Qualitative research Select a qualitative question you are interested in investigating. Discuss the basics of qualitative research: what are the characteri

Qualitative research Select a qualitative question you are interested in investigating. Discuss the basics of qualitative research: what are the characteristics, what is included, what are the 4 designs of the qualitative type research, which type would be appropriate for your qualitative research question and why? Appraisal and
Application of








Evidence-Based Practice for Nurses: Appraisal and Application of Research, Fourth Edi-tion, drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approach
addresses different learning styles, making this the ideal text to ensure mastery of key concepts.
The pedagogical aids that appear in most chapters include the following:

Chapter Objectives
These objectives provide
instructors and students
with a snapshot of the
key information they will
encounter in each chapter.
They serve as a checklist to
help guide and focus study.

Key Terms
Found in a list at the
beginning of each chapter
and in bold within the
chapter, these terms
will create an expanded
vocabulary in evidence-based

At the end of this chapter, you will be able to:

Key terms

CHAPter OBJeCtiVes

‹ Define evidence-based practice (EBP)
‹ List sources of evidence for nursing

‹ Identify barriers to the adoption
of EBP and pinpoint strategies to
overcome them

‹ Explain how the process of diffusion
facilitates moving evidence into
nursing practice

‹ Define research
‹ Discuss the contribution of research
to EBP

‹ Categorize types of research
‹ Distinguish between quantitative and
qualitative research approaches

‹ Describe the sections found in
research articles

‹ Describe the cycle of scientific

‹ Identify historical occurrences that
shaped the development of nursing
as a science

‹ Identify factors that will continue to
move nursing forward as a science

‹ Discuss what future trends may
influence how nurses use evidence to
improve the quality of patient care

‹ Identify five unethical studies
involving the violation of the rights of
human subjects

applied research
basic research
cycle of scientific

deductive reasoning
descriptive research
discussion section
early adopters
empirical evidence
evidence-based practice

explanatory research

inductive reasoning
Jewish Chronic Disease

Hospital study
list of references
methods section
model of diffusion of

Nazi experiments
Nuremberg Code
predictive research
pyramid of evidence

qualitative research
quantitative research
replication study
research utilization
results section
review of literature
theoretical framework
Tuskegee study
Willowbrook studies

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Critical Thinking Exercises
As an integral part of the learning
process, the authors present
scenarios and questions to spark
insight into situations faced in

Test Your Knowledge
These questions serve
as benchmarks for the
knowledge acquired
throughout the chapter.

After an outcome has been selected and measured, data are compiled and
evaluated to draw conclusions. Demonstrating the effectiveness of an
innovation is a challenge, and conclusions must not extend beyond the
scope of the data. Evaluation is facilitated when appropriate outcomes
and associated indicators are chosen. If the outcome is not clearly defined,
then the measurements and subsequent evaluation will be flawed. For
example, suppose that you are a member of an interdisciplinary team
that has developed a nursing protocol that reduces the amount of time
the patient remains on bed rest after a cardiac catheterization procedure
from 6 hours to 4 hours. The outcome selected is absence of bleeding from
the femoral arterial puncture site. No other indicators are measured. The
results obtained after implementing the protocol revealed that there was
an increase in bleeding at the femoral arterial site in the 4-hour bed rest
patients compared to the 6-hour bed rest patients. Before concluding that
a shorter bed rest time leads to an increase in femoral bleeding, a few
additional questions need to be considered. First, was absence of bleed-
ing defined in a measurable way? Because bleeding might be interpreted
in several different ways, a precise definition of bleeding should have
been provided to ensure consistency in reporting. Second, when should
patients be assessed for absence of bleeding? Is the absence of bleeding to
be assessed when the patient first ambulates or at a later time? Input from
the staff prior to changing the nursing protocol could have clarified these
questions, resulting in more reliable results.

Another consideration in outcome evaluation is to obtain data relative to
current practice for comparison purposes. To document the need for a practice
change and to support a new protocol, baseline data might need to be collected

tEst YOur knOWlEdgE 18-3


1. Baseline data are unimportant in outcome measurement.

2. Precise description of indicators is essential.

3. For complex analyses, the assistance of a statistician may be needed.

4. Input from staff can help clarify outcome measurement.

How did you do? 1. F; 2. T; 3. T; 4. T


After an outcome
has been
selected and
measured, data
are compiled
and evaluated to
draw conclusions.
Evaluation is
facilitated when
outcomes and
are chosen—
conversely, if
the outcome
is not clearly
defined, then the
and subsequent
evaluation will be

498 ChaptER 18 Evaluating Outcomes of Innovations

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treatment of human response, and advocacy in the care of individuals, fami-
lies, communities, and populations” (ANA, 2003, p. 6). From the early days of
the profession, students have been taught that a scientific attitude and method
of work combined with “experience, trained senses, a mind trained to think,
and the necessary characteristics of patience, accuracy, open-mindedness,
truthfulness, persistence, and industry” (Harmer, 1933, p. 47) are essential
components of good practice. Harmer goes on to say, “Each time this habit of
looking, listening, feeling, or thinking is repeated it is strengthened until the
habit of observation is firmly established” (p. 47). This still holds true today.
Benner (1984) studied nurses in practice and concluded that to become an
expert nurse one has to practice nursing a minimum of 5 years. There are no
shortcuts to becoming an expert in one’s field. The development of knowledge
and skill takes time and work. As nurses encounter new situations, learning
takes place. Nursing knowledge develops and is refined as nurses practice
(Waterman, Webb, & Williams, 1995). In this way, nurses adapt theories to
fit their practices. Unfortunately, much that is learned about theory during
practice remains with the nurse because nurses rarely share their practice
expertise through conference presentations and publications. The discipline
will be enriched when nurses engage more formally in disseminating their
knowledge about theory in practice.

The Relationships Among Theory,
Research, and Practice
Practice relies on research and theory and also provides the questions that
require more work by theorists and researchers. Each informs and supports
the other in the application and development of nursing knowledge. When
the relationships among theory, research, and practice are in harmony, the
discipline is best served, ultimately resulting in better patient outcomes
(Maas, 2006). The relationships are dynamic and flow in all directions.

CRiTiCAL THinking ExERCisE 5-2

A nurse on a surgical floor observes that several new approaches are being used to dress wounds.
She observes that some methods appear to promote healing faster than others do. While
reviewing the research literature, she is unable to locate any research about the dressings she is
using. How might she go about testing her theory that some methods are better than others? Can
this be done deductively, inductively, or using mixed methods? Are any theories presently available
related to wound healing, and if so, where might she locate these? What concepts might be
important in forming the question?






5.1 How Are Theory, Research, and Practice Related? 141

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Quick tidbits and facts are
pulled out in chapter margins
to highlight important
aspects of the chapter topic.


Rapid Review
This succinct list at the end
of the chapter compiles
the most pertinent and key
information for quick review
and later reference.

Apply What You Have
This outstanding feature
applies newly acquired
knowledge to specific
evidence-based practice
scenarios and research

apparent. Organizing the review with a grid is a positive strategy to overcome
the barrier of lack of time because it reduces the need to repeatedly sort through
articles during future discussions. Also, within this text’s digital resources, you
will find a grid to use for this exercise. Two articles (Cohen & Shastay, 2008;
Tomietto, Sartor, Mazzocoli, & Palese, 2012) are summarized as an example.

Read Kliger, Blegen, Gootee, and O’Neil (2009). Enter information about
this article into the first two columns. In column 1, use APA format, like
in the example, because this is the most commonly used style for nursing

Rapid Review
» Today’s work environment requires that nurses be adept at gathering

and appraising evidence for clinical practice and assisting patients with
healthcare information needs.

» Literature reviews provide syntheses of current research and scholarly
literature. A well-done literature review can provide support for EBP.

» An understanding of the scientific literature publication cycle provides
a basis for making decisions about the most current information on a

» Primary sources are original sources of information presented by the
people who created them. Secondary sources are resulting commentar-
ies, summaries, reviews, or interpretations of primary sources.

» Many research journals involve peer review.

» There are many ways to categorize sources. Scholarly, trade, and popular
literature is one way. Another categorizing system involves periodicals,
journals, and magazines.

» There are four types of review: narrative, integrative, meta-analysis, and

» Understanding how sources are structured can simplify a search of the

» Sources can be identified through both print indexes and electronic data-
bases. Topics, subject matter, and format may vary but all include citation

» Helpful strategies to use when conducting a search include cita-
tion chasing, measurements of recall and precision, keyword and
controlled vocabulary searches, Boolean operators, truncation,

4.5 Keeping It Ethical 129

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Aitken, L. M., Hackwood, B., Crouch, S., Clayton, S., West, N., Carney, D., &

Jack, L. (2011). Creating an environment to implement and sustain
evidence based practice: A developmental process. Australian Critical
Care, 24, 244–254.

American Medical Association. (1998). Information from unethical
experiments (CEJA Report 5–A-98). Retrieved from http://www.ama-assn

American Nurses Association. (2010). National Database of Nursing Quality
Indicators: Guidelines for data collection on the American Nurses
Association’s National Quality forum endorsed measures: Nursing Care
Hours per Patient Day, Skill Mix, Falls, Falls with Injury. Retrieved from

Barnsteiner, J., & Prevost, S. (2002). How to implement evidence-based
practice. Some tried and true pointers. Reflections on Nursing Leadership,
28(2), 18–21.

Barta, K. M. (1995). Information-seeking, research utilization, and barriers
to research utilization of pediatric nurse educators. Journal of Professional
Nursing, 11, 49–57.

Benner, P. (1984). From novice to expert: Excellence and power in clinical
nursing practice. Menlo Park, CA: Addison-Wesley.

aPPlY What YOu havE lEarnED

Sign into a database for nursing literature (i.e., CINAHL, ProQuest, PubMed). For this chapter, you
will need to obtain the following two articles:

Pipe, T. B., Kelly, A., LeBrun, G., Schmidt, D., Atherton, P., & Robinson, C. (2008).
A prospective descriptive study exploring hope, spiritual well-being, and quality of life in
hospitalized patients. MEDSURG Nursing, 17, 247–257.

Flanagan, J. M., Carroll, D. L., & Hamilton, G. A. (2010). The long-term lived experience of
patients with implantable cardioverter defibrillators. MEDSURG Nursing, 19, 113–119.

One of these articles used qualitative methods, and the other used quantitative methods. Identify
which is which. After you have done that, for each article identify the various sections that make
up a research article. You may want to share these articles with nurses during your next clinical
experience and consider ways the recommendations can be incorporated into practice.









, In

36 CHAPter 1 What Is Evidence-Based Practice?

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Case Examples
Found in select chapters,
these vignettes illustrate
research questions and
studies in actual clinical
settings and provide critical
thinking challenges.

Some researchers claim their work is nursing research because the researcher
is a nurse or because the researcher studied nurses. But it is the focus on nurs-
ing practice that defines nursing research. The mere fact that the research was
conducted by a nurse or that nurses were studied does not necessarily qualify
the research as nursing research. Historically, and even today, approaches to
practice are often based on “professional opinion” when research is absent.
Case Example 5-1 provides such a historical illustration. It also demonstrates
the value of systematically studying the effects of interventions.

CAsE ExAmPLE 5-1

Early methods of Resuscitation: An Example of Practice Based on Untested Theory

hroughout the past century, nursing students have been taught how to resuscitate patients
who stop breathing. As early as 1912, students were taught a variety of methods for
providing artificial respiration. It was theorized that moving air in and out of the lungs

would be effective. One of these techniques was designed for resuscitating infants. Byrd‘s Method
of Infant Resuscitation (Goodnow, 1919) directed the nurse to hold the infant‘s legs in one hand,
and the head and back in the other. The nurse would then double the child over by pressing the
head and the knees against the chest. Then the nurse would extend the knees to undouble the
child. This would be repeated, but “not too rapidly” (Goodnow, 1919, p. 305). At intervals,
the nurse would dip the child into a mustard bath in the hope that this would also stimulate
respiration. The nurse would continue this until help arrived.

Other methods of artificial respiration taught included Sylvester‘s method for adults (Goodnow,
1919). The patient was placed flat on his back. The nurse would grasp the patient‘s elbows and
press them close to his sides, pushing in the ribs to expel air from the chest. The arms would then
be slowly pulled over the head, allowing the chest to expand. The arms would be lowered to put
pressure on the chest, and the cycle was then repeated. This was to be done at the rate of 18 to
20 cycles per minute.

By 1939, postmortem examinations after unsuccessful resuscitations showed veins to be engorged
while the arteries were empty (Harmer & Henderson, 1942). Although this evidence indicated
other factors needed to be considered, resuscitation techniques continued to focus only on the
respiratory system. The same methods of resuscitation that were in use in 1919 were still being
taught in 1942. Although students were still being taught the Sylvester method, they were also
learning the new “Schäfer method” (Harmer & Henderson, 1942, p. 9401). This method involved
placing the patient in a prone position. The nurse would straddle the thighs, facing the patient‘s
head, and alternatively apply and remove pressure to the thorax.

Eventually, it was noted that what was believed to be best practice was not effective. Results
of postmortem examinations indicated that something was missing in the techniques, and
therefore research was begun to determine best practice. Today, nursing students are taught
cardiopulmonary resuscitation techniques based on updated research and theories.

136 CHAPTER 5 Linking Theory, Research, and Practice

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fully operational in 1996. It aims to improve the effectiveness of nursing practice
and healthcare outcomes. Some initiatives include conducting systematic reviews,
collaborating with expert researchers to facilitate development of practice infor-
mation sheets, and designing, promoting, and delivering short courses about EBP.

2.2 keeping It Ethical

Ethical research exists because international, national, organizational, and
individual factors are in place to protect the rights of individuals. Without
these factors, scientific studies that violate human rights, such as the Nazi
experiments, could proceed unchecked. Many factors of ethical research,
which evolved in response to unethical scientific conduct, are aimed at pro-
tecting human rights. Human rights are “freedoms, to which all humans are
entitled, often held to include the right to life and liberty, freedom of thought
and expression, and equality before the law” (Houghton Mifflin, 2007). Rights
cannot be claimed unless they are justified in the eyes of another individual or
group of individuals (Haber, 2006). When individuals have rights, others have
obligations, that is, they are required to act in particular ways. This means
that when nursing research is being conducted, subjects participating in stud-
ies have rights, and all nurses are obligated to protect those rights.

International and National Factors:
guidelines for Conducting Ethical
One of the earliest international responses to unethical scientific conduct was
the Nuremberg Code. This code was contained in the written verdict at the
trial of the German Nazi physicians accused of torturing prisoners during
medical experiments. Writers of the Nuremberg Code (Table 2-3) identified
that voluntary consent was absolutely necessary for participation in research.
Research that avoided harm, produced results that benefited society, and
allowed participants to withdraw at will was deemed ethical. The Nuremberg
Code became the standard for other codes of conduct.

Key Terms
human rights:
Freedoms to which all
humans are entitled

Requirements to act in
particular ways

At the end of this section, you will be able to:

‹ Discuss international and national initiatives designed to promote ethical conduct
‹ Describe the rights that must be protected and the three ethical principles that must be
upheld when conducting research

‹ Explain the composition and functions of IRBs at the organizational level
‹ Discuss the nurse’s role as patient advocate in research situations

2.2 Keeping It Ethical 55

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Keeping It Ethical
Relevant ethical content
concludes each chapter
to ensure that ethics are a
consideration during every
step of the nursing process.


Appraisal and
Application of


Edited by
Nola A. Schmidt, PhD, RN, CNE

College of Nursing and Health Professions

Valparaiso University
Valparaiso, Indiana

Janet M. Brown, PhD, RN
Professor Emeritus

College of Nursing and Health Professions
Valparaiso University
Valparaiso, Indiana




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Library of Congress Cataloging-in-Publication Data
Names: Schmidt, Nola A., editor. | Brown, Janet M. (Janet Marie), 1947– 
Title: Evidence-based practice for nurses : appraisal and application of 
   research / [edited by] Nola A. Schmidt and Janet M. Brown.
Description: Fourth edition. | Burlington, Massachusetts : Jones & Bartlett 
   Learning, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2017036581 | ISBN 9781284122909
Subjects: | MESH: Nursing Research–methods | Evidence-Based Nursing
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21 20 19 18 17 10 9 8 7 6 5 4 3 2 1






For Mom, whose love and support are endless.

—N. A. S.

To my husband, my children, and my granddaughters and grandson, who enrich my life in every way.

—J. M. B.





Contributors xix
Reviewers xxi
Preface xxiii
Acknowledgments xxix

UNIT 1 Introduction to Evidence-Based
Practice 1

CHAPTER 1 What Is Evidence-Based Practice? 3
Nola A. Schmidt and Janet M. Brown

1.1 EBP: What Is It? 3
1.2 What Is Nursing Research? 14
1.3 How Has Nursing Evolved as a Science? 23
1.4 What Lies Ahead? 31
1.5 Keeping It Ethical 34


CHAPTER 2 Using Evidence Through Collaboration
to Promote Excellence in Nursing
Practice 43
Emily Griffin and Marita G. Titler

2.1 The Five Levels of Collaboration 43
2.2 Keeping It Ethical 54

UNIT 2 Acquisition of Knowledge 67

CHAPTER 3 Identifying Research Questions 69
Susie Adams

3.1 How Clinical Problems Guide
Research Questions 69

3.2 Developing Hypotheses 77
3.3 Formulating EBP Questions 84
3.4 Keeping It Ethical 87

CHAPTER 4 Finding Sources of Evidence 93
Patricia Mileham

4.1 Purpose of Finding Evidence 93
4.2 Types of Evidence 96
4.3 How Sources Are Organized 102
4.4 How to Search for Evidence 110
4.5 Keeping It Ethical 123

CHAPTER 5 Linking Theory, Research, and Practice 131
Elsabeth Jensen

5.1 How Are Theory, Research, and Practice
Related? 131

5.2 Keeping It Ethical 141


UNIT 3 Persuasion 147

CHAPTER 6 Key Principles of Quantitative Designs 149
Rosalind M. Peters

6.1 Chart the Course: Selecting the Best Design 149
6.2 What Is Validity? 155
6.3 Categorizing Designs According to Time 161
6.4 Keeping It Ethical 166

CHAPTER 7 Quantitative Designs: Using Numbers to
Provide Evidence 171
Rosalind M. Peters

7.1 Experimental Designs 171
7.2 Quasi-Experimental Designs 177
7.3 Nonexperimental Designs 180
7.4 Specific Uses for Quantitative Designs 186
7.5 Keeping It Ethical 188

CHAPTER 8 Epidemiologic Designs: Using Data to
Understand Populations 193
Amy C. Cory

8.1 Epidemiology and Nursing 193
8.2 Infectious Diseases and Outbreak

Investigations 195
8.3 Measures of Disease Frequency 197
8.4 Descriptive Epidemiology 200
8.5 Descriptive Study Designs 204


8.6 Analytic Study Designs 208
8.7 Screening 213
8.8 Evaluating Health Outcomes and Services 215
8.9 Keeping It Ethical 216

CHAPTER 9 Qualitative Designs: Using Words to Provide
Evidence 221
Kristen L. Mauk

9.1 What Is Qualitative Research? 221
9.2 The Four Major Types of Qualitative

Research 230
9.3 Keeping It Ethical 244

CHAPTER 10 Collecting Evidence 253
Jan Dougherty

10.1 Data Collection: Planning and Piloting 253
10.2 Collecting Quantitative Data 255
10.3 Validity and Reliability 263
10.4 Collecting Qualitative Data 271
10.5 Keeping It Ethical 278

CHAPTER 11 Using Samples to Provide Evidence 285
Ann H. White

11.1 Fundamentals of Sampling 285
11.2 Sampling Methods 290
11.3 Sample Size: Does It Matter? 299
11.4 Keeping It Ethical 302


CHAPTER 12 Other Sources of Evidence 309
Cynthia L. Russell

12.1 The Pyramid of the 5 Ss 309
12.2 Using the Pyramid of the 5 Ss for Evidence-Based

Practice 320
12.3 Keeping It Ethical 324

UNIT 4 Decision 329

CHAPTER 13 What Do the Quantitative Data Mean? 331
Rosalind M. Peters, Nola A. Schmidt,
and Moira Fearncombe

13.1 Using Statistics to Describe the Sample 331
13.2 Using Frequencies to Describe Samples 333
13.3 Measures of Central Tendency 337
13.4 Distribution Patterns 341
13.5 Measures of Variability 344
13.6 Inferential Statistics: Can the Findings

Be Applied to the Population? 352
13.7 Reducing Error When Deciding About

Hypotheses 355
13.8 Using Statistical Tests to Make Inferences About

Populations 361
13.9 What Does All This Mean for EBP? 370
13.10 Keeping It Ethical 373

CHAPTER 14 What Do the Qualitative Data Mean? 379
Kristen L. Mauk

14.1 Qualitative Data Analysis 379


14.2 Qualitative Data Interpretation 385
14.3 Qualitative Data Evaluation 391
14.4 Keeping It Ethical 396

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