Generating Cumulative Knowledge:
Evidence for Practice
Sr. Callista Roy, PhD, RN, FAAN
Professor and Nurse Theorist Boston
College Connell School of Nursing
Council Advancement Nursing Science
Washington , DC
September 14, 2012
Purpose-Discovery through Innovation
To purpose a pathway to cumulative knowledge as a basis
for evidence for practice by:
Synthesizing research based on one conceptual model
 Deriving middle-range theories based on the cumulative
knowledge
 Providing a broad definition for evidence for practice and
demonstrate the evidence for the derived theories
 Presenting an exemplar of how cumulative knowledge can
create change for practice

Cumulative Knowledge
 Annual Review of Nursing Research—started in 1983, H. Werley
Publishes state of the science papers—integrated review on one
topic
 Metaanalysis—usually of clinical trials
 Critique of Use as Evidence—Move from
focus on empirics to focus on diverse
patterns of knowing and use of
theory-guided, evidence-based
holistic nursing practice
Fawcett, Watson, Neuman, Walker & Fitzpatrick, 2001
Cumulative Knowledge Based on One
Theoretical Model—Roy Adaptation Model
 Have common concepts close to practice
 Concepts cross clinical areas, based on adapting people and
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groups; can be generalized
Large number of studies
Multiple methods
Measurements may be the same
Basis within heritage of nursing perspective
Results of Literature Review 1995-2010
 178 studies met research and links to model
criteria
 106 were referred journal publications and 72
were dissertations
 Articles published in 47 English-language
journals
 Dissertations completed at 32 different
universities in the United States
Studies Organized by Method
Quantitative Studies (n=127)

Descriptive (59)

Explaining, Predicting and Prescribing (43)

Interventions (25)
Qualitative Studies (n=40)

Content Analysis (n=8)
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Grounded Theory (n=4)
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Ethnography (n=3)

Phenomenology (n=17)

Mixed Methods (n=6)

Case Study (n=2)
350 Research Studies in Data Base
from 1970-2010 by 5-year Intervals
Process of Using Studies to Create MRT
1. Observations (studies) are clustered together
2. Similarities identified
3. Major concepts identified-Critics, Conceptual
clarity needed,RAM concepts developed over 42
years of publications, with definitions/theoretical
basis
4. Concepts interrelated in theoretical statementsRAM has set of generic propositions
5. Even with 178 plus researchers, still commonalities
for cumulative knowledge are great
Middle-range Theories
 Significant milestone that marks considerable progress in
knowledge development beginning 1991-1995
 Have a transformational effect on entire discipline of
nursing
 Help to answer questions about overall mission, goals and
nature of discipline of nursing and differentiate from other
disciplines
 Clear indication that nursing discipline has undergone a
turning point toward producing more accessible and
functional theories that guide productive research programs
and provide theory and research-based evidence for practice
Meleis, 2007
Major Clusters of Studies-Developing
Middle range Theories
 General coping
 Coping with life events
 Coping with loss
 Coping with chronic health conditions
 Coping with family health
Coping with Life Events
Examples of Studies--Quantitative
1. Descriptive survey. 300 women identified common postpartum
problems and adaptation strategies to cope with these
problems during the first 2 to 8 weeks following delivery of
full term healthy newborns (Martin, 1995)
2. Multivariate –to explain. Public data set used to test a model of
decision-making responses related to Advance Directives
(ADS) with 938 aging subjects. Results were analyzed using
causal modeling and path analysis (Zhang, 2004)
Examples of Studies–Quantitative and
Qualitative
 Intervention study. 105 preschool children having
immunization injections. The aim was to examine
the effects distraction and cutaneous stimulation on
the pain of having the injection (Sparks, 1999)

Phenomenological study. Described the experience
of five emergency nurses who routinely handle
traumatic and violent events (Wright, 2007)
Coping with Life Events: Concepts
1. Developmental, expected
postpartum, menopause, advanced
directives, immunizations
2. Situational Events, unexpected, specific
—verbal abuse or observing trauma-nurses; date
violence
Challenges of health changes
—mother and child, e.g. NICU, cerebral palsy,
cancer
Statements from Studies that Relate
Coping Strategies to Outcomes
1. Cognator processes of taking direct action, planning ahead,
handling systematically and use of resources and experience can
affect adaptive responses in self-esteem, role transition, sensation,
and health attitudes.
2. In new role development or an unexpected role event expanding
input can lead to effective role transition or role effectiveness.
3.When life event or health challenges involve too many or
unfamiliar challenges selective attention can help integrate the
experience.
4. For nurses facing specific event challenges problem-focused
behaviors, use of knowledge and skill and humor can lead to role
effectiveness, teamwork, and protected mental health.
5. Time perspective can be useful in resolving moral distress.
6. Use of personal and spiritual self, particularly seeing moral ends can
protect mental health.
7. Relating to others during developmental challenges is used for help,
support and emotional sharing.
8. Relating to others during life challenges is used for support and
empathy.
9. Relating to others in health challenges is needed but may be lacking,
leaving the person with a duty to be strong.
10. The use of a common language between those dealing with health
challenges and the nurse can lessen anxiety and fear.
11. The pooled effect of contextual stimuli such as context, age, and
socioeconomic status and residual stimuli such as childhood abuse and
witness of violence affect the mental health outcomes of abuse.
12. The unique bonding and connecting of mothers of ill children does not
eliminate the craving for normalacy
Middle Range Theory of Coping with Life Events,
Developmental Events
Middle Range Theory of Coping with Life Events,
Situational Events
Views of Evidence for Practice
1. Sometimes evidence means, reduced to biomedical,
empirical and positivistic variables and criteria
2. Critical dialogue about eclectic views of evidence that may
incorporate more components more congruent with
nursing science and emanate from how nursing knowledge
and knowing how been defined
3. Included widening meaning of evidence to make it more
pluralistic, to incorporate humanistic experience as
evidence of models of care used
4. We have not explored criteria for judging evidence within
this framework—no definite ideas reached
Meleis, 2007
Level 1 EBP: High Potential for Implementation in
Practice
 Proposition supported by more than one study
 Unequivocal support of hypothesis
 Low risk
 High clinical need
Level 2 EBP: Needs Further Clinical Evaluation Before
Implementation
 Proposition supported
 Generalizability not clear
 Risk not clear
 High clinical need
Level 3 EBP: Needs Further Testing Before Implementation
Translational Research
 National Institutes of Health made translational research a priority
 Clinical and Translational Science Award (CTSA) program began
in 2006; in 2008 were 60 such centers; in 2012 expect 60
 T1 means bench to bedside; e.g. harnessing knowledge from basic
sciences to produce new drugs, devices, and treatment s
 T2 seeks to close the gap and improve quality by improving
access, reorganizing and coordinating system care, helping
clinicians and patients to exchange behaviors, make more
informed choices, providing reminders and point –of-care
decision support tools, and strengthening patient-clinician
relationship
 Take clinical studies into everyday clinical practice and health
decision making
Wolfe, 2011
Coping is Significant for Health:
Recommendations for Practice
Intervention: We propose that a major responsibility for every
nurse in practice is to coach each patient in the use of ones’
own coping strategies; when to use one and when another;
what coping strategies works best for them in a given
situation and what situations call for learning new strategies
Change for Practice: Add a nurse-discharge planner for every
inpatient unit. This nurse would not be concerned primarily with
finding long-term placements for patients across many settings. Rather
the nurse in this re-defined role would work with the primary care
nurses on a given unit from the time the patient is admitted to plan for
coordinating the patient’s ability to cope with their developmental and
situational life events across settings.
Pathway to Cumulative Knowledge as
Evidence for Practice, the Basis of Change