Identify barriers to the adoption of EBP and pinpoint strategies to overcome them

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Identify barriers to the adoption of EBP and pinpoint strategies to overcome them

Identify barriers to the adoption of EBP and pinpoint strategies to overcome them
Consider a patient centered issue you have observed recently. Formulate a research question related to that issue. Identify the independent and dependent variable, hypothesis and type of hypothesis. What type of research study design would you use to address that issue, what type of sampling or sampling strategy would you use? Defend your choices with support from your textbook or other peer-reviewed journal source..

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.