NURSING RESEARCH READING, USING, AND CREATING EVIDENCE

FOURTH EDITION

JANET HOUSER, PHD, RN Provost and Professor Rueckert-Hartman College for Health Professions Regis University Denver, Colorado

JONES & BARTLETT LEARNING

2

World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com

Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.

Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]

Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.

The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Nursing Research: Reading, Using, and Creating Evidence, Fourth Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.

There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in

3

the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only.

The author, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used.

15833-5

Production Credits VP, Executive Publisher: David D. Cella Executive Editor: Amanda Martin Editorial Assistant: Emma Huggard Senior Production Editor: Amanda Clerkin Senior Marketing Manager: Jennifer Scherzay Product Fulfillment Manager: Wendy Kilborn Composition: S4Carlisle Publishing Services Cover Design: Scott Moden Rights & Media Specialist: Wes DeShano Media Development Editor: Troy Liston Cover Image: © Valentina Razumova/Shutterstock Printing and Binding: LSC Communications Cover Printing: LSC Communications

Library of Congress Cataloging-in-Publication Data Names: Houser, Janet, 1954- author. Title: Nursing research : reading, using, and creating evidence / Janet Houser. Description: Fourth edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2016038194 | ISBN 9781284110043 Subjects: | MESH: Clinical Nursing Research–methods | Evidence-Based

4

Nursing | Research Design Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072–dc23 LC record available at https://lccn.loc.gov/2016038194

6048

Printed in the United States of America 20 19 18 17 16 10 9 8 7 6 5 4 3 2 1

5

Contents Preface Acknowledgments Contributors About the Author

Part I: An Introduction to Research

1 The Importance of Research as Evidence in Nursing Research as Evidence for Nursing Practice

What Is Nursing Research?

Research: A Fundamental Nursing Skill

The Evolution of Research in Nursing

Contemporary Nursing Research Roles

Research Versus Problem Solving

Research as Evidence in Nursing Practice

Evidence-Based Practice

The Importance of Evidence-Based Practice in Nursing

How Can Evidence Be Used in Health Care?

Strategies for Implementing Evidence-Based Practice

Strategies for Overcoming Barriers

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Future Directions for Nursing Research

Summary of Key Concepts

For More Depth and Detail

References

2 The Research Process and Ways of Knowing Introduction

The Research Process

Classification of Research by Philosophical Assumptions About the Nature of the World

Choosing a Design

Classifications of Research by the Intent of the Researcher

Classifications of Research by the Nature of the Design

Classifications of Research by the Time Dimension

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

6

3 Ethical and Legal Considerations in Research Introduction

Learning from the Past, Protecting the Future

International Guides for the Researcher

National Guidelines for the Nurse Researcher

The Ethical Researcher

Legal and Regulatory Guidelines for Conducting Research

Institutional Review Boards

Research Involving Animals

Research Misconduct

The HIPAA Privacy Rule

Reading Research for Evidence-Based Practice

Using Research in Nursing Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

Part II: Planning for Research

4 Finding Problems and Writing Questions Introduction

Finding and Developing Research Problems

Developing the Research Question

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

5 The Successful Literature Review An Introduction to the Literature Review

Purpose, Importance, and Scope of the Literature Review

Types of Literature Used in the Review

Searching for the Evidence in a Research Problem

Competencies for Information Literacy

Reading the Literature Review Section

Using Evidence-Based Literature in Nursing Practice

Creating a Strong Literature Review

Summary of Key Concepts

For More Depth and Detail

References

6 Selecting an Appropriate Research Design Introduction

What Is a Design?

7

The Basis for Design Selection

The Design Decisions

Reading Research for Evidence-Based Practice

Using Research in Evidence-Based Practice

Creating Evidence for Practice

Summary of Key Concepts

For More Depth and Detail

References

Part III: Research Process

7 The Sampling Strategy Introduction

Selection Strategy: How Were the Subjects Chosen?

The Sample Selection Strategy

Reading the Sampling Section of a Research Study

Using Research as Evidence for Practice

Creating an Adequate Sampling Strategy

Summary of Key Concepts

For More Depth and Detail

References

8 Measurement and Data Collection Introduction

Measurement

The Measurement Strategy

Strategies to Minimize Measurement Error

Collecting Data Using Instruments

Data Management Procedures

Reading About Measurement and Data Collection

Using Measurements from a Research Study

Creating Measures and Collecting Data

Summary of Key Concepts

References

9 Enhancing the Validity of Research Introduction

Minimizing Threats to Internal Validity

Factors That Jeopardize Internal Validity

Factors That Jeopardize External Validity

Balancing Internal and External Validity

Trustworthiness in Qualitative Research

Strategies to Promote the Validity of Qualitative Research

Reading a Research Study to Determine Validity

Using Valid Studies as Evidence for Nursing Practice

Creating a Valid Research Study

Summary of Key Concepts

8

For More Depth and Detail

References

Part IV: Research That Describes Populations

10 Descriptive Research Questions and Procedures Introduction

Descriptive Research Studies

Characteristics of a Descriptive Design

Describing Groups Using Surveys

Describing Groups Relative to Time

Describing the Responses of Single Subjects

Designs That Describe Relationships

Reading Descriptive Research

Using Descriptive Research in Evidence-Based Nursing Practice

Creating Descriptive Research

Summary of Key Concepts

References

11 Summarizing and Reporting Descriptive Data Introduction

An Overview of Descriptive Data Analysis

Understanding Levels of Measurement

Identifying Shape and Distribution

Describing the Center and Spread

Common Errors in Summarizing Data

Reading the Descriptive Data Section in a Research Study

Using Descriptive Data Analysis in Practice

Creating Descriptive Data Summaries for a Research Study

Reporting Descriptive Results

Summary of Key Concepts

References

Part V: Studies that Measure Effectiveness

12 Quantitative Questions and Procedures Introduction

Quantitative Research Questions

Characteristics of a Quantitative Design

The Gold Standard: Experimental Design

More Common: Quasi-Experimental Designs

Designs That Focus on Intact Groups

Time-Series Designs

Reading Quantitative Research

Using Quantitative Research in Evidence-Based Nursing Practice

Generalizing the Results of Quantitative Studies

Creating Quantitative Research

9

Summary of Key Concepts

References

13 Analysis and Reporting of Quantitative Data Introduction

Some General Rules of Quantitative Analysis

Types of Quantitative Analysis

An Overview of Quantitative Analysis

Selecting the Appropriate Quantitative Test

Reading the Analysis Section of the Research Report

Using Quantitative Results as Evidence for Practice

Creating a Quantitative Analysis

Summary of Key Concepts

References

Part VI: Research That Describes the Meaning of an Experience

14 Qualitative Research Questions and Procedures An Introduction to Qualitative Research

Characteristics of Qualitative Research Methods

Enhancing the Trustworthiness of Qualitative Studies

Classifications of Qualitative Traditions

Reading Qualitative Research Studies

Using Qualitative Research Studies as Evidence

Creating Qualitative Evidence

Summary of Key Concepts

References

15 Analyzing and Reporting Qualitative Results Introduction to Qualitative Analysis

The Qualitative Analysis Process

Management and Organization of Data

Software for Qualitative Analysis

Reliability and Validity: The Qualitative Version

Reporting Qualitative Results

Reading the Qualitative Analysis Section of a Report

Using Qualitative Analysis in Nursing Practice

Creating Qualitative Analyses

Summary of Key Concepts

References

Part VII: Research Translation

16 Translating Research into Practice Introduction

The Nurse’s Role in Knowledge Translation

Identifying Problems for Knowledge Translation

Communicating Research Findings

10

Finding and Aggregating Evidence

Models for Translating Research into Practice

Summary of Key Concepts

References

Glossary

Index

11

The Pedagogy Nursing Research: Reading, Using, and Creating Evidence, Fourth Edition demonstrates how to use research as evidence for successful nursing practice. Fully updated and revised, this readerfriendly new edition provides students with a fundamental understanding of how to appraise and utilize research, translating it into actionable guidelines for practice. Organized around the different types of research that can be used in evidence-based practice, it addresses contemporary methods including the use of technology in data collection, advice for culturally competent research, and suggestions for accessing hard-to-reach subjects. Additionally, it explores both quantitative and qualitative traditions and encourages students to read, use, and participate in the research process. The pedagogical aids that appear in most chapters include the following:

12

13

14

15

16

17

18

Preface This nursing research text is based on the idea that research is essential for nurses as evidence for practice. Its contents are intended to be relevant for nursing students, and practicing nurses who must apply evidence to practice. All nurses should be able to read research, determine how to use it appropriately in their practice, and participate in the research process in some way during their careers as professionals. This text is intended to support all these efforts.

Evidence-based practice is one of the most exciting trends in nursing practice to emerge in decades. However, its integration into daily practice requires a solid understanding of the foundations of research design, validity, and application. This text is intended as a reader-friendly approach to a complex topic so that beginners can grasp the fundamentals of appraising research, experienced nurses can use research in practice, and practicing nurses can gain skills to create bedside research projects or participate effectively on research teams.

This text is presented in an uncluttered, straightforward manner. Although it uses many bulleted lists to make the material visually interesting, the sidebars, figures, and tables are limited to those that illustrate truly important concepts. This format allows the reader to grasp the information quickly and to navigate the text efficiently. Margin notes provide definitions of new terms when they first appear, and the Gray Matter features offer information about key concepts that are of particular importance.

This text differs in its approach from traditional texts in that it does not focus primarily on interpreting inferential research; rather, it seeks to impart a fundamental understanding of all types of research that may be used as evidence. It adds depth by considering the use of qualitative research in nursing practice—a natural fit with this holistic profession. This text also addresses contemporary concerns for today’s nurses, including ethical and legal issues. Although both ethics and legal issues are mentioned in many research texts, a full chapter is devoted to these topics in this text so that the intricacies of these issues can be thoroughly considered.

The integrated discussion of both the quantitative and the qualitative traditions is another unique facet of this text’s coverage of the research process. Most nurse researchers have learned to appreciate the need to consider all paradigms when approaching a research question; separating the two approaches when discussing the fundamental interests of researchers results in a polarized view. Intuitively, nurses know that the lines between quantitative

19

and qualitative designs are not always so clear in practice and that they should consider multiple ways of knowing when evaluating research questions. The planning process covered here helps the novice researcher consider the requirements of both approaches in the context of sampling, measurement, validity, and other crucial issues they share. Detailed descriptions of the procedures for each type of design are given attention in separate chapters.

The chapters are organized around the types of research processes that make up the evidence base for practice. The first section of the text provides information that is applicable to all research traditions, whether descriptive, quantitative, or qualitative. Part I provides an overview of issues relevant to all researchers: understanding the way research and practice are related, the ways that knowledge is generated, and legal and ethical considerations. Part II describes the processes that go into planning research. The chapters in Part III consider the various decisions that must be made in each phase of the research process.

The evidence generated by descriptive, survey, and qualitative designs is placed in the context of both the definition of evidence-based practice and application in practice guidelines. In Parts IV, V, and VI, each major classification of research is explored in depth through review of available designs, guidelines for methods and procedures, and discussion of appropriate analytic processes. Brief examples of each type of research are provided, along with notes explaining the features demonstrated in each case in point. Finally, Part VII details the models and processes used to translate research into clinical practice.

Many chapters begin with a feature called “Voices from the Field” that relates a real-life story of a nurse’s experience with the research process, illustrating the way that the material covered in that chapter might come to life. The main content for each chapter is broken into five parts:

A thorough review of the topic under consideration is presented first. This review lays out the fundamental knowledge related to the topic. Next, the nurse isa guided to consider the aspects of a study that should be appraised when reading research. All nurses—regardless of their experience—should be able to read research critically and apply it appropriately to practice, and the second section of each chapter addresses this skill. Added features include advice on where to look for the key elements of a research paper, the wording that might be used to describe them, and specific things to look for during the evaluation process. Evaluation checklists support this process. The third section of the chapter focuses on using research in practice. This section supports the nurse in determining if and how research findings might be used in his or her practice.

20

The fourth section is intended for nurses who may be involved with teams that are charged with creating research or who may plan bedside research projects to improve practice. This section gives practical advice and direction about the design and conduct of a realistic, focused nursing research project. The final section of each chapter contains summary points and a critical appraisal exercise so that the nurse can immediately apply the chapter concepts to a real research report.

All of these features are intended to help the reader gain a comprehensive view of the research process as it is used to provide evidence for professional nursing practice. The use of this text as a supportive resource for learning and for ongoing reference in clinical practice has been integrated into the design of each element of the text. The goal is to stimulate nurses to read, use, and participate in the process of improving nursing practice through the systematic use of evidence. Accomplishing this goal improves the profession for all of us.

21

Acknowledgments It is a bit misleading to conclude that a text is produced solely by the person whose name appears on the cover. Help and support are needed from many people on both professional and personal fronts to complete a project of this size. The help of editorial staff is always welcome; advice from Amanda Martin was invaluable in merging the interests of writing with those of producing a book that others will want to read. I appreciate Amanda Clerkin’s calm and steady approach after our sixth manuscript together, and I’ve learned a lot from reading Jill Hobbs’s edits, which I must begrudgingly admit make my writing much better.

My family—my husband, Floyd; my sisters, Anne and Ande; my niece, Stef; and mini-me, Amanda—provided me with enough encouragement to keep going, even as they reminded me there is life beyond the pages of a book.

I must thank Regis University profusely for providing me with inspirational colleagues and a place that supports my work. Pat Ladewig, as always, provided pragmatic advice and guidance from her impressive experience publishing her own texts. My contributors and reviewers each provided a unique viewpoint and helped me discover the best way to ensure that students “get it.”

Writing always makes me realize how much I miss my mom, Marty, who encouraged me to publish from the time she surreptitiously sent one of my poems to Highlights magazine when I was 9 years old. She was proud of that poem, framed the issue, and had my grandmother embroider it on a pillow. Seeing this book in print would have impressed her only slightly more, but I know she’s smiling.

22

Contributors Michael Cahill, MS, CPHQ Parker Adventist Hospital Parker, Colorado Summarizing and Reporting Descriptive Data

Sheila Carlon, PhD, RHIA, FAHIMA Regis University Denver, Colorado Ethical and Legal Considerations in Research

Phyllis Graham-Dickerson, PhD, RN, CNS Regis University Denver, Colorado Qualitative Research Questions and Procedures Analyzing and Reporting Qualitative Results

LeeAnn Hanna, PhD, RN, CPHQ, FNAHQ HCA, TriStar Centennial Medical Center Nashville, Tennessee Finding Problems and Writing Questions

Kimberly O’Neill, MS, MLIS Dayton Memorial Library, Regis University Denver, Colorado The Successful Literature Search

23

About the Author

Janet Houser, PhD, RN

Regis University

Dr. Janet Houser is currently Provost at Regis University in Denver, Colorado. Prior to her appointment, she was Dean of the Rueckert-Hartman College for Health Professions and the Vice Provost for Resource Planning.

Dr. Houser has a BSN, an MN in Maternal-Child Health, an MS in healthcare administration, and a PhD in applied statistics and research methods. She has taught nurses, administrators, pharmacists, and physical therapy students from undergraduate through doctoral level, primarily in the subjects of research methods, biostatistics, and quantitative methods. Previous to her position as Dean, Dr. Houser was faculty and Associate Dean for Research and Scholarship.

Dr. Houser spent 20 years in healthcare administration with the Mercy Health System. Her last position was as Regional Director for Professional Practice for Mercy Health Partners in Cincinnati, Ohio, where she was responsible for professional practice and clinical research in 29 facilities.

Dr. Houser has published five books, Clinical Research in Practice: A Guide for the Bedside Scientist, Nursing Research: Reading, Using, and Creating Evidence, which is in its fourth edition, and Evidence-Based Practice: An Implementation Guide. She has more than 30 peer-reviewed publications in journals and has presented her research at regional, national, and international conferences.

24

© Valentina Razumova/Shutterstock

25

Part I: An Introduction to Research 1 The Importance of Research as Evidence in Nursing 2 The Research Process and Ways of Knowing 3 Ethical and Legal Considerations in Research

26

© Valentina Razumova/Shutterstock

27

Chapter 1: The Importance of Research as Evidence in Nursing

CHAPTER OBJECTIVES The study of this chapter will help the learner to

Define nursing research and discuss how research is used in nursing practice. Describe the evolution of nursing research. Investigate the roles that nurses play in research processes. Contrast research and other types of problem solving. Explore how research is used as evidence guiding the practice of nursing. Read research and appraise the credibility of the journal, authors, and publication process.

KEY TERMS Blinded

Evidence-based practice

Evidence-based practice guideline

External validity

Journal club

Magnet status

National Institute of Nursing Research (NINR)

Nursing process

Nursing research

Outcomes measurement

Peer review

Principal investigator

Quality improvement

Randomized controlled trial

Replication

Systematic review

28

Research as Evidence for Nursing Practice The practice of nursing is deeply rooted in nursing knowledge, and nursing knowledge is generated and disseminated through reading, using, and creating nursing research. Professional nurses rely on research findings to inform their practice decisions; they use critical thinking to apply research directly to specific patient care situations. The research process allows nurses to ask and answer questions systematically that will ensure that their decisions are based on sound science and rigorous inquiry. Nursing research helps nurses in a variety of settings answer questions about patient care, education, and administration. It ensures that practices are based on evidence, rather than eloquence or tradition.

VOICES FROM THE FIELD I was working as the clinical nurse specialist in a busy surgical intensive care unit (ICU) when we received a critically ill patient. He was fresh from cardiac surgery and quite unstable; he needed multiple drugs and an intra-aortic balloon pump just to maintain his perfusion status. The patient was so sick that we were not able to place him on a special bed for pressure relief. For the first 24 hours, we were so busy trying to keep him alive that we did not even get a chance to turn him.

Approximately 36 hours into his ICU admission, he was stable enough to place on a low-air-loss mattress for pressure-ulcer prevention. When we were finally able to turn him, we noted he had a small stage II pressure ulcer on his coccyx. Despite the treatments that we used, the pressure ulcer evolved into a full-thickness wound. The patient recovered from his cardiac surgical procedure but, unfortunately, required surgeries and skin grafts to close the pressure ulcer wound.

The experience I had with this patient prompted me to review the evidence-based practice (EBP) guidelines we had in place to prevent pressure ulcers in critically ill patients. I wanted to make sure we could prevent this kind of incident from happening again, but I had a lot of questions. Could we preventively place high-risk patients on low-air- loss mattresses while they were still in the perioperative service? Did we even know which patients were at risk for pressure ulcers? Which assessment tools did nurses use to assess the patient’s risk? When a high-risk patient was identified, which interventions did the nurses use to prevent pressure ulcers? How were the ulcers treated once they appeared?

I was fortunate that my chief nursing officer (CNO) was a strong advocate for EBP, and she encouraged me to initiate an EBP review of pressure ulcer prevention and treatment. Specifically, I wanted to find out which nursing interventions were supported by research evidence when we were trying to prevent pressure ulcers in the surgical ICU. As

29

part of my review, I contacted other inpatient units at the hospital to determine what they were doing.

I discovered that the surgical ICU was no different from the other inpatient units in this regard: There was no standard, evidence-based nursing practice for pressure ulcer prevention. Units were not consistently using the same skin assessment tools, so it was difficult to objectively communicate risk from one unit to another. The tools we were using were not necessarily based on research. It was clear that we needed to identify the best available evidence and devise a protocol.

We started by establishing an evidence-based skin care council for the hospital. This team consisted of bedside nurses from all inpatient units and the perioperative service. Initially the council reviewed the hospital’s current nursing skin assessment forms, and we conducted a review of the literature on pressure ulcer prev