Nursing Research Methods and Critical Appraisal for Evidence-Based Practice

NINETH EDITION

Geri LoBiondo-Wood, PhD, RN, FAAN Professor and Coordinator, PhD in Nursing Program, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Judith Haber, PhD, RN, FAAN

The Ursula Springer Leadership Professor in Nursing, New York University, Rory Meyers College of Nursing, New York, New York

Table of Contents

Cover image

Title page

About the authors

Contributors

Reviewers

To the faculty

To the student

Acknowledgments I. Overview of Research and Evidence-Based Practice

Introduction

References

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

References

Research questions, hypotheses, and clinical questions

References

Gathering and appraising the literature

References

Theoretical frameworks for research

References

Processes and Evidence Related to Qualitative Research

Introduction

References

Introduction to qualitative research

References

Qualitative approaches to research

References

Appraising qualitative research

Critique of a qualitative research study

References

III. Processes and Evidence Related to Quantitative Research

Introduction

References

Introduction to quantitative research

References

Experimental and quasi-experimental designs

References

Nonexperimental designs

References

Systematic reviews and clinical practice guidelines

References

Sampling

References

Legal and ethical issues

References

Data collection methods

References

Reliability and validity

References

Data analysis: Descriptive and inferential statistics

References

Understanding research findings

References

Appraising quantitative research

Critique of a quantitative research study

References

Application of Research: Evidence-Based Practice

Introduction

References

Strategies and tools for developing an evidence-based practice

References

Developing an evidence-based practice

References

Quality improvement

References

Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer coaching and hepatitis A and B vaccine completion among homeless men recently released on parole

Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and mental health at 1 and 3 months after their infant schild s death in an intensive care unit

Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating pain: A qualitative study

Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic growth and coping in parents and siblings of adolescent cancer survivors

Example of a systematic Review/Meta analysis (Al mallah et al., 2015) The impact of nurse led clinics on the mortality and morbidity of patients with cardiovascular diseases

Glossary

Index

Special features

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NURSING RESEARCH: METHODS AND CRITICAL APPRAISAL FOR EVIDENCE-BASED PRACTICE, NINTH EDITION ISBN: 978- 0-323-43131-6

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Notices Knowledge and best practice in this field are constantly changing.

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As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

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Library of Congress Cataloging-in-Publication Data

Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor. Title: Nursing research : methods and critical appraisal for evidence-based practice / [edited by] Geri LoBiondo-Wood, Judith Haber. Other titles: Nursing research (LoBiondo-Wood) Description: 9th edition. | St. Louis, Missouri : Elsevier, [2018] |

Includes bibliographical references and index. Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper) Subjects: | MESH: Nursing Research—methods | Research Design | Evidence-Based Nursing—methods Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available at https://lccn.loc.gov/2017008727

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About the authors

Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator of the PhD in Nursing Program at the University of Texas Health Science Center at Houston, School of Nursing (UTHSC-Houston) and former Director of Research and Evidence- Based Practice Planning and Development at the MD Anderson Cancer Center, Houston, Texas. She received her Diploma in Nursing at St. Mary’s Hospital School of Nursing in Rochester, New York; Bachelor’s and Master’s degrees from the University of Rochester; and a PhD in Nursing Theory and Research from New York University. Dr. LoBiondo-Wood teaches research and evidence-based practice principles to undergraduate, graduate, and doctoral students. At MD Anderson Cancer Center, she developed and implemented the Evidence-Based Resource Unit Nurse (EB- RUN) Program. She has extensive national and international experience guiding nurses and other health care professionals in the development and utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress in Transplantation and a reviewer for Nursing Research, Oncology Nursing Forum, and Oncology Nursing. Her research and publications focus on chronic

illness and oncology nursing. Dr. Wood has received funding from the Robert Wood Johnson Foundation Future of Nursing Scholars program for the past several years to fund full-time doctoral students.

Dr. LoBiondo-Wood has been active locally and nationally in many professional organizations, including the Oncology Nursing Society, Southern Nursing Research Society, the Midwest Nursing Research Society, and the North American Transplant Coordinators Organization. She has received local and national awards for teaching and contributions to nursing. In 1997, she received the Distinguished Alumnus Award from New York University, Division of Nursing Alumni Association. In 2001 she was inducted as a Fellow of the American Academy of Nursing and in 2007 as a Fellow of the University of Texas Academy of Health Science Education. In 2012 she was appointed as a Distinguished Teaching Professor of the University of Texas System and in 2015 received the John McGovern Outstanding Teacher Award from the University of Texas Health Science Center at Houston School of Nursing.

Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership Professor in Nursing at the Rory Meyers College of Nursing at New York University. She received her undergraduate nursing education at Adelphi University in New York, and she holds a Master’s degree in Adult Psychiatric–Mental Health Nursing and a PhD in Nursing Theory and Research from New York University. Dr. Haber is internationally recognized as a clinician and educator in psychiatric–mental health nursing. She was the editor of the award- winning classic textbook, Comprehensive Psychiatric Nursing, published for eight editions and translated into five languages. She has extensive clinical experience in psychiatric nursing, having been an advanced practice psychiatric nurse in private practice for over

30 years, specializing in treatment of families coping with the psychosocial impact of acute and chronic illness. Her NIH-funded program of research addressed physical and psychosocial adjustment to illness, focusing specifically on women with breast cancer and their partners and, more recently, breast cancer survivorship and lymphedema prevention and risk reduction. Dr. Haber is also committed to an interprofessional program of clinical scholarship related to interprofessional education and improving oral-systemic health outcomes and is the Executive Director of a national nursing oral health initiative, the Oral Health Nursing Education and Practice (OHNEP) program, funded by the DentaQuest and Washington Dental Service Foundations.

Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA Psychiatric Nurse of the Year Award, the 2005 APNA Outstanding Research Award, and the 1998 ANA Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae Award, the 2011 Distinguished Teaching Award, and the 2014 NYU Meritorious Service Award. In 2015, Dr. Haber received the Sigma Theta Tau International Marie Hippensteel Lingeman Award for Excellence in Nursing Practice. Dr. Haber is a Fellow in the American Academy of Nursing and the New York Academy of Medicine. Dr. Haber has consulted, presented, and published widely on evidence-based practice, interprofessional education and practice, as well as oral-systemic health issues.

Contributors

Terri Armstrong, PhD, ANP-BC, FAANP, Senior Investigator, Neuro-oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

Julie Barroso, PhD, ANP, RN, FAAN, Professor and Department Chair, Medical University of South Carolina, Charleston, South Carolina

Carol Bova, PhD, RN, ANP, Professor of Nursing and Medicine, Graduate School of Nursing, University of Massachusetts, Worcester, Massachusetts

Dona Rinaldi Carpenter, EdD, RN, Professor and Chair, University of Scranton, Department of Nursing, Scranton, Pennsylvania

Maja Djukic, PhD, RN, Assistant Professor, Rory Meyers College of Nursing, New York University, New York, New York

Mei R. Fu, PhD, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York University, New York, New York

Mattia J. Gilmartin, PhD, RN, Senior Research Scientist , Executive Director, NICHE Program, Rory Meyers College of Nursing, New York University, New York, New York

Deborah J. Jones, PhD, MS, RN, Margaret A. Barnett/PARTNERS Professorship , Associate Dean for Professional Development and Faculty Affairs , Associate Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Carl Kirton, DNP, RN, MBA, Chief Nursing Officer, University Hospital, Newark, New Jersey; , Adjunct Faculty, Rory Meyers College of Nursing, New York University, New York, New York

Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN, Professor, Rory Meyers College of Nursing, New York University, New York, New York

Elaine Larson, PhD, RN, FAAN, CIC, Anna C. Maxwell Professor of Nursing Research , Associate Dean for Research, Columbia University School of Nursing, New York, New York

Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Gail D’Eramo Melkus, EdD, ANP, FAAN, Florence & William Downs Professor in Nursing Research, Associate Dean for Research, Rory Meyers College of Nursing, New York University, New York, New York

Susan Sullivan-Bolyai, DNSc, CNS, RN, FAAN, Associate

Professor, Rory Meyers College of Nursing, New York University, New York, New York

Marita Titler, PhD, RN, FAAN, Rhetaugh G. Dumas Endowed Professor , Department Chair, Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan

Mark Toles, PhD, RN, Assistant Professor, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina

Reviewers Karen E. Alexander, PhD, RN, CNOR, Program Director RN- BSN, Assistant Professor, Department of Nursing, University of Houston Clear Lake-Pearland, Houston, Texas

Donelle M. Barnes, PhD, RN, CNE, Associate Professor, College of Nursing, University of Texas, Arlington, Arlington, Texas

Susan M. Bezek, PhD, RN, ACNP, CNE, Assistant Professor, Division of Nursing, Keuka College, Keuka Park, New York

Rose M. Kutlenios, PhD, MSN, MN, BSN, ANCC Board Certification, Adult Psychiatric/Mental Health Clinical Specialist, ANCC Board Certification, Adult Nurse Practitioner, Nursing Program Director and Associate Professor, Department of Nursing, West Liberty University, West Liberty, West Virginia

Shirley M. Newberry, PhD, RN, PHN, Professor, Department of Nursing, Winona State University, Winona, Minnesota

Sheryl Scott, DNP, RN, CNE, Assistant Professor and Chair, School of Nursing, Wisconsin Lutheran College, Milwaukee, Wisconsin

ment 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 they 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. Research 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, 2015). There is a consensus that the research role of the baccalaureate and master’s graduate calls for critical appraisal skills. 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. 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 relate to the development of evidence-based practice. Understanding the processes 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. Five published 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 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 designs 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 research evidence. 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.

Types of research: Qualitative and quantitative Research is classified into two major categories: qualitative and quantitative. A researcher chooses between these categories based 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 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 of losing 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. ➤ Example: vanDijk et al. (2016) explored how patients assign a number to their postoperative pain experience (see Appendix C). Although qualitative research is systematic in its method, it uses a subjective approach. Data from qualitative studies help nurses understand experiences or phenomena that affect patients; these data also assist in generating theories that lead clinicians to develop improved patient care and stimulate 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 TextChapter

Research problem Abstract and/or in article introduction or separately labeled: “Problem”

Purpose Abstract and/or in introduction, or end of literature review or theoretical framework section, or labeled separately: “Purpose”

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

TF and/or 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”

Research design Stated or implied in abstract or introduction or in “Methods” or “Methodology” section

8–10

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

Legal-ethical issues Stated or implied in sections: “Methods,” “Procedures,” “Sample,” or “Subjects”

Instruments Found in sections: “Methods,” “Instruments,” or “Measures” 14

Validity and reliability

Specifically stated or implied in sections: “Methods,” “Instruments,” “Measures,” or “Procedures”

Data collection procedure

In methods section under subheading “Procedure” or “Data Collection,” or as separate heading: “Procedure”

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

CF, Conceptual framework; TF, theoretical framework.

The primary difference is that a qualitative study seeks to interpret meaning and phenomena, whereas quantitative research seeks to test a hypothesis or answer research questions using statistical methods. Remember as you read research articles that, depending on the nature of the research problem, a researcher may vary the steps slightly; however, all of the steps should be addressed systematically.

Critical reading skills To develop an expertise in evidence-based practice, you will need to be able to critically read all types of research articles. As you read a research article, you may be struck by the difference in style or format of a research article versus a clinical article. The terms of a research article are new, and the content is different. You may also be thinking that the research article is hard to read or that it is technical and boring. You may simultaneously wonder, “How will I possibly learn to appraise all the steps of a research study, the terminology, and the process of evidence-based practice? I’m only on Chapter 1. This is not so easy; research is as hard as everyone says.”

Remember that learning occurs with time and help. Reading research articles can be difficult and frustrating at first, but the best

way to become a knowledgeable research consumer is to use critical reading skills when reading research articles. As a student, you are not expected to understand a research article or critique it perfectly the first time. Nor are you expected to develop these skills on your own. An essential objective of this book is to help you acquire critical reading skills so that you can use research in your practice. Becoming a competent critical thinker and reader of research takes time and patience.

Learning the research process further develops critical appraisal skills. You will gradually be able to read a research article and reflect on it by identifying assumptions, key concepts, and methods, and determining whether the conclusions are based on the study’s findings. Once you have obtained this critical appraisal competency, you will be ready to synthesize the findings of multiple studies to use in developing an evidence-based practice. This will be a very exciting and rewarding process for you. Analyzing a study critically can require several readings. As you review and synthesize a study, you will begin an appraisal process to help you determine the study’s worth. An illustration of how to use critical reading strategies is provided in Box 1.1, which contains an excerpt from the abstract, introduction, literature review, theoretical framework literature, and methods and procedure section of a quantitative study (Nyamathi et al., 2015) (see Appendix A). Note that in this article there is both a literature review and a theoretical framework section that clearly support the study’s objectives and purpose. Also note that parts of the text from the article were deleted to offer a number of examples within the text of this chapter. BOX 1.1 Example of Critical Appraisal Reading Strategies

Introductory Paragraphs, Study’s Purpose and Aims

Globally, incarcerated populations encounter a host of public health care issues; two such issues—HAV and HBV diseases—are vaccine preventable. In addition, viral hepatitis disproportionately impacts the homeless because of increased risky sexual behaviors and drug use (Stein, Andersen, Robertson, & Gelberg, 2012), along with substandard living conditions (Hennessey, Bangsberg, Weinbaum, & Hahn, 2009). Purpose—Despite knowledge of awareness of risk factors for HBV infection, intervention programs designed to enhance completion of the three-series

Twinrix HAV/HBV vaccine and identification of prognostic factors for vaccine completion have not been widely studied. The purpose of this study was to first assess whether seronegative parolees previously randomized to any one of three intervention conditions were more likely to complete the vaccine series as well as to identify the predictors of HAV/HBV vaccine completion.

Literature Review— Concepts

Despite the availability of the HBV vaccine, there has been a low rate of completion for the three-dose core of the accelerated vaccine series (Centers for Disease Control and Prevention, 2012). Among incarcerated populations, HBV vaccine coverage is low; in a study among jail inmates, 19% had past HBV infection, and 12% completed the HBV vaccination series (Hennessey, Kim, et al., 2009). Although HBV is well accepted behind bars—because of the lack of funding and focus on prevention as a core in the prison system— few inmates complete the series (Weinbaum, Sabin, & Santibanez, 2005). In addition, prevention may not be priority.

Preventable disease vaccinations Homelessness

Authors contend that, although the HBV vaccine is cost-effective, it is underutilized among high-risk (Rich et al., 2003) and incarcerated populations (Hunt & Saab, 2009). For homeless men on parole, vaccination completion may be affected by level of custody; generally, the higher the level of custody, the higher the risk an inmate poses.

Conceptual Framework

The comprehensive health seeking and coping paradigm (Nyamathi, 1989), adapted from a coping model (Lazarus & Folkman, 1984), and the health seeking and coping paradigm (Schlotfeldt, 1981) guided this study and the variables selected (see Fig. 1.1). The comprehensive health seeking and coping paradigm has been successfully applied by our team to improve our understanding of HIV and HBV/hepatitis C virus (HCV) protective behaviors and health outcomes among homeless adults (Nyamathi, Liu, et al., 2009)—many of whom had been incarcerated (Nyamathi et al., 2012).

Methods/Design The study used a randomized clinical trial. Specific Aims and Hypotheses

In this model, a number of factors are thought to relate to the outcome variable, completion of the HAV/HBV vaccine series. These factors include sociodemographic factors, situational factors, personal factors, social factors, and health seeking and coping responses.

Subject Recruitment and Accrual

An RCT where 600 male parolees participating in an RDT program were randomized into one of three intervention conditions aimed at assessing program efficacy on reducing drug use and recidivism at 6 and 12 months, as well as vaccine completion in eligible subjects. There were four inclusion criteria for recruitment purposes in assessing program efficacy on reducing drug use and recidivism: (1) history of drug use prior to their latest incarceration, (2) between ages of 18 and 60, (3) residing in the participating RDT program, and (4) designated as homeless as noted on the prison or jail discharge form.

Procedure The study was approved by the University of California, Los Angeles Institutional Review Board and registered with clinical Trials.gov. Building upon previous studies, we developed varying levels of peer- coached and nurse-led programs designed to improve HAV/HBV vaccine receptivity at 12-month follow-up among homeless offenders recently released to parole. See Appendix A for details in the “Interventions” section.

Intervention Fidelity

Several strategies for treatment fidelity included study design, interventionist’s training, and standardization of interventions. See the Interventions section in Appendix A.

HBA, Hepatitis A virus; HBV, hepatitis B virus; RCT, randomized clinical trial.

HIGHLIGHT Start an IPE Journal Club with students from other health professions programs on your campus. Select a research study to read, understand, and critically appraise together. It is always helpful to collaborate on deciding whether the findings are applicable to clinical practice.

Strategies for critiquing research studies Evaluation of a research article requires a critique. A critique is the process of critical appraisal that objectively and critically evaluates a research report’s content for scientific merit and application to practice. It requires some knowledge of the subject matter and knowledge of how to critically read and use critical appraisal criteria. You will find:

Summarized examples of critical appraisal criteria for qualitative studies and an example of a qualitative critique in Chapter 7
Summarized critical appraisal criteria and examples of a quantitative critique in Chapter 18
An in-depth exploration of the criteria for evaluation required in quantitative research critiques in Chapters 8 through 18
Criteria for qualitative research critiques presented in Chapters 5 through 7
Principles for qualitative and quantitative research in Chapters 1 through 4

Critical appraisal criteria are the standards, appraisal guides, or questions used to assess an article. In analyzing a research article, you must evaluate each step of the research process and ask questions about whether each step meets the criteria. For instance, the critical appraisal criteria in Chapter 3 ask if “the literature review identifies gaps and inconsistencies in the literature about a subject, concept, or problem,” and if “all of the concepts and

variables are included in the review.” These two questions relate to critiquing the research question and the literature review components of the research process. Box 1.1 lists several gaps identified in the literature by Nyamathi and colleagues (2015) and how the study intended to fill these gaps by conducting research for the stated objective and purpose (see Appendix A). Remember that when doing a critique, you are pointing out strengths as well as weaknesses. Standardized critical appraisal tools such as those from the Center for Evidence Based Medicine (CEBM) Critical Appraisal Tools (www.cebm.net/critical-appraisal) can be used to systematically appraise the strength and quality of evidence provided in research articles (see Chapter 20).

Critiquing can be thought of as looking at a completed jigsaw puzzle. Does it form a comprehensive picture, or is a piece out of place? What is the level of evidence provided by the study and the findings? What is the balance between the risks and benefits of the findings that contribute to clinical decisions? How can I apply the evidence to my patient, to my patient population, or in my setting? When reading several studies for synthesis, you must assess the interrelationship of the studies, as well as the overall strength and quality of evidence and applicability to practice. Reading for synthesis is essential in critiquing research. Appraising a study helps with the development of an evidence table (see Chapter 20).

Overcoming barriers: Useful critiquing strategies throughout the text, you will find features that will help refine the skills essential to understanding and using research in your practice. A Critical Thinking Decision Path related to each step of the research process in each chapter will sharpen your decision- making skills as you critique research articles. Look for Internet resources in chapters that will enhance your consumer skills. Critical Thinking Challenges, which appear at the end of each chapter, are designed to reinforce your critical reading skills in relation to the steps of the research process. Helpful Hints, designed to reinforce your understanding, appear at various points throughout the chapters. Evidence-Based Practice Tips, which will

51 http://www.cebm.net/critical-appraisal

help you apply evidence-based practice strategies in your clinical practice, are provided in each chapter.

When you complete your first critique, congratulate yourself; mastering these skills is not easy. Best of all, you can look forward to discussing the points of your appraisal, because your critique will be based on objective data, not just personal opinion. As you continue to use and perfect critical analysis skills by critiquing studies, remember that these skills are an expected competency for delivering evidence-based and quality nursing care.

Evidence-based practice and research Along with gaining comfort while reading and critiquing studies, there is one final step: deciding how, when, and if to apply the studies to your practice so that your practice is evidence based. Evidence-based practice allows you to systematically use the best available evidence with the integration of individual clinical expertise, as well as the patient’s values and preferences, in making clinical decisions (Sackett et al., 2000). Evidence-based practice involves processes and steps, as does the research process. These steps are presented throughout the text. Chapter 19 provides an overview of evidence-based practice steps and strategies.

When using evidence-based practice strategies, the first step is to be able to read a study and understand how each section is linked to the steps of the research process. The following section introduces you to the research process as presented in published articles. Once you read a study, you must decide which level of evidence the study provides and how well the study was designed and executed. Fig. 1.1 illustrates a model for determining the levels of evidence associated with a study’s design, ranging from systematic reviews of randomized clinical trials (RCTs) (see Chapters 9 and 10) to expert opinions. The rating system, or evidence hierarchy model, presented here is just one of many. Many hierarchies for assessing the relative worth of both qualitative and quantitative designs are available. Early in the development of evidence-based practice, evidence hierarchies were thought to be very inflexible, with systematic reviews or meta-analyses at the top and qualitative research at the bottom. When assessing a clinical

question that measures cause and effect, this may be true; however, nursing and health care research are involved in a broader base of problem solving, and thus assessing the worth of a study within a broader context of applying evidence into practice requires a broader view.

FIG 1.1 Levels of evidence: Evidence hierarchy for rating levels of evidence associated with a study’s

design. Evidence is assessed at a level according to its source.

The meaningfulness of an evidence rating system will become clearer as you read Chapters 8 through 11. ➤ Example: The Nyamathi et al. (2015) study is Level II because of its experimental, randomized control trial design, whereas the vanDijk et al. (2016) study is Level VI because it is a qualitative study. The level itself does not tell a study’s worth; rather it is another tool that helps you think about a study’s strengths and weaknesses and the nature of

the evidence provided in the findings and conclusions. Chapters 7 and 18 will provide an understanding of how studies can be assessed for use in practice. You will use the evidence hierarchy presented in Fig. 1.1 throughout the book as you develop your research consumer skills, so become familiar with its content.

This rating system represents levels of evidence for judging the strength of a study’s design, which is just one level of assessment that influences the confidence one has in the conclusions the researcher has drawn. Assessing the strength of scientific evidence or potential research bias provides a vehicle to guide evaluation of research studies for their applicability in clinical decision making. In addition to identifying the level of evidence, one needs to grade the strength of a body of evidence, incorporating the domains of quality, quantity, and consistency (Agency for Healthcare Research and Quality, 2002).

Quality: Extent to which a study’s design, implementation, and analysis minimize bias.
Quantity: Number of studies that have evaluated the research question, including overall sample size across studies, as well as the strength of the findings from data analyses.
Consistency: Degree to which studies with similar and different designs investigating the same research question report similar findings.

The evidence-based practice process steps are: ask, gather, assess and appraise, act, and evaluate (Fig. 1.2). These steps of asking clinical questions; identifying and gathering the evidence; critically appraising and synthesizing the evidence or literature; acting to change practice by coupling the best available evidence with your clinical expertise and patient preferences (e.g., values, setting, and resources); and evaluating if the use of the best available research evidence is applicable to your patient or organization will be discussed throughout the text.

FIG 1.2 Evidence-based practice steps.

To maintain an evidence-based practice, studies are evaluated using specific criteria. Completed studies are evaluated for strength, quality, and consistency of evidence. Before one can proceed with an evidence-based project, it is necessary to understand the steps of the research process found in research studies.

Research articles: Format and style Before you begin reading research articles, it is important to understand their organization and format. Many journals publish research, either as the sole type of article or in addition to clinical or theoretical articles. Many journals have some common features but also unique characteristics. All journals have guidelines for manuscript preparation and submission. A review of these guidelines, which are found on a journal’s website, will give you an idea of the format of articles that appear in specific journals.

Remember that even though each step of the research process is discussed at length in this text, you may find only a short paragraph or a sentence in an article that provides the details of the step. A publication is a shortened version of the researcher(s) completed work. You will also find that some researchers devote more space in an article to the results, whereas others present a longer discussion of the methods and procedures. Most authors give more emphasis to the method, results, and discussion of implications than to details of assumptions, hypotheses, or definitions of terms. Decisions about the amount of material presented for each step of the research process are bound by the following:

A journal’s space limitations

A journal’s author guidelines
The type or nature of the study
The researcher’s decision regarding which component of the study is the most important

The following discussion provides a brief overview of each step of the research process and how it might appear in an article. It is important to remember that a quantitative research article will differ from a qualitative research article. The components of qualitative research are discussed in Chapters 5 and 6, and are summarized in Chapter 7.

Abstract An abstract is a short, comprehensive synopsis or summary of a study at the beginning of an article. An abstract quickly focuses the reader on the main points of a study. A well-presented abstract is accurate, self-contained, concise, specific, nonevaluative, coherent, and readable. Abstracts vary in word length. The length and format of an abstract are dictated by the journal’s style. Both quantitative and qualitative research studies have abstracts that provide a succinct overview of the study. An example of an abstract can be found at the beginning of the study by Nyamathi et al. (2015) (see Appendix A). Their abstract follows an outline format that highlights the major steps of the study. It partially reads as follows:

Purpose/Objective: “The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of the three levels of peer counseling (PC) and nurse delivered intervention was compared at 12 month follow up.”

In this example, the authors provide a view of the study variables. The remainder of the abstract provides a synopsis of the background of the study and the methods, results, and conclusions. The studies in Appendices A through D all have abstracts.

HELPFUL HINT An abstract is a concise short overview that provides a reference to the research purpose, research questions, and/or hypotheses, methodology, and results, as well as the implications for practice or

future research.

Introduction Early in a research article, in a section that may or may not be labeled “Introduction,” the researcher presents a background picture of the area researched and its significance to practice (see Chapter 2).

Definition of the purpose The purpose of the study is defined either at the end of the researcher’s initial introduction or at the end of the “Literature Review” or “Conceptual Framework” section. The study’s purpose may or may not be labeled (see Chapters 2 and 3), or it may be referred to as the study’s aim or objective. The studies in Appendices A through D present specific purposes for each study in untitled sections that appear in the beginning of each article, as well as in the article’s abstract.

Literature review and theoretical framework Authors of studies present the literature review and theoretical framework in different ways. Many research articles merge the “Literature Review” and the “Theoretical Framework.” This section includes the main concepts investigated and may be called “Review of the Literature,” “Literature Review,” “Theoretical Framework,” “Related Literature,” “Background,” “Conceptual Framework,” or it may not be labeled at all (see Chapters 2 and 3). By reviewing Appendices A through D, you will find differences in the headings used. Nyamathi et al. (2015) (see Appendix A) use no labels and present the literature review but do have a section labeled theoretical framework, while the study in Appendix B has a literature review and a conceptual framework integrated in the beginning of the article. One style is not better than another; the studies in the appendices contain all the critical elements but present the elements differently.

HELPFUL HINT Not all research articles include headings for each step or component of the research process, but each step is presented at

some point in the article.

Hypothesis/research question A study’s research questions or hypotheses can also be presented in different ways (see Chapter 2). Research articles often do not have separate headings for reporting the “Hypotheses” or “Research Question.” They are often embedded in the “Introduction” or “Background” section or not labeled at all (e.g., as in the studies in the appendices). If a study uses hypotheses, the researcher may report whether the hypotheses were or were not supported toward the end of the article in the “Results” or “Findings” section. Quantitative research studies have hypotheses or research questions. Qualitative research studies do not have hypotheses, but have research questions and purposes. The studies in Appendices A, B, and D have hypotheses. The study in Appendix C does not, since it is a qualitative study; rather it has a purpose statement.

Research design The type of research design can be found in the abstract, within the purpose statement, or in the introduction to the “Procedures” or “Methods” section, or not stated at all (see Chapters 6, 9, and 10). For example, the studies in Appendices A, B, and D identify the design in the abstract.

One of your first objectives is to determine whether the study is qualitative (see Chapters 5 and 6) or quantitative (see Chapters 8, 9, and 10). Although the rigor of the critical appraisal criteria addressed do not substantially change, some of the terminology of the questions differs for qualitative versus quantitative studies. Do not get discouraged if you cannot easily determine the design. One of the best strategies is to review the chapters that address designs. The following tips will help you determine whether the study you are reading employs a quantitative design:

Hypotheses are stated or implied (see Chapter 2).
The terms control and treatment group appear (see Chapter 9).
The terms survey, correlational, case control, or cohort are used (see

Chapter 10).

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Nursing Research Methods and Critical Appraisal for Evidence-Based Practice