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Course Name Nursing Research

Course Code: NUR50105
Faculty: Adnan Yaqoob
Designation: Assistant Professor
Qualification: MScN, BScN
Department: LSN, UOL
EVIDENCE BASED PRACTICE

At the end of this session, the learners will be able to;

• Explain Evidence Based Practice through research.

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WHAT IS EVIDENCE-BASED
PRACTICE?
 The ultimate goal of nursing is an evidence-based
practice that promotes quality, cost-effective outcomes
for patients, families, healthcare providers, and the
healthcare system.
 Evidence-based practice evolves from the integration
of the best research evidence with clinical expertise and
patient needs and values .
 Figure identifies the elements of evidence-based practice
and demonstrates the major contribution of the best
research evidence to the delivery of this practice.

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EBP CONT..

 The best research evidence is the empirical knowledge generated from the synthesis of
quality study findings to address a practice problem.
 A team of expert researchers, healthcare professionals, and sometimes policy makers and
consumers will synthesize the best research evidence to develop standardized guidelines
for clinical practice.
 For example, a team of experts conducted, critically appraised, and synthesized research
related to the chronic health problem of hypertension (HTN) to develop an evidence-based
practice guideline.

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CLINICAL EXPERTISE

 Clinical expertise is the knowledge and skills of the healthcare professional providing
care.
 The clinical expertise of a nurse depends on his or her years of clinical experience, current
knowledge of the research and clinical literature, and educational preparation.
 The stronger the nurse's clinical expertise, the better his or her clinical judgment is in
using the best research evidence in practice
(Craig & Smyth, 2007; Sackett et al., 2000).

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EBP: CLINICAL EXPERTISE
CONT..

 Evidence-based practice also incorporates the needs and values

of the patient
 The patient's need(s) might focus on health promotion, illness
prevention, acute or chronic illness management, or
rehabilitation.
 In addition, patients bring values or unique preferences,
expectations, concerns, and cultural beliefs to the clinical
encounter.
 With evidence-based practice, patients and their families are
encouraged to take an active role in the management of their
health
(Pearson, Field, & Jordan, 2007).
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EBP: CLINICAL EXPERTISE
CONT..

 It is the unique combination of the best research evidence being implemented by an expert
nurse clinician in providing quality, cost-effective care to a patient with specific health
needs and values that results in evidence-based practice
(Brown, 2009; Craig & Smyth, 2007; Sackett et al., 2000).
 Extensive research is needed to develop sound empirical knowledge for synthesis into the
best research evidence needed for practice.
 This research evidence might be synthesized to develop guidelines, standards, protocols,
or policies to direct the implementation of a variety of nursing interventions.

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EBP: CLINICAL EXPERTISE
CONT..

 For example, a national guideline was developed for the management of hypertension and
is entitled “The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure:
 The JNC 7 Report.” Experts synthesized the relevant studies and published their findings
in the Journal of the American Medical Association (Chobanian et al., 2003).
 The complete guideline for the management of high blood pressure is available online at
www.nhlbi.nih.gov/guidelines/hypertension.

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EBP: CLINICAL EXPERTISE
CONT..

 This guideline provides direction for management of high blood pressure by registered
nurses; advanced practice nurses (nurse practitioners, clinical nurse specialists, nurse
midwives, and nurse anesthetists); and physicians.
 For example, the guideline includes the classification of blood pressure (normal,
prehypertension, hypertension stage 1, and hypertension stage 2) and the major
cardiovascular disease (CVD) risk factors.
 You need to use this evidence-based guideline in monitoring your patients’ blood pressures
(BPs) and educating them about life style modifications to improve their BP and CVD risk
factors with high BP

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Table adapted from: National Heart, Lung, and Blood Institute. (2003). The seventh report of the Joint National Committee on prevention, detection, evaluation, and
treatment of high blood pressure: The JNC 7 report. Bethesda, MD: National Institutes of Health. Retrieved June 6, 2009, from
www.nhlbi.nih.gov/guidelines/hypertension.

Classification of Blood Pressure (BP) Nursing Interventions

BP Category Sys BP, mm Hg Dia BP, mm Hg Life style CVD Risk Factors
(*) (*) Modification (‡) Education (§)
Normal <120 and <80 Encourage Yes
Prehypertension 120-139 or 80-89 Yes Yes
Stage 1 hypertension 140-159 or 90-99 Yes Yes
Stage 2 hypertension ≥160 or ≥100 Yes Yes
(*) Treatment is determined by the highest BP category, either systolic or diastolic.
(†) Treat patients with chronic kidney disease or diabetes to BP goal of less than 130/80 mm Hg
(‡) Life Style Modification: Balanced diet, exercise program, normal weight, and nonsmoker
(§) CVD risk factors: Hypertension; obesity (body mass index ≥30 kg/m 2); dyslipidemia; diabetes
mellitus; cigarette smoking; physical inactivity; microalbuminuria, estimated glomerular filtration rate
<60 mL/min; age (>55 for men, >65 for women); and family history of premature CVD (men age <55,
women age <65).

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LEVELS OF EVIDENCE

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PURPOSES OF RESEARCH

Purposes of Research in Implementing an Evidence-Based Nursing Practice:

 Through nursing research, empirical knowledge can be developed to improve nursing
care, patient outcomes, and the healthcare delivery system.
 For example, nurses need a solid research base to implement and document the
effectiveness of selected nursing interventions in treating particular patient problems and
promoting positive patient and family outcomes.
 In addition, nurses need to use research findings to determine the best way to deliver
healthcare services to ensure that the greatest number of people receive quality care.
 Accomplishing these goals will require you to critically appraise, synthesize, and apply
research evidence that provides description, explanation, prediction, and control of
phenomena in your clinical practice.

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DESCRIPTION
 Description involves identifying and understanding the nature of nursing phenomena and, sometimes, the relationships
among them
(Chinn & Kramer, 2008).
Through research, nurses are able to:
1. Describe what exists in nursing practice,
2. Discover new information,
3. (promote understanding of situations, and
4. Classify information for use in the discipline.

Some examples of clinically important research evidence that is developed from research focused on description include:
 Identification of the responses of individuals to a variety of health conditions
 Identification of the cluster of symptoms for a particular disease
 Description of the health promotion and illness prevention strategies used by a variety of populations
 Determination of the incidence of a disease locally, nationally, and internationally. (This type of research was a priority in
2009 with the incidence of H1NI [swine] flu.)

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DESCRIPTION: EXAMPLE

 Ryan et al. (2007) conducted a study to determine the cluster of symptoms that represent an acute
myocardial infarction (AMI).
 These researchers synthesized their findings as follows:
 Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters
identified in this study included all of the symptoms that are included typically as symptoms of AMI
(chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness).
 These AMI symptom clusters must be communicated clearly to the public in a way that will assist
them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior.

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DESCRIPTION: EXAMPLE
CONT..

 Symptom clusters for AMI must also be communicated to the professional community in a
way that will facilitate assessment and rapid intervention for AMI.
(Ryan et al., 2007, p. 72.)
 The findings from this study provide nurses’ insights into the varying symptom clusters of
patients experiencing an AMI.
 You can use this research evidence to promote early recognition of the signs and symptoms
of AMI in your patients so they might be referred promptly for treatment.
 This type of research focused on description is essential groundwork for studies that will
provide explanation, prediction, and control of nursing phenomena in practice.

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EXPLANATION

Explanation clarifies the relationships among phenomena and identifies the reasons why
certain events occur.
 Research focused on explanation provides the following types of evidence essential for
practice.
 Determination of the assessment data (both subjective data from the health history and
objective data from physical exam) that need to be gathered to address a patient's
health need
 The link of assessment data to a diagnosis
 The link of causative risk factors or etiologies to illness, morbidity, and mortality
 Determination of the relationships among health risks, health behaviors, and health
status

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EXPLANATION
CONT..
 King, Gerich, Guzick, King, and McDermott (2009) studied women with a history of gestational diabetes
mellitus (hGDM) to determine if this condition was related to risk factors for coronary heart disease (CHD) and
diabetes mellitus (DM).
 The CHD risk factors examined included elevated triglycerides and low density lipoprotein cholesterol (LDL-c)
and decreased high density lipoprotein cholesterol (HDL-c). These researchers found that the women with
hGDM had significantly lower HDL-c ( p = 0.02) and significantly higher triglycerides ( p = 0.001) than a
control group without hGDM.
 “The combination of high triglycerides and low HDL-c occurred in 25% of the hGDM cases versus 0% of
controls, p = 0.01. Two-hour post-load glucose indicated that 45% of hGDM cases were pre-diabetic versus
20% of controls, p = 0.05”
(King et al., 2009, p. 299)
 However, the women with hGDM had significantly lower LDL-c versus the controls ( p = 0.01). The
researchers identified the following conclusions, recommendations for future research, and implications for
practice.

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EXPLANATION: SUMMARY
CONT..
 In summary, our data suggest that women with a distant hGDM are at risk for developing diabetes
and may be at increased risk for CHD. … Future research focused on long-term follow-up in
cohorts of women with hGDM could help to further clarify the relationship between the risk for
diabetes and the risk for CHD.
 Since GDM occurs in relatively young women, long-term risk assessment and follow-up of
women with an hGDM may provide an excellent opportunity to enact primary prevention
strategies to reduce the risk for diabetes and CHD in the long run (King et al., 2009, p. 304).
 Explanatory research such as this promotes an increased understanding of the relationships
among the variables hGDM, CHD, and DM.
 Nurses can use this knowledge in educating their patients with GDM about their potential health
risks. In addition, relationships identified through explanatory research provide the basis for
conducting research focused on predicting and controlling phenomena in practice.

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PREDICTION

 Through prediction, one can estimate the probability of a specific outcome in a given
situation (Chinn & Kramer, 2008).
 However, predicting an outcome does not necessarily enable one to modify or control the
outcome.
 It is through prediction that the risk of illness is identified and linked to possible screening
methods to identify the illness.
 Knowledge generated from research focused on prediction is critical for evidence-based
practice and includes the following:
 Prediction of the risk for a disease in different populations
 Prediction of behaviors that promote health and prevent illness
 Prediction of the health care required based on a patient's need and values

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PREDICTION
CONT..

 For example, Scheetz, Zhang, and Kolassa (2007, p. 399) examined “crash scene variables
to predict the need for trauma center care in older persons.”
 The researchers analyzed 26 crash scene variables and developed triage decision rules for
managing persons with severe and moderate injuries.
 Further research is needed to determine whether the triage decision rules improve the
health outcomes of the elderly following trauma.
 Predictive studies isolate independent variables that require additional research to ensure
that their manipulation or control results in successful outcomes for patients, healthcare
professionals, and healthcare agencies
(Creswell, 2009; Kerlinger & Lee, 2000).

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CONTROL

 If one can predict the outcome of a situation, the next step is to control or manipulate the
situation to produce the desired outcome.
 In health care, control is the ability to write a prescription to produce the desired results.
Using the best research evidence, nurses could prescribe specific interventions to meet the
needs of patients and their families
(Brown, 2009; Craig & Smyth, 2007).
 Extensive research in the following areas can provide empirical evidence that enables nurses
to deliver care that will increase the control over the outcomes desired for practice.
 Testing interventions to improve the health status of individuals, families, and communities
 Testing interventions to improve healthcare delivery

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CONTROL
CONT..

 Extensive research has been conducted in the area of safe administration of IM injections.
 This research has been critically appraised, synthesized, and developed into an evidence-
based guideline to direct the administration of medications by an IM route to infants,
children, and adults in a variety of practice settings
(Beyea & Nicoll, 1995; Nicoll & Hesby, 2002; Wynaden et al., 2006).
 The guideline for IM injections is based on the best research evidence and identifies the
appropriate needle size and length to use for administering different types of medications;
the safest injection site (ventrogluteal site) for many medications; and the best injection
technique to deliver a medication, minimize patient discomfort, and prevent physical
damage
(Beyea & Nicoll, 1995; Greenway, 2004; Nicoll & Hesby, 2002; Rodger & King, 2000).

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CONTROL
CONT..

 The outcomes from using this evidence-based guideline in practice include:

 Adequate administration of medication to promote patient health
 Minimal patient discomfort
 No physical damage to the patient, all of which promote high-quality, cost-effective
care
 Using this guideline in your practice promotes the delivery of evidence-based nursing care

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NURSING'S PARTICIPATION IN RESEARCH :
PAST TO PRESENT

 Nursing's participation in research has changed drastically over the last 160 years and
holds great promise for the twenty-firs century. Initially, nursing research evolved slowly,
from the investigations of Nightingale in the nineteenth century to the studies of nursing
education in the 1930s and 1940s and the research of nurses and nursing roles in the 1950s
and 1960s.
 In the 1970 through the 1990s, an increasing number of nursing studies focused on clinical
problems and produced findings that had a direct impact on practice.
 Clinical research continues to be a major focus for the twenty-first century, with the goal
of developing an evidence-based practice for nursing. Reviewing the history of nursing
research enables you to identify the accomplishments and understand the need for further
research to determine the best research evidence for use in practice.

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NURSING'S PARTICIPATION IN RESEARCH:
PAST TO PRESENT

 Nightingale's (1859) initial research focused on the importance of a healthy environment in

promoting patients’ physical and mental well-being.
 She studied aspects of the environment such as ventilation, cleanliness, purity of water, and diet to
determine the influence on patients’ health, which continue to be important areas of study today
(Herbert, 1981).
 However, Nightingale is most noted for her collection and analysis of soldier morbidity and
mortality data during the Crimean War.

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NURSING'S PARTICIPATION IN RESEARCH:
PAST TO PRESENT

 This research enabled her to change the attitudes of the military and society toward the
care of the sick.
 The military began to view the sick as having the right to adequate food, suitable quarters,
and appropriate medical treatment.
 These interventions drastically reduced the mortality rate from 43% to 2% in the Crimean
War (Cook, 1913).
 Nightingale also used research knowledge to make significant changes in society, such as
testing public water, improving sanitation, preventing starvation, and decreasing morbidity
and mortality (Palmer, 1977).

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NURSING RESEARCH:
1900 S THROUGH 1970 S
 The American Journal of Nursing was first published in 1900, and late in the 1920s and
1930s, case studies began appearing in this journal.
 A case study involves an in-depth analysis and a systematic description of one patient or a
group of similar patients to promote understanding of healthcare interventions.
 Case studies are one example of the practice-related research that has been conducted in
nursing over the last century.
 In the 1960s an increasing number of clinical studies focused on quality care and the
development of criteria to measure patient outcomes.
 Intensive care units were developed, which promoted the investigation of nursing
interventions, staffing patterns, and cost-effectiveness of care
(Gortner & Nahm, 1977)

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NURSING RESEARCH:
1900 S THROUGH 1970 S

 An additional research journal, the International Journal of Nursing Studies, was published in
1963. In 1965 the ANA sponsored the first of a series of nursing research conferences to promote
the communication of research findings and the use of these findings in clinical practice.
 In the late 1960s and 1970s, nurses were involved in the development of models, conceptual
frameworks, and theories to guide nursing practice.
 The nursing theorists’ work provided direction for future nursing research. In 1978 Chinn became
the editor of a new journal Advances in Nursing Science, which included nursing theorists’ work
and related research.
 Another event influencing research during the 1970s was the establishment of the ANA
Commission on Nursing Research in 1970. In 1972 the commission established the Council of
Nurse Researchers to advance research activities, provide an exchange of ideas, and recognize
excellence in research.

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NURSING RESEARCH:
1980 S AND 1990 S

 The conduct of clinical research was the focus of the 1980s, and clinical journals began
publishing more studies.
 One new re search journal was published in 1987, Scholarly Inquiry for Nursing Practice,
and two in 1988, Applied Nursing Research and Nursing Science Quarterly.
 Although the body of empirical knowledge generated through clinical research increased
rapidly in the 1980s, little of this knowledge was used in practice.
 During 1982 and 1983 the materials from a federally funded project, Conduct and
Utilization of Research in Nursing (CURN), were published to facilitate the use of
research to improve nursing practice (Horsley, Crane, Crabtree, & Wood, 1983).

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NURSING RESEARCH:
1980 S AND 1990 S

 Outcomes research emerged as an important methodology for documenting the

effectiveness of healthcare services in the 1980s and 1990s.
 This effectiveness research evolved from the quality assessment and quality assurance
functions that originated with the professional standards review organizations (the PSROs)
in 1972.
 William Roper, director of the Health Care Finance Administration (HCFA), promoted
outcomes research during the 1980s to determine quality and cost-effectiveness of patient
care.
 In 1989 the Agency for Health Care Policy and Research (AHCPR) was established to
facilitate the conduct of outcomes research (Rettig, 1991).

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NURSING RESEARCH:
TWENTY-FIRST CENTURY

 The vision for nursing in the twenty-first century is the development of a scientific
knowledge base that enables nurses to implement an evidence-based practice (Brown,
2009; Melnyk & Fineout-Overholt, 2005).
 This vision is consistent with the mission of National Institute of Nursing Research
(NINR), which is to support clinical and basic research to establish a scientific basis for
the care of individuals across the lifespan—from management of patients during illness
and recovery to the reduction of risks for disease and disability, the promotion of healthy
lifestyles, promoting quality of life in those with chronic illness, and care for the
individuals at the end of life (NINR, 2009).

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NURSING RESEARCH:
TWENTY-FIRST CENTURY
The American Association of Colleges of Nursing (AACN), developed in 1932 to promote the
quality of nursing education, revised their position statement of nursing research in 2006 and
provided future direction for the discipline in moving toward evidence based practice.
To ensure an effective research enterprise in nursing, the discipline must:
(1) Create a research culture;
(2) Provide high-quality educational programs (baccalaureate, master's, practice-focused
doctorate, research-focused doctorate, and postdoctorate) to prepare a workforce of nurse
scientists;
(3) Develop a sound research infrastructure; and
(4) Obtain sufficient funding for essential research (AACN, 2006).

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REFERENCE

Burns, N., & Grove, S. K. (2010). Understanding Nursing Research: Building an Evidence-

Based Practice. St. Louis, MO: Elsevier Health Sciences.

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