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CHAPTER

33

NursingResearch: CurrentPerspectives andFuture Trends

Susan M. Bauer-Wu, DNSc, RNMary E. Cooley, PhD, CRNP, CS

Martha W. Healey, RN, MS, FNP

Nurse managers need to have an appreciation of nursing research for a numberof reasons. Recognition that nursing knowledge is not static, but ever changing andimproving, is the hallmark to excellence in patient care. Supporting a practice envi-

ronment that questions if the care given is the best it can be is a win-winfor everyone:patients receive the best possible care, nursing staff is empowered and stimulated tothink outside of the box, and they can feel assured that they are providing the highestquality of care based on evidence. Supporting an evidence-based practice environmentallows nursing managers and administrators to benefit from such secondary gainsas patient and nurse satisfaction, which can have a positive impact on staff retentionand fiscal matters.

It is important to realize that the term nursing research implies two aspects: theuse of research methods (conducting research) and techniques to evaluate and guidepractice (utilizing research) (Norris, 1999). Involving clinical staff in nursing researchactivities is very important and can be accomplished in a variety of ways. Staff can teamup with a nurse scientist (e.g., doctoral-prepared nurse researcher) to be the clinicalexperts on a study. As co-investigators, they can provide valuable insights into thepatient experience and essential information about the logistics of carrying out thestudy. Clinical staff can partner with the nurse scientist in a mentored relationship.In this way, clinicians function as co-principal investigators who are involved in everystep of the study from development, to implementation, to dissemination of findings.Nurses can play a key role in recruitment and data collection activities, which can beincorporated into usual patient care. Finally, clinical nurses are integral to the successof research utilization and evidence-based practice activities. Involving staff at thislevel makes research real to them and helps them to embrace practice changes that

are based on research findings.


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Nursing Management: Principles and Practice

This chapter provides an overview of nursing research and its application in theclinical setting. Attention will be given to both the general nuts and bolts of conductingresearch as well as the use of research to guide nursing practice. The conduct and

utilization of research are interdependent processes in that both processes are neededto advance the science of nursing practice. An understanding of these processes canguide nurse managers to make effective decisions about incorporating research intotheir clinical environments.

Basics of Conducting Research

Conducting research is quite labor and resource intensive and requires researchskills and experience. Before embarking on such an undertaking, it is critical tounderstand the different types of research, the steps to conduct research, and thenecessary resources that are required. The following section will provide a briefoverview and important considerations for the conduct of research. For noviceresearchers who are planning to carry out a study, it is highly recommended to usecomprehensive research methods textbooks as well as to team up or consult with anexperienced researcher.

Although research can be performed independently, it is more likely to be suc-cessful with a research team. Each member of the team brings complementary skillsand resources to collaborate on projects of shared interest. Ideally the researchteam is interdisciplinary, composed of members from disciplines such as nursing,

medicine, statistics, immunology, psychology, pharmacology, and economics. Aninterdisciplinary collaborative approach is necessary to achieve a richness of researchinformation for the discipline of nursing (Nies, Hepworth, & Fickens, 2001, p. 411).In successful interdisciplinary team functioning, team members rely upon and trustthe contributions of other members and are likely to generate higher quality data,publications, presentations, and improved health outcomes (Nies et al.).

Research Methodology

There are three general methods for conducting research: quantitative, qualitative,and triangulation. Quantitative research generates hard data that are quantifiednumerically and are often hypothesis driven. It uses deductive logic to systemati-cally and objectively answer questions regarding a topic about which one has someknowledge (Begley, 1996). Qualitative research, on the other hand, is inductiveand exploratory and generally is not hypothesis driven (Bailey, 1997). Qualitativeresearch methods study things in their natural settings, attempting to make sense of,or interpret, phenomena in terms of the meanings people bring to them (Begley,p. 122). One method is not necessarily superior to the other. The choice of whichto use, quantitative or qualitative, depends upon the research questions and how to

most appropriately answer them. The decision may be influenced by constraints of


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Chapter 33. Nursing Research: Current Perspectives and Future Trends

time and resources and the researchers particular skills (Begley). A mixed methodsapproach combines quantitative and qualitative methods and is known as triangula-tion. This method can sometimes provide a fuller and more accurate description of

the phenomenon or population studied than a single approach (Begley). Althoughtriangulation often adds richness and strength to the study, it also increases thecomplexity of the research design, requiring more time and resources. Regardlessof the research method chosen, there are specific steps that generally occur whenconducting research (see Figure 33-1).

Figure 33-1. Steps of Conducting Research

1. Define the clinical problem.

2. Identify the research question(s).

3. Conduct a comprehensive review of the literature.

4. Identify the conceptual framework (not always in qualitative).5. State the purpose, specific aims, and hypotheses (if quantitative).

6. Define the study variables and determine how they will be assessed and measured (i.e.,

selection of instruments, if quantitative, and interview guide, if qualitative).

7. Describe the sample and data collection procedures.

8. Analyze the data.

9. Interpret the results.

10. Disseminate the findings.

When considering what method or design to use, it is important to determine thestate of the scienceof the phenomena of interest. In some areas of nursing science, there

is a lack of substantial rigorous evidence to guide clinical practice. Sometimes, whatevidence is known comes from studies in which the sample was small or restrictedto a single clinical setting or population. If this is the case, replication researchcan strengthen confidence in (or refute) the original findings, or it could increasegeneralizability beyond the original study sample(s) (Gould, 2002). Focusing onsecondary data analysis is another option to consider. With secondary data analysis,the data were collected for another purpose yet are available for analysis to answerother research questions. This approach is often less expensive (and sometimesfree), can be accomplished with less effort than primary data collection, and can beanalyzed in less time (Nicoll & Beyea, 1999).

Defining the Problem and Identifyingthe Research Question(s)

Nurses in clinical practice are well positioned to identify clinical problems worthyof investigation. Many of the best research questions arise through observations andexperiences in day-to-day patient care. Nurses may wonder if there is a better wayto carry out a procedure or if there are innovative approaches to addressing such

patient issues as symptom management. McCorkle (1990) identified four methods


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that a nurse can use to identify a research problem: (a) direct observations, thoughts,and experience, (b) discussion with experienced nurses, (c) reading the literatureand recognizing discrepancies, and (d) evaluating a theory about a substantive field.

Once a problem has been identified, the next step is to carefully analyze it to developthe research question(s) (McCorkle, p. 30).

Perhaps the most important step to performing good research is identifying theresearch question(s). These need to be focused, clear, and explicit. A study with anexquisite design and meticulous data collection procedures can produce meaninglessfindings if the research question is vague and lacks the characteristics of a good clinicalresearch question. These characteristics can be remembered by using the mnemonicFINER: Feasible, Interesting, Novel, Ethical, Relevant (Cummings, Browner, & Hul-ley, 1988). Feasible means that the study is doablethere is an adequate numberof eligible subjects, sufficient resources (including technology), affordable in timeand money, and the project is manageable in scope (Cummings et al.). Interestingmeans that the investigator has a genuine interest and passion to complete this study.Clinical research can be a lengthy and laborious process, and investigators can easilydrift away from completing all the steps of a study if they lose interest in the topic.Novel means that the study has the potential to provide new findings, extend previousfindings, or confirm or refute previous findings. Ethical means that the study can becarried out while maintaining the best interests of the research subjects and that itdoes not pose unacceptable risks or invasion of privacy. Finally, relevant means thatthe study has a strong likelihood for advancing scientific knowledge (i.e., nursingscience), influencing clinical management and health policy, and guiding futureresearch (Cummings et al.).

Nurse-Sensitive Outcomes and Measurement

Nurse-sensitive outcome indicators focus on how patients, and their conditions,are affected by interaction with nursing staff (American Nurses Association, 1995,viii). In order for an outcome to be identified as sensitive to nursing, there needsto be empirical evidence linking nursing input and interventions to the outcome(Doran, 2003). Research has already generated an initial list of outcomes that haveconsistently been found to be sensitive to nursing care provision across the continuumof healthcare settings. These include (a) clinical outcomes related to the managementof symptoms (e.g., pain, nausea and vomiting, fatigue), (b) functional outcomes as-sociated with self-care abilities and physical and psychosocial functioning, (c) safetyoutcomes, which include adverse incidents and complications (e.g., decubitus ulcers,falls), and (d) perceptual outcomes related to satisfaction with nursing care and withthe results of that care (Doran).

Identifying the most appropriate instruments to measure study outcomes can bechallenging and time-consuming. Beck (1999) stated that the choice of a researchinstrument is critical to the success of a study and the confidence that can be placedin the research findings (p. 21). Instruments need to be both valid (measuring what

it is intended to measure) and reliable (measuring the same phenomenon over time).


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There are various types of validity (e.g., content, criterion, construct) and reliability(e.g., inter-rater, test-retest, homogeneity/equivalence) that need to be evaluated andconsidered before using an instrument. Criteria for assessing research instruments

are described in Figure 33-2.

Figure 33-2. Questions for Assessing Research Instruments

I. Assessing the development of the instrument

Did the developer identify a theoretical basis for the instrument?

How was the instrument conceptually defined?

How was the instrument operationally defined?

How were the instrument items generated and refined?

What types of validity did the developer assess? (content, criterion-related, construct)

How were these types of validity assessed?

Were acceptable levels of validity achieved?

What types of reliability did the developer assess? (stability, equivalence, internal consis-tency)

What were the sample characteristics of the subjects involved in the developers psychomet-

ric testing?

II. Assessing the psychometric testing of the instrument by other researchers

What types of samples has the instrument been used with?

What types of reliability were assessed?

What levels of reliability were achieved with these samples?

What types of validity were assessed?

What levels of validity were achieved with these samples?

Note. From Opening Students Eyes. The Process of Selecting a Research Instrument, by C.T.

Beck, 1999, Nurse Educator, 24(3), pp. 2123. Copyright 1999 by Lippincott Williams & Wilkins.Reprinted with permission.

Human Subject Considerations

It is imperative to understand issues related to the protection of human subjects andto obtain necessary training in this area before one institutes her or his first researchproject. An appreciation of historical issues helps to underscore the importance ofhuman subject considerations.

At the conclusion of World War II, the unethical treatment of human subjectswas revealed during the Doctors Trial of the Nuremberg Proceedings. During thistrial, 20 German physicians were accused of planning and enacting the EuthanasiaProgram, the systematic killing of those deemed unworthy of life. In addition, theywere accused of conducting pseudoscientific medical experiments on concentrationcamp prisoners without their consent, many of whom subsequently died. As a result,the Nuremberg Code was established to address the necessity for voluntary consentof human subjects, the importance of due diligence to minimize risks to humansubjects, and the need to allow subjects the right to terminate participation at any

time (Trials of War Criminals, 19491953).


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Unethical treatment of human subjects was not exclusive to World War II and NaziGermany; it also was occurring in the United States. The Tuskegee Syphilis Study, initi-ated by the U.S. Public Health Service, was conducted from 1932 to 1972. The study

was a nontherapeutic study examining the long-term effects of syphilis on AfricanAmerican men from Macon County, Alabama. The participants received incentives ofmedical examinations, meals, a small stipend, and burial insurance. However, none ofthe participants received informed consent outlining the risk related to participation.In addition, curative treatment for the disease, penicillin discovered in 1946, waswithheld from these men. Press reports in the early 1970s caused the study to close,and more than 100 men had died and others suffered needlessly (Jones, 1993). TheTuskegee Syphilis Study triggered congressional hearings and initiated new laws forthe protection of human subjects.

As a result of the Tuskegee Syphilis Study, the National Research Act was signedinto law in 1974. This act established the National Commission for the Protection ofHuman Subjects of Biomedical and Behavioral Research, created regulations for theprotection of human subjects, and established institutional review boards (IRBs) forany research involving human subjects. In addition, the National Commission for theProtection of Human Subjects of Biomedical and Behavioral Research met in 1976 toidentify the basic ethical principles to guide research conduct involving human subjects.The Belmont Report was generated from discussions at this and subsequent meetingsand serves as the gold standard regarding the ethical principles used in human subjectresearch (National Commission for the Protection of Human Subjects of Biomedicaland Behavioral Research, 1979). Its principles are autonomyrespecting people;beneficenceminimizing the risk to human subjects; and justicedistributing the

benefits and burdens of research among human research subjects (National Commis-sion for the Protection of Human Subjects of Biomedical and Behavioral Research).

IRBs are comprised of a minimum of five voluntary members (men and women,professionals, at least one community member, and one nonscientific individual).The mission of the IRB is to protect the rights and welfare of human subjectsinvolved in research studies. Investigators using human subjects or information thatcan be linked to a specific individual must submit an application to their institutionsIRB for approval before initiating a study. Applications for review by the IRB need toinclude the study proposal, a copy of the informed consent, the specific institutionsapplication form, and any additional information that is required by the specificinstitution. Research studies cannot begin until an investigator receives approvalby the IRB. In many institutions, it is not uncommon for this approval process totake at least two months, so this period of time must be factored into the timelinefor completing the study. In addition, funding agencies require that IRB approvalbe received before funding is released; and, in some cases, IRB approval is requiredupon submission of the grant application.

Most institutions in the United States require that all key personnel involvedin research receive training and certification in the protection of human researchsubjects. The National Institutes of Health requires such training for anyonereceiving federal funding for research. The Collaborative IRB Training Initiative(CITI), conceived by the leadership of the Fred Hutchinson Cancer Center and

the University of Miami, now includes more than 1,000 member institutions and


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provides a Web-based comprehensive selection of educational modules that canbe used to satisfy institutional instructional mandates in the protection of humanresearch subjects (CITI, 2000).

Additionally, the researcher also must consider the Health Insurance Portabilityand Accountability Act (HIPAA) when conducting research with human subjects.Enacted in 1996, HIPAA represents the first federal privacy standards to protect themedical records and other healthinformation of individuals both living and deceased(U.S. Department of Health and Human Services, 2001, 2003). Healthcare providersand other healthcare entities,health insurers, and pharmacieshave been requiredto comply with these federal standards since April 14, 2003. The standards addressthe use and disclosure of all individually identifiable health information.

To become more knowledgeable about the regulations surrounding the useof human research subjects and the IRB process, novice researchers may benefitfrom participating in educational programs, contacting members of the IRB tolearn directly from them, or becoming a member of a review board. More detailedinformation is available on the government Web sites regarding the use and protec-tion of human subjects in research (http://www.hhs.gov/ohrp and http://www.hhs.gov/ocr/hipaa/).

Funding

To successfully conduct research, the investigator frequently needs to obtain fund-

ing to support the salaries of those conducting the study and to pay for supplies andother associated research expenses. Determining how and where to obtain fundingcan be a bit daunting at first. The following section describes how researchers canbegin to address the funding issue and provides several resources to begin the searchfor funding.

The fiscal requirements for the study and the investigators level of expertise playa significant role in determining where the researcher should apply for funding.During the early phases of writing the proposal, it is helpful to construct a budgetthat realistically reflects the amount of money it will take to complete the study. Thebudget includes the cost for personnel, space, transportation, and supplies.

The amount of funding awarded is often on a smaller scale to novice research-ers, but it expands with experience and the scope of the research project. Thisdevelopmental process allows the researcher to establish a reputation within his orher discipline while providing assurance to the donors that the investigator is fiscallyresponsible and capable of completing proposed research projects (Malone, 1996).Each granting or funding source will have specific areas of interest, requirements, andguidelines for projects that the agency will fund. The investigator can thus determinewhich funding source is the best match for the proposed research project. This matchwill be based on the scope of the project, the researchers level of expertise, and thecriteria set forth by the granting agency.

There are numerous resources about funding available to researchers, includ-

ing the researchers institution, local and national organizations, foundations,


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industry, and the U.S. government. A detailed review of grant writing opportuni-ties can be found in Chapter 34. A systematic approach will assist the researcherto determine the appropriate funding source. Using worksheets, the researcher

can list requirements of a proposed study (the aims of the study, the total budget,and the proposed length of time it will take to complete the study) and fundingsource criteria (the amount of money granted, type of research supported, andthe type of researchers supported). These worksheets will aid in determining themost appropriate match and the most likely source for successful funding (TheFoundation Center, 2003).

To get started, researchers conducting pilot studies may consider applying forsupport from their own institution, local professional nursing associations, andlocal organizations or foundations. Individuals with more experience may chooseto investigate national foundations, organizations, and government resources forfunding opportunities. There are many books and an abundance of online resourcesavailable to assist in the search for funding (see Table 33-1).

Additional strategies to enhance the chance of obtaining funding for projectsinclude contacting the funding source to discuss a specific proposal and asking ifthe project interests them; joining and becoming active in one or more nursingorganizations; becoming involved in local funding organizations; networking withresearchers and finding an experienced doctoral-prepared researcher to mentor,collaborate, and review your proposal; following the research application direc-tions explicitly; and allowing plenty of time to complete the proposal and submitit on time.

The conduct of research requires knowledge and skills of research processes,

time, patience, institutional support, and financial resources. A brief overviewof the some of the steps in conducting research was provided as well as tips forsuccessful implementation of clinical research studies, including development ofa good research question, considerations for the study of human subjects, andidentification of appropriate funding resources.

Research Utilization

The ultimate goal of clinical nursing research is to improve patient outcomes.Therefore, once a research project is complete, the dissemination and utilization ofthe findings are imperative. Unfortunately, a gap often exists between research andpractice. Despite evidence that the use of research-based nursing practice improvespatient outcomes and decreases the cost of care, consistent implementation ofresearch-based practices has been a challenge in many clinical settings (Fagin, 1982;Goode et al., 2000; Heater, Becker, & Olson, 1988; Thompson, 1998). This sectiondiscusses the evolution of research utilization in nursing practice, common barriersto the implementation of research findings, and strategies that may be useful inincorporating research into the clinical setting.

Interest in transferring research findings into clinical practice became evident in

nursing during the latter part of the 1970s (Horsley, Crane, & Bingle, 1978; Krueger,


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1978; Stetler & Marram, 1976). As Table 33-2 illustrates, a variety of models haveevolved over time to help guide nurses in the use of research findings (Rossworm &Larrabee, 1999; Stetler, 2001; Titler et al., 2001). A common theme among all of the

models is that they use a specific critical-thinking process to access and evaluate studiesfor utility, feasibility, and cost (White, Leske, & Pearcy, 1995). A major component ofthese models is a synthesis of the literature to determine whether a change in practiceis warranted. In some cases, there may be insufficient research available upon whichto base a practice decision. Therefore, one option may be for the clinician to conducta research study to gain the additional evidence needed (see Figure 33-3). On theother hand, if a change in practice is warranted, implementation and subsequentevaluation of the effectiveness of the change are appropriate.

Table 33-2. Overview of Research Utilization Models

Research Utilization Model Proposed Steps of Model

Western Interstate Colleges of HigherEducation in Nursing Regional Pro-gram for Nursing Research Develop-ment (Krueger, 1978)

Gather and critique research studies.Develop a research protocol.Use change theory to implement research in clinical

setting.

Conduct and Utilization of Research inNursing Model (Horsley et al., 1978)

Identify clinical problem.Gather and critique research studies.Develop practice protocol.Test protocol in clinical setting.Decide about usefulness.Extend innovation.

Implement strategies to maintain innovation.

Stetler Model of Research Utilization(Stetler, 2001)

Preparation: Select problem.Validation: Critique and synthesize research studies.Comparative evaluation/decision making: Decide wheth-

er to use findings.Translation/application: Implement research findings.Evaluation: Evaluate and make refinements.

Iowa Model of Evidence-Based Prac-tice to Promote Quality Care (Titler etal., 2001)

Select topic based on priority of the organization.Form a team.Critique and synthesize research.Decide if there is sufficient research to guide practice.Pilot test change in practice.

Decide about adopting the innovation in practice setting.Institute the change.Evaluate outcomes.

Model for Evidence-Based Practice(Rossworm & Larrabee, 1999)

Assess need for change in practice.Link problem with intervention and outcomes.Synthesize best evidence.Design a change in practice.Implement and evaluate change in practice.Integrate and maintain change in practice.

Recent research utilization models have incorporated concepts related to evidence-

based practice. Although research utilization and evidence-based practice are related


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concepts, they are not synonymous. Research utilization is the process by whichresearch findings become incorporated into clinical practice, whereas evidence-basedpractice is the conscientious and judicious use of the best available evidence to guide

decision making about clinical care (Nicoll & Beyea, 2000; Sackett, Rosenberg, Grey,Haynes, & Richardson, 1996). Both processes require first finding the evidence bylocating relevant data sources within the published literature, and then evaluatingwhat evidence is found. Sources of credible information other than primary studiesmay be used as evidence in evidence-based practice. Potential sources of informa-tion may include systematic reviews of randomized trials or observational studies,case reports, consensus of national or local experts, quality improvement data, orclinical observations (Guyatt et al., 2000; Stetler, 2001). Hence, the major differencebetween research utilization and evidence-based practice is that evidence-basedpractice allows for the integration of clinical expertise and patient preferences with

Figure 33-3. Relationship Between Research Utilization and the Conduct ofResearch

Note. From Building a Foundation for Evidence-Based Practice: Experiences in a Tertiary Hospi-

tal, by E.A. Mohide and B. King, 2003, Evidence-Based Nursing, 6, p. 101. Copyright 2003 by the

Dana-Farber Cancer Institute. Reprinted with permission.


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the results of systematic research to guide practice decisions (Nicoll & Beyea, 2000;Omery & Williams, 1999).

Barriers to the Implementation of Research

Many clinical activities are based on tradition, trial and error, and expert opinion,rather than scientific evidence. Some may not be research-based simply because theresearch to support these practices is inconclusive or the practices have never beeninvestigated in a systematic manner. As nursing begins to build a scientific base for clinicalpractice, however, a shift toward incorporating research findings into the practice settingis critical. To facilitate the transfer of knowledge gained through research, it is necessaryto understand the common barriers to implementation of research findings as well asstrategies that may be used to enhance adoption of research utilization activities.

Multiple studies have examined the barriers associated with research utilization,and the findings have been consistent across studies, across time, and among nursesin various roles (Funk, Tornquist, & Champagne, 1995; Retsas, 2000; Sitzia, 2001;Walczak, McGuire, Haisfield, & Beezley, 1994). Common barriers to using researchevidence in practice are lack of organizational support to use research, inaccessibilityof research findings, and attributes of nurses. Lack of organizational support wasidentified as the most important perceived barrier for not using research findings.Nurses identified that not having enough time to read and critique studies and nothaving adequate support to understand study findings impeded their ability to use

research (Retsas; Walczak et al.). In an exploratory study, nurse managers lack ofsupport was associated with a lack of research utilization projects within the clinicalsetting (Caine & Kenrick, 1997). Similarly, another study found that clinical manag-ers could influence research if they used their position and authority to promotethe use of research in practice. Specific behaviors that support the use of researchare providing resources, such as adequate staffing and training opportunities, andhelping nurses overcome opposition by physicians, other healthcare providers, andadministrators to conducting the proposed research (Valente, 2003).

Other common barriers cited by nurses are that research findings are difficultto read, relevant literature is not compiled in one place, and the implications forpractice are not clear. Often, there may be limited research in ones area of interestand even when research is available, the quality of the research (i.e., methodologicinadequacies) may be problematic. Lastly, several studies identified that the attributesof nurses themselves can interfere with research utilization activities. Attitudes ofnurses and educational level have been associated with barriers to use of researchfindings in practice. Not surprisingly, nurses with more positive attitudes towardresearch were more likely to implement research findings (Hatcher & Tranmer,1997). Similarly, a higher level of education was associated with a higher likelihoodof using research-based findings in practice (Brown, 1997). Nurses who had researchcoursework included within their basic nursing education reported fewer barriersto using research as compared to nurses who did not have research within their

curriculum.


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Strategies to Enhance Use of Research

in the Clinical SettingNurse managers efforts to initiate and maintain change within the clinical practice

arena are always complex. The process involves changing the behavior of multiplecaregivers within an organizational system. Therefore, incorporation of researchutilization activities into clinical practice is best accomplished as a broad-based orga-nizational initiative that uses a multifaceted approach (Royle & Blythe, 1998). Goodeand Bulecheck (1992) identified a model for incorporating research utilization as anorganizational process, which included three major building blocks: organizationalcommitment, a research utilization committee to facilitate change, and having aplanned change process so that the change occurs in an orderly fashion.

The first building block is establishing an organizational commitment to developa successful research utilization program. Nurse executives need to create an organi-zational culture that promotes inquiry and stimulates critical examination of clinicalpractices. The commitment to research should be explicitly stated in the organizationsmission statements and reflected in job performance and merit programs. Most im-portantly, administrators must provide financial support for nurses participation inresearch-related activities. In addition, it is essential to provide adequate resources fornurses to gain the skills needed to understand and critique research (see Figure 33-4).Potential resources include having a doctoral-prepared nurse available for consultationand collaboration in research activities, providing educational opportunities for nurses

to enhance their knowledge of research, and providing access to a library or electronicdatabases so that nurses can perform literature searches.

Figure 33-4. Guidelines to Critiquing Research

In critiquing a study, you need to address questions such as the following:

1. Was the problem studied significant to generate or refine knowledge for nursing practice?

2. What are the major strengths of the study?

3. What are the major weaknesses of the study?

4. Was the methodology of the study sound?

5. Are the findings from the study an accurate reflection of reality or credible?

6. What is the significance of the findings for nursing practice?

7. Are the findings consistent with those from previous studies?

8. Can the study, as conducted, be replicated by other researchers?

Answering these questions requires careful examination of the problem, purpose, literature review,

framework, methods, results, and findings of the study.

Note. From Understanding Nursing Research(p. 380), by N. Burns and S.K. Grove, 1999, Phila-

delphia: Saunders. Copyright 1999 by Saunders. Reprinted with permission.

Another important component of a strong research utilization program is theestablishment of a research utilization or evidence-based practice committee (Flem-

ing, Hazelett, & Brunt, 2003). It is best to have members of the committee represent


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a variety of clinical specialties and all types of nursing staff, such as staff nurses,nurse managers, advanced practice nurses (APNs), and a nurse scientist. A variedcommittee structure enables all levels of nurses to be involved in the research process

and influence the adoption of change within the institution. This committee canbe linked to other committees that address policies and procedures to facilitate theproduction of evidence-based clinical practices.

Finally, having a planned change process in place facilitates the adoption andimplementation of research-based practices. Involvement of staff at all levels is critical togather support and educate personnel about how research-based practice can improvethe quality of care. Staff nurses and APNs can be instrumental in identification of patientcare problems that need to be addressed within the organization. These problems can beidentified through quality improvement activities and then directed toward the researchutilization committee. Once the committee has synthesized the literature and made thedetermination of whether to change policy and procedures or to more clearly definethe interventions that are in place, implementation within the system is initiated.

Several authors have advocated that APNs act as change agents for facilitatingresearch utilization within an organization (DeBourgh, 2001; Goode & Bulecheck,1992; McGuire, Walczak, & Krumm, 1994). APNs have skills related to the use ofresearch and implementing change within an organizational setting. Thus, they canwork collaboratively with the clinical and managerial staff and a doctoral-preparednurse to champion research-based changes. An ideal situation is to have a nurse scientistavailable for collaboration and consultation regarding research-related activities withinthe institution. In other situations, fostering collaborative relationships through jointappointments with an academic institution may provide the support needed to develop

and implement a research utilization program. Building collaborative relationshipsamong researchers and clinicians provides the leadership, expertise, and clinical insightneeded to bridge the gap between research and clinical practice.

Figure 33-5 lists other strategies for facilitating research utilization. An importantstrategy for transferring research into clinical practice is to ensure that researchfindings are communicated to clinicians in an efficient and interpretable format(Sitzia, 2000; Valente, 2003). To facilitate the transfer of research-based knowledgeinto a busy clinical setting, Valente (2003) developed research fact sheets on topics

Figure 33-5. Strategies for Promoting Research-Based Practice in the

Clinical Setting Identify a doctorally-prepared nurse for consultation and collaboration in research-related activi-

ties. Encourage advanced practice nurses (e.g., clinical nurse specialists, nurse practitioners) to act

as coaches for establishment of research-related activities. Involve all types of nurses in research-related activities. Establish research-related committees. Establish journal clubs to share reading and critique of research. Link quality improvement and research utilization activities. Implement classes that promote understanding of research utilization skills. Provide clinicians with research findings in an efficient and interpretable format. Create a forum for dialogue between researchers and clinicians. Develop interdisciplinary research teams with members from academic and practice settings.


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that are important for clinical practice. The research-based fact sheets provide a one-page summary of key concepts related to the particular topic, explain the evidencebase supporting those concepts, and list references. The fact sheets are organized

around particular clinical questions such as Why does smoking cessation need tohappen? and then presents the evidence in a concise, eye-catching colorful waythat is distributed by mail to all nursing staff. Other resources for finding out aboutresearch-based practice are listed in Table 33-3.

Table 33-3. Resources for Research-Based Practice

Resource Services Provided Contact Information

Agency for Healthcare

Research and Quality

Access to clinical guidelines based on re-views of research evidence

www.ahrq.gov

American Society ofClinical Oncology

Practice guidelines for patients and clini-cians

Technology assessmentArticles and resources related to practice

guidelines and technology assessment

www.asco.org

Health Information

Research Unit:

Evidence-Based Health

Informatics

Brings together quality-assessed summa-ries of best current studies of diagnosis,course, and management of clinicaldisorders

http://hiru.mcmaster.ca

The Cochrane

Collaboration

Produces international guidelines basedon systematic review of clinical trials

Offers practical advice about how to over-come barriers in implementing an evi-dence-based practice (EBP) program

Spanish language version available

www.cochrane.org

Critiquing research for

use in nursing practice

(Ida Grove, IA: Horn

Video Productions,

1996)

Instructional software for teaching select-ed research utilization skills of readingand critiquing an article

www.fhs.mcmaster.ca/lro

/newacqs_cdrom.htm

Medical Library

Association

Contains a master list of Web resourcesfor EBP

Links to an EBP journal for healthcareavailable

Tutorials on how to effectively search theliterature for information

http://mlanet.org/index

.html

National Comprehen-

sive Cancer Network

Practice guidelinesOncology outcomes databaseEducational conferences

www.nccn.org

Oncology Nursing

Society

EBP resource centerClinical guidelines

www.ons.org

(Continued on next page)


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Table 33-3. Resources for Research-Based Practice (Continued)

Resource Services Provided Contact Information

Virginia Henderson

Sigma Theta Tau Inter-

national Library

Hosts two services to support evidence-based nursing practice:

The Registry of Nursing Research is anelectronic research resource.

The Online Journal of Knowledge Synthe-sis for Nursingpublishes critical reviewsof research literature for the purpose ofguiding research and practice.

www.stti.iupui.edu/library

The WISDOM Centre Provides EBP-related training via the

Internet

www.shef.ac.uk/uni

/projects/wrp/seminar

.html#EBP

Note. Based on information from Cooke & Grant, 2002; Mast, 2000; Sitzia, 2001.

There continues to be a gap between the discovery of clinically relevant researchand the application of that research into practice. Traditionally, emphasis has beenplaced upon the conduct of research. It is equally important, however, to translatethe knowledge gained from research into practice. Thus, it is time for researchutilization activities to assume a greater role in education, practice, and researchactivities. To date, little research has been conducted to identify effective strategiesfor enhancing research utilization in the clinical setting (Omery & Williams,1999).New innovative approaches, such as using a team of interdisciplinary scholars geared

toward developing and testing interventions that assist in the transfer of knowledgefrom research to practice, are needed to advance knowledge in this area (Estabrooks,Floyd, Scott-Findley, OLeary, & Gushta, 2003).

Summary

This chapter has provided an overview of nursing research in the clinical setting,addressing both the conduct and utilization of research. Nurse managers can play akey role in research facilitation by supporting clinical staff and incorporating strategiesto enhance nursing research activities. The conduct and utilization of research areinterdependent processes, yet both are essential to advance the science of nursingpractice. This point is simply summarized in the following excerpt.

In a practice discipline like nursing, scientific knowledge is assumedto contribute to the betterment of nursing care. The mechanism of suchan improvement is through more knowledgeable and better informednurses. The assumption is that nursing research develops nursing sci-ence, which in turn is available to be used to practice nursing in betterways. (Kirkevold, 1997, p. 977)


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The conduct of research requires knowledge and skills of research processes,time, patience, institutional support, and financial resources. A brief overview ofsome of the steps in conducting research was provided as well as tips for successful

implementation of clinical research studies, including development of a goodresearch question, considerations for the study of human subjects, and identificationof appropriate funding resources.

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