Describe the cycle of scientific development

Describe the cycle of scientific development
Appraisal and Application of




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THE PEDAGOGY Evidence-Based Practice for Nurses: Appraisal and Application of Research, Fourth Edi-tion, drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most chapters include the following:

Chapter 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.

At the end of this chapter, you will be able to:

Key terms

CHAPter OBJeCtiVes

‹ Define evidence-based practice (EBP) ‹ List sources of evidence for 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

abstract applied research barriers basic research cycle of scientific

development 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 theory Tuskegee study Willowbrook studies

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Critical Thinking Exercises As an integral part of the learning process, the authors present scenarios and questions to spark insight into situations faced in practice.

Test Your Knowledge These questions serve as benchmarks for the knowledge acquired throughout the chapter.

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 bleed- ing 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, resulting in more reliable results.

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

tEst YOur knOWlEdgE 18-3


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


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.

498 ChaptER 18 Evaluating Outcomes of Innovations

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treatment of human response, and advocacy in the care of individuals, fami- lies, communities, and populations” (ANA, 2003, p. 6). From the early days of the profession, students 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.

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.

CRiTiCAL THinking ExERCisE 5-2

A nurse on a surgical floor observes that several new approaches are being used to dress wounds. She observes that some methods appear to promote healing faster than others do. 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?

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5.1 How Are Theory, Research, and Practice Related? 141

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FYI Quick tidbits and facts are pulled out in chapter margins to highlight important aspects of the chapter topic.


Rapid Review This succinct list at the end of the chapter compiles the most pertinent and key information for quick review and later reference.

Apply What You Have Learned This outstanding feature applies newly acquired knowledge to specific evidence-based practice scenarios and research studies.

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 commentar- ies, summaries, reviews, or interpretations of primary sources.

» Many research journals involve peer review.

» There are many ways to categorize sources. Scholarly, trade, and 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 data- bases. Topics, subject matter, and format may vary but all include citation information.

» Helpful strategies to use when conducting a search include cita- tion chasing, measurements of recall and precision, keyword and controlled vocabulary searches, Boolean operators, truncation,

4.5 Keeping It Ethical 129

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reFerenCes Aitken, L. M., Hackwood, B., Crouch, S., Clayton, S., West, N., Carney, D., &

Jack, L. (2011). Creating an environment to implement and sustain evidence based practice: A developmental process. Australian Critical Care, 24, 244–254.

American Medical Association. (1998). Information from unethical experiments (CEJA Report 5–A-98). Retrieved from http://www.ama-assn .org/resources/doc/code-medical-ethics/230a.pdf

American Nurses Association. (2010). National Database of Nursing Quality Indicators: Guidelines for data collection on the American Nurses Association’s National Quality forum endorsed measures: Nursing Care Hours per Patient Day, Skill Mix, Falls, Falls with Injury. Retrieved from care%20service/nursestaffing7-13-10materials.ashx

Barnsteiner, J., & Prevost, S. (2002). How to implement evidence-based practice. Some tried and true pointers. Reflections on Nursing Leadership, 28(2), 18–21.

Barta, K. M. (1995). Information-seeking, research utilization, and barriers to research utilization of pediatric nurse educators. Journal of Professional Nursing, 11, 49–57.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.

aPPlY What YOu havE lEarnED

Sign into a database for nursing literature (i.e., CINAHL, ProQuest, PubMed). For this chapter, 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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36 CHAPter 1 What Is Evidence-Based Practice?

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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.

Some researchers claim their work is nursing research because the researcher is a nurse or because the researcher studied nurses. But it is the focus on nurs- ing practice that defines nursing research. The mere fact that the research 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 methods of Resuscitation: An Example of Practice Based on Untested Theory

T hroughout 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.

136 CHAPTER 5 Linking Theory, Research, and Practice

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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 infor- mation sheets, and designing, promoting, and delivering short courses about EBP.

2.2 keeping It Ethical

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 pro- tecting 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 stud- ies have rights, and all nurses are obligated to protect those rights.

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.

Key Terms human rights: Freedoms to which all humans are entitled

obligations: Requirements to act in particular ways

At the end of this section, you will be able to:

‹ Discuss international and national initiatives designed to promote ethical conduct ‹ Describe the rights that must be protected and the three ethical principles that must 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

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Keeping It Ethical Relevant ethical content concludes each chapter to ensure that ethics are a consideration during every step of the nursing process.


Appraisal and Application of


Edited by Nola A. Schmidt, PhD, RN, CNE

Professor College of Nursing and Health Professions

Valparaiso University Valparaiso, Indiana

Janet M. Brown, PhD, RN Professor Emeritus

College of Nursing and Health Professions Valparaiso University Valparaiso, Indiana




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Library of Congress Cataloging-in-Publication Data Names: Schmidt, Nola A., editor. | Brown, Janet M. (Janet Marie), 1947– editor. Title: Evidence-based practice for nurses : appraisal and application of research / [edited by] Nola A. Schmidt and Janet M. Brown. Description: Fourth edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017036581 | ISBN 9781284122909 Subjects: | MESH: Nursing Research–methods | Evidence-Based Nursing Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072–dc23 LC record available at


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DEDICATION For Mom, whose love and support are endless.

—N. A. S.

To my husband, my children, and my granddaughters and grandson, who enrich my life in every way.

—J. M. B.

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Contributors xix Reviewers xxi Preface xxiii Acknowledgments xxix

UNIT 1 Introduction to Evidence-Based Practice 1

CHAPTER 1 What Is Evidence-Based Practice? 3 Nola A. Schmidt and Janet M. Brown

1.1 EBP: What Is It? 3 1.2 What Is Nursing Research? 14 1.3 How Has Nursing Evolved as a Science? 23 1.4 What Lies Ahead? 31 1.5 Keeping It Ethical 34


CHAPTER 2 Using Evidence Through Collaboration to Promote Excellence in Nursing Practice 43 Emily Griffin and Marita G. Titler

2.1 The Five Levels of Collaboration 43 2.2 Keeping It Ethical 54

UNIT 2 Acquisition of Knowledge 67

CHAPTER 3 Identifying Research Questions 69 Susie Adams

3.1 How Clinical Problems Guide Research Questions 69

3.2 Developing Hypotheses 77 3.3 Formulating EBP Questions 84 3.4 Keeping It Ethical 87

CHAPTER 4 Finding Sources of Evidence 93 Patricia Mileham

4.1 Purpose of Finding Evidence 93 4.2 Types of Evidence 96 4.3 How Sources Are Organized 102 4.4 How to Search for Evidence 110 4.5 Keeping It Ethical 123

CHAPTER 5 Linking Theory, Research, and Practice 131 Elsabeth Jensen

5.1 How Are Theory, Research, and Practice Related? 131

5.2 Keeping It Ethical 141


UNIT 3 Persuasion 147

CHAPTER 6 Key Principles of Quantitative Designs 149 Rosalind M. Peters

6.1 Chart the Course: Selecting the Best Design 149 6.2 What Is Validity? 155 6.3 Categorizing Designs According to Time 161 6.4 Keeping It Ethical 166

CHAPTER 7 Quantitative Designs: Using Numbers to Provide Evidence 171 Rosalind M. Peters

7.1 Experimental Designs 171 7.2 Quasi-Experimental Designs 177 7.3 Nonexperimental Designs 180 7.4 Specific Uses for Quantitative Designs 186 7.5 Keeping It Ethical 188

CHAPTER 8 Epidemiologic Designs: Using Data to Understand Populations 193 Amy C. Cory

8.1 Epidemiology and Nursing 193 8.2 Infectious Diseases and Outbreak

Investigations 195 8.3 Measures of Disease Frequency 197 8.4 Descriptive Epidemiology 200 8.5 Descriptive Study Designs 204


8.6 Analytic Study Designs 208 8.7 Screening 213 8.8 Evaluating Health Outcomes and Services 215 8.9 Keeping It Ethical 216

CHAPTER 9 Qualitative Designs: Using Words to Provide Evidence 221 Kristen L. Mauk

9.1 What Is Qualitative Research? 221 9.2 The Four Major Types of Qualitative

Research 230 9.3 Keeping It Ethical 244

CHAPTER 10 Collecting Evidence 253 Jan Dougherty

10.1 Data Collection: Planning and Piloting 253 10.2 Collecting Quantitative Data 255 10.3 Validity and Reliability 263 10.4 Collecting Qualitative Data 271 10.5 Keeping It Ethical 278

CHAPTER 11 Using Samples to Provide Evidence 285 Ann H. White

11.1 Fundamentals of Sampling 285 11.2 Sampling Methods 290 11.3 Sample Size: Does It Matter? 299 11.4 Keeping It Ethical 302


CHAPTER 12 Other Sources of Evidence 309 Cynthia L. Russell

12.1 The Pyramid of the 5 Ss 309 12.2 Using the Pyramid of the 5 Ss for Evidence-Based

Practice 320 12.3 Keeping It Ethical 324

UNIT 4 Decision 329

CHAPTER 13 What Do the Quantitative Data Mean? 331 Rosalind M. Peters, Nola A. Schmidt, and Moira Fearncombe

13.1 Using Statistics to Describe the Sample 331 13.2 Using Frequencies to Describe Samples 333 13.3 Measures of Central Tendency 337 13.4 Distribution Patterns 341 13.5 Measures of Variability 344 13.6 Inferential Statistics: Can the Findings

Be Applied to the Population? 352 13.7 Reducing Error When Deciding About

Hypotheses 355 13.8 Using Statistical Tests to Make Inferences About

Populations 361 13.9 What Does All This Mean for EBP? 370 13.10 Keeping It Ethical 373

CHAPTER 14 What Do the Qualitative Data Mean? 379 Kristen L. Mauk

14.1 Qualitative Data Analysis 379


14.2 Qualitative Data Interpretation 385 14.3 Qualitative Data Evaluation 391 14.4 Keeping It Ethical 396

CHAPTER 15 Weighing In on the Evidence 403 Carol O. Long

15.1 Deciding What to Do 403 15.2 Appraising the Evidence 405 15.3 Clinical Practice Guidelines: Moving Ratings and

Recommendations into Practice 414 15.4 Keeping It Ethical 417

UNIT 5 Implementation 423

CHAPTER 16 Transitioning Evidence to Practice 425 Maria Young

16.1 Evidence-Based Practice Models to Overcome Barriers 425

16.2 Creating Change 435 16.3 Keeping It Ethical 443

CHAPTER 17 Developing Oneself as an Innovator 449 Diane McNally Forsyth

17.1 Who Is an Innovator? 449 17.2 Developing Oneself 454 17.3 Professionalism 461 17.4 Keeping It Ethical 464


UNIT 6 Confirmation 469

CHAPTER 18 Evaluating Outcomes of Innovations 471 Kathleen A. Rich

18.1 What Is an Outcome? 471 18.2 Choosing Outcomes 473 18.3 Evaluating the Outcomes 480 18.4 Keeping It Ethical 482

CHAPTER 19 Sharing the Insights with Others 489 Janet M. Brown and Nola A. Schmidt

19.1 Dissemination: What Is My Role? 489 19.2 The 3 Ps of Dissemination 491 19.3 Using Technology to Disseminate

Knowledge 505 19.4 Making the Most of Conferences 507 19.5 Keeping It Ethical 509

Glossary 514 Index 531


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Susie Adams, PhD, RN, PMHNP, FAANP Professor and Director PMHNP Program School of Nursing Vanderbilt University Nashville, Tennessee

Janet M. Brown, PhD, RN Professor Emeritus Valparaiso University Valparaiso, Indiana

Amy C. Cory, PhD, MPH, RN, CPNP, PC Associate Professor College of Nursing and Health Professions Valparaiso University Valparaiso, Indiana

Jan Dougherty, MS, RN, FAAN Director Family and Community Services Banner Alzheimer’s Institute Phoenix, Arizona

Moira Fearncombe, MEd, BS Lake Barrington, Illinois

Diane McNally Forsyth, PhD, RN Professor Graduate Programs in Nursing Winona State University Rochester, Minnesota

Emily Griffin, MSN, ARNP, FNP-BC Lecturer 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, FAAN 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

Director RN-BSN and MSN Programs Colorado Christian University Lakewood, Colorado

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 La Porte Hospital La Porte, Indiana

Cynthia L. Russell, PhD, RN, ACNS-BC, FAAN 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 Department Chair Systems, Populations

and Leadership 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 Assistant Professor Indiana University Northwest College of Health and Human Services Gary, Indiana


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Billie Blake, EdD, MSN, BSN, RN, CNE Associate Dean of Nursing BSN Director Professor St. John’s River State College Orange Park, Florida

Tish Conejo, PhD, RN Professor MidAmerica Nazarene University Olathe, Kansas

Patricia Grust, PhD, RN, CLNC Clinical Associate Professor Hartwick College Oneonta, New York

Susan Montenery, DNP, RN, CCRN Assistant Professor of Nursing Coastal Carolina University Conway, South Carolina

Chantel H. Murray, MSN, MBA, RN Professor/Clinical Expert Eastern University St. Davids, Pennsylvania

Catherine A. Schmitt, PhD, RN, CNOR Assistant Professor University of Wisconsin, Oshkosh Menasha, Wisconsin

Cynthia Softhauser, PhD, MSN, RN, AHN-BC, CNE

Associate Professor Indiana University South Bend Mishawaka, Indiana

Susan Steele-Moses, DNS, APRN-CNS, AOCN Academic Research Director Our Lady of the Lake College Baton Rouge, Louisiana

Cathy J. Thompson, PhD, RN, CCNS, CNE Visiting Professor University of Colorado, Colorado Springs South Fork, Colorado


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We are most pleased to offer the Fourth Edition of this text. For this revision, we have extensively altered the “Apply What You Have Learned” feature. The new topic is adherence with hand hygiene, changed from medication errors in the last edition. We selected this clinical problem because it involves all healthcare providers in all settings and significantly impacts patient outcomes. Additionally, nurse educators are well-positioned to help students gain an appreciation for hand hygiene guidelines and build good hand hygiene habits. This feature continues to unfold 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.

A new feature of the textbook includes two diagrams that summarize sta- tistical analyses (Chapter 13) and designs (back cover). In response to user feedback, we updated the “Hierarchy of Evidence” to include types of evidence for each level. In Chapter 12, we made edits to the 5 Ss to better distinguish this hierarchy from the Hierarchy of Evidence.

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 teach students educational strategies that develop a lifelong commitment to examining nursing practice critically in light of scientific advances. Although many texts and references deal with the principles, methods, and ap- praisal 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 edition of this textbook continues to provide substantive strate- gies to assist students with applying evidence at the point of care.

The American Association of Colleges of Nursing (AACN) charges nursing programs with preparing 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 nurs- ing 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 hand hygiene 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.

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.

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 more consistency between chapters in this edition. The Hierarchy of Evidence and questions to consider when appraising nursing studies are printed inside the back cover for easy reference.

The unique feature of integrating ethical content throughout the chapters remains. Organizing content in this manner helps 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 Third 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 each subsection 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.

New challenges arose while we wrote this Fourth 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, we have significantly transformed the Apply What You Have Learned exercise for Chapter 4. Students are provided with directions 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, we have included a table below contain- ing the evidence used throughout the Apply What You Have Learned exercises.

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.

Citation Chapter(s) Search Terms (Limiters)

Articles to Search in CINAHL

Al-Hussami, M., Darawad, M., & Almhairat, I. I. (2011). Predictors of compliance handwashing practice among healthcare professionals. Healthcare Infection, 16, 79–84.

4, 7 Al-Hussami (author) “handwashing practice” (all fields)

Al-Tawfiq, J. A., & Pittet, D. (2013). Improving hand hygiene compliance in healthcare settings using behavior change theories: Reflections. Teaching and Learning in Medicine, 25, 374–382.

4, 5 Al-Tawfiq (author) Pittet (author) “reflections” (title)

Chhapola, V., & Brar, R. (2015). Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit. International of Nursing Practice, 21, 486–492.

1, 4, 8 Chhapola (author)


Citation Chapter(s) Search Terms (Limiters)

Articles to Search in CINAHL

Chun, H., Kim, K., & Park, H. (2015). Effects of hand hygiene education and individual feedback on hand hygiene behavior, MRSA, acquisition rate, and MRSA colonization pressure among intensive care unit nurses. International Journal of Nursing Practice, 21, 709–715.

4, 6, 7 Chun (author) “individual feedback” (all fields)

Dyson, J., Lawton, R., Jackson, C., & Cheater, F. (2013). Development of a theory-based instrument to identify barriers and louvers to best hand hygiene practice among healthcare practitioners. Implementation Science, 8(111), 1–9.

4, 10 Dyson (author) Lawton (author) “barriers” (all fields)

Fakhry, M., Hannah, G. B., Anderson, O., Holmes, A., & Nathwain, D. (2012). Effectiveness of an audible reminder on hand hygiene adherence. American Journal of Infection Control, 40, 320–323.

4, 6, 7 “audible reminder” (title) “hand hygiene” (title)

Huis, A., Schoonhoven, L., Grol, R., Donders, R., Hulscher, M., & van Achterber, T. (2014). Impact of a team and leaders-directed strategy to improve nurses’ adherence to hand hygiene guidelines: A cluster randomized trial. International Journal of Nursing Studies, 50, 464–474.

4, 7 Huis (author) Donders (author)

Jackson, C., Lowton, K., & Griffiths, P. (2014). Infection prevention as “a show”: A qualitative study of nurses’ infection prevention behaviours. International Journal of Nursing Studies, 51, 400–408.

4, 9, 14 Jackson (author) Lowton (author) “International Journal of Nursing Studies” (publication name)

Johnson, L., Jrueber, S., Schlotzhauer, C., Phillips, E., Bullock, P., Basnett, J., & Hahn-Cover, K. (2014). A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections. American Journal of Infection Control, 42, 1146–1151.

4 Johnson (author) “multifactorial action plan” (all fields)

Kingston, L., O’Connell, N. H., & Dunne, C. P. (2016). Hand hygiene-related clinical trials reported since 2010: A systematic review. Journal of Hospital Infection, 92, 309–320.

4, 12 Kingston (author) “systematic review” 2016 (publication date)

Mortell, M. (2012). Hand hygiene compliance: Is there a theory-practice-ethics gap? Infection Control, 21, 1011–1014.

3 Mortell (author) 2012 (publication date)


Citation Chapter(s) Search Terms (Limiters)

Articles to Search in CINAHL

Salmon, S., & McLaws, M. (2015). Qualitative findings from focus group discussion on hand hygiene compliance among health care workers in Vietnam. American Journal of Infection Control, 43, 1086–1091.

1, 4, 9 Salmon (author) McLaws (author)

Whitby, M., & McLaws, M. (2007). Methodological difficulties in hand hygiene research. Journal of Hospital Infection, 67, 194–195.

4, 10 Whitby (author) “methodological difficulties” (title)

Obtain From JBI

Nguyen, P. (2016). Hand hygiene: Alcohol-based solutions. The Joanna Briggs Institute.


Citation Chapter(s) URLs

Sources From the Web

National Cancer Institute 2 .php

Bromwich, J. E. (2016, April 20). You’ve been washing your hands wrong. New York Times.

12 /health/washing-hands.html?_r=0

Emotional Intelligence (EQ) Assessment 17

The New Enneagram Test 17

World Health Organization 3 /Hand_Hygiene_Why_How_and_When _Brochure.pdf?ua=1

Available in the Digital Resources

Resource Chapter

Grid 4 Visit this text’s accompanying digital resources to find links to these materials.

Poster guideline for making an EBP poster presentation



REFERENCES Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press. Schmidt, N. A., & Brown, J. M. (2007). Use of the innovation–decision process teach-

ing strategy to promote evidence-based practice. Journal of Professional Nursing, 23, 150–156.

xxviii PREFACE

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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. The efforts of Karen Stacy, Patti Reid, and Julie Ault to protect sacred writing times were instru- mental in allowing us to meet deadlines. Without their help and understand- ing, writing sessions would not have been as productive as they were. Special thanks are in order for Jones & Bartlett Learning staff, especially Amanda Martin, Christina Freitas, and Alex Schab, who offered invaluable editorial assistance. We are grateful for the ways Jones & Bartlett has developed and marketed the book over the four 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.


Introduction to Evidence-Based Practice


Without evidence, clinical practice cannot advance scientifically.

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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

abstract applied research barriers basic research cycle of scientific

development deductive reasoning descriptive research discussion section early adopters empirical evidence evidence-based practice


evidence hierarchy 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 qualitative research quantitative research replication study research research utilization results section review of literature theoretical framework theory Tuskegee study Willowbrook studies

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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

What Is Evidence-Based Practice? Nola A. Schmidt and Janet M. Brown

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 mem- ber 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?


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) classic 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 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 prefer- ences and needs are the basis of care decisions and therefore essential to EBP.

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, 2015), 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 estab- lished a collaboration “to promote evidence-informed health decision-making by producing high-quality, relevant, accessible systematic reviews and other synthesized research evidence ” (Cochrane Collaboration, 2017). 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). Why? Many nursing questions cannot be answered by a single study, and human conditions are not always amenable to clinical trials. Also, the research

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 nurs- ing research, some of which build a stronger case than others do.

KEY TERMS evidence-based practice (EBP): Practice based on the best available evidence, patient preferences, and clinical judgment

research utilization: Changing practice based on the results of a single research study

4 CHAPTER 1 What Is Evidence-Based Practice?

utilization process does not place value on the importance of clinical decision making, nor is it noted for being patient focused.

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

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 guidelines 3. Critically appraise evidence 3. Decision

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)

TABLE 1-1 Models of EBP

Look carefully at the steps in each EBP model cited in Table 1-1. Are you reminded of a similar process?


1.1 EBP: What Is It? 5

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.

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 on 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 ap- proach 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 interven- tion. 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” (IA Users Club, Inc., 2015, p. 1). Whereas on very rare occasions a “gut feeling” may be reliable, most patients would prefer health care that is based on stronger evi- dence. 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

6 CHAPTER 1 What Is Evidence-Based Practice?

to borrow evidence from other disciplines. For example, pediatric nurses rely heavily on theories of development as a basis for nursing interventions. Bor- rowed 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 tradi- tion, authority, trial and error, personal experience, and intuition.

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, random controlled studies are considered more strongly designed than correlational or descriptive studies. When multiple studies have been conducted about a particular topic, the findings of the studies can be combined into a systematic review, which can be used with even more confidence. To rank evidence from lowest to highest, nurses refer to the evidence hierarchy (Figure 1-1). You will find the need to frequently refer to this figure as you learn about research designs and appraising evidence.

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. Consider the history of controlling scurvy in the British Navy.

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

KEY TERMS theory: A set of concepts linked through propositions to explain a phenomenon

evidence hierarchy: A model showing how evidence can be categorized from strong to weak

barriers: Factors that limit or prevent change

1.1 EBP: What Is It? 7

I• Meta-analysis • Systematic reviews of RCTs • Current practice guidelines

II • Randomized controlled trials

III • Controlled trials without randomization (quasi-experimental)

IV• Cohort studies (epidemiologic) • Case-controlled studies (epidemiologic)

V • Systematic review of descriptive studies • Systematic review of qualitative studies (meta-synthesis) • Correlational studies

VI • Single descriptive study • Single qualitative study • Case series studies (epidemiologic) • Case reports • Concept analysis

VII• Opinion of authorities • Reports of expert committees • Manufacturer’s recommendations • Traditional literature reviews



FIGURE 1-1 Evidence Hierarchy

8 CHAPTER 1 What Is Evidence-Based Practice?

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 supple- ments. 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 ad- opted 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 be- ing 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.

(Modified with the permission of Simon & Schuster Publishing Group from the Free Press edition of Diffusion of Innovations, 5th Edition, by Everett M. Rogers. Copyright ©1995, 2003 by Everett M. Rogers. 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. 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. More recently, 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. This was confirmed by Warren et al. (2016), who compared perception of nurses who worked at Magnet facilities with those who did not. They found that nurses working at Magnet hospitals thought that their organizations were equipped to implement EBP. They also found that younger RNs who were newer to practice were more likely to have positive beliefs about EBP.

KEY TERM innovation: Something new or novel

1.1 EBP: What Is It? 9

Overcoming Barriers Studies demonstrate that the reasons nurses do not draw on research are related to individual and organizational factors. Individual factors are those charac- teristics 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 (Paris, Callahan, & Pierson, 2011), organizational culture, and the inability of individuals to evaluate nursing research have been identified as barriers by registered nurses (Majid et al., 2011; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012; Solomons & Spross, 2011; Van Patter Gale & Schaffer, 2009), clinical nurse specialists and educators (Malik, McKenna, & Plummer, 2016), nurse managers (Spieres, Lo, Hofmeyer, & Cummings, 2016), and chief nurse executives (Melnyk et al., 2016).

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; Pen- nington, Moscatel, Dacar, & Johnson, 2010; Reicherter, Gordes, Glickman, & Hakim, 2013; Valente, 2010). Practical strategies for successfully overcoming these barriers are summarized in Table 1-2.

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 practice. The model of diffusion of innovations (Rogers, 2003) has been used in the nursing literature for this purpose (L’Esperance & Perry, 2016; Schmidt & Brown, 2007; Van Patter Gale & Schaffer, 2009). You are already familiar with the concept of diffusion. From studying chemistry you know that diffusion

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.


KEY TERM model of diffusion of innovations: Model to assist in understanding how new ideas come to be accepted practice

10 CHAPTER 1 What Is Evidence-Based Practice?

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. 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.

TABLE 1-2 Strategies for Overcoming Barriers to Adopting an EBP

1.1 EBP: What Is It? 11

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 communi- cated 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.

Barrier Strategy

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).

12 CHAPTER 1 What Is Evidence-Based 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 (Figure 1-2).

KEY TERMS early adopters: Individuals who are the first to embrace an innovation

laggards: Individuals who are slow or fail to adopt an innovation

Fastest Growing Consumer Technologies





Color TV




Home computer

Electric power


Clothes dryer

Air conditioning

Clothes washer


Dish washer


0 10 20 30 40 50 60 70 80

Years to penetration of US households

0-50% 51%-80%

FIGURE 1-2 Diffusion of Technological Innovations Over Time

Courtesy of Asymco.

1.1 EBP: What Is It? 13

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?


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

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, 2016). 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.

14 CHAPTER 1 What Is Evidence-Based Practice?

Following a systematic approach (Box 1-1) 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.

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, effective- ness 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.

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 defini- tions, it will become clear.

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.

BOX 1-1 Steps of the Research Process

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.

KEY TERMS research: Systematic study that leads to new knowledge and/or solutions to problems or questions

replication studies: Repeated studies to obtain similar results

descriptive research: A category of research that is concerned with providing accurate descriptions of phenomena

explanatory research: Research concerned with identifying relationships among phenomena

predictive research: Research that forecasts precise relationships between dimensions of phenomena or differences between groups

basic research: Research to gain knowledge for the sake of gaining knowledge; bench research

1.2 What Is Nursing Research? 15

One way to classify research is by its aims. Descriptive research answers “What is it?” This category of research is concerned with providing accurate descrip- tions 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 pre- cise relationships between dimensions of phenomena or differences between groups. This category of research addresses when the phenomena will occur. Table 1-3 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 find- ings typically have immediate application to bring about changes in practice, education, or administration.

KEY TERMS applied research: Research to discover knowledge that will solve a clinical problem

quantitative research: Research that uses numbers to obtain precise measurements

qualitative research: Research that uses words to describe human behaviors

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)

Predict 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.

TABLE 1-3 An Example of Building Knowledge in Nursing Science: Pain and Chest Tube Removal (CTR)

16 CHAPTER 1 What Is Evidence-Based Practice?

Study Aim of Research Findings

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)

Predict 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.

Puntillo & Ley (2004)

Predict 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 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.

Pinheiro et al. (2015)

Predict Patients were randomly assigned to either an experimental group that received 1% subcutaneous lidocaine or a control group that received a combination of inflammatory agents and opioids. There was no significant difference in pain reported by patients.

Note: CTR = chest tube removal.

1.2 What Is Nursing Research? 17

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. Sometimes, researchers even combine quantitative and qualita- tive methods in the same study.

Quantitative researchers views the world as objective. This implies that re- searchers 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. Some study designs typically as- sociated with quantitative methods include descriptive survey, correlational, quasi-experimental, and experimental designs. For example, a nurse researcher may measure patient satisfaction with nursing care by having them complete a survey to rate their satisfaction, using a scale of 0–5.

In contrast, the premise of qualitative research is that the world is not ob- jective. 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. Some methods that are recog- nized as qualitative include phenomenology, grounded theory, ethnography, and historical. For example, a nurse researcher may measure patient satisfac- tion with nursing care by conducting individual interviews and summarizing common themes that patients expressed. Table 1-4 provides a comparison of these two approaches.

Another important point about quantitative and qualitative approaches is that there are two styles of reasoning associated with them. Deductive reasoning,

When you look at the word “quantitative,” what root word do you see? Do you see that it comes from the word “quantity”? So, one knows that the focus will be on numbers.


When you look for the root word in “qualitative,” do you see the word “quality”? This shows that the emphasis is on words, rather than on numbers.


KEY TERMS empirical evidence: Evidence that is verifiable by experience through the five senses or experiment

deductive reasoning: Thinking that moves from the general to the particular

18 CHAPTER 1 What Is Evidence-Based Practice?

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 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 1-3).

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

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

Possible designs Descriptive Survey Correlational Quasi-experimental Experimental

Phenomenological Ethnographic Grounded Theory Historical

TABLE 1-4 Comparisons of Quantitative and Qualitative Approaches

KEY TERMS inductive reasoning: Thinking that moves from the particular to the general

abstract: The first section of a research article that provides an overview of the study

1.2 What Is Nursing Research? 19

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 retriev- ing articles that are not applicable to the clinical question.

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.

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





FIGURE 1-3 Ways of Reasoning

KEY TERMS introduction: Part of a research article that states the problem and purpose

review of literature: An unbiased, comprehensive, synthesized description of relevant previously published studies

20 CHAPTER 1 What Is Evidence-Based Practice?

gaps in the knowledge base to show readers how the study adds to existing knowledge.

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 con- cepts and provides linkages to what is being measured in the study. Authors frequently use a model or diagram to explain their theoretical framework.

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 re- search 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 regard- ing how the study was implemented.

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.

The body of a research article concludes with a discussion section. Authors provide an interpretation of the results and discuss how the findings ex- tend 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.

The article concludes with the list of references that are cited in the ar- ticle. 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 sec- tion, it is wise for readers to obtain a copy of the entire article, including the reference list.

KEY TERMS 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

methods section: Major portion of a research article that describes the study design, sample, and data collection

results section: Component of a research article that reports the methods used to analyze data and characteristics of the sample

discussion section: Portion of a research article where interpretation of the results and how the findings extend the body of knowledge are discussed

list of references: Publication information for each article cited in a research report

1.2 What Is Nursing Research? 21

How Research Is Different from EBP Research and EBP complement one another, but it is important to understand how they differ. Research is about generating new knowledge, and EBP is about applying new knowledge to practice. Research questions are often posed when a gap in the literature is discovered. For example, perhaps all of the studies about the effect of relaxation on anxiety have been done about adults. Because only adults have been studied, a gap in the literature exists about the effect of relaxation on anxiety in adolescents. In contrast, most EBP questions are raised while nurses are providing care to patients. Research is a scientific process that involves collecting and analyzing data from research subjects to evaluate the findings in light of the research question that is posed. While EBP also involves analysis of data, the data are about patients, and the analysis focuses on whether or not patient outcomes have improved (see Table 1-5).

Research EBP

Generates new knowledge Applies new knowledge to point of care

Fills gap in literature Based on evidence in literature

Research question Clinical question

Subjects Patients

Designed to describe a phenomenon, find a relationship, or test an intervention

Designed to change practice in clinical setting

Analysis of data Analysis of data

Evaluates findings in light of research question

Evaluates practice change by measuring patient outcomes

TABLE 1-5 Comparison of Research and EBP


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

22 CHAPTER 1 What Is Evidence-Based Practice?

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

Nursing has been described as both an art and a science. Historically, the em- phasis 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 reaf- firming 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 1-4 depicts the cycle of scientific development. Scientists begin by developing grand theories to explain phenomena. A grand theory is a broad general- ization 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 dis- seminate research findings. Findings are applied to patient care, resulting in changes in practice, and are used to refine established theories and pro- pose 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.

KEY TERM cycle of scientific development: A model of the scientific process

1.3 How Has Nursing Evolved as a Science? 23

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 educa- tion and recommended that advanced educational preparation for nurses was





Social & political factors

FIGURE 1-4 Cycle of Scientific Development

24 CHAPTER 1 What Is Evidence-Based Practice?

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 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 morbid- ity 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.

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 Foun- dation (1955), the Walter Reed Institute of Research (1957), and the National League for Nursing Research for Studies Service (1959), were established. The

FYI In the early 1900s, nursing research was primarily focused on education preparation.

1.3 How Has Nursing Evolved as a Science? 25

availability of funds 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 Cumula- tive 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 evolu- tion 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 expos- ing 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 applica- tion of nursing research. The Lysaught Report (1970) confirmed that research focusing on clinical problems was essential but that research on nursing edu- cation 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.

26 CHAPTER 1 What Is Evidence-Based Practice?

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 in- volving 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 de- mand 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.

1.3 How Has Nursing Evolved as a Science? 27

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 be- came 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 move- ment (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 consid- ered a political priority, remained elusive throughout the decade. Although the H.R. 3962—Affordable Health Care for America Act—was passed, significant changes had yet to be implemented.

28 CHAPTER 1 What Is Evidence-Based Practice?

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 Box 1-2 for a listing of the current NDNQI measures. Many of these measures are used by hospitals that have received Magnet Recognition for nursing excellence.

Staffing and Workforce Indicators

Hospital Readmission Rates

Psychiatric Physical/Sexual Assault Rate

Catheter-Associated Urinary Tract Infection Rate

Central Line–Associated Bloodstream Infection Rate

Patient Falls

Pressure Injury Prevalence

Nurse Turnover

Pediatric Pain Assessment

Pediatric Peripheral IV Infiltration Rate

Restraint Prevalence

RN Education/Specialty Certification

RN Survey

Practice Environment Scale Job Satisfaction

Ventilator-Associated Pneumonia Rate

Data from Press Ganey National Database of Nursing Quality Indicators® (2016). Nursing-Sensitive Quality Indicators. Personal communication from

BOX 1-2 2016 NDNQI Measures

1.3 How Has Nursing Evolved as a Science? 29

Another significant accomplishment during this time was the mapping of human genes. Conducted by the Human Genome Project (HGP), an interna- tional 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 Despite the growth in nursing research and the focus on evidence-based practice, improvement of patient outcomes is lagging. Evidence shows that hospitals are not meeting core benchmarks in these areas. In a study by Mylnek et al. (2016), a third of hospitals failed to meet NDNQI performance metrics. Additionally, oversight of the NDNQI shifted from the ANA to Press Ganey. This change is congruent with the stronger emphasis that is being placed on benchmarking, using national data and a trend toward withholding reimburse- ment to organizations that do not meet these critical indicators. For example, there have been reductions in Medicaid reimbursement to organizations that have patient satisfaction scores below a certain cutoff. This trend highlights the need for nursing research about new interventions that improve patient outcomes and strategies for translating these findings into practice.

Since 2010, the Affordable Care for America Act has been passed, and changes to this act are on the horizon. Thus, nurses will be able to glean potential re- search questions as healthcare policy evolves. 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.

Globalization continues to be an important social factor in health care. For example, globalization contributes to an increasing threat of pandemic. Outbreaks of Ebola and Zika provide challenges that may be addressed through nursing research. 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.

30 CHAPTER 1 What Is Evidence-Based Practice?

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.



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

The electronic medical record (EMR) is fast becoming standard in health care. Concerns about the protection of personal information are paramount. Additionally, 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.

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, nurs- ing 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

1.4 What Lies Ahead? 31

health care. Middle range and practice theories that are more useful in clini- cal 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 Box 1-3.

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 impor- tance of basing patient care on evidence. Educators need to create innovative


Chronic illness

Cultural and ethnic considerations

End-of-life/palliative care



Healthcare delivery systems

Health disparities

Health promotion


Management of pandemics/natural disasters

Mental health

Nursing informatics

Opioid epidemic

Patient outcomes/quality of care

Safe administration of medications

Symptom management

BOX 1-3 Nursing Research Priorities

32 CHAPTER 1 What Is Evidence-Based Practice?

strategies that teach students to identify clinical problems, use technology to retrieve evidence, read and analyze re- search, 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.

Nurses who work in clinical settings and who are pre- pared 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.

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 bar- riers 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 1-2. Over the course of your career, your actions will convince laggards that EBP really does create excellence in patient care.

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.

Recall a question you encountered during your last clinical experience. How might you have answered that question using an EBP approach?


1. How can nurses who use EBP best be described?

a. As change agents b. As early adopters c. As innovators d. As laggards


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

1.4 What Lies Ahead? 33

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 interna- tional 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, 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 con- ducted 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 publishers must decide whether or not they will abide by guidelines outlined in the Declaration of Helsinki (Angelski, Fernandez, Weijer, & Gao, 2012).

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,

KEY TERMS Nazi experiments: An example of unethical research using human subjects during World War II

Nuremberg Code: Ethical code of conduct for research that uses human subjects

Tuskegee study: An unethical study about syphilis in which subjects were denied treatment so that the effects of the disease could be studied

34 CHAPTER 1 What Is Evidence-Based Practice?

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.

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 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.

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 dis- abilities (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

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.

KEY TERMS Jewish Chronic Disease Hospital study: Unethical study involving injection of cancer cells into subjects without their consent

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

Do you think that the findings from unethical studies should be published? Why or why not?


1.5 Keeping It Ethical 35

obtain care for their children and fell victim to being coerced to allow their children to participate in the study.

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.

» 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 communica-

tion 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 evidence hierarchy to rank evidence from strongest to weakest. » Research can be categorized as descriptive, explanatory, or predictive; basic or applied; and

quantitative or qualitative.

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