Integrating research, evidence-based practice, and quality improvement processes

Geri LoBiondo-Wood and Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following:

• State the significance of research, evidence-based practice, and quality improvement.

• Identify the role of the consumer of nursing research.

• Define evidence-based practice.

• Define quality improvement.

• Discuss evidence-based and quality improvement decision making.

• Explain the difference between quantitative and qualitative research.

• Explain the difference between the types of systematic reviews.

• Identify the importance of critical reading skills for critical appraisal of research.

• Discuss the format and style of research reports/articles.

• Discuss how to use a quantitative evidence hierarchy when critically appraising research studies.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

We invite you to join us on an exciting nursing research adventure that begins as you read the first page of this chapter. The adventure is one of discovery! You will discover that the nursing research literature sparkles with pride, dedication, and excitement about this dimension of professional nursing practice. As you progress through your educational program, you are taught how to ensure quality and safety in practice through acquiring knowledge of the various sciences and health care principles. Another critical component of clinical knowledge is research knowledge as it applies to practicing from an evidence base.

Whether you are a student or a practicing nurse whose goal is to use research as the foundation of your practice, you will discover that nursing research, evidence-based practice, and quality improvement processes position our profession at the cutting edge of change and improvement in patient outcomes. You will also discover the cutting edge “who,” “what,” “where,” “when,” “why,” and “how” of nursing research, and develop a foundation of evidence-based practice knowledge and competencies that will equip you for twenty-first–century clinical practice.

Your nursing research adventure will be filled with new and challenging learning experiences that develop your evidence-based practice skills. Your critical thinking, critical reading, and clinical decision-making skills will expand as you develop clinical questions, search the research literature, evaluate the research evidence found in the literature, and make clinical decisions about applying the “best available evidence” to your practice. For example, you will be encouraged to ask important clinical questions such as: “What makes a telephone education intervention more effective with one group of patients with a diagnosis of congestive heart failure but not another?” “What is the effect of computer learning modules on self-management of diabetes in children?” “What research has been conducted in the area of identifying barriers to breast cancer screening in African-American women?” “What is the quality of studies conducted on telehealth?” “What nursing-delivered smoking cessation interventions are most effective?” This book will help you begin your adventure into evidence-based nursing practice by developing an appreciation of research as the foundation for evidence-based practice and quality improvement.

Nursing research, evidence-based practice, and quality improvement

Nurses are constantly challenged to stay abreast of new information to provide the highest quality of patient care (IOM, 2011). Nurses are challenged to expand their “comfort zone” by offering creative approaches to old and new health problems, as well as designing new and innovative programs that make a difference in the health status of our citizens. This challenge can best be met by integrating rapidly expanding research and evidence-based knowledge about biological, behavioral, and environmental influences on health into the care of patients and their families.

It is important to differentiate between research, evidence-based practice, and quality improvement. Research is the systematic, rigorous, critical investigation that aims to answer questions about nursing phenomena. Researchers follow the steps of the scientific process, which are outlined later in this chapter and discussed in detail in each chapter of this textbook. There are two types of research: quantitative and qualitative. The methods used by nurse researchers are the same methods used by other disciplines; the difference is that nurses study questions relevant to nursing practice. The conduct of research provides knowledge that is reliable and useful for practice. Research studies published in journals, are read and evaluated for use in clinical practice. The findings of studies provide evidence that is evaluated, and its applicability to practice is used to inform clinical decisions.

Evidence-based practice is the collection, evaluation, and integration of valid research evidence, combined with clinical expertise and an understanding of patient and family values and preferences, to inform clinical decision making (Sackett et al., 2000). Research studies are gathered from the literature and assessed so that decisions about application to practice can be made, culminating in nursing practice that is evidence based. For example, to help you understand the importance of evidence-based practice, think about one of the latest reports from the Cochrane Collaboration by Murphy and colleagues (2012), which assessed whether follow-up affects the psychological well being of women following miscarriage (see Appendix E). Based on their search and synthesis of the literature, they put forth several conclusions regarding the implications for practice and further research for nurses working in the field of maternal child care.

Quality improvement (QI) is the systematic use of data to monitor the outcomes of care processes as well as the use of improvement methods to design and test changes in practice for the purpose of continuously improving the quality and safety of health care systems (Cronenwett et al., 2007). While research supports or generates new knowledge, evidence-based practice and QI uses currently available knowledge to improve health care delivery. When you first read about these three processes you will notice that they all have similarities. Each begins with a question. The difference is that in a research study the question is tested with a design appropriate to the question and specific methodology (i.e., sample, instruments, procedures, and data analysis) used to test the research question and contribute to new, generalizable knowledge. In the evidence-based practice and QI processes, a question is used to search the literature for already completed studies in order to bring about improvements in care.

All nurses share a commitment to the advancement of nursing science by conducting research and using research evidence in practice. Scientific investigation promotes accountability, which is one of the hallmarks of the nursing profession and a fundamental concept of the American Nurses Association (ANA) Code for Nurses (ANA, 2004). There is a consensus that the research role of the baccalaureate and master’s graduate calls for the skills of critical appraisal. That is, nurses must be knowledgeable consumers of research, who can evaluate the strengths and weaknesses of research evidence and use existing standards to determine the merit and readiness of research for use in clinical practice (AACN, 2008; QSEN, 2012). Therefore to use research for an evidence-based practice and to practice using the highest quality processes, you do not have to conduct research; however, you do need to understand and appraise the steps of the research process in order to read the research literature critically and use it to inform clinical decisions.

As you venture through this text, you will see the steps of the research, evidence-based practice, and QI processes. The steps are systematic and orderly and relate to the development of evidence-based practice. Understanding the step-by-step process that researchers use will help you develop the assessment skills necessary to judge the soundness of research studies.

Throughout the chapters, terminology pertinent to each step is identified and illustrated with examples from the research literature. Five published research studies are found in the appendices and used as examples to illustrate significant points in each chapter. Judging the study’s strength and quality, as well as its applicability to practice is key. Before you can judge a study, it is important to understand the differences among studies. There are many different study designs that you will see as you read through this text and the appendices. There are standards not only for critiquing the soundness of each step of a study, but also for judging the strength and quality of evidence provided by a study and determining its applicability to practice.

This chapter provides an overview of research study types and appraisal skills. It introduces the overall format of a research article and provides an overview of the subsequent chapters in the book. It also introduces the QI and evidence-based practice processes, a level of evidence hierarchy model, and other tools for helping you evaluate the strength and quality of evidence provided by a study. These topics are designed to help you read research articles more effectively and with greater understanding, so that you can make evidence-based clinical decisions and contribute to quality and cost-effective patient outcomes. The remainder of this book is devoted to helping you develop your evidence-based practice expertise.

Types of research: Qualitative and quantitative

Research is classified into two major categories: qualitative and quantitative. A researcher chooses between these categories based primarily on the question being asked. That is, a researcher may wish to test a cause-and-effect relationship, or to assess if variables are related, or may wish to discover and understand the meaning of an experience or process. A researcher would choose to conduct a qualitative research study if the question to be answered is about understanding the meaning of a human experience such as grief, hope, or loss. The meaning of an experience is based on the view that meaning varies and is subjective. The context of the experience also plays a role in qualitative research. That is, the experience of loss as a result of a miscarriage would be different than the experience from the loss of a parent.

Qualitative research is generally conducted in natural settings and uses data that are words or text rather than numeric to describe the experiences being studied. Qualitative studies are guided by research questions and data are collected from a small number of subjects, allowing an in-depth study of a phenomenon. For example, Seiler and Moss (2012) explored the experiences of nine nurse practitioners involved in providing health care to the homeless (see Appendix C). Although qualitative research is systematic in its method, it uses a subjective approach. Data from qualitative studies help nurses to understand experiences or phenomena that affect patients; these data also assist in generating theories that lead clinicians to develop improved patient care and stimulates further research. Highlights of the general steps of qualitative studies and the journal format for a qualitative article are outlined in Table 1-1. Chapters 5 through 7 provide an in-depth view of qualitative research underpinnings, designs, and methods.

TABLE 1-1

STEPS OF THE RESEARCH PROCESS AND JOURNAL FORMAT: QUALITATIVE RESEARCH

RESEARCH PROCESS STEPS AND/OR FORMAT ISSUES	USUAL LOCATION IN JOURNAL HEADING OR SUBHEADING
Identifying the phenomenon	Abstract and/or in introduction
Research question study purpose	Abstract and/or in beginning or end of introduction
Literature review	Introduction and/or discussion
Design	Abstract and/or in introductory section or under method section entitled “Design” or stated in method section
Sample	Method section labeled “Sample” or “Subjects”
Legal-ethical issues	Data collection or procedures section or in sample section
Data collection procedure	Data collection or procedures section
Data analysis	Methods section under subhead “Data Analysis” or “Data Analysis and Interpretation”
Results	Stated in separate heading: “Results” or “Findings”
Discussion and recommendation	Combined in separate section: “Discussion” or “Discussion and Implications”
References	At end of article

Whereas qualitative research looks for meaning, quantitative research encompasses the study of research questions and/or hypotheses that describe phenomena, test relationships, assess differences, seek to explain cause-and-effect relationships between variables, and test for intervention effectiveness. The numeric data in quantitative studies are summarized and analyzed using statistics. Quantitative research techniques are systematic, and the methodology is controlled. Appendices A, B, and D illustrate examples of different quantitative approaches to answering research questions. Table 1-2 indicates where each step of the research process can usually be located in a quantitative research article, and where it is discussed in this text. Chapters 2, 3, and 8 through 18 describe processes related to quantitative research.

TABLE 1-2

STEPS OF THE RESEARCH PROCESS AND JOURNAL FORMAT: QUANTITATIVE RESEARCH

RESEARCH PROCESS STEPS AND/OR FORMAT ISSUE	USUAL LOCATION IN JOURNAL HEADING OR SUBHEADING	TEXT CHAPTER
Research problem	Abstract and/or in article introduction or separately labeled: “Problem”	2
Purpose	Abstract and/or in introduction, or end of literature review or theoretical framework section, or labeled separately: “Purpose”	2
Literature review	At end of heading “Introduction” but not labeled as such, or labeled as separate heading: “Literature Review,” “Review of the Literature,” or “Related Literature”; or not labeled or variables reviewed appear as headings or subheadings	3
Theoretical framework (TF) and/or conceptual framework (CF)	Combined with “Literature Review” or found in separate section as TF or CF; or each concept used in TF or CF may appear as separate subheading	3, 4
Hypothesis/research questions	Stated or implied near end of introduction, may be labeled or found in separate heading or subheading: “Hypothesis” or “Research Questions”; or reported for first time in “Results”	2
Research design	Stated or implied in abstract or introduction or in “Methods” or “Methodology” section	8, 9, 10
Sample: type and size	“Size” may be stated in abstract, in methods section, or as separate subheading under methods section as “Sample,” “Sample/Subjects,” or “Participants”; “Type” may be implied or stated in any of previous headings described under size	12
Legal-ethical issues	Stated or implied in sections: “Methods,” “Procedures,” “Sample,” or “Subjects”	13
Instruments	Found in sections: “Methods,” “Instruments,” or “Measures”	14
Validity and reliability	Specifically stated or implied in sections: “Methods,” “Instruments,” “Measures,” or “Procedures”	15
Data collection procedure	In methods section under subheading “Procedure” or “Data Collection,” or as separate heading: “Procedure”	14
Data analysis	Under subheading: “Data Analysis”	16
Results	Stated in separate heading: “Results”	16, 17
Discussion of findings and new findings	Combined with results or as separate heading: “Discussion”	17
Implications, limitations, and recommendations	Combined in discussion or as separate major headings	17
References	At end of article	4
Communicating research results	Research articles, poster, and paper presentations	1, 20