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Clinical Nursing Practice Research
Development of Nursing Knowledge: Evidence-Based Practice
Course Objective 1
Science: Definition: a coherent body of knowledge composed of research findings &
tested theories for a specific discipline (we don’t call it science unless it is based on
research).
Science is both a . . . a product (end point) and a process (mechanism to reach an end
point).
Philosophy of Science: Two major philosophical views or paradigms:
Paradigm = philosophical view
Positivist Paradigm (logical positivism) hard science uses this paradigm.
Objective reality, independent of human observation
Reality is objective. Doesn’t matter what you perceive. “if a tree falls in the forest & no
one hears it, does it make a sound”… YES, absolutely. The sound is totally independent
of human observation.
Control of the environment: want to make sure the results are specific & reproducible.
Data are empirical (through the 5 senses), rooted in objectivity.
Data are quantifiable, measurable. No subjectivity at all. Difference in objective &
subjective test (these people would rather have objective test )
Deductive process: good example of the difference between inductive & deductive is in
Schmit, page 14.
Naturalist Paradigm sociology background uses this view
Reality is multiple & subjective
If a tree falls in the forest & no one hears it, does it make a sound. No, there is no
sound.
Emphasis on human or “lived” experience. The whole focus is the human experience.
Data are words: narratives, subjective. Nothing objective about methodology.
Process is inductive.
Research Methodologies: Quantitative and Qualitative
Quantitative Methods – based on logical positivism; data are
numerical/objective/empiric; process is deductive
(Sounds like adding things up)
Scientific Method: build body of knowledge that describes, explains, predicts &
prescribes. You don’t have to wonder if it will work, you know it will work.
Formal, objective, systematic process
Data objective (5 senses).
Findings statistically analyzed
Emphasis is on control / randomization. The more control used, the more valid the
results are seen.
Humans are a composite of many body systems. If you can understand each of those
body systems in isolation, you understand the whole.
Can generate and test theory; generalize the findings to a larger population.
Limitation: Human beings are complex, and are more than the sum of their parts.
Not all questions in nursing can be empirically tested.
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Qualitative Methods – based on naturalism; data are words; subjective; process
inductive (quality of life)
Describe and promote understanding of human experiences as they are lived. No
randomization in this kind of study. You select the people. You don’t want to interview
the person if they haven’t had the experience.
Formal, subjective, systematic process.
Data are words – narratives. The person describes their experience. You want them to
talk, but you have a poker face. Don’t let them know if you approve/disapprove of their
experience. We have to know what our values are, so we can know what it is & put it
aside.
Narratives analyzed for common themes. Once you have a common theme you have a
picture of the phenomenon.
Sample sizes are very small. Maybe 6 or 8. 15 would be a large sample size.
Often provide starting point, then start a qualitative study.
Lay groundwork for quantitative.
Theory generating but CANNOT test theory.
Limitation: Small sample sizes
Concern about generalizability.
Ways of Acquiring Knowledge in Nursing: all of these are in the book
Tradition: this is the way we’ve always done it.
Borrowing: borrow from other disciplines, but we need to make it ours
Trial & error: hopefully learn the right way quickly
Personal experience: we learn a great deal from personal experience… (notice the
relationship between trial & error)
Authority: “I’m the head nurse & I say it should be that way”. Maybe use the procedure
manual (although it isn’t one solution fits all)
Research or scientific inquiry: This is the only way to do it.
Nursing Research:
Research or scientific inquiry:
Is the most sophisticated method for acquiring knowledge
Combines other ways of knowing to create a system to obtain knowledge that is
more reliable than other ways of knowing
THE accepted process for obtaining knowledge in nursing.
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Nursing care research (NIH 1989) (don’t need to memorize these). Builds the body of
knowledge.
– Understanding nursing care of individuals and groups and the biological,
physiological, social, behavioral, and environmental mechanisms influencing
health and disease that are relevant to nursing care
– Knowledge about health and promotion of health over the lifespan, care of persons
with health problems and disabilities, and nursing actions that enhance the ability
of individuals to respond effectively to actual or potential health problems
Research in Nursing: Broader study of nurses and the nursing profession, including
historic, ethical, and political studies.
Notes from September 3, 2008
Nursing Research: Links Theory & Practice:
Theory: systematic, abstract explanation of some aspect of reality.
Concepts: are the building blocks
Concepts linked through propositions to provide an explanation of reality.
Concepts in a theory about taking a test:
Read
Listen to lecture
Study
Take notes
Good sleep
Coffee
Theory links research to practice.
Evidence-Based Practice (EBP)
Theory supported by research findings (evidence) becomes:
the foundation of theory-based clinical practice in nursing. Important to us
because the best way to gain knowledge is through research… not because our
boss said that is how it has to be done….
Theories have to be tested to determine accuracy. We have to have evidence.
EBP: Definition
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“the conscientious, explicit and judicious use of theory-derived, research-based
information in making decisions abut care delivery to individuals or groups. . .and in
consideration of individual needs and preferences” Ingersoll (2000)
p. 4 of text.
She took this info from Schmidt & Brown… as a secondary reference from Ingersoll…
not a good way to do references. (secondary)
Ex:
Ingersoll (as cited in Schmidt & Brown, 2009)
3 components of EBP
Theory derived, research based information
Clinical expertise
Individual consideration of individual needs & preferences
EBP: Three components
1. Research-based information
2. Clinical expertise of the nurse (knows a homeless person probably won’t take
ampicillian 4X a day… her expertise told her to give an antibiotic that only
needed to be taken once a day).
3. Patient preferences
EBP: Models: Stetler Model; fairly well explained in book.
Focuses on: can be used by an individual person in my own practice or used by a team
of nurses, or even in advanced practice.
Focuses on individual or groups of practitioners. Composed of 5 phases: preparation,
validation, decision making….
5 phases
– Preparation phase:
– clarify the purpose (what do you really want to know)… what are you trying to
find out…
– Identify the sources of research evidence. (in a group, we will determine who
finds what… Medline, etc… look for most recent & highest level of research)
– Initiate the search for the relevant research evidence
– Validation phase
Analyze the evidence
Sufficient: (do I have enough evidence)
Credible (see if the evidence is credible)
– Decision making
Organize the evidence
Determine the meaning for practice
Decide what evidence to implement
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– Apply the evidence
Implement the change
Not as easy as it sounds… most people are adverse to change. (British Army
wouldn’t give citrus to sailors to prevent scurvy even though there was proof that it
worked).
– Evaluate the outcomes
Did you get the outcome you wanted
Degree to which it was implemented
Were the desired outcomes met?
EBP: Models: ARCC Model (not discussed in text)
Advancing Research and Clinical Practice Through Close Collaboration
Mentorship model: originally developed by Bernadette Melnek. She is author of one of
our optional readings. Advanced practice nse w/ skill in EBP facilitates improvements in
care via EPB (primary difference between this & settler is the mentorship)
Has been expanded by Melnyk & Fineout-Overholt (they are the EBP gurus)
EBP: Steps in the process (5)
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Ask the burning clinical question. (something sparks me to want to go out & find
evidence).
Search for the best evidence (PICO format… best format to put question in)
Critical appraisal of the results
Integrate the evidence
Evaluate the effectiveness of the intervention.
EBP: Hierarchy of Evidence
Level I: Systematic reviews/meta-analysis of all RCTs
Level II: Evidence obtained from at least 1 RCT
Level III: Evidence from CT without randomization
Level IV: Evidence from case-control & cohort studies
Level V: Evidence from systematic reviews of descriptive/qualitative studies
Level VI: Evidence from 1 descriptive/qual study
Level VII: Evidence from the opinion of authorities or expert committees
Pyramid of evidence… this is dealing w/ quantative…
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We really want to prescribe something that will work every time.
Qualitative research can only describe…
Book has figure on p. 320… minus number 6 from above.
Absolute best is systematic reviews/meta analysis of all Randomized controlled trial.
When we use EBP, we are looking for the best evidence that is available NOW. Can’t
worry about what is not there…
Formulating EBP Questions
EBP questions vs research questions
Research question: generate new knowledge
EBP question: make decisions about patient care based on the best current evidence
gathered using a systematic problem-solving approach.
Formulating EBP Questions: PICO Format
P: patient population or patient condition (population in my question)
I: Intervention of interest
C: Comparison of interest (almost interchangeable w/ intervention) On quiz, she will not
give us I and C… she will give either I or C…
O: Outcome of interest (what do you want to happen)
Helps to find the evidence when you put your question in this format…
Take burning question & put it in this format.
I may refine how I word it…
Sometimes people use T on the end… (stands for Timeline)
Be as specific as possible at first.
Areas of interest: Is there a new intervention for decub ulcers that would work better in
immobile elderly nursing home residents than the one currently in use?
P: immobile elderly nursing home residents
I: what are we already doing (turning the patients every 2 hours)
C: something new (decubitus and intervention)
O: outcome wanted… decubitus ulcer better…reduction in size/depth, increase in
granulation tissue…
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Then go back & do another search & see if I can get anything better.
Women between 20 & 35 who want to quit smoking… which is better, patch or gum.
P: women between 20 & 35 who smoke
I: nicotine patch
C: nicotine gum
O: smoking cessation
Health care workers…which works best alchol based hand sanitizers or soap… effective
handwashing
P: health care workers
I: alcohol based hand sanitizer
C: soap
O: decreased germs
Do parents who are permitted to touch and/or hold their premature infants during the
time the infant is in the neonatal ICU bond with the infants better than those who are not
able to do this?
P: parents of premature infants in ICU
I: touch
C: no touch
O: bonding
Barriers to the use of research
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Research findings not disseminated
Some clinicians don’t read research or know how to evaluate it (no requirement
for AD nurses to do any research)
Some don’t value research or don’t think they have time.
Some are aware of findings but don’t think they have the power to effect change.
(this has improved w/ Magnet status)
Bringing about change is not easy
Book has a table of ways to circumvent: Table 1-1 “wonderful table” page 9
Evidence-Based Clinical Practice Guidelines
Specific practice recommendations that are based on a rigorous review of the best
evidence on a specific topic.
You will find these kinds of things in speciality journals… very common in primary care.
Pay attention to them in the area you are interested in…
Remember: make sure you are looking at the latest version. JNC 8 is the latest… don’t
implement something that is old. “worth looking at”
Why is research important to nursing?
It provides the evidence on which we base our practice
We ARE a practice discipline
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Activities are always “goal directed”
Research knowledge – specifically to improve patient care. Builds the body of
knowledge to improve patient care.
We don’t do research for the sake of research… we are looking specifically to improve
our care.
Research Expectations for the Baccalaureate Nurse
Read, interpret and evaluate research
Identify nursing problems
Collect the best evidence available…
Continually evaluate your own practice…
Share research findings w/ colleagues
You won’t be fired for not doing these things… but it will show up in your evaluations &
maybe even pay raises.