Explain how the process of diffusion facilitates moving evidence into nursing practice

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Explain how the process of diffusion facilitates moving evidence into nursing practice

Explain how the process of diffusion facilitates moving evidence into nursing practice

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 http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/dspc/health%20 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 https://lccn.loc.gov/2017036581


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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