingale, through her use of meticulous
record keeping and data analysis, was able to demonstrate that mortality rates
decreased when sanitary methods were improved (Riddle, 2006). By using the data
she had gathered, Nightingale developed interventions that, when applied to
medical and surgical patients, reduced mortality rates caused by unsanitary
conditions. In general, the term EBP describes a model of care whereby nurses,
using current evidence or research knowledge, make decisions using clinical
expertise and patient preferences to guide patient care (Melnyk & Fineout-
Overholt, 2011). The University of Minnesota (n.d.) has on its website the
following definition of evidence-based care: “Evidence-Based Practice is the
thoughtful integration of the best available evidence coupled with clinical
expertise.”
Clinical practice based on evidence would seem to be an important goal for
nurses, yet many nurses acknowledge that they do not incorporate research findings
into their practices (Fink, Thompson, & Bonnes, 2005). Why this is so has been
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explored by many researchers (Hommelstad & Ruland, 2004; Pettengill, Gillies, &
Clark, 1994; Retsas, 2000; Rutledge, Greene, Mooney, Nail, & Ropka, 1998;
Sitzia, 2001) and is a topic that remains under continued examination (French,
2002).
Several models have emerged and serve as the foundation for evidence-based
nursing practice. Some models are the conduct and utilization of research in
nursing (CURN) project, the Stetler model, and the Iowa model for EBP to
promote quality care.
conduct and utilization of re s e arch in nurs ing (CURN): Early study conducted about how nurses transition
research findings into practice
Ste tle r mode l: Step-by-step instructions for integrating research into practice
Iowa mode l for EBP to promote quality care : A systematic method explaining how organizations change
practice
CURN
The CURN project was one of the earliest attempts to increase the use of research
in practice by registered nurses (RNs). It was a 5-year project awarded to the
Michigan Nurses’ Association by the Division of Nursing in the 1970s and focused
on helping nurses transition research findings into their practice settings (Polit &
Beck, 2011). An outcome of the CURN project was a realization that practicing
nurses would use research only if it had been widely disseminated and was
relevant to their practice (Horsely, Crane, & Bingle, 1978). The CURN project
moved nursing practice from customs, opinions, and authority to searching for the
best research available and integrating the evidence with a nurse’s clinical
expertise, patient preferences, and existing resources (Polit & Beck, 2011).
To appreciate the importance of the CURN project, consider that in the 1970s
nurses engaged in practice behaviors solely because “we’ve always done it this
way.” For example, consider the practice of restraining patients by tying them to
their beds or chairs to prevent falls. It has only been through research studies
examining this practice that nurses now know that although tying patients to beds or
chairs may have prevented falls, it also predisposed patients to other injuries, such
as strangling, as they tried to get out of the restraints. Because 70% of accidents
among hospitalized patients are related to falls, the need to conduct research and
disseminate the findings about the prevention of patient falls remains a priority
(Agency for Healthcare Research and Quality, 2005). Without the work of the
CURN project, an understanding of how nurses embrace and use research in their
clinical practice might not have occurred.
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The Stetler Model
Whereas the CURN project has given nurses insight about how and why nurses
embrace research in clinical practice, the Stetler model (Stetler, 2001) focuses on
how individual practitioners adopt research findings at the bedside. Originally
developed in 1976 as the Stetler/Merram model for research utilization, this model
can be used to systematically integrate research into practice. The model was
updated to facilitate examination of both the product and process of research.
Products of research are things such as research findings. An example is that 9 out
of 10 dentists recommend a certain chewing gum for their patients who chew gum.
The process of research tells how to go about solving a problem. For example,
nurses on a busy medical-surgical unit want to explore why they have noticed an
increase in patient falls. They begin to examine the problem by conducting a chart
audit of all the patients who have fallen in the past year. Next they determine
whether there are any common factors. When the common factors are identified, a
list of risk factors is developed that can guide interventions to reduce the number of
falls. These nurses are engaging in a process of research. As evidenced in these
examples, both product and process are important to facilitate EBP.
Because Stetler’s model (2001) is prescriptively designed, it provides
practitioners with step-by-step instructions for integrating research into practice
and is useful to help nurses deliver safe patient care. In the updated version of the
model (see Figure 16-1), Stetler provides a traditional graphic accompanied by a
narrative of the five phases of the model.
In the first phase of the model, known as the preparation phase, Stetler (2001)
encourages nurses to be very clear about the purpose, the context, and the sources
of any research evidence. Questions to be answered include what are the issues,
who are the stakeholders, and how will we define our outcomes? Questions such as
these assist nurses to be very purposeful in their thinking when making decisions
about EBP.
The second phase of the model is the validation phase. In this phase, nurses
analyze the evidence to determine whether it is sufficient and credible to use in the
practice setting. You should be familiar with techniques, such as creating a grid to
summarize and weigh research articles, that are important for successfully
progressing through this phase.
FYI
In today’s rapidly changing, highly complex healthcare environment, patient outcomes based on evidence
544
provide the foundation for safe, quality patient care. Several models have emerged and serve as the
foundation for evidence-based nursing practice, including the CURN project, the Stetler model, and the Iowa
model for EBP to promote quality care.
FIGURE 16-1 Stetler Model of Research Utilization to
Facilitate EBP
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Source: Reproduced from Stetler, CB (2001). Updating the Stetler Model of research utilization to
facilitate evidence-based practice. Nursing Outlook , 49(6), 272–279.
The third phase, also called the comparative evaluation/decision making phase,
is when nurses engage in labeling, condensing, organizing, and attributing meaning
to all the assembled evidence. Questions that could be considered during this phase
are: Do you have all the data needed to make a good decision? Is the evidence that
you have uncovered reliable? How strong is the evidence for any recommendations
being made? For example, you may not want to make a practice change if the only
evidence came from a nonpeer-reviewed journal and was based on the
manufacturer’s recommendations because this may not be very strong evidence.
Many associations define beforehand what level of evidence to require when
identifying evidence-based standards, guidelines, or recommendations. For
instance, the American Association of Critical-Care Nurses defines levels of
evidence as follows:
» Level A: Evidence includes meta-analysis of multiple controlled studies or meta-
synthesis of qualitative studies with results that consistently support a specific
action, intervention, or treatment.
» Level B: Evidence includes well-designed controlled studies, both randomized
and nonrandomized, with results that consistently support a specific action,
intervention, or treatment.
546
» Level C: Recommendations are based on qualitative studies, descriptive or
correlational studies, integrative reviews, systematic reviews, or randomized
controlled trials with inconsistent results.
» Level D: Recommendations are based on peer-reviewed professional
organizational standards, with clinical studies to support recommendations.
» Level E: Recommendations are based on theory-based evidence from expert
opinion or multiple case reports, and level M are manufacturer’s
recommendations only (Armola et al., 2009).
By the end of this third phase in the Stetler model, a decision is made about
whether to use the evidence to guide practice.
In the fourth phase, the challenge is to translate or apply the research in the
practice setting (Stetler, 2001). For many organizations this may be easier said than
done. For example, consider the difficulties encountered when integrating into
practice knowledge about discharge planning for patients with heart failure (HF).
While many nurses understand the concept of discharge planning and the practice of
beginning discharge planning upon admission, the ability to develop processes that
support discharge are lacking as demonstrated by all-cause readmissions of 10–
50% for this patient population (Joynt & Jha, 2011). This illustrates how difficult it
can be to adopt innovations in a social system. When applying research to practice,
it is important for nurses to think carefully about how the evidence will be
communicated, disseminated, and applied. In this example, relevant questions to
consider include who will be responsible for implementing HF guidelines into
practice, what resources (time, money, personnel) are available to operate the
program, and how will the success of the program be measured? Change is at the
heart of this phase.
In the fifth and final phase of the Stetler model (2001), nurses evaluate the
outcomes of the change in practice. Continuing with the example of HF discharge
planning, questions from the fourth phase provide a means for evaluating how well
research is applied to practice. In the fourth phase it was decided that practice
should be based on the knowledge that patients respond best to HF discharge
advice when they are hospitalized because of symptoms related to HF and when
they indicate they are ready to make changes. Practice was altered to have nurses
assess patient readiness to make changes and immediately provide written and
verbal HF management information. The success of this practice change can be
evaluated by comparing how often patients are given HF management information
with how many of them are being readmitted for symptoms of HF.
547
FYI
By understanding barriers to creating EBP, nurses are better able to anticipate potential problems when
initiating research activities in clinical practice. Barriers to applying research to practice include
organizational culture, nurses’ belief systems related to practice, and research-related barriers.
The Iowa Model
The Iowa model for EBP to promote quality care is a systematic method that
explains how organizations change practice (see Figure 16-2). Originally a
research utilization model, it has been updated recently to include more emphasis
on EBP and renamed the Iowa model of evidence-based practice to promote quality
care (Titler et al., 2001). In this model nurses consider the following questions: Is
the topic a priority for the organization? Is there a sufficient research base? Is
change appropriate for adoption for practice? By considering these questions,
nurses address many of the same issues as in the Stetler model (2001), such as the
need to gather relevant research, identify outcomes to be achieved, apply the
research to practice, and evaluate the application of the research to practice.
Barriers to Connecting Research and Practice
By understanding barriers to creating EBP, nurses are better able to anticipate
potential problems when initiating research activities in clinical practice. Several
studies have examined barriers to applying research to practice and have found
organizational culture, nurses’ belief systems related to practice, and research-
related barriers as some of the reasons why integration of research findings is
difficult for practicing nurses at the point of care (Fink et al., 2005; Retsas, 2000).
barrie rs : Factors that limit or prevent change
FIGURE 16-2 The Lowa Model of Evidence-Based Practice
to Promote Quality Care
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Source: Used/reproduced with permission from Marita G. Titler, PhD, RN, FAAN, University of Iowa
Hospitals and Clinics. Copyright 1998.
Organizational Culture
That health care is practiced in a rapidly changing, highly complex environment is
no surprise to nurses. Nurses are constantly challenged to provide patients with
high-quality, safe care with limited resources. How successful nurses are at
delivering high-quality patient care can depend on how effective professional
549
organizations are in fostering nurses’ abilities to develop and initiate interventions
aimed at safe patient care. Funk, Tornquist, and Champagne (1995) identified
several organizational characteristics necessary to create and sustain an evidence-
based culture: (1) adequate resources for research activities, (2) support and
encouragement for inquiry, and (3) an expectation for staff to engage in research
activities. The Institute of Medicine (2004) report called for organizational leaders
to “incorporate multiple academic and other research-based organizations to
support HCOs [healthcare organizations] in the identification and adoption of
evidence-based management systems” (p. 155). This is good news to nurses who
have often practiced in environments that seldom recognized the need for, nor
appreciated, the evidence needed for best practice.
Within the nursing profession there is evidence of changing expectations, as
noted by the American Nurses Association’s (ANA) development of Nursing
Quality Indicators (ANA, 2014). These indicators show the outcomes of nursing
care and are meant to address patient safety and quality of care. Organizations
committed to quality assurance collect data on the following initiatives:
Nurs ing Quality Indicators : Outcomes of nursing care, identified by the American Nurses Association, that
address patient safety and quality of care
Patient satisfaction with pain management
Patient satisfaction with educational information
Patient satisfaction with overall care
Patient satisfaction with nursing care
Mix of RNs, licensed practical nurses (LPNs), and unlicensed staff caring for
patients in acute care settings
Total nursing care hours provided per patient day
CRITICAL THINKING EXERCISE 16-1
© Jules_Kitano/ShutterStock, Inc.
Why do nurses seem reluctant to incorporate research findings into their practice? The next time you are on
a clinical unit, ask the staff how they apply research findings in their practice.
Pressure ulcers
Patient falls
Hospital-acquired infection rate
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Nursing staff satisfaction
Nurses are expected to use the best evidence available to achieve the best
patient outcomes possible (Krugman, 2003). Many organizations have come to
appreciate the link between EBP and positive patient outcomes as a result of
changing reimbursement policies. Third-party payers are demanding the
implementation of policies, processes, and practices that have the greatest potential
to contribute to the best outcomes. When organizations support EBP, the potential
exists to balance costs as well as benefits to patients (Hill, 1999). The reason this
balance is important has to do with the limited resources being experienced in
health care today. Payers, in an effort to conserve their expenditures, are interested
in knowing where their dollars are being spent. They want to know what patients
are getting for their money (Hill, 1999). This does not mean payers are interested
only in the dollar value; they are also interested in the quality of the care. In other
words, a balance needs to be achieved between quality and cost of care. If the cost
is low but patients are continually being readmitted because they did not receive
appropriate care in the beginning, nothing would be gained. Conversely, high cost
does not necessarily translate into quality care.
Nurses’ Belief Systems Related to Practice
Nurses are no different from most humans when asked to make changes. For many
people, change is difficult. Some might react by outright refusal to change. Others
pretend to go along with the change but in reality are not in favor of it. Some totally
embrace the change. Studies indicate that nurses generally have a positive attitude
toward research (Thompson, 2001), but they often feel that they do not have the
authority to change their practice (Sitzia, 2001). Some nurses, while having been
exposed to research in their basic programs, have in the ensuing years done little
with the knowledge they gained in school. For others, no formal instruction related
to research was required, making the ability to read, understand, and analyze
research a skill that was never developed (Polit & Beck, 2011). Creating
educational opportunities for nurses to learn about EBP will help to overcome this
barrier.
Research-Related Barriers
Research-related barriers make it difficult for the nurse at the point of care to
understand, interpret, and/or use the research. Because the ability to replicate a
study and achieve the same results means a nurse can have greater confidence in
applying the evidence to practice, it would seem there is a need to conduct and
disseminate research findings in a way that bedside nurses can understand.
Unfortunately, this is not the case because, for most practicing nurses, the complex
551
statistics and research jargon act as barriers to understanding research articles
(Polit & Beck, 2011). The authors suggest that there are no perfect studies, and
nurses would be wise to consider research findings as they engage in EBP.
TEST YOUR KNOWLEDGE 16-1
1. Which of the following described the use of research by RNs?
a. Stetler model
b. Iowa model
c. CURN
d. Institute of Medicine Report
2. Which of the following are ANA Nursing Quality Indicators? (Select all that apply.)
a. pressure ulcers
b. patient satisfaction with pain management
c. staffing mix
d. nurse satisfaction
How did you do? 1. c; 2. a, b, c, d
16.2 Creating Change
At the end of this section, you will be able to:
‹ Discuss strategies for creating change to support EBP
‹ Describe strategies for engaging others in change
‹ List Kotter’s eight phases of change
The key to transitioning evidence to practice is to reframe thinking about
organizational culture, knowledge about research, attitudes about research, and
skills in using research. Change is at the heart of reframing our thinking to make
decisions about EBP.
What Is Change?
Change is a process that creates an alteration in a person or the environment.
Fullan (2001) defined change as a “double-edged” sword (p. 1). For many people
change represents excitement and challenge, while for others change is feared and
avoided. Just as we needed to understand the barriers to research utilization, we
now need to understand how change can affect EBP. On one hand, if nurses are in
organizations that operate from a philosophy of “we have done it this way for
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years,” one can expect change to be painful. On the other hand, it can be equally
disturbing if one is in an organization that seems to change with the seasons. So,
what is the solution? Prepare, prepare, prepare, or as Fullan noted, it is about
strategizing. Think of EBP as a process. By using some of the models described in
this chapter, nurses can strategize about how to embed evidence into practices,
processes, and policies. You can learn more about the change process by reading
the works of Beer, Eisenstat, and Spector (1990), Hammel (2002), and Kotter
(1996).
change : A process that creates an alteration in a person or environment
FYI
Just as nurses need to understand the barriers to research utilization, they need to understand how change
can affect EBP. One place to start when engaging others in transitioning to EBP is to conduct an
assessment of the practice environment.
Engaging Others in Change
One place to start engaging others in transitioning to EBP is to conduct an
assessment of the practice environment. In conducting the assessment, nurses may
find it helpful to include as many of their colleagues as possible.
Table 16-1 provides an example of a tool for assessing the practice
environment. Although this tool is by no means an exhaustive list of questions, it
provides the reader with an understanding of the types of questions to be asked to
gain a complete picture of a practice environment. After the data are collected,
decide whether a problem exists. To illustrate this concept, recall the medical-
surgical unit where the nurses perceived an increase in patient falls. Suppose when
the data were examined, patient falls appeared actually to have decreased. One
would have a difficult time convincing colleagues on the unit, much less nursing
administrators, that there was a need to change practice, process, or policy. From
this scenario it would seem that another important activity to engage others in
transitioning evidence to practice is the need to be able to demonstrate that a
problem exists.
CRITICAL THINKING EXERCISE 16-2
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© Jules_Kitano/ShutterStock, Inc.
Identify a nurse on your clinical unit who has a skill for creating tables in a computer program. Who would
be good at collecting and organizing data? Find another nurse who has a talent for public speaking. Try to
include as many colleagues as possible.
TABLE 16-1 Assessment of Practice Environment
Date of Assessment: ___________________________
Practice Environment Being Assessed: ___________________________
Answer as many of the following questions as possible. The more complete the answers, the better the
quality of the assessment.
1. What types of patients do you take care of on your unit?
2. What is the average daily census on the unit?
3. What care delivery model do the nurses on the unit use to care for patients?
4. What is the staffing mix on the unit? How many RNs, LPNs, aides?
5. How are practice errors reported?
6. Who is responsible for reporting practice errors?
7. What are the top three practice errors reported on your unit?
8. When errors are identified, what is done to correct the error?
9. Where is the policy and procedure manual on your unit?
10. How easy is it for you to access the policy and procedure manual?
11. How often are policies and procedures updated in your organization?
12. Who is responsible for updating policies and procedures?
13. How much input do staff nurses have related to creating or revising policy and procedure?
14. What are the quality initiatives in place on the unit at present?
15. How well is the unit doing related to the quality initiatives?
16. How are the results of quality initiatives communicated to staff?
What if you did not have this skill related to creating and communicating a
problem statement? What could you do next? One approach that might be
considered is to develop competencies related to data collection and problem
identification. Identify someone on the unit or within the organization who collects,
organizes, and presents the data and problem well. You can recognize these
colleagues by their job title or because you understand the issues and data when
listening to their presentations. Some job titles are clinical nurse specialist, process
improvement specialist, or data abstractor specialist. Another way to develop
abilities to gather, organize, and present data is to volunteer to help a more
experienced nurse or volunteer to participate on an organization’s process
improvement committee. Through such collaboration, two things are accomplished.
First, a better understanding of the process can be gained. Second, you develop a
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collegial relationship with someone who can assist you in the future.
A journal club is another technique to engage others in transitioning evidence
to practice (Krugman, 2003). If you do not feel comfortable taking the lead on this,
ask a nurse manager, nurse educator, advanced practice nurse (APN), or nursing
administrator in your organization for help. In many organizations, journal clubs
take the form of brown bag lunches, nursing grand rounds, or unit-based potlucks.
These gatherings provide a relaxed atmosphere where nurses can be exposed to
practice issues and current evidence and ask questions. For some individuals, it is
easier to ask questions and challenge assumptions with those they interact with on a
daily basis. For others, a more formal structure to the inquiry and learning process
may be necessary. The disciplined clinical inquiry model (Figure 16-3) is useful
for structuring a journal club (Sanares & Heliker, 2002). This model was
developed to empower nurses in clinical practice to consider the patient, the
clinical setting, resources, and evidence as they transition evidence to practice.
Because the model addresses unit problems and relies on the unit staff to be
engaged in the process, nurses tend to be more collaborative, thus creating a unit
culture of support and accomplishment.
journal club: A strategy for disseminating research among nurses by discussing articles in a small group
dis cipline d clinical inquiry mode l: A model developed to empower nurses, at the unit level, to transition
evidence to practice
Many of the preceding examples for engaging others in the change process were
at one time voluntary. However, in today’s current healthcare environment, meeting
established outcomes is mandatory and influences an organization’s financial
bottom line where payers reimburse based on those outcomes. For example, the
American College of Cardiology (ACC) and the American Heart Association have
strong evidence for how to treat patients with HF and myocardial infarcts. The
ACC has developed guidelines that have demonstrated improved patient outcomes
when the guidelines are followed. Payers are evaluating the effect of these
guidelines on patient outcomes. Organizations that have initiated practice, process,
and policy changes are recognizing that high-quality, low-cost care that patients
receive means better patient outcomes with increased reimbursements.
Organizations are changing by using standardized order sets where practice
guidelines are embedded into physician orders or nursing care plans, care maps,
clinical pathways, or electronic documentation systems. Care maps and clinical
pathways tend to be multidisciplinary in nature and outline for practitioners how a
patient’s hospital stay will proceed within a particular diagnosis. With the advent
of the electronic documentation system, best practice interventions are identified as
pop-up screens or highlighted electronic reminders. Healthcare providers are
expected to follow the guidelines. Care maps or clinical pathways, although not
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mandatory, are effective means to incorporate EBP.
FIGURE 16-3 Disciplined Clinical Inquiry Model
Source: Sanares, D., & Heliker, D. (2006). A framework for nursing clinical inquiry: Pathway toward
EBNP. In K. Malloch & T. Porter-O’Grady (Eds.), Introduction to evidence-based practice in
nursing and health care (p. 37). Sudbury, MA: Jones and Bartlett.
Making Change Happen
What can we say about change? Because individuals do not view the concept of
change in the same manner, identifying strategies to make change less frequent or
less frightening for others is desirable. Constant organizational change can be
stressful. Think how you would feel if every 6 months the policies related to
charting changed. It would be frustrating to learn a new way of charting so
frequently. Conversely, never making any changes or making changes very slowly
can also be frustrating. Much has been written about the change process. John
Kotter (1996) is known for his work on change. He proposed an eightstep process
that has been described as a top-down transformation process (Fullan, 2001).
Although not widely noted in the nursing literature, Kotter’s eight change phases
model is useful here because of its simplicity. The phases of the model are as
follows: establish urgency, create a coalition, develop a vision and strategy,
communicate the vision, empower broad-based action, generate shortterm wins,
consolidate improvements and produce more change, and anchor new approaches.
The “top” of his model is the starting point in any change effort and should not be
confused with an administrative top (Figure 16-4).
change phas e s mode l: An eight-phase process to describe organizational change
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Kotter’s model (1996) can be applied to clinical situations. For example,
suppose there is a desire to develop a policy about patients leaving the unit to
smoke, but a consensus cannot be reached about what the policy should be. Because
there is no policy, nurses do not feel that they have the authority to stop patients
from leaving the unit. Frustration builds after repeated attempts to create a policy
are unsuccessful.
FIGURE 16-4 Phases of Change Model
Source: Adapted from Kotter (1996).
How could this situation be changed? Using Kotter’s model of change (Kotter,
1996), the first phase is to create a sense of urgency. One strategy to accomplish
this is to collect data about the problem. Data can be a powerful tool for creating a
sense of urgency by communicating the scope of an issue. For example, suppose
you learn that an organization’s all-cause readmission rate for HF patients is 25%.
This high rate is problematic because patient satisfaction decreases for patients
who experience frequent readmissions and organizations are not reimbursed for
readmissions. It is important for an organization to understand why this is occurring
and to reduce the rate of readmission. In your work to understand why HF patients
are being readmitted, you realize the discharge process may not be as complete as
it needs to be. Now consider how much strength could be added to the description
of the problem if colleagues from other units were engaged in collecting data. By
taking the time to collect data about an issue and present it to others, a sense of
urgency is created.
Communicating the sense of urgency often results in the development of a
coalition, the second phase of Kotter’s model (1996). A coalition is a group of
colleagues who share similar thoughts and a vision for change. In the example about
the HF discharge process for patients, a coalition is created when colleagues
recognize the potential impact on patient readmission rates in the creation of a
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discharge process. A benefit of creating a coalition is the collaboration and
cooperation that arise.
A cohesive group sharing similar thoughts and ideas can work toward
developing a vision and strategy for change, the third phase of Kotter’s model
(1996). Through the process of collaboration and cooperation of the coalition
members, a clear vision and strategy have the greatest potential of being developed.
After the vision and strategy for change have been developed, the group must
communicate the vision to others. Communicating the vision is the fourth phase of
the model (Kotter, 1996). Often, it seems that change is not possible because
communication has not been clear. Unclear communication can lead to
misunderstandings and misconceptions about the change that is being suggested,
resulting in unnecessary resistance. Communication then becomes an important
phase of the change process. Good communication contributes to the potential to
gain increased support to change the policy.
Creating a sense of urgency, building a coalition, developing a vision and
strategy, and communicating a vision do not cause a policy, process, or practice to
change. Kotter (1996) described this fifth phase as empowering broad-based
action. The diversity of the coalition should be considered. A diverse group of
members from the nursing unit can help develop, communicate, and sustain the
vision for a policy, process, or practice change. The sustained support of the group
is needed to ensure that the new policy is understood and followed. Empowering
broad-based action means that members from all departments have a responsibility
and accountability for the success or failure of any policy, practice, or process. To
understand this idea further, suppose the proposed HF discharge process has been
approved. The process requires that physicians write recommendations for their
patients to monitor their weight, make a follow-up appointment with the physician,
follow a low-sodium diet, take medications as prescribed, know what to do if
symptoms get worse, and know what type of activity is allowed. The process
requires that nurses and other ancillary staff members, from the perspective of their
disciplines, teach patients about HF. Other healthcare providers also have a
responsibility to notify nurses if they become aware of a patient’s intent or inability
to embrace the recommended plan of care for the management of HF upon
discharge. If the HF discharge process was considered only a nursing process, then
the needed change would be less likely to occur.
FYI
Constant organizational change can be stressful, and never making any changes or making changes very
slowly can also be frustrating. It is essential to identify strategies that make change desirable to others. An
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effective strategy is to implement change in phases: establish urgency, create a coalition, develop a vision
and strategy, communicate the vision, empower broad-based action, generate shortterm wins, consolidate
improvements and produce more change, and anchor new approaches.
When a variety of healthcare providers is empowered, there is a greater chance
for success. Succeeding in some aspect of any proposed change becomes the focus
for Kotter’s (1996) sixth phase of the change process, which is to generate
shortterm wins. This could mean recognizing individuals on the unit who embrace
the new process. Tell them how much you appreciate their support of the new
process, policy, or practice. For example, a dietician begins to routinely visit HF
patients in order to assess their knowledge of low-sodium diets. This action
represents a shortterm win. By acknowledging the dietician’s effort, the opportunity
exists to reinforce the change. Each time someone on the healthcare team role
models the desired practice change, a shortterm win is created.
Kotter’s (1996) seventh phase involves consolidating the improvements. Each
time changes can be articulated, there is a greater chance of producing more
change. In the HF discharge process, for example, each time all members of the
healthcare team are united in their efforts to enforce the new process, success has
been achieved. Each success builds on previous successes, perpetuating adherence
to the process. Consolidating improvements that produce more change also creates
a sense of teamwork.
The more successes the healthcare team can recognize, the stronger the practice
becomes, essentially anchoring the change in practice. The process of anchoring the
change is the last, or eighth, phase of the process (Kotter, 1996). Although
identified as the last phase, it should not be considered unimportant. If change does
not become anchored, thus transforming practice behaviors, then all of our energies
have been wasted. The need to consider how change will be anchored is an aspect
that must be considered and identified early in the change process. You may want to
remember this and make sure you think about how you will anchor a practice
behavior change.
From this discussion it should be apparent to you how the concepts of engaging
others in the change process and Kotter’s (1996) strategies for change are
intertwined. Depending on the type of evidence we wish to transition to the
bedside, it is important for you to identify and know the stakeholders in the change
process.
Stakeholder Involvement
Whenever you consider a practice change, it is important to consider the
stakeholders. Identification of stakeholders is important because it allows for
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clarification of the purpose of the proposed change, decreases misunderstandings
related to the change, and facilitates implementation of the change. Table 16-2
presents an example of a questionnaire that can be used to identify stakeholders.
The following illustrates how implementing a change without collaborating with
stakeholders can have negative results. Nurses on a busy medical-surgical unit have
discovered that many patients are not being assessed in the morning. This is causing
some difficulty for patients because physicians need morning assessments
completed so they can make treatment changes. Upon further examination it is
discovered that the physical therapy department, in an effort to balance their
staffing and workload, has changed its routine and staff are now coming to the unit
first thing in the morning before the nurses have had a chance to assess the patients.
Nurses on the unit voice their concerns, but change does not occur, and the physical
therapy staff continues with the new schedule.
TABLE 16-2 Stakeholder Identification Tool
The following list of questions, when answered, may help to identify many of the stakeholders to any
proposed change of practice, process, or policy.
1. What is the proposed change?
2. Does it affect practice, process, or policy?
3. What are the components of the practice, process, or policy?
4. What is the setting and context for the practice, process, or policy?
5. What is the history behind the practice, process, or policy?
6. What is the structure and administrative design of the practice, process, or policy?
7. Who participates in the practice, process, or policy?
8. Who sponsors the practice, process, or policy?
9. Are there any groups that will be excluded by the practice, process, or policy?
10. Who are the direct beneficiaries of the practice, process, or policy?
11. Are there any indirect beneficiaries of the practice, process, or policy?
12. Does the proposed change to practice, process, or policy create opportunities for any particular
group(s)?
13. Do any particular groups stand to lose power as a result of the proposed change to practice, process,
or policy?
14. Is there a funding group for the proposed change to practice, process, or policy?
What factors contribute to some of the negative outcomes associated with the
physical therapy scheduling change? Had the physical therapy staff identified all the
stakeholders, they might have discovered that their proposed practice change would
affect patient care negatively. Because patients were being taken out of their rooms
before breakfast, nurses were unable to complete morning assessments; thus,
physicians did not have the information to make decisions about treatment options.
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The only group that benefited from the change was the physical therapy department,
which was able to balance its staffing and workload. When input from stakeholders
is not solicited, mistrust can develop among healthcare providers, often putting
patients in the middle of the feuding disciplines.
TEST YOUR KNOWLEDGE 16-2
1. Which of the following are ways to engage others in transitioning evidence to practice? (Select all
that apply.)
a. journal club
b. collaborating with an APN
c. developing care maps
d. maintaining status quo
2. Put Kotter’s eight phases of change in order.
a. develop a clear vision
b. anchor the change
c. create a coalition
d. empower people to clear obstacles
e. establish a sense of urgency
f. consolidate and keep moving
g. secure shortterm wins
h. share the vision
How did you do? 1. a, b, c; 2. e, c, a, h, d, g, f, b
16.3 Keeping It Ethical
At the end of this section, you will be able to:
‹ Discuss dilemmas that can be encountered during change
One must compare the benefits of any proposed change to the potential cost that
might be incurred as a result of that change (resulting in a cost-benefit ratio).
Sadly, many individuals in health care think about cost only in terms of dollars and
cents. Although the financial bottom line cannot be ignored, other kinds of cost must
be considered such as time, personnel, patient preferences, and relationships. If
changes are made to practice, process, and policy without considering other
aspects of cost, change may be inadvertently sabotaged.
cos t-be ne fit ratio: Comparison of benefits to potential costs that might result from change
561
To illustrate this point, consider how health care has changed to a system of
reimbursement based on a patient’s length of stay (LOS). Suppose a patient is
admitted to the hospital with HF, and the insurance will pay $10,000 for his care. It
costs the hospital $10,000 to provide 6 days of care for this type of patient. If the
patient stays for 6 days, the hospital breaks even. If the patient goes home in fewer
than 6 days, the hospital profits because it still receives $10,000. If the patient stays
longer than 6 days, the extra costs of providing care such as salaries, food, and
supplies are assumed by the hospital.
Some nurses decide to approach administration and change the care process
whereby HF patients are discharged in 4 days. Is this a good idea? Will patients be
ready to go home in 4 days? HF patients often need several days for medications to
work. They also need education related to diet and activity. Some patients are so
weak that they need the services of physical therapy. The proposed decrease in
LOS for HF patients means that the physical therapist would need to see patients
within 24 hours of admission. Will HF patients be too sick during that time to
benefit from a physical therapy evaluation? Patients who are discharged before they
are ready are at risk for being readmitted just days after discharge, potentially
adding cost and compromising quality of care. Readmissions can result in patient
and family dissatisfaction and mistrust of healthcare providers and the healthcare
system. This example illustrates how one simple change, discharging HF patients 2
days early, has the potential to increase cost while expected benefits are not
realized. To achieve the most positive benefits, it is important to examine all
aspects of any proposed change.
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Now that the policy has been written and has received the necessary administrative approvals, the
committee must devise an implementation plan. Use strategies identified in this chapter to create your plan,
being sure to consider communication channels, equipment needs, and any education that the staff might
need. Include what outcomes you measure to know whether the policy reduces medication errors.
RAPID REVIEW
» Three models serve as a foundation for EBP: CURN, Stetler model, and Iowa
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model.
» Barriers to EBP include organizational culture, nurses’ belief systems, and
research-related barriers.
» The ANA has developed Nursing Quality Indicators that address patient safety
and quality of nursing care.
» Change is a process that results in an alteration. Some individuals adapt well to
change, whereas others resist it.
» Strategies for transitioning evidence to practice include forming a journal club,
creating a care map, and collaborating with an APN.
» Kotter’s model outlines eight phases of change that can be used to guide the
process.
» The cost-benefit ratio must be examined when planning for change because
dilemmas can arise when changing practices, processes, and policies.
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https://www.lib.umn.edu/apps/instruction/ebp/
CHAPTER 17
Developing Oneself as an Innovator
Diane McNally Forsyth
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ List four characteristics of an innovator
‹ Provide examples of innovative behaviors in clinical practice
‹ Establish two goals to develop oneself in a new job
‹ Explain how to implement at least one characteristic for a team leader as
applied to one’s job
‹ Outline a plan to develop your professionalism as a nurse
‹ List three behaviors important to maintaining professional integrity over the
course of your career
KEY TERMS
awareness
behavioral inventory for professionalism
career development
change agent
communication
critical thinking
developing oneself
flexibility to change
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information overload
innovator
interprofessional collaboration
ladder program
leader
lifelong learning
mentor
personal development file
preceptors
professionalism
role model
self-awareness
sense of inquiry
socialization
team leadership skills
wheel of professionalism in nursing
17.1 Who Is an Innovator?
At the end of this section, you will be able to:
‹ List four characteristics of an innovator
‹ Provide examples of innovative behaviors in clinical practice
An innovator is one who is willing to try new things in practice, using evidence, to
enhance the quality of patient care and to foster nursing knowledge. According to
Rogers (2003), “innovativeness is the degree to which an individual … is
relatively earlier in adopting new ideas than other members of a social system” (p.
18). It is vital that a nurse be an innovator because one’s practice is ever evolving
in the face-paced world of health care. Retaining and using new information is
enhanced when one becomes an active participant in change (Chubinski, 1996).
Will you be the first to learn about something new on your unit? Will you wait to
see how those who took a class earlier evaluate it before you register? Evolving
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into an evidence-based practice (EBP) leader on one’s unit or practice area is a
process that occurs with effort and time.
innovator: One who is willing to try new things
le ade r: One who takes initiative for change and empowers others
Innovator Characteristics
There are several characteristics of an innovator. These include (1) a sense of
inquiry (Titler, 2001), (2) flexibility to change (Shaver, 2001), (3) awareness of
self and of the unit (MacIntosh, 2003), and (4) good communication skills
(Rogers, 2003).
s e ns e of inquiry: Curiosity
fle xibility to change : Being open and positive about change
aware ne s s : Understanding about oneself and the world
communication: Process of creating and sharing information with one another to reach mutual understanding
Sense of Inquiry
First, an innovator needs a sense of inquiry or curiosity. Maintaining currency in
practice is critical. How many nursing articles will a nurse read to stay abreast of
changes in practice? When in nursing school, reading is automatic. However, as a
graduate nurse, it is not uncommon to dislike reading nursing journals. New
graduates tend to focus on technical nursing tasks, leaving less time to reflect on
their practice. Bjorkstrom, Athlin, and Johansson (2008) explored new graduates’
perceptions of their professionalism after graduation and found that they rated
themselves low in “knowledge mastery” and “desire to contribute through
research” (p. 1386). However, reading the latest information in one’s field is vital
for maintaining a fresh practice in the constantly changing nursing world.
Thinking critically about a nursing dilemma is a part of this characteristic. How
might a practice problem be solved? What is new evidence to improve a practice?
Following one’s sense of inquiry can lead to improved patient care. One example is
when a nurse noted that a policy about staff accompaniment for patients going off
the unit for tests and procedures was flawed. This nurse discussed it with
supervisors, gathered input for needed changes, and then moved the policy
revisions through the necessary practice committees in that institution to make a
change. In this example, both staff and patients benefited from the enhancement.
The decision to be an innovator begins with knowledge. According to Rogers
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(2003), information seeking and information processing are foundational and a
means to gain an understanding about a proposed change or problem. Data to
support EBP planning, implementation, and evaluation must be “credible and
persuasive” (Bradley et al., 2004, p. 6), so practicing one’s sense of inquiry should
be a daily behavior. A sense of inquiry to continually seek knowledge and critique
the evidence is key (Titler, 2001).
Having a sense of inquiry or curiosity is analogous to being a critical thinker.
Inherent in obtaining knowledge for an innovator are critical thinking strategies.
Richard Paul’s (1990) theory of critical thinking includes a set of interdependent or
micro skills. These skills include (1) identifying the problem for practice; (2)
deciphering the purpose by reading critically to understand the why behind the
problem; (3) uncovering assumptions that may include personal or institutional
biases; (4) recognizing and using different paradigms, such as looking at the
evidence in different ways; (5) demonstrating different methods of reasoning by
examining values and rationale behind decisions for change; (6) examining data,
which entails an understanding of statistical or other methods for critiquing; (7)
creating alternate solutions using creativity to invent new options to the problem;
and (8) evaluating one’s thinking to improve it (Chubinski, 1996). Experienced
nurses often use these skills automatically. Because research skills to review and
evaluate the evidence and strength of evidence are foundational to EBP, such
critical thinking skills will serve the innovator well.
critical thinking: Skill set that involves critical appraisal of information
Flexibility
The second innovator characteristic is flexibility to change. In any practice setting,
change is constant, so being open to and maintaining a positive attitude about
change makes it easier for oneself and one’s peers. A successful change in the
practice setting occurs when a skilled change agent, an innovator, manages the
many feelings associated with change, such as feelings of achievement, loss, pride,
and stress (Marquis & Huston, 2006). On one hand, flexibility is being willing to
try a new product or implement a new policy; your peers and patients will benefit
from trying this change. You will also benefit personally by updating your practice.
On the other hand, if nurses do not try the new product or implement the new policy,
their practices will stagnate. Flexibility to change also requires openness to failure
because sometimes new ideas do not work as planned. One example occurred when
a new graduate nurse read a research article about a new procedure and tried to
implement it in her unit. Unfortunately, this change was rejected by most staff
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members on the unit. Reasons for this might have been that implementation of the
new procedure worked fine in the research setting but did not carry through to the
practice setting, this particular unit was different from the one in the research
setting, or the nurse was a novice change agent and therefore unable to understand
the process of making policy changes on her unit. Whatever the reason for failure, it
is important to keep trying to implement new changes for the benefit of patients.
Strive to evaluate why a proposed change did not work and use unit resources to try
the new procedure in a different way. Rogers (2003) noted that the innovation–
decision process may lead to rejection for a variety of reasons. Think of the many
experiments that failed at first, such as Thomas Edison’s search for electricity.
change age nt: Individual who leads or champions change
FYI
An innovator is one who is willing to try new things in practice, using evidence, to enhance the quality of
patient care and to foster nursing knowledge. Evolving into an EBP leader on one’s unit or practice area is a
process that occurs with effort and time.
Awareness
Awareness is a third characteristic of an innovator. This awareness is about oneself
and one’s clinical practice area (MacIntosh, 2003). Self-awareness is about
knowing yourself; how you think, act, use your senses to make decisions, and why
you do these things. It entails your ethical, cultural, and spiritual values. Think
about the reasons you became a nurse or why you opted to work in a specific
practice area. A better understanding of how one thinks leads to knowledge of why
one acts in ways that ultimately affect practice decisions.
s e lf-aware ne s s : Knowing yourself
An example was when a nurse disagreed with an institutional policy change
relating to withdrawal of food and fluids for terminally ill patients in specific
circumstances because he had different beliefs about life and death. He spoke with
his nurse manager and the chaplain assigned to that unit in an effort to alleviate his
discomfort. By understanding the ethical rationale behind this institutional policy
and devising strategies he could use when faced with such a situation, he was able
to continue working on this unit. Because of his self-awareness, he was able to seek
resources to understand the meaning of the new policy and promote his continued
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job satisfaction.
Awareness of one’s unit is also an important component of self-awareness. On
one level, knowing the names and some characteristics about coworkers is basic.
On a higher level, understanding what motivates certain people or knowing how
different people react to changes can assist the innovator when change education is
needed. The unit, or social system, is where the staff shares a common culture. It is
important to know this culture, because diffusion of innovation occurs within the
social system (Rogers, 2003). MacIntosh (2003) noted the importance of realizing
one’s practice as a part of finding one’s professional identity when beginning work
as a new graduate. In this stage, she noted that “nurses begin to develop an
awareness of their work contexts that enables them to recognize discrepancies,
compare competence, experience dissonance, and attempt to balance differences”
(p. 732). Having an awareness of one’s unit and colleagues increases self-
awareness that will enhance one’s practice.
Socialization to the unit helps to assimilate the new nurse. Things that help
with unit awareness include uncovering who the formal and informal leaders are,
how education occurs, levels of communication for implementing practice changes,
and possible motivators that are positive rewards for staff (often this is food).
Awareness of both oneself and the unit assists the innovator to create positive
changes that can improve patient care and allow the new nurse to be an effective
team member.
s ocialization: Awareness about formal and informal rules of behavior
Communication Skills
Another characteristic of an innovator is use of good communication skills.
Although these are vital skills as a nurse and leader, they are also important as an
innovator. Rogers (2003) defined communication as “a process in which
participants create and share information with one another in order to reach a
mutual understanding” (p. 335). Communication behavior of innovators includes
increased social participation and being connected through interpersonal networks
(Rogers, 2003). Two parts of communication are related to being an innovator for
EBP. During day-to-day practice, one must communicate clearly to one’s peers and
patients; this is a natural part of one’s professional practice and is learned in your
nursing program. Communicating with those of varying backgrounds is vital to
foster a positive work environment and be collaborative (Prince, 2006). The
second part of communication as an innovator means communicating to a wider
audience. For example, communicating practice changes to others is an important
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aspect of disseminating EBP. As you lead your peers in unit changes,
communicating effectively to others will involve both parts of communication.
When planning an EBP change, it is important to discuss proposed changes with
peers to gather broader input. Later, communication might mean one-on-one sharing
of information or teaching a large group, such as a class about the new topic. This
could also entail diffusion of research from your institution at a conference, sharing
current research related to a specialty practice, and/or publishing.
Communicating about EBP with peers can occur in many ways. Creating one’s
professional network not only assists the development of leadership skills but also
contributes to positive growth as a professional. This might mean belonging to a
specialty organization or getting involved in institutional committees. Frequently,
these groups provide EBP discussions. Another way to discuss new practice ideas
is through a journal club, either face to face or online. Journal clubs foster
increased knowledge about practice change, as well as a better understanding of
research designs (Baker, 2013). All of these characteristics of an innovator blend
to enhance EBP. These are also characteristics of a leader. When one is an
innovator, one is also a leader. This does not necessarily mean becoming a nurse
manager; rather, it means leading your unit or specialty area or hospital in creating
positive changes for nursing practice. When innovators manifest these
characteristics in a confident manner, they become role models for other nurses,
too. Nursing is a team practice. When going solo, you are less likely to be
successful in creating change. The hospital may have educators or other advanced
practice nurses who can assist you in creating changes for EBP. Use of a
professional network and institutional resources can be helpful when solving a
clinical issue.
CRITICAL THINKING EXERCISE 17-1
© Jules_Kitano/ShutterStock, Inc.
Think of a nurse you consider to be an innovator. What characteristics does this person have? How might
you model these characteristics?
TEST YOUR KNOWLEDGE 17-1
1. Which of the following are characteristics of an innovator? (Select all that apply.)
a. sense of curiosity
b. cynical nature
c. inflexible
d. self-aware
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True/False
2. Innovators are critical thinkers.
3. Change keeps nursing practice up to date.
4. All change is positive.
5. The culture of the social system can inhibit change.
How did you do? 1. a, d; 2. T; 3. T; 4. F; 5. T
17.2 Developing Oneself
At the end of this section, you will be able to:
‹ Establish two goals to develop oneself in a new job
‹ Explain how to implement at least one characteristic for a team leader as
applied to one’s job
Self-development benefits you as well as your employer and your patients. Each
time you gain new knowledge, whether from reading or a formal class, your
patients will benefit by receiving the latest information. Because this increases the
quality of care, your institution benefits, too. Therefore, it is imperative that nursing
professionals commit to long-term growth and development (Watson, 2005).
Lifelong Learning
Lifelong learning simply means to continue adding skills and knowledge about the
profession as it continues to evolve. Students learn how to do basic nursing in their
undergraduate program, but it is imperative to continue to evolve as a professional
nurse. Florence Nightingale (1859/1969) recognized this when she stated her
reason for writing Notes on Nursing: “I do not pretend to teach her [sic] how, I ask
her to teach herself, and for this purpose I venture to give her some hints” (p. 4).
Continued learning is up to each person.
life long le arning: Adding skills and knowledge about the profession as it continues to evolve
The innovator characteristics described previously are developed through
lifelong learning. Generally, one learns how to learn in school. The clinical and
theory skills gained in college should be applied upon entering the nursing practice
world. Just as you are learning to apply theory to patient situations throughout your
nursing education, nurses must continue to do the same throughout their nursing
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careers. MacIntosh (2003) found in her research that as new graduates developed a
“reputation for professional expertise” (p. 735), an important stage was pursuing
learning and growth.
There are formal and informal ways of gaining knowledge and growing
professionally throughout one’s career. Explore whether your facility offers partial
payment for this learning. Many facilities provide partial tuition reimbursement for
graduate classes or continuing education credits. Many state boards of nursing
require continuing education credits for registered nurse (RN) license maintenance;
hourly classes, online modules, or daylong conferences provide this continuing
education.
Formal means of learning are accomplished by enrolling in a higher degree
program, such as a master’s or doctoral program of study. There are four Advanced
Practice Registered Nurse (APRN) certifications: certified registered nurse
anesthetist, certified nurse–midwife, clinical nurse specialist, and certified nurse
practitioner (APRN Joint Dialogue Group Report, 2008). APRNs then focus on at
least one of six populations: family/individual across the life span, adult-
gerontology, pediatrics, neonatal, women’s health/gender-related, or psychiatric-
mental health (APRN Joint Dialogue Group Report, 2008). Education for APRNs is
available in master’s, doctorate, and postgraduate certificate programs of study.
Options for a master’s degree include a focus in areas beyond clinical practice,
such as education, leadership, or informatics, or the Clinical Nurse Leader (CNL)
role. The CNL is “a leader in the healthcare system across all settings in which
health care is delivered, not just in the acute care setting” (American Association of
Colleges of Nursing [AACN], 2007, “Educating the Clinical Nurse Leader”
section). In general, nursing doctoral programs are of two types: Doctor of
Philosophy (PhD) and Doctor of Nursing Practice (DNP). PhD programs focus on
generating theory and research to build the body of nursing knowledge. DNP
programs focus on creating expert clinicians who are able to apply research to
clinical practice. In the future, the DNP degree may be necessary to become
certified as an APRN. In the past, admission to doctoral programs required some
practice experience in a specific clinical specialty; however, because of the need
for educators and researchers in nursing, more doctoral programs admit new
baccalaureate graduates directly into their programs (AACN, 2005). Explore
possible graduate programs that fit your learning style (i.e., online programs or in-
person classes), your future goals, and the potential job market in your area.
Ultimately, choose the program that fits you best.
Attending structured learning programs is another formal way of developing
oneself as a professional. Conferences are excellent opportunities for learning new
practices. These have the added advantage of renewing one’s spirit and enthusiasm
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for nursing. They also provide opportunities for networking that improve self-
growth. Participating in practice updates or classes offered by your institution is
vital. Often these are mandatory.
de ve loping one s e lf: Engaging in activities that promote long-term professional growth and development
Informal methods for growth include reading journals or new nursing books,
reviewing current literature (i.e., the Cochrane database or Joanna Briggs Institute),
participating in nursing journal clubs, or talking with peers and advanced practice
nurses about innovations in practice. Professional organizations offer another
excellent method to promote lifelong learning. Many times, speakers provide
reports about current research at meetings. Specialty organizations include a variety
of members, many with vast experiences in that specialty. Asking questions of these
experts provides the novice nurse with increased learning. It is also possible to
find in such organizations a mentor who will assist with your professional growth.
A preceptor is an experienced nurse who is familiar with unit practices and who
acts as a guide throughout the orientation process.
me ntor: One who assists with professional growth
FYI
Self-development benefits you as well as your employer and your patients. Each time you gain new
knowledge, whether from reading or a formal class, your patients, and by extension your institution, benefit
by receiving the latest information and increased quality of care.
The timing of lifelong learning is a factor that enters into one’s personal and
professional lives. One must look for opportunities as they happen, even though the
timing is not always right. For example, if you have an opportunity to attend a
national conference in your specialty area but you think you cannot afford the time
or money to go, think about the professional benefits if you attended. Look for
resources to foster attendance, such as institutional funds, community agency
scholarships, or grants. Discuss it with your supervisor and your mentor. Many
times options open up to enable conference attendance.
It is important not to get into a rut with your work because this can stifle your
lifelong learning. “In seeking and responding to stimulation, nurses actively look
for and engage in activities to prod their development” (MacIntosh, 2003, p. 735).
Discovering ways for professional stimulation, such as connecting with others in a
similar practice at a national or regional conference, tends to bolster current
practice.
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CRITICAL THINKING EXERCISE 17-2
© Jules_Kitano/ShutterStock, Inc.
Consider a specialty organization that you might consider joining. Find the organization’s home page on the
Web and explore opportunities for networking.
Developing on the Job
It is a good idea to uncover the ways to move up the ranks in any new job. Maybe it
is becoming a charge nurse or volunteering for a unit or institutional committee.
Perhaps the institution has a process for promotion in a rank, such as a career
ladder program. Try to uncover institutional promotional methods before starting a
new job. Ask the human resources representative or your supervisor to go over
these steps so that you know what they are before taking the job. For example, if
your institution has a ladder-type promotion, ask what criteria are needed to move
up the ladder. Often peer reviews factor into annual performance reviews, so
cultivate peer relationships and get feedback as a routine part of your practice.
ladde r program: An organizational process for promotion and career advancement
Orientation
Take full advantage of the orientation program in any new job and learn from all the
classes offered. During orientation, seek out possible mentors. Frequently, these
knowledgeable nurses do presentations during orientation sessions or act as
preceptors during clinical orientation. A mentor is a seasoned nurse who acts as a
competent role model and acts to support, guide, teach, and encourage (Mijares &
Bond, 2013) the novice nurse. During this time of newness on your unit, be sure to
observe other nurses and ask them questions about how they do certain procedures
or use various resources.
pre ce ptors : Knowledgeable nurses who provide clinical orientation for new employees
role mode l: One who demonstrates desired characteristics and skills
Frequently, resource time is offered to new employees as a part of the
orientation process. Use this time to look up resources at your new hospital, such as
manuals, toolkits, the committee structure (i.e., unit, specialty divisions, or
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hospitalwide), opportunities to volunteer for committees, or other unit activities.
Inquire about the research process and how evidence-based changes are
implemented on the unit. Ask whether there are journal clubs or similar venues
where practice updates are discussed. Many times facilities have interest groups
whose purpose is to discuss specific practices.
Schedule a time during orientation to meet with nurses in advanced roles (such
as clinical nurse specialists, nurse practitioners, or nurse researchers) who may be
resources for your unit. Get to know these nurses because they can provide
excellent resources and updates for your unit. Inquire whether nursing and/or
interdisciplinary rounds or other learning opportunities are provided. If you have a
professional development staff educator assigned to your unit, determine his or her
role in EBP updates. Talk with your nurse manager or supervisor about how he or
she sees EBP and how you will receive updates for your practice. Try to
understand the level of support from senior leadership because this is important for
maintaining an innovative environment (Blakeney, Carleton, McCarthy, & Coakley,
2009).
Locate sources for maintaining practice updates. During your orientation, build
in time to visit the hospital library or website for the latest practice updates.
Frequently, practice or education committees discuss a current research article that
is germane to that specialty. Ask your preceptor about such committees or councils
and arrange to sit in on one of their meetings to observe how they field questions
about practice changes. Try to learn about the process of how changes occur in your
facility, such as the route that practice changes take for approval. One example of
understanding EBP change is attending a specialty practice committee as a new
employee and being impressed by the excellent debate about updating a practice
policy. When the process for change is better understood, it is easier to prepare for
new updates because you know where change information stems from.
Learning from role models is a good way to learn, provided it is positive role
modeling. Role modeling can be informally observed by any nurses on the unit, or it
may be formalized by having a preceptor or by asking someone to act as a mentor.
Any or all of these role models are helpful to enhance professionalism for novice
nurses. Ask positive role models how they use current evidence in their practice.
However, be forewarned that the expert nurse might not be able to provide
specifics because that person weaves change so inherently into practice that it is
difficult for this nurse to share what the novice needs to know (Benner, 1984).
profe s s ionalis m: A set of behaviors that exemplify the role of the professional nurse
On the down side, new graduates may observe practices that are not desirable
or even safe. A word of caution here: As the new person on the unit, you need to be
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careful about questioning those practices or your self-development could be
stunted. You need to alert someone, especially if what you observe is unsafe,
because there may be people who remain quite behind in their adoption of new
practices. An example of this was when a new employee learned how to use
correct body mechanics when moving patients. When she was first on the unit and
assisted staff members with moving a patient from a bed to a cart, she commented
that the others were not using correct body mechanics, as she had learned. An
experienced nurse negated her comments, noting that this was the fastest way to
move patients and the way it was always done. The new employee was puzzled by
this comment because she understood the statistics behind back injuries, so she
discussed this with her nurse educator. As a result, all staff members on the unit
needed to relearn proper body mechanics to prevent injuries, thereby enhancing
clinical practice for all, not just the new graduate. Talking to a preceptor or another
trusted peer can offer insight into these observations. Be careful not to be overly
critical of unit practice because there may be reasons behind the actions that are not
readily apparent. As a new person on the unit, you need to gain some trust among
your peers, and this takes time. Becoming aware of discrepancies between
expectations and what actually occurs on the unit is a stage of becoming a
professional and feeling comfortable with one’s own practice (MacIntosh, 2003).
Eventually, new nurses can work to change outdated practices through the proper
channels.
After a short time in the orientation process, new employees begin to realize the
vast amount that they do not know about their specific practice area. This is the
time to read literature in this specialty practice area. Sometimes reviewing nursing
texts and past notes is sufficient. Now that specific practices are seen on a daily
basis in a new job, theory means more because it is applied. Explore current
research about new practices. Glean all that you can as soon as you can to foster
self-development in your new specialty area. Having a rationale for making a
practice change is helpful both to convince yourself that the change can be effective
and to convince others.
As their formal orientation is completed, new employees frequently experience
a time of uncertainty. New nurses might question whether this is the right unit or
specialty area. They long for their days of classes when they had more guidance as
a student, and they struggle with learning the vast amount of information about
quality patient care. Moving from a novice to a competent nurse can be frustrating,
such as learning how to organize one’s shift with the many tasks, delegating to
unlicensed personnel, and managing patient crises. It is so easy to leave work and
want to forget about it. Yet this is the time when a true innovator will set goals and
strive toward enhanced professionalism. Learn all that you can about your new
practice and facility. Take advantage of all learning opportunities. Push your
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comfort zone so that as you feel more confident about one type of patient care
diagnosis, you can seek out new opportunities for learning about other nursing
interventions. Perhaps this is the time to volunteer for a unit committee so that you
can learn more about the inner workings of creating and changing policy or to offer
to present a topic for a staff development class. Remind yourself that this is part of
developing as a professional.
Performance Appraisals and Reviews
In any job, there is some type of appraisal and review. Usually it is tied to salary or
other promotional mechanisms, so it is important to pay attention to the details
applicable for your agency. This process is designed to provide an opportunity to
reflect on your strengths, areas for improvement, what you have done since the last
review, and what you plan to accomplish within the next time period. Normally,
setting goals is a part of this review process. However, acting in a goal-centered
manner provides a framework for practice as well. Goals might be individual, such
as seeking a promotion, or getting more active in workgroups. Other goals might
include activities to enhance professionalism, such as active work in a nursing
organization. Whether you set goals only once per year during your annual
performance review with your supervisor or you have daily goals, they serve to
offer reflection for your practice and foster increased awareness. All of nursing
should be goal oriented, such as how goals are always present in any nurse–patient
interaction. Goals should incorporate EBP, such as monthly exploring the use of a
new EBP guideline or technique for your practice.
Frequently, input from peers or other supervisors is requested as a part of a
performance review. This is the time to ask peers who have provided helpful
feedback for your development, such as preceptors or mentors. It is also helpful to
organize your input, enabling your supervisor to get a full picture of your
accomplishments. Watson (2005) suggested a personal development file or folder
as a means to compile what you accomplish in your career because those “little
things … [merge] into a substantial amount of additional career development
activity” (p. 992; emphasis added). Make notes or include documents to remind you
to include those items as a part of your review process. If you expended a special
effort to teach a nursing student on your unit, make a note about it at the time to
include in this self-appraisal. If you assisted with data collection for a research
project, try to obtain a study summary to include for your records. Keep an accurate
file of your continuing education documents. Organized personal record keeping is
important and provides objective data for the performance review.
pe rs onal de ve lopme nt file : A compilation of career accomplishments
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care e r de ve lopme nt: Experience and education that contribute to one’s professional growth
Developing Team Leadership Skills
The impact of team effectiveness for one’s unit is significant (Timmermans, Van
Linge, Van Petegem, Van Rompaey, & Denekens, 2012). Interprofessional
collaboration is engaging with other professionals to provide evidence-based
care. It is essential for quality patient care (Institute of Medicine, 2010) and
requires a relationship between team learning and innovations in nursing
(Timmermans et al., 2012). To implement EBP on a unit, all members need to be
involved and work together to create the change. A small number of unit leaders
can positively influence other unit staff members to enhance patient care with new
evidence for practice change. Although nurses are likely involved in making
decisions, the unit staff is directed to implement the changes. This is where
awareness about one’s unit is important. Use informal and formal leaders.
Strategically organize common groups within the unit, such as those who work
similar schedules. An example of this is “communication groups” within the unit
where a small number of staff members are assigned to each group, a leader is
assigned who acts as the communicator to the other members in that group, and the
leader provides information, communicates about changes, and/or clarifies
questions.
inte rprofe s s ional collaboration: Engaging with other professionals to provide evidence-based care
Another strategy suggested by Titler (2006) is a unit change champion. Change
champions are staff members on the unit who continually promote new ideas for
change and act as role models. Characteristics of successful change champions are
the following: (1) expert clinician, (2) informal leader who is respected among
peers, (3) positive working relationship with other interdisciplinary team members,
(4) passionate about the topic of practice, and (5) commitment to improving the
quality of patient care (Titler, 2006). These characteristics are important for any
innovator as well. Innovators might be known as change champions or by any other
title used by the institution to implement practice changes.
Developing team leadership skills occurs over time. This is also where
innovator characteristics, a sense of inquiry, flexibility to change, awareness of self
and of the unit, and good communication skills are needed. As you develop, your
team leadership skills will emerge.
te am le ade rs hip s kills : Behaviors that collaboratively engage others while working toward a goal
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TEST YOUR KNOWLEDGE 17-2
Identify the following as either formal or informal means of developing oneself as a professional.
1. Attending conferences
2. Finding a mentor
3. Enrolling in graduate education
4. Reading a journal
5. Attending a mandatory in-service
How did you do? 1. Formal; 2. Informal; 3. Formal; 4. Informal; 5. Formal
17.3 Professionalism
At the end of this section, you will be able to:
‹ Outline a plan to develop your professionalism as a nurse
Models of Professionalism
Professionalism is how one deports oneself within the nursing profession. Miller,
Adams, and Beck (1993) developed a behavioral inventory for professionalism
in nursing to measure the following: (1) education and training, including continuing
education; (2) skill based on theoretical knowledge; (3) a code of ethics; (4) a
professional organization; and (5) service. For example, their inventory measures
continuing education attendance, the number of journals read, nursing books
recently purchased, professional organization memberships, whether nursing
theories are applied in one’s practice, and participation in organization and
community service. These authors surveyed more than 500 nurses and found that
92.3% reported reading from 1 to 10 nursing articles per month; however, only
15.9% belonged to a professional organization.
be havioral inve ntory for profe s s ionalis m: A measure of education and training, skill, ethics, professional
organization, and service
FYI
Perhaps the most important aspect of being a professional is to use what was learned in one’s basic nursing
program, especially the application of theory to clinical situations. Continuing to apply learning contributes to
ongoing EBP as one uses newer research and theory as a part of one’s practice.
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The wheel of professionalism in nursing (Figure 17-1) depicts components to
enhance professionalism (Miller, 1984). The behaviors included in the wheel
indicate degrees of professionalism; these behaviors might also be used as
measures in working up a clinical ladder in one’s facility. One example is that
active participation in a specialty organization could assist with promotions in
some institutions where such professional behaviors are a part of that institution’s
philosophy. Other examples include routinely reading articles related to one’s
practice to enhance theory application for practice, pursuing continuing education
regularly for competence, and making practice changes for one’s own practice to
enhance professional autonomy.
whe e l of profe s s ionalis m in nurs ing: A model depicting behaviors of the professional nurse
Perhaps the most important aspect of being a professional is to use what was
learned in one’s basic nursing program, especially the application of theory to
clinical situations. One can innovate; however, one is still obligated to use a theory
base for safe patient care. Continuing to apply learning contributes to ongoing EBP
as one uses newer research and theory as a part of one’s practice.
A difficult component of professionalism for those new to the practice world
involves information overload. Rogers (2003) defined this as “the state of an
individual or system in which excessive communication inputs cannot be processed
and utilized, leading to breakdown” (pp. 368–369). With added technology,
healthcare professionals must manage an array of communication media and
evidence for updated practice arriving at breakneck speed. Although it is complex
enough for the new nurse to become proficient with patient care and learn to
manage multiple patients, the additional expectations for keeping up with multiple
modes of communication add increased stress. Learning how to manage technology
is vital. Using all of the innovator characteristics can assist a new nurse to become
an effective member of the team and provide quality patient care. Incorporating
EBP will become a routine part of professional practice.
information ove rload: State of an individual in which excessive communication cannot be processed or used
FIGURE 17-1 Wheel of Professionalism in Nursing
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Source: Copyright 1984 Barbara Kemp Miller. Reprinted with permission.
A Final Word About Developing Oneself as an
Innovator
Recognizing a possible gap between experiences in education programs and the
actual workplace means that new graduates must seek resources to bridge this gap.
Welding (2011) noted that nurse residency programs are a formal means to bridge
this gap, aiming to promote success and productivity for new graduates. Even
without a residency program, being proactive eases this transition into practice for
new graduates and puts them on the road to becoming innovators and leaders in
practice. When nurses develop a strong sense of inquiry, are flexible toward
change, become aware of self and of the unit, and implement good communication
skills, they can be innovators, thus enhancing quality patient care for the facility. It
is imperative that innovators continue to learn and assimilate ongoing changes
about new evidence into their practice. Normally, practice is incorporated into
education programs and initiatives by “what practitioners do (and choose not to do)
but also what they are and the knowledge and thought that underpin their actions”
582
(Coles, 2002, p. 8). In today’s ever-changing world, knowledge is not always
adequate; one must incorporate knowledge gained into one’s practice.
17.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ List three behaviors important to maintaining professional integrity over the
course of your career
It may not be evident to you at this point in your career, but nursing professionals
have an obligation to develop self-awareness. In your nursing program, you are
being socialized to become a lifelong learner. Developing yourself is necessary if
you are to remain current about practice issues and new technologies. A sense of
self-awareness can bring a level of maturity that is necessary for ethical decision
making.
Professional nurses need to promote themselves and the profession by making
others aware of their accomplishments. There are many ways to achieve this. For
example, when you earn a certification, be certain that your accomplishment is
recognized by your organization. Make yourself
CRITICAL THINKING EXERCISE 17-3
© Jules_Kitano/ShutterStock, Inc.
What is your professional ethical duty, according to the Code of Ethics for Nurses (ANA, 2001), when you
see any unsafe practice or see another nurse “fudging” patient assessment data?
available to promote nursing as a career through interactions with youth. Writing an
editorial on a health topic that interests you or that you are passionate about is
another way to make nursing more visible. The Code of Ethics for Nurses with
Interpretive Statements (American Nurses Association [ANA], 2001) holds nurses
accountable for the development of the profession. For instance, if a student
cheated on his or her work during nursing school, such “unprofessional behaviors
developed in school … adversely … [affect] the nurse’s ability to properly care for
patients” once employed as an RN (Rhodes, Schutt, Langham, & Bilotta, 2003, p.
28).
583
FYI
Nurses have a duty to give back to the profession. All nurses have a responsibility to assist novice nurses.
EBP is more likely to thrive in environments where nurses feel supported and are provided with resources
necessary to develop both personally and professionally.
At this point in your development, you have begun to build a personal
development file. This will be especially important to you as you seek your first
position as an RN and apply to graduate school. It is desirable to include a
representative picture of your abilities. However, it would be unethical for you to
overstate your capabilities. Records should never be falsified and must accurately
reflect your work history.
As a nurse, you must take advantage of both formal and informal opportunities
for professional growth. For example, your employer might provide educational
benefits. Investigate conferences that will help to establish you as an expert in your
field. Willingly accept responsibility for reporting back to your colleagues what
you have learned.
Nurses have a duty to give back to the profession. All nurses have a
responsibility to assist novice nurses to establish their practices. Recall the
characteristics of a preceptor who was particularly helpful to you. Emulate this
behavior with students you encounter. As your career progresses, make it a
personal goal to always be mentoring at least one person. EBP is more likely to
thrive in environments where nurses feel supported and are provided with the
resources necessary to develop both personally and professionally.
TEST YOUR KNOWLEDGE 17-3
1. Which of the following are ethical behaviors? (Select all that apply.)
a. Reading journal articles for a club meeting
b. Skipping the afternoon conference sessions to go shopping
c. Providing an accurate and meticulous resume
d. Sharing information at a staff meeting about a new innovation that you heard about at a
conference
e. Ignoring a student assigned to your unit who has a question about a procedure
f. Reporting a nurse who recorded vital signs when in fact they that were not measured
How did you do? 1. a, c, d, f
APPLY WHAT YOU HAVE LEARNED
584
© Lisovskaya Natalia/ShutterStock, Inc.
Do you have what it takes to be an innovator? Complete these assessments to learn more about your
leadership styles.
1. Emotional Quotient Assessment at http://www.ihhp.com/?page=freeEQquiz
2. The New Enneagram Test at http://www.9types.com/newtest/index.php
RAPID REVIEW
» The four characteristics of an innovator are a sense of inquiry, flexibility to
change, awareness of self and the unit, and good communication skills.
» A sense of inquiry is one’s curiosity and can lead to seeking knowledge that
improves patient care. This characteristic is analogous to being a critical
thinker.
» Flexibility is the willingness to try something new, and it requires an openness to
failure.
» Self-awareness is knowing yourself, and it helps you understand how you make
decisions about practice. Awareness about the unit facilitates change because of
understanding the social system.
» Communication skills are vital to leading and being a change agent.
» Lifelong learning takes place in formal and informal ways, both of which can
contribute to EBP. Formal ways of learning include enrolling in graduate
programs, attending conferences, and participating in in-services. Informal
learning can involve reading literature, attending journal clubs, networking at
meetings, and mentoring.
» Orientation, ladder programs, and personal development files are ways to
develop oneself on the job.
» Setting goals and peer review are components of performance appraisals and
employment reviews.
» EBP practice changes are facilitated when a team approach is used.
» The wheel of professionalism in nursing is a model that lists professional
behaviors.
» Nurses are obligated to develop themselves as lifelong learners to thrive both
585
http://www.ihhp.com/?page=freeEQquiz
http://www.9types.com/newtest/index.php
personally and professionally.
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American Association of Colleges of Nursing Task Force on Future Faculty. (2005). Faculty shortages in
baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply.
Retrieved from http://www.aacn.nche.edu/publications/whitepapers/facultyshortages.htm
American Nurses Association. (2001). The code of ethics for nurses with interpretative statements.
Washington, DC: Author.
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Baker, J. D. (2013). Journal club as a resource for practice. AORN Journal, 98(2), 102–106.
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Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park,
CA: Addison-Wesley.
Bjorkstrom, M. E., Athlin, E. E., & Johansson, I. S. (2008). Nurses’ development of professional self—from
being a nursing student in a baccalaureate programme to an experienced nurse. Journal of Clinical
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Blakeney, B. A., Carleton, P. F., McCarthy, C., & Coakley, E. (2009). Unlocking the power of innovation.
Online Journal of Issues in Nursing, 14(2), 1–11. Retrieved from
http://www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/
Vol142009/No2May09/Innovation.html
Bradley, E. H., Webster, T. R., Baker, D., Schlesinger, M., Inouye, S. K., Barth, M. C., … Koren, M. J. (2004,
July). Translating research into practice: Speeding adoption of innovative health care programs.
Commonwealth Fund, 1–12. Retrieved from
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Chubinski, S. (1996). Creative critical-thinking strategies. Nurse Educator, 21(6), 23–27.
Coles, A. (2002). Developing professional judgment. Journal of Continuing Education in the Health
Professions, 22, 3–10.
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Nursing/Future%20of%20Nursing%202010%20Report%20Brief
MacIntosh, J. (2003). Reworking professional nursing identity. Western Journal of Nursing Research, 25, 725–
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Marquis, B. L., & Huston, C. J. (2006). Leadership roles and management functions in nursing: Theory
and application (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Mijares, L., & Bond, M. L. (2013). Mentoring: A concept analysis. Journal of Theory Construction and
Testing, 17(1), 23–28.
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programs in Texas (Doctoral dissertation). Dissertation Abstracts International, 46, 1118B.
Miller, B. K., Adams, D., & Beck, L. (1993). A behavioral inventory for professionalism in nursing. Journal of
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http://www.nursing.vanderbilt.edu/msn/pdf/cm_AACN_CNL
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http://www.aacn.nche.edu/education-resources/APRNReport
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http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No2May09/Innovation.html
http://www.cmwf.org/programs/elders/bradley_translating_research_724
http://iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Report%20Brief
Professional Nursing, 9, 290–295.
Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York, NY: Dover. (Original work
published 1859)
Paul, R. (1990). Critical think ing: What every person needs to survive in a rapidly changing world.
Rohnert Park, CA: Center for Critical Thinking and Moral Critique.
Prince, B. (2006). Strategies to explore innovation in nursing practice. Nursing Standard, 21(9), 48–55.
Rhodes, M. K., Schutt, M. S., Langham, G. W., & Bilotta, D. E. (2003). The journey to nursing professionalism:
A learner-centered approach. Nursing Education Perspectives, 33(1), 27–29.
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Shaver, J. L. F. (2001). Looking to the future of academic administrative leadership. In N. L. Chaska (Ed.), The
nursing profession: Tomorrow and beyond (pp. 931–943). Thousand Oaks, CA: Sage.
Timmermans, O., Van Linge, R., Van Petegem, P., Van Rompaey, B., & Denekens, J. (2012). Team learning and
innovation in nursing, a review of the literature. Nurse Education Today, 32, 65–70.
doi:10.1016/j.nedt.2011.07.006
Titler, M. (2001). Research utilization and evidence based practice. In N. L. Chaska (Ed.), The nursing
profession: Tomorrow and beyond (pp. 423–437). Thousand Oaks, CA: Sage.
Titler, M. (2006). Developing an evidence-based practice. In G. LoBiondo-Wood & J. Haber (Eds.), Nursing
research: Methods and critical appraisal for evidence-based practice (pp. 439–481). St. Louis, MO:
Mosby.
Watson, R. (2005). Self-development and self-appraisal. In L. Caputi & L. Engelmann (Eds.), Teaching
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MEDSURG Nursing, 20(1), 37–40.
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Confirmation
UNIT 6
Evaluating outcomes and networking
with others substantiate adoption or
rejection of innovations.
588
CHAPTER 18
Evaluating Outcomes of Innovations
Kathleen A. Rich
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Define outcome
‹ Discuss ways outcomes can be classified
‹ Discuss factors that should be considered when selecting outcomes ‹ Discuss
how data are used to evaluate outcomes
‹ List three dilemmas that can arise when nurses are involved in testing
protocols
KEY TERMS
benchmarking
care-related outcomes
continuous quality improvement
Forces of Magnetism
indicators
intermediate outcomes
long-term outcomes
mandated reporting
nursing outcomes
nursing-sensitive outcomes
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organizational priorities
outcome
outcomes research
patient populations
patient-related outcomes
performance-related outcomes
short-term outcomes
team membership
18.1 What Is an Outcome?
At the end of this section, you will be able to:
‹ Define outcome
‹ Discuss ways outcomes can be classified
Implementing an innovation, policy, or procedure does not necessarily guarantee
that it will become the standard of care. Ongoing evaluation of an innovation
through outcome measurements is necessary to ensure successful incorporation into
clinical practice. According to Webster’s, an outcome is defined as a consequence
or visible result. Nursing outcomes measure states, behaviors, or perceptions of
individuals, families, or communities (Moorehead, Johnson, Maas, & Swanson,
2013). Outcomes research examines the end results of health services on
individuals and is intended to provide scientific evidence relating to decisions
made by all who participate in health care. It also takes into account the patient’s
preferences and values (Krumholz, 2009). In nursing research, the outcome is
frequently known as the dependent variable (Polit & Beck, 2010).
outcome : Consequence or visible result
nurs ing outcome s : Measures of states, behaviors, or perceptions of individuals, families, or communities as
they relate to nursing and health outcome s re s e arch: Studies about the effects of care and treatments on
individuals and populations
Outcomes may be classified by several different methods. One way outcomes
can be classified is by focusing on who is being measured. Nurses may measure
outcomes for individuals, groups, or organizations.
Another way that outcomes can be grouped is by type: care-related, patient-
590
related, and performance-related outcomes (Kleinpell, 2009). An example of a
care-related outcome is the rate of pressure ulcer formation in patients on bed rest
for more than 24 hours. Patient knowledge related to fluid restriction is an example
of a patient-related outcome. Nursing staff adherence to best practice guidelines
when providing discharge education to a heart failure patient is an example of a
performance-related outcome.
care -re late d outcome s : A category of outcomes that measures the effect of nursing interventions patie nt-
re late d outcome s : A type of outcome related to patient behaviors or actions pe rformance -re late d
outcome s : A type of outcome related to how nurses perform their job
Time is another way of classifying outcomes. Short-term outcomes are results
achieved in a relatively brief period of time that usually involve a change in
condition, such as absence of postoperative pain, or an increase in knowledge or
skills, such as a patient’s ability to draw up insulin. Another category of outcome
classified by time is intermediate outcomes. They exist when changes occur after
an innovation is introduced. Lifestyle modifications, such as weight loss and
smoking cessation after enrolling in a wellness program, can be examples of
intermediate outcomes. Long-term outcomes are primary changes in patients’
behaviors or status, such as compliance with statin therapy resulting in a lower
cholesterol level (Mauskop & Borden, 2011).
s hort-te rm outcome s : Results achieved in a brief period of time inte rme diate outcome s : Changes that
occur after an innovation is introduced long-te rm outcome s : Primary changes in patient behaviors or status
over time
Nursing administrators are responsible for reporting nursing-sensitive
outcomes at their institutions to demonstrate effectiveness of nursing care.
Outcomes of nursing care should be measurable. These measurements can assist in
determining responsibility in patient care (Micik et al., 2013). One nursing-
sensitive outcome considered a National Patient Safety Goal mandated by The Joint
Commission is to reduce the risk of healthcare-associated infections with central
line bloodstream infections (Joint Commission, 2014). The Joint Commission
requires healthcare organizations to have education and evidence-based
policies/protocols relative to central lines. Hospitals are also required to provide
their central line infection rate to key participants. Two desirable outcomes that
result from these practices are an improved communication among all involved
healthcare providers regarding central lines and an associated reduction in
hospital-acquired central line bloodstream infections.
nurs ing-s e ns itive outcome s : Results that demonstrate the effectiveness of nursing care
Outcome-based measurements are a means used to establish evidence-based
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practice (EBP) and to evaluate the care delivered. In healthcare organizations,
many activities are outcome driven. The rising costs of health care, increasingly
stringent accreditation standards, and public reporting are several reasons why
outcomes are closely scrutinized and are integral to ensuring the successful
implementation of an innovation. In health care, outcomes are typically quantitative,
not qualitative. Legislated in 2010, the Patient Protection and Affordable Care Act
has improvement in healthcare quality among its goals. Within this legislation is a
mandate regarding the development of a sharedsavings program promoting
accountability to a patient population (Patient Protection and Affordable Care Act,
2010). Termed Accountable Care Organizations (ACOs), the intent is to develop
partnerships between hospitals and physicians to provide efficient quality care. The
Centers for Medicare and Medicaid Services (CMS) reimburses ACOs based on
patient outcomes. There are currently 33 CMS quality outcome measures that ACOs
are held accountable to that affect reimbursement (CMS, 2013).
Evaluating outcomes is not static, but rather an ongoing process. Outcomes must
be well defined for the evaluation to be meaningful. The effectiveness of any
innovation is measured by the outcomes that result. These results are compared to
baseline data in order to draw conclusions about the effectiveness of the
innovation. The process continues as the innovation becomes standard practice.
CRITICAL THINKING EXERCISE 18-1
© Jules_Kitano/ShutterStock, Inc.
Consider your last clinical experience. Are you aware of any outcomes that are being monitored on the unit
or in the facility? If so, what are they and how would you classify them?
TEST YOUR KNOWLEDGE 18-1
Match the type of outcome with the indicator. (Select all that apply.)
1. System-related outcome a. Patient will not hemorrhage after delivery
2. Patient-related outcome b. Patient will maintain weight loss over 2 years
3. Care-related outcome c. Patient will be afebrile after surgery
4. Long-term outcome d. The rate of hospital-acquired infections
5. Short-term outcome e. Patient satisfaction will be 90% or greater
How did you do? 1. e; 2. a, b, c; 3. d; 4. b; 5. a, c
592
18.2 Choosing Outcomes
At the end of this section, you will be able to:
‹ Discuss factors that should be considered when selecting outcomes
Choosing outcomes that appropriately fit an innovation is vital. This allows for an
accurate evaluation of practice changes. During the selection process, outcomes
should be considered for their significance and scope. Considerations may include
disease-specific outcomes, response to interventions, quality of life, and fiscal
impact (Burns & Grove, 2011). Outcomes should be measured using specific
quantitative criteria, sometimes referred to as indicators. For example, if
postoperative pain control is of interest, then pain should be quantified through a
recognized indicator such as the numeric rating scale. If an outcome such as quality
of life is the focus, then using an established instrument, such as the SF-36, which is
a validated multipurpose health survey tool, is preferred (Contopoulos-Loannidis,
Karvouni, Kouri, & Ioannidis, 2009). Instruments that have been tested for
reliability and validity improve credibility of the evaluation process. Table 18-1
lists examples of outcomes and associated indicators.
indicators : Quantitative criteria used to measure outcomes
FYI
Outcome-based measurements are a means used to establish EBP and to evaluate the care delivered. The
effectiveness of any innovation is measured by the outcomes that result.
When determining outcomes to be measured, there are four major factors to
consider: patient populations, team membership, organizational priorities, and
mandated reporting. It is best when the selected outcomes address multiple
factors. Journals, books, and websites are available to assist. Table 18-2 lists
selected organizations with their associated websites that contain health outcome
information.
patie nt populations : A group of patients with similar characteristics te am me mbe rs hip: The composition of a
team with respect to expertise and leadership organizational prioritie s : Situations of high importance because
of volume of patients or costs mandate d re porting: Data that must be shared with supervising or governmental
agencies by a specified timeline
TABLE 18-1 Outcomes and Indicators
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Outcome Indicator
Dyspnea reduction Dyspnea rating scale
Decrease in postoperative pain Pain numeric rating scale
Absence of skin ulcers Pressure sore staging
Reduction in patient falls Falls risk assessment tool
Knowledge: blood pressure medication Blood pressure
TABLE 18-2 Selected Health Outcome Information Websites
Organization Website
AcademyHealth http://www.academyhealth.org
Agency for Healthcare
Research and Quality
http://www.ahrq.gov/clinic/outcomix.htm
Centers for Medicare and
Medicaid Services
http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/
sharedsavingsprogram/Quality_Measures_Standards.html
Harvard College Library
Health Data Resources
http://guides.library.harvard.edu/content.php?
pid=176649&sid=1487349
Health Care Excel http://www.hce.org/index.php/medicare/hospitals/
10-medicare/81-hospital-resources
Institute for Healthcare
Improvement
http://www.ihi.org
The Joint Commission http://www.jointcommission.org
National Cancer Institute http://outcomes.cancer.gov/
National Committee for
Quality Assurance
http://www.ncqa.org/
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http://www.academyhealth.org
http://www.ahrq.gov/clinic/outcomix.htm
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality_Measures_Standards.html
http://guides.library.harvard.edu/content.php?pid=176649&sid=1487349
http://www.hce.org/index.php/medicare/hospitals/10-medicare/81-hospital-resources
http://www.ihi.org
http://www.jointcommission.org
http://outcomes.cancer.gov/
http://www.ncqa.org/
Patient-Centered
Outcomes Research
Institute
http://www.pcori.org/research-we-support/pcor/
University of Iowa
College of Nursing
http://www.nursing.uiowa.edu/cncce/nursing-outcomes-
classification-overview
Patient Population
It is necessary to select outcomes that reflect the patient population served by the
healthcare facility. Use of a generic patient outcome is a good strategy to measure
outcomes when populations are diverse. For example, measuring symptom control
or increased knowledge may apply to many disease conditions (Burns & Grove,
2011). The Nursing Outcomes Classification (NOC), developed at the University of
Iowa College of Nursing, is a standardized list of generic patient outcome
classifications that can be used to evaluate the efficacy of nursing interventions
(Moorehead et al., 2013). Currently, 490 outcomes in the NOC system are
associated with the North American Nursing Diagnosis Association and the nursing
interventions classification. Each outcome is coded and consists of several
components: a definition, a list of numeric indicators from which the nurse selects
to evaluate the patient’s status, a target outcome rating, and a 5-point Likert-type
scale for measuring the status. “Knowledge: Healthy Diet” is an example of an
NOC patient outcome and is defined as the extent of understanding conveyed about
the recommended diet. The outcome may be applied to a diverse group of patients
in a wide spectrum of healthcare settings. Included in this outcome are indicators
that the nurse may choose for evaluation purposes, such as description of diet and
description of potential for food and medication interaction (Moorehead et al.,
2013). The Likert-type scale yields data ranging from none (1) to extensive (5) for
each indicator.
Team Membership
When selecting an outcome, consideration should be given to the composition of
members who form the team responsible for monitoring the outcome (Minnick,
2009). This includes the personnel members and capabilities that would be
involved in implementing the innovation and outcome measurements. Utilizing an
interdisciplinary approach including nursing, education, ancillary support services,
and quality improvement allows for incorporation of different viewpoints and
knowledge. It may also result in recommendation of new outcomes that were not
595
http://www.pcori.org/research-we-support/pcor/
http://www.nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview
previously considered. The creation of interdisciplinary relationships in the
formulation and approval of policies and protocols is required to achieve
American Nurses Credentialing Center (ANCC) Magnet Recognition (ANCC,
2013).
Advanced practice nurses (APNs) are integral members of interdisciplinary
teams. The APN has expert clinical knowledge about rapidly occurring changes in
the healthcare environment. APNs are familiar with institutional data and are able
to assist with comparison to national benchmarks. APNs can assist with selecting
realistic outcomes. An outcome that is realistic has a base definition that is true to
life (Minnick, 2009). For example, selecting an outcome such as “improved quality
of life in heart failure patients” is vague and has a multitude of meanings dependent
upon the individual and the severity of the associated disease condition. People
with slight limitation of physical activities might have a different perception of
quality of life than do individuals who are unable to carry out physical activities
without discomfort or symptoms at rest. Therefore, the vaguely written outcome
cannot be realistically evaluated. APNs can assist to narrow the focus, thus making
an outcome more measurable.
Staff nurses may be involved at several different levels during outcome
selection and subsequent measurements. Nurses are familiar with the continuous
quality improvement (CQI) process through participation with internal quality
improvement measures. Staff nurses are often members of the interdisciplinary team
involved in protocol development. They frequently provide insightful suggestions
about approaches that can be used in the clinical setting to obtain outcome
measurements. Staff nurses can identify patients who meet criteria for inclusion in
the protocol. They can also collect data such as reviewing charts for compliance in
documentation.
continuous quality improve me nt: A participatory process involving indicators that measure quality
Organizational Priorities
A second consideration is selecting outcomes that address organizational priorities
(Burston, Chaboyer, & Gillespie, 2013). Sometimes outcomes can be linked to the
mission of the healthcare organization. For example, a faith-based hospital may
focus attention on ensuring that all patients receive a spiritual assessment.
Organizations may also use outcomes to evaluate specific areas that need
improvement. CQI activities are an evaluation of existing practices that involve
delivery of services to the people (Newhouse & Pettit, 2006). The goal of CQI is to
improve service. CQI measures can be generic indicators or can be narrowed into
596
disease-specific outcomes.
FYI
Choosing outcomes that appropriately fit an innovation is vital. Outcomes should be considered for their
significance and scope and should be measured using specific quantitative criteria, called indicators. The
four major factors to consider are patient populations, organizational priorities, mandated reporting, and team
selection.
Mandated Reports
Multiple publicly reported nursing indicators can be used to measure outcomes of
EBP protocols. Hospitals and other healthcare agencies are required to gather data
about specific disease entities and to report their findings to public agencies.
Outcome data, available on State Boards of Health and the CMS websites, are
published to make comparisons among healthcare facilities. Organizations use these
data to gain a picture of how they compare to similar facilities. This is known as
benchmarking. Clinical practice guidelines or standards of care recommended by
professional organizations can also drive outcome selection.
be nchmarking: Comparison of organizational outcome data to other organizations or national databases
CRITICAL THINKING EXERCISE 18-2
© Jules_Kitano/ShutterStock, Inc.
Your nurse manager selects you to represent the unit on a team monitoring patient safety. What outcomes
would you suggest the team monitor?
There is often overlap among the various organizations that mandate reporting.
For example, consider health care related to the use of aspirin for patients with
cardiac disease. The American College of Cardiology (ACC) and American Heart
Association (AHA) have issued joint guidelines delineating the performance
measures for patients experiencing an ST-elevation or non-ST-elevation myocardial
infarction (MI) (AHA, 2008). These performance measures require that healthcare
providers instruct patients to continue on an aspirin regimen after discharge (AHA,
2008). The Joint Commission requires hospitals to report on 4 of the 14 core
measure sets that include MI (Joint Commission, 2013). One of the 33 CMS ACO
outcomes includes use of aspirin or other antithrombotics in patients with ischemic
597
vascular disease that includes those with a discharge diagnosis of MI (CMS, 2013).
Achieving an acceptable score on this outcome requires a multidisciplinary effort
by physicians, nurses, and pharmacists.
In addition to reporting mandatory CMS and Joint Commission data, many
healthcare facilities are members of not-for-profit organizations to benchmark
indicators. For example, hospitals can subscribe to databases maintained by the
ACC and the Society of Thoracic Surgeons. The ACC (2010) has seven databases
that include cardiac catheterization/percutaneous coronary intervention,
implantable cardioverter defibrillator, carotid revascularization, and acute
coronary syndrome among others. The Society of Thoracic Surgeons (2013)
provides statistics about adult and congenital heart surgery and for thoracic surgery
patients. Organizations such as these provide EBP guidelines for various disease
entities, allowing subscribers to review the latest information for protocol
development and implementation within the facility.
Another such organization is the Institute for Healthcare Improvement (IHI).
The IHI is a not-for-profit organization that targets healthcare improvements on a
global level (IHI, 2013). IHI promotes the concept known as “bundles” that are
defined as a group of disease-specific interventions that together have a larger
impact on prevention of a complication or disease (Resar, Griffin, Haraden, &
Nolan, 2012). As an example, a reduction in the incidence of ventilator-associated
pneumonia (VAP) was proposed through implementation of five interventions
grouped together known as the “ventilator bundle.” VAP is defined as a nosocomial
pneumonia that develops 48 hours or longer after a patient has an artificial airway
such as a tracheostomy or endotracheal tube inserted (Centers for Disease Control
and Prevention, 2014). VAP is the most serious complication of a three-tier
surveillance definition for ventilator-associated events developed by the Centers
for Disease Control and Prevention (Magill et al., 2013). The mortality rate for
patients diagnosed with VAP ranges from 25% to 40%, and the diagnosis adds an
estimated cost of up to $40,000 to a hospital admission (Greene & Sposato, 2009).
The ventilator bundle consists of these strategies: keeping the head of the bed
elevated at least 30 degrees at all times unless clinically contraindicated, daily
sedation vacations, assessments of weaning readiness, peptic ulcer prevention, and
deep vein thrombosis prophylaxis. To evaluate VAP protocol, based on the
ventilator bundle, an outcome could be to reduce the incidence of VAP by 75%.
In the Magnet Recognition Program (ANCC, 2013), healthcare organizations
are required to provide examples of nurse-sensitive quality indicators as part of the
application process or to maintain Magnet Recognition. There are 14 components,
known as Forces of Magnetism, that exhibit nursing excellence. Table 18-3 lists
these forces. For example, for a healthcare organization to meet Force 7, Quality
Improvement, evidence must show that nursing staff members participate in CQI
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activities and that CQI is perceived to improve care within the facility (ANCC,
2013). In addition, the organization must provide examples of a change in nursing
practice that occurred as a result of data originating from fiscal, satisfaction, or
clinical outcomes. The following scenario demonstrates how one outcome can be
used to address mandates from The Joint Commission, IHI, and the Magnet
Recognition Program.
Force s of Magne tis m: Qualities that exhibit nursing excellence
TABLE 18-3 Fourteen Forces of Magnetism
Force 1 Quality of Nursing Leadership
Force 2 Organizational Structure
Force 3 Management Style
Force 4 Personnel Policies and Programs
Force 5 Professional Models of Care
Force 6 Quality of Care
Force 7 Quality Improvement
Force 8 Consultation and Resources
Force 9 Autonomy
Force 10 Community and the Healthcare Organization
Force 11 Nurses as Teachers
Force 12 Image of Nursing
Force 13 Interdisciplinary Relationships
Force 14 Professional Development
Source: American Nurses Credentialing Center (2013). Available at
http://www.nursecredentialing.org/Magnet/ProgramOverview/HistoryoftheMagnetProgram/ForcesofMagnetism
Continuing with VAP as an example, suppose the infection prevention nurse in
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your facility reports that, despite implementing the ventilator bundle, the VAP rate
has not decreased in the last two quarters. A multidisciplinary committee consisting
of nursing, respiratory therapy, infection prevention, quality improvement, and staff
education examines the evidence. The committee determines that regularly
scheduled oral hygiene, including teeth brushing, while on the ventilator has been
linked with a reduction of plaque and oropharyngeal colonization.
The committee decides to change oral care products currently used in your
facility and recommends a change in protocol. The new ventilator oral care
protocol is developed and presented to the staff along with a review of related
infection control findings related to VAP. The staff are enthusiastic about the change
in oral care products and the new protocol. Over the next few months, follow-up
reporting will be provided to the nursing staff. The quarterly VAP rate will be
compared to the rate prior to the implementation of the new protocol to determine
the effectiveness of the practice change.
TEST YOUR KNOWLEDGE 18-2
1. Which of the following are considerations when selecting outcomes? (Select all that apply.) a.
organizational mission
b. publicly reported benchmarks
c. type of patients served at healthcare facility d. expertise of team members
2. Which of the following statements is false?
a. Journals, books, and websites are available to assist nurses in selecting outcomes.
b. NOC outcomes could be used in evaluation plans.
c. Benchmarking is a way to compare facility with national data.
d. Clinical guidelines are only suggestions and are not evidence based.
How did you do? 1. a, b, c, d; 2. d
18.3 Evaluating the Outcomes
At the end of this section, you will be able to:
‹ Discuss how data are used to evaluate outcomes
CRITICAL THINKING EXERCISE 18-3
© Jules_Kitano/ShutterStock, Inc.
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You are asked to join an interdisciplinary committee formed to examine glucose management in intensive
care unit (ICU) patients. You note that the current ICU practice is to administer a sliding scale subcutaneous
insulin dose based on the bedside glucose obtained at 6-hour time intervals. A retrospective chart review of
50 ICU patients receiving the sliding scale insulin dosage for 24 hours reveals that glycemic control in ICU
patients is not present. Consequently, the committee develops an evidence-based intravenous (IV) insulin
protocol based on hourly glucose measurements. Glycemic control in ICU patients is the outcome selected,
and you are going to use a blood sugar result of less than 180 mg/dL within 8 hours of instituting the IV
protocol as a measurement indicator. Staff nurses collect data on 50 patients over a 3-month time period and
compare those to the baseline data shown here:
Mean Blood Glucose
Level Before Change
Mean Blood Glucose
Level After Change
On admission 250 248
8 hours after admit 235 194
12 hours after admit 230 180
24 hours after admit 212 181
Although these reductions were statistically significant (p = .02), the outcome was not met. What other variables
could be accounting for the fact that the outcome was not met? Would you continue to use the IV insulin
protocol?
After an outcome has been selected and measured, data are compiled and evaluated
to draw conclusions. Demonstrating the effectiveness of an innovation is a
challenge, and conclusions must not extend beyond the scope of the data. Evaluation
is facilitated when appropriate outcomes and associated indicators are chosen. If
the outcome is not clearly defined, then the measurements and subsequent
evaluation will be flawed. For example, suppose that you are a member of an
interdisciplinary team that has developed a nursing protocol that reduces the
amount of time the patient remains on bed rest after a cardiac catheterization
procedure from 6 hours to 4 hours. The outcome selected is absence of bleeding
from the femoral arterial puncture site. No other indicators are measured. The
results obtained after implementing the protocol revealed that there was an increase
in bleeding at the femoral arterial site in the 4-hour bed rest patients compared to
the 6-hour bed rest patients. Before concluding that a shorter bed rest time leads to
an increase in femoral bleeding, a few additional questions need to be considered.
First, was absence of bleeding defined in a measurable way? Because bleeding
might be interpreted in several different ways, a precise definition of bleeding
should have been provided to ensure consistency in reporting. Second, when should
patients be assessed for absence of bleeding? Is the absence of bleeding to be
assessed when the patient first ambulates or at a later time? Input from the staff
prior to changing the nursing protocol could have clarified these questions,
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resulting in more reliable results.
FYI
After an outcome has been selected and measured, data are compiled and evaluated to draw conclusions.
Evaluation is facilitated when appropriate outcomes and associated indicators are chosen—conversely, if the
outcome is not clearly defined, then the measurements and subsequent evaluation will be flawed.
Another consideration in outcome evaluation is to obtain data relative to current
practice for comparison purposes. To document the need for a practice change and
to support a new protocol, baseline data might need to be collected to demonstrate
limitations of the current standard of care. Consideration must be given to all
extraneous variables that may be influencing the outcome, such as time, equipment,
safety, and costs. It could be helpful to involve a statistician to perform complex
analyses.
TEST YOUR KNOWLEDGE 18-3
True/False
1. Baseline data are unimportant in outcome measurement.
2. Precise description of indicators is essential.
3. For complex analyses, the assistance of a statistician may be needed.
4. Input from staff can help clarify outcome measurement.
How did you do? 1. F; 2. T; 3. T; 4. T
18.4 Keeping It Ethical
At the end of this section, you will be able to:
‹ List three dilemmas that can arise when nurses are involved in testing
protocols
As a staff nurse, it is likely that you will be involved at some point in evaluating
patient care outcomes. At the very least, your documentation will be a source of
data. There are other ways for you to become involved in evaluation. When nurses
are involved in testing protocols, ethical dilemmas can arise. Issues can concern
the selection of the sample, data collection, and reporting.
When considering the recruitment of patients to participate in protocol testing,
you must make certain that they fit the criteria and are not included simply to reach
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the sample size needed. You are obligated to collect data as directed by the
protocol. Reflect back to the example of reducing the number of hours on bed rest
following cardiac catheterization. Suppose you were to assess for bleeding in one
of your patients but were unable to do that assessment because of an emergency on
the unit. You might be tempted to guess or enter data collected at a later time. But
for the integrity of the process, it would be preferable to indicate that the data are
missing. Another issue that can arise is that sometimes nurses have a tendency to
change behaviors when they are aware that data are being collected. For example, a
hospital is implementing a smoking cessation program. Because the nursing staff
know that their unit is being compared to other units in the facility, they are very
careful to follow the program exactly as outlined. However, after data collection is
concluded and the protocol is found to be effective, it would not be in the best
interest of patients for nurses to return to using former protocols.
FYI
When nurses are involved in testing protocols, ethical dilemmas can arise. Issues can concern the selection
of the sample, data collection, and reporting.
TEST YOUR KNOWLEDGE 18-4
1. Which of the following behaviors is unethical? (Select all that apply.) a. ensuring patients enrolled
in a protocol meet criteria b. filling in all missing data at the conclusion of your shift c. refusing to
participate in outcome measurement d. continuing to follow protocols after data collection ends How
did you do? 1. b, c
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
It has been 6 months since the medication policy was implemented throughout your facility. Now it is time to
evaluate whether the desired outcomes have been met. You invite the chair of the Quality Improvement
Committee to attend the next meeting of the EBP Committee. You ask her to report on the monthly
incidence of medication errors for the past 6 months and the errors from the same months in the previous
year. This will allow committee members to compare error rates before and after implementation of the
policy. Review her report within this text’s digital resources. What conclusions can you draw about the
effectiveness of the policy?
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RAPID REVIEW
» An outcome is a consequence or a visible result. Nursing outcomes measure
states, behaviors, or perceptions of individuals, families, or communities.
» Outcomes research examines the effect of care on individuals and populations.
» Outcomes can be classified by focusing on who is to be measured: individuals,
groups, or organizations. They can also be grouped as care-related, patient-
related, and performance-related. They also may be classified according to
time: short term, intermediate, and long term.
» Outcomes that demonstrate the effectiveness of nursing care are known as
nursing-sensitive outcomes.
» Indicators specify how the outcome should be measured. Usually, quantitative
measures are used.
» Four major factors should be considered in regard to outcomes: patient
populations, team selection, organizational priorities, and mandated reporting.
» Outcomes may be derived from a variety of sources such as NOC, clinical
practice guidelines, standards of care, and Forces of Magnetism. CQI and
benchmarking are processes that involve outcome evaluation.
» Conclusions are best drawn when outcomes are clearly defined, data are
carefully collected, and findings are compared to baseline data. Considerations
should be given to possible extraneous variables.
» Ethical issues can concern selection of the sample, data collection, and reporting.
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ST-elevation myocardial infarction. Circulation, 118, 2596–2648.
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Burns, N., & Grove, S. (2011). Understanding nursing research: Building an evidence-based practice (5th
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b484-471c-9c35-6822a53ee4a2/File/VAP_09
Institute for Healthcare Improvement. (2013). About IHI. Retrieved from
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-managers/executive-summaries
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CHAPTER 19
Sharing the Insights with Others
Janet M. Brown and Nola A. Schmidt
CHAPTER OBJECTIVES
At the end of this chapter, you will be able to:
‹ Discuss the importance of dissemination of research findings to building
evidence-based practice ‹ Recognize the importance of dissemination in the
cycle of science
‹ Explain how poster presentations are useful to disseminate new knowledge
‹ List the essential components of a well-constructed poster
‹ Describe strategies that make oral presentations successful
‹ List elements that must be considered when preparing a manuscript
‹ Discuss the process for submitting a manuscript for publication
‹ Demonstrate professional behaviors when attending conferences
‹ List strategies to get the most out of conference attendance
‹ Discuss why nurses are obligated to participate in the process of dissemination
KEY TERMS
authorship
call for abstracts
dissemination
manuscript
networking
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papers
posters
presentations
19.1 Dissemination: What Is My Role?
At the end of this section, you will be able to:
‹ Discuss the importance of dissemination of research findings to building
evidence-based practice ‹ Recognize the importance of dissemination in the
cycle of science
Recently, national efforts have been aimed at realizing the goal of dissemination for
the purpose of improving patient outcomes and reducing costs (Coleman, Rosenbek,
& Roman, 2013). Evidence-based practice (EBP) cannot be successful if nurses
fail to read or hear about new knowledge. Evidence must be made available in
accessible and comprehensible ways so that innovations are adopted.
Dissemination is the communication of clinical, research, and theoretical findings
for the purpose of transitioning new knowledge to the point of care. EBP cannot
evolve unless communication channels in the societal system are used effectively to
bring about change. Dissemination of findings is most successful if multiple
methods are used over time. These methods need to be systematic, coordinated, and
efficient (Kerner, Rimer, & Emmons, 2005). In the profession of nursing, there are
three major ways that new knowledge is disseminated: posters, presentations, and
papers. These are often referred to as the 3 Ps of dissemination.
dis s e mination: Communication of clinical research and theoretical findings to transition new knowledge to the
point of care
Every healthcare discipline faces the challenge of conveying research findings
to clinicians in a timely manner. Dissemination is facilitated when activities are
carefully and appropriately considered. A dissemination plan, targeted at the needs
of the nurses who will use the information, is critical to ensuring efficient adoption
of an innovation. Researchers should craft messages in a way that is understandable
to clinicians (Gagnon, 2011).
FYI
Dissemination is the communication of clinical, research, and theoretical findings for the purpose of
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transitioning new knowledge to the point of care. EBP cannot evolve unless communication channels in the
societal system are used effectively to bring about change.
Cronenwett (1995) noted that most nurses are not familiar with research
methods and that because they are busy providing patient care, they have little time
to keep up with new knowledge. To help keep nurses well informed of new
knowledge, she suggested that attention be given to: (1) what information should be
disseminated, (2) whom the information should be targeted to, and (3) the most
effective way for nurses to access the information. One can readily see how her
three points are congruent with Rogers’s (2003) theory of diffusion of innovation.
For example, suppose an EBP guideline for the provision of mouth care to
terminally ill patients is revised. For this practice to be effectively disseminated,
details about what products to use, appropriate techniques, and patient outcomes
should be communicated over time to members of the social system. Therefore, in
this example, it would be most important to get this information to hospice, long-
term care, and home care nurses. Disseminating the revised guideline in
professional journals targeted to these types of nurses would be appropriate. Also,
involving their professional organizations, such as the Hospice and Palliative
Nurses Association, in the dissemination process, by posting the revised guideline
on their websites, would be beneficial. Coleman et al. (2013) have emphasized the
importance of organizational commitment to ensuring translation of research
findings to practice. To ensure dissemination, they recommended several key
strategies: » Engaging organizational leadership, both clinical and administrative
» Identifying ways to support adoption of new practices
» Collecting, analyzing, and presenting outcome data to demonstrate change
» Explaining how social and political factors influence adoption
Recall the four phases of the cycle of scientific development: theory
development, research, dissemination, and application to practice. All nurses must
be accountable for professional activities that facilitate dissemination. Just as
theorists and researchers have responsibilities to communicate findings, nurses
have responsibilities to actively seek and apply new knowledge. Without
dissemination, there is no reason to develop theories and conduct research because
nurses would not read and hear about the latest findings.
TEST YOUR KNOWLEDGE 19-1
1. New knowledge is effectively disseminated through: (Select all that apply.) a. papers
b. posters
c. proclamations
d. presentations
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2. Dissemination is important for which of the following reasons?
a. Publishers need to make a profit.
b. Most research grants require reporting.
c. New knowledge is transmitted to patient care.
d. Theorists and researchers need something to do.
3. Dissemination is an important phase in
a. the cycle of scientific development
b. the Krebs cycle
c. the cycle of life
d. the cycle of professional nursing
How did you do? 1. a, b, d; 2. c; 3. a
19.2 The 3 Ps of Dissemination
At the end of this section, you will be able to:
‹ Explain how poster presentations are useful to disseminate new knowledge
‹ List the essential components of a well-constructed poster
‹ Describe strategies that make oral presentations successful
‹ List elements that must be considered when preparing a manuscript
‹ Discuss the process for submitting a manuscript for publication
Posters
Posters are an important scholarly venue for disseminating evidence (Bindon &
Davenport, 2013). A major advantage of poster presentations over other methods is
that opportunities for networking exist. Poster sessions allow for interactions
among professionals. Presenters receive immediate feedback from a variety of
individuals who attend the poster session. Interactions allow for the exchange of
ideas about areas of common interest (Bingham & O’Neal, 2013).
pos te rs : A scholarly venue for disseminating evidence
ne tworking: Interacting with colleagues to exchange information and build relationships
The versatility of the poster as a medium for dissemination makes it effective in
a variety of situations. Posters are often used in the clinical arena to convey
innovations or describe EBP. At professional conferences, research studies are
often summarized in a poster display. Nurses may have opportunities to display
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posters at their places of employment. A poster could be displayed on a unit or in
an area where staff members are likely to gather, such as the cafeteria or hallway.
Because dissemination from individuals in clinical practice is essential to
building nursing knowledge, unit-based posters are an excellent opportunity for
nurses to disseminate the unique knowledge they possess. Evidence-based projects,
quality improvement, and interesting patient case studies lend themselves to poster
presentations. For example, a nurse notes that a better way is needed for securing
scalp needles used with infants. Over time, he devises a technique that is superior
to other taping methods. A poster presentation would be an ideal way to share his
innovation with other nurses.
Poster presentations are a mainstay of professional conferences. Most all major
conferences include at least one poster session, and such sessions are growing in
popularity to the point that it is not uncommon to have several sessions throughout a
conference. Because poster submissions are usually competitive, it is an honor to
have a poster selected for display.
FYI
The 3 Ps of dissemination are posters, presentations, and papers. Nurses have an obligation to facilitate
dissemination and can best participate in this by learning the proper processes and methods of the 3 Ps of
dissemination.
How to Be a Poster Presenter
There is a typical process for selecting individuals to present at poster
presentations. To be considered for presentation, individuals are required to submit
an abstract summarizing the project. Abstracts are peer reviewed using stringent
criteria. To increase the likelihood of having an abstract selected, attention to
poster guidelines when writing an abstract for submission is critical. For example,
it would be expected that the abstract contain the exact headings as specified in the
guidelines. Another way to increase the chances of having an abstract accepted for
presentation is to consider whether the poster would be appropriate for the
audience expected at the conference. Notices, also known as a call for abstracts,
publicize that submissions for abstracts are being sought. Calls for abstracts
typically include information about submission and provide clues about the
intended audience. Information in the call for abstracts can help one decide whether
a topic is congruent with the conference objectives. A title that communicates the
significance of content being disseminated is likely to capture the interest of the
reviewer (Garner, Morey, Yang, & Faruque, 2012). For example, if childhood
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obesity is the focus of a conference, it is unlikely that a poster about obesity in
older adults would be selected. Carefully matching one’s scholarly work to the
appropriate conference can reduce wasted effort and disappointment. See Table 19-
1 for tips on how to write a good abstract.
call for abs tracts : Notices publicizing the desire for posters or presentations at conferences
Individuals who submit abstracts for consideration at a conference are notified
about the outcome of the review. With the acceptance of an abstract come several
professional obligations. It is important to indicate acceptance of the invitation. If
circumstances have changed and it is necessary to decline, doing so in a timely
manner will allow the selection committee to fill the spot. When a commitment to
present is made, it is essential to fulfill that commitment. Conference attendees
become disgruntled if presenters are absent. If circumstances warrant an absence,
having a colleague present is an acceptable alternative. Registration and payment of
conference fees are required of most presenters, but sometimes a reduced fee is
available.
TABLE 19-1 Tips on How to Write a Good Abstract
‹ Target appropriate audience and conference aim
‹ Ensure abstract is submitted by the deadline
‹ Carefully follow directions for formatting
‹ Use appropriate font and font size (Arial and Times New Roman 10 and 12
allow maximum wordage in a limited space)
‹ Adhere to the word limit specified
‹ Provide biographical and contact information as requested
‹ Keep title clear and concise using fewer than 10 words
‹ Write in past tense
‹ Provide key information in a succinct manner
‹ Correct errors
‹ Ask a colleague to provide feedback
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‹ Check for spelling mistakes
‹ Take 5 minutes to conduct a final check
Source: Adapted from Coad & Devitt (2005), Duchin & Sherwood (1990), and Bingham & O’Neal
(2013).
FIGURE 19-1 Example of Self-designed Business Card
When at the conference, presenters have a responsibility to fulfill the
obligations of being a presenter. There are designated times for setting up and
taking down posters. Presenters should adhere to these scheduled times. Presenters
should make themselves available next to their posters during poster sessions to
answer questions and convey excitement about the topic (Ellerbee, 2006). It is not
unusual for attendees to seek out specific presenters who have similar interests.
This type of networking is invaluable. Poster sessions provide an excellent forum
for nurses from different settings to meet and exchange information (Ilic & Rowe,
2013). Having handouts containing information not included in the abstract
promotes dissemination. It is often helpful to offer business cards to individuals
who are interested in your work (Ellerbee, 2006). If your organization does not
provide business cards, it is easy to make your own (Figure 19-1).
Tips for Creating Effective Posters
Regardless of the environment or setting in which posters will be displayed, they
should be created to effectively communicate ideas. Attention to both content and
appearance is necessary. Creating posters requires more skill and effort than is
usually anticipated, but although it is time consuming, most nurses find the process
to be rewarding (Singh, 2013). Hand (2010) recommended starting work on a
poster about 2 months before presentation.
Many strategies can be used to enhance delivery of the message. No matter how
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attractive a poster appears, if attention is not given to content, dissemination of
information is diminished. It is helpful to ask, “What is it that viewers should know
after reading this poster?” Having this outcome in mind focuses the scope of the
content to be presented. The message should be straightforward, and the text should
be written in a common and meaningful language. Complete sentences are not
needed, and content can be mixed with charts and graphs. Staggering bullets in an
outline format is an effective way to present content and avoid redundancy. Jargon,
abbreviations, and symbols should be avoided unless it is certain that the intended
audience will recognize them. The goal is to be succinct yet to deliver a complete
message (Bindon & Davenport, 2013). It should take viewers no longer than 5
minutes to read a poster (Hand, 2010).
Specific content to be included on a poster is often outlined in the call for
abstracts. Every poster should have a title and indicate the authors and their
affiliations. It is acceptable to include a logo of the affiliation. Most posters also
include a purpose statement. Other content is determined by the type of information
that is being presented. See Table 19-2 for a listing of content typically included in
posters. Acknowledgment should be given to organizations that provided funding
for the project. It is also acceptable to acknowledge individuals who provided
assistance for the project.
TABLE 19-2 Content Typically Included in Posters
Source: Adapted from Small Business Encyclopedia (n.d.).
No matter how well content is articulated in a poster, if the display is not
visually appealing, individuals will not be enticed to read it. Consideration should
be given to the layout, font, color, and graphics.
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Arranging poster elements in a logical sequence allows the viewer to move
easily from one section to another through the material. Title, author, and affiliation
are usually centered at the top of the poster. Layout of the poster should be balanced
with content flowing from top to bottom of each section. Typically, displays are
divided into three sections. For example, 6 by 4 feet is a common poster size. The
center section should be 4 feet wide, leaving a 1-foot section on each side (see
Figure 19-2). Important information should be placed at eye level at the center of
the poster. Arrows can be used to direct viewers, and it is acceptable to vary the
orientation of the pages (Bindon & Davenport, 2013; Ellerbee, 2006). Layouts
should appear scholarly and professional. Presenters should avoid cluttering
layouts with items such as ribbons, lace, and flowers because these items distract
from the information being presented.
It is important to select fonts that make the content easy to read (Ellerbee,
2006). Titles and headings should be easily visible from 3 to 6 feet away. This
means that letters should have a font size of 96 points or more (2–3 inches high).
Other text should be visible from 2 to 4 feet away; therefore, font sizes of 24 to 36
points (about 1 inch high) are recommended. A simple way to test whether the font
is large enough is to place the poster on the ground. If it can be read while standing
over it, the font size is sufficiently large. Fonts should be limited to one or two
different styles. A roman-style font with a serif type is recommended. It is easier to
differentiate similar looking letters and numbers because serif type-faces have tails
or feet. When each line is limited to no more than 30 characters and no more than
six lines of text per heading, content can be kept organized and succinct.
Consistency in the use of capitalization and punctuation should be maintained.
Capital letters are usually used for titles and headings.
FIGURE 19-2 Logical Layout for EBP Posters
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Image © Photos.com
Although selecting colors for posters is fun, choices should make material more
attractive and emphasize important content (Bindon & Davenport, 2013).
Sometimes easels are provided for poster displays. If this is the case, background
colors are not easily altered and will usually be brown, dark blue, or dark gray
(Ellerbee, 2006). Selecting three to four colors that complement standard
backgrounds is advised (Bindon & Davenport, 2013). Dark-colored fonts on lighter
backgrounds are the easiest to read. Bright colors attract, and complementary
colors provide the greatest contrast (Singh, 2013). Red and green are often used to
highlight critical information; however, use of these two colors should be limited
because some individuals have difficulty distinguishing them (Ellerbee, 2006).
Sometimes presenters select colors because they represent a particular topic. For
example, a poster on breast cancer may include pink as an accent color because this
color is associated with breast cancer. Because color choices have both scientific
and artistic implications, presenters can make color choices based on evidence
from the literature.
Including graphics is an effective way to present content in a parsimonious
manner. Bar charts, line graphs, pie charts, diagrams, and scatter plots can
communicate a wealth of information in a limited space. They are also an effective
way to integrate color into the display. Clip art is another kind of graphic that can
add interest to posters. For example, if the topic is about infant care, then a border
showing babies would be appropriate. Overuse of clip art is discouraged. Clip art
of nurses’ caps and the medical caduceus are not suitable to include in scholarly
nursing presentations.
There are several alternatives available for printing and assembling posters.
The most common approach is to use a software package, such as Adobe Photoshop
or Microsoft PowerPoint (Singh, 2013). Using software also allows for
experimenting with spacing, colors, and layouts. Additionally, corrections can be
made easily and business logos can be incorporated. Some presenters have access
at work to large printers capable of printing on paper up to 4 feet wide. An
alternative is to employ a printing company that can quickly print a poster from
digital files. Entire posters are printed on a single sheet of paper that can be rolled
and placed in a tube for easy transport to conferences. There are some
disadvantages to this approach. Because large printers are slow and require skill to
use, printing ahead of time is advisable. If typographical errors are found and
revisions are needed, the entire poster, rather than a single slide, could require
reprinting. Another drawback to using large printers is that presenters have a
tendency to include too much information, making it difficult to read the posters.
A cost-effective alternative to printing on one large poster is to print
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http://Photos.com
PowerPoint slides out individually. These can then be placed directly on the
bulletin board. Printing the slides on higher grade paper conveys a sense of quality
and professionalism. Some presenters laminate their slides to protect them;
however, glare may result, making reading more difficult. Office supply companies
can print and laminate PowerPoint slides, but it is wise to obtain price quotes
before engaging in these services. Construction paper, color-coded art paper, or
commercial paper with preprinted designs are inexpensive ways to add color.
Picture mattes can be used to frame slides and offer another way to add color,
dimension, and distinct boundaries for content sections. Preformed letters or
stencils are sometimes used on picture mattes for the title, author, and affiliation.
Although mattes can be more costly than construction paper, they can be reused
over a number of years. Regardless of the method selected to print materials, it is
never acceptable to handwrite posters for a professional presentation.
Presenters often use Velcro, push pins, or staples to attach their posters to
display boards. Regardless of the method used, it is important to securely anchor
the poster. Coming prepared with extra supplies is helpful because it is not
uncommon to encounter problems when hanging posters. If traveling to conferences
by air, it is wise to carry aboard posters to ensure that materials arrive with you.
No matter how many times presenters proofread their posters, it is still possible
for an error to be overlooked. Completing posters with sufficient time for obtaining
feedback from colleagues is invaluable. For feedback to be constructive,
colleagues must be comfortable offering criticism and suggestions. It is
recommended that after assembling posters, presenters step back and critically
appraise their work. Referring back to submission criteria while appraising can
ensure that posters meet conference goals.
Oral Presentations
Like posters, oral presentations are an effective way to disseminate new
knowledge. There is a growing expectation for nurses who practice at the bedside
to engage in conference presentations (Happell, 2009). The submission process for
an oral presentation is very similar to poster abstract submissions. In fact, nurses
must often decide whether to deliver a poster or presentation when submitting an
abstract to a conference. Authors elect to present orally when the topic is too
complex to present in the space of a poster. Philosophical and theoretical work is
best suited for oral presentations. Whereas posters work especially well for
disseminating information about pilots and work in progress, completed work may
be disseminated best through oral presentations.
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pre s e ntations : Scholarly oral presentations to disseminate new knowledge
There are professional responsibilities, similar to poster presentations, that
must be fulfilled when accepting invitations to present papers. Many times
presenters must submit their PowerPoint slides and handouts in advance of the
conference. Objectives for presentations are often requested so that conference
planners can apply for continuing education credits. Late fees might be assessed to
presenters failing to meet deadlines. Should presenters find themselves unable to
attend a conference, sending colleagues to substitute is preferable to canceling.
Successful oral presentations are a result of careful preparation and attention to
detail. Principles related to layout, font, color, and graphics of poster preparation
are applicable to the preparation of slides that accompany oral presentations.
Presentations begin by showing a title slide (Wax, Cartin, & Pinette, 2011)
followed by a slide acknowledging funding sources and contributors. It is
recommended to have one slide for every 30–60 seconds (Wax et al., 2011). Time
should be allotted for questions at the end of the presentation. It is recommended
that the last slide of the presentation be blank. This serves as a cue to the audience
that the presentation is concluded. Novice presenters are advised to read papers
from typed scripts rather than ad-libbing. Without experience, ad-libbing frequently
results in a disorganized presentation that goes beyond the time limits (Happell,
2009). One can expect that one double-spaced typed page with 1-inch margins
using an average sized font equals 2 minutes of speaking time. The best way to
gauge the length of the presentation, however, is to rehearse the presentation aloud
while using the visual aids. Typically, people speak faster when presenting than
when rehearsing. Inserting visual cues into the script, such as “slow down” or
“breathe,” serves as a reminder for maintaining an appropriate speaking pace.
Another helpful strategy to aid delivery is to enlarge the font so that the script is
easier to read. Also, large font and familiarity with content can be invaluable if
there is inadequate lighting at the podium (Happell, 2009; Wax et al., 2011). It is
recommended to rehearse alone the first few times, followed by practicing in front
of a small group of people. It may be helpful to use a laser pointer to draw attention
to important points on your slides. For hints about how to effectively use a pointer,
see Table 19-3.
As with posters, steps can be taken to avoid disaster. For example, having the
presentation loaded on a flash drive can serve as a backup if needed. While
traveling, never put presentation materials into checked baggage; always keep it on
your person. Before presenting, it is wise to take advantage of the speaker ready
room to ensure that presentation slides are functioning. To reduce anxiety, it may be
helpful to observe other presentations that occur in the assigned presentation room.
This allows for observing lighting, podium, microphone, and the slide management
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system (Wax et al., 2011).
TABLE 19-3 Tips for Using Laser Pointers
Use device sparingly.
Do not wave the beam around the screen or room.
Brace the pointer against the podium to minimize tremor.
Once the point is made, turn the laser off.
Provide your own pointer.
Bring spare batteries.
Source: Data from Wax, J. R., Cartin, A., & Pinette, M. G. (2011). Preparing a research presentation:
A guide for investigators. American Journal of Obstetrics and Gynecology, 205(28e), 1–5.
It is smart to avoid the two most common mistakes made by presenters. First,
when presenters read directly from slides, the audience can become disengaged
from the presentation. Keeping PowerPoint slides bulleted with phrases
discourages this practice. Presenters should strive to present more depth and detail
about the topic through speaking rather than through visual aids. The second most
common mistake occurs when presenters disregard time constraints. It is expected
that presenters adhere to the time limitations for their presentations (Wax et al.,
2011). It is inconsiderate to continue speaking after room moderators have
indicated that the time has expired. Another way presenters disregard time
constraints is by failing to be present during the entire paper session. Four to six
papers are typically grouped together over 90 minutes. Presenters should arrive
well before paper sessions begin and confirm their presence with room moderators
and confirm that last-minute scheduling changes have not been made. Arriving early
also allows an opportunity to test audiovisual aids. Presenters are expected to make
themselves available at the conclusion of paper sessions because attendees might
wish to network. Having business cards to share with colleagues during this time is
advisable.
CRITICAL THINKING EXERCISE 19-1
© Jules_Kitano/ShutterStock, Inc.
You have been asked by a professor at your college to collaborate on a paper for publication in a peer-
reviewed nursing journal. The professor expects you to do all of the research and writing and stated that you
will be acknowledged for your assistance but that your name will not appear as an author on the article.
What ethical issues need to be discussed in this situation? What action, if any, would you take?
Papers
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Scholarly papers are published in a variety of venues and are essential for
disseminating knowledge. Nurses in clinical areas are in an excellent position to
write and submit papers about case studies, EBP, and quality management projects.
Researchers, theorists, and nurse educators also publish papers for the purpose of
extending nursing’s body of knowledge. Although there are many types of scholarly
papers, the process of submission tends to be the same and is similar to the process
of submitting a poster abstract. Several helpful strategies can assist novice writers
to get started. One strategy is to submit a paper based on an already presented
poster because the abstract and outline are already prepared. Gray (2005)
recommended writing daily for 15–30 minutes and provided some tips for
accomplishing this (see Table 19-4). Writing daily helps to form good habits about
writing and leads to feelings of accomplishment. Another strategy is to recruit a
colleague and have standing appointment times designated for writing.
Collaborating with others creates accountability and can also be fun. It can be
productive when novice writers collaborate with more seasoned writers.
pape rs : Manuscripts published in professional journals
When collaborating with others, it is important to determine authorship at the
onset. Authors are listed in terms of their contribution to the paper. Usually the idea
for the paper was generated by the first author. Other authors are listed in an order
reflecting the amount of their contributions to writing. Others who participated in
the project, but not in the writing, can receive an acknowledgment rather than
authorship (Valente, 2013). When writing teams have good collegial relationships,
authorship may be rotated among members of the team. Early in one’s career, it is
advisable to give consideration to the way one’s name will appear in publications.
For example, some authors include a middle name or initial. Consistently using the
same format builds publication recognition and facilitates citation chasing.
authors hip: List of authors in an order that reflects the amount of their contributions
TABLE 19-4 Tips for Writing for 15–30 Minutes a Day
Write in the same place every day.
Write at the same time every day, preferably in the morning.
Put your writing time in your calendar as an appointment.
Start your writing session in the same way each day.
Learn to stop internal and external interruptions.
Source: Adapted from Gray (2005).
After the decision to publish has been made, the next decision is to determine
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where the manuscript will be submitted (Valente, 2013). Manuscript is the term
used for a scholarly paper prior to its publication. Just as with poster abstracts,
consideration should be given to matching the topic and the intended audience with
the purpose of the publication. Reading articles in journals to get a feel for their
styles can help in determining whether the manuscript would be a good fit. Query
letters can be sent to journal editors to receive feedback about their interest in
publishing the manuscript. It is accepted practice to send query letters to several
editors simultaneously because the letter does not obligate the author to publish in a
particular journal. Journal editors use query letters to decide whether to accept
manuscripts for their journal. See Box 19-1 for an example of a query letter.
manus cript: A scholarly paper prior to its publication
BOX 19-1
Example of Query Letter
June 1, 2014
Ms. Brenda Tipton
Senior Editor, Nursing Division
Kraft and Frank Learning
53 Hall Street
Harrington, TN 32167
Dear Ms. Tipton
I am in the process of preparing a manuscript entitled “How to Publish for Nursing: Tips for Getting It
Done.” This manuscript is important because the national trend is for nurses in clinical practice to publish in
the specialty areas. The intended audience is staff nurses, and it will be about 15 pages in length. The
manuscript is not under review by any other journal. It is my original work and there is no conflict of interest
to declare. Would you be interested in reviewing this manuscript for Hot Issues in Nursing? Please contact
me regarding your interest as indicated below.
Cordially,
Suzanne Smith, BSN, RN
Critical Care Staff Nurse
123 Main Street
Springfield, IN 11111
555-454-6789
Suzy.Smith@yahoo.com
CRITICAL THINKING EXERCISE 19-2
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mailto:Suzy.Smith@yahoo.com
© Jules_Kitano/ShutterStock, Inc.
When you publish an article, how do you want your name to appear?
When a decision is made about where the manuscript will be submitted,
reviewing author guidelines is necessary. Adhering to the guidelines from the
beginning saves time by eliminating the need to adjust a manuscript later. Journals
specify the type of style to be used for preparation of manuscripts and expect that
authors adhere strictly (Garner et al., 2012). For example, some journals require
American Psychological Association style, while others may require Modern
Language Association style. Guidelines also specify the number of words in an
abstract, page limits, font, headings, and other criteria. It is essential that the
guidelines be followed meticulously because manuscripts can be rejected when
authors fail to follow the criteria. Familiarity with the language and tone used in the
journal will also facilitate writing. For example, it is preferred in some journals to
use the term nurses, whereas the term clinicians is used in other journals.
Resources, such as Garner and colleagues (2012) and Holmes, Hodgson,
Nishimura, and Simari (2009), provide suggestions for writing effective research
reports or other types of articles.
Obtaining feedback from colleagues during the writing process can be
invaluable. Gray (2005) suggested sharing early drafts with nonexperts and later
drafts with experts. Nonexperts can include family members, students, or
colleagues in other disciplines. Because these individuals are less likely to
understand the content, problems with organization and clarity are more likely to be
identified. Experts are individuals with advanced degrees in nursing. Such
individuals can provide reviews about the content as well as organization and
clarity. Another way to obtain feedback is to join a writing circle (Gray, 2005). In
writing circles, writers convene weekly, giving feedback on only a few manuscript
pages. The group is given 5 minutes to read the work of one member. Discussion
follows during which members indicate for each paragraph the topic sentence,
providing rationales for their choices. If the writing is clear and organized, there
will be agreement about the topic sentences. For nurses affiliated with universities,
writing centers offer another resource for obtaining feedback. Just as with
submission of poster abstracts, it is essential to review manuscripts many times
prior to actually submitting them for publication.
There are many similarities between the process of submitting an abstract for
presentation at a conference and submitting a manuscript for publication. It is
important to review the author guidelines for instructions about submission. Many
journals only accept submissions online. Editors of peer-reviewed journals send
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blinded copies of manuscripts to several experts for review. Peer reviewers may
be selected because of their expertise about the topic, research method, method of
analysis, or theory. For journals not using a peer review process, manuscripts are
reviewed by the editor. The length of time it takes for the review varies among
journals, but one can expect to wait 3–6 months for a response. It may be tempting
to submit manuscripts to multiple journals at the same time, but this is absolutely
unacceptable practice. A manuscript cannot be submitted to a second journal unless
it is rejected by the first or the author withdraws the manuscript submission.
Eventually, authors receive notice about the status of manuscripts. Editorial
decisions about manuscripts usually fall into one of four categories: accept, accept
with minor revisions, accept with major revisions, and not accepted for
publication. Feedback from peer reviewers is usually included with notification of
the decision. It is rare for a manuscript to be accepted for publication outright.
Most often, minor or major revisions are required. Using feedback from peer
reviewers to make revisions is often an effective way to ensure acceptance of the
manuscript on a second submission. Although it is natural for authors to be
disappointed when manuscripts are rejected, they should immediately investigate
other opportunities for submission. Feedback from peer reviewers can be used to
make revisions, and another journal can be targeted.
TEST YOUR KNOWLEDGE 19-2
1. When making a poster, which of the following should you do?
a. Use full sentences and avoid using bullets.
b. Use color to emphasize important points.
c. Use fancy or script font because viewers find them attractive.
d. Avoid including acknowledgment of funding sources because of space limitations.
2. Which of the following are strategies that are helpful when beginning to write a paper? (Select all
that apply.) a. Writing 15–30 minutes a week
b. Collaborating with others
c. Selecting a journal for submission
d. Adapting a poster presentation
3. When delivering oral presentations, presenters should do which of the following? (Select all that
apply.) a. Respect time constraints.
b. Remain to the end of the paper session to network.
c. Read from the PowerPoint slides.
d. Ad-lib to make the presentation more conversational.
How did you do? 1. b; 2. b, c, d; 3. a, b
19.3 Using Technology to Disseminate
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Knowledge
At the end of this section, you will be able to:
‹ Describe how technology can aid in dissemination
‹ Discuss three different technologies that can be used to disseminate new
knowledge
In this digital age, information and news can be communicated throughout the world
in a matter of minutes (sometimes even in seconds!). For the U.S. general public,
the Internet has become the main source of information about science and
technology (National Science Board, 2010). Americans rely equally on television
and Internet for the answers. Thus, it raises the question, Why does it take so long
to disseminate research findings into practice given the multitude of technologies
available for use? Reliance on traditional methods, such as presentations, posters,
and papers, by healthcare providers could be one barrier to dissemination. To
address this barrier, the use of more sophisticated communication technologies to
reach a larger audience is needed. For example, the Internet enables nurses to
extend the focus of EBP to include public policy and public health, and it provides
greater exploration, understanding, and management of EBP initiatives (Paxton,
2013). Although using technology for dissemination sounds easy, it requires much
more than simply placing a resource on an Internet site. Successful dissemination
requires special skills researchers and clinicians typically do not possess.
Therefore, collaborating with professionals who have a strong understanding of
advertising and the use of media and websites is essential.
Nurses must capitalize on current and emerging technologies and their uses.
Whereas websites have become commonplace, many forms of media can be used to
engage individuals. Participatory media involving blogs, wikis, video blogs, social
networking sites, microblogging sites, podcasts, and mashups offer various ways to
engage others (Haigh & Costa, 2012). For example, Craig and Wong (2013) found
that students, using wiki technology for an assignment, reported that the global
nature of this technology enhanced their ability to collaborate internationally.
Another example is the use of online videos. One well-known collection of videos
is posted on the TED (Technology, Entertainment, Design) website (Sugimoto &
Thelwall, 2013). Social media networks, such as Facebook and Twitter, provide
the potential to facilitate dissemination of evidence. For example, Harris (2013)
found that social media networks promoted effective dissemination of effective
public health practice among state health departments nationwide.
Electronic journals, as communication channels, are developing as new
information platforms; however, promotional activities are essential to effective
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use (Vasishta, 2013). Although library websites are the best way to promote
electronic journals, Vasishta found that most library websites fall short of providing
an effective platform for electronic journals. Because clinicians find it difficult to
access these resources, communication of new ideas is limited. Until the visibility
of electronic journals is increased, they will fail to reach their potential audiences.
TEST YOUR KNOWLEDGE 19-3
True/False
1. The Internet is fast becoming the first place Americans look for information about science and
technology.
2. Collaboration is needed for the successful use of technology to disseminate best practices.
3. Electronic journals are easily accessible from any library website.
How did you do? 1. T; 2. T; 3. F
19.4 Making the Most of Conferences
At the end of this section, you will be able to:
‹ Demonstrate professional behaviors when attending conferences
‹ List strategies to get the most out of conference attendance
Not only are conferences excellent venues for dissemination of new knowledge, but
they also provide opportunities for developing connections with colleagues who
have similar interests, meeting experts in the field, and exploring career
opportunities. Nurses are drawn to conferences with themes that are compatible
with their interests so they can participate in meaningful exchanges of ideas
(McIntyre, Millar, & Thomas, 2007). Sometimes, employers send nurses to
conferences that fit with organizational goals (Brown & Schmidt, 2009). For
example, a hospital administrator may send several nurses to a conference on how
to apply for Magnet Recognition. Nurses may also be sent to conferences if
education is needed to comply with governmental or accrediting regulations
(Murray, 2008). If nurses are active in professional organizations, they may attend
conferences as delegates. Conferences that assist nurses to meet professional goals
merit consideration (Murray, 2008). For example, it may be wise for nurses to
select conferences that offer continuing education units if that is required for license
renewal. Conference participants should take full advantage of networking
opportunities to make the most of their experiences (Brown & Schmidt, 2009).
Maintaining a professional demeanor at all times is advantageous because you
never know who you might meet or what opportunities could arise (Brown &
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Schmidt, 2009). For example, it is possible to be offered the opportunity to
interview for a position with a leading expert in your specialty. Invitations to
collaborate on papers and research studies are not uncommon. For individuals
considering graduate study, networking with students and faculty from programs
under consideration can be helpful. Questions about various programs can be
answered when conversing with these individuals. It pays to be professional at all
times. For example, individuals may find themselves sitting next to the dean of the
graduate program under consideration. It would be quite uncomfortable to have an
admission interview with this dean if the image portrayed is unfavorable.
FYI
Not only are conferences excellent venues for dissemination of new knowledge, but they also provide
opportunities for developing connections with colleagues who have similar interests, meeting experts in the
field, and exploring career opportunities. Professional behaviors always make favorable impressions and
should be practiced when attending conferences.
Professional behaviors always make favorable impressions and should be
practiced when attending conferences. Participants should dress professionally.
Although attending a conference is a day away from work, it should not be
considered a day off. Wearing sweatpants or jeans to be comfortable is not
acceptable. It is customary for individuals to wear business suits or skirts or
trousers that are paired with conservative blouses, sweaters, or jackets. Layering
clothing is always wise because presentation rooms can vary in temperature.
Arriving on time, introducing yourself to others, and offering a handshake make
excellent first impressions. Inquiring where someone is from or why they chose to
attend this conference is a good way to begin a conversation. If individuals find
areas of common interest, having a business card to share facilitates networking.
Allowing cell phones to ring during presentations shows disrespect for both
presenters and members of the audience. Phones should be either turned off or
silenced. It is also rude to converse with other attendees during presentations.
It is best to take full advantage of conferences because they can be costly to
attend (Brown & Schmidt, 2009). Reviewing conference programs in their entirety
allows participants to select sessions that pertain to their interests. Abstracts
contain valuable information that helps identify presentations and posters of
interest. Highlighting or writing out a schedule of preferred sessions ensures that
time is maximized. It can be disappointing to overlook a scheduled session of
interest. When planning a schedule, keep in mind that it is acceptable to change
rooms between presentations during the same session time. If attending conferences
with colleagues, it can be tempting to attend all sessions together. However, to
626
maximize exposure to new ideas, it is wise to split up and share information later.
In addition to the sessions, conferences offer many other opportunities for
networking. Attending interdisciplinary conferences may offer an opportunity to
foster a collaborative approach to EBP (Newhouse & Spring, 2010). Some of the
most important exchanges of information occur during conversations in hallways or
at receptions. Viewing poster sessions, visiting vendor exhibits, and attending
meals and breaks provide opportunities to meet new people or renew friendships.
If there is a respected authority you would like to meet, introduce yourself. Most
experts are eager to discuss their work. Networking, like dissemination, is vital to
building the discipline of nursing.
TEST YOUR KNOWLEDGE 19-4
1. When attending a conference, which of the following behaviors are acceptable? (Select all that
apply.) a. Wear business attire.
b. Keep cell phones on silent or vibrate.
c. Feel free to come in and out of sessions at will.
d. Share business cards with other attendees.
2. Which of the following strategies help make the most of conferences? (Select all that apply.) a.
Attending receptions
b. Attending all sessions with your friends
c. Planning a schedule in advance
d. Talking with experts
How did you do? 1. a, b, d; 2. a, c, d
19.5 Keeping It Ethical
At the end of this section, you will be able to:
‹ Identify ethical concerns when presenting or publishing
‹ Discuss why nurses are obligated to participate in the process of dissemination
Ethical principles related to the dissemination of EBP are as critical as ethical
principles are in research conduct (Garcia, 2004). One critical ethical practice is
to acknowledge authorship on all scholarly works. There are numerous guidelines
to distinguish individuals who are authors from those who contributed to the study
or project (Welker & McCue, 2006). To be an author, one should have made
significant contributions to the ideas in the paper, participated in data analysis,
contributed to the process of writing, and given approval on the final version of the
paper (Ohler, 2003).
Another ethical consideration involving the 3 Ps relates to conflict of interest.
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Conflict of interest is a concept that refers to a situation when an individual may
personally benefit from his or her actions. For example, a nurse may be paid by a
company to promote a new device or drug during a presentation. It is not uncommon
for presenters and authors to have to sign a form disclosing a conflict of interest,
and sometimes presenters may have to add a slide to their presentation stating
whether or not a conflict of interest exists (Ohler, 2003).
Presenters and authors also have to disclose off-label use of drugs if given
during a study. When a drug is used in a different way than described in the FDA-
approved drug label, it is called “off-label.” Off-label could apply to using a drug
for unapproved age groups, doses, forms, or purposes. Like conflict of interest,
forms or slides that disclose the off-label use of drugs may be expected.
The overall purpose of research dissemination is to begin the process of getting
new knowledge used for the good of society (Cronenwett, 1995, p. 430). There are
increased demands for healthcare providers and systems to be efficient and
effective in providing patient care. Nurses can no longer plead ignorance of new
knowledge. They must be accountable for creating best practice by rapidly moving
new information to the point of care (Cronenwett, 1995).
Having accountability means that nurses must use their resources wisely.
Opportunities for dissemination are limited; space in journals and presentation
times at conferences must be allocated fairly. Authors should never simply tweak a
manuscript that has already been published to resubmit to another journal for
publication as original work. Furthermore, it is a waste of time and money for
nurses to attend conferences but not participate fully. Nurses are obligated to fulfill
expectations placed on them by employers who sponsor attendance at conferences.
FYI
Nurses have a responsibility to actively participate in the process of dissemination. Reading articles,
attending conferences, presenting posters and papers, and networking with other professionals are expected
activities.
Nurses have a responsibility to actively participate in the process of
dissemination. Reading articles, attending conferences, presenting posters and
papers, and networking with other professionals are expected activities. Nurses can
organize scholarly events in their facilities such as research days where posters
about unit-based projects are presented. The power of sharing information about
unit-based activities should not be underestimated. The discipline of nursing is
lacking dissemination from individuals in clinical practice. Dissemination of
knowledge within nursing also raises the visibility of nursing to the public. To
support these types of activities, nurses must advocate for budget dollars and
release time from employers.
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At the conclusion of the journey through this text, it is hoped that an
appreciation for nursing research and its importance to EBP has ensued. With the
knowledge and skills acquired through the content and application exercises, you
are equipped to be an innovator by engaging in the process of moving evidence
over time through the communication channels of social systems to improve patient
care.
TEST YOUR KNOWLEDGE 19-5
True/False
1. Because information is growing at a rapid pace, it is acceptable for nurses to plead ignorance
about new knowledge.
2. All nurses are obligated to participate in the process of dissemination.
How did you do? 1. F; 2. T
APPLY WHAT YOU HAVE LEARNED
© Lisovskaya Natalia/ShutterStock, Inc.
Because the process that the EBP Committee used was effective in creating a policy that reduced
medication errors, several members submitted an abstract to a professional conference. You have just
received notification that the abstract was accepted as a poster presentation. Within this text’s digital
resources, you will find the acceptance letter and guidelines for presentation of posters at this conference.
While being certain to follow these guidelines, use the ideas in this chapter to create a poster that effectively
disseminates your information.
RAPID REVIEW
» Dissemination is the communication of clinical, research, and theoretical findings
for the purpose of transitioning new knowledge to the point of care. It is an
important step of the cycle of scientific development.
» The 3 Ps of dissemination are posters, papers, and presentations.
» Posters are an excellent medium for disseminating information in a succinct and
visually interesting manner. A mainstay of professional conferences, they can
also be used at places of employment to communicate unit-based projects.
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» Oral presentations are an effective way to disseminate new knowledge when the
topic is too complex to present in the space of a poster. Presenters have
professional responsibilities, such as adhering to the time allotted and making
themselves available for networking.
» A manuscript is a scholarly paper prior to its publication. Like posters, many
papers undergo a rigorous peer review process before being accepted for
publication.
» Technology offers an efficient and expedient way to disseminate information;
however, collaboration may be needed to effectively communicate through the
Internet.
» Maintaining a professional demeanor at conferences is advantageous. There are
many strategies for making the most of conference attendance such as writing out
a schedule and talking with experts.
» Nurses have a responsibility to actively participate in dissemination by reading
articles, attending conferences, presenting posters and papers, and networking
with other professionals.
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GLOSSARY
abstract The first section of a research article that provides an overview of the
study
accessible population The group of elements to which the researcher has
reasonable access
active rejection Purposefully deciding not to adopt an innovation
adoption Applying an innovation to practice
aggregate data Data collected from individuals that are grouped to represent a
population
AGREE II Appraisal of Guidelines Research and Evaluation; internationally
developed instrument to evaluate clinical practice guidelines alpha level
Probability of making a type I error; typically designated as .05 or .01 at the end of
the tail in a distribution alternate form A test for instrument reliability in which
two different versions of new instruments are given. Scores are correlated, and
strong positive correlations indicate good reliability; also known as parallel form
amodal A data set that does not have a mode
analysis of variance An inferential statistical test used when the level of
measurement is interval or ratio and more than two groups are being compared
analytic epidemiology Investigation of the determinants of disease
anonymity Keeping the names of subjects separate from data so that no one, not
even the researcher, knows subjects’ identities; concealing the identity of subjects,
even from the researcher applied research Research to discover knowledge that
will solve a clinical problem
assent Permission given by children to participate in research
associative relationship A type of relationship such that when one variable
changes the other variable changes attrition rate Dropout rate; loss of subjects
before the study is completed; threat of mortality
auditability When another researcher can clearly follow decisions made by the
investigator, arriving at the same or comparable conclusions audit trail The
documentation of the research process and researcher’s decision making in
qualitative studies authorship List of authors in an order that reflects the amount of
their contributions autonomous Having the ability to make decisions
awareness Understanding about oneself and the world
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axial coding The analysis of categories and labels after completion of open coding
barriers Factors that limit or prevent change
basic research Research to gain knowledge for the sake of gaining knowledge;
bench research
behavioral inventory for professionalism A measure of education and training,
skill, ethics, professional organization, and service Belmont Report A report
outlining three major principles (respect for persons, beneficence, and justice)
foundational for the conduct of ethical research with human subjects
benchmarking Comparison of organizational outcome data to other organizations
or national databases
beneficence The principle of doing good
between-groups design Study design where two groups of subjects can be
compared
bias When extraneous variables influence the relationship between the independent
and dependent variables bimodal A data set with two modes
bivariate analysis The use of statistics to describe the relationship between two
variables
Boolean operators Words, such as and, or, or not, that specify the relationship
between search terms bracketing A strategy used by qualitative researchers to set
aside personal interpretations to avoid bias call for abstracts Notices publicizing
the desire for posters or presentations at conferences
call number Unique identification number assigned to items in a library by subject
and author name
career development Experience and education that contribute to one’s professional
growth
care-related outcomes A category of outcomes that measures the effect of nursing
interventions
case-control studies A type of retrospective study in which researchers begin with
a group of people who already have the disease; studies that compare two groups:
those who have a specific condition and those who do not have the condition case
reports or series Epidemiologic reports used to describe rare diseases or
outcomes
case studies A description of a single or novel event; a unique methodology used in
qualitative research that may also be considered a design or strategy for data
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collection categorical data The lowest level of measurement whereby data are
categorized simply into groups; nominal data causal relationship When one
variable determines the presence or change in another variable
causality The relationship between a cause and its effect
change A process that creates an alteration in a person or environment
change agent Individual who leads or champions change
change phases model An eight-phase process to describe organizational change
Chi square A common statistic used to analyze nominal and ordinal data to find
differences between groups CINAHL Cumulative Index to Nursing and Allied
Health Literature; database for nursing and health-related literature citation
chasing Using a reference list to identify sources of evidence
clinical practice guidelines Recommendations based on evidence that serve as
useful tools to direct clinical practice cluster sampling Random sampling method
of selecting elements from larger to smaller subsets of an accessible population;
multistaging sampling coding Assignment of labels to each line of transcript in
qualitative analysis
coefficient of variation A percentage used to compare standard deviations when
the units of measure are different or when the means of the distributions being
compared are far apart coercion The threat of harm or the offer of an excessive
reward with the intent to force an individual to participate in a research study
cohort comparison Nonexperimental cross-sectional design in which more than
one group is studied at the same time so that conclusions about a variable over time
can be drawn without spending as much time cohort studies Quasi-experimental
studies using two or more groups; epidemiologic designs in which subjects are
selected based on their exposure to a determinant communication Process of
creating and sharing information with one another to reach mutual understanding
community-based participatory action research Active involvement of
community members throughout the research process comparative designs
Descriptive design type that compares two or more groups or variables
complex hypothesis A hypothesis describing the relationships among three or more
variables
Computer Assisted Qualitative Data Analysis Software (CAQDAS) Computer
software that assists in the management, coding, grouping, and analysis of
qualitative data concept analyses Scholarly papers that explore the attributes and
characteristics of a concept
concepts Words or phrases that convey a unique idea that is relevant to a theory
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conceptual definitions Definitions of concepts contained in a theory that sound
like dictionary definitions concurrent validity A test for criterion-related validity
when a new instrument is administered at the same time as an instrument known to
be valid; scores of the two instruments are compared, and strong positive
correlations indicate good validity conduct and utilization of research in
nursing (CURN) Early study conducted about how nurses transition research
findings into practice confessionist tales Qualitative researchers’ personalized
accounts that provide insight about data collection and scientific rigor confidence
intervals Ranges established around means that estimate the probability of being
correct
confidentiality The protection of subjects’ identities from everyone except the
researcher
confirmability One of four criteria for a trustworthy qualitative study that relates to
the rigorous attempts to be objective and the maintenance of audit trails to
document the research process; findings can be substantiated by participants
confounding variables Factors that interfere with the relationship between the
independent and dependent variables; extraneous variable; Z variable construct A
word or phrase used to communicate a specific key idea to others construct
validity A threat to external validity when the instrument does not accurately
measure the theoretical concepts content validity A kind of validity to ensure that
the instrument measures the concept; a test in which experts on the topic are asked
to judge each item on an instrument by assigning a rating to determine its fit with the
concept being measured continuous data Interval-or ratio-level data that use a
continuum of numeric values with equal intervals continuous quality
improvement A participatory process involving indicators that measure quality
control Ability to manipulate, regulate, or statistically adjust for factors that can
affect the dependent variable controlled vocabularies Standardized hierarchical
lists that represent major subjects within a database convenience sampling
Nonprobability sampling method in which elements are selected because they are
easy to access convergent testing A test for construct validity in which new
instruments are administered at the same time as an instrument known to be valid;
scores of the two instruments are compared, and strong, positive correlations
indicate good validity correlated t test A variation of the t test used when there is
only one group or when the groups are related; paired t test correlation coefficient
An estimate, ranging from 0.00 to +1.00, that indicates the reliability of an
instrument; a statistic used to describe the relationship between two variables
correlational designs Nonexperimental designs used to study relationships among
two or more variables cost-benefit ratio Comparison of benefits to potential costs
that might result from change
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count data The raw number of health phenomena under investigation in
epidemiology
covary When change in one variable is associated with change in another variable
credibility One of four criteria for establishing a trustworthy qualitative study;
refers to the truth or believability of findings criterion-related validity Degree to
which the observed score and the true score are related
critical thinking Skill set that involves critical appraisal of information
Cronbach’s alpha A test for instrument reliability used with interval or ratio items;
all items are simultaneously compared using a computer crossover designs
Experimental designs that use two or more treatments; subjects receive treatments
in a random order cross-sectional Nonexperimental design used to gather data
from a group of subjects at only one point in time; study design to measure exposure
and disease as each exists in a population or representative sample at one specific
point of time cycle of scientific development A model of the scientific process
data reduction The simplification of large amounts of data obtained from
qualitative interviews or other sources data saturation In qualitative research, the
time when no new information is being obtained and repetition of information is
consistently heard Declaration of Helsinki An international standard providing
physician guidelines for conducting biomedical research deductive reasoning
Thinking that moves from the general to the particular
degrees of freedom A statistical concept used to refer to the number of sample
values that are free to vary; n – 1
dependability One of four criteria for a trustworthy qualitative study that relates to
consistency in the findings over time; auditability; findings are reflective of data
dependent variable Outcome or variable that is influenced by the independent
variable; Y variable descriptive correlational designs Correlational design type
used to explain the relationship among the variables or groups using a
nondirectional hypothesis descriptive designs Designs that provide a picture of a
situation as it is naturally happening without manipulation of any of the variables
descriptive epidemiology Examination of the distribution of disease in a population
in terms of person, place, and time descriptive research A category of research that
is concerned with providing accurate descriptions of phenomena descriptive
statistics Collection and presentation of data that explain characteristics of
variables found in a sample descriptive studies Nonexperimental studies used to
provide information about a phenomenon
determinants Factors that are capable of bringing a change in health
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developing oneself Engaging in activities that promote long-term professional
growth and development
dichotomous Nominal measurement when only two possible fixed responses exist
such as yes or no
direct observation Observing phenomena using the five senses; capturing
information by watching participants direction The way two variables covary
directional hypothesis Statement describing the direction of a relationship among
two or more variables disciplined clinical inquiry model A model developed to
empower nurses, at the unit level, to transition evidence to practice discussion
section Portion of a research article where interpretation of the results and how the
findings extend the body of knowledge are discussed dissemination
Communication of clinical research and theoretical findings to transition new
knowledge to the point of care distribution The pattern of disease occurrence in
and among populations or subgroups
divergent testing A test for construct validity in which new instruments are
administered at the same time as an instrument measuring the opposite of the
concept; scores of the two instruments are compared, and strong negative
correlations indicate good validity double-blind experimental designs Studies in
which subjects and researchers do not know whether subjects are receiving
experimental interventions or standard of care early adopters Individuals who are
the first to embrace an innovation
ecologic fallacy When false assumptions are made about individuals based on
aggregated data and associations from populations ecologic studies Correlational
studies that are population-based rather than individual-based effect size An
estimate of how large a difference will be observed between the groups
effects of selection Threats to external validity when the sample does not represent
the population
electronic indexes Electronic listings of electronic or print resources
elements Basic unit of the population such as individuals, events, experiences, or
behaviors
emic The insider’s or participant’s perspective
empirical evidence Evidence that is verifiable by experience through the five
senses or experiment
empirical indicators Measures of the variables being studied
empirical testing Collection of objectively measurable data that are gathered
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through the five senses to confirm or refute a hypothesis; hypothesis testing
endemic The expected occurrence of a particular disease within a community or
population
epidemic A widespread occurrence of a disease in a community or population that
is in excess of what is expected epidemiology The study of distribution and
determinants of disease in human populations
equivalence An attribute of reliability in which there is agreement between
alternate forms of an instrument or alternate raters ethnography A type of
qualitative research that describes a culture
ethnonursing Systematic study and classification of nursing care beliefs, values,
and practices in a particular culture ethnoscience A method used in anthropology
to discover new knowledge
etic The outsider’s perspective; the perspective of the researcher
etiology The cause of disease
evidence-based practice (EBP) Practice based on the best available evidence,
patient preferences, and clinical judgment evidence hierarchies Predetermined
scales that guide decisions for ranking evidence; levels of evidence exclusion
criteria Characteristics of elements that will not be included in the sample
exempt Certain studies may be low enough risk not to require consent from
individuals
expedited review A type of review by an institutional review board that can occur
quickly; an IRB may conduct an expedited review if there is minimal risk to human
subjects experimental designs Designs involving random assignment to groups and
manipulation of the independent variable explanatory research Research
concerned with identifying relationships among phenomena
exploding Technique for searching subject headings that identifies all records
indexed to that term
exploratory designs Nonexperimental design type used when little is known about
a phenomenon
ex post facto Research design in which researchers look back in time to determine
possible causative factors; retrospective research design exposure The contact
with a disease or disease-producing agent
external validity The degree to which the results of the study can be generalized to
other subjects, settings, and times extraneous variables Factors that interfere with
the relationship between the independent and dependent variables; confounding
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variable; Z variable face validity A test for content validity when colleagues or
subjects examine an instrument and are asked whether it appears to measure the
concept factor analysis A test for construct validity that is a statistical approach to
identify items that group together factorial designs Experimental designs allowing
researchers to manipulate more than one intervention
false negative When a screening gives a negative result despite the presence of the
disease
false positive When a screening gives a positive result even though the disease is
not present
fieldwork The time researchers spend interacting with participants through
interviews, observations, and detailed records flexibility to change Being open
and positive about change
focus groups A strategy to obtain data from a small group of people using
interview questions
follow-up A longitudinal design used to follow subjects, selected for a specific
characteristic or condition, into the future Forces of Magnetism Qualities that
exhibit nursing excellence
full review A type of review by an institutional review board that requires all
members of the board to participate; an IRB conducts a full review if there is
potential risk to human subjects gatekeeper Person who facilitates or hinders the
entry of the researcher into a particular group or setting generalize Applying
findings from a sample to a wider population
GRADE Grades of recommendations, assessment, development, and evaluation; an
international, universal system for evaluating evidence grey literature Unpublished
reports, conference papers, and grant proposals
grounded theory A type of qualitative research that examines the process of a
phenomenon and culminates in the generation of a theory Hawthorne effect
Subjects’ behaviors may be affected by personal values or desires to please the
experimenter; reactivity health services research Research involving phenomena,
such as cost, political factors, and culture, related to the delivery of health care
heterogeneous The degree to which elements are diverse or not alike
historical A type of qualitative research used to examine events or people to
explain and understand the past to guide the present and future history A threat to
internal validity when the dependent variable is influenced by an event that
occurred during the study homogeneity The degree to which elements are similar
or homogenous
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homogenous Elements that share many common characteristics
human rights Freedoms to which all humans are entitled
hypotheses Formal statements regarding the expected or predicted relationship
among two or more variables hypothesis testing Collection of objectively
measurable data that are gathered through the five senses to confirm or refute a
hypothesis; empirical testing; a test for construct validity impressionist tales
Qualitative researchers’ storytelling and personal descriptions about the experience
of conducting the study incidence The number of new cases of a disease in a
population during a specified period of time
inclusion criteria Characteristics that each element must possess to be included in
the sample
independent t test A variation of the t test used when data values vary
independently from one another independent variable Variable that influences the
dependent variable or outcome; intervention or treatment that is manipulated by the
researcher; X variable indexes A listing of electronic or print resources
indicators Quantitative criteria used to measure outcomes
individual nurse level Practice changes that can be implemented by an individual
nurse
inductive reasoning Thinking that moves from the particular to the general
inferential statistics Analysis of data as the basis for prediction related to the
phenomenon of interest informants Individuals in a qualitative study; participants
information overload State of an individual in which excessive communication
cannot be processed or used informed consent An ethical practice requiring
researchers to obtain voluntary participation by subjects after subjects have been
informed of possible risks and benefits innovation Something new or novel
innovator One who is willing to try new things
institutional review boards Committees that review research proposals to
determine whether research is ethical instrumentation A threat to internal validity
when there are inconsistencies in data collection
integrative review A scholarly paper that synthesizes published studies to answer
questions about phenomena of interest interaction of treatment and history A
threat to external validity when historical events affect the intervention interaction
of treatment and setting A threat to external validity when an intervention
conducted in one setting cannot be generalized to a different setting interaction of
treatment with selection of subjects A threat to external validity where the
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independent variable might not affect individuals the same way interlibrary loan A
service whereby libraries provide items in their collections to each other upon
request; lending of items through a network of libraries intermediate outcomes
Changes that occur after an innovation is introduced
internal consistency An attribute of reliability when all items on an instrument
measure the same concept internal validity The degree to which one can conclude
that the independent variable produced changes in the dependent variable
international level Changes that result from collaboration among nurses from
different countries
interprofessional collaboration Engaging with other professionals to provide
evidence-based care interrater reliability A test for instrument reliability when
two observers measure the same event. Scores are correlated, and strong positive
correlations indicate good reliability interval A continuum of numeric values with
equal intervals that lacks an absolute zero
intervention study In epidemiology, a study that has a treatment that can be
manipulated by the researcher interviews A method for collecting data in person or
over the telephone
introduction Part of a research article that states the problem and purpose
Iowa model for EBP to promote quality care A systematic method explaining
how organizations change practice item to total correlation A test for instrument
reliability in which each item is correlated to the total score; reliable items have
strong correlations with the total score Jewish Chronic Disease Hospital study
Unethical study involving injection of cancer cells into subjects without their
consent journal A scholarly or professional resource
journal club A strategy for disseminating research among nurses by discussing
articles in a small group justice The principle of equity or fairness in the
distribution of burdens and benefits
key informants Individuals who have intimate knowledge of a subject and are
willing to share it with the researcher keyword A word used to search electronic
databases; a significant word from a title or document used as an index to content
known group testing A test for construct validity in which new instruments are
administered to individuals known to be high or low on the characteristic being
measured Kuder-Richardson coefficient A test for instrument reliability for use
with dichotomous items; all items are simultaneously compared using a computer
kurtosis The peakedness or flatness of a distribution of data
ladder program An organizational process for promotion and career advancement
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laggards Individuals who are slow or fail to adopt an innovation
leader One who takes initiative for change and empowers others
levels of evidence Predetermined scales that guide decisions for ranking evidence;
evidence hierarchies levels of measurement A system of classifying measurements
according to a hierarchy of measurement and the type of statistical tests that is
appropriate; levels are nominal, ordinal, interval, and ratio lifelong learning
Adding skills and knowledge about the profession as it continues to evolve
Likert scales Ordinal-level scales containing seven points on an agree or disagree
continuum
list of references Publication information for each article cited in a research report
lived experience The perspective of an individual who has experienced the
phenomenon
longitudinal designs Designs used to gather data about subjects at more than one
point in time
long-term outcomes Primary changes in patient behaviors or status over time
magazine A resource targeted to the general reading audience
magnitude The strength of the relationship existing between two variables
mandated reporting Data that must be shared with supervising or governmental
agencies according to a specified timeline manipulation The ability of researchers
to control the independent variable
manuscript A scholarly paper prior to its publication
maturation A threat to internal validity when subjects change by growing or
maturing
mean The mathematical average calculated by adding all of the data values and
then dividing by the total number of values measurement error The difference
between the true score and the observed score
measures of central tendency Measures, such as the mean, median, and mode, that
provide information about the typical case found in the data measures of
variability Measures providing information about differences among data within a
set; measures of dispersion median The point at the center of a data set
mediators Extraneous variables that come between the independent and dependent
variables
member checks A strategy used in qualitative studies when the researcher goes
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back to participants and shares the results with them to ensure the findings reflect
what participants said memoing A technique used in qualitative research to record
ideas that come to researchers as they live with the data mentor One who assists
with professional growth
meta-analysis A scholarly paper that combines results of studies, both published
and unpublished, into a measurable format and statistically estimates the effects of
proposed interventions metaparadigm Four broad concepts core to nursing:
person, environment, health, and nursing
meta-synthesis A systematic review that contains only qualitative studies; a
scholarly paper that combines results from qualitative studies methodological
Studies for the purpose of creating and testing new instruments
methods section Major portion of a research article that describes the study
design, sample, and data collection minimal risk The probability and magnitude of
harm from participating in a research study are not greater than those encountered in
daily life modality The number of modes found in a data distribution
mode The most frequently occurring value in a data set
model Pictorial representation of concepts and their interrelationships
model of diffusion of innovations Model to assist in understanding how new
ideas come to be accepted practice model of EBP levels of collaboration A model
explaining how five levels are intertwined to contribute to EBP
model testing Correlational design to test a hypothesized theoretical model; causal
modeling or path analysis moderators Extraneous variables that affect the
relationship among the independent and dependent variables mortality A threat to
internal validity when there is a loss of subjects before the study is completed;
attrition rate multiple experimental groups designs Experimental designs using
two or more experimental groups with one control group multiple regression An
inferential statistical test used to describe the relationship of three or more
variables multitrait-multimethod testing Test for construct validity in which a
new instrument, established instrument of the same concept, and established
instrument of the opposite concept are given at the same time; strong positive and
negative correlations indicate good validity multivariate analysis The use of
statistics to describe the relationships among three or more variables at interval
and ratio levels narrative reviews Reviews based on common or uncommon
elements of works without concern for research methods, designs, or settings;
traditional literature review national level Collaboration among nurses throughout
the country to effect practice changes
Nazi experiments An example of unethical research using human subjects during
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World War II
negative case analysis A qualitative strategy involving the analysis of cases that do
not fit patterns or categories negatively skewed A distribution when the mean is
less than the median and the mode; the longer tail is pointing to the left nesting A
strategy best used when a search contains two or more Boolean operators
networking Interacting with colleagues to exchange information and build
relationships
network sampling Recruitment of participants based on word of mouth or referrals
from other participants; snowball sampling nominal The lowest level of
measurement whereby data are categorized simply into groups; categorical data
nondirectional hypothesis Statement of the relationship among two variables that
does not predict the direction of the relationship nonequivalent control group
pretest-posttest design A quasi-experimental design where two groups are
measured before and after an intervention nonequivalent groups posttest-only
design A preexperimental design involving two groups measured after an
intervention with little control for extraneous variables nonexperimental designs
Research designs that lack manipulation of the independent variable and random
assignment nonparametric Inferential statistics involving nominal-or ordinal-level
data to make inferences about the population nonprobability sampling Sampling
methods that do not require random selection of elements
nonpropositional knowledge The art of nursing or knowledge that is obtained
through practice
nonsignificant When results of the study could have occurred by chance; findings
that support the null hypothesis normal distribution Data representation with a
distinctive bell-shaped curve, symmetric about the mean null hypothesis A
hypothesis stating that there is no relationship between the variables; the statistical
hypothesis Nuremberg Code Ethical code of conduct for research that uses human
subjects nursing outcomes Measures of states, behaviors, or perceptions of
individuals, families, or communities as they relate to nursing and health Nursing
Quality Indicators Outcomes of nursing care, identified by the American Nurses
Association, that address patient safety and quality of care nursing-sensitive
outcomes Results that demonstrate the effectiveness of nursing care
obligations Requirements to act in particular ways
observation A technique to gather data
odds ratio The statistic reported when epidemiologists conduct a case-control
study
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one-group posttest-only design A preexperimental design involving one group and
a posttest with little control over extraneous variables open coding The grouping
of qualitative data into categories that seem logical
operational definitions Definitions that explicitly state how the variable will be
measured or operationalized; empirical definitions ordinal A continuum of numeric
values where the intervals are not meant to be equal
organizational level When nurses in an organization effect practice changes
organizational priorities Situations of high importance because of volume of
patients or costs
outcome Consequence or visible result
outcomes research Studies about the effects of care and treatments on individuals
and populations
pandemic Epidemic that has spread worldwide
panel design Longitudinal design where the same subjects, drawn from the general
population, provide data at multiple points in time papers Manuscripts published in
professional journals
parallel form A test for instrument reliability in which two different versions of
new instruments are given. Scores are correlated, and strong positive correlations
indicate good reliability; also known as alternate form parametric Inferential
statistical tests involving interval-or ratio-level data to make inferences about the
population participant observation Role of the researcher in qualitative methods
when the researcher is not only an observer but also a participant during data
collection participants Individuals in a qualitative study; informants
passive rejection Lack of consideration given to adopting an innovation; hence, old
practices are continued patient populations A group of patients with similar
characteristics
patient-related outcomes A type of outcome related to patient behaviors or actions
Pearson’s r An inferential statistic used when two variables are measured at the
interval or ratio level; Pearson product–moment correlation peer debriefing A
technique used in qualitative research in which the researcher enlists the help of
another person, who is a peer, to discuss the data and findings peer review When
experts and editors rigorously evaluate a manuscript submitted for publication
percentage distributions Descriptive statistics used to group data to make results
more comprehensible; calculated by dividing the frequency of an event by the total
number of events percentile A measure of rank representing the percentage of cases
645
that a given value exceeds
performance-related outcomes A type of outcome related to how nurses perform
their job
period prevalence The number of existing cases of disease in a population during a
specified period of time periodical A resource that is published on a set schedule
persistent observation When the researcher has spent sufficient quality time with
participants while attempting to describe and capture the essence of the
phenomenon personal development file A compilation of career accomplishments
personal narrative A way of conveying the meaning of experiences through
storytelling
phenomenology A type of qualitative research that describes the lived experience
to achieve understanding of an experience from the perspective of the participants
physiological measures Data obtained from the measurement of biological,
chemical, and microbiological phenomena PICOT model A model in EBP used to
formulate EBP questions; the acronym stands for patient population, intervention of
interest, comparison of interest, outcome of interest, and time frame used to
formulate EBP
pilot A small study to test a new intervention with a small number of subjects
before testing with larger samples; adopting an innovation on a trial basis
plagiarism The use of another’s work without giving proper credit
point prevalence The number of existing cases of disease in a population at a
particular point in time popular literature Works written to inform or entertain the
general public
population The entire group of elements that meet study inclusion criteria
population parameters Characteristics of a population that are inferred from
characteristics of a sample positional operators Terms that specify the number of
words that can appear between search terms
position of the median Calculated by using the formula (n + 1) / 2, where n is the
number of data values in the set positive predictive value The probability that a
person who screens positive actually has the disease positively skewed A
distribution in which the mean is greater than the median and the mode; the longer
tail is pointing to the right posters A scholarly venue for disseminating evidence
power analysis A statistical method used to determine the acceptable sample size
that will best detect the true effect of the independent variable practice guidelines
Systematically developed statements to assist healthcare providers with making
646
appropriate decisions about health care for specific clinical circumstances
preceptors Knowledgeable nurses who provide clinical orientation for new
employees
precision A search strategy that narrows the parameters of the search
predictive correlational design Correlational design when researchers
hypothesize which variables are predictors or outcomes predictive research
Research that forecasts precise relationships between dimensions of phenomena or
differences between groups predictive validity A test for criterion-related validity
where a new instrument is given at two different times and scores are correlated;
strong positive correlations indicate good validity preexperimental A posttest-
only design that involves manipulation of the independent variable but lacks control
for extraneous variables presentations Scholarly oral presentations to disseminate
new knowledge
prevalence The number of existing cases of disease present in the population
primary sources Original information presented by the person or people
responsible for creating it
print index Printed listing of electronic or print resources
probability Likelihood or chance that an event will occur in a situation
probability sampling Sampling method in which elements in the accessible
population have an equal chance of being selected for inclusion in the study
problem statement A formal statement describing the problem addressed in the
study
professionalism A set of behaviors that exemplify the role of the professional
nurse
proportion A type of ratio where the numerator is included in the denominator
proposition A statement about the relationship between two or more concepts
propositional knowledge The science of nursing or knowledge that is obtained
from research and scholarship prospective designs Studies over time with
presumed causes that follow subjects to determine whether the hypothesized effects
actually occur psychometrics The development of instruments to measure
psychological attributes
purpose statement A statement indicating the aim of the study
purposive sampling Nonprobability sampling method used in qualitative studies to
select a distinct group of individuals who either have lived the experience or have
expertise in the event or experience being studied; sampling method to recruit
647
specific persons who could provide inside information pyramid of evidence A
model showing how evidence can be categorized from strong to weak
qualification Limiting fields of search, commonly using limits such as author, title,
or subject
qualitative data analysis The production of knowledge that results from analysis of
words
qualitative research Research that uses words to describe human behaviors
quantitative research Research that uses numbers to obtain precise measurements
quasi-experimental designs Research designs involving the manipulation of the
independent variable but lacking random assignment to experimental and control
groups questionnaires Printed instruments used to gather numerical data
quota sampling Nonprobability sampling method involving selection of elements
from an accessible population that has been divided into groups or strata random
assignment Assignment technique in which subjects have an equal chance of being
in either the treatment or the control group random error Error that occurs by
chance during measurement
random sampling Technique for selecting elements whereby each has the same
chance of being selected
randomization The selection, assignment, or arrangement of elements by chance
randomized controlled trials Experimental studies that typically involve large
samples and are conducted in multiple sites range The difference between the
maximum and minimum values in a data set
rate A measure of disease frequency in a defined population over a specified
period of time
ratio The highest level of measurement that involves numeric values that begin with
an absolute zero and have equal intervals; in epidemiology a mathematical
relationship between two numbers reactivity The influence of participating in a
study on the responses of subjects; Hawthorne effect
realist tales A real-life account of the culture being studied presented in a third-
person voice that clearly separates researchers from participants recall A strategy
used to search for the number of records retrieved with a keyword; the broad
“catch” of retrieved records record Basic building block in an electronic or print
database
referential adequacy A technique used in qualitative research in which multiple
648
sources of data are compared and the findings hold true reflexivity Using a journal
to record thoughts, ideas, and decisions during qualitative data gathering regional
level When nurses from a large geographic location collaborate to change practice
rejection Decision not to adopt an innovation
relative risk The statistic reported by epidemiologists when they conduct a cohort
study
reliability Obtaining consistent measurements over time
replicated When another researcher has findings similar to a previous study
replication Repeated studies to obtain similar results
representativeness The degree to which elements of the sample are like elements
in the population
research Systematic study that leads to new knowledge and/or solutions to
problems or questions
research hypothesis A hypothesis indicating that a relationship among two or more
variables exists
research imperative An ethical rule stating that nurses should advance the body of
knowledge
research problem Area of concern when there is a gap in knowledge that requires
a solution
research question An interrogatory statement describing the variables and
population of the research study research topic A clinical problem of interest
research utilization Changing practice based on the results of a single research
study
respect for persons Principle that individuals should be treated as autonomous and
that those with diminished autonomy are entitled to protection results section
Component of a research article that reports the methods used to analyze data and
characteristics of the sample retrospective designs Research designs in which
researchers look back in time to determine possible causative factors; ex post facto
review of literature An unbiased, comprehensive, synthesized description of
relevant previously published studies role model One who demonstrates desired
characteristics and skills
Rule of 68–95–99.7 Rule stating that for every sample 68% of the data will fall
within one standard deviation of the mean; 95% will fall within two standard
deviations of the mean; 99.7% of the data will fall within three standard deviations
649
of the mean sample A select group of elements that is representative of all eligible
elements
sample statistics Numerical data describing characteristics of the sample
sampling bias A threat to external validity when a sample includes elements that
over-or underrepresent characteristics when compared to elements in the target
population sampling distribution A theoretical distribution representing an infinite
number of samples that can be drawn from a population sampling error Error
resulting when elements in the sample do not adequately represent the population
sampling frame A list of all possible elements in the accessible population
sampling interval The interval (k) between each element selected when using
systematic random sampling sampling plan Plan to determine how the sample will
be selected and recruited
scales Used to assign a numeric value or score on a continuum
scholarly literature Works written and edited by professionals in the discipline for
other colleagues scientific literature publication cycle A model describing how
research becomes disseminated in publications screening Testing people without
known disease to determine whether they have a disease; used to reduce morbidity
and mortality in populations search field Where each piece of information
contained in the record is entered
secondary sources Commentaries, summaries, reviews, or interpretation of
primary sources; often written by those not involved in the original work selection
bias A threat to internal validity when the change in the dependent variable is a
result of the characteristics of the subjects before they entered a study self-
awareness Knowing yourself
semiquartile range The range of the middle 50% of the data
sense of inquiry Curiosity
sensitivity The ability of the test to correctly identify people with the disease by
positive test results short-term outcomes Results achieved in a brief period of
time
significance level The alpha level established before the beginning of a study
simple hypothesis A hypothesis describing the relationship among two variables
simple random sampling Randomly selecting elements from the accessible
population skewed An asymmetrical distribution of data
snowball sampling Recruitment of participants based on word of mouth or
650
referrals from other participants socialization Awareness about formal and
informal rules of behavior
Solomon four-group design An experimental design involving four groups—some
receive the intervention, others serve as controls; some are measured before and
after the intervention, others are measured only after the intervention specificity
The ability of the test to correctly identify people without the disease by negative
results split-half reliability A test for instrument reliability in which the items are
divided to form two instruments. Both instruments are given and the halves are
compared using the Spearman-Brown formula stability An attribute of reliability
when instruments render the same scores with repeated measures under the same
circumstances standard deviation A measure of variability used to determine the
number of data values falling within a specific interval in a normal distribution
statistical conclusion validity The degree that the results of the statistical analysis
reflect the true relationship among the independent and dependent variables
statistical hypothesis A hypothesis stating that there is no relationship among the
variables; null hypothesis statistically significant When critical values fall in the
tails of normal distributions; when findings did not happen by chance alone
Statistics The branch of mathematics that collects, analyzes, interprets, and
presents numerical data in terms of samples and populations statistics The
numerical outcomes and probabilities derived from calculations on raw data
Stetler model Step-by-step instructions for integrating research into practice
stopwords Words, such as a, the, and in, that are so commonly used that they can
hinder accurate record retrieval strategic sampling Sampling in historical
research to locate a small group of people who were either witnesses of or
participants in the phenomenon being studied stratified random sampling
Selecting elements from an accessible population that has been divided into groups
or strata studies A level in the pyramid of evidence that contains quantitative and
qualitative studies, case studies, and concept analyses study validity Ability to
accept results as logical, reasonable, and justifiable based on the evidence
presented subject headings A set of controlled vocabulary used to classify
materials; organization of databases according to topic subject searching
Searching databases using controlled vocabulary
subjects Individuals who participate in studies, typically studies using a
quantitative design
summaries A level in the pyramid of evidence containing detailed descriptions of
evidence
survey designs Descriptive design type involving data obtained through subjects’
651
self-report
synopses A level in the pyramid of evidence containing brief descriptions of
evidence
syntheses A level in the pyramid of evidence containing evidence to present a
whole depiction of a phenomenon systematic error Error that occurs in the same
way with each measurement
systematic random sampling Sampling method in which every kth element is
selected from a numbered list of all elements in the accessible population; the
starting point on the list is randomly selected systematic review A rigorous and
systematic synthesis of research findings about a clinical problem
systems A level in the pyramid of evidence involving electronic medical records
integrated with practice guidelines t statistic Inferential statistical test to determine
whether a statistically significant difference between groups exists tailedness The
degree to which a tail in a distribution is pulled to the left or to the right
target population All elements that meet the study inclusion criteria
team leadership skills Behaviors that collaboratively engage others while working
toward a goal
team membership The composition of a team with respect to expertise and
leadership
temporal ambiguity The inability to control for confounding variables and the
inability to determine whether the exposure truly occurred before the disease
testing A threat to internal validity when a pretest influences the way subjects
respond on a posttest test-retest reliability A test for instrument reliability when
new instruments are given at two different times under the same conditions; scores
are correlated, and strong positive correlations indicate good reliability
theoretical framework The structure of a study that links the theory concepts to the
study variables; a section of a research article that describes the theory used
theoretical sampling Nonprobability sampling method used in grounded theory to
collect data from an initial group of participants theory A set of concepts linked
through propositions to explain a phenomenon
therapeutic imperative An ethical rule stating that nurses should perform actions
that benefit the patient time series design A quasi-experimental design where one
group is measured prior to administering the intervention and then multiple times
after the intervention trade literature Works written for professionals in a
discipline using a more casual tone than used in scholarly literature traditional
literature review Article based on common or uncommon elements of works with
652
little concern for research methods, designs, or settings; narrative literature review
transferability One of four criteria for a trustworthy qualitative study that relates to
whether findings from one study can be transferred to a similar context; application
of findings to a different situation translational research Research for the purpose
of linking research findings to the point of care
translational research model A model that provides specific strategies
organizations can use to improve adoption of an evidence-based innovation trend
A type of longitudinal design to gather data from different samples across time
triangulation Use of different research methods in qualitative research to gather
and compare data
truncation A search strategy that uses a symbol at the end of a group of letters that
form the root search term trustworthiness The quality, authenticity, and truthfulness
of findings from qualitative research
Tuskegee study An unethical study about syphilis in which subjects were denied
treatment so that the effects of the disease could be studied two-group posttest-
only designs Experimental designs when subjects are randomly assigned to an
experimental or control group and measured after the intervention two-group
pretest-posttest design Subjects are randomly assigned to the experimental or
control group and measured before and after the intervention; classic or true
experiment type I error When the researcher rejects the null hypothesis when it
should have been accepted
type II error When the researcher inaccurately concludes that there is no
relationship among the independent and dependent variables when an actual
relationship does exist; when the researcher accepts the null hypothesis when it
should have been rejected uncertainty Degree to which alternatives are perceived
relative to the occurrence of an event and the probability of these alternatives
unimodal A data set with one mode, such as a normal distribution
univariate analysis The use of statistical tests to provide information about one
variable
unstructured observations A method of data collection associated with qualitative
research in which phenomena of interest are allowed to emerge over time as
observations are made validity The degree that an instrument measures what it is
supposed to measure
visual analog scale Ratio-level scale of a 100-mm line anchored on each end with
words or symbols
vulnerable population A special group of people needing protection because of
653
members’ limited ability to provide informed consent or because of their risk for
coercion wheel of professionalism in nursing A model depicting behaviors of the
professional nurse
wildcards Symbols substituted for one or more letters in a search term
Willowbrook studies An unethical study involving coercion of parents to allow
their children to participate in the study in exchange for admission to a long-term
care facility within-groups design Comparisons are made about the same subjects
at two or more points in time or on two or more measures z scores Standardized
units used to compare data gathered using different measurement scales
654
INDEX
The index that appeared in the print version of this title was intentionally removed from the eBook . Please
use the search function on your eReading device to search for terms of interest. For your reference, the
terms that appear in the print index are listed below.
A
abstracts
call for
research articles, component of
AcademyHealth
ACC. See American College of Cardiology access to content
accessible population
defined
sample and population, relationship between ACE Star Model of Knowledge Transformation ACPM. See
American College of Preventive Medicine action, empowering
active rejection of innovation
ADA. See American Diabetes Association adoption
defined
of innovation
advanced practice nurses (APNs)
EBP performance criteria
interdisciplinary teams
Advances in Nursing Science advocacy
advocates for patients, nurses as
qualitative research, ethical issue in Affordable Health Care for America Act Agency for Healthcare
Research and Quality (AHRQ) evidence, ranking
health outcome information website
nursing research and EBP
translational research
nursing practice guidelines
nursing research problems, identifying ages, frequency and percentage distributions of aggregate data
AGREE II instrument. See Appraisal of Guidelines Research and Evaluation instrument AHA. See American
Heart Association AHRQ. See Agency for Healthcare Research and Quality AIDS epidemic
alpha level, and type I errors alternate form test for reliability
American Anthropological Association (2004) American College of Cardiology (ACC)
American College of Preventive Medicine (ACPM) American Diabetes Association (ADA)
American Heart Association (AHA)
American Journal of Nursing American Nurses Association (ANA)
655
establishment of
human rights protection, guidelines for nursing practice, defined
Nursing Quality Indicators
American Nurses Credentialing Center Magnet Recognition Program healthcare facilities achieving
interdisciplinary teams
mandated report
nursing research and EBP
American Nurses Foundation
American Pain Society
American Psychological Association (APA) style, reference lists, guidelines for amodal data, defined
ANA. See American Nurses Association analysis of covariance (ANCOVA) analysis of variance (ANOVA)
analytic epidemiology
analytic study designs
case-control studies
cohort studies
intervention studies
ANCOVA. See analysis of covariance Annual Review of Nursing Research anonymity
qualitative research, ethical issue in samples, ethics of
ANOVA. See analysis of variance anxiety, defined
APNs. See advanced practice nurses Applied Nursing Research applied research, defined
Appraisal of Guidelines Research and Evaluation instrument (AGREE II) Arizona State University at Tempe
artifacts, in qualitative research
assent, ethics of
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) nursing practice guidelines
nursing research and EBP
associative hypotheses vs. causal hypotheses associative relationships
complex hypothesis
defined
directional hypotheses
hypotheses
research question, example for
attrition rate
internal validity
sample size, determining
audit trail, in qualitative research
auditability, defined
authority, for evidence
authorship of papers
autonomous, defined
656
awareness, as characteristic of innovators AWHONN. See Association of Women’s Health, Obstetric and
Neonatal Nurses axial coding, defined
B
barriers
connecting research and practice to
nurses’ belief systems related to practice organizational culture
research-related barriers
defined
overcoming
basic research, defined
behavioral inventory for professionalism Belmont Report
beneficence
ethical guidelines for research
justice
respect for persons
bench research, defined
benchmarking, for mandated reports
beneficence, defined
benefits, as ethical issue in qualitative research Benner, Patricia
between-groups design
bias
quantitative design, in
sampling
selection bias
bimodal data
bivariate analysis
Boolean operators for electronic databases bracketing of data
Brown Report
budget for quantitative data collection business cards
C
call for abstracts, described
call number
Canadian Task Force on Preventive Health Care (CTFPHC) canonical correlation
CAQDAS. See Computer Assisted Qualitative Data Analysis Software care-related outcomes, described
career development
Careful Nursing Philosophy
case control studies
657
evidence in quantitative studies, appraising retrospective design
case reports or series
case studies
defined
qualitative data, collecting
studies, in pyramid of evidence
categorical data level of measurement
categories generated from data
causal hypotheses, associative hypotheses vs.
causal relationships
directional hypotheses
hypotheses, in
research question, example for
simple/complex
causality
experimental designs
quantitative designs
CDC trends positive influenza test
Centers for Medicare and Medicaid Services (CMS) health outcome information website
mandated reports
change
anchoring, in the change phases model defined
making change happen others, engaging in
practice environment, assessment of
stakeholder involvement
change agent, innovator as
change phases model
Chi square statistic
CINAHL. See Cumulative Index to Nursing and Allied Health Literature CINAHL Headings
CINL. See Cumulative Index to Nursing Literature citation chasing, as search strategy
citations
databases
ethics of
clinical experience, and identifying research problems Clinical Nurse Leader (CNL)
clinical pathways, and change
clinical practice guidelines (CPGs)
evaluation of, instrument for
explained
practice settings, use of
658
clinical problems guiding research questions nursing research problems, identifying problem of interest, narrowing
problem solving, nursing process, and research process problem statements, developing
clinical significance and statistical significance, differentiating between cluster sampling
CNL. See Clinical Nurse Leader coalitions, development of
Cochrane, Archie
Cochrane Center
Cochrane Collaboration
establishment of
evidence, ranking
subject-specific databases
Cochrane Database of Systematic Reviews Cochrane Library
electronic databases, advanced searches of literature search
subject-specific databases
synopses of evidence, searching for
Code of Ethics for Nurses with Interpretive Statements (ANA) coding, for data management
coefficient of variation
coercion
cohort comparison studies
cohort studies
collaboration levels
individual nurse level
international level
model of EBP levels of collaboration
national level
organizational level
regional level
colors for posters
Commission on Nursing Research
communication, as characteristic of innovators community-based participatory action research community health,
as focus of nursing research comparative design, defined
comparative evaluation/decision making phase of Stetler model comparison, in the PICOT model
competence boundaries, in qualitative research complex hypothesis
associative and causal relationships
defined
research question, example for
simple vs.
Computer Assisted Qualitative Data Analysis Software (CAQDAS) computer software for data management
concept analyses
defined
659
studies, in pyramid of evidence
concepts, in theories
conceptual definitions
conclusions, drawing and verifying
concurrent validity
Conduct and Utilization of Research in Nursing Project (CURN) conferences
insights, disseminating
taking advantage of
confessionist tales
confidence intervals, in inferential statistics confidentiality
IRB area of concern
qualitative research, ethical issue in samples, ethics of
confirmability
defined
qualitative research, evaluation of
trustworthiness, establishing
conflicts in qualitative research, ethics of confounding
confounding variables
construct, defined
construct validity
defined
external validity
testing for
content validity
defined
testing for
contingency coefficients
continuing education credits
continuing review, as IRB area of concern continuous data, defined
continuous quality improvement (CQI)
control
experimental designs
quantitative design
controlled vocabularies
convenience sampling
correlated test
correlation coefficients
defined
reliability, estimate of
660
variables, relationship between
correlational designs
causality, not proving
defined
descriptive correlational designs
model-testing correlational designs
predictive correlational designs
cost-benefit ratio, ethics of
costs of qualitative research, ethics of count data
covary
correlations
defined
CPGs. See clinical practice guidelines CQI. See continuous quality improvement credibility defined
qualitative research, evaluation of
trustworthiness, establishing
criterion-related validity
defined
testing for
Critical-Care Nurses
critical thinking, by innovators
critical values in statistical tests
Cronbach’s alpha
cross-sectional designs
cross-sectional studies
crossover designs
longitudinal design
true experimental design
CTFPHC. See Canadian Task Force on Preventive Health Care culture in decision-making process
Cumulative Index to Nursing and Allied Health Literature (CINAHL) CINAHL Headings
establishment of
information organization system
Internet access to
literature search
subject-specific databases
synopses
Cumulative Index to Nursing Literature (CINL) CURN. See Conduct and Utilization of Research in Nursing
Project cycle of scientific development
D
661
data. See also evidence collection distribution patterns
asymmetric distribution
normal distribution
qualitative research
analyzing and interpreting for
collecting for
data analysis
appraisal of
systematic review
data extraction
data interpretation
data management, coding and data reduction data reduction
data analysis and interpretation for qualitative research data management
data saturation
qualitative research
sample size, determining
trustworthiness, establishing
databases
electronic
electronic indexes
format of
topic and subject matter
variations in
Declaration of Helsinki
deductive reasoning, defined
deductive research
degrees of freedom
dependability
defined
qualitative research, evaluation of
trustworthiness, establishing
dependent variables
description methodology
descriptive correlational designs
descriptive designs, nonexperimental designs descriptive epidemiology defined
person
place
time
descriptive research, defined
662
descriptive statistics
statistical symbols for
descriptive studies
descriptive study designs
case reports or series
cross-sectional studies
ecologic studies
determinants
defined
developing oneself, defined
dichotomous, defined
diet
dilemmas in qualitative research, ethics of direct observations
direction, and covariance of variables directional hypotheses
defined
further categorization of
nondirectional vs.
research question, example for
disciplined clinical inquiry model
disciplined reflection, described
discriminate function analysis
discussion section of research articles disease frequency, measures of
epidemiologic measures
prevalence and incidence
dispersion
dissemination of insights
dissemination, defined
responsibility of nurses for
role of the nurse
3 Ps of dissemination
overview
papers
posters
presentations, oral
Dissertation Abstracts Online
literature search
subject-specific database
distribution
defined
663
distribution of data
asymmetric distribution
normal distributions
divergent testing
construct validity, testing for
defined
DNP degree. See Doctor of Nursing Practice degree Dock, Lavinia
Doctor of Nursing Practice (DNP) degree doctoral programs in nursing
double-blind experimental designs
E
early adopters, defined
EBP. See evidence-based practice ecologic fallacy
ecologic studies
effect size (ES)
effects of selection, defined
electronic indexes
electronic medical record (EMR)
elements, defined
emic perspective, defined
empirical evidence, defined
empirical indicators, defined
empirical testing defined
questions, framing for
EMR. See electronic medical record endemic, defined
endemic diseases
EPCs. See Evidence-based Practice Centers epidemic, defined
epidemiologic designs
analytic study designs
case-control studies
cohort studies
intervention studies
664
chapter objectives and key terms
descriptive epidemiology
person
place
time
descriptive study designs
case reports or series
cross-sectional studies
ecologic studies
disease frequency, measures of
epidemiologic measures
prevalence and incidence
epidemiology and nursing
ethics
health outcomes and services, evaluation of infectious diseases and outbreak investigations learning, applying
rapid review
screening
epidemiologic measures
epidemiologic triangle
epidemiology
defined
equivalence, as attribute of reliability error, reducing
hypotheses, decisions about
level of significance: adjusting the risk of making type I and type II errors type I and type II errors
ethics
beneficence
dilemmas encountered during change
EBP research questions
evidence and agency policy, conflicts between evidence, other sources of
guidelines for ethical research
institutional review boards
internal and external validity
justice
nurses as patient advocates
qualitative research
665
designs
issues in
quantitative designs
in research
respect for persons
samples, using to provide evidence
statistical analyses, conducting
testing protocols, dilemmas in
ethnograph
ethnography
data collection and management
defined
method
nursing research examples
overview of
philosophical underpinnings
questions to ask, examples of
Ethnography and Institutional Review Boards ethnonursing
ethnoscience
etic perspective, defined
etiology, defined
evaluation, of qualitative research
evaluation phase of Stetler model
evidence
appraising
clinical practice guidelines, developing and using evidence, ranking
five-step approach to
qualitative designs
quantitative designs
questions to consider
relevancy, determining
borrowed from other disciplines, as source of evidence decisions about
ethics
learning, applying
ranking
clinical questions to ask
clinically significant statistics, definitions of evidence hierarchies
levels of evidence
systems for
666
rapid review
sources of
Evidence-Based Nursing/EBN Online, synopses of evidence, searching for evidence-based practice (EBP)
adopting
best sources for
667
chapter objectives and key terms
databases to search for
defined
described
ethics in research
five-step approach to
future developments
learning, applying
models of
nursing as science, evolution of
nursing research, describing
pyramid of evidence, using for
quantitative data, interpretation and appraisal of questions, formulating
rapid review
samples, appraising
Evidence-based Practice Centers (EPCs) evidence collection
668
chapter objectives and key terms
data collection: planning and piloting
ethics
learning, applying
qualitative data collecting
appraising
words, collecting
quantitative data collection
appraising data collection
issues in
levels of measurement
numbers
rapid review
evidence, finding sources of
669
chapter objectives and key terms
ethics
evidence, searching for access to content
EBP, best sources for
electronic databases
general search strategies
print indexes
evidence types
peer-reviewed and refereed sources
periodicals, journals, and magazines
primary and secondary sources
reviews, types of
scholarly, trade, and popular literature scientific literature publication cycle rapid review
sources, organization of
databases
experts, consulting with
literature search, importance of
sources, structure of
evidence hierarchies, defined
evidence, other sources of
670
chapter objectives and key terms
ethics
evidence-based practice, using pyramid for learning, applying
pyramid of evidence
overview of
studies
summaries
synopses
syntheses
systems
rapid review
evidence, transitioning to practice
change, creating
change, engaging others in
change, explained
making change happen
stakeholder involvement
chapter objectives and key terms
EBP models to overcome barriers, barriers to connecting research and practice ethics
learning, applying
rapid review
evidence types
peer-reviewed and refereed sources
periodicals, journals, and magazines
primary and secondary sources
reviews, types of
scholarly, trade, and popular literature scientific literature publication cycle evidence, using through
collaboration
671
chapter objectives and key terms
collaboration levels
individual nurse level
international level
model of EBP levels of collaboration
national level
organizational level
regional level
ethics
beneficence
guidelines for ethical research
institutional review boards
justice
nurses as patient advocates
respect for persons
learning, applying
rapid review
ex post facto designs exclusion criteria for samples
exempt categories of research
Expanded Academic ASAP database
expedited review of research study, defined experience, previous, as source of evidence experimental designs
cause and effect relationships, evidence for crossover designs
defined
factorial designs
multiple experimental groups designs
purpose of
required features of
Solomon four-group designs
true experimental designs
two-group posttest-only designs
two-group pretest-posttest designs
experts, consulting with, for information explanatory research, defined
exploding technique for searching electronic databases exploratory design, defined
exposure, defined
external validity
672
construct validity
defined
interaction of treatment and history
interaction of treatment and setting
interaction of treatment with selection of subjects reactivity
selection, effects of
extraneous variables
defined
quantitative design
F
face validity
factor analysis
factorial designs
false-negative result, defined
false-positive result, defined
feedback, for manuscripts
fieldwork
preparing for
qualitative research
finding evidence, purpose of
Fisher’s exact probability test
flexibility to change, as characteristic of innovators focus groups
defined
grounded theory
qualitative data, collecting
follow-up studies, in longitudinal design fonts for posters
Forces of Magnetism
formats of information sources
frequency
samples, using to describe
symbol for
frequency polygon
From Novice to Expert (Benner) full review
Code of Federal Regulations
of research study, defined
G
673
gatekeeper, in ethnography
generalizability of evidence application generalize, defined
Gerontological Nursing Interventions Research Center globalization, and nursing research Goldmark Report
Google Scholar
GRADE. See Grades of Recommendations, Assessment, Development, and Evaluation Grades of
Recommendations, Assessment, Development, and Evaluation (GRADE) grand theories
graphics for posters
grey literature, defined
grounded theory
data collection and management
defined
method
nursing research examples
philosophical underpinnings
reports, formats for
grouped data frequencies, using to described samples H
harm in qualitative research, ethics of Harvard College Library Health Data Resources Hawthorne effect
Health Care Excel
“Health Information Literacy Project, The”
health outcome information websites
health outcomes and services, evaluation of health services research, quantitative designs for Health-STAR
heterogeneous
elements, defined
sample size, determining
HGP. See Human Genome Project historical research
data collection and management
defined
method
nursing research examples
philosophical underpinnings
reports, formats for
history, and internal validity
homogeneity, and sample size
homogeneous elements, defined
honesty in qualitative research, ethics of housecalls program
Human Genome Project (HGP)
human rights, defined
human subjects, protection of
during data collection
674
in research projects
hypotheses
associative vs. causal defined
evaluation criteria
nondirectional vs. directional null vs. research principles for making decisions about research, special language
of
simple vs. complex types of
hypothesis testing
construct validity, testing for
defined
I
immersion
impressionist tales
improvements, consolidation of, in change phases model incentives for participation incidence
inclusion criteria
independent test
independent variables, defined
indexes, defined
indicators, and choosing outcomes
individual nurse level of collaboration inductive reasoning, defined
inductive research
infectious diseases
inferential statistics
chance
defined
language of
statistical symbols
testing for differences among groups
analysis of variance
Chi square statistic
Kolmogorov-Smirnov test
Mann-Whitney U test
median test
sign test
statistic
Wilcoxin matched pairs test
testing for relationships among variables contingency coefficients
Kendall’s Tau
675
multiple regression
Pearson’s r
Phi coefficients
point biserials
Spearman Rho
when to use
influenza positive test, CDC trends
informants, in qualitative research
information overload
information sources, structure of
informed consent
ethical research
evidence collection, ethics of
IRB area of concern
qualitative research, ethical issue in samples, ethics of
innovation, defined
innovations, outcomes of, evaluating
ethics
outcomes
describing
evaluating
outcomes, choosing
health outcome information websites
mandated reports
organizational priorities
outcomes and associated indicators
patient population
team membership
innovator, developing oneself as
describing
ethics
lifelong learning
oneself, developing
development on the job
team leadership skills, developing
professionalism
innovators, characteristics of
communication skills
flexibility
676
sense of inquiry
types of
Inside Nursing: A Critical Ethnography of Clinical Nursing Practice (Street) insights, sharing with others
677
chapter objectives and key terms
conferences, making the most of
dissemination, role of the nurse in ethics
learning, applying
rapid review
3 Ps of dissemination
overview
papers
posters
presentations, oral
Institute for Healthcare Improvement
mandated reports
Institute of Research and Service in Nursing Education at Teachers College institutional review boards (IRBs)
Code of Federal Regulations
components and areas of concern
ethics
exempt categories of research
reviews, types of
instrumentation, and internal validity integrative reviews
reviews, types of
syntheses, in pyramid of evidence
interaction of treatment and history
interaction of treatment and selection of subjects interaction of treatment and setting
interlibrary loans
intermediate outcomes, described
internal consistency, as attribute of reliability internal validity
defined
history
instrumentation
maturation
mortality
selection bias
statistical conclusion validity
testing
International Journal of Nursing Research international level of collaboration
678
Internet
advanced search options
CINAHL, access to
evidence collection, ethics of
search engines and database
interprofessional collaboration
interrater reliability
defined
high quality of study, assuring
quantitative data collection
reliability, testing for
interval level of measurement
interventions
in PICOT model
in qualitative research, ethics of
studies
interviews
data collection, in qualitative research defined
ethnographic research
qualitative data, collecting
introduction, research articles, component of intuition, personal, as source of evidence inverse relationships of
variables
Iowa Model of EBP
described
quality care, promoting
IRBs. See institutional review boards item to total correlation
J
Jewish Chronic Disease Hospital studies justice, lacking
respect for persons, lack of
unethical research in
Joanna Briggs Institute
evidence, ranking
international collaboration
nursing practice, improving
subject-specific databases
jobs, personal development on
ladder programs
orientation
679
performance appraisals and reviews
journal clubs
Journal of Nursing Scholarship journals, as type of evidence
justice, ethics of
K
Kendall’s Tau
key informants, in qualitative research keywords
electronic databases, basic searches of information organization system
knowledge, integration of
known group testing
Kolcaba’s theory
Kolmogorov-Smirnov test
Kotter’s model
Kuder-Richardson coefficient
kurtosis, defined
L
laggards, defined
layout for posters
leader
defined
team leadership skills
levels of evidence, ranking
levels of measurement
defined
interval
nominal
ordinal
quantitative data collection
ratio
LexisNexis Academic database
libraries and librarians, consulting, for information Library of Congress organization system lifelong learning
Likert scales
defined
quantitative research data collection line-by-line coding
list of references, citation guidelines for literature, evaluation and search, systematic review of lived experience
long-term outcomes, described
680
longitudinal designs
Lysaught Report
M
magazines, as evidence type
Magnet Recognition Program, ANCC
healthcare facilities achieving
interdisciplinary teams
mandated reports
nursing research and EBP
magnitude, of relationship between variables mandated reporting manipulation
experimental designs
quantitative design
Mann-Whitney U test
MANOVA. See multiple analysis of variance manuscripts
feedback about, obtaining
guidelines for
submission of
time for response to
master’s in nursing programs
maturation, and internal validity
mean
defined
measures of central tendency
symbol for
measurement error
defined
validity and reliability
measurement levels. See levels of measurement measures of central tendency
defined
mean
median
mode
measures of variability
comparing variability when units of measure are different correlation coefficients
defined
percentile
range
semiquartile range
681
standard deviation
tailedness: the rule of 68-95-99.7
median
defined
measures of central tendency
symbol for
median test
mediators
Medical Subject Headings (MeSH)
MEDLINE
electronic databases, advanced searches of literature search
subject-specific databases
synopses
member checks
qualitative research, evaluation of
trustworthiness, establishing
memoing, in qualitative research
mentor
MeSH. See Medical Subject Headings meta-analyses
evidence in quantitative studies, appraising reviews, types of
syntheses, in pyramid of evidence
meta-ethnography
meta-synthesis, in pyramid of evidence metaparadigm, defined
methodological studies
methods section, research articles, component of middle range theories
minimal risk in research studies, defined mirage of recovery
modality, defined
mode
defined
measure of central tendency
model, defined
model of diffusion of innovations
barriers, overcoming
steps in
model of EBP levels of collaboration model-testing correlational designs
moderators
Modern Language Association style
monitoring, as IRB area of concern
mortality of subjects, and internal validity multicausality, in quantitative designs multiple analysis of variance
682
(MANOVA) multiple experimental groups designs
multiple regression
multiple regression path analysis
multitrait method of testing for construct validity multivariate analysis
N
narrative reviews, types of
National Cancer Institute
National Center for Nursing Research, National Institutes of Health National Commission for the Protection of
Human Subjects of Biomedical and Behavioral Research National Committee for Quality Assurance
National Database of Nursing Quality Indicators (NDNQI) creation of
measures
National Guideline Clearinghouse (NGC) clinical practice guidelines
nursing practice guidelines
nursing research and EBP
national initiatives to identify research problems National Institute of Mental Health
National Institute of Nursing Research (NINR) national research priorities
nursing research and EBP
National Institutes of Health
National League for Nursing Research for Studies Service national level of collaboration
National Library of Medicine
National Nursing Practice Network
Nazi experiments
described
respect for persons, lack of
NDNQI. See National Database of Nursing Quality Indicators negative case analysis
negative correlation in associative relationships negatively skewed distribution of data nesting, in electronic
databases
network meta-analysis
networking
conferences, at
posters, using
neutrality
NGC. See National Guideline Clearinghouse Nightingale, Florence
EBP, principles of
lifelong learning
research and dissemination
theory and deductive research
NINR. See National Institute of Nursing Research NOC. See nursing outcomes classification nominal level of
measurement
683
nondirectional hypotheses
defined
vs. directional hypotheses research question, example for
nonequivalent control group pretest-posttest designs nonequivalent-groups posttest-only design nonexperimental
designs
correlational designs
defined
descriptive designs
general categories of
purposes of
nonparametric tests
nonprobability sampling methods
convenience sampling
overview
purposive sampling
quota sampling
theoretical sampling
nonpropositional knowledge, defined
nonsignificant probability
normal distribution of data
defined
Rule of 68-95-99.7
Notes on Nursing: What It Is, and What It Is Not (Nightingale) null hypotheses
defined
vs. research hypotheses research question, example for
type I and type II errors
number in sample, symbol for
number in subsample, symbol for
numbers for quantitative data, collecting observation
overview of
physiological
questionnaires
scales
Nuremberg Code
articles of
defined
guidelines for ethical research
nurse executives, and EBP performance criteria Nurse in Research: ANA Guidelines on Ethical Values, The
(ANA) nurse managers, and EBP performance criteria nurses’ belief systems, as barriers to connecting
research and practice Nursing Best Practice Guidelines Program nursing education
684
evidence-based practice
lifelong learning
nursing research, focus of
nursing outcomes classification (NOC)
nursing outcomes, defined
Nursing Outlook
nursing practice
defined by ANA
theory, using
nursing process
problem solving and research process, differences from problem solving and research process, similarities to
nursing quality indicators, explained
nursing research. See also research describing
priorities in
research articles, components of
research, types of
systematic approach to research
Nursing Research
nursing research problems, identifying clinical experience
national initiatives
nursing theories, current
professional literature
research, previous research problem, defined
research question, narrowing
Nursing Science Quarterly nursing-sensitive outcomes, described
nursing theories, and identifying research problems Nutting, Mary Adelaide
O
obligations, defined
observation
defined
IRB area of concern
qualitative data, collecting
quantitative research data collection odds ratio (OR), defined
Oncology Nursing Society (ONS)
one-group posttest-only design
one-group pretest-posttest design
oneself, developing
development on the job
685
lifelong learning
team leadership skills, developing
Online Journal of Knowledge Synthesis for Nursing, The ONS. See Oncology Nursing Society open coding,
defined
operational definitions for research
ordinal level of measurement
organizational culture as barrier to connecting research and practice organizational level of collaboration
organizational priorities, and choosing outcomes orientation programs, and personal development outbreak
investigations
outcome-based measurements, described
outcomes
choosing
health outcome information websites
mandated reports
organizational priorities
outcomes and associated indicators
patient population
team membership
described
evaluating
PICOT model
outcomes research, defined
ownership of data and conclusions, ethics of P
pandemic, defined
panel designs, in longitudinal studies papers
collaboration with colleagues
feedback, obtaining
manuscript guidelines
manuscript submission
manuscripts, response time for
writing daily
parallel form testing for reliability
parametric tests
participant observation, in qualitative research participants in qualitative research
ethical principles for consideration
researcher as sampling
passive rejection of innovation
Patient-Centered Outcomes Research Institute patient populations, and choosing outcomes patient-related
outcomes, described
patients, PICOT model
686
patterns, generated from data
PCOR. See patient-centered outcomes research Pearson’s r
peer debriefing
qualitative research, evaluation of
trustworthiness, establishing
peer review, of evidence
percentage distributions
of ages
percentage, symbol for
percentile, defined
percentile ranks, and normal distributions performance appraisals and reviews
performance-related outcomes, described period prevalence, defined
periodicals, as evidence
persistent observation, defined
person, descriptive characteristics by personal development files
performance appraisals and reviews
professional integrity, maintaining
personal narrative, in reports
phenomenology
data collection and management
defined
method
nursing research examples
philosophical underpinnings
reports, formats for
phenomenon descriptions, in nonexperimental designs Phi coefficients
physiological measures
defined
quantitative research data collection PICOT model
pilot
adoption of innovation
data collection methods
studies
place, descriptive characteristics by
plagiarism, citations, ethics of
planning for data collection
point biserials, defined
point prevalence, defined
687
popular literature, as evidence type
population
defined
sample, relationship to
population parameters
position of the median
defined
formula for
positional operators
positive correlation, in associative relationships positive predictive value
defined
positively skewed distribution of data posters
abstracts, writing
colors, selecting
contents included in
defined
effective, creating fonts for
graphics for
logical layout for
poster presentations, making
PowerPoint slides
posttest, defined
power analysis, defined
PowerPoint slides
practice guidelines
characteristics of
syntheses, in pyramid of evidence
practice perspective
research, language of
theory in practice
theory, language of
theory testing, importance of
preceptors, in orientation programs
precision, in searching electronic databases predictive correlational designs
predictive research, defined
predictive validity
preexperimental designs
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) preparation phase of Stetler
model
688
presentations
common mistakes
successful, tips for
pretest, defined
prevalence
primary sources, as type of evidence
print indexes
evidence, searching for
information organization system
PRISMA. See Preferred Reporting Items for Systematic Reviews and Meta-Analyses privacy
IRB area of concern
qualitative research, ethical issue in probability
defined
inferential statistics
probability sampling methods
cluster sampling
simple random sampling
stratified random sampling
systematic random sampling
problem of interest. See also research questions, identifying problem solving
nursing process and research process, differences from nursing process and research process, similarities to
problem statements
defined
developing
professional behaviors
professional integrity, maintaining
professionalism
innovator, developing oneself as
models of
orientation programs
proportion, defined
proposition, defined
propositional knowledge, defined
prospective designs, defined. See also longitudinal designs PsychINFO, literature search
psychometrics, defined
Publication Manual of the American Psychological Association PubMed
PubMed Clinical Queries
purpose statements purposive sampling
nonprobability methods
689
qualitative research
pyramid of evidence
define
overview of
studies
summaries
synopses
syntheses
systems
Q
qualification, defined
qualitative data
levels of
meaning, strategies for generating
qualitative data analysis
data management
explained
qualitative data evaluation
overview of
standards for
trustworthiness, establishing
qualitative data interpretation
conclusions, drawing and verifying
rapid review
reports, writing
qualitative data, meaning of
690
chapter objectives and key terms
ethics
learning, applying
qualitative data analysis
qualitative data evaluation
qualitative data interpretation
rapid review
qualitative designs
691
chapter objectives and key terms
ethics
evidence, appraising
learning, applying
qualitative research, described
qualitative research, types of
comparison of methods
ethnography
grounded theory
historical
phenomenology
rapid review
qualitative evaluation
qualitative research
data collection, common pitfalls in
defined
described
data analysis and interpretation
data collection
evaluation
overview of
sampling
inductive reasoning
quantitative research, comparison to
types of
comparison of methods
ethnography
grounded theory
historical
phenomenology
quality domains, in the AGREE II instrument quality improvement committees
quantitative data, collecting
appraising data collection
case studies
ethics focus groups
692
interviews
issues in
levels of measurement
observation
preparing to go into field
questionnaires
quantitative data, meaning of
693
chapter objectives and key terms
distribution patterns
EBP, meanings for
error, reducing
ethics
frequencies, using to describe samples inferential statistics
learning, applying
measures of central tendency
measures of variability
comparing variability when units of measure are different correlation coefficients
defined
percentile
range
semiquartile range
standard deviation
tailedness: the rule of 68-95-99.7
rapid review
statistical tests, using to infer to populations inferential statistics, terms and symbols used in testing for
differences among group
testing for relationships among variables statistics, using to describe samples quantitative designs
694
chapter objectives and key terms
ethics
evidence, appraising
experimental designs
key principles of
best design, selecting
695
chapter objectives and key terms
designs, purposes of
ethics
learning, applying
rapid review
time dimensions of designs
validity
learning, applying
quasi-experimental designs
rapid review
specific uses for
quantitative research
deductive reasoning
defined
quasi-experimental designs
defined
experimental design, compared to
nonequivalent control group pretest-posttest designs preexperimental designs
time series designs
types of
query letters for manuscripts
questionnaires
consistency of
defined
qualitative data, collecting
quantitative research data collection quota sampling
R
“RAAR” and type I and II errors
random assignment, in quantitative design random error, defined
random sampling, in quantitative design randomization
experimental designs
probability sampling methods
quantitative design
696
randomized controlled trial (RCT)
characteristics of
evidence in quantitative studies, appraising true experimental designs
range, as measure of variability
rate, defined
ratio, defined
ratio level of measurement
RCT. See randomized controlled trial reactivity, and external validity
realist tales
reasoning, ways of
recall, and searching electronic databases reciprocity in qualitative research, ethics of record, defined
record numbers in databases
refereed sources as type of evidence
references, citation guidelines for
referential adequacy
reflexivity
regional level of collaboration
regional resource centers of excellence for EBP
Registered Nurses’ Association of Ontario rejection, defined
relative risk, defined
reliability
attributes of
defined
testing for
replication of studies
replication studies
reports
approaches to reporting qualitative data format for
writing
representativeness of samples
checking for
defined
inclusion and exclusion criteria
nonprobability sampling methods
probability sampling methods
sampling bias
sampling error
steps to ensure
research. See also nursing research defined
697
mixed methods, using
previous, and identifying research problems research articles, components of
special language of
research design, overview of
research hypotheses
defined
null vs.
research question, example for
research imperative, defined
Research in Nursing and Health research integrity
research problem, defined
research process
problem solving and nursing process, differences from problem solving and nursing process, similarities to
research quality
research questions, identifying
698
chapter objectives and key terms
clinical problems guiding research questions
nursing research problems, identifying problem of interest, narrowing
problem solving, nursing process, and research process problem statements, developing
defined
EBP questions, formulating
ethics
hypotheses, developing
defined
evaluation criteria
types of
learning, applying
rapid review
research-related barriers
research topic, defined
research utilization, defined
research variables, in descriptive designs respect for persons
results
dissemination of
results section of research articles
use and misuse of
resuscitation, early methods of, based on untested theory retrospective design
review of literature
research articles, component of
reviews, types of
integrative reviews
meta-analyses
narrative reviews
systematic reviews
understanding, importance of
risk/benefit analysis as IRB area of concern risk-benefit ratios
risk in qualitative research, ethics of Robb, Isabel Hampton
role models, and orientation programs
Royal College of Nursing
Rule of 68-95-99.7, and data distribution rule of 30, for sample size
699
S
safeguards, as IRB area of concern
sample
defined
population, relationship to
sampling, for qualitative research
size, determining
subjects, recruitment and retention of sample statistics, defined
samples, using to provide evidence
ethics
nonprobability methods
probability methods
sample size
sampling, fundamentals of
sampling bias
nonprobability sampling methods
probability sampling methods
representativeness of samples
sampling distribution
sampling error
probability
representativeness of samples
sampling frame, defined
sampling interval, defined
sampling methods nonprobability methods
convenience sampling
overview
purposive sampling
quota sampling
theoretical sampling
probability methods
cluster sampling
simple random sampling
stratified random sampling
systematic random sampling
sampling plan, defined
scales
defined
700
quantitative research data collection “Schäfer method”
Scholarly Inquiry for Nursing Practice scholarly literature, as type of evidence science, evolution of nursing
as
historical overview
scientific development, cycle of
scientific literature publication cycle scientific research, as source of evidence search field, defined
search strategies, general
secondary sources, as type of evidence selection bias
self-awareness, as characteristic of innovators semiquartile range, as measure of variability sense of inquiry, as
characteristic of innovators sensitivity, defined
short-term outcomes, described
short-term wins, in change phases model Sigma Theta Tau International (STTI)
EBP conference
sign test
signed rank test
significance level, and determining sample size simple hypothesis
associative/causal relationships
vs. complex hypotheses defined
directional hypotheses
research question, example for
simple random sampling
skewed distribution of data
kurtosis
negative and positive
snowball sampling
qualitative research
socialization, as characteristic of innovators Solomon four-group designs
limitations of
true experimental design
spatial clustering
Spearman Rho
specificity, defined
split-half reliability
stability, as attribute of reliability staff nurses, and EBP performance criteria stakeholder involvement, change in
standard deviation
measure of variability
normal distribution and percentage distribution symbol for
standard score, symbol for State Boards of Health, mandated reports to statistical conclusion validity, internal
validity statistical hypothesis, defined. See also null hypotheses statistical methods for research
statistical significance and clinical significance, differentiating between statistical symbols for descriptive
701
statistics statistical tables, reading, tips for
statistically significant, defined
statistics
defined
symbols for
using, to describe the sample
Stetler model
stopwords
strategic sampling
stratified random sampling
Street, Annette
STTI. See Sigma Theta Tau International students, assisting, as professional responsibility studies, in pyramid of
evidence
study validity, defined
subject headings, defined
subject reactivity
subject searching, defined
subject selection, as IRB area of concern subjects
recruitment and retention of
of a study, defined
summaries, in pyramid of evidence
survey design, defined
symbols
electronic databases, basic searches of inferential statistics
synopses, in pyramid of evidence
syntheses, in pyramid of evidence
systematic error, defined
systematic random sampling
systematic reviews
defined
reviews, types of
steps in
syntheses, in pyramid of evidence
systems, in pyramid of evidence
T
statistic
tailedness, as measure of variability
target population
702
defined
sample and population, relationship between team leadership skills, developing
team membership
temporal ambiguity, defined
test-retest reliability
testing, for internal validity
Texas Department of Health
The Joint Commission
themes, generated from data
theoretical framework
research articles, component of
research, special language of
theoretical sampling
theory deductive research
defined
inductive research
practice, using in
research using mixed methods
special language of
testing, importance of
theory, research, and practice, linking
703
chapter objectives and key terms
ethics of
learning, applying
rapid review
relationship between
therapeutic imperative, defined
time, categorizing designs according to cross-sectional designs
longitudinal designs
retrospective design
time, descriptive characteristics by
time frames
manuscripts, responses to
quantitative data collection
time series designs
trade literature, as evidence type
trade-offs in qualitative research, ethics of trade publications, as evidence type
tradition, as basis for information
traditional literature review, in pyramid of evidence transferability
defined
qualitative research, evaluation of
trustworthiness, establishing
transitional discharge model for mental health translation/application phase of Stetler model translational
research, for quantitative designs translational research model, described trend studies
trial and error, as source of evidence triangulation
true experimental designs
crossover designs
factorial designs
multiple experimental groups designs
randomized controlled trials, characteristics of Solomon four-group designs
two-group posttest-only designs
two-group pretest-posttest designs
truncation, in searching electronic databases trust in qualitative research, ethics of trustworthiness
confirmability
credibility
defined
704
dependability
qualitative data, establishing for
strategies for meeting criteria
transferability
Tuskegee studies
beneficence, lacking
described
justice, lacking
two-group posttest-only design
two-group pretest-posttest designs
type I errors
defined
null hypotheses
risk of making, adjusting
type II errors
defined
internal validity null hypotheses
risk of making, adjusting
U
uncertainty, about evidence
ungrouped data
unimodal data, defined
unintentional plagiarism
univariate analysis
University of Iowa College of Nursing
University of Iowa Hospitals and Clinics at Iowa City University of North Carolina at Chapel Hill University of
Texas at San Antonio
unstructured observation of qualitative data urgency, sense of, in change phases model U.S. Preventive Services
Task Force (USPSTF) U.S. Surgeon General’s Office
V
validation phase of Stetler model
validity
construct validity
content validity
criterion-related validity
defined
external validity
705
internal validity
and reliability
measurement error
types of
variables
number of, and sample size
relationships and differences, explaining relationships and differences, predicting research, special language of
vision, in the change phases model
visual analog scale
defined
quantitative research data collection vulnerable population in samples, ethics of W
Wald, Lillian
Walter Reed Institute of Research
Western Interstate Commission for Higher Education Western Journal of Nursing Research wheel of
professionalism in nursing
WHI. See Women’s Health Initiative Wilcoxin matched pairs test
wildcards, in searching electronic databases Willowbrook studies
beneficence, lacking
described
justice, lacking
respect for persons, lack of
within-groups design
Women’s Health Initiative (WHI)
World Health Organization
worthiness of a project in qualitative research, ethics of Y
Youth Risk Behavior Surveillance System (YRBSS) Z
z scores
706
Questions to Consider When
Appraising Nursing Studies
Introduction
1. Does the introduction demonstrate the need for the study?
2. Is the problem clearly and concisely identified?
3. Is the problem presented with enough background material to acquaint the reader with the importance
of the problem?
4. Is the purpose of the study clearly stated?
5. Are the terms and variables relevant to the study clearly defined?
6. Are the assumptions clearly and simply stated?
7. If appropriate to the design, are hypotheses stated?
8. Does the study use a theoretical framework to guide its design?
Review of the Literature
1. Is the ROL relevant to the problem?
2. Is the review adequate in terms of the range and scope of ideas, opinions, and points of view relevant
to the problem?
3. Is the review well organized and synthesized?
4. Does the review provide for critical appraisal of the contribution of each of the major references?
5. Does the review conclude with a summary of the literature with implications for the study?
6. Is the ROL adequately and correctly documented?
Methods
1. Is the research approach appropriate?
2. Was the protection of human subjects considered?
3. Are the details of data collection clearly and logically presented?
4. Are the instrument(s) appropriate for the study both in terms of the problem and the approach?
5. Are the instrument(s) described sufficiently in terms of content, structure, validity and reliability?
6. Is the population and the method for selecting the sample adequately described?
7. Is the method for selection of the sample appropriate?
8. Is the sample size sufficient?
9. Is attrition of sample reported and explained?
10. Does the design have controls at an acceptable level for the threats to internal validity?
707
11. What are the limits to generalizability in terms of external validity?
Results
1. Is the presentation of data clear?
2. Are the characteristics of the sample described?
3. Was the best method(s) of analysis selected?
4. Are the tables, charts, and graphs pertinent?
Discussion
1. Are the results based on the data presented?
2. Is the evidence sufficient to draw conclusions?
3. Are the results interpreted in the context of the problem/purpose, hypothesis, and theoretical
framework/literature reviewed?
4. Are the conclusions and generalizations clearly stated?
5. Are the limitations of the findings clearly delineated?
6. Are the generalizations within the scope of the findings or beyond the findings?
7. Does the study contribute to nursing knowledge?
708
Title Page
Copyright
Dedication
Contents
Contributors
Reviewers
Preface
Acknowledgments
Unit 1 Introduction to Evidence-Based Practice
Chapter 1 What Is Evidence-Based Practice?
1.1 EBP: What Is It?
1.2 What Is Nursing Research?
1.3 How Has Nursing Evolved as a Science?
1.4 What Lies Ahead?
1.5 Keeping It Ethical
Chapter 2 Using Evidence Through Collaboration to Promote Excellence in Nursing Practice
2.1 The Five Levels of Collaboration
2.2 Keeping It Ethical
Unit 2 Acquisition of Knowledge
Chapter 3 Identifying Research Questions
3.1 How Clinical Problems Guide Research Questions
3.2 Developing Hypotheses
3.3 Formulating EBP Questions
3.4 Keeping It Ethical
Chapter 4 Finding Sources of Evidence
4.1 Purpose of Finding Evidence
4.2 Types of Evidence
4.3 How Sources Are Organized
4.4 How to Search for Evidence
4.5 Keeping It Ethical
Chapter 5 Linking Theory, Research, and Practice
5.1 How Are Theory, Research, and Practice Related?
5.2 Keeping It Ethical
Unit 3 Persuasion
Chapter 6 Key Principles of Quantitative Designs
6.1 Chart the Course: Selecting the Best Design
6.2 What Is Validity?
6.3 Categorizing Designs According to Time
6.4 Keeping It Ethical
Chapter 7 Quantitative Designs: Using Numbers to Provide Evidence
7.1 Experimental Designs
7.2 Quasi-Experimental Designs
7.3 Nonexperimental Designs
7.4 Specific Uses for Quantitative Designs
7.5 Keeping It Ethical
Chapter 8 Epidemiologic Designs: Using Data to Understand Populations
8.1 Epidemiology and Nursing
8.2 Infectious Diseases and Outbreak Investigations
8.3 Measures of Disease Frequency
8.4 Descriptive Epidemiology
8.5 Descriptive Study Designs
8.6 Analytic Study Designs
8.7 Screening
8.8 Evaluating Health Outcomes and Services
8.9 Keeping It Ethical
Chapter 9 Qualitative Designs: Using Words to Provide Evidence
9.1 What Is Qualitative Research?
9.2 The Four Major Types of Qualitative Research
9.3 Keeping It Ethical
Chapter 10 Collecting Evidence
10.1 Data Collection: Planning and Piloting
10.2 Collecting Quantitative Data
10.3 Validity and Reliability
10.4 Collecting Qualitative Data
10.5 Keeping It Ethical
Chapter 11 Using Samples to Provide Evidence
11.1 Fundamentals of Sampling
11.2 Sampling Methods
11.3 Sample Size: Does It Matter?
11.4 Keeping It Ethical
Chapter 12 Other Sources of Evidence
12.1 The Pyramid of Evidence: The 5 Ss
12.2 Using the Pyramid for Evidence-Based Practice
12.3 Keeping It Ethical
Unit 4 Decision
Chapter 13 What Do the Quantitative Data Mean?
13.1 Using Statistics to Describe the Sample
13.2 Using Frequencies to Describe Samples
13.3 Measures of Central Tendency
13.4 Distribution Patterns
13.5 Measures of Variability
13.6 Inferential Statistics: Can the Findings Be Applied to the Population?
13.7 Reducing Error When Deciding About Hypotheses
13.8 Using Statistical Tests to Make Inferences About Populations
13.9 What Does All This Mean for EBP?
13.10 Keeping It Ethical
Chapter 14 What Do the Qualitative Data Mean?
14.1 Qualitative Data Analysis
14.2 Qualitative Data Interpretation
14.3 Qualitative Data Evaluation
14.4 Keeping It Ethical
Chapter 15 Weighing In on the Evidence
15.1 Deciding What to Do
15.2 Appraising the Evidence
15.3 Clinical Practice Guidelines: Moving Ratings and Recommendations into Practice
15.4 Keeping It Ethical
Unit 5 Implementation
Chapter 16 Transitioning Evidence to Practice
16.1 Evidence-Based Practice Models to Overcome Barriers
16.2 Creating Change
16.3 Keeping It Ethical
Chapter 17 Developing Oneself as an Innovator
17.1 Who Is an Innovator?
17.2 Developing Oneself
17.3 Professionalism
17.4 Keeping It Ethical
Unit 6 Confirmation
Chapter 18 Evaluating Outcomes of Innovations
18.1 What Is an Outcome?
18.2 Choosing Outcomes
18.3 Evaluating the Outcomes
18.4 Keeping It Ethical
Chapter 19 Sharing the Insights with Others
19.1 Dissemination: What Is My Role?
19.2 The 3 Ps of Dissemination
19.3 Using Technology to Disseminate Knowledge
19.4 Making the Most of Conferences
19.5 Keeping It Ethical
Glossary
Index
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