I’m working on a nursing writing question and need a sample draft to help me learn.
Search Engines & Databases
What search engines or databases are you using to identify the articles for your Weekly Article Summary assignment? What key words are you using for your search? Have they been effective in finding articles that are relevant to your clinical practice? Include rationale.
Methods and Critical Appraisal for EvidenceBased Practice
Geri LoBiondo-Wood, PhD, RN, FAAN
Professor and Coordinator, PhD in Nursing Program, University of Texas Health Science Center at Houston,
School of Nursing, Houston, Texas
Judith Haber, PhD, RN, FAAN
The Ursula Springer Leadership Professor in Nursing, New York University, Rory Meyers College of
Nursing, New York, New York
Table of Contents
About the authors
To the faculty
To the student
I. Overview of Research and Evidence-Based Practice
1. Integrating research, evidence-based practice, and quality improvement processes
2. Research questions, hypotheses, and clinical questions
3. Gathering and appraising the literature
4. Theoretical frameworks for research
II. Processes and Evidence Related to Qualitative Research
5. Introduction to qualitative research
6. Qualitative approaches to research
7. Appraising qualitative research
Critique of a qualitative research study
III. Processes and Evidence Related to Quantitative Research
8. Introduction to quantitative research
9. Experimental and quasi-experimental designs
10. Nonexperimental designs
11. Systematic reviews and clinical practice guidelines
13. Legal and ethical issues
14. Data collection methods
15. Reliability and validity
16. Data analysis: Descriptive and inferential statistics
17. Understanding research findings
18. Appraising quantitative research
Critique of a quantitative research study
Critique of a quantitative research study
IV. Application of Research: Evidence-Based Practice
19. Strategies and tools for developing an evidence-based practice
20. Developing an evidence-based practice
21. Quality improvement
Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer
coaching and hepatitis A and B vaccine completion among homeless men recently released on
Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and
mental health at 1 and 3 months after their infant schild s death in an intensive care unit
Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating
pain: A qualitative study
Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic
growth and coping in parents and siblings of adolescent cancer survivors
Example of a systematic Review/Meta analysis (Al mallah et al., 2015) The impact of nurse led
clinics on the mortality and morbidity of patients with cardiovascular diseases
3251 Riverport Lane
St. Louis, Missouri 63043
NURSING RESEARCH: METHODS AND CRITICAL APPRAISAL FOR EVIDENCE-BASED
PRACTICE, NINTH EDITION ISBN: 978-0-323-43131-6
Copyright Â© 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisherâ€™s permissions policies, and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986.
Library of Congress Cataloging-in-Publication Data
Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor.
Title: Nursing research : methods and critical appraisal for evidence-based
practice / [edited by] Geri LoBiondo-Wood, Judith Haber.
Other titles: Nursing research (LoBiondo-Wood)
Description: 9th edition. | St. Louis, Missouri : Elsevier,  | Includes
bibliographical references and index.
Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper)
Subjects: | MESH: Nursing Researchâ€”methods | Research Design |
Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072â€”dc23 LC record available
Executive Content Strategist: Lee Henderson
Content Development Manager: Lisa Newton
Content Development Specialist: Melissa Rawe
Publishing Services Manager: Jeff Patterson
Book Production Specialist: Carol Oâ€™Connell
Design Direction: Renee Duenow
Printed in China
Last digit is the print number:
About the authors
Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator of the PhD in Nursing
Program at the University of Texas Health Science Center at Houston, School of Nursing (UTHSCHouston) and former Director of Research and Evidence-Based Practice Planning and Development
at the MD Anderson Cancer Center, Houston, Texas. She received her Diploma in Nursing at St.
Maryâ€™s Hospital School of Nursing in Rochester, New York; Bachelorâ€™s and Masterâ€™s degrees from
the University of Rochester; and a PhD in Nursing Theory and Research from New York University.
Dr. LoBiondo-Wood teaches research and evidence-based practice principles to undergraduate,
graduate, and doctoral students. At MD Anderson Cancer Center, she developed and implemented
the Evidence-Based Resource Unit Nurse (EB-RUN) Program. She has extensive national and
international experience guiding nurses and other health care professionals in the development and
utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress in
Transplantation and a reviewer for Nursing Research, Oncology Nursing Forum, and Oncology Nursing.
Her research and publications focus on chronic illness and oncology nursing. Dr. Wood has
received funding from the Robert Wood Johnson Foundation Future of Nursing Scholars program
for the past several years to fund full-time doctoral students.
Dr. LoBiondo-Wood has been active locally and nationally in many professional organizations,
including the Oncology Nursing Society, Southern Nursing Research Society, the Midwest Nursing
Research Society, and the North American Transplant Coordinators Organization. She has received
local and national awards for teaching and contributions to nursing. In 1997, she received the
Distinguished Alumnus Award from New York University, Division of Nursing Alumni
Association. In 2001 she was inducted as a Fellow of the American Academy of Nursing and in 2007
as a Fellow of the University of Texas Academy of Health Science Education. In 2012 she was
appointed as a Distinguished Teaching Professor of the University of Texas System and in 2015
received the John McGovern Outstanding Teacher Award from the University of Texas Health
Science Center at Houston School of Nursing.
Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership Professor in Nursing at the Rory
Meyers College of Nursing at New York University. She received her undergraduate nursing
education at Adelphi University in New York, and she holds a Masterâ€™s degree in Adult
Psychiatricâ€“Mental Health Nursing and a PhD in Nursing Theory and Research from New York
University. Dr. Haber is internationally recognized as a clinician and educator in psychiatricâ€“
mental health nursing. She was the editor of the award-winning classic textbook, Comprehensive
Psychiatric Nursing, published for eight editions and translated into five languages. She has
extensive clinical experience in psychiatric nursing, having been an advanced practice psychiatric
nurse in private practice for over 30 years, specializing in treatment of families coping with the
psychosocial impact of acute and chronic illness. Her NIH-funded program of research addressed
physical and psychosocial adjustment to illness, focusing specifically on women with breast cancer
and their partners and, more recently, breast cancer survivorship and lymphedema prevention and
risk reduction. Dr. Haber is also committed to an interprofessional program of clinical scholarship
related to interprofessional education and improving oral-systemic health outcomes and is the
Executive Director of a national nursing oral health initiative, the Oral Health Nursing Education and
Practice (OHNEP) program, funded by the DentaQuest and Washington Dental Service
Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA Psychiatric
Nurse of the Year Award, the 2005 APNA Outstanding Research Award, and the 1998 ANA
Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae Award, the 2011
Distinguished Teaching Award, and the 2014 NYU Meritorious Service Award. In 2015, Dr. Haber
received the Sigma Theta Tau International Marie Hippensteel Lingeman Award for Excellence in
Nursing Practice. Dr. Haber is a Fellow in the American Academy of Nursing and the New York
Academy of Medicine. Dr. Haber has consulted, presented, and published widely on evidencebased practice, interprofessional education and practice, as well as oral-systemic health issues.
Terri Armstrong, PhD, ANP-BC, FAANP, Senior Investigator, Neuro-oncology Branch, Center
for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
Julie Barroso, PhD, ANP, RN, FAAN, Professor and Department Chair, Medical University of
South Carolina, Charleston, South Carolina
Carol Bova, PhD, RN, ANP, Professor of Nursing and Medicine, Graduate School of Nursing,
University of Massachusetts, Worcester, Massachusetts
Dona Rinaldi Carpenter, EdD, RN,
Nursing, Scranton, Pennsylvania
Professor and Chair, University of Scranton, Department of
Maja Djukic, PhD, RN, Assistant Professor, Rory Meyers College of Nursing, New York
University, New York, New York
Mei R. Fu, PhD, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York
University, New York, New York
Mattia J. Gilmartin, PhD, RN, Senior Research Scientist , Executive Director, NICHE Program,
Rory Meyers College of Nursing, New York University, New York, New York
Deborah J. Jones, PhD, MS, RN, Margaret A. Barnett/PARTNERS Professorship , Associate
Dean for Professional Development and Faculty Affairs , Associate Professor, University of Texas
Health Science Center at Houston, School of Nursing, Houston, Texas
Carl Kirton, DNP, RN, MBA, Chief Nursing Officer, University Hospital, Newark, New
Jersey; , Adjunct Faculty, Rory Meyers College of Nursing, New York University, New York,
Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN,
College of Nursing, New York University, New York, New York
Professor, Rory Meyers
Elaine Larson, PhD, RN, FAAN, CIC, Anna C. Maxwell Professor of Nursing
Research , Associate Dean for Research, Columbia University School of Nursing, New York, New
Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center
at Houston, School of Nursing, Houston, Texas
Gail Dâ€™Eramo Melkus, EdD, ANP, FAAN, Florence & William Downs Professor in Nursing
Research, Associate Dean for Research, Rory Meyers College of Nursing, New York University,
New York, New York
Susan Sullivan-Bolyai, DNSc, CNS, RN, FAAN, Associate Professor, Rory Meyers College of
Nursing, New York University, New York, New York
Marita Titler, PhD, RN, FAAN, Rhetaugh G. Dumas Endowed Professor , Department Chair,
Department of Systems, Populations and Leadership, University of Michigan School of Nursing,
Ann Arbor, Michigan
Mark Toles, PhD, RN, Assistant Professor, University of North Carolina at Chapel Hill, School
of Nursing, Chapel Hill, North Carolina
Karen E. Alexander, PhD, RN, CNOR, Program Director RN-BSN, Assistant Professor,
Department of Nursing, University of Houston Clear Lake-Pearland, Houston, Texas
Donelle M. Barnes, PhD, RN, CNE,
Arlington, Arlington, Texas
Associate Professor, College of Nursing, University of Texas,
Susan M. Bezek, PhD, RN, ACNP, CNE,
College, Keuka Park, New York
Assistant Professor, Division of Nursing, Keuka
Rose M. Kutlenios, PhD, MSN, MN, BSN, ANCC Board Certification, Adult Psychiatric/Mental
Health Clinical Specialist, ANCC Board Certification, Adult Nurse Practitioner, Nursing
Program Director and Associate Professor, Department of Nursing, West Liberty University, West
Liberty, West Virginia
Shirley M. Newberry, PhD, RN, PHN,
University, Winona, Minnesota
Professor, Department of Nursing, Winona State
Sheryl Scott, DNP, RN, CNE, Assistant Professor and Chair, School of Nursing, Wisconsin
Lutheran College, Milwaukee, Wisconsin
To the faculty
Geri LoBiondo-Wood, Geri.L.Wood@uth.tmc.edu, Judith Haber, firstname.lastname@example.org
The foundation of the ninth edition of Nursing Research: Methods and Critical Appraisal for EvidenceBased Practice continues to be the belief that nursing research is integral to all levels of nursing
education and practice. Over the past three decades since the first edition of this textbook, we have
seen the depth and breadth of nursing research grow, with more nurses conducting research and
using research evidence to shape clinical practice, education, administration, and health policy.
The National Academy of Medicine has challenged all health professionals to provide team-based
care based on the best available scientific evidence. This is an exciting challenge. Nurses, as
clinicians and interprofessional team members, are using the best available evidence, combined
with their clinical judgment and patient preferences, to influence the nature and direction of health
care delivery and document outcomes related to the quality and cost-effectiveness of patient care.
As nurses continue to develop a unique body of nursing knowledge through research, decisions
about clinical nursing practice will be increasingly evidence based.
As editors, we believe that all nurses need not only to understand the research process but also to
know how to critically read, evaluate, and apply research findings in practice. We realize that
understanding research, as a component of evidence-based practice and quality improvement
practices, is a challenge for every student, but we believe that the challenge can be accomplished in
a stimulating, lively, and learner-friendly manner.
Consistent with this perspective is an ongoing commitment to advancing implementation of
evidence-based practice. Understanding and applying research must be an integral dimension of
baccalaureate education, evident not only in the undergraduate nursing research course but also
threaded throughout the curriculum. The research role of baccalaureate graduates calls for
evidence-based practice and quality improvement competencies; central to this are critical appraisal
skillsâ€”that is, nurses should be competent research consumers.
Preparing students for this role involves developing their critical thinking skills, thereby
enhancing their understanding of the research process, their appreciation of the role of the critiquer,
and their ability to actually critically appraise research. An undergraduate research course should
develop this basic level of competence, an essential requirement if students are to engage in
evidence-informed clinical decision making and practice, as well as quality improvement activities.
The primary audience for this textbook remains undergraduate students who are learning the
steps of the research process, as well as how to develop clinical questions, critically appraise
published research literature, and use research findings to inform evidence-based clinical practice
and quality improvement initiatives. This book is also a valuable resource for students at the
masterâ€™s, DNP, and PhD levels who want a concise review of the basic steps of the research process,
the critical appraisal process, and the principles and tools for evidence-based practice and quality
This text is also an important resource for practicing nurses who strive to use research evidence
as the basis for clinical decision making and development of evidence-based policies, protocols, and
standards or who collaborate with nurse-scientists in conducting clinical research and evidencebased practice. Finally, this text is an important resource for considering how evidence-based
practice, quality improvement, and interprofessional collaboration are essential competencies for
students and clinicians practicing in a transformed health care system, where nurses and their
interprofessional team members are accountable for the quality and cost-effectiveness of care
provided to their patient population. Building on the success of the eighth edition, we reaffirm our
commitment to introducing evidence-based practice, quality improvement processes, and research
principles to baccalaureate students, thereby providing a cutting-edge, research consumer
foundation for their clinical practice. Nursing Research: Methods and Critical Appraisal for EvidenceBased Practice prepares nursing students and practicing nurses to become knowledgeable nursing
research consumers by doing the following:
â€¢ Addressing the essential evidence-based practice and quality improvement role of the nurse,
thereby embedding evidence-based competencies in clinical practice.
â€¢ Demystifying research, which is sometimes viewed as a complex process.
â€¢ Using a user-friendly, evidence-based approach to teaching the fundamentals of the research
â€¢ Including an exciting chapter on the role of theory in research and evidence-based practice.
â€¢ Providing a robust chapter on systematic reviews and clinical guidelines.
â€¢ Offering two innovative chapters on current strategies and tools for developing an evidencebased practice.
â€¢ Concluding with an exciting chapter on quality improvement and its application to practice.
â€¢ Teaching the critical appraisal process in a user-friendly progression.
â€¢ Promoting a lively spirit of inquiry that develops critical thinking and critical reading skills,
facilitating mastery of the critical appraisal process.
â€¢ Developing information literacy, searching, and evidence-based practice competencies that
prepare students and nurses to effectively locate and evaluate the best research evidence.
â€¢ Emphasizing the role of evidence-based practice and quality improvement initiatives as the basis
for informing clinical decisions that support nursing practice.
â€¢ Presenting numerous examples of recently published research studies that illustrate and highlight
research concepts in a manner that brings abstract ideas to life for students. These examples are
critical links that reinforce evidence-based concepts and the critiquing process.
â€¢ Presenting five published articles, including a meta-analysis, in the Appendices, the highlights of
which are woven throughout the text as exemplars of research and evidence-based practice.
â€¢ Showcasing, in four new inspirational Research Vignettes, the work of renowned nurse
researchers whose careers exemplify the links among research, education, and practice.
â€¢ Introducing new pedagogical interprofessional education chapter features, IPE Highlights and IPE
Critical Thinking Challenges and quality improvement, QSEN Evidence-Based Practice Tips.
â€¢ Integrating stimulating pedagogical chapter features that reinforce learning, including Learning
Outcomes, Key Terms, Key Points, Critical Thinking Challenges, Helpful Hints, EvidenceBased Practice Tips, Critical Thinking Decision Paths, and numerous tables, boxes, and figures.
â€¢ Featuring a revised section titled Appraising the Evidence, accompanied by an updated
Critiquing Criteria box in each chapter that presents a step of the research process.
â€¢ Offering a student Evolve site with interactive review questions that provide chapter-by-chapter
review in a format consistent with that of the NCLEXÂ® Examination.
â€¢ Offering a Student Study Guide that promotes active learning and assimilation of nursing
â€¢ Presenting Faculty Evolve Resources that include a test bank, TEACH lesson plans, PowerPoint
slides with integrated audience response system questions, and an image collection. Evolve
resources for both students and faculty also include a research article library with appraisal
exercises for additional practice in reviewing and critiquing, as well as content updates.
The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice is
organized into four parts. Each part is preceded by an introductory section and opens with an
engaging Research Vignette by a renowned nurse researcher.
Part I, Overview of Research and Evidence-Based Practice, contains four chapters: Chapter 1,
â€œIntegrating Research, Evidence-Based Practice, and Quality Improvement Processes,â€ provides an
excellent overview of research and evidence-based practice processes that shape clinical practice.
The chapter speaks directly to students and highlights critical reading concepts and strategies,
facilitating student understanding of the research process and its relationship to the critical
appraisal process. The chapter introduces a model evidence hierarchy that is used throughout the
text. The style and content of this chapter are designed to make subsequent chapters user friendly.
The next two chapters address foundational components of the research process. Chapter 2,
â€œResearch Questions, Hypotheses, and Clinical Questions,â€ focuses on how research questions and
hypotheses are derived, operationalized, and critically appraised. Students are also taught how to
develop clinical questions that are used to guide evidence-based inquiry, including quality
improvement projects. Chapter 3, â€œGathering and Appraising the Literature,â€ showcases cuttingedge information literacy content and provides students and nurses with the tools necessary to
effectively search, retrieve, manage, and evaluate research studies and their findings. Chapter 4,
â€œTheoretical Frameworks for Research,â€ is a user-friendly theory chapter that provides students
with an understanding of how theories provide the foundation of research studies and evidencebased practice projects.
Part II, Processes and Evidence Related to Qualitative Research, contains three interrelated
qualitative research chapters. Chapter 5, â€œIntroduction to Qualitative Research,â€ provides an
exciting framework for understanding qualitative research and the significant contribution of
qualitative research to evidence-based practice. Chapter 6, â€œQualitative Approaches to Research,â€
presents, illustrates, and showcases major qualitative methods using examples from the literature as
exemplars. This chapter highlights the questions most appropriately answered using qualitative
methods. Chapter 7, â€œAppraising Qualitative Research,â€ synthesizes essential components of and
criteria for critiquing qualitative research reports using published qualitative research study.
Part III, Processes and Evidence Related to Quantitative Research, contains Chapters 8 to
18Chapter 8Chapter 9Chapter 10Chapter 11Chapter 12Chapter 13Chapter 14Chapter 15Chapter
16Chapter 17Chapter 18. This group of chapters delineates essential steps of the quantitative
research process, with published clinical research studies used to illustrate each step. These
chapters are streamlined to make the case for linking an evidence-based approach with essential
steps of the research process. Students are taught how to critically appraise the strengths and
weaknesses of each step of the research process in a synthesized critique of a study. The steps of the
quantitative research process, evidence-based concepts, and critical appraisal criteria are
synthesized in Chapter 18 using two published research studies, providing a model for appraising
strengths and weaknesses of studies, and determining applicability to practice. Chapter 11, a
unique chapter, addresses the use of the types of systematic reviews that support an evidence-based
practice as well as the development and application of clinical guidelines.
Part IV, Application of Research: Evidence-Based Practice, contains three chapters that
showcase evidence-based practice models and tools. Chapter 19, â€œStrategies and Tools for
Developing an Evidence-Based Practice,â€ is a revised, vibrant, user-friendly, evidence-based toolkit
with exemplars that capture the essence of high-quality, evidence-informed nursing care. It â€œwalksâ€
students and practicing nurses through clinical scenarios and challenges them to consider the
relevant evidence-based practice â€œtoolsâ€ to develop and answer questions that emerge from clinical
situations. Chapter 20, â€œDeveloping an Evidence-Based Practice,â€ offers a dynamic presentation of
important evidence-based practice models that promote evidence-based decision making. Chapter
21, â€œQuality Improvement,â€ is an innovative, engaging chapter that outlines the quality
improvement process with information from current guidelines. Together, these chapters provide
an inspirational conclusion to a text that we hope motivates students and practicing nurses to
advance their evidence-based practice and quality improvement knowledge base and clinical
competence, positioning them to make important contributions to improving health care outcomes
as essential members of interprofessional teams.
Stimulating critical thinking is a core value of this text. Innovative chapter features such as
Critical Thinking Decision Paths, Evidence-Based Practice Tips, Helpful Hints, Critical Thinking
Challenges, IPE Highlights, and QSEN Evidence-Based Practice Tips enhance critical thinking,
promote the development of evidence-based decision-making skills, and cultivate a positive value
about the importance of collaboration in promoting evidence-based, high quality and cost-effective
Consistent with previous editions, we promote critical thinking by including sections called
â€œAppraising the Evidence,â€ which describe the critical appraisal process related to the focus of the
chapter. Critiquing Criteria are included in this section to stimulate a systematic and evaluative
approach to reading and understanding qualitative and quantitative research and evaluating its
strengths and weaknesses. Extensive resources are provided on the Evolve site that can be used to
develop critical thinking and evidence-based competencies.
The development and refinement of an evidence-based foundation for clinical nursing practice is
an essential priority for the future of professional nursing practice. The ninth edition of Nursing
Research: Methods and Critical Appraisal for Evidence-Based Practice will help students develop a basic
level of competence in understanding the steps of the research process that will enable them to
critically analyze research studies, judge their merit, and judiciously apply evidence in clinical
practice. To the extent that this goal is accomplished, the next generation of nursing professionals
will have a cadre of clinicians who inform their practice using theory, research evidence, and
clinical judgment, as they strive to provide high-quality, cost-effective, and satisfying health care
experiences in partnership with individuals, families, and communities.
To the student
Geri LoBiondo-Wood, Geri.L.Wood@uth.tmc.edu, Judith Haber, email@example.com
We invite you to join us on an exciting nursing research adventure that begins as you turn the first
page of the ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based
Practice. The adventure is one of discovery! You will discover that the nursing research literature
sparkles with pride, dedication, and excitement about the research dimension of professional
nursing practice. Whether you are a student or a practicing nurse whose goal is to use research
evidence as the foundation of your practice, you will discover that nursing research and a
commitment to evidence-based practice positions our profession at the forefront of change. You will
discover that evidence-based practice is integral to being an effective member of an
interprofessional team prepared to meet the challenge of providing quality whole person care in
partnership with patients, their families/significant others, as well as with the communities in which
they live. Finally, you will discover the richness in the â€œWho,â€ â€œWhat,â€ â€œWhere,â€ â€œWhen,â€ â€œWhy,â€
and â€œHowâ€ of nursing research and evidence-based practice, developing a foundation of
knowledge and skills that will equip you for clinical practice and making a significant contribution
to achieving the Triple Aim, that is, contributing to high quality and cost-effective patient outcomes
associated with satisfying patient experiences!
We think you will enjoy reading this text. Your nursing research course will be short but filled
with new and challenging learning experiences that will develop your evidence-based practice
skills. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice
reflects cutting-edge trends for developing evidence-based nursing practice. The four-part
organization and special features in this text are designed to help you develop your critical
thinking, critical reading, information literacy, interprofessional, and evidence-based clinical
decision-making skills, while providing a user-friendly approach to learning that expands your
competence to deal with these new and challenging experiences. The companion Study Guide, with
its chapter-by-chapter activities, serves as a self-paced learning tool to reinforce the content of the
text. The accompanying Evolve website offers review questions to help you reinforce the concepts
discussed throughout the book.
Remember that evidence-based practice skills are used in every clinical setting and can be applied
to every patient population or clinical practice issue. Whether your clinical practice involves
primary care or critical care and provides inpatient or outpatient treatment in a hospital, clinic, or
home, you will be challenged to apply your evidence-based practice skills and use nursing research
as the foundation for your evidence-based practice. The ninth edition of Nursing Research: Methods
and Critical Appraisal for Evidence-Based Practice will guide you through this exciting adventure,
where you will discover your ability to play a vital role in contributing to the building of an
evidence-based professional nursing practice.
Geri LoBiondo-Wood, Judith Haber
No major undertaking is accomplished alone; there are those who contribute directly and those
who contribute indirectly to the success of a project. We acknowledge with deep appreciation and
our warmest thanks the help and support of the following people:
â€¢ Our students, particularly the nursing students at the University of Texas Health Science Center
at Houston School of Nursing and the Rory Meyers College of Nursing at New York University,
whose interest, lively curiosity, and challenging questions sparked ideas for revisions in the ninth
â€¢ Our chapter contributors, whose passion for research, expertise, cooperation, commitment, and
punctuality made them a joy to have as colleagues.
â€¢ Our vignette contributors, whose willingness to share evidence of their research wisdom made a
unique and inspirational contribution to this edition.
â€¢ Our colleagues, who have taken time out of their busy professional lives to offer feedback and
constructive criticism that helped us prepare this ninth edition.
â€¢ Our editors, Lee Henderson, Melissa Rawe, and Carol Oâ€™Connell, for their willingness to listen to
yet another creative idea about teaching research in a meaningful way and for their expert help
with manuscript preparation and production.
â€¢ Our families: Rich Scharchburg; Brian Wood; Lenny, Andrew, Abbe, Brett, and Meredith Haber;
and Laurie, Bob, Mikey, Benjy, and Noah Goldberg for their unending love, faith, understanding,
and support throughout what is inevitably a consumingâ€”but excitingâ€”experience.
PA R T I
Overview of Research and Evidence-Based
Research Vignette: Terri Armstrong
1. Integrating research, evidence-based practice, and quality
2. Research questions, hypotheses, and clinical questions
3. Gathering and appraising the literature
4. Theoretical frameworks for research
With a little help from my friends
Terri Armstrong, PhD ANP-BC, FAANP, FAAN
National Cancer Institute
National Institute of Health
I grew up surrounded by family and strong role models of women working in health care in a
small town in Ohio. When in college, the three most important women in my life (my mom,
grandmother, and great-grandmother) were all diagnosed with cancer. This led me to seek out a
nursing position in oncology, and over time, I was able to be actively involved in their care. This
experience taught me so much and led to the desire to do more to make the daily lives of people
with cancer better. After obtaining a masterâ€™s in oncology and a postmasterâ€™s nurse practitioner, an
opportunity to work with Dr. M. Gilbert, a well-known caring physician who specialized in the care
and treatment of patients with central nervous system (CNS) tumors and a great mentor, became
available, so my work with people with CNS tumors began.
After several years, I realized that the quality of life of the brain tumor patients and families was
significantly impacted by the symptoms they experienced. Over 80% were unable to return to work
from the time of diagnosis, and their daily lives (and those of their families) were often consumed
with managing the neurologic and treatment-related symptoms. I realized that obtaining my PhD
would be an important step to learn the skills I would need to try to find answers to solve the
problems CNS tumor patients were facing.
At that time, many of the conceptual models identified solitary symptoms and their impact on the
person. I learned from my experience and in caring for patients that symptoms seldom occurred in
isolation and that the meaning the symptoms had for patientsâ€™ daily lives was important, as was
learning about the patientsâ€™ perception of that impact. I developed a conceptual model to identify
those relationships and guide my research (Armstrong, 2003). My focus since then has been on
patient-centered outcomes research, focusing on the impact of symptoms on the illness trajectory,
tolerance of therapy, and potential to influence survival. My work is never done in isolation. I have
been fortunate to work with research teams, including those who work alongside me and important
collaborators across disciplines and the world. Team research, in which the views of various
disciplines are brought together, is important in every step of researchâ€”from the hypothesis to
study design and finally interpretation of the results.
My work is interconnected, but I believe it can be categorized into three general areas:
1. Improving assessment and our understanding of the experience of patients with CNS tumors.
Patients with primary brain tumors are highly symptomatic, with implications for functional status,
and are used in making treatment decisions. I led a team that developed the M.D. Anderson
Symptom Inventory for Brain Tumors (MDASI-BT) (Armstrong et al., 2005; Armstrong et al.,
2006) and spinal cord tumors (MDASI-Spine) (Armstrong, Gning, et al., 2010). We have
completed studies showing that symptoms are associated with tumor progression (Armstrong et
al., 2011). We have also been able to quantify limitations of patientsâ€™ functional status (Armstrong
et al., 2015), in a way that caregivers report is congruent with the patient, and have found that
electronic technology (such as iPads) can be used for this (Armstrong et al., 2012). Our work with
the Collaborative Ependymoma Research Organization (CERN, www.cern-foundation.org) has
allowed us to reach out to patients with this rarer tumor to understand the natural history and
impact of the disease and its treatment on patients around the world (Armstrong, Vera-Bolanos,
et al., 2010; Armstrong, Vera-Bolanos, & Gilbert, 2011). Based on these surveys, we have
developed materials to inform patients and are launching an expansion of this project, in which
we will evaluate risk factors (both based on history and genetics) for the occurrence of these
tumors in both adults and children.
2. Incorporation of clinical outcomes assessment into brain tumor clinical trials.
Clinical trials often assess the impact of therapy on how the tumor appears on imaging or survival,
but the impact on the person is often not assessed. I have been fortunate to work with Dr. M.
Gilbert and Dr. J. Wefel to incorporate these outcomes into large clinical trials, providing clear
evidence that it was feasible to incorporate patient outcomes measures and that the results of
these evaluations could impact the interpretation of the clinical trial (Armstrong et al., 2013;
Gilbert et al., 2014). As a result of my involvement in these efforts, I recently chaired a daylong
workshop exploring the use of clinical outcomes assessments (COAs) in brain tumor trials, a
workshop cosponsored by the FDA and the Jumpstarting Brain Tumor Drug Development
(JSBTDD) consortia that also included members of the academic community, patient advocates,
pharmaceutical industry, and the NIH. This successful workshop has resulted in a series of white
papers that were recently published on the importance of including these in clinical trials
(Armstrong, Bishof, et al., 2016; Helfer et al., 2016).
3. Identification of clinical and genomic predictors of toxicity.
Toxicity associated with treatment also impacts the patient. For example, Temozolomide, the most
common agent used in the treatment of brain tumors, has a low overall incidence of myelotoxicity
(impact on blood counts that help to fight infection or clot the blood). However, in the select
patients who develop toxicity, there are significant clinical implications (treatment holds or
cessation, and even death). I work with an interdisciplinary group that began to explore the
clinical predictors of this toxicity and then explored associated genomic changes associated with
risk (Armstrong et al., 2009). Currently, I am also working with a research team exploring risk
factors and pathogenesis of radiation-induced fatigue and sleepiness, which is a major symptom
in a large percentage of patients undergoing cranial radiotherapy for their brain tumor
(Armstrong, Shade, et al., 2016). The ultimate goal of this part of my research is to begin to
uncover phenotypes associated with symptoms and to uncover the underlying biologic processes,
so that we can initiate measures prior to the occurrence of symptoms, rather than waiting for
them to occur and then trying to mitigate them.
In addition to conducting focused outcomes research as outlined previously, I have over 25 yearsâ€™
dedication to the clinical care of persons with tumors of the CNS. This work is the best part of my
job and is a critical linkage and inspiration in my research, with the goal of improving the daily
life of patients and improving our understanding of the underlying biology of symptoms and
experience that our patients have.
1. Armstrong T. S. Symptoms experience a concept analysis. Oncology Nursing Society
2. Armstrong T. S, Cohen M. Z, Eriksen L., Cleeland C. Content validity of self-report
measurement instruments an illustration from the development of the Brain Tumor Module of
the M. D. Anderson Symptom Inventory. Oncology Nursing Society 2005;32(3):669-676.
3. Armstrong T. S, Mendoza T., Gning I., et al. Validation of the M. D. Anderson Symptom
Inventory Brain Tumor Module (MDASI-BT). Journal of Neuro-Oncology 2006;80(1):27-35.
4. Armstrong T. S, Cao Y., Scheurer M. E, et al. Risk analysis of severe myelotoxicity with
temozolomide The effects of clinical and genetic factors. Neuro-Oncology 2009;11(6):825-832.
5. Armstrong T. S, Gning I., Mendoza T. R, et al. Reliability and validity of the M. D. Anderson
Symptom Inventory-Spine Tumor Module. Journal of Neurosurgery Spine 2010;12(4):421-430.
6. Armstrong T. S, Vera-Bolanos E., Bekele B. N, et al. Adult ependymal tumors prognosis and
the M. D. Anderson Cancer Center experience. Neuro-Oncology 2010;12(8):862-870.
7. Armstrong T. S, Vera-Bolanos E., Gilbert M. R. Clinical course of adult patients with
ependymoma results of the Adult Ependymoma Outcomes Project. Cancer 2011;117(22):51335141.
8. Armstrong T. S, Vera-Bolanos E., Gning I., et al. The impact of symptom interference using the
MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) on prediction of recurrence
in primary brain tumor patients. Cancer 2011;117(14):3222-3228.
9. Armstrong T. S, Wefel J. S, Gning I., et al. Congruence of primary brain tumor patient and
caregiver symptom report. Cancer 2012;118(20):5026-5037.
10. Armstrong T. S, Wefel J. S, Wang M., et al. Net clinical benefit analysis of radiation therapy
oncology group 0525 a phase III trial comparing conventional adjuvant temozolomide with
dose-intensive temozolomide in patients with newly diagnosed glioblastoma. Journal of
Clinical Oncology 2013;31(32):4076-4084.
11. Armstrong T. S, Vera-Bolanos E., Acquaye A. A, et al. The symptom burden of primary brain
tumors evidence for a core set of tumor and treatment-related symptoms. Neuro-Oncology
2015;18(2):252-260 Epub August 19, 2015.
12. Armstrong T. S, Bishof A. M, Brown P. D, et al. Determining priority signs and symptoms for
use as clinical outcomes assessments in trials including patients with malignant gliomas panel 1
report. Neuro-Oncology 2016;18(Suppl. 2):ii1-ii12.
13. Armstrong T. S, Shade M. Y, Breton G., et al. Sleep-wake disturbance in patients with brain
tumors.;: Neuro-Oncology, in press2016;
14. Gilbert M. R, Dignam J. J, Armstrong T. S, et al. A randomized trial of bevacizumab for newly
diagnosed glioblastoma. New England Journal of Medicine 2014;370(8):699-708.
15. Helfer J. L, Wen P. Y, Blakeley J., et al. Report of the Jumpstarting Brain Tumor Drug
Development Coalition and FDA clinical trials clinical outcome assessment endpoints workshop
(October 15, 2014, Bethesda, MD). Neuro-Oncology 2016;18(Suppl. 2):ii26-ii36.
Integrating research, evidence-based practice,
and quality improvement processes
Geri LoBiondo-Wood, Judith Haber
After reading this chapter, you should be able to do the following:
â€¢ State the significance of research, evidence-based practice, and quality improvement (QI).
â€¢ Identify the role of the consumer of nursing research.
â€¢ Define evidence-based practice.
â€¢ Define QI.
â€¢ Discuss evidence-based and QI decision making.
â€¢ Explain the difference between quantitative and qualitative research.
â€¢ Explain the difference between the types of systematic reviews.
â€¢ Identify the importance of critical reading skills for critical appraisal of research.
â€¢ Discuss the format and style of research reports/articles.
â€¢ Discuss how to use an evidence hierarchy when critically appraising research studies.
levels of evidence
Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing
exercises, and additional research articles for practice in reviewing and critiquing.
We invite you to join us on an exciting nursing research adventure that begins as you read the first
page of this chapter. The adventure is one of discovery! You will discover that the nursing research
literature sparkles with pride, dedication, and excitement about this dimension of professional
practice. As you progress through your educational program, you are taught how to ensure quality
and safety in practice through acquiring knowledge of the various sciences and health care
principles. A critical component of clinical knowledge is understanding research as it applies to
practicing from a base of evidence.
Whether you are a student or a practicing nurse whose goal is to use research as the foundation
of your practice, you will discover that research, evidence-based practice, and quality
improvement (QI) positions our profession at the cutting edge of change and improvement in
patient outcomes. You will also discover the cutting edge â€œwho,â€ â€œwhat,â€ â€œwhere,â€ â€œwhen,â€ â€œwhy,â€
and â€œhowâ€ of nursing research, and develop a foundation of evidence-based practice knowledge
and competencies that will equip you for your clinical practice.
Your nursing research adventure will be filled with new and challenging learning experiences
that develop your evidence-based practice skills. Your critical thinking, critical reading, and clinical
decision-making skills will expand as you develop clinical questions, search the research literature,
evaluate the research evidence found in the literature, and make clinical decisions about applying
the â€œbest available evidenceâ€ to your practice. For example, you will be encouraged to ask
important clinical questions, such as, â€œWhat makes a telephone education intervention more
effective with one group of patients with a diagnosis of congestive heart failure but not another?â€
â€œWhat is the effect of computer learning modules on self-management of diabetes in children?â€
â€œWhat research has been conducted in the area of identifying barriers to breast cancer screening in
African American women?â€ â€œWhat is the quality of studies conducted on telehealth?â€ â€œWhat
nursing-delivered smoking cessation interventions are most effective?â€ This book will help you
begin your adventure into evidence-based practice by developing an appreciation of research as the
foundation for evidence-based practice and QI.
Nursing research, evidence-based practice, and quality
Nurses are challenged to stay abreast of new information to provide the highest quality of patient
care (Institute of Medicine [IOM], 2011). Nurses are challenged to expand their â€œcomfort zoneâ€ by
offering creative approaches to old and new health problems, as well as designing new and
innovative programs that make a difference in the health status of our citizens. This challenge can
best be met by integrating rapidly expanding research and evidence-based knowledge about
biological, behavioral, and environmental influences on health into the care of patients and their
It is important to differentiate between research, evidence-based practice, and QI. Research is the
systematic, rigorous, critical investigation that aims to answer questions about nursing phenomena.
Researchers follow the steps of the scientific process, outlined in this chapter and discussed in detail
in each chapter of this textbook. There are two types of research: quantitative and qualitative. The
methods used by nurse researchers are the same methods used by other disciplines; the difference is
that nurses study questions relevant to nursing practice. Published research studies are read and
evaluated for use in clinical practice. Study findings provide evidence that is evaluated, and
applicability to practice is used to inform clinical decisions.
Evidence-based practice is the collection, evaluation, and integration of valid research evidence,
combined with clinical expertise and an understanding of patient and family values and
preferences, to inform clinical decision making (Sackett et al., 2000). Research studies are gathered
from the literature and assessed so that decisions about application to practice can be made,
culminating in nursing practice that is evidence based. âž¤ Example: To help you understand the
importance of evidence-based practice, think about the systematic review and meta-analysis from
Al-Mallah and colleagues (2015), which assessed the impact of nurse-led clinics on the mortality
and morbidity of patients with cardiovascular disease (see Appendix E). Based on their synthesis of
the literature, they put forth several conclusions regarding the implications for practice and further
research for nurses working in the field of cardiovascular care.
QI is the systematic use of data to monitor the outcomes of care processes as well as the use of
improvement methods to design and test changes in practice for the purpose of continuously
improving the quality and safety of health care systems (Cronenwett et al., 2007). While research
supports or generates new knowledge, evidence-based practice and QI uses currently available
knowledge to improve health care delivery. When you first read about these three processes, you
will notice they have similarities. Each begins with a question. The difference is that in a research
study the question is tested with a design appropriate to the question and specific methodology
(i.e., sample, instruments, procedures, and data analysis) used to test the research question and
contribute to new, generalizable knowledge. In the evidence-based practice and QI processes, a
question is used to search the literature for already completed studies in order to bring about
improvements in care.
All nurses share a commitment to the advancement of nursing science by conducting research
and using research evidence in practice. Research promotes accountability, which is one of the
hallmarks of the nursing profession and a fundamental concept of the American Nurses Association
(ANA) Code for Nurses (ANA, 2015). There is a consensus that the research role of the
baccalaureate and masterâ€™s graduate calls for critical appraisal skills. That is, nurses must be
knowledgeable consumers of research, who can evaluate the strengths and weaknesses of research
evidence and use existing standards to determine the merit and readiness of research for use in
clinical practice. Therefore, to use research for an evidence-based practice and to practice using the
highest quality processes, you do not have to conduct research; however, you do need to
understand and appraise the steps of the research process in order to read the research literature
critically and use it to inform clinical decisions.
As you venture through this text, you will see the steps of the research, evidence-based practice,
and QI processes. The steps are systematic and relate to the development of evidence-based
practice. Understanding the processes that researchers use will help you develop the assessment
skills necessary to judge the soundness of research studies.
throughout the chapters, terminology pertinent to each step is identified and illustrated with
examples. Five published studies are found in the appendices and used as examples to illustrate
significant points in each chapter. Judging the studyâ€™s strength and quality, as well as its
applicability to practice, is key. Before you can judge a study, it is important to understand the
differences among studies. There are different study designs that you will see as you read through
this text and the appendices. There are standards not only for critiquing the soundness of each step
of a study, but also for judging the strength and quality of evidence provided by a study and
determining its applicability to practice.
This chapter provides an overview of research study designs and appraisal skills. It introduces
the overall format of a research article and provides an overview of the subsequent chapters in the
book. It also introduces the QI and evidence-based practice processes, a level of evidence hierarchy
model, and other tools for helping you evaluate the strength and quality of research evidence.
These topics are designed to help you read research articles more effectively and with greater
understanding, so that you can make evidence-based clinical decisions and contribute to quality
and cost-effective patient outcomes.
Types of research: Qualitative and quantitative
Research is classified into two major categories: qualitative and quantitative. A researcher chooses
between these categories based on the question being asked. That is, a researcher may wish to test a
cause-and-effect relationship, or to assess if variables are related, or may wish to discover and
understand the meaning of an experience or process. A researcher would choose to conduct a
qualitative research study if the question is about understanding the meaning of a human
experience such as grief, hope, or loss. The meaning of an experience is based on the view that
meaning varies and is subjective. The context of the experience also plays a role in qualitative
research. That is, the experience of loss as a result of a miscarriage would be different than the
experience of losing a parent.
Qualitative research is generally conducted in natural settings and uses data that are words or
text rather than numeric to describe the experiences being studied. Qualitative studies are guided
by research questions, and data are collected from a small number of subjects, allowing an in-depth
study of a phenomenon. âž¤ Example: vanDijk et al. (2016) explored how patients assign a number
to their postoperative pain experience (see Appendix C). Although qualitative research is systematic
in its method, it uses a subjective approach. Data from qualitative studies help nurses understand
experiences or phenomena that affect patients; these data also assist in generating theories that lead
clinicians to develop improved patient care and stimulate further research. Highlights of the
general steps of qualitative studies and the journal format for a qualitative article are outlined in
Table 1.1. Chapters 5 through 7 provide an in-depth view of qualitative research underpinnings,
designs, and methods.
Steps of the Research Process and Journal Format: Qualitative Research
Research Process Steps and/or Format Issues Usual Location in Journal Heading or Subheading
Identifying the phenomenon
Abstract and/or in introduction
Research question study purpose
Abstract and/or in beginning or end of introduction
Introduction and/or discussion
Abstract and/or in introductory section or under method section entitled â€œDesignâ€ or stated in method section
Method section labeled â€œSampleâ€ or â€œSubjectsâ€
Data collection or procedures section or in sample section
Data collection procedure
Data collection or procedures section
Methods section under subhead â€œData Analysisâ€ or â€œData Analysis and Interpretationâ€
Stated in separate heading: â€œResultsâ€ or â€œFindingsâ€
Discussion and recommendation
Combined in separate section: â€œDiscussionâ€ or â€œDiscussion and Implicationsâ€
At end of article
Whereas qualitative research looks for meaning, quantitative research encompasses the study of
research questions and/or hypotheses that describe phenomena, test relationships, assess
differences, seek to explain cause-and-effect relationships between variables, and test for
intervention effectiveness. The numeric data in quantitative studies are summarized and analyzed
using statistics. Quantitative research techniques are systematic, and the methodology is controlled.
Appendices A, B, and D illustrate examples of different quantitative approaches to answering
research questions. Table 1.2 indicates where each step of the research process can usually be
located in a quantitative research article and where it is discussed in this text. Chapters 2, 3, and 8
through 18 describe processes related to quantitative research.
Steps of the Research Process and Journal Format: Quantitative Research
Research Process Steps
and/or Format Issue
TF and/or CF
Sample: type and size
Usual Location in Journal Heading or Subheading
Abstract and/or in article introduction or separately labeled: â€œProblemâ€
Abstract and/or in introduction, or end of literature review or theoretical framework section, or labeled separately: â€œPurposeâ€
At end of heading â€œIntroductionâ€ but not labeled as such, or labeled as separate heading: â€œLiterature Review,â€ â€œReview of the Literature,â€ or
â€œRelated Literatureâ€; or not labeled or variables reviewed appear as headings or subheadings
Combined with â€œLiterature Reviewâ€ or found in separate section as TF or CF; or each concept used in TF or CF may appear as separate subheading
Stated or implied near end of introduction, may be labeled or found in separate heading or subheading: â€œHypothesisâ€ or â€œResearch Questionsâ€; or
reported for first time in â€œResultsâ€
Stated or implied in abstract or introduction or in â€œMethodsâ€ or â€œMethodologyâ€ section
â€œSizeâ€ may be stated in abstract, in methods section, or as separate subheading under methods section as â€œSample,â€ â€œSample/Subjects,â€ or
â€œParticipantsâ€; â€œTypeâ€ may be implied or stated in any of previous headings described under size
Stated or implied in sections: â€œMethods,â€ â€œProcedures,â€ â€œSample,â€ or â€œSubjectsâ€
Found in sections: â€œMethods,â€ â€œInstruments,â€ or â€œMeasuresâ€
Specifically stated or implied in sections: â€œMethods,â€ â€œInstruments,â€ â€œMeasures,â€ or â€œProceduresâ€
In methods section under subheading â€œProcedureâ€ or â€œData Collection,â€ or as separate heading: â€œProcedureâ€
Under subheading: â€œData Analysisâ€
Stated in separate heading: â€œResultsâ€
Combined with results or as separate heading: â€œDiscussionâ€
Validity and reliability
Data collection procedure
Discussion of findings and
Implications, limitations, and Combined in discussion or as separate major headings
At end of article
Research articles, poster, and paper presentations
CF, Conceptual framework; TF, theoretical framework.
The primary difference is that a qualitative study seeks to interpret meaning and phenomena,
whereas quantitative research seeks to test a hypothesis or answer research questions using
statistical methods. Remember as you read research articles that, depending on the nature of the
research problem, a researcher may vary the steps slightly; however, all of the steps should be
Critical reading skills
To develop an expertise in evidence-based practice, you will need to be able to critically read all
types of research articles. As you read a research article, you may be struck by the difference in style
or format of a research article versus a clinical article. The terms of a research article are new, and
the content is different. You may also be thinking that the research article is hard to read or that it is
technical and boring. You may simultaneously wonder, â€œHow will I possibly learn to appraise all
the steps of a research study, the terminology, and the process of evidence-based practice? Iâ€™m only
on Chapter 1. This is not so easy; research is as hard as everyone says.â€
Remember that learning occurs with time and help. Reading research articles can be difficult and
frustrating at first, but the best way to become a knowledgeable research consumer is to use critical
reading skills when reading research articles. As a student, you are not expected to understand a
research article or critique it perfectly the first time. Nor are you expected to develop these skills on
your own. An essential objective of this book is to help you acquire critical reading skills so that you
can use research in your practice. Becoming a competent critical thinker and reader of research
takes time and patience.
Learning the research process further develops critical appraisal skills. You will gradually be able
to read a research article and reflect on it by identifying assumptions, key concepts, and methods,
and determining whether the conclusions are based on the studyâ€™s findings. Once you have
obtained this critical appraisal competency, you will be ready to synthesize the findings of multiple
studies to use in developing an evidence-based practice. This will be a very exciting and rewarding
process for you. Analyzing a study critically can require several readings. As you review and
synthesize a study, you will begin an appraisal process to help you determine the studyâ€™s worth. An
illustration of how to use critical reading strategies is provided in Box 1.1, which contains an
excerpt from the abstract, introduction, literature review, theoretical framework literature, and
methods and procedure section of a quantitative study (Nyamathi et al., 2015) (see Appendix A).
Note that in this article there is both a literature review and a theoretical framework section that
clearly support the studyâ€™s objectives and purpose. Also note that parts of the text from the article
were deleted to offer a number of examples within the text of this chapter.
Example of Critical Appraisal Reading Strategies
Globally, incarcerated populations encounter a host of public health care issues; two such issuesâ€”HAV and HBV diseasesâ€”are vaccine preventable. In addition, viral
hepatitis disproportionately impacts the homeless because of increased risky sexual behaviors and drug use (Stein, Andersen, Robertson, & Gelberg, 2012), along with
Studyâ€™s Purpose substandard living conditions (Hennessey, Bangsberg, Weinbaum, & Hahn, 2009).
Purposeâ€”Despite knowledge of awareness of risk factors for HBV infection, intervention programs designed to enhance completion of the three-series Twinrix
HAV/HBV vaccine and identification of prognostic factors for vaccine completion have not been widely studied. The purpose of this study was to first assess whether
seronegative parolees previously randomized to any one of three intervention conditions were more likely to complete the vaccine series as well as to identify the
predictors of HAV/HBV vaccine completion.
Despite the availability of the HBV vaccine, there has been a low rate of completion for the three-dose core of the accelerated vaccine series (Centers for Disease Control
and Prevention, 2012). Among incarcerated populations, HBV vaccine coverage is low; in a study among jail inmates, 19% had past HBV infection, and 12% completed
the HBV vaccination series (Hennessey, Kim, et al., 2009). Although HBV is well accepted behind barsâ€”because of the lack of funding and focus on prevention as a core
in the prison systemâ€”few inmates complete the series (Weinbaum, Sabin, & Santibanez, 2005). In addition, prevention may not be priority.
Authors contend that, although the HBV vaccine is cost-effective, it is underutilized among high-risk (Rich et al., 2003) and incarcerated populations (Hunt & Saab,
For homeless men on parole, vaccination completion may be affected by level of custody; generally, the higher the level of custody, the higher the risk an inmate poses.
The comprehensive health seeking and coping paradigm (Nyamathi, 1989), adapted from a coping model (Lazarus & Folkman, 1984), and the health seeking and coping
paradigm (Schlotfeldt, 1981) guided this study and the variables selected (see Fig. 1.1). The comprehensive health seeking and coping paradigm has been successfully
applied by our team to improve our understanding of HIV and HBV/hepatitis C virus (HCV) protective behaviors and health outcomes among homeless adults
(Nyamathi, Liu, et al., 2009)â€”many of whom had been incarcerated (Nyamathi et al., 2012).
Methods/Design The study used a randomized clinical trial.
In this model, a number of factors are thought to relate to the outcome variable, completion of the HAV/HBV vaccine series. These factors include sociodemographic
and Hypotheses factors, situational factors, personal factors, social factors, and health seeking and coping responses.
An RCT where 600 male parolees participating in an RDT program were randomized into one of three intervention conditions aimed at assessing program efficacy on
Recruitment and reducing drug use and recidivism at 6 and 12 months, as well as vaccine completion in eligible subjects.
There were four inclusion criteria for recruitment purposes in assessing program efficacy on reducing drug use and recidivism: (1) history of drug use prior to their
latest incarceration, (2) between ages of 18 and 60, (3) residing in the participating RDT program, and (4) designated as homeless as noted on the prison or jail discharge
The study was approved by the University of California, Los Angeles Institutional Review Board and registered with clinical Trials.gov.
Building upon previous studies, we developed varying levels of peer-coached and nurse-led programs designed to improve HAV/HBV vaccine receptivity at 12-month
follow-up among homeless offenders recently released to parole. See Appendix A for details in the â€œInterventionsâ€ section.
Several strategies for treatment fidelity included study design, interventionistâ€™s training, and standardization of interventions. See the Interventions section in Appendix
HBA, Hepatitis A virus; HBV, hepatitis B virus; RCT, randomized clinical trial.
Start an IPE Journal Club with students from other health professions programs on your campus.
Select a research study to read, understand, and critically appraise together. It is always helpful to
collaborate on deciding whether the findings are applicable to clinical practice.
Strategies for critiquing research studies
Evaluation of a research article requires a critique. A critique is the process of critical appraisal that
objectively and critically evaluates a research reportâ€™s content for scientific merit and application to
practice. It requires some knowledge of the subject matter and knowledge of how to critically read
and use critical appraisal criteria. You will find:
â€¢ Summarized examples of critical appraisal criteria for qualitative studies and an example of a
qualitative critique in Chapter 7
â€¢ Summarized critical appraisal criteria and examples of a quantitative critique in Chapter 18
â€¢ An in-depth exploration of the criteria for evaluation required in quantitative research critiques in
Chapters 8 through 18
â€¢ Criteria for qualitative research critiques presented in Chapters 5 through 7
â€¢ Principles for qualitative and quantitative research in Chapters 1 through 4
Critical appraisal criteria are the standards, appraisal guides, or questions used to assess an
article. In analyzing a research article, you must evaluate each step of the research process and ask
questions about whether each step meets the criteria. For instance, the critical appraisal criteria in
Chapter 3 ask if â€œthe literature review identifies gaps and inconsistencies in the literature about a
subject, concept, or problem,â€ and if â€œall of the concepts and variables are included in the review.â€
These two questions relate to critiquing the research question and the literature review components
of the research process. Box 1.1 lists several gaps identified in the literature by Nyamathi and
colleagues (2015) and how the study intended to fill these gaps by conducting research for the
stated objective and purpose (see Appendix A). Remember that when doing a critique, you are
pointing out strengths as well as weaknesses. Standardized critical appraisal tools such as those
from the Center for Evidence Based Medicine (CEBM) Critical Appraisal Tools
(www.cebm.net/critical-appraisal) can be used to systematically appraise the strength and quality
of evidence provided in research articles (see Chapter 20).
Critiquing can be thought of as looking at a completed jigsaw puzzle. Does it form a
comprehensive picture, or is a piece out of place? What is the level of evidence provided by the
study and the findings? What is the balance between the risks and benefits of the findings that
contribute to clinical decisions? How can I apply the evidence to my patient, to my patient
population, or in my setting? When reading several studies for synthesis, you must assess the
interrelationship of the studies, as well as the overall strength and quality of evidence and
applicability to practice. Reading for synthesis is essential in critiquing research. Appraising a study
helps with the development of an evidence table (see Chapter 20).
Overcoming barriers: Useful critiquing strategies
throughout the text, you will find features that will help refine the skills essential to understanding
and using research in your practice. A Critical Thinking Decision Path related to each step of the
research process in each chapter will sharpen your decision-making skills as you critique research
articles. Look for Internet resources in chapters that will enhance your consumer skills. Critical
Thinking Challenges, which appear at the end of each chapter, are designed to reinforce your
critical reading skills in relation to the steps of the research process. Helpful Hints, designed to
reinforce your understanding, appear at various points throughout the chapters. Evidence-Based
Practice Tips, which will help you apply evidence-based practice strategies in your clinical practice,
are provided in each chapter.
When you complete your first critique, congratulate yourself; mastering these skills is not easy.
Best of all, you can look forward to discussing the points of your appraisal, because your critique
will be based on objective data, not just personal opinion. As you continue to use and perfect critical
analysis skills by critiquing studies, remember that these skills are an expected competency for
delivering evidence-based and quality nursing care.
Evidence-based practice and research
Along with gaining comfort while reading and critiquing studies, there is one final step: deciding
how, when, and if to apply the studies to your practice so that your practice is evidence based.
Evidence-based practice allows you to systematically use the best available evidence with the
integration of individual clinical expertise, as well as the patientâ€™s values and preferences, in
making clinical decisions (Sackett et al., 2000). Evidence-based practice involves processes and
steps, as does the research process. These steps are presented throughout the text. Chapter 19
provides an overview of evidence-based practice steps and strategies.
When using evidence-based practice strategies, the first step is to be able to read a study and
understand how each section is linked to the steps of the research process. The following section
introduces you to the research process as presented in published articles. Once you read a study,
you must decide which level of evidence the study provides and how well the study was designed
and executed. Fig. 1.1 illustrates a model for determining the levels of evidence associated with a
studyâ€™s design, ranging from systematic reviews of randomized clinical trials (RCTs) (see Chapters
9 and 10) to expert opinions. The rating system, or evidence hierarchy model, presented here is just
one of many. Many hierarchies for assessing the relative worth of both qualitative and quantitative
designs are available. Early in the development of evidence-based practice, evidence hierarchies
were thought to be very inflexible, with systematic reviews or meta-analyses at the top and
qualitative research at the bottom. When assessing a clinical question that measures cause and
effect, this may be true; however, nursing and health care research are involved in a broader base of
problem solving, and thus assessing the worth of a study within a broader context of applying
evidence into practice requires a broader view.
FIG 1.1 Levels of evidence: Evidence hierarchy for rating levels of evidence associated with a studyâ€™s
design. Evidence is assessed at a level according to its source.
The meaningfulness of an evidence rating system will become clearer as you read Chapters 8
through 11. âž¤ Example: The Nyamathi et al. (2015) study is Level II because of its experimental,
randomized control trial design, whereas the vanDijk et al. (2016) study is Level VI because it is a
qualitative study. The level itself does not tell a studyâ€™s worth; rather it is another tool that helps
you think about a studyâ€™s strengths and weaknesses and the nature of the evidence provided in the
findings and conclusions. Chapters 7 and 18 will provide an understanding of how studies can be
assessed for use in practice. You will use the evidence hierarchy presented in Fig. 1.1 throughout
the book as you develop your research consumer skills, so become familiar with its content.
This rating system represents levels of evidence for judging the strength of a studyâ€™s design,
which is just one level of assessment that influences the confidence one has in the conclusions the
researcher has drawn. Assessing the strength of scientific evidence or potential research bias
provides a vehicle to guide evaluation of research studies for their applicability in clinical decision
making. In addition to identifying the level of evidence, one needs to grade the strength of a body
of evidence, incorporating the domains of quality, quantity, and consistency (Agency for Healthcare
Research and Quality, 2002).
â€¢ Quality: Extent to which a studyâ€™s design, implementation, and analysis minimize bias.
â€¢ Quantity: Number of studies that have evaluated the research question, including overall sample
size across studies, as well as the strength of the findings from data analyses.
â€¢ Consistency: Degree to which studies with similar and different designs investigating the same
research question report similar findings.
The evidence-based practice process steps are: ask, gather, assess and appraise, act, and evaluate
(Fig. 1.2). These steps of asking clinical questions; identifying and gathering the evidence; critically
appraising and synthesizing the evidence or literature; acting to change practice by coupling the best
available evidence with your clinical expertise and patient preferences (e.g., values, setting, and
resources); and evaluating if the use of the best available research evidence is applicable to your
patient or organization will be discussed throughout the text.
FIG 1.2 Evidence-based practice steps.
To maintain an evidence-based practice, studies are evaluated using specific criteria. Completed
studies are evaluated for strength, quality, and consistency of evidence. Before one can proceed
with an evidence-based project, it is necessary to understand the steps of the research process found
in research studies.
Research articles: Format and style
Before you begin reading research articles, it is important to understand their organization and
format. Many journals publish research, either as the sole type of article or in addition to clinical or
theoretical articles. Many journals have some common features but also unique characteristics. All
journals have guidelines for manuscript preparation and submission. A review of these guidelines,
which are found on a journalâ€™s website, will give you an idea of the format of articles that appear in
Remember that even though each step of the research process is discussed at length in this text,
you may find only a short paragraph or a sentence in an article that provides the details of the step.
A publication is a shortened version of the researcher(s) completed work. You will also find that
some researchers devote more space in an article to the results, whereas others present a longer
discussion of the methods and procedures. Most authors give more emphasis to the method,
results, and discussion of implications than to details of assumptions, hypotheses, or definitions of
terms. Decisions about the amount of material presented for each step of the research process are
bound by the following:
â€¢ A journalâ€™s space limitations
â€¢ A journalâ€™s author guidelines
â€¢ The type or nature of the study
â€¢ The researcherâ€™s decision regarding which component of the study is the most important
The following discussion provides a brief overview of each step of the research process and how
it might appear in an article. It is important to remember that a quantitative research article will
differ from a qualitative research article. The components of qualitative research are discussed in
Chapters 5 and 6, and are summarized in Chapter 7.
An abstract is a short, comprehensive synopsis or summary of a study at the beginning of an article.
An abstract quickly focuses the reader on the main points of a study. A well-presented abstract is
accurate, self-contained, concise, specific, nonevaluative, coherent, and readable. Abstracts vary in
word length. The length and format of an abstract are dictated by the journalâ€™s style. Both
quantitative and qualitative research studies have abstracts that provide a succinct overview of the
study. An example of an abstract can be found at the beginning of the study by Nyamathi et al.
(2015) (see Appendix A). Their abstract follows an outline format that highlights the major steps of
the study. It partially reads as follows:
Purpose/Objective: â€œThe study focused on completion of the HAV and HBV vaccine series among
homeless men on parole. The efficacy of the three levels of peer counseling (PC) and nurse
delivered intervention was compared at 12 month follow up.â€
In this example, the authors provide a view of the study variables. The remainder of the abstract
provides a synopsis of the background of the study and the methods, results, and conclusions. The
studies in Appendices A through D all have abstracts.
An abstract is a concise short overview that provides a reference to the research purpose, research
questions, and/or hypotheses, methodology, and results, as well as the implications for practice or
Early in a research article, in a section that may or may not be labeled â€œIntroduction,â€ the researcher
presents a background picture of the area researched and its significance to practice (see Chapter 2).
Definition of the purpose
The purpose of the study is defined either at the end of the researcherâ€™s initial introduction or at the
end of the â€œLiterature Reviewâ€ or â€œConceptual Frameworkâ€ section. The studyâ€™s purpose may or
may not be labeled (see Chapters 2 and 3), or it may be referred to as the studyâ€™s aim or objective.
The studies in Appendices A through D present specific purposes for each study in untitled sections
that appear in the beginning of each article, as well as in the articleâ€™s abstract.
Literature review and theoretical framework
Authors of studies present the literature review and theoretical framework in different ways. Many
research articles merge the â€œLiterature Reviewâ€ and the â€œTheoretical Framework.â€ This section
includes the main concepts investigated and may be called â€œReview of the Literature,â€ â€œLiterature
Review,â€ â€œTheoretical Framework,â€ â€œRelated Literature,â€ â€œBackground,â€ â€œConceptual
Framework,â€ or it may not be labeled at all (see Chapters 2 and 3). By reviewing Appendices A
through D, you will find differences in the headings used. Nyamathi et al. (2015) (see Appendix A)
use no labels and present the literature review but do have a section labeled theoretical framework,
while the study in Appendix B has a literature review and a conceptual framework integrated in the
beginning of the article. One style is not better than another; the studies in the appendices contain
all the critical elements but present the elements differently.
Not all research articles include headings for each step or component of the research process, but
each step is presented at some point in the article.
A studyâ€™s research questions or hypotheses can also be presented in different ways (see Chapter 2).
Research articles often do not have separate headings for reporting the â€œHypothesesâ€ or â€œResearch
Question.â€ They are often embedded in the â€œIntroductionâ€ or â€œBackgroundâ€ section or not labeled
at all (e.g., as in the studies in the appendices). If a study uses hypotheses, the researcher may report
whether the hypotheses were or were not supported toward the end of the article in the â€œResultsâ€
or â€œFindingsâ€ section. Quantitative research studies have hypotheses or research questions.
Qualitative research studies do not have hypotheses, but have research questions and purposes.
The studies in Appendices A, B, and D have hypotheses. The study in Appendix C does not, since it
is a qualitative study; rather it has a purpose statement.
The type of research design can be found in the abstract, within the purpose statement, or in the
introduction to the â€œProceduresâ€ or â€œMethodsâ€ section, or not stated at all (see Chapters 6, 9, and
10). For example, the studies in Appendices A, B, and D identify the design in the abstract.
One of your first objectives is to determine whether the study is qualitative (see Chapters 5 and 6)
or quantitative (see Chapters 8, 9, and 10). Although the rigor of the critical appraisal criteria
addressed do not substantially change, some of the terminology of the questions differs for
qualitative versus quantitative studies. Do not get discouraged if you cannot easily determine the
design. One of the best strategies is to review the chapters that address designs. The following tips
will help you determine whether the study you are reading employs a quantitative design:
â€¢ Hypotheses are stated or implied (see Chapter 2).
â€¢ The terms control and treatment group appear (see Chapter 9).
â€¢ The terms survey, correlational, case control, or cohort are used (see Chapter 10).
â€¢ The terms random or convenience are mentioned in relation to the sample (see Chapter 12).
â€¢ Variables are measured by instruments or scales (see Chapter 14).
â€¢ Reliability and validity of instruments are discussed (see Chapter 15).
â€¢ Statistical analyses are used (see Chapter 16).
In contrast, qualitative studies generally do not focus on â€œnumbers.â€ Some qualitative studies
may use standard quantitative terms (e.g., subjects) rather than qualitative terms (e.g., informants).
Deciding on the type of qualitative design can be confusing; one of the best strategies is to review
the qualitative chapters (see Chapters 5 through 7). Begin trying to link the studyâ€™s design with the
level of evidence associated with that design as illustrated in Fig. 1.1. This will give you a context
for evaluating the strength and consistency of the findings and applicability to practice. Chapters 8
through 11 will help you understand how to link the levels of evidence with quantitative designs. A
study may not indicate the specific design used; however, all studies inform the reader of the
methodology used, which can help you decide the type of design the authors used to guide the
The population from which the sample was drawn is discussed in the section â€œMethodsâ€ or
â€œMethodologyâ€ under the subheadings of â€œSubjectsâ€ or â€œSampleâ€ (see Chapter 12). Researchers
should tell you both the population from which the sample was chosen and the number of subjects
that participated in the study, as well as if they had subjects who dropped out of the study. The
authors of the studies in the appendices discuss their samples in enough detail so that the reader is
clear about who the subjects are and how they were selected.
Reliability and validity
The discussion of the instruments used to study the variables is usually included in a â€œMethodsâ€
section under the subheading of â€œInstrumentsâ€ or â€œMeasuresâ€ (see Chapter 14). Usually each
instrument (or scale) used in the study is discussed, as well as its reliability and validity (see
Chapter 15). The studies in Appendices A, B, and D discuss each of the measures used in the
â€œMethodsâ€ section under the subheading â€œMeasuresâ€ or â€œInstruments.â€ The reliability and validity
of each measure is also presented.
In some cases, the reliability and validity of commonly used, established instruments in an article
are not presented, and you are referred to other references.
Procedures and collection methods
The data collection procedures, or the individual steps taken to gather measurable data (usually
with instruments or scales), are generally found in the â€œProceduresâ€ section (see Chapter 14). In the
studies in Appendices A through D, the researchers indicate how they conducted the study in detail
under the subheading â€œProcedureâ€ or â€œInstruments and Procedures.â€ Notice that the researchers in
each study included in the Appendices provided information that the studies were approved by an
institutional review board (see Chapter 13), thereby ensuring that each study met ethical standards.
The data-analysis procedures (i.e., the statistical tests used and the results of descriptive and/or
inferential tests applied in quantitative studies) are presented in the section labeled â€œResultsâ€ or
â€œFindingsâ€ (see Chapters 16 and 17). Although qualitative studies do not use statistical tests, the
procedures for analyzing the themes, concepts, and/or observational or print data are usually
described in the â€œMethodâ€ or â€œData Collectionâ€ section and reported in the â€œResults,â€ â€œFindings,â€
or â€œData Analysisâ€ section (see Appendix C and Chapters 5 and 6).
The last section of a research study is the â€œDiscussionâ€ (see Chapter 17). In this section the
researchers tie together all of the studyâ€™s pieces and give a picture of the study as a whole. The
researchers return to the literature reviewed and discuss how their study is similar to, or different
from, other studies. Researchers may report the results and discussion in one section but usually
report their results in separate â€œResultsâ€ and â€œDiscussionâ€ sections (see Appendices A through D).
One particular method is no better than another. Journal and space limitations determine how these
sections will be handled. Any new or unexpected findings are usually described in the â€œDiscussionâ€
Recommendations and implications
In some cases, a researcher reports the implications and limitations based on the findings for
practice and education, and recommends future studies in a separate section labeled â€œConclusionsâ€;
in other cases, this appears in several sections, labeled with such titles as â€œDiscussion,â€
â€œLimitations,â€ â€œNursing Implications,â€ â€œImplications for Research and Practice,â€ and â€œSummary.â€
Again, one way is not better than the otherâ€”only different.
All of the references cited are included at the end of the article. The main purpose of the reference
list is to support the material presented by identifying the sources in a manner that allows for easy
retrieval. Journals use various referencing styles.
Communicating a studyâ€™s results can take the form of a published article, poster, or paper
presentation. All are valid ways of providing data and have potential to effect high-quality patient
care based on research findings. Evidence-based nursing care plans and QI practice protocols,
guidelines, or standards are outcome measures that effectively indicate communicated research.
If you have to write a paper on a specific concept or topic that requires you to critique and
synthesize the findings from several studies, you might find it useful to create an evidence table of
the data (see Chapter 20). Include the following information: author, date, study type, design, level
of evidence, sample, data analysis, findings, and implications.
Systematic reviews: Meta-analyses, integrative reviews, and
Other article types that are important to understand for evidence-based practice are review articles.
Review articles include systematic reviews, meta-analyses, integrative reviews (sometimes called
narrative reviews), meta-syntheses, and meta-summaries. A systematic review is a summation and
assessment of a group of research studies that test a similar research question. Systematic reviews
are based on a clear question, a detailed plan which includes a search strategy, and appraisal of a
group of studies related to the question. If statistical techniques are used to summarize and assess
studies, the systematic review is labeled as a meta-analysis. A meta-analysis is a summary of a
number of studies focused on one question or topic, and uses a specific statistical methodology to
synthesize the findings in order to draw conclusions about the area of focus. An integrative review
is a focused review and synthesis of research or theoretical literature in a particular focus area, and
includes specific steps of literature integration and synthesis without statistical analysis; it can
include both quantitative and qualitative articles (Cochrane Consumer Network, 2016; Uman, 2011;
Whittemore, 2005). At times reviews use the terms systematic review and integrative review
interchangeably. Both meta-synthesis and meta-summary are the synthesis of a number of
qualitative research studies on a focused topic using specific qualitative methodology (Kastner et
al., 2016; Sandelowski & Barrosos, 2007).
The components of review articles will be discussed in greater detail in Chapters 6, 11, and 20.
These articles take a number of studies related to a clinical question and, using a specific set of
criteria and methods, evaluate the studies as a whole. While they may vary somewhat in approach,
these reviews all help to better inform and develop evidence-based practice. The meta-analysis in
Appendix E is an example of a systematic review that is a meta-analysis.
Clinical guidelines are systematically developed statements or recommendations that serve as a
guide for practitioners. Two types of clinical guidelines will be discussed throughout this text:
consensus, or expert-developed guidelines, and evidence-based guidelines. Consensus guidelines,
or expert-developed guidelines, are developed by an agreement of experts in the field. Evidencebased guidelines are those developed using published research findings. Guidelines are developed
to assist in bridging practice and research and are developed by professional organizations,
government agencies, institutions, or convened expert panels. Clinical guidelines provide clinicians
with an algorithm for clinical management or decision making for specific diseases (e.g., breast
cancer) or treatments (e.g., pain management). Not all clinical guidelines are well developed and,
like research, must be assessed before implementation. Though they are systematically developed
and make explicit recommendations for practice, clinical guidelines may be formatted differently.
Guidelines for practice are becoming more important as third party and government payers are
requiring practices to be based on evidence. Guidelines should present scope and purpose of the
practice, detail who the development group included, demonstrate scientific rigor, be clear in its
presentation, demonstrate clinical applicability, and demonstrate editorial independence (see
As a health care provider, you are responsible for continuously improving the quality and safety of
health care for your patients and their families through systematic redesign of health care systems
in which you work. The Institute of Medicine (2001) defined quality health care as care that is safe,
effective, patient-centered, timely, efficient, and equitable. Therefore, the goal of QI is to bring about
measurable changes across these six domains by applying specific methodologies within a care
setting. While several QI methods exist, the core steps for improvement commonly include the
â€¢ Conducting an assessment
â€¢ Setting specific goals for improvement
â€¢ Identifying ideas for changing current practice
â€¢ Deciding how improvements in care will be measured
â€¢ Rapidly testing practice changes
â€¢ Measuring improvements in care
â€¢ Adopting the practice change as a new standard of care
Chapter 21 focuses on building your competence to participate in and lead QI projects by
providing an overview of the evolution of QI in health care, including the nurseâ€™s role in meeting
current regulatory requirements for patient care quality. Chapter 19 discusses QI models and tools,
such as cause-and-effect diagrams and process mapping, as well as skills for effective teamwork
and leadership that are essential for successful QI projects.
As you venture through this textbook, you will be challenged to think not only about reading and
understanding research studies, but also about applying the findings to your practice. Nursing has
a rich legacy of research that has grown in depth and breadth. Producers of research and clinicians
must engage in a joint effort to translate findings into practice that will make a difference in the care
of patients and families.
â€¢ Research provides the basis for expanding the unique body of scientific evidence that forms the
foundation of evidence-based nursing practice. Research links education, theory, and practice.
â€¢ As consumers of research, nurses must have a basic understanding of the research process and
critical appraisal skills to evaluate research evidence before applying it to clinical practice.
â€¢ Critical appraisal is the process of evaluating the strengths and weaknesses of a research article
for scientific merit and application to practice, theory, or education; the need for more research on
the topic or clinical problem is also addressed at this stage.
â€¢ Critical appraisal criteria are the measures, standards, evaluation guides, or questions used to
judge the worth of a research study.
â€¢ Critical reading skills will enable you to evaluate the appropriateness of the content of a research
article, apply standards or critical appraisal criteria to assess the studyâ€™s scientific merit for use in
practice, or consider alternative ways of handling the same topic.
â€¢ A level of evidence model is a tool for evaluating the strength (quality, quantity, and consistency)
of a research study and its findings.
â€¢ Each article should be evaluated for the studyâ€™s strength and consistency of evidence as a means
of judging the applicability of findings to practice.
â€¢ Research articles have different formats and styles depending on journal manuscript
requirements and whether they are quantitative or qualitative studies.
â€¢ Evidence-based practice and QI begin with the careful reading and understanding of each article
contributing to the practice of nursing, clinical expertise, and an understanding of patient values.
â€¢ QI processes are aimed at improving clinical care outcomes for patients and better methods of
Critical thinking challenges
How might nurses discuss the differences between evidence-based practice and research
with their colleagues in other professions?
â€¢ From your clinical practice, discuss several strategies nurses can undertake to promote evidencebased practice.
â€¢ What are some strategies you can use to develop a more comprehensive critique of an evidencebased practice article?
â€¢ A number of different components are usually identified in a research article. Discuss how these
sections link with one another to ensure continuity.
â€¢ How can QI data be used to improve clinical practice?
Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing
exercises, and additional research articles for practice in reviewing and critiquing.
1. Agency for Healthcare Research and Quality. Systems to rate the strength of scientific
evidence. File inventory, Evidence Report/Technology Assessment No. 47. AHRQ Publication No.
2. Al-Mallah M.H, Farah I, Al-Madani W, et al. The impact of nurse-led clinics on the mortality
and mortality of patients with cardiovascular diseases A systematic review and meta-analysis.
Journal of Cardiovascular Nursing 2015;31(1):89-95 Available at:
3. American Nurses Association (ANA). Code of ethics for nurses for nurses with interpretive
statements. Washington, DC: The Association;2015.
4. Cochrane Consumer Network, The Cochrane Library, 2016, retrieved online. Available at:
5. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses.
Nursing Outlook 2007;55(3):122-131.
6. Institute of Medicine [IOM]. The future of nursing Leading change, advancing health.
Washington, DC: National Academic Press;2011.
7. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality
chasm A new health system for the 21st century. Washington, DC: National Academy
8. Kastner M, Antony J, Soobiah C, et al. Conceptual recommendatio…
Purchase answer to see full