103 –

FUNDAMENTALS OF
NURSING
Chapter 2 –
Evidence-Based
Practice & Research
Maria Lourdes L. Reposar
 EVIDENCE-BASED PRACTICE
• Evidence-based practice (EBP), or evidence-based nursing, occurs
when the nurse can “integrate best current evidence with clinical
expertise & patient/family preferences & values for delivery of
optimal health care”.
• Evidence-based Practice (EBP) is the process of making clinical
decisions based upon evidence, combined with clinical experience
and patient’s expectations.
• As evidence changes, so must practice.
• A model for changing practice as a result of evidence uses the
following steps: (Melnyk, Fineoout-Overholt, Stillwell & Williamson, 2010)
o Cultivate spirit of inquiry. Nurses need to be curious & willing to
investigate how various practices compare & which might be best for a
specific client.
o Ask clinical questions. For consistency & efficiency, nurses should state
the question in a standard format such as PICOT (the elements of a clinical
research question – patient, intervention, comparison, outcome and (sometimes) time.)
o Search for the best evidence. In the previous step, key terms are
identified that facilitate identifying relevant evidence in the literature.
o Critically appraise the evidence. Several toolkits or schema are
available to assist the nurse in determining the most valid, reliable,
& applicable evidence. In some cases, relevant studies may already
have been synthesized.
o Integrate the evidence with clinical expertise & client/family
preferences & values. Evidence must not be automatically applied
to the care of individual clients. Each nurse must determine how
the evidence fits with the clinical condition of the client, available
resources, institutional policies & the client’s wishes. Only then can
an appropriate intervention be established.
• Implement & evaluate the outcomes of the intervention. The nurse gathers
all relevant data that may indicate whether or not the intervention was
successful. If the outcomes carried from those reported in the evidence,
this evaluation can help determine the reasons for the variable responses &
will contribute to improving the evidence available for future situation.

Research is used as the source of evidence for the conception of EBP

Research entails using formal and systemic processes to address problems and
answer questions
The disciplined thinking and the careful planning and execution that characterize
research means that the resulting findings should be accurate, dependable and
free from bias.
COMPONENTS OF EVIDENCE-BASED PRACTICE
 NURSING RESEARCH
Definition:
 Nursing research develops knowledge about health and the
promotion of health over the full lifespan, care of persons
with health problems and disabilities, and nursing actions to
enhance the ability of individuals to respond effectively to
actual or potential health problems.
Nursing Research and Evidence-Based Practice
 As early as 1854, Florence Nightingale demonstrated the
importance of research in nursing care
 When Nightingale arrived in Crimea in November 1854, she
found the military hospital barracks overcrowded, filthy, rat
and flea infested, and lacking in food, drugs and essential
medical supplies.
 As a result, men died from starvation and disease such as
dysentery, cholera and typhus.
 By systematically collecting, organizing and reporting data
(evidence), Nightingale was able to institute reforms and
significantly reduce mortality rates.
 Although the Nightingale tradition influenced the
establishment of American nursing books, the research
approach did not take hold until the 20th century.
 The journal Nursing Research was 1st published in 1952 to
serve as a vehicle for communicating nurses’ research findings
 In 1985, after intense lobbying by the American Nurses
Association (ANA) the U.S. Congress passed a bill creating the
National Center for Nursing Research as a part of the National
Institute of Health.
In 1993 it was elevated and became the National Institute of
Nursing Research (NNR).
• Approaches to Nursing Research
Nurse researcher use two major approaches to
investigating client’s response to health alteration and
nursing intervention.
oQuantitative
oQualitative
 These approaches originate from different
philosophical perspectives and use different methods
of data gathering
QUANTITATIVE RESEARCH
 Quantitative research entails the systemic collection, statistical
analysis, and interpretation of numerical data.
 It is characterized by planned and fixed study processes, careful
attention to extraneous variables (Any variables that could
influence the results of the study other than the specific
variable/s being studied for their influence) or contaminating
factors in the study environment and an objective and
distanced relationship between the researcher and what is
being studied.
 Reports of quantitative research are characterized by statistical
information, tables and graphs.
 It is linked to the philosophical perspective of logical positivism,
which maintain that “truth” is absolute and can be discovered by
careful measurement.
 This perspective proposes that phenomena are best understood by
examining their component parts; this is referred to as a reduction-
istic perspective.
 Positivism is the philosophical perspective of natural science such as
biology and chemistry. It focuses on the who, what, when, why and
how questions (Cannon 2014).
o What causes ______________?
o Which treatment for a condition is more effective?
o What factors are associated with a specific condition or outcome?
o If I know X, to what extent can I predict the occurrence of Y?
QUALITATIVE RESEARCH
 Qualitative research is the systemic collection and
systhematic analysis of narrative data.
 The research collects and analyzes words, rather than
numbers.
 The qualitative approach to research is rooted in the
philosophical perspective of naturalism (sometimes
referred to as constructivism), which maintains that
reality is relative or contextual and constructed by
individuals who are experiencing a phenomenon.
 This philosophical perspective is reflected in the human
sciences such as anthropology, sociology, and existential
psychology.
 A qualitative approach to research to research its
characterized by flexible and evolving study processes and by
minimized “distancing” between the researcher and study
informant.
 In contrast to a quantitative study, where objectivity is sought
and valued, in a qualitative study, the researcher’s subjectivity
and values are seen as inevitable and even desirable.
 Qualitative research has a holistic perspective and results in a
report that may read like a story.
 Nurse researchers tend to use one of three distinct
qualitative traditions: phenomenology, ethnography,
or grounded theory.
oPhenomenology – focuses on lived experiences
oEthnography – focuses on cultural patterns of
thoughts and behaviors
oGrounded theory – focuses on social processes
 Additional qualitative types include historical and
case study research.
 A qualitative approach to research is useful for research
questions such as these;
o What are the experience of receiving diagnosis X or
undergoing treatment Y? (phenomenology)
o What are the typical behaviors of certain groups of
clients (who may be defined by a diagnosis or
membership in a cultural or ethnic group)?
(ethnography)
o How do individuals cope with X? (grounded theory)
 Nursing research is a general term for the systemic
investigation of the methods, goals, values and
outcomes of nursing practice.
 As is true for other healthcare professionals, many
nurses rely upon custom, habit or institutional
norms to guide nursing practice. One of the
central goals of nursing research is to subject such
practice to rigorous, scientific inquiry.
 Basic research is a catch-all term for scientific research aimed at
advancing fundamental knowledge without any immediate goal or
practical use in mind. Most nursing research is more applied and
goal-driven, although to the extent that nursing research (and
research in other healthcare professions) depends upon a broad
scientific understanding of the human body and disease processes,
nursing research is indirectly dependent upon basic research, and
benefits from this research.
o An example of basic research would be investigating the way
cancer cells use signaling pathways to multiply. The research
might or might not subsequently yield insights into the
pathophysiology of cancer, and to new cancer treatments.
 Evidence-based practice (EBP) is a subset of nursing
research. The goal of EBP is to examine accepted practice in
the light of external clinical evidence to identify practice
that are or is not supported by research using sound
methodology. EBP therefore identifies the best evidence to
guide nursing practice.
o An example of EBP would be encouraging early
ambulation as tolerated for post-surgical patients
because a randomized control trial demonstrated that
this practice led to a statistically significant reduction in
rates of pneumonia and shorter hospital stays
 Quality improvement (QI) or performance improvement (PI) is
subset of nursing research that is concerned with improving
processes and outcomes at the institutional level. Among other
goals, QI/PI aims to help organizations work in ways that are
more safe, effective, timely and efficient. QI/PI is a process that
encourages continuous, ongoing experimentation and
improvement.
o An example of QI/PI would be formulating a set of clinically
validated guidelines for reducing falls, such as mandating that RN’s
complete a fall-risk assessment on admission, and then measuring
and re-measuring over time the implementation and impacts of
such a tool on fall rates within the organization.
 Nursing research – in all its various forms – comprises
one ‘leg’ of the ‘three-legged stool’ of nursing
education, nursing practice, and nursing research.
Ideally, these three activities are interdependent:
each is mutually dependent upon the other, and
contributes to betterment of the profession.
THE RESEARCH PROCESS
 Research is not simply a body of knowledge. It is a dynamic
process with distinct steps and phases. Below is a broad
overview of that process.
 Formulate the Question.
o The first step in any research project is to decide what will
be investigated.
o The best research questions are clear, concise and focused.
o For example, the research question “what challenges do
new nurses face?” is too broad, and would be very difficult
to investigate.
 o A better question might be, “what are the leading challenges to
retaining bachelors-prepared nurses in their first year of practice in
a major academic medical center?”
 Define the Purpose or Goal.
o Nursing research is an inherently applied discipline: its purpose is
to improve the breadth and depth of nursing knowledge, and to
thereby improve nursing practice.
o When you conduct research, keep in mind your intended audience,
and what you hope to achieve with your research.
o If you cannot answer these questions, you should return to your
research question and re-formulate it.
 Choose a Theoretical Framework & Research Design.
o While nursing research is typically ‘practice oriented,’ it is
nonetheless important to be cognizant of how the themes and
concepts in your research fit together, and to spell out how you
will investigate your topic for your audience.
o Will you be investigating individuals’ feelings and narratives?
o Will you be measuring the statistical significance of a particular
clinical intervention?
o Will you be synthesizing the results of previous studies, or
conducting original research? Your answers to these questions
will help determine the purpose, methods, assumptions and
limits of your research.
 Perform a Literature Review.
o Research never exists in a vacuum, and any research project
should survey existing research.
o A competent literature review, however, is not simply a dry
recitation of past findings.
o Rather, it should be a dynamic summary and analysis of existing
knowledge that points out the links between this past work and
the new research being conducted.
o The literature review is a useful introduction for the research
audience that both situates the author’s research in a broader
context, and helps to justify the importance of and need for the
research question the author investigates.
 Select the Population and Sample.
o Regardless of your research goals, framework or
methodology, you will need to define who will be
included in your study, and who will not.
o The population or sample you investigate needs to
match your research question, and just as importantly,
must be available for you to study.
o Populations may be defined by any number of variables,
such as age, gender, clinical role/status, or professional
setting.
 Perform Ethical Review & Obtain Approval.
o An essential part of the research process is to ensure that your
research topic is ethically sound, and to obtain clearances from your
organization or institution to conduct the research.
o This concern is always important, but perhaps especially so for
nurses, who often deal with private and highly sensitive medical data,
access to which may be restricted by HIPAA and other regulations.
o You will probably need to present your research proposal to an
Institutional Review Board (IRB), or other similar institution for
approval.
o Plan ahead, because review and approval can be a lengthy process,
and the panel may require that you make revisions or otherwise alter
your research design.
 Collect & Analyze Data.
o Once you know your research design and methodology, you’ll
need to gather and interpret your data.
o This data may be qualitative or quantitative, or a mix of both.
Before you do your collection, make sure you have the
knowledge and means to make sense of your data.
o You may need to use statistical analysis for quantitative research,
or determine your methodology for analyzing subjective feelings,
values and narratives for qualitative research.
o Again, allow time: data collection and analysis is often
challenging and time-consuming.
 Organize, Write & Edit.
o Your research question, methodology, and population
sample should help you structure your write-up of the
project.
o One way to structure your paper is to think in terms of
broad categories: introduction, methods, results, discussion,
and conclusions and recommendations.
o Using headings and sub-headings to ‘break up’ your
research is often helpful to readers.
o Also be sure to acknowledge the limitations of your
research and areas for further inquiry.
 Compose Citations, Sources & Bibliography.
o Every research study must clearly acknowledge sources
and properly cite them.
o To do so is not only important for reasons of intellectual
integrity, but also because readers should be able to
reference your sources should they choose to do further
reading and investigation.
o Follow your organization or institution’s accepted format;
one commonly used format in nursing research is the
American Psychological Association (APA) style.
 Communicate Findings.
o This final stage in the research process is a crucial one.
o After all, research that never finds its way to its intended
audience is inert.
o Communicating your findings often includes publication; it
may also include speaking about and presenting your research
to professional audiences and to the public.
o However this communication occurs, be open to feedback.
o The questions and debates your research inspires may form
the basis for your next investigation, or for research conducted
by others in conversation with your own.
Roles and Responsibilities for Nurses
 Becoming a nurse researcher requires education and
experience in the process of scientific inquiry. That process is
then combined with the nurse’s already established clinical
experience and expertise.
 A nurse scientist is a registered nurse with a strong clinical
background who has also been educated at the doctoral level
to conduct research.
However, nurses participate as consumers and critics of research
by conducting the important work of translating, applying, and
evaluating the new knowledge with clients and systems.
 Nurses also participate on research teams or with research
protocols to plan, apply, collect data, and evaluate the
process. Each of these roles (nurse scientist, principal
investigator, research team member, research consumer,
and advocate for research clients) offers a substantial
contribution to the process of scientific knowledge
development in nursing and health care.
 Interdisciplinary experiences can further enrich the nurse’s
understanding of the concept or phenomenon and add to
the research team’s perspective of the research project.
Protecting the Rights of Study Participants
 During the research design phase of the process, the researcher
must determine how to safeguard the rights of the research
participants.
 An important role of the nurse researcher is that of advocate for the
clients’ rights during the process; see the accompanying display
regarding the human rights that require protection during research.
• Obtaining informed consent requires that the researcher provide
full disclosure, the communication of complete information to
potential research subjects regarding the nature of the study, the
subject’s right to refuse participation, and the likely risks and
benefits that would be incurred (Polit et al., 2005).
 The nature, seriousness, and likelihood of risks (physical,
psychological, social, and legal) are explained to the
participants.
 The researcher must also identify what precautions will
be taken to minimize the risks.
 Protection of subjects requires that the potential
benefits outweigh potential risks.
 To give informed consent in research, persons must be
mentally capable of understanding the study, risks, and
benefits (Nokes & Nwakeze, 2007).
 Nurses have an obligation to collaborate in the
research, provided the researcher has followed proper
protocols.
 The researcher must obtain permission from the agency
to use its facility as part of the research setting.
 Staff nurses who are expected to participate in the
research process must have an adequate understanding
of the nature of the study.
 Likewise, the staff nurse has the right to refuse to
participate in the study
PROTECTING HUMANS RIGHTS IN RESEARCH
1. Right not to be harmed.
o The risk of harm to a research subject is exposure to the possibility of
injury going beyond everyday situations.
o The risk can be immediate or delayed and can be physical, emotional,
legal, financial, or social in nature.
o For instance, withholding standard care from a client in labor for the
purpose of studying the course of natural childbirth clearly poses a
potential physical danger.
o Risks can also involve psychological factors such as exposure to stress or
anxiety, or social factors, such as loss of confidentiality or loss of privacy.
o Potential risks of participating in a study need to be detailed in informed
consent documents.
2.Right to full disclosure.
o Full disclosure, the act of making clear the client’s role in
a research situation, is a basic right.
o This means that deception, by either witholding
information about a client’s participation in a study or
giving the client false or misleading information about
what participating in the study will involve, must not
occur.
3.Right to self-determination.
o Many clients feel pressured to participate in studies
o They believe that they must please the physicians and nurses
who are responsible for their treatment and care
o The right to self-determination means that participants
should feel free from constraints, coercion, or any undue
influence to participate in a study.
o Hidden inducements – for instance, suggesting to potential
participants that by taking part in the study they might
become famous, make an important contribution to science,
or receive special attention-must be stictly avoided.
4.Right to Privacy
o Privacy enables a client to participate without
worrying about later embarrassment.
o The anonymity of the study participant must be
ensured even if the investigator cannot link a specific
person to the information reported.
o Confidentiality means that any information a
participant relates will not be made public or available
to others without the participant’s consent.
o Investigators must inform research participants
about the laws (such as the Privacy and Security
Rules of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and measures
that provide for the rights.
o Such measures may include the use of pseudonyms
or code numbers or reporting only aggregate or
group data in published research.
Research-Related Role Expectations for Nurses with
Different Levels of Educational Preparation
 Baccalaureate degree
Basic understanding of the research process
Able to understand and apply research findings from
nursing & other disciplines in clinical practice
Understand the basic elements of evidence-based
practice
Work with others to identify potential research
problems
Collaborate on research teams
 Master’s degree
Evaluate research findings
Implement evidence-based practice guidelines
Form and lead research teams in work settings and
professional groups
Identify practice and systems problems that require
study
Work with scientists to initiate research
 Practice-focused doctoral (DNP) degree
Focus on the evaluation and use of research rather than
the conduct of research
Translate scientific knowledge into complex clinical
interventions tailored to meet individual, family, and
community health and illness needs.
Use leadership skills to evaluate the translation of research
into practice
Collaborate with scientists on new health policy research
opportunities that evolve from the translation and
evaluation processes
 Research-focused doctoral (PhD) degree
Conduct independent research
Seek needed support for the initial phases of a
research program
Involves others in research projects
 Postdoctoral preparation
Establish and pursue a focused research agenda