Strengths And Challenges Of Implementing Ebp In Healthcare Systems


Review Grove, Gray, & Burns Chapter 6

Revisit the posted PPT on research process then answer the question

Discussion Questions:

a. Summarize your understanding of this week’s step of the research process

b. What challenges did you encounter in applying this week’s step of the research process?

c. How did you mitigate the challenges?

d. What’re your plans for the next step of the research process?

Understanding Nursing Research
Building an Evidence-Based Practice
Susan K. Grove, PhD, RN, ANP-BC, GNP-BC
Professor Emerita, College of Nursing, The University of Texas at Arlington, Arlington, Texas
Adult Nurse Practitioner, Family Practice, Grand Prairie, Texas
Jennifer R. Gray, PhD, RN, FAAN
George W. and Hazel M. Jay Professor, College of Nursing, Associate Dean, College of Nursing,
The University of Texas at Arlington, Arlington, Texas
Nancy Burns, PhD, RN, FCN, FAAN
Professor Emerita, College of Nursing, The University of Texas at Arlington, Arlington, Texas
Faith Community Nurse, St. Matthew Cumberland Presbyterian Church, Burleson, Texas
Table of Contents
Cover image
Title page
Inside Front Cover
Contributor and Reviewers
Chapter 1: Introduction to Nursing Research and Evidence-Based Practice
What is Nursing Research?
What is Evidence-Based Practice?
Purposes of Research for Implementing an Evidence-Based Nursing Practice
Historical Development of Research in Nursing
Acquiring Knowledge in Nursing
Acquiring Knowledge Through Nursing Research
Understanding Best Research Evidence for Practice
What Is Your Role in Nursing Research?
Key Concepts
Chapter 2: Introduction to Quantitative Research
What is Quantitative Research?
Problem-Solving and Nursing Processes: Basis for Understanding the Quantitative Research Process
Identifying the Steps of the Quantitative Research Process
Reading Research Reports
Practice Reading Quasi-Experimental and Experimental Studies
Key Concepts
Chapter 3: Introduction to Qualitative Research
Values of Qualitative Researchers
Rigor in Qualitative Research
Qualitative Research Approaches
Qualitative Research Methodologies
Data Collection Methods
Data Management
Data Analysis
Key Concepts
Chapter 4: Examining Ethics in Nursing Research
Historical Events Influencing the Development of Ethical Codes and Regulations
Protecting Human Rights
Understanding Informed Consent
Understanding Institutional Review
Examining the Benefit-Risk Ratio of a Study
Understanding Research Misconduct
Examining the Use of Animals in Research
Key Concepts
Chapter 5: Research Problems, Purposes, and Hypotheses
What Are Research Problems and Purposes?
Identifying the Problem and Purpose in Quantitative, Qualitative, and Outcomes Studies
Determining the Significance of a Study Problem and Purpose
Examining the Feasibility of a Problem and Purpose
Examining Research Objectives, Questions, and Hypotheses in Research Reports
Understanding Study Variables and Research Concepts
Key Concepts
Chapter 6: Understanding and Critically Appraising the Literature Review
Purpose of the Literature Review
Sources Included in a Literature Review
Critically Appraising Literature Reviews
Reviewing the Literature
Key Concepts
Chapter 7: Understanding Theory and Research Frameworks
What is a Theory?
Understanding the Elements of Theory
Levels of Theoretical Thinking
Examples of Critical Appraisal
Key Concepts
Chapter 8: Clarifying Quantitative Research Designs
Identifying Designs Used in Nursing Studies
Descriptive Designs
Correlational Designs
Understanding Concepts Important to Causality in Designs
Examining the Validity of Studies
Elements of Designs Examining Causality
Quasi-Experimental Designs
Experimental Designs
Randomized Controlled Trials
Introduction to Mixed-Methods Approaches
Key Concepts
Chapter 9: Examining Populations and Samples in Research
Understanding Sampling Concepts
Representativeness of a Sample in Quantitative and Outcomes Research
Probability Sampling Methods
Nonprobability Sampling Methods Commonly Used in Quantitative Research
Sample Size in Quantitative Studies
Sampling in Qualitative Research
Sample Size in Qualitative Studies
Research Settings
Key Concepts
Chapter 10: Clarifying Measurement and Data Collection in Quantitative Research
Concepts of Measurement Theory
Accuracy, Precision, and Error of Physiological Measures
Use of Sensitivity, Specificity, and Likelihood Ratios to Determine the Quality of Diagnostic AND Screening Tests
Measurement Strategies in Nursing
Data Collection Process
Key Concepts
Chapter 11: Understanding Statistics in Research
Understanding the Elements of the Statistical Analysis Process
Understanding Theories and Concepts of the Statistical Analysis Process
Using Statistics to Describe
Determining the Appropriateness of Inferential Statistics in Studies
Using Statistics to Examine Relationships
Using Statistics to Predict Outcomes
Using Statistics to Examine Differences
Interpreting Research Outcomes
Key Concepts
Chapter 12: Critical Appraisal of Quantitative and Qualitative Research for Nursing
When are Critical Appraisals of Studies Implemented in Nursing?
What are the Key Principles for Conducting Intellectual Critical Appraisals of Quantitative and Qualitative Studies?
Understanding the Quantitative Research Critical Appraisal Process
Example of a Critical Appraisal of a Quantitative Study
Understanding the Qualitative Research Critical Appraisal Process
Example of a Critical Appraisal of a Qualitative Study
Key Concepts
Chapter 13: Building an Evidence-Based Nursing Practice
Benefits and Barriers Related to Evidence-Based Nursing Practice
Searching for Evidence-Based Sources
Critically Appraising Research Syntheses
Developing Clinical Questions to Identify Existing Research-Based Evidence for Use in Practice
Models to Promote Evidence-Based Practice in Nursing
Implementing Evidence-Based Guidelines in Practice
Introduction to Evidence-Based Practice Centers
Introduction to Translational Research
Key Concepts
Chapter 14: Outcomes Research
Theoretical Basis of Outcomes Research
Nursing-Sensitive Outcomes
Origins of Outcomes and Performance Monitoring
Federal Government Involvement in Outcomes Research
Advanced Practice Nursing Outcomes Research
Outcomes Research and Nursing Practice
Methodologies for Outcomes Studies
Statistical Methods for Outcomes Studies
Critical Appraisal of Outcomes Studies
Key Concepts
Inside Back Cover
Inside Front Cover
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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
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Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributor and Reviewers
Diane Doran, RN, PhD, FCAHS, Professor Emerita, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto,
Toronto, Ontario Revised Chapter 14
Lisa D. Brodersen, EdD, MA, RN , Professor, Coordinator of Institutional Research and Effectiveness, Allen College,
Waterloo, Iowa
Sara L. Clutter, PhD, RN , Associate Professor of Nursing, Waynesburg University, Waynesburg, Pennsylvania
Jacalyn P. Dougherty, PhD, RN , Nursing Research Consultant, JP Dougherty LLC, Aurora, Colorado
Joanne T. Ehrmin, RN, COA-CNS, PhD, MSN, BSN , Professor, University of Toledo, College of Nursing, Toledo, Ohio
Betsy Frank, PhD, RN, ANEF , Professor Emerita, Indiana State University College of Nursing, Health, and Human
Services, Terre Haute, Indiana
Tamara Kear, PhD, RN, CNS, CNN , Assistant Professor of Nursing, Villanova University, Villanova, Pennsylvania
Sharon Kitchie, PhD, RN , Adjunct Instructor, Keuka College, Keuka Park, New York
Madelaine Law rence, PhD, RN , Associate Professor, University of North Carolina at Wilmington, Wilmington, North
Robin Moyers, PhD, RN-BC, Nurse Educator, Carl Vinson VA Medical Center, Dublin, Georgia
Sue E. Odom, DSN, RN , Professor of Nursing, Clayton State University, Morrow, Georgia
Teresa M. O’Neill, PhD, APRN, RNC, Professor, Our Lady of Holy Cross College, New Orleans, Louisiana
Sandra L. Siedlecki, PhD, RN, CNS, Senior Nurse Scientist, Cleveland Clinic, Cleveland, Ohio
Sharon Souter, PhD, RN, CNE, Dean and Professor, University of Mary Hardin Baylor, Belton, Texas
Molly J. Walker, PhD, RN, CNS, CNE, Professor, Angelo State University, San Angelo, Texas
Cynthia Ward, DNP, RN-BC, CMSRN, ACNS-BC, Surgical Clinical Nurse Specialist, Carilion Roanoke Memorial
Hospital, Roanoke, Virginia
Angela Wood, PhD, RN, Certified High-Risk Prenatal Nurse, Associate Professor and Chair, Department of Nursing,
Carson-Newman University, Jefferson City, Tennessee
Fatma A. Youssef, RN, DNSc, MPH , Professor Emerita, Marymount University, School of Health Professions,
Arlington, Virginia
To all nurses who change the lives of patients through applying the best research
—Susan, Jennifer, and Nancy
To my husband Jay Suggs who has provided me endless love and support during
my development of research textbooks over the last 30 years.
To my husband Randy Gray who is my love and my cheerleader.
To my husband Jerry who has supported all of my academic endeavors through 58
years of marriage.
Research is a major force in nursing, and the evidence generated from research is
constantly changing practice, education, and health policy. Our aim in developing this
essentials research text, Understanding Nursing Research: Building an Evidence-Based
Practice, is to create an excitement about research in undergraduate students. The text
emphasizes the importance of baccalaureate-educated nurses being able to read,
critically appraise, and synthesize research so this evidence can be used to make changes
in practice. A major goal of professional nursing and health care is the delivery of
evidence-based care. By making nursing research an integral part of baccalaureate
education, we hope to facilitate the movement of research into the mainstream of
nursing. We also hope this text increases student awareness of the knowledge that has
been generated through nursing research and that this knowledge is relevant to their
practice. Only through research can nursing truly be recognized as a profession with
documented effective outcomes for the patient, family, nurse provider, and healthcare
system. Because of this expanded focus on evidence-based practice (EBP), we have
subtitled this edition Building an Evidence-Based Practice.
Developing a sixth edition of Understanding Nursing Research has provided us with an
opportunity to clarify and refine the essential content for an undergraduate research text.
The text is designed to assist undergraduate students in overcoming the barriers they
frequently encounter in understanding the language used in nursing research. The
revisions in this edition are based on our own experiences with the text and input from
dedicated reviewers, inquisitive students, and supportive faculty from across the country
who provided us with many helpful suggestions.
Chapter 1, Introduction to Nursing Research and Evidence-Based Practice, introduces
the reader to nursing research, the history of research, and the significance of research
evidence for nursing practice. This chapter has been revised to include the most relevant
types of research synthesis being conducted in nursing—systematic review, metaanalysis, meta-synthesis, and mixed-methods systematic review. The discussion of
research methodologies and their importance in generating an evidence-based practice
for nursing has been updated and expanded to include the exploratory-descriptive
qualitative research method. A discussion of the Quality and Safety Education for
Nursing (QSEN) competencies and their link to research has been included in this
edition. Selected QSEN competencies are linked to the findings from studies presented
as examples throughout the text to increase students’ understanding of the importance in
delivering quality, safe health care to patients and families.
Chapter 2, Introduction to Quantitative Research, presents the steps of the quantitative
research process in a concise, clear manner and introduces students to the focus and
findings of quantitative studies. Extensive, recent examples of descriptive, correlational,
quasi-experimental, and experimental studies are provided, which reflect the quality of
current nursing research.
Chapter 3, Introduction to Qualitative Research, describes five approaches to
qualitative research and the philosophies upon which they are based. These approaches
include phenomenology, grounded theory, ethnography, exploratory-descriptive
qualitative, and historical research. Data collection and analysis methods specific to
qualitative research are discussed. Guidelines for reading and critically appraising
qualitative studies are explained using examples of published studies.
Chapter 4, Examining Ethics in Nursing Research, provides an extensive discussion of
the use of ethics in research and the regulations that govern the research process.
Detailed content and current websites are provided to promote students’ understanding
of the Health Insurance Portability and Accountability Act (HIPAA), the U.S.
Department of Health and Human Services Protection of Human Subjects, and the
Federal Drug Administration regulations. Guidelines are provided to assist students in
critically appraising the ethical discussions in published studies and to participate in the
ethical review of research in clinical agencies.
Chapter 5, Research Problems, Purposes, and Hypotheses, clarifies the difference
between a problem and a purpose. Example problem and purpose statements are
included from current qualitative, quantitative, and outcome studies. Detailed guidelines
are provided with examples to direct students in critically appraising the problems,
purposes, hypotheses, and variables in studies.
Chapter 6, Understanding and Critically Appraising the Literature Review, begins with
a description of the content and quality of different types of publications that might be
included in a review. Guidelines for critically appraising published literature reviews are
explored with a focus on the differences in the purpose and timing of the literature
review in quantitative and qualitative studies. The steps for finding appropriate sources,
reading publications, and synthesizing information into a logical, cohesive review are
Chapter 7, Understanding Theory and Research Frameworks, briefly describes grand,
middle range, physiological, and scientific theories as the bases for study frameworks.
The purpose of a research framework is discussed with the acknowledgement that the
framework may be implicit. Guidelines for critically appraising the study framework are
presented as well. The guidelines are applied to studies with frameworks derived from
research findings and from different types of theories.
Chapter 8, Clarifying Quantitative Research Designs, addresses descriptive,
correlational, quasi-experimental, and experimental designs and criteria for critically
appraising these designs in studies. The major strengths and threats to design validity
are summarized in a table and discussed related to current studies. This chapter has
been expanded to include an introduction to randomized controlled trials (RCT) and
mixed-methods approaches being conducted by nurses.
Chapter 9, Examining Populations and Samples in Research, provides a detailed
discussion of the concepts of sampling in research. Different types of sampling methods
for both qualitative and quantitative research are described. Guidelines are included for
critically appraising the sampling criteria, sampling method, and sample size of
quantitative and qualitative studies.
Chapter 10, Clarifying Measurement and Data Collection in Quantitative Research, has
been updated to reflect current knowledge about measurement methods used in nursing
research. Content has been expanded and uniquely organized to assist students in
critically appraising the reliability and validity of scales; precision and accuracy of
physiologic measures; and the sensitivity, specificity, and likelihood ratios of diagnostic
and screening tests.
Chapter 11, Understanding Statistics in Research, focuses on the theories and concepts
of the statistical analysis process and the statistics used to describe variables, examine
relationships, predict outcomes, and examine group differences in studies. Guidelines
are provided for critically appraising the results and discussion sections of nursing
studies. The results from selected studies are critically appraised and presented as
examples throughout this chapter.
Chapter 12, Critical Appraisal of Quantitative and Qualitative Research for Nursing
Practice, summarizes and builds on the critical appraisal content provided in previous
chapters and offers direction for conducting critical appraisals of quantitative and
qualitative studies. The guidelines for critically appraising qualitative studies have been
significantly revised and simplified. This chapter also includes a current qualitative and
quantitative study, and these two studies are critically appraised using the guidelines
provided in this chapter.
Chapter 13, Building an Evidence-Based Nursing Practice, has been significantly
updated to reflect the current trends in health care to provide evidence-based nursing
practice. Detailed guidelines are provided for critically appraising the four common
types of research synthesis conducted in nursing (systematic review, meta-analysis, metasynthesis, and mixed-method systematic review). These guidelines were used to critically
appraise current research syntheses to assist students in examining the quality of
published research syntheses and the potential use of research evidence in practice. The
chapter includes theories to assist nurses and agencies in moving toward EBP.
Translational research is introduced as a method for promoting the use of research
evidence in practice.
Chapter 14, Introduction to Outcomes Research, was significantly revised by Dr. Diane
Doran, one of the leading authorities in the conduct of outcomes research. The goal of
this chapter is to increase students’ understanding of the impact of outcomes research on
nursing and health care. Content and guidelines are provided to assist students in
reading and critically appraising the outcomes studies appearing in the nursing
The sixth edition is written and organized to facilitate ease in reading, understanding,
and critically appraising studies. The major strengths of the text are as follows:
• State-of-the art coverage of EBP—a topic of vital importance in nursing.
• Balanced coverage of qualitative and quantitative research methodologies.
• Rich and frequent illustration of major points and concepts from the most current
nursing research literature from a variety of clinical practice areas.
• Study findings implications for practice and link to QSEN competencies were provided.
• A clear, concise writing style that is consistent among the chapters to facilitate student
• Electronic references and websites that direct the student to an extensive array of
information that is important in reading, critically appraising, and using research
knowledge in practice.
This sixth edition of Understanding Nursing Research is appropriate for use in a variety
of undergraduate research courses for both RN and general students because it provides
an introduction to quantitative, qualitative, and outcomes research methodologies. This
text not only will assist students in reading research literature, critically appraising
published studies, and summarizing research evidence to make changes in practice, but
it also can serve as a valuable resource for practicing nurses in critically appraising
studies and implementing research evidence in their clinical settings.
Learning Resources to Accompany Understanding
Nursing Research, 6th Edition
The teaching/learning resources to accompany Understanding Nursing Research have been
expanded for both the instructor and student to allow a maximum level of flexibility in
course design and student review.
Evolve Instructor Resources
A comprehensive suite of Instructor Resources is available online at and consists of a Test Bank, PowerPoint
slides, an Image Collection, Answer Guidelines for the Appraisal Exercises provided for
students, and new TEACH for Nurses Lesson Plans, which replace and enhance the
Instructor’s Manual provided for previous editions.
Test Bank
The Test Bank consists of approximately 550 NCLEX® Examination–style questions,
including approximately 10% of questions in alternate item formats. Each question is
coded with the correct answer, a rationale from the textbook, a page cross-reference, and
the cognitive level in the new Bloom’s Taxonomy (with the cognitive level from the
original Bloom’s Taxonomy in parentheses). The Test Bank is provided in ExamView and
Evolve LMS formats.
PowerPoint Slides
The PowerPoint slide collection contains approximately 800 slides, now including
seamlessly integrated Audience Response System Questions, images, and new Unfolding
Case Studies. The PowerPoints have been simplified and converted into bulleted-list
format (using less narrative). Content details in the slides have been moved as
appropriate into the Notes area of the slides. New Unfolding Case Studies focus on
practical EBP/PICO questions, such as a nurse on a unit needing to perform a literature
search or to identify a systematic review or meta-analysis. PowerPoint presentations are
fully customizable.
Image Collection
The electronic Image Collection consists of all images from the text. This collection can
be used in classroom or online presentations to reinforce student learning.
New TEACH for Nurses Lesson Plans
TEACH for Nurses is a robust, customizable, ready-to-use collection of chapter-bychapter Lesson Plans that provide everything you need to create an engaging and
effective course. Each chapter includes the following:
• Objectives
• Teaching Focus
• Key Terms
• Nursing Curriculum Standards
QSEN/NLN Competencies
BSN Essentials
• Student Chapter Resources
• Instructor Chapter Resources
• Teaching Strategies
• In-Class/Online Case Study
Evolve Student Resources
The Evolve Student Resources include interactive Review Questions, a Research Article
Library consisting of 10 full-text research articles, Critical Appraisal Exercises based on
the articles in the Research Article Library, and new Printable Key Points.
• The interactive Review Questions (approximately 25 per chapter) aid the student in
reviewing and focusing on the chapter material.
• The Research Article Library is an updated collection of 10 research articles, taken from
leading nursing journals.
• The Critical Appraisal Exercises are a collection of application exercises, based on the
articles in the Research Article Library, that help students learn to appraise and apply
research findings. Answer Guidelines are provided for the instructor.
• New Printable Key Points provide students with a convenient review tool.
Study Guide
The companion Study Guide, written by the authors of the main text, provides both timetested and innovative exercises for each chapter in Understanding Nursing Research, 6th
Edition. Included for each chapter are a brief Introduction, a Key Terms exercise, Key
Ideas exercises, Making Connections exercises, Exercises in Critical Analysis, and Going
Beyond exercises. An integral part of the Study Guide is an appendix of three published
research studies, which are referenced throughout. These three recently published
nursing studies (two quantitative studies and one qualitative study) can be used in
classroom or online discussions, as well as to address the Study Guide questions. The
Study Guide provides exercises that target comprehension of concepts used in each
chapter. Exercises — including fill-in-the-blank, matching, and multiple-choice questions
— encourage students to validate their understanding of the chapter content. Critical
Appraisal Activities provide students with opportunities to apply their new research
knowledge to evaluate the quantitative and qualitative studies provided in the back of the
Study Guide.
New to this edition are the following features: an increased emphasis on evidencebased practice; new Web-Based Activities, an increased emphasis on high-value learning
activities, reorganized back-matter for quick reference, and quick-reference printed tabs.
• Increased emphasis on evidence-based practice: This edition of the Study Guide
features an expanded focus on evidence-based practice (EBP) to match that of the
revised textbook. This focus helps students who are new to nursing research see the
value of understanding the research process and applying it to evidence-based nursing
• Web-Based Activities: Each chapter now includes a Web-Based Activity section, to teach
students to use the Internet appropriately for scholarly research and EBP.
• Increased high-value learning activities: The use of crossword puzzles has been
reduced to allow room for the addition of learning activities with greater learning
• Back matter reorganized for quick reference: The “Answers to Study Guide Exercises”
has been retitled “Answer Key” and not numbered as an appendix. Each of the three
published studies are now separate appendix (three appendices total), rather than a
single appendix. This simplifies cross referencing in the body of the Study Guide.
• Quick-reference printed tabs: Quick-reference printed tabs have been added to
differentiate the Answer Key and each of the book’s three published studies (four tabs
total), for improved navigation and usability.
Developing this essentials research text was a 2-year project, and there are many people
we would like to thank. We want to extend a very special thank you to Dr. Diane Doran
for her revision of Chapter 14 focused on outcomes research. We are very fortunate that
she was willing to share her expertise and time so that students might have the most
current information about outcomes research.
We want to express our appreciation to the Dean and faculty of The University of Texas
at Arlington College of Nursing for their support and encouragement. We also would
like to thank other nursing faculty members across the world who are using our book to
teach research and have spent valuable time to send us ideas and to identify errors in the
text. Special thanks to the students who have read our book and provided honest
feedback on its clarity and usefulness to them. We would also like to recognize the
excellent reviews of the colleagues, listed on the previous pages, who helped us make
important revisions in the text.
In conclusion, we would like to thank the people at Elsevier who helped produce this
book. We thank the following individuals who have devoted extensive time to the
development of this sixth edition, the instructor’s ancillary materials, student study
guide, and all of the web-based components. These individuals include: Lee Henderson,
Billie Sharp, Charlene Ketchum, Bridget Healy, Jayashree Balasubramaniam, and Vallavan
Susan K. Grove PhD, RN, ANP-BC, GNP-BC
Jennifer R. Gray PhD, RN, FAAN
Nancy Burns PhD, RN, FCN, FAAN
C H AP T E R 1
Introduction to Nursing Research and
Evidence-Based Practice
What Is Nursing Research?
What Is Evidence-Based Practice?
Purposes of Research for Implementing an Evidence-Based Nursing Practice
Historical Development of Research in Nursing
Florence Nightingale
Nursing Research: 1900s through the 1970s
Nursing Research: 1980s and 1990s
Nursing Research: in the Twenty-First Century
Acquiring Knowledge in Nursing
Trial and Error
Personal Experience
Role Modeling
Acquiring Knowledge through Nursing Research
Introduction to Quantitative and Qualitative Research
Introduction to Outcomes Research
Understanding Best Research Evidence for Practice
Strategies Used to Synthesize Research Evidence
Levels of Research Evidence
Introduction to Evidence-Based Guidelines
What Is Your Role in Nursing Research?
Key Concepts
Learning Outcomes
After completing this chapter, you should be able to:
1. Define research, nursing research, and evidence-based practice.
2. Describe the purposes of research in implementing an evidence-based practice for
3. Describe the past and present activities influencing research in nursing.
4. Discuss the link of Quality and Safety Education for Nurses (QSEN) to research.
5. Apply the ways of acquiring nursing knowledge (tradition, authority, borrowing, trial and
error, personal experience, role modeling, intuition, reasoning, and research) to the
interventions implemented in your practice.
6. Identify the common types of research—quantitative, qualitative, or outcomes—
conducted to generate essential evidence for nursing practice.
7. Describe the following strategies for synthesizing healthcare research: systematic
review, meta-analysis, meta-synthesis, and mixed-methods systematic review.
8. Identify the levels of research evidence available to nurses for practice.
9. Describe the use of evidence-based guidelines in implementing evidence-based practice.
10. Identify your role in research as a professional nurse.
Key Terms
Authority, p. 16
Best research evidence, p. 3
Borrowing, p. 16
Case study, p. 11
Clinical expertise, p. 4
Control, p. 8
Critical appraisal of research, p. 27
Deductive reasoning, p. 18
Description, p. 6
Evidence-based guidelines, p. 25
Evidence-based practice (EBP), p. 3
Explanation, p. 7
Gold standard, p. 25
Inductive reasoning, p. 18
Intuition, p. 18
Knowledge, p. 15
Mentorship, p. 18
Meta-analysis, p. 22
Meta-synthesis, p. 23
Mixed-methods systematic review, p. 23
Nursing research, p. 3
Outcomes research, p. 21
Personal experience, p. 17
Prediction, p. 7
Premise, p. 18
Qualitative research, p. 20
Qualitative research synthesis, p. 23
Quality and Safety Education for Nurses (QSEN), p. 15
Quantitative research, p. 19
Reasoning, p. 18
Research, p. 3
Role modeling, p. 17
Systematic review, p. 22
Traditions, p. 16
Trial and error, p. 17
Welcome to the world of nursing research. You may think it strange to consider
research a world, but it is a truly new way of experiencing reality. Entering a new world
means learning a unique language, incorporating new rules, and using new experiences
to learn how to interact effectively within that world. As you become a part of this new
world, you will modify and expand your perceptions and methods of reasoning. For
example, using research to guide your practice involves questioning, and you will be
encouraged to ask such questions as these:
• What is the patient’s healthcare problem?
• What nursing intervention would effectively manage this problem in your practice?
• Is this nursing intervention based on sound research evidence?
• Would another intervention be more effective in improving your patient’s outcomes?
• How can you use research most effectively in promoting an evidence-based practice
Because research is a new world to many of you, we have developed this text to
facilitate your entry into and understanding of this world and its contribution to the
delivery of quality, safe nursing care. This first chapter clarifies the meaning of nursing
research and its significance in developing an evidence-based practice (EBP) for nursing.
This chapter also explores the research accomplishments in the profession over the last
160 years. The ways of acquiring knowledge in nursing are discussed, and the common
research methodologies used for generating research evidence for practice (quantitative,
qualitative, and outcomes research) are introduced. The critical elements of evidencebased nursing practice are introduced, including strategies for synthesizing research
evidence, levels of research evidence or knowledge, and evidence-based guidelines.
Nurses’ roles in research are described based on their level of education and their
contributions to the implementation of EBP.
What is Nursing Research?
The word research means “to search again” or “to examine carefully.” More specifically,
research is a diligent, systematic inquiry, or study that validates and refines existing
knowledge and develops new knowledge. Diligent, systematic study indicates planning,
organization, and persistence. The ultimate goal of research is the development of an
empirical body of knowledge for a discipline or profession, such as nursing.
Defining nursing research requires determining the relevant knowledge needed by
nurses. Because nursing is a practice profession, research is essential to develop and
refine knowledge that nurses can use to improve clinical practice and promote quality
outcomes (Brown, 2014; Doran, 2011). Expert researchers have studied many
interventions, and clinicians have synthesized these studies to provide guidelines and
protocols for use in practice. Practicing nurses and nursing students, like you, need to be
able to read research reports and syntheses of research findings to implement evidencebased interventions in practice and promote positive outcomes for patients and families.
For example, extensive research has been conducted to determine the most effective
technique for administering medications through an intramuscular (IM) injection. This
research was synthesized and used to develop evidence-based guidelines for
administering IM injections (Cocoman & Murray, 2008; Nicoll & Hesby, 2002).
Nursing research is also needed to generate knowledge about nursing education,
nursing administration, healthcare services, characteristics of nurses, and nursing roles.
The findings from these studies influence nursing practice indirectly and add to
nursing’s body of knowledge. Research is needed to provide high-quality learning
experiences for nursing students. Through research, nurses can develop and refine the
best methods for delivering distance nursing education and for using simulation to
improve student learning. Nursing administration and health services studies are
needed to improve the quality, safety, and cost-effectiveness of the healthcare delivery
system. Studies of nurses and nursing roles can influence nurses’ quality of care,
productivity, job satisfaction, and retention. In this era of a nursing shortage, additional
research is needed to determine effective ways to recruit individuals and retain them in
the profession of nursing. This type of research could have a major impact on the quality
and number of nurses providing care to patients and families in the future.
In summary, nursing research is a scientific process that validates and refines existing
knowledge and generates new knowledge that directly and indirectly influences nursing
practice. Nursing research is the key to building an EBP for nursing (Brown, 2014).
What is Evidence-Based Practice?
The ultimate goal of nursing is an evidence-based practice that promotes quality, safe,
and cost-effective outcomes for patients, families, healthcare providers, and the
healthcare system (Brown, 2014; Craig & Smyth, 2012; Melnyk & Fineout-Overholt, 2011).
Evidence-based practice (EBP) evolves from the integration of the best research evidence
with clinical expertise and patients’ needs and values (Institute of Medicine [IOM], 2001;
Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Figure 1-1 identifies the
elements of EBP and demonstrates the major contribution of the best research evidence
to the delivery of this practice. The best research evidence is the empirical knowledge
generated from the synthesis of quality study findings to address a practice problem.
Later, this chapter discusses the strategies used to synthesize research, levels of best
research evidence, and sources for this evidence. A team of expert researchers, healthcare
professionals, and sometimes policy makers and consumers will synthesize the best
research evidence to develop standardized guidelines for clinical practice. For example, a
team of experts conducted, critically appraised, and synthesized research related to the
chronic health problem of hypertension (HTN) to develop an EBP guideline. Research
evidence from this guideline is presented as an example later in this section.
FIG 1-1 Model of Evidence-Based Practice (EBP).
Clinical expertise is the knowledge and skills of the healthcare professional who is
providing care. The clinical expertise of a nurse depends on his or her years of clinical
experience, current knowledge of the research and clinical literature, and educational
preparation. The stronger the nurse’s clinical expertise, the better is his or her clinical
judgment in using the best research evidence in practice (Brown, 2014; Craig & Smyth,
2012). EBP also incorporates the needs and values of the patient (see Figure 1-1). The
patient’s need(s) might focus on health promotion, illness prevention, acute or chronic
illness management, rehabilitation, and/or a peaceful death. In addition, patients bring
values or unique preferences, expectations, concerns, and cultural beliefs to the clinical
encounter. With EBP, patients and their families are encouraged to take an active role in
the management of their health. It is the unique combination of the best research
evidence being applied by expert nurse clinicians in providing quality, safe, and costeffective care to a patient and family with specific health needs and values that results in
Extensive research is needed to develop sound empirical knowledge for synthesis into
the best research evidence needed for practice. Findings from a single study are not
enough evidence for determining the effectiveness of an intervention in practice.
Research evidence from multiple studies are synthesized to develop guidelines,
standards, protocols, algorithms (clinical decision trees), or policies to direct the
implementation of a variety of nursing interventions. As noted earlier, a national
guideline has been developed for the management of hypertension, The Seventh Report of
the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7). The complete JNC 7 guideline for the management of high blood
pressure is available online at (National
Heart, Lung, and Blood Institute [NHLBI], 2003). In January of 2014, the American
Society of Hypertension (ASH) and the International Society of Hypertension (ISH)
published new clinical practice guidelines for the management of hypertension in the
community (Weber et al, 2014). The JNC 7 guideline and the ASH and ISH clinical
practice guideline identified the same classification system for blood pressure (Table 11). These guidelines include the classification of blood pressure as normal,
prehypertension, hypertension stage 1, and hypertension stage 2. Both guidelines also
recommend life style modifications (balanced diet, exercise program, normal weight, and
nonsmoker) and cardiovascular disease (CVD) risk factors (hypertension, obesity,
dyslipidemia, diabetes mellitus, cigarette smoking, physical inactivity, microalbuminuria,
and family history of premature CVD) education. You need to use an evidence-based
guideline in monitoring your patients’ blood pressure (BP) and educating them about
lifestyle modifications to improve their BP and reduce their CVD risk factors (NHLBI,
2003; Weber et al., 2014).
Table 1-1
Classification of Blood Pressure with Nursing Interventions for Evidence-Based
Practice (EBP)
Treatment is determined by the highest BP category, systolic or diastolic.

Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80 mm Hg.

Lifestyle modification—balanced diet, exercise program, normal weight, and nonsmoker.
CVD risk factors—hypertension; obesity (body mass index ≥ 30 kg/m 2), dyslipidemia, diabetes mellitus, cigarette smoking,
physical inactivity, microalbuminuria, estimated glomerular filtration rate < 60 mL/min, age (> 55 years for men, > 65 years
for women), and family history of premature CVD (men < 55 years, women < 65 years).
Adapted from National Heart, Lung, and Blood Institute. (2003). The seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Retrieved June 18, 2013 from,; and Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S., Lindholm, L. H.,
Kenerson, J. G., et al. (2014). Clinical practice guidelines for the management of hypertension in the community: A
statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension,
32(1), 4-5.
The Eighth Joint National Committee (JNC 8) published “2014 Evidence-Based
Guideline for the Management of High Blood Pressure in Adults” in December of 2013
(James et al. 2013). However, these guidelines currently lack the recognition of any
national organization. Additional work is needed to ensure that the guidelines are
approved by the NHLBI, ASH, the American Heart Association (AHA), and/or the
American College of Cardiology (ACC). For this textbook, the evidence-based guidelines
for management of hypertension presented in Table 1-1 are recommended for students
and nurses to use in caring for their patients (Weber et al., 2014).
Figure 1-2 provides an example of the delivery of evidence-based nursing care to
African American women with high BP. In this example, the best research evidence is
classification of BP and education on lifestyle modification (LSM) and CVD risk factors
based on the ASH (Weber et al., 2014) and JNC 7 (NHLBI, 2003) guidelines for
management of high BP (see Table 1-1). These guidelines, developed from the best
research evidence related to BP, LSM, and CVD risks monitoring and education, is
translated by registered nurses and nursing students to meet the needs and values of
African American women with high BP. The quality outcome of EBP in this example is
women with a BP less than 140/90 mm Hg or referral for medication treatment (see
Figure 1-2). A detailed discussion of how to locate, critically appraise, and use national
standardized guidelines in practice is found in Chapter 13.
FIG 1-2 Evidence-based practice for African American women with high blood pressure (BP).
Purposes of Research for Implementing an
Evidence-Based Nursing Practice
Through nursing research, empirical knowledge can be developed to improve nursing
care, patient outcomes, and the healthcare delivery system. For example, nurses need a
solid research base to implement and document the effectiveness of selected nursing
interventions in treating particular patient problems and promoting positive patient and
family outcomes. Also, nurses need to use research findings to determine the best way to
deliver healthcare services to ensure that the greatest number of people receive quality,
safe care. Accomplishing these goals will require you to locate EBP guidelines or to
appraise critically, synthesize, and apply research evidence that provides a description,
explanation, prediction, and control of phenomena in your clinical practice.
Description involves identifying and understanding the nature of nursing phenomena
and, sometimes, the relationships among them (Chinn & Kramer, 2011). Through
research, nurses are able to (1) describe what exists in nursing practice; (2) discover new
information; (3) promote understanding of situations; and (4) classify information for use
in the discipline. Some examples of clinically important research evidence that have been
developed from research focused on description include:
• Identification of the incidence and spread of infection in healthcare agencies
• Identification of the cluster of symptoms for a particular disease
• Description of the responses of individuals to a variety of health conditions and aging
• Description of the health promotion and illness prevention strategies used by a variety
of populations
• Determination of the incidence of a disease locally (e.g., incidence of West Nile virus in
Texas), nationally, and internationally (e.g., spread of bird flu).
Rush, Watts, and Janke (2013, p. 10) have conducted a qualitative study to describe
“rural and urban older adults’ perspectives of strength in their daily lives.” (The types of
research conducted in nursing—quantitative, qualitative, and outcomes—are discussed
later in this chapter.) They noted the following in this study:
“Nurses’ strength enhancement efforts should raise older adults’ awareness that strength is
not an unlimited resource but needs to be constantly replenished…. Older adult participants
described changes in strength that ranged from fluctuating daily changes to insidious,
gradual declines and to drastic and unexpected losses…. Older adults’ strategies for staying
strong were consistent with their more holistic views of strength but may not be approaches
nurses typically take into account. Although nurses need to give continued emphasis to
promoting physical activity, they must also give equal attention to encouraging mental and
social activities because of the important role they play for older adults staying strong.”
Rush et al., 2013, p. 15
The findings from this study provided nurses with descriptions of older adults’
perspectives of strength and the strategies that they use to stay strong. You can use the
findings from this study to encourage physical, mental, and social activities to assist
older adults in staying strong. This type of research, focused on description, is essential
groundwork for studies to provide explanations, predictions, and control of nursing
phenomena in practice.
Explanation clarifies the relationships among phenomena and identifies possible reasons
why certain events occur. Research focused on explanation provides the following types
of evidence essential for practice:
• Determination of assessment data (subjective data from the health history and
objective data from the physical examination) that need to be gathered to address a
patient’s health need
• The link of assessment data to a diagnosis
• The link of causative risk factors or causes to illness, morbidity, and mortality
• Determination of the relationships among health risks, health behaviors, and health
• Determination of links among demographic characteristics, disease status,
psychosocial factors, and patients’ responses to treatment.
For example, Manojlovich, Sidani, Covell, and Antonakos (2011) conducted an
outcomes study to examine the links or relationships between a “nurse dose” (nurse
characteristics and staffing) and adverse patient outcomes. The nurse characteristics
examined were education, experience, and skill mix. The staffing variables included fulltime employees, registered nurse (RN)-to-patient ratio, and RN hours per patient day.
The adverse outcomes examined were methicillin-resistant Staphylococcus aureus (MRSA)
infections and reported patient falls for a sample of inpatient adults in acute care units.
The researchers found that the nurse characteristics and staffing variables were
significantly correlated with MRSA infections and reported patient falls. Therefore the
nursing characteristics and staffing were potential predictors of the incidence of MRSA
infections and patient falls. This study illustrates how explanatory research can identify
relationships among nursing phenomena that can be the basis for future research
focused on prediction and control.
Through prediction, one can estimate the probability of a specific outcome in a given
situation (Chinn & Kramer, 2011). However, predicting an outcome does not necessarily
enable one to modify or control the outcome. It is through prediction that the risk of
illness or injury is identified and linked to possible screening methods to identify and
prevent health problems. Knowledge generated from research focused on prediction is
critical for EBP and includes the following:
• Prediction of the risk for a disease or injury in different populations
• Prediction of behaviors that promote health and prevent illness
• Prediction of the health care required based on a patient’s need and values
Lee, Faucett, Gillen, Krause, and Landry (2013) conducted a quantitative study to
examine the factors that were perceived by critical care nurses (CCNs) to predict the risk
of musculoskeletal (MSK) injury from work. They found that greater physical workload,
greater job strain, more frequent patient-handling tasks, and lack of a lifting team or
devices were predictive of the CCNs’ perceptions of risk of MSK injury. They
recommended that “occupational health professionals, nurse managers, and nursing
organizations should make concerted efforts to ensure the safety of nurses by providing
effective preventive measures. Improving the physical and psychosocial work
environment may make nursing jobs safer, reduce the risk of MSK injury, and improve
nurses’ perceptions of job safety” (Lee et al., 2013, p. 43). This predictive study isolated
independent variables (physical workload, job strain, patient-handling tasks, and lack of
lifting devices or teams) that were predictive of MSK injuries in CCNs. The variables
identified in predictive studies require additional research to ensure that their
manipulation or control results in quality outcomes for patients, healthcare
professionals, and healthcare agencies (Creswell, 2014; Doran, 2011; Kerlinger & Lee,
If one can predict the outcome of a situation, the next step is to control or manipulate the
situation to produce the desired outcome. In health care, control is the ability to write a
prescription to produce the desired results. Using the best research evidence, nurses
could prescribe specific interventions to meet the needs of patients and their families
(Brown, 2014; Craig & Smyth, 2012). The results of multiple studies in the following areas
have enabled nurses to deliver care that increases the control over the outcomes desired
for practice:
• Testing interventions to improve the health status of individuals, families, and
• Testing interventions to improve healthcare delivery
• Synthesis of research for development into EBP guidelines
• Testing the effectiveness of EBP guideline in clinical agencies
Extensive research has been conducted in the area of safe administration of IM
injections. This research has been critically appraised, synthesized, and developed into
evidence-based guidelines to direct the administration of medications by an IM route to
infants, children, and adults in a variety of practice settings (Cocoman & Murray, 2008;
Nicoll & Hesby, 2002). The EBP guideline for IM injections is based on the best research
evidence and identifies the appropriate needle size and length to use for administering
different types of medications, the safest injection site (ventrogluteal) for many
medications, and the best injection technique to deliver a medication, minimize patient
discomfort, and prevent physical damage (Cocoman & Murray, 2008; Greenway, 2004;
Nicoll & Hesby, 2002; Rodger & King, 2000). Using the evidence-based knowledge for
administering IM injections helps control the achievement of the following outcomes in
practice: (1) adequate administration of medication to promote patient health; (2)
minimal patient discomfort; and (3) no physical damage to the patient.
Broadly, the nursing profession is accountable to society for providing quality, safe, and
cost-effective care for patients and families. Therefore the care provided by nurses must
be constantly evaluated and improved on the basis of new and refined research
knowledge. Studies that document the effectiveness of specific nursing interventions
make it possible to implement evidence-based care that will produce the best outcomes
for patients and their families. The quality of research conducted in nursing affects not
only the quality of care delivered, but also the power of nurses in making decisions about
the healthcare delivery system. The extensive number of clinical studies conducted in the
last 50 years has greatly expanded the scientific knowledge available to you for
describing, explaining, predicting, and controlling phenomena within your nursing
Historical Development of Research in Nursing
The development of research in nursing has changed drastically over the last 160 years
and holds great promise for the twenty-first century. Initially, nursing research evolved
slowly, from the investigations of Nightingale in the nineteenth century to the studies of
nursing education in the 1930s and 1940s and the research of nurses and nursing roles in
the 1950s and 1960s. From the 1970s through the 2010s, an increasing number of nursing
studies that focused on clinical problems have produced findings that directly affected
practice. Clinical research continues to be a major focus today, with the goal of
developing an EBP for nursing. Reviewing the history of nursing research enables you to
identify the accomplishments and understand the need for further research to determine
the best research evidence for use in practice. Table 1-2 outlines the key historical events
that have influenced the development of research in nursing.
Table 1-2
Historical Events Influencing the Development of Research in Nursing
Florenc e Nightingale is rec ognized as the first nurse researc her.
America n Journa l of Nursing is published.
Teac hers College at Columbia University offers the first educ ational doc toral program for nurses.
First Master’s in Nursing Degree is offered at Yale University.
Assoc iation of Collegiate S c hools of Nursing is organized to promote c onduc t of researc h.
Americ an Nurses Assoc iation (ANA) publishes study of nursing func tions and ac tivities.
First researc h journal in nursing, Nursing Resea rch, is published.
Institute of Researc h and S ervic e in Nursing Educ ation is established.
Americ an Nurses Foundation is established to fund nursing researc h.
S outhern Regional Educ ational Board (S REB), Western Interstate Commission on Higher Educ ation (WICHE), Midwestern Nursing Researc h S oc iety
(MNRS ), and New England Board of Higher Educ ation (NEBHE) are established to support and disseminate nursing researc h.
1963 Interna tiona l Journa l of Nursing Studies is published.
1965 ANA sponsors the first nursing researc h c onferenc es.
1967 S igma Theta Tau International Honor S oc iety of Nursing publishes Ima ge, emphasizing nursing sc holarship; now Journa l of Nursing Schola rship.
1970 ANA Commission on Nursing Researc h is established.
1972 Coc hrane published Effectiveness a nd Efficiency, introduc ing c onc epts relevant to evidenc e-based prac tic e (EBP).
ANA Counc il of Nurse Researc hers is established.
1973 First Nursing Diagnosis Conferenc e is held, whic h evolved into North Americ an Nursing Diagnosis Assoc iation (NANDA).
1976 S tetler/Marram Model for Applic ation of Researc h Findings to Prac tic e is published.
1978 Resea rch in Nursing & Hea lth and Adva nces in Nursing Science are published.
1979 Western Journa l of Nursing Resea rch is published.
1980s- S ac kett and c olleagues developed methodologies to determine “best evidenc e” for prac tic e.
1982- Conduc t and Utilization of Researc h in Nursing (CURN) Projec t is published.
1983 Annua l Review of Nursing Resea rch is published.
1985 National Center for Nursing Researc h (NCNR) is established to support and fund nursing researc h.
1987 Schola rly Inquiry for Nursing Pra ctice is published.
1988 Applied Nursing Resea rch and Nursing Science Qua rterly are published.
1989 Agenc y for Healthc are Polic y and Researc h (AHCPR) is established and publishes EBP guidelines.
1990 Nursing Dia gnosis, offic ial journal of NANDA, is published; now Interna tiona l Journa l of Nursing Terminologies a nd Cla ssifica tions.
ANA established the Americ an Nurses Credentialing Center (ANCC), whic h implemented the Magnet Hospital Designation Program for Exc ellenc e in
Nursing S ervic es.
1992 Hea lthy People 2000 is published by U.S . Department of Health and Human S ervic es (U.S . DHHS ).
Clinica l Nursing Resea rch is published.
1993 NCNR is renamed the National Institute of Nursing Researc h (NINR) to expand funding for nursing researc h.
Journa l of Nursing Mea surement is published.
Coc hrane Collaboration is initiated, providing systematic reviews and EBP guidelines (http://www.c oc
1994 Qua lita tive Hea lth Resea rch is published.
1999 AHCPR is renamed Agenc y for Healthc are Researc h and Quality (AHRQ).
2000 Hea lthy People 2010 is published by U.S . DHHS .
Biologica l Resea rch for Nursing is published.
2001 S tetler publishes her model Steps of Resea rch Utiliza tion to Fa cilita te Evidence-Ba sed Pra ctice.
Institute of Medic ine (IOM) report Crossing the Qua lity Cha sm: A New Hea lth System for the 21st Century published, foc using on key healthc are issues of
quality and safety.
2002 The Joint Commission revises ac c reditation polic ies for hospitals supporting evidenc e-based health c are.
NANDA bec omes international—NANDA-I.
2003 IOM report Hea lth Professions Educa tion: A Bridge to Qua lity published, identifying six c ompetenc ies essential for educ ation of nurses and other health
2004 Worldviews on Evidence-Ba sed Nursing is published.
2005 Quality and S afety Educ ation for Nurses (QS EN) initiative for development of c ompetenc ies for prelic ensure and graduate educ ation is developed.
2006 Americ an Assoc iation of Colleges of Nursing (AACN) position statement on nursing researc h is published.
2007 QS EN website ( is launc hed, featuring teac hing strategies and resourc es to fac ilitate the attainment of the QS EN c ompetenc ies.
2010 IOM report The Future of Nursing: Lea ding Cha nge rec ommends that 80% of the nursing workforc e be prepared at the bac c alaureate level by the year 2020.
2011 NINR c urrent strategic plan published.
Americ an Nurses Assoc iation (ANA) c urrent researc h agenda is developed.
2013 Current QS EN c ompetenc ies for prelic ensure nurses available online at ompetenc ies/pre-lic ensure-ksas.
2013 Hea lthy People 2020 available at U.S . DHHS website, sobjec tives2020/default.aspx.
AHRQ c urrent mission and funding priorities available online (
NINR c urrent mission and funding opportunities available online (
Florence Nightingale
Nightingale (1859) is recognized as the first nurse researcher, with her initial studies
focused on the importance of a healthy environment in promoting patients’ physical and
mental well-being. She studied aspects of the environment, such as ventilation,
cleanliness, purity of water, and diet, to determine the influence on patients’ health,
which continue to be important areas of study today (Herbert, 1981). Nightingale is also
noted for her data collection and statistical analyses, especially during the Crimean War.
She gathered data on soldier morbidity and mortality rates and the factors influencing
them and presented her results in tables and pie charts, a sophisticated type of data
presentation for the period (Palmer, 1977). Nightingale was the first woman elected to the
Royal Statistical Society (Oakley, 2010) and her research was highlighted in Scientific
American (Cohen, 1984).
Nightingale’s research enabled her to instigate attitudinal, organizational, and social
changes. She changed the attitudes of the military and society about the care of the sick.
The military began to view the sick as having the right to adequate food, suitable
quarters, and appropriate medical treatment, which greatly reduced the mortality rate
(Cook, 1913). Nightingale improved the organization of army administration, hospital
management, and hospital construction. Because of Nightingale’s research evidence and
influence, society began to accept responsibility for testing public water, improving
sanitation, preventing starvation, and decreasing morbidity and mortality rates (Palmer,
Nursing Research: 1900s through the 1970s
The American Journal of Nursing was first published in 1900 and, late in the 1920s and
1930s, case studies began appearing in this journal. A case study involves an in-depth
analysis and systematic description of one patient or group of similar patients to
promote understanding of healthcare interventions. Case studies are one example of the
practice-related research that has been conducted in nursing over the last century.
Nursing educational opportunities expanded, with Teachers College at Columbia
University offering the first educational doctoral program for nurses in 1923 and Yale
University offering the first master ’s degree in nursing in 1929. In 1950 the American
Nurses Association (ANA) initiated a 5-year study on nursing functions and activities. In
1959 the findings from this study were used to develop statements on functions,
standards, and qualifications for professional nurses. During that time, clinical research
began expanding as nursing specialty groups, such as community health, psychiatricmental health, medical-surgical, pediatrics, and obstetrics, developed standards of care.
The research conducted by the ANA and specialty groups provided the basis for the
nursing practice standards that currently guide professional practice (Gortner & Nahm,
In the 1950s and 1960s nursing schools began introducing research and the steps of the
research process at the baccalaureate level, and Master of Science in Nursing (MSN) level
nurses were provided a background for conducting small replication studies. In 1953 the
Institute for Research and Service in Nursing Education was established at Teachers
College of Columbia University and began providing research experiences for doctoral
students (Gortner & Nahm, 1977). The increase in research activities prompted the
publication of the first research journal, Nursing Research, in 1952. The American Nurses
Foundation was established in 1955 to fund nursing research projects. The Southern
Regional Educational Board (SREB), Western Interstate Commission on Higher
Education (WICHE), Midwestern Nursing Research Society (MNRS), and New England
Board of Higher Education (NEBHE) were formed in 1957 to support and disseminate
nursing research across the United States.
In the 1960s an increasing number of clinical studies focused on quality care and the
development of criteria to measure patient outcomes. Intensive care units were
developed, which promoted the investigation of nursing interventions, staffing patterns,
and cost-effectiveness of care (Gortner & Nahm, 1977). An additional research journal,
the International Journal of Nursing Studies, was published in 1963. In 1965 the ANA
sponsored the first of a series of nursing research conferences to promote the
communication of research findings and the use of these findings in clinical practice.
In the late 1960s and 1970s nurses were involved in the development of models,
conceptual frameworks, and theories to guide nursing practice. The nursing theorists’
work provided direction for future nursing research. In 1978, Chinn became the editor of
a new journal, Advances in Nursing Science, which included nursing theorists’ work and
related research. Another event influencing research was the establishment of the ANA
Commission on Nursing Research in 1970. In 1972 the commission established the
Council of Nurse Researchers to advance research activities, provide an exchange of
ideas, and recognize excellence in research. The commission also influenced the
development of federal guidelines for research with human subjects and sponsored
research programs nationally and internationally (See, 1977).
The communication of research findings was a major issue in the 1970s (Barnard, 1980).
Sigma Theta Tau International, the Honor Society for Nursing, sponsored national and
international research conferences, and chapters of this organization sponsored many
local conferences to communicate research findings. Sigma Theta Tau first published
Image, now entitled Journal of Nursing Scholarship, in 1967; it includes research articles
and summaries of research conducted on selected topics. Stetler and Marram developed
the first model in nursing to promote the application of research findings to practice in
1976. Two additional research journals were first published in the 1970s, Research in
Nursing & Health in 1978 and the Western Journal of Nursing Research in 1979.
Professor Archie Cochrane originated the concept of evidence-based practice with a
book he published in 1972, Effectiveness and Efficiency: Random Reflections on Health
Services. Cochrane advocated the provision of health care based on research to improve
its quality. To facilitate the use of research evidence in practice, the Cochrane Center was
established in 1992 and the Cochrane Collaboration in 1993. The Cochrane Collaboration
and Library house numerous resources to promote EBP, such as systematic reviews of
research and evidence-based guidelines for practice (see later; also see the Cochrane
Collaboration at
In the 1970s the nursing process became the focus of many studies, with investigations
of assessment techniques, nursing diagnoses classification, goal-setting methods, and
specific nursing interventions. The first Nursing Diagnosis Conference, held in 1973,
evolved into the North American Nursing Diagnosis Association (NANDA). In 2002
NANDA became international, known as NANDA-I. NANDA-I supports research
activities focused on identifying appropriate diagnoses for nursing and generating an
effective diagnostic process. NANDA’s journal, Nursing Diagnosis, was published in 1990
and was later renamed the International Journal of Nursing Terminologies and
Classifications. Details on NANDA-I can be found on their website
Nursing Research: 1980s and 1990s
The conduct of clinical research was the focus of the 1980s, and clinical journals began
publishing more studies. One new research journal was published in 1987, Scholarly
Inquiry for Nursing Practice, and two in 1988, Applied Nursing Research and Nursing Science
Quarterly. Although the body of empirical knowledge generated through clinical
research increased rapidly in the 1980s, little of this knowledge was used in practice.
During 1982 and 1983, the studies from a federally funded project, Conduct and
Utilization of Research in Nursing (CURN), were published to facilitate the use of
research to improve practice (Horsley, Crane, Crabtree, & Wood, 1983).
In 1983 the first volume of the Annual Review of Nursing Research was published
(Werley & Fitzpatrick, 1983). These volumes include experts’ reviews of research
organized into four areas—nursing practice, nursing care delivery, nursing education,
and the nursing profession. These summaries of current research knowledge encourage
the use of research findings in practice and provide direction for future research.
Publication of the Annual Review of Nursing Research continues today, with leading expert
nurse scientists providing summaries of research in their areas of expertise. The
increased research activities in nursing resulted in the publication of Clinical Nursing
Research in 1992 and the Journal of Nursing Measurement in 1993.
Qualitative research was introduced in the late 1970s; the first studies appeared in
nursing journals in the 1980s. The focus of qualitative research was holistic, with the
intent to discover meaning and gain new insight and understanding of issues relevant to
nursing. The number of qualitative researchers and studies expanded greatly in the
1990s, with qualitative studies appearing in most of the nursing research and clinical
journals. In 1994 a journal focused on disseminating qualitative research, Qualitative
Health Research, was first published.
Another priority of the 1980s was to obtain increased funding for nursing research.
Most of the federal funds in the 1980s were designated for medical studies involving the
diagnosis and treatment of diseases. However, the ANA achieved a major political victory
for nursing research with the creation of the National Center for Nursing Research
(NCNR) in 1985. The purpose of this center was to support the conduct and
dissemination of knowledge developed through basic and clinical nursing research,
training, and other programs in patient care research (Bauknecht, 1985). Under the
direction of Dr. Ada Sue Hinshaw, the NCNR became the National Institute of Nursing
Research (NINR) in 1993 to increase the status of nursing research and obtain more
Outcomes research emerged as an important methodology for documenting the
effectiveness of healthcare services in the 1980s and 1990s. This effectiveness research
evolved from the quality assessment and quality assurance functions that originated with
the professional standards review organizations (PSROs) in 1972. In 1989 the Agency for
Healthcare Policy and Research (AHCPR) was established to facilitate the conduct of
outcomes research (Rettig, 1991). AHCPR also had an active role in communicating
research findings to healthcare practitioners and was responsible for publishing the first
clinical practice guidelines. These guidelines included a synthesis of the best research
evidence, with directives for practice developed by healthcare experts in various areas.
Several of these evidence-based guidelines were published in the 1990s and provided
standards for practice in nursing and medicine. The Healthcare Research and Quality Act
of 1999 reauthorized the AHCPR, changing its name to the Agency for Healthcare
Research and Quality (AHRQ). This significant change positioned the AHRQ as a
scientific partner with the public and private sectors to improve the quality and safety of
patient care.
Building on the process of research utilization, physicians, nurses, and other
healthcare professionals focused on the development of EBP for health care during the
1990s. A research group led by Dr. David Sackett at McMaster University in Canada
developed explicit research methodologies to determine the “best evidence” for practice.
David Eddy first used the term evidence-based in 1990, with the focus on providing EBP for
medicine (Craig & Smyth, 2012; Sackett et al., 2000). The American Nurses Credentialing
Center (ANCC) implemented the Magnet Hospital Designation Program for Excellence
in Nursing Services in 1990, which emphasized EBP for nursing. The emphasis on EBP in
nursing resulted in more biological studies and randomized controlled trials (RCTs)
being conducted and led to the publication of Biological Research for Nursing in 2000.
Nursing Research: in the Twenty-First Century
The vision for nursing research in the twenty-first century includes conducting quality
studies using a variety of methodologies, synthesizing the study findings into the best
research evidence, and using this research evidence to guide practice (Brown, 2014; Craig
& Smyth, 2012; Melnyk & Fineout-Overholt, 2011). EBP has become a stronger focus in
nursing and healthcare agencies over the last 15 years. In 2002, The Joint Commission
(formerly called the Joint Commission on Accreditation of Healthcare Organizations),
responsible for accrediting healthcare organizations, revised the accreditation policies
for hospitals to support the implementation of evidence-based health care. To facilitate
the movement of nursing toward EBP in clinical agencies, Stetler (2001) developed her
Research Utilization to Facilitate EBP Model (see Chapter 13 for a description of this
model). The focus on EBP in nursing was supported with the initiation of the Worldviews
on Evidence-Based Nursing journal in 2004.
The American Association of Colleges of Nursing (AACN), established in 1932 to
promote the quality of nursing education, revised their position statement on nursing
research in 2006 to provide future directions for the discipline. To ensure an effective
research enterprise in nursing, the discipline must (1) create a research culture, (2)
provide high-quality educational programs (baccalaureate, master ’s, practice-focused
doctorate, research-focused doctorate, and postdoctorate) to prepare a workforce of
nurse scientists, (3) develop a sound research infrastructure, and (4) obtain sufficient
funding for essential research (AACN, 2006). The complete AACN position statement on
nursing research can be found online at In 2011 the ANA
published a research agenda compatible with the AACN (2006) research position
The focus of healthcare research and funding has expanded from the treatment of
illness to include health promotion and illness prevention. Healthy People 2000 and
Healthy People 2010, documents published by the U.S. Department of Health and Human
Services (U.S. DHHS, 2000), have increased the visibility of health promotion goals and
research. Healthy People 2020 information is now available at the U.S. DHHS (2013)
website Some of the new topics covered by Healthy
People 2020 include adolescent health, blood disorders and blood safety, dementias
(including Alzheimer ’s Disease), early and middle childhood, genomics, global health,
healthcare-associated infections, lesbian, gay, bisexual, and transgender health, older
adults, preparedness, sleep health, and social determinants of health. In the next decade,
nurse researchers will have a major role in the development of interventions to promote
health and prevent illness in individuals, families, and communities.
The AHRQ is the lead agency supporting research designed to improve the quality of
health care, reduce its cost, improve patient safety, decrease medical errors, and broaden
access to essential services. AHRQ (2013) conducts and sponsors research that provides
evidence-based information on healthcare outcomes, quality, cost, use, and access. This
research information is needed to promote effective healthcare decision making by
patients, clinicians, health system executives, and policy makers. The AHRQ (2013)
website ( provides the most current information on this agency and
includes current guidelines for clinical practice.
Current Actions of the National Institute of Nursing Research
The mission of the National Institute of Nursing Research (NINR) is to “promote and
improve the health of individuals, families, communities, and populations. The Institute
supports and conducts clinical and basic research and research training on health and
illness across the lifespan to build the scientific foundation for clinical practice, prevent
disease and disability, manage and eliminate symptoms caused by illness, and improve
palliative and end-of-life care” (NINR, 2013). The NINR is seeking expanded funding for
nursing research and is encouraging a variety of methodologies (quantitative, qualitative,
and outcomes research) to be used to generate essential knowledge for nursing practice.
The NINR (2013) website ( provides the most current information on
the institute’s research funding opportunities and supported studies. The strategic plan
for the NINR (2011) is available online at
Linking Quality and Safety Education for Nursing Competencies and
Nursing Research
In 2001 the Institute of Medicine (IOM) published a report, Crossing the Quality Chasm: A
New Health System for the 21st Century, that emphasized the importance of quality and
safety in the delivery of health care. In 2003 the IOM published a report, Health
Professions Education: A Bridge to Quality, which identified the six competency areas
essential for inclusion in nursing education to ensure that students were able to deliver
quality, safe care. Specific competencies were identified for the following six areas:
patient-centered care, teamwork and collaboration, evidence-based practice, quality
improvement, safety, and informatics. The Quality and Safety Education for Nurses
(QSEN) initiative is focused on developing the requisite knowledge, skills, and attitude
(KSA) statements for each of the competencies for pre-licensure and graduate education.
The QSEN initiative has been funded since 2005 by the Robert Wood Johnson
The QSEN Institute website (, launched in 2007, features teaching
strategies and resources to facilitate the accomplishments of the QSEN competencies in
nursing educational programs. The most current competencies for the prelicensure
educational programs can be found online at (QSEN, 2013; Sherwood & Barnsteiner, 2012). The EBP competency is defined as
“integrating the best current evidence with clinical expertise and patient/family
preferences and values for delivery of optimal health care” (QSEN, 2013). Undergraduate
nursing students need to be skilled in critical appraisal of studies, use of appropriate
research evidence in practice, adherence to institutional review board (IRB) guidelines,
and appropriate data collection. Diffusion of the QSEN competencies across nursing
educational programs is a major focus for educators who are shaping students’ learning
experiences and outcomes based on these competencies (Barnsteiner, Disch, Johnson,
McGuinn, Chappell, & Swartwout, 2013). In this text, the QSEN competencies are linked
to relevant research content and the findings from selected studies. Your expanded
knowledge of research is an important part of your developing an EBP and is necessary to
attain the QSEN competencies.
Acquiring Knowledge in Nursing
Acquiring knowledge in nursing is essential for the delivery of quality, safe patient and
family nursing care. Some key questions about knowledge include the following: What is
knowledge? How is knowledge acquired in nursing? Is most of nursing’s knowledge
based on research?
Knowledge is essential information, acquired in a variety of ways, that is expected to be
an accurate reflection of reality and is incorporated and used to direct a person’s actions
(Kaplan, 1964). During your nursing education, you acquire an extensive amount of
knowledge from your classroom and clinical experiences. You learn to synthesize,
incorporate, and apply this knowledge so that you can practice as a nurse.
The quality of your nursing practice depends on the quality of the knowledge that you
acquire. Therefore you need to question the quality and credibility of new information
that you hear or read. For example, what are the sources of knowledge that you are
acquiring during your nursing education? Are the nursing interventions taught based
more on research or tradition? Which interventions are based on research, and which
need further study to determine their effectiveness?
Nursing has historically acquired knowledge through traditions, authority, borrowing,
trial and error, personal experience, role modeling, intuition, and reasoning. However, in
the last 20 years, most nursing texts include content that is based on research evidence,
and most faculty members support their lectures and educational strategies with study
findings. This section introduces different ways of acquiring knowledge in nursing.
Traditions include “truths” or beliefs based on customs and trends. Nursing traditions
from the past have been transferred to the present by written and oral communication
and role modeling, and they continue to influence the practice of nursing. For example,
some of the policy and procedure manuals in hospitals contain traditional ideas.
Traditions can positively influence nursing practice because they were developed from
effective past experiences. However, traditions also can narrow and limit the knowledge
sought for nursing practice. For example, nursing units are frequently organized and run
according to set rules or traditions that may not be efficient or effective. Often these
traditions are neither questioned nor changed because they have existed for years and
are frequently supported by those with power and authority. Nursing’s body of
knowledge needs to be more evidence-based than traditional if nurses are to have a
powerful impact on patient outcomes.
An authority is a person with expertise and power who is able to influence opinion and
behavior. A person is given authority because it is thought that she or he knows more in a
given area than others. Knowledge acquired from an authority is illustrated when one
person credits another as the source of information. Nurses who publish articles and
books or develop theories are frequently considered authorities. Students usually view
their instructors as authorities, and clinical nursing experts are considered authorities
within the clinical practice setting. It is important that nurses with authority teach and
practice based on research evidence versus being based on customs and traditions.
Some nursing leaders have described part of nursing’s knowledge as information
borrowed from disciplines such as medicine, sociology, psychology, physiology, and
education (McMurrey, 1982). Borrowing in nursing involves the appropriation and use of
knowledge from other fields or disciplines to guide nursing practice. Nursing has
borrowed in two ways. For years, some nurses have taken information from other
disciplines and applied it directly to nursing practice. This information was not
integrated within the unique focus of nursing. For example, some nurses have used the
medical model to guide their nursing practice, thus focusing on the diagnosis and
treatment of disease. This type of borrowing continues today as nurses use advances in
technology to become highly specialized and focused on the detection and treatment of
disease. The second way of borrowing, which is more useful in nursing, involves
integrating information from other disciplines within the focus of nursing. For example,
nurses borrow knowledge from other disciplines such as psychology and sociology, but
integrate this knowledge in their holistic care of patients and families experiencing acute
and chronic illnesses.
Trial and Error
Trial and error is an approach with unknown outcomes that is used in a situation of
uncertainty in which other sources of knowledge are unavailable. Because each patient
responds uniquely to a situation, there is uncertainty in nursing practice. Hence nurses
must use trial and error in providing nursing care. However, this trial and error approach
frequently involves no formal documentation of effective and ineffective nursing actions.
With this strategy, knowledge is gained from experience, but often it is not shared with
others. The trial and error approach to acquiring knowledge also can be time-consuming
because you may implement multiple interventions before finding one that is effective.
There also is a risk of implementing nursing actions that are detrimental to a patient’s
health. If studies are conducted on nursing interventions, selection and implementation
of interventions need to be based on scientific knowledge rather than on trial and error.
Personal Experience
Personal experience involves gaining knowledge by being personally involved in an
event, situation, or circumstance. Personal experience enables the nurse to gain skills and
expertise by providing care to patients and families in clinical settings. Learning that
occurs from personal experience enables the nurse to cluster ideas into a meaningful
whole. For example, you may read about giving an IM injection or be told how to give an
injection in a classroom setting, but you do not know how to give an injection until you
observe other nurses giving injections to patients and actually give several injections
The amount of personal experience affects the complexity of a nurse’s knowledge base.
Benner (1984) conducted a phenomenological qualitative study to identify the levels of
experience in the development of clinical knowledge and expertise, and these include (1)
novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert. Novice nurses
have no personal experience in the work they are to perform, but have some
preconceptions and expectations about clinical practice that they acquired during their
education. These preconceptions and expectations are challenged, refined, confirmed, or
refuted by personal experience in a clinical setting. The advanced beginner nurse has just
enough experience to recognize and intervene in recurrent situations. For example, the
advanced beginner is able to recognize and intervene in managing patients’ pain.
Competent nurses are able to generate and achieve long-range goals and plans because
of years of personal experience. The competent nurse also can use her or his personal
knowledge to take conscious, deliberate actions that are efficient and organized. From a
more complex knowledge base, the proficient nurse views the patient as a whole and as a
member of a family and community. The proficient nurse recognizes that each patient
and family responds differently to illness and health. The expert nurse has an extensive
background of experience and is able to identify accurately and intervene skillfully in a
situation. Personal experience increases the ability of the expert nurse to grasp a
situation intuitively, with accuracy and speed.
Benner ’s qualitative research (1984) provided an increased understanding of how
knowledge is acquired through personal experience. As you gain clinical experience
during your educational program and after you graduate, you will note your movement
through these different levels of knowledge.
Role Modeling
Role modeling is learning by imitating the behaviors of an expert. In nursing, role
modeling enables the novice nurse to learn through interactions with or examples set by
highly competent, expert nurses. Role models include admired teachers, expert
clinicians, researchers, or those who inspire others through their example. An intense
form of role modeling is mentorship, in which the expert nurse serves as a teacher,
sponsor, guide, and counselor for the novice nurse. The knowledge gained through
personal experience is greatly enhanced by a quality relationship with a role model or
mentor. Many new graduates enter internship programs provided by clinical agencies so
that expert nurses can mentor them during the novice’s first few months of employment.
Intuition is an insight into or understanding of a situation or event as a whole that
usually cannot be explained logically (Grove, Burns, & Gray, 2013). Because intuition is a
type of knowing that seems to come unbidden, it may also be described as a “gut
feeling” or “hunch.” Because intuition cannot easily be explained scientifically, many
people are uncomfortable with it. Some even think that it does not exist. However,
intuition is not the lack of knowing; rather, it is a result of deep knowledge (Benner,
1984). This knowledge is so deeply incorporated that it is difficult to bring it to the
surface consciously and express it in a logical manner. Some nurses can intuitively
recognize when a patient is experiencing a health crisis. Using this intuitive knowledge,
these nurses can assess the patient’s condition, intervene, and contact the physician as
needed for medical intervention.
Reasoning is the processing and organizing of ideas to reach conclusions. Through
reasoning, people are able to make sense of their thoughts, experiences, and research
evidence (Grove et al., 2013). This type of logical thinking is often evident in the oral
presentation of an argument, in which each part is linked to reach a logical conclusion.
The science of logic includes inductive and deductive reasoning. Inductive reasoning
moves from the specific to the general; particular instances are observed and then
combined into a larger whole or a general statement (Chinn & Kramer, 2011). An
example of inductive reasoning follows.
Particular Instances
A headache is an altered level of health that is stressful.
A terminal illness is an altered level of health that is stressful.
General Statement
Therefore it can be induced that all altered levels of health are stressful.
Deductive reasoning moves from the general to the specific or from a general premise
to a particular situation or conclusion (Chinn & Kramer, 2011). A premise or proposition
is a statement of the proposed relationship between two or more concepts. An example
of deductive reasoning follows.
All humans experience loss.
All adolescents are humans.
Therefore it can be deduced that all adolescents experience loss.
In this example, deductive reasoning is used to move from the two general premises
about humans and adolescents to the conclusion that “All adolescents experience loss.”
However, the conclusions generated from deductive reasoning are valid only if they are
based on valid premises. Research is a means to test and confirm or refute a premise or
proposition so that valid premises can be used as a basis for reasoning in nursing
Acquiring Knowledge Through Nursing Research
Acquiring knowledge through traditions, authority, borrowing, trial and error, personal
experience, role modeling, intuition, and reasoning is important in nursing. However,
these ways of acquiring knowledge are inadequate in providing an EBP (Brown, 2014;
Craig & Smyth, 2012). The knowledge needed for practice is specific and holistic, as well
as process-oriented and outcomes-focused. Thus a variety of research methods are
needed to generate this knowledge. This section introduces quantitative, qualitative, and
outcomes research methods that are used to generate empirical knowledge for nursing
practice. These research methods are essential to generate evidence for the following
specific goals of the nursing profession (AACN, 2006; ANA, 2011; NINR, 2013):
• Promoting an understanding of patients’ and families’ experiences with health and
illness (a common focus of qualitative research)
• Implementing effective nursing interventions to promote patient health (a common
focus of quantitative research)
• Providing quality, safe, and cost-effective care within the healthcare system (a common
focus of outcomes research)
Introduction to Quantitative and Qualitative Research
Quantitative and qualitative research methods complement each other because they
generate different types of knowledge that are useful in nursing practice. Familiarity with
these two types of research will help you identify, understand, and critically appraise
these studies. Quantitative and qualitative research methodologies have some
similarities; both require researcher expertise, involve rigor in implementation of studies,
and generate scientific knowledge for nursing practice. Some of the differences between
the two methodologies are presented in Table 1-3.
Table 1-3
Characteristics of Quantitative and Qualitative Research Methods
Philosophic al origin
Foc us
Basis of knowing
Theoretic al foc us
Researc her involvement
Quantitative Research
Logic al positivism
Conc ise, objec tive, reduc tionistic
Logistic , deduc tive
Cause and effec t relationships
Tests theory
Qualitative Research
Naturalistic , interpretive, humanistic
Broad, subjec tive, holistic
Dialec tic , induc tive
Meaning, disc overy, understanding
Develops theory and frameworks
S hared interpretation
Most of the studies conducted in nursing have used quantitative research methods.
Quantitative research is a formal, objective, systematic process in which numerical data
are used to obtain information about the world. The quantitative approach toward
scientific inquiry emerged from a branch of philosophy called logical positivism, which
operates on strict rules of logic, truth, laws, and predictions. Quantitative researchers
hold the position that “truth” is absolute and that a single reality can be defined by
careful measurement. To find truth, the researcher must be objective, which means that
values, feelings, and personal perceptions cannot enter into the measurement of reality.
Quantitative research is conducted to test theory by describing variables (descriptive
research), examining relationships among variables (correlational research), and
determining cause and effect interactions between variables (quasi-experimental and
experimental research; Grove et al., 2013; Shadish, Cook, & Campbell, 2002). Chapter 2
describes the different types of quantitative research and the quantitative research
Qualitative research is a systematic, subjective approach used to describe life
experiences and situations and give them meaning (Munhall, 2012). This research
methodology evolved from the behavioral and social sciences as a method of
understanding the unique, dynamic, holistic nature of humans. The philosophical base of
qualitative research is interpretive, humanistic, and naturalistic and is concerned with
understanding the meaning of social interactions by those involved (Standing, 2009).
Qualitative researchers believe that truth is complex and dynamic and can be found only
by studying people as they interact with and in their sociohistorical settings (Creswell,
2014; Munhall, 2012). Nurses’ interest in conducting qualitative research began in the late
1970s. Currently, an extensive number of qualitative studies are being conducted that use
various qualitative research methods. Qualitative research is conducted to promote an
understanding of human experiences and situations and develop theories that describe
these experiences and situations. Because human emotions are difficult to quantify (i.e.,
assign a numerical value to), qualitative research seems to be a more effective method of
investigating emotional responses than quantitative research (see Table 1-3). Chapter 3
describes the different types of qualitative research.
Types of Quantitative and Qualitative Research
Several types of quantitative and qualitative research have been conducted to generate
nursing knowledge for practice. These types of research can be classified in a variety of
ways. The classification system for this book is presented in Box 1-1 and includes the
most common types of quantitative and qualitative research conducted in nursing. The
quantitative research methods are classified into four categories—descriptive,
correlational, quasi-experimental, and experimental (Grove et al., 2013; Kerlinger & Lee,
2000; Shadish et al., 2002; see Chapter 2).
Classification of Research Methods Presented
in this Textbook
B ox 1- 1
Quantitative Research
Qualitative Research
Grounded theory
Exploratory-descriptive qualitative
Outcomes Research
• Descriptive research explores new areas of research and describes situations as they
exist in the world.
• Correlational research examines relationships and is conducted to develop and refine
explanatory knowledge for nursing practice.
• Quasi-experimental and experimental studies determine the effectiveness of nursing
interventions in predicting and controlling the outcomes desired for patients and
The qualitative research methods included in this text are phenomenological,
grounded theory, ethnographic, exploratory-descriptive, and historical research (see Box
• Phenomenological research is an inductive descriptive approach used to describe an
experience as it is lived by an individual, such as the lived experience of chronic pain.
• Grounded theory research is an inductive research technique used to formulate, test,
and refine a theory about a particular phenomenon. Grounded theory research initially
was described by Glaser and Strauss (1967) in their development of a theory about
• Ethnographic research was developed by the discipline of anthropology for
investigating cultures through an in-depth study of the members of the culture. Health
practices vary among cultures, and these practices need to be recognized in delivering
care to patients, families, and communities.
• Exploratory-descriptive qualitative research is conducted to address an issue or
problem in need of a solution and/or understanding. Qualitative nurse researchers use
this methodology to explore an issue or problem area using varied qualitative
techniques, with the intent of describing the topic of interest and promoting
• Historical research is a narrative description or analysis of events that occurred in the
remote or recent past. Thr…
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