Essentials of Nursing Research & Biostatistics Bijayalaskhmi Dash
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Introduction to Nursing ResearchCHAPTER 1

Meaning of Research
Research is diligent, systematic inquiry or investigation to validate and refine existing knowledge and generate new knowledge with some specific goals. It is a systematic process which focused on uncovering new knowledge to help understand phenomena, answer questions, or address problems. The main goal of research is the gathering and interpreting of information to answer questions. A number of different definitions for research exist however common to all of them is an agreement that research is systematic, disciplined and focused on gathering information to understand a phenomena, answer questions or solve research problems. The systematic nature of the research process means that research is undertaken in a methodological fashion using a rigorous approach to collect information (data) about a phenomena or research problem and to analyze and interpret that information in order to begin to answer questions or solve problems since research is directed at ultimately helping us to answer a question or address a problem. In general research means, the research process which deals with the ways and strategies used by researchers to understand the world around us. In the broadest sense of the word, the definition of research includes any gathering of data, information and facts for the advancement of knowledge.
The strict definition of scientific research is performing a methodical study in order to prove a hypothesis or answer a specific question. Finding a definitive answer is the central goal of any experimental process.
Definitions of Research
‘A careful enquiry or examination in seeking facts or principles, a diligent investigation to ascertain something.’
—Clifferd Woody
‘A honest, exhaustive, intelligent searching for facts and their meaning or implications with inference to a given problem. It is a process of arriving at dependable solutions and systematic collection and analysis and interpretation of data’.
—PM Cook
‘Systematic search for answers to questions about facts and the relationship between and among the facts.’
  • Research is a systematic attempt to provide answers to questions (Tuckman, 1999).
  • Research may be defined as the systematic and objective analysis and recording of controlled observations that may lead to the development of generalizations, principles, or theories, resulting in prediction and possible control of events (Best and Kahn, 1998).2
  • Research is a systematic way of asking questions, a systematic method of inquiry (Drew, Hardman and Hart, 1996).
Characteristics of Research
  • Research must be systematic and follow a series of steps and a rigid standard protocol.
  • The rules for research are broadly similar but may vary slightly between the different fields of science.
  • Scientific research must be organized and undergo planning, including performing literature reviews of past research and evaluating what questions need to be answered.
  • The scientific definition of research generally states that a variable must be manipulated, although case studies and purely observational science do not always comply with this norm.
  • Research must be directed towards solution of problem.
  • They requires clear articulation of a goal.
  • Researches should be logical and systematic in nature.
  • Should be relevant to what is required.
  • Should be empirical and replicable in nature.
  • Procedure should be reproducible in nature.
  • Controlled movement of the research procedure.
  • Often divides main problem into sub problems.
  • Guided by specific problem, question, or hypothesis.
  • Accepts certain critical assumptions.
  • Requires collection and interpretation of data.
  • Cyclical (helical) in nature.
  • It is carried out to find out cause and effect relationship.
  • Researches emphasizes on development of generalizations, principles of theories and help in predicting future occurrences.
  • Applying all possible tests to validate the procedure and tries to eliminate bias.
  • Should be carried out by based upon observable experiences or empirical evidences to establish knowledge and concepts through verifications.
  • It demands accurate observation and description.
  • Helps in answering various pertinent questions.
  • Involves gathering information from primary or firsthand information sources using existing data for a new purpose.
General Aims of Research
Observe and Describe
This aim is especially applicable for descriptive research where the researcher observe and describe the gather information that illuminates relationships, patterns and links between variables. An example would be an investigation of the link between students’ study skills and course drop-out rates.
Prediction in research fulfils one of the basic desires of humanity, to discern the future and know what fate holds. Such foresight used to involve studying the stars or looking at the 3entrails of animals. To a certain extent, most scientists regularly use prediction in research as a fundamental of the scientific method, when they generate a hypothesis and predict what will happen. For example, some environments were unhealthier than others, especially in a hot climate where gangrene was a problem. The purpose of this type of research is to develop a model that predicts the likely course of events given particular intervening variables or circumstances.
The main aim of research is to explain the phenomena. Exploratory type of research investigates an area or issue on which little previous work has been carried out. In an organisational setting it may be used to discover whether or not a problem exists. Explanatory type of research also aims to show why relationships, patterns and links occur. For example, how could study skills support improve student retention? And does this depend on other factors such as different types of support available.
Sometimes research is implemented strategically, where researchers take account of current situations and speculate as to their future implications. For example, the introduction of a specific government policy might raise implications for practitioners involved in its implementation. Research of this nature might speculate as to what these implications might be and develop a programme of inquiry that can inform future responses to these issues.
To evaluate the impact of something, e.g. a new policy, event, law, treatment regime or the introduction of a new system.
A human child has to meet and solve his problems. The problems which present themselves in his physical surroundings, his intellectual association and in his social contacts can grow in number and complexity as the child grows older an older. His success in life is in large measure determined by individual's capacity and competence to solve them. Problem exists for him at every step; his growth, development and living lie in their solution. In school, the child is to be trained in the art and craft of problem-solution.
The problem-solving method aims at presenting the knowledge to be learned in the form of a problem. It beings with a problematic solution and consists of continues, meaningful, well-integrated activity. The problems are set to the students in a natural way and it is ensure that the students are genuinely interested to solve them. Problem-solving approach is considered to be specific to a situation and individuals involved in a particular problem at a particular time. Decision-making and problem-solving processes are interdependent. There are also intangible its effect only can be felt. So, analytical and critical thinking and decision-making is a thinking process that requires skills in rational and logical thinking.
Definitions of Problem-solving Method
According to Yoakum and Simpson: ‘A problem occurs in a situation in which a felt-difficulty to act is realized. It is a difficulty that is clearly present and recognized by the thinker. It may be purely mental difficulty or it may be physical and involve the manipulation of data. The distinguishing thinks about a problem however is that it impresses the individual who meets it as needing a solution. He recognizes it as a challenge.’4
LA Averill has said, ‘the only worthwhile life is a life which contains its problem; to live without any longings and ambitions is to live only half-way.’
Purposes of Problem-solving
  • Train students in the act of reasoning
  • Give practical knowledge
  • Discover new knowledge
  • Solve a puzzling problem
  • Improve knowledge of the students
  • Overcome inferences in the attainment of objective.
Problem-solving Process
The problem-solving process consists of a series of steps that are followed depending on the type of problem to be solved. These are:
  • Problem definition or identification of problem
  • Problem analysis
  • Generating possible solution
  • Analyzing the solution
  • Selecting the best solution
  • Implementing the solution
  • Evaluation and revision.
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Problem Definition
The normal process for solving a problem initiating involves defining the problem which is to be solved. In this first stage, there is a need to write down what exactly the problem entails, 5which helps to identify the real problem that is under study and needs an immediate solution. This is considered as the most essential steps of the problem-solving, because by defining the problem it helps in proper perceiving which helps in analyzing the problems. Without this next steps cannot be executed. Eminent author of the subject are of this opinion that a problem well-defined is half solved. Sufficient time should be spent on defining the problem as it is not always easy to define the problem and to see the fundamental thing that is causing difficulty and that needs correction. Right answer to the right question can be possible by having only clear definition.
Problem Analysis
After perceiving the problem the next step is to analyze how the problem affects the researcher and his or her current situation and the other people involved in this situation. In addition, the gravity of the problem and all the factors which are contributing to the problem are determined. Furthermore, the analysis helps in understanding the source of the problem and how it affects the current development and researcher's environment.
Generating Possible Solution
When the real problem is discovered, its contributing factors should be investigated. At this stage, focus must be on identifying and generating all possible solutions for a problem. Each potential idea for solution of a problem must be considered without discarding it through value judgment, however, each idea should be treated as a new idea in its own right and worthy of consideration.
Analysis the Solution
In this section of the problem-solving process, various factors about each of the potential solutions are investigated where in the entire positive and negative aspects of each solution against the problem are analyzed. The feasibility of each solution are also analyzed.
Selecting the Best Solution
At this stage, an attempt is made to compare the available solutions. The available solutions can not only compared in terms solving the problem but also in terms of feasibility, resources needed and time taken. The eventually the best solution is selected based on careful judgment, which is supposed to solve the problem swiftly and smoothly. The alternatives also evaluated on three matters those are:
  1. Suitability: Will it solve the problem partially, permanently or temporarily?
  2. Feasibility: Will it work and how much will it cost/can we afford it?
  3. Acceptability: It is acceptance to know involved and responsible.
The decision maker should list benefits, cost and risks associated with each alternatives. Each alternative and improvement, its benefits any cost of action be weighed then the best solution should be chosen.
Implementing the Solution
Implementing the solution is the step of the problem-solving process which is putting plan into action. Here we practically solve the problem by implementing the selected solution.
Evaluation and Revision
This is the final stage of the problem-solving process where after implementation of the most potential solution and evaluation is made to judge the effectiveness of the solution in resolving 6the problem. This stage also helps to redefine the problem and revise the problem-solving process in case the initial solution fails to manage the problem effectively.
Advantages of Problem-solving
  • Improves problem-solving abilities
  • Student cantered rather than teacher centered
  • Collaboration among learners
  • Constructivism of learners with guidance of teachers
  • Allows for multiple intelligence
  • Extended time frames
  • Deeper understanding of knowledge
  • Multi-disciplinary.
Scientific Method
The scientific method is a logical and rational order of steps by which scientists come to conclusions about the world around them. The scientific method helps to organize thoughts and procedures so that scientists can be confident in the answers they find. Scientists use observations, hypotheses, and deductions to make these conclusions, various possibilities using the scientific method is to eventually come to an answer to the original question.
The scientific method, as defined by various scientists and philosophers, has a fairly rigorous structure that should be followed.
Characteristics of Scientific Method
  • Empirical: Science is based purely around observation and measurement, and the vast majority of research involves some type of practical experimentation.
  • The scientific method relies upon data: The scientific method uses some type of measurement to analyze results, feeding these findings back into theories of what we know about the world. There are two major ways of obtaining data, through measurement and observation. These are generally referred to as quantitative and qualitative measurements.
  • The scientific method is intellectual and visionary: Science requires vision, and the ability to observe the implications of results. Collecting data is part of the process, and it also needs to be analyzed and interpreted.
    However, the visionary part of science lies in relating the findings back into the real world. Even pure sciences, which are studied for their own sake rather than any practical application, are visionary and have wider goals.
  • Science uses experiments to test predictions: This process of induction and generalization allows scientists to make predictions about how they think that something should behave, and design an experiment to test it.
    This experiment does not always mean setting up rows of test tubes in the lab or designing surveys. It can also mean taking measurements and observing the natural world.
  • Systematic and methodical: Scientists are very conservative in how they approach results and they are naturally very sceptical. It takes more than one experiment to change the way that they think, however loud the headlines, and any results must be retested and repeated until a solid body of evidence is built up. This process ensures that researchers do not make mistakes or purposefully manipulate evidence. Scientific method always follows order and it is a systematic processes.7
  • Scientists’ attempt to control external factors that are not under direct investigation: The scientist in the laboratory or in the field should control external factors influencing investigation. For example when the scientist prepare some analgesic medicine and observe their effectiveness she has to control other pain relief method like avoidance of yoga.
  • Findings of scientific methods can be generalized: The conclusion drawn from any scientific method can be generalized for general population which means that they can be used in situation other than the one under study. Theory can drawn from it. Sometimes based on the findings we can suggest recommendations what can be done further.
  • Scientific methods are based on assumptions or hypothesis: Before starting any investigation the researcher adopt some assumption for his/her research which forms the basis for the research and devolve some hypothesis which indicate the tentative result for the study. The two things are very essential without which study cannot be started.
Difference between Problem-solving and Research
S. no.
Overcoming felt difficulties
Based on principles and facts and theories
Depends on individuals own experiences on problem
Depends on individuals own experiences on problem
Counselee consults counselor
Researcher consults experts
Short time
Long waiting
Information gathering
Review of literature
No theory
Solution suggested
Outcome considered
Solution chosen
Data collected and analyzed
Solution implemented and evaluated
Findings interpreted and conclusions drawn
Types of Research
Basic vs Applied
  • Basic or ‘pure’ research: Basic or ‘pure’ research is also called as the fundamental or the theoretical research. It is basic and original. Here pursuit of knowledge or finding truth can lead to the discovery of a new theory. Basic or ‘pure’ research can result in the development or refinement of a theory that already exists. It can helps in getting knowledge without thinking formally of implementing it in practice based on the honesty, love and integrity of the researcher for discovering the truth. Often uses laboratory setting findings may not be directly useful in practice may be used later in development of treatment/drug/theory.
  • Applied research: Applied or ‘practical’ research based on the concept of the pure research. It directed toward generating knowledge that can be used in the near future and often conducted to seek solutions to existing problems (Burns and Grove, 2005; Kerlinger, 1986; Polit and Beck, 2004) generally applied research is problem oriented. Conducted in 8actual practice conditions which helps in finding results or solutions for real life problems and make decisions, predict/control outcomes. It also provides evidence of usefulness to society, evaluate interventions helps in testing empirical content of a theory and helps in testing the validity of a theory but under some condition. Knowledge intended to directly influence clinical practice. The research findings contribute to some modifications of present practices, i.e. patient care, education, administration.
Qualitative vs Quantitative
  • Qualitative research: Qualitative research concern with qualitative phenomenon which focus on the whole of the human experience and the meaning given by the individuals experiencing it. It gives a broader understanding and deeper insight into the complex human behavior qualitative research is local, concrete. Observations and findings depend on understanding contexts and the meanings held by the people in those contexts and the meanings of the things in those contexts. Qualitative research generally possesses loosely structured research process analysis is thematic and research process is inductive.
  • Quantitative research: Quantitative research is based the measurement of quantity. It is formal, objective, systematic process to describe, test the relationships and examine the cause-effect interaction among variables. It is applicable to phenomenon that can expressed in terms of quantity. Quantitative research generally possesses highly structured research process statistical analysis research process is deductive.
Experimental vs Nonexperimental
  • Experimental: Experimental research design concerned with testing a hypothesis and finding the cause-effect relationship between variables in which the researcher makes changes by independent variables and studies its effect on dependent variables under controlled conditions. It may be conducted in laboratory setting or at actual field experiment. There are three criteria in experimental design which are:
    • Manipulation: Researcher manipulates some of the subjects.
    • Control: Researcher introduces one/more control over the experimental situation including the use of control group.
    • Randomization: Researcher assigns subjects to a control/experimental group on a random basis.
  • Nonexperimental: Researcher collects data and describes a phenomena as they exist without any intervention. It describes or looks at relationships(s) or correlation between variables. The three characteristics of experimental research such as manipulation, randomization and control are absent here.
Descriptive vs Analytical
  • Descriptive research: It is used to gain more information about characteristics with in a particular field of study. It is a simplest form of research which helps in identifying various features of a problem. It is generally restricted to the problems that are describable and not arguable and the problems in which valid standards can be developed for standards. Existing theories can be easily put under test by empirical observations through this research and underlines factors that may lead to experimental research. It is not directed by hypothesis.
  • Analytical research: Analytical research is a specific type of research that involves critical thinking skills and the evaluation of facts and information relating to the research being conducted. In analytical research researcher uses the facts, information already available. 9From analytical research, a person finds out critical details to add new ideas to the material being produced within analytical research articles, data and other important facts that pertain to a project is compiled, after the information is collected and evaluated, the sources are used to prove a hypothesis or support an idea. Analysis is made to study the relationship between disease and other condition with different variables.
Retrospective vs Prospective
Retrospective means observe the past, retrospective studies examines the data already collected in the past. Here the outcomes have all occurred before the starting of the investigation. This type of study is known by a variety of names. Retrospective studies are generally more economical and produce results more quickly than prospective study. In these studies a phenomena existing in present is linked to the phenomena that occurred in past before the study was initiated. For example, review of medical records to assess the previous history of cholesterol levels in myocardial patients, in this type of study sometimes we move from effects which had already occurred to identify its cause. To identify predisposing factors of any diseases are the examples of retrospective studies.
The study starts with a presumed cause and then goes forward in time to the presumed effect. Independent variables is in present and its effect on dependent variables is studied in forward, i.e. in future to test the association. These studies are more costly than retrospective study but these studies are stronger than the other. For example, study describing social support and coping mechanisms of women with ovarian CA. Cohort studies are also the examples of prospective studies.
Research on nursing practice began slowly, but since 1950 has been accelerating rapidly. The ultimate purpose of nursing is to provide high quality patient care. Nursing research must address questions relevant to the profession of nursing. It grow the body of literature which means body of knowledge related to nursing profession. Clinical nursing practice without research is based on tradition without empirical evidences. Research is needed to evaluate the effectiveness of nursing treatment modalities, to determine the impact of nursing care on the health of the patients or to test theories.
Definitions of Nursing Research
According to International Council of Nurses (1986)—‘Nursing research is a way to identify new knowledge, improve professional education and practices and use of resources effectively.’
According to ANA, 1981 ‘nursing research develops knowledge about health and promotion of health over the full life span, care of person with health problems and disabilities to respond effectively to actual or potential health problems.’
Polit and Beck (2004) have broadly defined nursing research as ‘systematic inquiry designed to develop knowledge about issues of importance to the nursing profession, including nursing practice, education, administration, and informatics’.
Burns and Grove (2005) have more narrowly defined nursing research as ‘a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences clinical nursing practice.10
Importance of Nursing Research
  • To develop more evidence-based practice skill in nursing: Evidence based practice is integrating research findings into clinical decision-making. It is the conscientious use of current best evidence in making decisions about patient care. Development of evidence-based practice, among the nurses using the current, best research findings in their delivery of care is very much essential. It is a problem-solving approach to clinical practice that integrates, a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question.
  • Improve the knowledge of nurses: Use of research in nursing can helps the nurses in updating them with the new knowledge. A knowledge base is necessary for the recognition of nursing as a science by health professionals, consumers, and society. By conducting research nurses can acquire new knowledge to improve patient care. She will review different literatures and she will develop herself as a knowledge based for conducting research.
  • Improve decision-making: The researches can helps the nurses to take proper decision because by using researches the nurse can come-out from their traditional system of nursing practices and move towards more evidence based practice. Research means evidence based practice by which it improve accountability for care-related decisions and expands nursing practice. The nurse can take decision independently by using research.
  • Changes in the conceptualization of nursing and increase the values: The science of nursing practice is one that is—soundly grounded in fundamental scientific concepts, theories and facts relevant to nursing. We have moved towards a more scientific definition of nursing practice, which is compatible with increased use of research findings by clinicians and practice research is now regarded as a fruitful source of practice theories. Nurse researchers are now feeling more of a responsibility to go beyond just reporting their findings. They are sharing the responsibility for transmitting their results into practice. By using research the meaning of nursing changed, they are not simply obeying doctors order and following the principles of evidence based practice. The value of nursing has been increased.
  • Reinforce identity of nursing as a profession: Nursing research can helps the nurse to take decision independently. The nurse can modify her care and improving the professional standards by using research. Research can improve the professional identities of nurses. Professions are those occupations possessing a particular combination of characteristics generally considered to be the expertise, autonomy, commitment, and responsibility. Using of research in the field of nursing can fulfil all the criteria. It will helps in intellectual growth, improving the body of knowledge in nursing and makes the identity of nursing profession.
  • Advances in the preparation of nurses to use research: The NLN has endorsed the position that the preparation of nurses to conduct research generally belongs at doctoral level. However students in baccalaureate program should acquire an understanding of the research process and its contribution to nursing practice as well as the ability to evaluate research findings for applicability to nursing practice.
Scope and Areas of Nursing Research
  • The scope of nursing research is to strengthen the body of knowledge in clinical nursing practices, education, administration and health systems and outcomes research.
  • Clinical research or practices, based on biological, behavioral, and others types of investigations, provides the scientific basis for the care of individuals across the life span and occurs in any setting where nursing care is provided.11
  • Health systems and outcomes research examines the availability, quality, and costs of health care services as well as ways to improve the effectiveness and appropriateness of clinical practice.
  • The nursing administration research focuses on issues related to management of nursing personnel, recruitment, placement, retention, attrition, nurse patient ratio, nurse's satisfaction, etc.
  • Finally, nursing education research focuses on how students learn the professional practice and discipline of nursing as well as how to improve educational strategies to prepare clinicians and scientists.
  • Therefore, the areas or scope of nursing research may be classified in the following four broad categories:
    1. Research in clinical nursing practices
    2. Research in nursing education
    3. Research in nursing administration
    4. Research in health systems and outcomes of care.
Research in Nursing Practice
The scope of nursing practice describes the ‘who,’ ‘what,’ ‘where,’ ‘when,’ ‘why,’ and ‘how’ of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership. The profession of nursing has one scope of practice that encompasses the full range of nursing practice, pertinent to general and specialty practice. The depth and breadth in which individual registered nurses engage in the total scope of nursing practice is dependent on their education, experience, role, and the population served.
The scope of clinical nursing research may range from examining nursing interventions and experiences for health promotion, illness prevention, and care for individuals, families and communities in diverse setting. Nursing research is different from biomedical research because it focuses on examining and expanding the view of health, which emphasizes on health promotion, restoration and rehabilitation, as well as a commitment to caring and comfort. However, the focus of biomedical science on the discovery of diseases causation and cure is essential but not solely sufficient to improve health. Thus, it is better to obtain an expanded view of human health and illness with broader context of lifestyle, culture, and socioeconomic status. Complex problems in human health require inter professional approaches. Nurses are uniquely qualified to lead and participate in interdisciplinary research teams because their education includes courses from all health related discipline (e.g. physiology, pharmacology, psychology, and sociology), and they focus on the integration of these disciplines in providing comprehensive care. Some of the common areas in clinical nursing practices are given below:
Evidence-based nursing care practices are in greater need to improve the quality of patient care. High quality and high cost-effective nursing care is only possible through research in this area of nursing profession. Nursing practices are the most researched field in nursing science, where nurse researcher regularly make modest attempts to generate or refine the nursing interventions for the following sub areas:
  • Health promotion, maintenance and disease prevention.
  • Patient safety and quality of health care.
  • Promotion and risk reduction interventions of health of vulnerable, minority groups and marginalized community.12
  • Patient-centerd care co-ordination.
  • Promotion of health and well being of older people.
  • Palliative and end of life care.
  • Development of evidence-based practices and translational research.
  • Care implication of genetic testing and therapeutics.
  • Nurses working environment.
  • Home care and community health nursing care practices.
  • Treatment compliance and adherence to treatment.
  • Description of holistic nursing situations—social, cultural, religious, traditional and family practices, which have health implications and fall under the nursing care.
Tenets Characteristic of Nursing Practice
  • Nursing practice is individualized: Nursing practice respects diversity and is individualized to meet the unique needs of the health care consumer or situation. Health care consumer is defined to be the patient, person, client, family, group, community, or population who is the focus of attention and to whom the registered nurse is providing services as sanctioned by the state regulatory bodies. The service to be provided to the individual family and community will be valid by proving it through research. What type of service will be more effective for individual and how the family is a one unit in providing care will be determined by research.
  • Nurses coordinate care by establishing partnerships: The registered nurse establishes partnerships with persons, families, support systems, and other providers, utilizing in-person and electronic communications, to reach a shared goal of delivering health care. Health care is defined as the attempt ‘to address the health needs of the patient and the public’ (ANA, 2001, p. 10). Collaborative inter professional team planning is based on recognition of each discipline's value and contributions, mutual trust, respect, open discussion, and shared decision-making. Previously there are no participation of family members in patient care which concept was now changed and research proved that the involvement of people in care of patient or in community can generate cost effective care and there will be a psychological satisfaction of patient and family members. This is only possible through by research.
  • Caring is central to the practice of the registered nurse: Professional nursing promotes healing and health in a way that builds a relationship between nurse and patient (Watson, 1999, 2008). ‘Caring is a conscious judgment that manifests itself in concrete acts, interpersonally, verbally, and nonverbally’ (Gallagher-Lepak and Kubsch, 2009, p. 171). While caring for individuals, families, and populations is the key focus of nursing, the nurse additionally promotes self care as well as care of the environment and society (Hagerty, Lynch-Sauer, Patusky and Bouwseman, 1993). Florence Nightingale through research proved that the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient.
  • Registered nurses use the nursing process to plan and provide individualized care to their health care consumers: Nurses use theoretical and evidence-based knowledge of human experiences and responses to collaborate with health care consumers to assess, diagnose, identify outcomes, plan, implement, and evaluate care. Nursing interventions are intended to produce beneficial effects, contribute to quality outcomes, and above all, do no harm. Nurses evaluate the effectiveness of their care in relation to identified outcomes and use evidence-based practice to improve care (ANA, 2010). Critical thinking underlies each 13step of the nursing process, problem-solving, and decision-making. The nursing process is cyclical and dynamic; interpersonal and collaborative; and universally applicable which is validated through research.
  • A strong link exists between the professional work environment and the registered nurse's ability to provide quality health care and achieve optimal outcomes: Professional nurses have an ethical obligation to maintain and improve health care practice environments conducive to the provision of quality health care (ANA, 2001). Extensive studies have demonstrated the relationship between effective nursing practice and the presence of a healthy work environment. Mounting evidence demonstrates that negative, demoralizing, and unsafe conditions in the workplace (unhealthy work environments) contribute to medical errors, ineffective delivery of care, and conflict and stress among health professionals which is also proved through research.
Research in Nursing Education
Nursing education is another important area of nursing research where nurse researchers try to generate or refine the knowledge, which is useful to improve the teaching learning methods and environment in nursing discipline. The main aim of nursing education is to continuously provide skilled nursing manpower to country, which is the need of hour for a country like India. There are several issues and sub-areas of nursing education on which nursing research may focus they are:
  • Testing the effectively and efficiency of the old teaching methods or techniques, and generating newer effective teaching tools and techniques.
  • Curriculum taught and learning experiences of nursing students at under graduate and postgraduate level.
  • Enhancing the psychometric domain of learning among nursing students in clinical practices.
  • Extent of strict discipline required for the nursing students to improve their learning and education.
  • Promoting clinical and classroom learning among nursing students.
  • Refining and generating evaluation methods to judge the efficiency of the teaching-learning process.
  • Identifying and managing problems of absenteeism and lack of motivation among nursing students.
  • Resolving any issue or phenomenon related to the teaching-learning process of the nursing students.
Research in Nursing Administration
Administration is one of the most difficult disciplines to manage. Similarly, nursing administration also encounters several problems and issues that require solution and a solution may be obtained through research. Therefore, there are several main subareas of nursing administration which requires investigation such as:
  • Assessing existing organizational structure, span of control, communication, staffing pattern, wages, benefits, performance evaluation practices, etc. and their effectiveness. In addition, developing new knowledge or refining the old knowledge regarding nursing administrative phenomena.14
  • Developing and testing different administrative model to enhance swift administration, employees, and customer satisfaction.
  • Retention and effective use of nursing personnel in providing the quality of nursing care.
  • Furthermore, research can be conducted on any phenomenon related to nursing administrative issues.
Research in Health Systems and Outcomes of Care
Research in health system and outcome of care is one of the important areas of nursing research, where nurse scholars may identify the success of presently existing health care delivery systems and models in country and to identify the ways and means to develop affordable quality of health care to individual, families and communities of the country.
Nursing research may not be completely separable from the biomedical research in this area, but nursing research is integrated with health services research regarding issues of organization, delivery, financing, quality, patient and provider behavior, informatics, effectiveness, cost, and outcomes.
Some of the common examples that require investigation in this area are given below:
  • Developing models of health care, which are affordable and accessible to people located in remote and hilly areas.
  • Developing cost-effective model of health care for rural and deprived communities.
  • Effective use of information and technology to provide health care services from tertiary care centres to the remote and outreach areas.
  • Evaluate the effectiveness of existing policies and programmes for health care of people, such as NHRH, etc.
If analyzed properly, historical knowledge can provide insight into the past, leading to resolution of present and future issues in nursing. The history of nursing comprises many changes and developments. The historical evolution of research in nursing can be traced back to Florence Nightingale, who made detailed records of observations about the effects of nursing actions. During 1970s and 1980s, numerous studies were conducted that focused on clinical practice.
Contribution of Florence Nightingale (1820—1910)
Florence nightingale was one of the founder of professional nursing and is considered as the first nurse researcher. During the Crimean war, she kept a meticulous record and statistics of mortality rates among the sick and the wounded.
Nightingale initiated nursing research nearly 150 years ago. Her notes on nursing (1859) describe her initial research activities, which focused on the importance of healthy environment in promoting patient physical and mental well-being. She mostly carried out her data collection and statistical analysis during the Crimean war. She gathered data on soldier morbidity and mortality. Her research enabled her to instigate attitudinal, organizational, and social change.
  • 1950: There was an increase in federal funding for research in nursing. American Nurses foundation was devoted exclusively to the promotion of research in nursing.15
  • 1952: For the first time, there was publication of nursing research.
  • 1953: The institute of Research and services in Nursing Education was lunched at Colombia University.
  • 1954: PHD programme was introduced in nursing education.
  • 1955: American Nursing Association (ANA) established American Nurses Foundation as an independent organization for the purpose of development of nursing research by conducting and supporting research projects.
  • 1957: A department of nursing research was established at Walter Reed Army Institute.
  • 1960: The 1960s brought reordering of nursing research. The focus was to target practice oriented research to improve the quality of patient care.
  • 1965: The ANA took an official position in educational preparation of licensed nurses in which the need for research in nursing and for educating nurse researches was recognized.
  • 1970: A content analysis of articles published in nursing research from 1970 to 1978 shaved a shift from research in nursing being conducted by a large group of members of other disciplines, especially social sciences which served as the basis for much of what nurses do in practice today.
  • 1976: The ANA commission on nursing research published guidelines for the academic preparation of nurses in participation in research and its utilization.
  • 1986: National Centre for Nursing Research (NCNR) was established at National Institute of Health(NIH) under the Health Research Extension Act, 1985.
  • 1990: The 1990s brought the promise of reducing the gap between practice and research. The publication healthy people 2000 in 1992 by the US Department of Health and Human services laid the national health agenda for the future.
  • 1993: National Centre for Nursing Research was renamed National Institute for Nursing Research (NINR). The Cochrane collaboration was established. In addition Journal of Nursing Measurements started being published.
  • 1994: The journal Qualitative Research started being published.
  • 1995: The Joanna Biggs Institute, an international EBP collaboration, was established in Australia.
  • 1997: Canadian Health Services Research foundation was established with federal funding.
  • 1999: US Agency for Health Care Policy and Research (AHCPR) was renamed as Agency for Health Care Research and Quality (AHCRQ).
  • 2000: NINR issued funding priorities for 2000–2004; annual funding exceeded US $100 million. The Canadian Institute of Health Research was launched. The journal Biological Research for Nursing started being published.
  • 2004: The journal world views on Evidence Based Nursing started being Published.
  • 2005: Sigma Theta Tau International issued a position paper on nursing research priorities that incorporated priorities from nursing.
Major Milestones of Nursing Research in India
Research related to nursing in India has its roots in the philosophy of Florence nightingale which stated that the profession is committed to the task enlarging professional body of knowledge through systematic approach to solve problems in nursing.
The statistics on the unsanitary conditions in the Indian army prepared by Florence Nightingale may be starting point of nursing research in India.16
Some of the main historical milestones that influenced the development of nursing research in India are as follows:
  • 1946: Bhore Committee (1943) submitted a report in which recommendations were made for the improvement of various aspects of nursing profession, nursing education, nursing research, working condition, nursing services in both hospital and community, sending nurses for higher education to abroad, etc.
  • 1953: MS Edith Buchanan, vice principal, Rajkumari Amrit Kaur (RAK), College of Nursing, New Delhi, was the first nurse from India who was sent to Columbia University to earn her Doctorate in Education (DEd) under a World Health Organization (WHO) fellowship programme.
  • 1955: MS Margaretta Craig, principal, College of Nursing, New Delhi, attended International Council of Nurses (INC) meet in France to present a paper on the need for nursing research.
  • 1960: First two years master degree programme in nursing was started by RAK College of Nursing, New Delhi, which influenced nursing research as a full subject with a thesis work on nursing topics.
    • Nursing research commenced on an all-India basis along with a master's programme in nursing in an intensive manner, although nurse leaders had been already participating in research at various levels.
    • Clinical studies were even being carried out on short term basis by the beginning level postgraduate nursing students.
  • 1963: A study of health services was carried out in connection with the revision of syllabus of General Nursing and Midwifery by the Indian Nursing Council in 1963. The study provided valuable insights into the trends in the health services and complication of nursing.
  • 1964: Dr Marie Ferguson, a public health nurse who joined RAK College of Nursing, New Delhi, was able to create greater appreciation and understanding and value of the research in nursing for nursing practices, administration and education. With senior nursing leaders of the country, she conducted a research study titled Activity Study to Define Nursing and Non-Nursing Functions of Nurses in selected health institutes of India.
  • 1966: Trained Nurses Association of India (TNAI) established a research section under the guidance of chairman MS Anna Gupta, Principal, RAK College of Nursing, under supervision of Dr Sulochana Krishnan.
  • 1971: TNAI conducted a study on the socioeconomic status of nurses in India.
  • 1976: Dr Marie Farrell and Dr Aparna Bhaduri of RAK College of Nursing, New Delhi, conducted seminars on nursing research for educationists at Delhi, Mussoorie (Uttarakhand) and Yercaud (Tamil Nadu) to strengthen the nursing research in India.
  • 1981: Dr Farrell and Dr Bhaduri's book health researcha community based approach was published by the World Health Organization (WHO).
  • 1982: During October a national conference titled nursing research in India. Prospect and retrospect was organized, which was the first conference in India related to nursing research, and was held at College of Nursing, Bangalore. Some of the recommendations of the participants of the conference were as follows:
    • Each college of nursing should have a research cell.
    • The faculty at nursing colleges should encourage students and provide them time for conducting research.
    • Colleges of nursing should foster research attitude among nursing students.17
    • Central and state governments and private organizations should include nursing research in their budget.
    • Opportunities should be provided for faculty to visit foreign countries on short-term basis to learn about nursing research.
    • Efforts should be taken to establish collaborative activities in the area of research and scholastic interactions with the nursing colleges in the other countries.
  • 1984: A nursing research workshop was conducted titled Teaching Nursing Research to Nursing College Teachers at Bangalore, which was sponsored by the University Grants Commission. This workshop was open to all the teachers of all nursing colleges in India.
    • A workshop was conducted on ‘Nursing Process’ by Dr Marie Farrell at Leelabai Thackersey College of Nursing, SNDT Women University, Mumbai, which was sponsored by the WHO.
  • 1986: The Nursing Research Society of India (NRSI) was established by Dr (Mrs) Inderjit Walia (president) and Mrs Uma Handa (secretory) to promote research within and related to nursing.
    • For the first time, MPhil program in nursing started at RAK College of Nursing, University of Delhi, New Delhi.
    • All undergraduate and postgraduate nursing student taught the uniform nursing research course developed by INC.
    • PhD in Nursing started in College of Nursing, PGIMER, Punjab University, Chandigarh.
  • 1998: Nursing Research Interest Section was organized by Mr R Rajarathnan (senior Nursing Tutor–NIMHANS)
  • 2002: Revised syllabus of GNM and PBBSc by INC has included nursing Research as a full subject.
  • 2004: Publication of Nightingale Nursing times was started by Jain and Co., Noida, Uttar Pradesh.
  • 2005: Publication of research based journal titled Nursing and Midwifery Research journal was started at PGIMER, Chandigarh.
  • 2006: National Consortium PhD Nursing has been constituted by INC under the ledership of Shri T Dileep Kumar (President) to promote research activities in various field of nursing.
  • 2007: Nursing Research Society of India has launched its official journal titled Journal of Nursing Research Society of India at College of Nursing, Bharati Vidyapeeth Deemed University, Pune.
  • 2008: Central institute of Nursing and Research (CIN) was brought in existence under control of Trained Nurses Association of India in New Delhi.
  • 2009: Indira Gandhi National Open University (IGNOU) started PhD in Nursing.
  • 2010: Faculty of nursing sciences started PhD in nursing.
  • 2011: Publication of several nursing scholarly journals started in India, such as Kerala Nursing Forum, Indian Journal of nursing studies, trends in Nursing Administration and Education, Indian journal of Holistic Nursing, the nurse, etc. Thus increasing no of nurses started publishing their research work in these journals, and these journals helped nurses to disseminate the research evidences generated by them.
  • 2012: Postgraduate and doctoral nurses use the database of thesis abstract for nursing research created by Nursing Research Society of India.18
  • 2013: Ministry of Health and Family Welfare, Government of India constituted an expert Advisory Committee of Nursing Education and Research to work and provide recommendation on starting the Doctoral Nursing programs in addition to undergraduate and postgraduate nursing programs in new six AIIMS started by the Government of India at Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh.
Use of Nursing Research in Practice
The use of research in nursing practice is a topic of pressing concern to the profession. Some would argue that the development of practice relevant research and the use of research findings into delivery of health care is unimportant. The amount of current literature devoted to topics related to use of research, the strong endorsement of the professional organization and the nature of federally funded projects all attest that the use of research findings in practice is a significant professional objective.
Barriers of Using Nursing Research
Barriers to the use of research findings by practicing nurses can be organized into three categories:
Values and Qualification of Practicing Nurses
  • Most nurses lack the preparation necessary to evaluate and implement research in their own environment. Although many baccalaureate programs now include some orientation to research, more course content is needed. Most practicing nurses have not had courses in nursing research and may not be qualified to understand, critically evaluate and implement research findings.
  • Most nurses depends on few journals, i.e. AJN, for their continuing education.
Process of Implementing Research
  • The CURN (conduct and utilization of research in nursing) suggests that in order to incorporate research based knowledge into the delivery of patient care, nurses must be able to:
    • Identify and synthesize results from many studies into a common research base.
    • Transform knowledge into clinical protocols.
    • Create specific nursing actions from the protocols.
    • Evaluate the innovation.
Institutional Factors
  • Organizational structures are also related to the use of research in nursing practices. Many staff nurses lack authority and control over their practices. They may feel powerless to effect changes in their clinical settings. In sufficient time and money can also prohibit involvement in nursing research.
  • Institutional factor is a critical factor in the conduct and use of research and the nurse administrator is in a particularly influential role.
The nursing profession is acutely aware of the problems discussed above and a number of ways to facilitate the translation of nursing research into practice have been advanced.19
Planned Changes
Lewin's three phases of planned changes:
It involves breaking down to old traditions and customs to make way for new alternatives. This might entail motivating nurses to abandon their usual approach to practice based on intuition and to substitute a desire to provide patient care based on tested theories and knowledge about human responses to health and illness.
It requires new patterns of behaviors acquired through the mechanism of identification and internalization.
It is the process by which the newly acquired behaviors become integrated into the nurse's personality and work role.
The CURN project which focused on transferring research based knowledge into protocols for nursing practices has identified seven specific steps in the research use process that must be incorporated into any planned change effort:
  • Systematically identifying patient care problems.
  • Identifying and assessing research based knowledge to solve identified patient care problems.
  • Designing a nurse practice innovation to meet the needs of the clinical problems.
  • Conducting clinical trials and evaluating the innovations.
  • Deciding whether to adopt, alter or reject the innovation.
  • Developing means to extend the new practice to other units.
  • Developing mechanisms to maintain the innovation over time.
Conceptualization of Nursing Research and Nursing Science
Nature of Nursing Science
Nursing research focuses on the role of nursing care in the prevention of illness, care of sick and the promotion and restoration of health. Although it relies upon and utilizes the substantive scientific information and methodology provided by the other biological and behavioral sciences, it differs from those other scientific areas in that it focuses on their relevance to nursing rather than other aspects of health care. The product of research is knowledge or science (National Academy of Sciences,1977).
Model for Conceptualization of Nursing Research and Nursing Sciences
  • The model is designed to enhance nursing exploration, it incorporates parallel conceptualization of medical research and the practice research of other health care professionals.
  • An important feature of the model is that it aids in the identification of two types of research, namely fundamental research and practice research and helps underscore the view that there are two categories of sciences: fundamental sciences and science of professional practice.
  • One of the most crucial aspects of the model is its recognition that the broad structure of fundamental science is not specific nor is it limited to the use of any particular category of 20health care professional. It recognizes that the theories and facts produced by fundamental research constitute a vast communal pool, and that from this pool each health professional group may selectively draw professionally relevant facts and theories.
Fundamental Research and Science
  • Traditionally ‘basic research’ has been understood as a way to establish fundamental theories, facts or statements of relationships among facts in some area of knowledge that are not intended for immediate use in some real life situations. The aim of basic research is to advance scientific knowledge and to facilitate further research in the area of knowledge.
  • The term fundamental research includes both the traditional basic or non problem oriented research and the more problem oriented research, which only recently has been recognized to have fundamental qualities.
  • Knowledge produced by fundamental research can not be introduced into practice without translation into some sort of intervention.
Practice Research and the Science of Practice
  • Nursing practice research requires relevant facts and theories from the communal pool of fundamental scientific knowledge, to bring these knowledge elements to bear upon a problem derived from professional practice.
  • The science resulting from nursing practice research, which is soundly grounded in fundamental science concepts, theories and facts relevant to nursing, is defined as the science of nursing practice.
  • The categories of research are:
    • Fundamental research (focus on fundamental process of biology and behavior)
    • Nursing practice research (focus on nursing process, nursing intervention)
    • Nursing profession research (focus on practitioner)
    • Delivery of nursing services research (focus on the provision of services)
    • Nursing education research (focus on the process of education).
The purpose of conducting research is to generate new knowledge or to validate existing knowledge based on a theory. Research studies involve systematic, scientific inquiry to answer specific research questions or test hypotheses using disciplined, rigorous methods. While research is about investigation, exploration, and discovery, it also requires an understanding of the philosophy of science. For research results to be considered reliable and valid, researchers must use the scientific method in orderly, sequential steps.
The process begins with burning (compelling) questions about a particular phenomenon, such as: What do we know about the phenomenon? What evidence has been developed and reported? What gaps exist in the knowledge base?
The first part of investigation involves a systematic, comprehensive review of the literature to answer those questions. Identified knowledge gaps typically provide the impetus for developing a specific research question (or questions), a hypothesis or hypotheses, or both. Next, a decision can be made on the underlying theory that will guide the study and aid selection of type of method to be used to explore the phenomenon.
The impact of evidence-based practice (EBP) has echoed across nursing practice, education, and science. The call for evidence-based quality improvement and health care 21transformation underscores the need for redesigning care that is effective, safe, and efficient. In line with multiple direction-setting recommendations from national experts, nurses have responded to launch initiatives that maximize the valuable contributions that nurses have made, can make, and will make, to fully deliver on the promise of EBP. Such initiatives include practice adoption; education and curricular realignment; model and theory development; scientific engagement in the new fields of research; and development of a national research network to study improvement.
Understanding EBP
Evidence-based practice (EBP) is a problem-solving approach to patient care that integrates the best evidence from well-designed studies with clinician's expertise, patient assessments, and patient's own preferences leads to better and safer care, better outcomes and lower health care costs. Unlike research, EBP is not about developing new knowledge or validating existing knowledge. It is about translating the evidence and applying it to clinical decision-making. The purpose of EBP is to use the best evidence available to make patient-care decisions. Most of the best evidence stems from research. But EBP goes beyond research use and includes clinical expertise as well as patient preferences and values. The use of EBP takes into consideration that sometimes the best evidence is that of opinion leaders and experts, even though no definitive knowledge from research results exists. Whereas research is about developing new knowledge, EBP involves innovation in terms of finding and translating the best evidence into clinical practice.
Concept of EBP and Research Utilization
Research utilization (RU) is the process of synthesizing, disseminating and using research generated knowledge to make an impact or change in the existing practice in society. The time lag between generating and using new knowledge by society has been a concern for many years. For example, the time lag between the discovery of citrus as a preventive measure for scurvy and its use on British ships was 264 years (Glaser, Abelson and Garrisons 1983).
So to fill the gap between research theory and practice EBP was developed. The roots of EBP in nursing can be traced in Florence Nightingale's era of nursing practice. Her concept of promoting health, prevention of diseases and care of sick were central ideas for her system.
During past decade research utilization term was used only to implement the research study. But later on it was expanded and termed as ‘evidence-based practice’ in nursing. Evidence-based nursing practice means utilization or implementation of best research evidence in our clinical practice to provide quality care to individual or groups and needs delivery quality and cost-effective also.
Best research evidence is produced by the conduct and synthesis of numerous high-quality studies in a specific health care. In nursing the best research evidence is focused on health promotion, illness prevention, diagnosis and management of acute and chronic illness (American Nurses Association, 2004).
Evidence-based practice (EBP) has been emphasized in medicine for many years and is now is a measure focus of nursing. The goal of EBP is the implementation of high quality, cost– effective care to promote positive outcomes for patients, providers and health care agencies. So, EBP has a broader focus than that of high quality health care delivery.
Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. Most professionals seek to ensure that their care is effective, compassionate, and meets the 22needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioner.
  • It is the conscientious, explicit and judicious use of theory derived research base information in making decision about care of delivery of individual or group of patients and in the consideration of individual needs and preferences (Ingersoll, 2000).
  • It is the using of best available to guide clinical decision making (Benefield, 2002).
  • It is the use of evidence to support decision-making in health care (Green berg and Pyle, 2004).
  • It is an integration of the best evidence available, nursing expertise and the values and preference of the individual, families and communities who are served (Sigma Theta Tau, 2005).
  • It is an integration of the best research evidence with clinical expertise and patient value to facilitate clinical decision-making (Di Censo et al. 2005).
  • Evidence-based nursing is an approach to health care practice that enables nurses to provide the highest quality care based on the best evidence available to meet the needs of their patients (Melnyk and Fineout-Overholt, 2005).
  • The integration of the best research evidence with clinical expertise and patient values.
Steps in the EBP Process
The EBP process has seven critical steps:
  1. Cultivate a spirit of inquiry.
  2. Ask a burning clinical question.
  3. Collect the most relevant and best evidence.
  4. Critically appraise the evidence.
  5. Integrate evidence with clinical expertise, patient preferences, and values in making a practice decision or change.
  6. Evaluate the practice decision or change.
  7. Disseminate EBP results.
Cultivate a Spirit of Inquiry
Cultivating a spirit of inquiry means that individually or collectively, nurses should always be Cultivating a spirit of inquiry how to improve health care delivery. For this the nurse should develop her own attitude to learn new things or attitude to enquiry what are the lacunas. By this the nurse can get different issues and problems inn health care delivery.
Ask a Burning Clinical Question
The burning clinical question commonly is triggered through either a problem focus or a knowledge focus. Problem-focused triggers may arise from identifying a clinical problem or from such areas as risk management, finance, or quality improvement. Knowledge-focused 23triggers may come from new research results or other literature findings, new philosophies of care, or new regulations. Sometime during giving care the nurse can face different challenges which can act as a base to go to next step.
Hierarchy of Evidence
Regardless of the origin, the next step in the EBP process is to review and appraise the literature. Whereas a literature review for research involves identifying gaps in knowledge, a literature review in EBP is done to find the best current evidence. Here the nurse researcher has to collect the most relevant and best evidence. In searching for the best available evidence, nurses must understand that a hierarchy exists with regard to the level and strength of evidence. All of the various hierarchies of evidence are similar to some degree. The highest (strongest) level of evidence typically comes from a systematic review, a meta-analysis, or an established evidence-based clinical practice guideline based on a systematic review. Other levels of evidence come from randomized controlled trials (RCTs), other types of quantitative studies, qualitative studies, and expert opinion and analyses.
Critical Appraisal
Once the evidence is gathered, the researcher must critically appraise each study to ensure its credibility and clinical significance. Critical appraisal often is thought to be tedious and time-consuming. But it's crucial to determine not only what was done and how, but how well it was done. An easy method for conducting critical appraisal is to answer these three key questions:
  • What were the results of the study? (In other words, what is the evidence?)
  • How valid are the results? (Can they be trusted?)
  • Will the results be helpful in caring for other patients? (Are they transferable?)
Final Steps of EBP
The final steps of the EBP process include integrating the evidence with one's clinical expertise, taking into account patient preferences, and evaluating the effectiveness of applying the evidence. Disseminating or reporting the results of EBP projects may help others learn about and apply the best evidence. Examples of potential EBP projects include implementing an evidence-based clinical practice guideline to reduce or prevent UTIs, evaluating an evidence-based intervention to improve wound healing, and applying an EBP to improve compliance with a specific treatment for a chronic disease.
  • Evaluate the practice decision or change
  • Disseminate EBP results.
Melnyk and Fineout–Overhott (2011) suggest that EBP involve five critical steps.
Select a Clinical Research Problem or Question
The first step of EBP is to select a research question from clinical area. The selection of clinical research problem can be result following triggers:
  • Knowledge focused triggers: These triggers come from advancement of knowledge of health care professionals though reading literature or attending professional conferences for, e.g. implementing of revised guidelines or standard to improve the health care practice.
  • Problem focused triggers: These triggers are identified by the health care professionals in response to clinical problem, barriers or any other difficulties face in day-to-day life in clinical area.24
The clinician should appropriately frame clinical research question by using following acronym called PICO. It stands for:
P = Who is patient population?
I = What is the potential intervention?
C = Is there a comparison of intervention and status?
O = What is the desired outcome?
For example, ‘are self management strategies more effective than medical care alone for improving health status, quality of life and occupational functioning among adult with coronary heart disease’?
Use of PICO approach:
P = Adult with coronary heart disease
I = Self-management strategies
C = Medical care
O = Health status, quality of life and occupational functioning.
Search Relevant Literature Review
Once the clinical question selected, the researcher should explore the relevant literature review through clinical studies, expert opinions or existing EBP guidelines.
Critically Appraise the Evidences
  • The available evidences should be evaluated for their strengthen and weakness.
  • It should be focused for evaluation of their feasibility like in term of cost, duration, need of manpower and other sources, etc.
Implement the Best Evidence in Practice
  • After critical appraisal of the evidence, the researchers should decide to implement the best available evidence in clinical setting.
  • The final evidences must be extensively discussed among the users with risk-benefit ration of evidences.
Evaluate the Efficacy of the Evidence
Finally after the implementation of the useful findings for the clinical practice; the researcher must determine the expected change in practice and the benefits of the evidence used.
‘A's of the Steps of EBP
  • Ask: Formulate the question
  • Acquire: Evidence search for answers
  • Appraise: The evidence for quality and relevance
  • Apply: The results
  • Assess: The outcome.
Strategy to Expand Research Use in Practice: Rogers’ Theory of Diffusion of Innovation
Most people believe that a good idea generated through research will spread rapidly and the idea will quickly be used. But this is seldom true. During most of the 20th century research findings where seldom used by nurses to improve practice.25
So to address this problem Rogers (1995) studies the processes for using research findings in society and developed a theory for communicating innovations or new ideas developed through research.
Roger's theory of diffusion of innovations includes a five stage process:
Knowledge Stage
This is the first stage of awareness of the existence of an innovation or a new ideas for use in practice. Knowledge of research finding can be obtained by formal communication through conference presentation, publications in clinical and research journal. Internet sites, news releases on television and in newspaper. In addition, informal communication within an agency from one nurse to another or among different health professionals can be effective in increasing awareness of research knowledge.
Persuasion Stage
In this stage an individual or a group is motivated to adopt the innovation. Innovations with highly relative advantages and beneficial result will be easily and rapidly adopted. In this stage, the proposed change is best communicated in small group or one-to-one interaction.
Decision Stage
All this stage, the innovation is either adopted or rejected. Adoption involves full acceptance and implementation of the innovation or intervention in practice.
Implementation Stage
In this stage, the intervention is put to use by an individual, a clinic a hospital unit, many units or a group of hospitals. A detailed plan for implementation that addresses the risk and benefits of the intervention will facilitate change.
Confirmation Stage
During this stage nurses evaluate the effectiveness of the change in practice and decided to either continue or discontinue it. After using the new interventions one-two month onwards, data must be collected about the effectiveness If any advantages evaluated then the innovation can be adopted easily. It there is no benefit occurred then intervention may be discontinued.
An Example for Research-based Protocol for Decreasing Discomfort with Intramuscular (IM) Injection
  • Wash hands, gather necessary equipment for the injection and put on gloves.
  • Explain to the patient that you will position him/her to decrease the discomfort of the IM injection based on research.
  • Position the patient in the prone position or lying face down.
  • Identify the ventrogluteal (VG) site.
  • Have the patient urn his/her toes inward. This internal rotation of the femur causes relaxation of the gluteal muscle which decreases the discomfort from the injection.
  • Give the injection and reposition the patient for comfort after the injection.
  • Document how the injection was given and patient's response or perceived level of comfort.
Importance or Purpose of EBP
  • It improve patient care.
  • It increases confidence in decision-making.26
  • It improves nurses and other health care professional's job satisfaction and reduce employees turnover in an organization.
  • EBP keeps practice current and relevant.
  • It improves the consumers (patient and their family) satisfaction in health care services.
  • Integration of EBP into nursing practice is essential for high quality patient care and most cost-efficient care.
  • EBP eliminates unsound or excessively risky practise in favor of those that have better outcomes.
Iowa Model of Evidence–based Practice in Nursing
The Iowa model of evidence-based practice provides direction for the development of EBP in a clinical agency. This EBP model was initially developed by Titler and colleagues in 1994 and revise in 2001.
In a health care agency a clinical problem may arise by knowledge trigger or by problem base trigger.
If a trigger is considered an agency priority, then a group is formed to search for the best evidence to manage the clinical concern (Titler 2001). Then the review of previous theory, scientific principles, expert opinion and case reports also review of literature are done to provide fairly strong evidence for use in practice. The strongest evidence is generated from meta-analysis of several controlled clinical trials.
Then this evidence would be pilot tested on a particular unit and then evaluated to determine the impact on patient care. If the outcomes are favorable from the pilot test, then the change would be made in practice and monitored over time to determine its impact on the agency environment, staff costs and the patient and family (Titler et al. 2001). If an agency strongly support the use of the Iowa model, implements patient care based on the best research evidence and monitors change in practice to ensure quality care, then the agency is promoting EBP.
An Example of the Iowa Model of Evidence-based Practice
  • The steps of Iowa model were used as a guide for implementing a research-based protocol for saline flush irrigation of peripheral venous catheters rather than heparin flush in adult patient.
  • Goode and Colleagues (1991) conducted a meta-analysis ‘to estimate the effects of heparin flush and saline flush solutions on maintain patency, preventing phlebitis and increasing duration of peripheral heparin locks (peripheral venous catheters)’.
  • The meta-analysis was conducted on 17 high-quality studies having total sample 4,153 and the samples were included a variety of medical-surgical and critical care units (only adult patients).
  • It was concluded, that saline is as effective as heparin in maintaining patency, preventing phlebitis and increasing duration in peripheral heparin locks of adult patients.
  • Quality care can be enhanced by using saline as the flush solutions, thereby eliminating problems associated with anticoagulant effects and drug incompatibilities.
  • Clinical relevance is evident that the use of saline to flush peripheral venous catheters promote quality out comes for the patient (i.e. patent heparin lock, fewer problems with anticoagulant effects and fewer drug incompatibilities); the nurse (decreased time to flush the catheter); the agency (extensive cost saving and quality patient care).
  • A decision at one level may lead to contact with another official who must approve the action.27
  • In addition, early savings could be attained. After that the change requires institutional approval and approval of nurses managing patients’ peripheral venous catheters.
    So the change from heparin flush to saline flush will involve:
    • Physician's ordering saline for flushing
    • Pharmacy will have to package saline for use a flush
    • The nurses also need the support to sue the saline flush and communicate the other health personals.
The Stetler model of research utilization helps practitioners assess how research findings and other relevant evidence can be applied in practice. This model examines how to use evidence to create formal change within organizations, as well how individual practitioners can use research on an informal basis as part of critical thinking and reflective practice. The model links research use, as a first step, with evidence-informed practice. The Stetler model provides a way to think about the relationship between research use and evidence-informed practice. These two concepts are not the same. Integrating both concepts enhances the overall application of research. The Stetler model first developed in 1976 and refined in 1994 and once again update in 2001.
This model consists of five phases:
  • Phase I: Preparation
  • Phase II: Validation
  • Phase III: Comparative evaluation/decision-making
  • Phase IV: Translation/application
  • Phase V: Evaluation
Phase I: Preparation—Purpose, Context and Sources of Research Evidence
This step include the identification of the purpose of consulting evidence (such as need to solve a problem and recognize the need to consider important contextual factors that could influence implementation. The researcher should note that the reasons for using evidence will also identify measurable outcomes.
Phase II: Validation—Credibility of Findings and Potential for/Detailed Qualifiers of Application
This step include critiquing and synthesizing of the evidence. When using the evidence the nurse has to assess each source of the evidence for its level of overall credibility, applicability and operational details, with the assumption that a methodologically weak study may still provide useful information in light of additional evidence and determine whether a given source has no credibility or fit and thus whether to accept or reject it for synthesis with other evidence and lastly summarize relevant details regarding each source in an ‘applicable statement of findings’ to look at the implications for practice.
Phase III: Comparative Evaluation/Decision-making—Synthesis and Recommendations per Criteria of Applicability
This step include:
  • Logically organize and display the summarized findings from across all validated sources in terms of their similarities and differences.
  • Determine whether it is desirable or feasible to apply these summarized findings in practice, based on applicability criteria, i.e. substantiating evidence, in terms of the overall strength 28of the accumulated findings. The criteria are fit to the targeted setting; current practice; and feasibility.
  • Based on the comparative evaluation, the user makes one of four choices:
    • Decide to use the research findings by putting knowledge into effect and moving forward in terms of the appropriate types of uses (instrumental, conceptual, symbolic).
    • Consider use by gathering additional internal information before acting broadly on the evidence.
    • Delay use since more research is required which you may decide to conduct based on local need (no further action is considered with the information available at this point).
    • Reject or not use (no further consideration).
Phase IV: Translation/Application—Operational Definition of Use/Actions for Change
When the nurse is using evidence-based practice she should be, write generalizations that logically take research findings and form action terms:
  • Identify type of research use.
  • Identify level of use (individual, group, organization).
  • Assess whether translation or use goes beyond actual findings/evidence.
  • Consider the need for appropriate, reasoned variation in certain cases.
  • Plan formal dissemination and change strategies and pilot project may be conducted.
Phase V: Evaluation
In this last stage of utilizing research evidence the nurse has to evaluate change strategies and pilot project.
  • Clarify expected outcomes relative to purpose of seeking evidence and whether the evaluation is related to a direct use or consider use decision.
  • Differentiate formal and informal evaluation of applying findings in practice.
  • Consider cost-benefit of various evaluation efforts.
  • Use research utilization as a process to enhance the credibility of evaluation data.
Barriers to EBP in Nursing
  • Lack of knowledge regarding EBP strategies.
  • Contradictory finding between research studies and literature create confusion among practitioners.
  • Lack of belief that EBP will result in more positive outcomes than traditional care.
  • Lack of time and resources to change the practice.
  • Lack of support from professional colleagues and organizations.
  • Over whelming patient load.
  • Peer pressure to continue with practices that are steeped in tradition.
  • Lack of continuing education programs for nurses.
  • Lack of initiatives among nursing leaders and mangers to create the environment of EBP.
  • Physician's dominance in clinical practice, thus nurses are not given autonomy to implement newer evidences.
  • Demands for certain types of treatment from patient side.
  • Lack of motivation to do new things in nursing's.
  • Fear of rejection or to change.