LESSON ELEVEN Nursing Research and Evidence-Based Practice Introduction Nursing research is an involved and dynamic process which has the potential to greatly improve nursing practice. It requires patience and discipline for those involved in a research study. It also involves critically reviewing research findings, determining their applicability to clinical practice, identifying the need for change to improve practice and implementing the required change. You may be a nurse who enjoys doing research or a nurse who questions your practice everyday and can provide the much needed research questions. You may also be a nurse willing to implement evidenced-based practice. Which ever you are -- questioning thus providing new research topics, implementing the research process or implementing the evidence gathered to change your practice -- all of us are needed if we are to keep nursing current and provide the best care we can for our clients based on scientific evidence. Learning Outcomes 1. Describes the concept of evidence-informed practice. 2. Describes how to find evidence to support quality, safe nursing care. 3. Understands the importance of critical inquiry in relation to new and evolving nursing knowledge and technologies. 4. Is aware of the significance of nursing informatics and other technologies used in health care. 5. Discusses the role of the nurse in reviewing research reports. 6. Describes the role of the nurse in collaborating with others to conduct research, participating in research and implementing research findings into practice. August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 1
Required Readings See required reading list Websites Canadian Journal of Nursing Research: http://cjnr.mcgill.ca/ Canadian Nursing Informatics Association: https://cnia.ca/ Nursing Best Practice Guidelines: http://www.rnao.org/page.asp?pageid=861&sitenodeid=133 August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 2
Nursing Research For some nurses, nursing research seems far removed from their everyday work experience. However, with the inclusion of research activities in nursing standards of practice and job descriptions, the expectation is that nurses use research to support and improve their practice. Nursing research is essential for defining nursing, providing a mechanism for establishing best practices, and advancing nursing practice. Through research, we can confirm what we know to be true by experience or we can correct our misconceptions. As a nurse giving direct care, you have probably asked yourself questions regarding nursing and certain practices. Often, by referring to nursing research studies that have been done, you can find the answers to your questions. Through the application of research findings in practice, we can improve client outcomes, enhance the professional practice environment, and contain the cost of health care. Knowledge can be acquired through many different ways such as tradition, people with specialized expertise (authorities), personal experience, trial and error, logical reasoning, and research. Research is the most sophisticated method of acquiring knowledge. The root meaning of the word research is to search again or to examine carefully. Research, by definition, is the systematic inquiry that uses orderly, disciplined methods to answer questions or solve problems. Research forms the foundation for professional nursing practice. Although the knowledge and skills required for research do not change between professions, there are distinctions among the various groups when doing research. The research within any profession must be consistent with the philosophical orientation and theories of that profession. Nursing's philosophical orientation, theories, and existing body of knowledge provide a basis for identifying the gaps in the knowledge base and determining what needs to be known. Nurses engage in research to answer questions such as, Do nurses comply with personal protection guidelines when handling body fluids? or Does giving information pamphlets preoperatively have a positive effect on client compliance with postoperative exercises? Often, these types of practice questions are the starting point of a research study. August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 3
Please Read: Lesson Eleven: Required Readings 1 Research Utilization and Evidence-Informed Practice Research utilization involves reading and critically evaluating nursing research and best practice knowledge, using relevant findings in practice, and evaluating results and communicating findings to others, to ultimately enhance client care in the clinical setting (CRNNS, 2003, p. 5). Essentially, it is the process by which research knowledge is communicated to the profession and used to improve practice, practice is then known as evidence-based or informed. When there is insufficient evidence from science, expert opinion or a combiniation of science and expert opinion is used. Evidence-informed nursing is the combination of the best scientific evidence from nursing and other research, with the special clinical perspective of nurses in performing client care activities pertinent to the nursing profession. Evidence-informed practice is the integration of the most informative research evidence with evidence from expert clinical practice and other sources to produce the best possible care for clients. Perry & Potter, 2010, p. 75 It is an approach to nursing in which nurses are aware of the evidence supporting their clinical practice and use this evidence to implement the best practice. Although this is relatively new to nursing, it is how we are able to give credibility and rationale to why we do what we do or why it is no longer necessay to continue to perform those tasks that have become obsolete. The article by Kelly et al. (2010) provided evidence of varying policies that do not always reflect current research, and a lack of research regarding oral hygiene care for stroke clients. Based on this article, nurses may decide to reevaluate the practice at their institution, get involved in writing research-based policies and procedures, or they may decide to conduct a research study, thus providing more evidence to change current practice for the better. Either way, nurses would be providing more scientific evidence for why we do what we do, thus promoting evidence-based practice. It is important as a nurse to be aware of barriers to research utilization in order to understand why evidence-informed practice for nursing is a slow evolution. The three most commonly cited barriers to research utilization in practice are: August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 4
1. Nurses lack of knowledge and negative attitudes about nursing research. Criticisms related to this include: Nurses have a limited research knowledge base. Research findings are communicated to researchers, not to nurses at the bedside. Findings are often not focused or useable in clinical practice. Findings are not expressed in terms understood by the bedside nurse. Nurses do not know how to apply research findings. 2. Perceived lack of institutional support. Institutional support required for the implementation of research findings needs to include: Library facilities with access to nursing research journals. Time for staff to read research and attend research conferences. Responsibility and accountability for nurses to change nursing practice. Administrative support, including financial assistance. 3. Limited nursing research applicable or available to clinical practice. Criticisms related to this include: Many studies rely on small, non-random samples so their findings cannot be applied to other practice settings. Therefore, a need for replication exists. Research findings are not readily accessible to nurses, as they are not generally communicated in practice journals. August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 5
Activity 1 Lesson Review 1. Why is it sometimes a challenge to obtain the best, most current evidence that you need for client care? 2. Identify resouces you can utilize when you have a question about an aspect of your nursing practice. 3. Why is the randomized controlled trial considered the gold standard (best!) in scientific research? 4. In your own words, describe what is meant by best practice guidelines or standards. August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 6
The Research Process Research, like the nursing process, is a problem solving approach. The first step in conducting research is to ask questions such as, Does this nursing practice make sense? Do we know anything about this? Nurses who have the closest contact with clients are often the best source of research questions. The next step is to make an effort to discover the answers to your questions using the latest journals, research and/or textbooks. If the answer cannot be found in the literature then maybe this is a topic for a research project. Some key components in the research process are as follows: Research Question Narrowing the topic to a researchable question is more difficult than it suggests. A researchable question is one that yields hard facts to help solve a problem, produce new research, or improve nursing practice. Literature Search You need to search the literature and find the level of knowledge about a topic. For example, is there little or no literature on a topic, or is there a theoretical framework related to the topic? This will determine whether your research design will be exploratory in nature or experimental with hypothesis. Purpose You will need to outline a purpose for the research project. The main benefit of the statement of a purpose is that it says exactly what you intend to do to answer your question. Research Design Determine your research design. The level of the study question influences your design. All research designs fall into one of two categories: descriptive or experimental. If your problem is new and little is known about it, your research will likely be exploratory descriptive. If the issue has been studied in the past and you are building on previous research, trying to prove a focused hypotheses then your research design will likely be experimental. Method Select a method to answer the question. The method, like the research design, depends again on the level of your question (i.e., exploratory and feasibility). It provides the steps, procedures, or activities that will be used to gather and analyze the data (information) you collect. For example, often in exploratory descriptive research studies participants are interviewed and asked a range of questions about the topic. The information that these interviews reveal is then organized and analyzed to determine its meaning. An experimental study may use a randomized controlled trial August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 7
as its method for gathering information, in which two groups of participants are compared. One receives an intervention, and one does not. Sample You must define the population for the research study and the method for selecting a sample from this population. Ethics The research project must account for protection of human rights. For example, coercion to participate would result in violation of human rights and rejection of a research proposal. Analysis Your research question, design, method of data collection, and level of measurement of your data will determine the way the data are analysed. For example, a descriptive exploratory study that collected data through interviews would not use statistical analysis. Once you have considered all these parts of the research process, the next step is to write a research proposal and hopefully get ethical approval and/or funding to conduct the research study. Reading Research Although all nurses in clinical practice may not have the time or opportunity to be involved in formal research projects, all nurses can and should use research to address practice questions. The first step in using research for nursing practice is understanding the research process that was just described for you. The next step is to use your understanding of nursing research to assist you in developing the ability to read and critique research articles. As you begin to read research articles, be kind with yourself. Skim reports and use your common sense. If you need help, ask someone who has more experience reading research reports. August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 8
Nursing Informatics One of the fastest growing specialties in nursing, nursing informatics involves the application of nursing science, computer science, and information technology in order to manage and communicate knowledge, data and information in nursing practice. Nurses can then use data, information and evidence-informed knowledge to provide care to clients and communities in any area. Examples of nursing informatics include the E-nursing strategy for Canada. Please Read: Lesson Eleven: Required Reading 2 August 2011 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 9