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overcome these barriers are discussed later in this chapter. another essential step, once
articles have been obtained, is the critical appraisal of the research.
EVALUATING THE SCIENTIFIC MERIT OF RESEARCH FINDINGS
Research findings that are to serve as a base for clinical practice must be sound. The
developers of the CURN model identified there criteria of determining the validity of
research findings, scientific merit, replication, and risk (haller, Reynold, and Horsley,
!"!#. The evaluation of the scientific merit has been discussed in the previous chapter.
Replication and risk are criteria that are highly relevant to the clinical usefulness of
findings.
Replication may be either an e$act or literal replication follo%ing the details of the
original design, or it may be a construct replication in %hich a similar hypothesis os tested
using a ne% method or design ( &lom'uist, !)* haller and Reynolds, !) #. The latter
helps to establish the validity of the construct across different situation and populations,
increasing the generali+ability of result. Replication provide the substantiating evidemce
that research conclusion are sound ( ettler and -arram, !"! #. n either from the process
is critical for research/based practice because it enhances scientific merit and helps to
prevent both type and type errors ( Haller, et al., !"! #. type errors or fals positive ,are potentially ha+ardous to client, so building practice on the basis of one study %ould be
unethical. The rigor %ith %hich the criterion of replication is applied is to some e$tend
dependent on the risk factor.
Risk can include both the potential ha+ard to the client and the potential costs to the
organi+ation. in a situation %here the risk is small, the findings may be applied more
liberally. f an innovation can be safety and cost effectively implemented and clinically
evaluated, the decision to try it prior to rigorous replication may be appropriate. 0ore$ample , a study of the effect of offering choices to mildly to moderately demented
nursing ho,e resident found that resident made decisions %hen given the opportunity
( 1epler and 2oesner, !!3 #. 1articipant %ith the last cognitive ability. %hose 0olstesin
-ini -ental tatus score %ere less than 3, %here able to make a choice bet%een
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alternatives %ithout an$iety, although they %ere less able to respond to open/ended choices.
The intervention is simple, virtually cost free, and the effect can be closely monitored for a
careful clinical evaluation.
ASSESING THE CLINICAL MERIT OF THE RESEARCH FINDINGS
4nce these three criteria have been considered, relevance to clinical practice can be
evaluated. appraising clinical merit involves e$amination of the follo%ing 5
. The significant of the problem or phenomenon.
3. The relative advantages of the innovation, including cost
6. The fit %ith the setting.
7. The feasibility of evaluating the innovation ( Horsley, et al., !6 #.
n determining %hether to use an innovation in practice. the clical %ill %eigh the
significant of the problem or phenomenon against the relative advantage of the innovation
over current practice. f an innovation relates to a minor or rarely encountered problem or
involves a change in %hich human and finance costs are e$cessive, the costs of changing
current practice may not be %orth%hile. The advantages need to be e$amined in relation to
%ho benefits and ho% much. 8 ne% approach that benefits Client significantly might %ell
be %orthy of adoption, even if costs the nurse in terms of effort or the agency in terms of
dollars. 8dvantages that are visible or tangible are more readily recogni+ed and can be
more convincing than those that are abstract or 9soft:. 0ortunately, better measure of
variables such as 'uality of life are becoming available and their significance is more
%idely recogni+ed. 4bviously the ideal innovation is beneficial in terms of client and
nursing outcomes and costs less than present practice.
8 good 9fit: %ith the organi+ation in is other important consideration ( Horsley, et
al., !6 #. This does not imply that an organi+ation cannot change to the fit an innovation,
but a change that is consistent %ith the philosophy and policies of an agency is more likely
to occur. 0or e$ample, if the philosophy is one of patient autonomy and collaborative
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practice among different health professionals, the instruction of patient/controlled analgesia
(1C8# is likely to fit %ith nurses and physicians beliefs. 1C8 is much more liable to be
effectively implemented in such a setting than one in %hich either nurse or physicians
believe that patient %ill take too much analgesia. 4ther factors in the organi+ation to be
considered, as %ell as philosophy and policy, are the structure, the decision/making
processes, and the personnel.
8ssessing the feasibility of adopting an innovation involves comparing the needed
resources %ith those available or obtainable. t may be possible to modify either the
innovation or the resource %ithin budgetary and other constrainst, but sometimes the
innovation may have to be re;ected for the particular setting despite its clinical merit. 0or
instance a change calling for a different location of bathrooms may not be possible at a
given time, but the research should be considered %hen renovation s are planned. another
aspect of feasibility assessment, is the consideration of the comple$ity, reversibility, and
divisibility of the innovation. 8 ne% techni'ue or strategy that is relatively straightfor%ard
or easily learned may be attainable %ithin limited resource and more readily adopted than
one that is comple$ and involves a ma;or training program for staff. f an innovation can be
introduced temporalily and can be readily reserved if it does not have the desired outcomes,
staff %ill be more %illing to give it a try. imilarly, if it can be introduce gradually, unit byunit or section by section, it %ill be less threatening as a ma;or change.
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TESTING THE FINDINGS IN PRACTICE
8 ne% approach or idea must be tested in practice before is adoption. This
evaluative process should be carried out systematically and rigorously, but the process
different from the conduct of research. ts purpose is to e$amine the feasibility of using
the innovation in a particular setting. t serves as the base for decision making about the
adoption of the innovation.
The CURN model for developing research based practice calls for a clinical trial
comparing baseline measure %ith actual outcomes after the introduction of the innovation
( Horsley, et al., !6 #. The innovation should be carried out %ithin the scientific limits of
the independent variable in the original study, possibly %ith minor ad;ustments relevant to
the setting. 0or e$ample, if a trial of positioning of premature neonates %ere to be
conducted, parameter of gestational age, birth age, %eigh, and diagnosis in the original
studies (0o$ and -olesky, !!=# %ould have to be respected, but the particular type of
mattress used in the neonatal intensive care unit might be different. The outcomes should
include as many as possible of the dependent variables in the research and should be
measured %ith the same instrument %hen clinically feasible. The use of some research
instrument a laboratory, and direct invasive measure may not be possible. Reliable indirect
measure may be used, such as measuring blood pressure %ith a sphygmomanometer rather
than having an intraarterial line.
The trial is planned in detail, including identification of needed resourch and costs.
t is essential to involve the nursing staff and other health professional in early discussion
and to obtain the necessary sanctions and approval. The staff involved in implementing the
innovation %ill need to learn the techni'ue, and separate group independent of those
implementing the innovation, %ill need to learn ho% to use the dependent measure.
The political reality of the agency or institution may have significant effect on the
trial and need to be considered. upose a long/term care institution of a no/restraint policy
based on the evidence of the potential harm of the use of restraint and the effectiveness of
alternative methods of maintaining resident safety resident safety ( -acioro%ski, -unro,
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>ietrick/?allagher, and @anich, !#. f the nursing staff is skeptical about the research
evidence, the nursing department %ill have to consider not only the effect of alternative
interventions, but also the political outcomes of the process. f the test is carried out on a
unit %here the staff are perceived by staff on other units to be more enthusiastic or vigilant,
a successful outcome may not convince staff on other unit. 4n the other hand, there may be
a risk conducting the test on a unit %here the staff are less enthusiastic, as the outcome may
not be positive.
4ther factor to be appraised %hen planning a trial are concurrent phenomena and
surrounding events. 4bvious occurrences such as seasonal change in staffing or client
populations could effect the outcome of a trial, and since health care agencies are rarely
static, fle$ibility and tracking of concurrent events are necessary. 8 trial may have to be
discontinued if there are ma;or change in the environment.
n the revised tetler model ( tetler, !!7 # a different level of testing can be
appropriate. @ith certain innovation a systematic test in individual nurseAs practice can
precede a larger clinical trial, or the change may remain an individual change rather than an
institutional one. 0or instance, based on study by Rosendahl and Ross (!3#, a nurse may
decide to e$amine the purposeful us of specific attending behavior %hen interacting %ith
client. 8 nurse manager might use data from a revie% of nurse turnover literature
(Cavanagh, !!# to test a particular strategy %ith the staff. These individual tests are not
merely a matter of trial and error, because the innovation, the research base and the level of
utili+ation, discussed in the follo%ing section.
@hen a research base is e$pected to form policy and lead to a change in practice,
the care taken in the evaluation phase can have a significant influence on ultimate use.
systematic evaluation of a ne% approach of techni'ue not only affects decision making
regarding the approachAs usefulness, but it also affect attitudes fundamental to successful
change.