Developing an Evidence-Based PracticeCopyright © 2014,

Developing an
Evidence-Based Practice
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by Mosby, an imprint of Elsevier Inc.
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Conscientious and judicious use of current best evidence in
conjunction with clinical expertise and patient values to guide
health care decisions
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Evidence-based practice is the conscientious and judicious use
of current best evidence in conjunction with clinical expertise
and patient values to guide health care decisions.

Research utilization
Evidence-based practice encompasses research utilization but
also case reports and expert opinion
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Research utilization is a subset of EBP that focuses on the
application of research findings.
Evidence-based practice is a broader term that encompasses
research utilization but also case reports and expert opinion.
Multifaceted, systemic process of promoting adoption of
evidence-based practices in delivery of health care services that
goes beyond dissemination of evidence-based guideline
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Dissemination: publications, conferences, consultations, and
training programs
Conscientious and judicious use of current best evidence in
conjunction with clinical expertise and patient values to guide
health care decisions
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Validates current practice, changes in practice, cost-
effectiveness, and quality of care
High-quality
Cost-effective
Outcomes
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Research

Conduct
Research
Utilization
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Questions about current nursing practice
Literature review
Need for investigation
Clinical research
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*Knowledge and problem-focused “trigger(s)” lead to questions
about current nursing practice.A literature review and critique
of studies finds that there is not a sufficient number of
scientifically sound studies to use as a base for practice.Need
for investigation.Nurses in practice collaborate with scientists
in nursing and other disciplines conducting clinical research.
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*Knowledge and problem-focused “trigger(s)” lead to questions
about current nursing practice.A literature review and critique
of studies finds that there is not a sufficient number of
scientifically sound studies to use as a base for practice.Need
for investigation.Nurses in practice collaborate with scientists
in nursing and other disciplines conducting clinical research.
Develop and implement improved practice
Other types of evidence
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Findings are then combined with evidence from existing
scientific knowledge to develop and implement improved
practice.
If there is insufficient research to guide practice, and
conducting a study is not feasible, other types of evidence (e.g.,
case reports, expert opinion, scientific principles, theory) are
used and/or combined with available research evidence.
Priority is given to projects in which a high proportion of
practice is guided by research evidence.
If a practice change is warranted, changes are implemented
using a process of planned change.

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Priority is given to projects in which a high proportion of
practice is guided by research evidence. Practice guidelines
usually reflect research and nonresearch evidence and therefore
are called EBP guidelines.
If a practice change is warranted, changes are implemented
using a process of planned change. The practice is first
implemented with a small group of patients, and an evaluation
is carried out.
EBP is refined based on evaluation data.
Outcomes are monitored.
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The EBP is then refined based on evaluation data, and the
change is implemented with additional patient populations for
which it is appropriate.
Patient/family, staff, and fiscal outcomes are monitored.

Selecting a topic
Problem-focused triggers
Quality improvement data
Risk-surveillance data
Benchmarking data
Financial data
Recurrent clinical problems
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Selecting a topic
Knowledge-focused triggers
Reading research
Listening to scientific papers at research conferences
Reviewing EBP guidelines published by federal agencies or
specialty organizations
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Critical that staff members:
Be involved in selecting the topic
View the potential practice as contributing significantly to
patient care
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No matter what method is used to select an EBP topic, it is
critical that the staff members who will implement the potential
practice changes are:
Involved in selecting the topic View it as contributing
significantly to the quality of care
Forming a team
Composition of the team
Key stakeholders identified
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Forming a teamThe composition of the team is directed by the
topic selected and should include interested stakeholders in the
delivery of care. Key stakeholders who can facilitate the EBP

project or put up barriers against successful implementation
should be identified. A stakeholder is a key individual or group
of individuals who will be directly or indirectly affected by the
implementation of the EBP.
Identification of key stakeholders:
How are decisions made?
What types of changes will be needed?
Who is involved in decision-making?
Who is likely to lead and champion implementation?
Who can influence the decisions?
What type of cooperation is needed?
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Questions to consider in identification of key stakeholders
include: How are decisions made in the practice areas where the
EBP will be implemented?What types of system changes will be
needed? Who is involved in decision-making? Who is likely to
lead and champion implementation of the EBP?Who can
influence the decision to proceed with implementation of an
EBP? What type of cooperation do you need from which
stakeholders to be successful?
Failure to involve or keep supportive stakeholders informed
may place the success of the EBP project at risk because they
are unable to anticipate and/or defend the rationale for changing
practice, particularly with resistors (non-supportive
stakeholders) who have a great deal of influence among their
peer group.

Question clearly defined:
Types of people and patients
Interventions or exposures
Outcomes
Relevant study designs
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A clearly defined question should specify
Types of people/patientsDiseases or conditions of
interestPatient population (e.g., age, gender, educational
status)Setting
Interventions or exposuresTypes of interventions of interest to
the projectComparison interventions (e.g. standard care,
alternative treatments)
Outcomes
Outcomes of primary importanceType of outcome data that
will be needed for decision-making (e.g. benefits, harm, cost)
Avoid including outcomes that may be interesting but of little
importance to the project
Relevant study designsProvide reliable data Search for the
highest level of evidence available
Consider using PICO
Patient, population, or problem
Intervention or treatment

Comparison intervention or treatment
Outcomes
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Evidence examined should include:
Clinical studies, meta-analyses, integrative literature reviews,
and existing EBP guidelines
Identify key search terms
Use the expertise of health science librarians
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It is helpful to categorize articles and read in this order:
Clinical (nonresearch)
Theory articles
Integrative and systematic reviews
Synthesis reports

EBP guidelines
Research articles
Meta-analyses
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There are many grading schemas available but all address:
Quality of the individual research
Strength of the body of evidence
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Before reviewing the literature, it is imperative that the team
agree on:
Methods for categorizing the type of research
Rating the quality of individual articles
Grading the strength of the body of evidence

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Date of publication or release
Authors of the guideline
Endorsement of the guideline
Clear purpose of what the guideline covers and the patient
groups for which it was designed
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Types of evidence (research, nonresearch) used in formulating
the guideline
Types of research included in formulating the guideline
Description of the methods used in grading the evidence
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Search terms and retrieval methods used to acquire research and
nonresearch evidence used in the guideline
Well-referenced statements regarding practice
Comprehensive reference list
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Review of the guideline by experts
Whether the guideline has been used or tested in practice and, if
so, with what types of patients and in what types of settings
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Best as a group project
Journal club
Novice and expert
Assistance from students
Use graduate students
Class project
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Best as a group projectUse a journal club to discuss critiques
done by each member of the group.Pair a novice and expert to
do critiques.Get assistance from students who may be interested
in the topic and want experience doing critiques.Assign the
critique process to graduate students interested in the
topic.Make a class project of critique and synthesis of research
for a given topic.
Use summary tables to synthesize information and include:
Study purpose
Research questions and hypotheses
Variables studied
Description of sample and setting
Research design

Methods used to measure each variable
Description of the intervention tested
Findings
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Use summary tables to synthesize information. Include:Study
purposeResearch questions/hypothesesThe variables studiedA
description of the study sample and settingThe type of research
designThe methods used to measure each variableDetailed
description of the independent variable/intervention testedThe
study findings
Practice changes based on evidence
Consider:
Relevance
Consistency
Sample characteristics
Feasibility
Risk-benefit ratio
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Practice changes should be based on evidence derived from
several sources demonstrating consistent findings.
Consider:Relevance for practiceConsistency in findings across
studies/guidelinesA significant number of studies/guidelines
with sample characteristics similar to those to which the
findings will be usedConsistency between research and
nonresearch evidence Feasibility for use in practiceThe
risk/benefit ratio
Put in writing the evidence base of the practice.
Clinicians need to know:
That recommended practices are based on evidence
The type of evidence (e.g., randomized clinical trial, expert
opinion) used in developing the EBP standard
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Implementing the practice change
Rogers’ model on diffusion of innovationsNature of the
innovation Manner in which it is communicated
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Implementing the practice change
Rogers’ model on diffusion of innovations theorizes that
adoption of innovations, such as EBPs are influenced by:The
nature of the innovation (e.g. the type and strength of evidence;
the clinical topic)The manner in which it is communicated
(disseminated) to members (nurses) of a social system
(organization, nursing profession)
Characteristics of innovations that influence adoption:
Advantage
Compatibility
Complexity
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Characteristics of innovations that influence adoption:The
relative advantage of the EBP (e.g. effectiveness, rel evance to
the task, social prestige)The compatibility with values, norms,
work, and perceived needs of usersThe complexity of the EBP
topic
Strategies to promote adoption:
Reinvention of the EBP guideline to fit the local context
Use of quick reference guides and decision aids

Use of clinical reminders
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Methods of communicating change:
Mass media
Educational strategies
Opinion leaders
Change champions
Core groups
Educational outreach
Performance gap assessment
Audit and feedback
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Methods of communicating change:
Mass media
Educational strategies PostersTrain-the-trainer
programsComputer assisted trainingCompetency testing
Opinion leadersMembers of the local peer groupViewed as a
respected source of influenceConsidered by associates as

technically competentTrusted to judge the fit between the
innovation and the local setting
Change championsPractitioners within the local group setting
Expert cliniciansPassionate about the innovationCommitted to
improving quality of careHave a positive working
relationshipsThey are encouraging and persistentParticularly
effective with nurses
Core groupsA select group of practitioners who disseminate
information and facilitate changeMembers represent various
shifts and days of the weekMembers knowledgeable about the
scientific basis for the practiceMembers take the responsibility
educating and effecting practice change with several peersThey
reinforce the practice change on a daily basis and provide
positive feedback
Educational outreach/academic detailingDone by a topic expert
who may be external to the practice settingMeets one-on-one
with practitioners These experts are able to explain the research
base for the EBPs to others and are able to respond
convincingly to challenges and debatesAdvanced practice nurses
often fill this role
Performance gap assessmentInforms members, at the beginning
of change, about a practice performance and opportunities for
improvementSpecific practice indicators selected
Audit and feedbackOngoing auditing of performance indicators
Aggregating data into reportsDiscussing the findings with
practitionersOccurs during the practice change
Social context and change
Strong leadership
Clear strategic vision
Good managerial relations
Visionary staff in key positions
A climate conducive to experimentation and risk taking
Effective data capture systems

Available resources to support change
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Goal is to collect and analyze data with regard to use of a new
EBP and then to modify the practice as necessary.
Evaluation should include both:
Process measures
Outcome evaluation
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Goal is to collect and analyze data with regard to use of a new
EBP and then to modify the practice as necessary
Evaluation should include both process and outcome measures
Process measures Focus on how the EBP change is being
implemented. Is staff using the practice in care delivery and
implementing the practice as noted in the written EBP standard?
Outcome evaluation Assess whether the patient, staff, and/or
fiscal outcomes expected are achievedBaseline data needed for a
pre/post comparison
Process measures should evaluateBarriers that staff encounter in

carrying out the practice Differences in opinions among health
care providersDifficulty in carrying out the steps of the practice
as originally designed Data can be collected from staff and/or
patient self-reports, medical record audits, or observation of
clinical practice
Outcome measures should evaluateThe practices that are
projected to changePractice before the change in practice is
implemented, after implementation, and every 6 to 12 months
Findings must be provided to clinicians to:
Reinforce the impact of the change in practice
Ensure that they are incorporated into quality improvement
programs
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Education must include knowledge and skills in the use of
research evidence in practice.
Communicate and integrate EBP into nursing profession.
Professional responsibility of all nurses to read and use research
in their practice and to communicate with nurse scientists the
many and varied clinical problems for which we do not yet have
a scientific base.
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The researcher
A direct care provider
The hospital administrator or CEO
The head nurse or CNO
A mixture of management and direct care providers
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ANSWER: E
RATIONALE: A group of people--and they should be key
stakeholders in the decision-making process--would be most
effective in implementing EBP changes.
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Education specialist
Information technologist
Opinion leader
Risk manager
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ANSWER: C
RATIONALE: Of course, all of these help, but opinion
leadership is multifaceted and complex, with role functions
varying by the circumstances. Few successful projects to
implement innovations in organizations have managed without
the input of identifiable opinion leaders. They champion the
cause.
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Strong leadership
Clear strategic vision
Visionary staff in key positions
A climate conducive to experimentation and risk taking
All of the above
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ANSWER: E
Rationale: All answers are correct.
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Patient outcomes
Cost savings

Who is successfully using it
Barriers overcome
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ANSWER: A
RATIONALE: Patient outcomes is slightly ahead of cost
savings. Both are important. Evaluation should include both
process and outcome measures. The process component focuses
on how the EBP change is being implemented. It is important to
know whether staff are using the practice in care delivery and
whether they are implementing the practice as noted in the
written EBP standard. Evaluation of the process also should
note (1) barriers that staff encounter in carrying out the practice
(e.g., lack of information, skills, or necessary equipment), (2)
differences in opinions among health care providers, and (3)
difficulty in carrying out the steps of the practice as originally
designed.
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Chapter 19
Strategies and Tools for Developing an Evidence-Based Practice
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Tool #1: Asking a Focused
Clinical Question
Develop the question by addressing these four issues:
Population
Intervention
Comparison
Outcome
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Develop the question by answering these four questions:What is
the population I am interested in?What is the intervention I am
interested in?What will this intervention be compared to? (Note:
Depending on the study design, this step may or may not
apply.)How will I know if the intervention makes things better
or worse (identify an outcome that is measurable)?
Categorize the Clinical Question
Therapy category:
Experimental or quasi-experimental
Outcome known
Therapy appraisal tool at:
http://www.casp-uk.net/wp-

content/uploads/2011/11/CASP_RCT_Appraisal_Checklist_14oc
t10.pdf.
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1. Therapy category: If the question is about the effectiveness
of a particular treatment or intervention, select studies with
experimental or quasi-experimental study design.
Use a therapy appraisal tool to evaluate the article. A tool can
be accessed at:
http://www.phru.nhs.uk/Pages/PHD/resources.htm
Outcome known or of probable clinical importance observed
over a clinically significant period of time.
Diagnosis category:
Cross-sectional
Comparison of the new and the “gold standard”
Diagnostic tool at:
content/uploads/2011/11/CASP_Diagnostic_Appraisal_Checklis
t_14oct10.pdf.
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2. Diagnosis category: If the question is about the usefulness,
accuracy, selection, or interpretation of a measurement
instrument or laboratory test, select studies with:Cross-sectional
study design (see Chapter 9) with people suspected to have the
condition of interestUse a diagnostic test appraisal tool to
evaluate the article. A diagnostic tool can be accessed at
Comparison of the results of the new instrument or test and the
“gold standard”
Prognosis category:
Nonexperimental
Follow-up
Determination of factors
Prognosis tool at:
content/uploads/2011/11/CASP_Cohort_Appraisal_C hecklist_14
oct10.pdf
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3. Prognosis category: If the question is about a patient’s likely
course for a particular disease state or to identify factors that
may alter the patient’s prognosis, select studies
with:Nonexperimental, usually longitudinal study of a particular

group for a particular outcome or diseaseFollow-up for a
clinically relevant period of time (time is the
exposure)Determination of factors in those who do and do not
develop a particular outcome
Use a prognosis appraisal tool to evaluate the article. A
prognosis tool can be accessed at
Harm category:
Nonexperimental
Exposure
Harm appraisal tool at:
content/uploads/2011/11/CASP_Case-
Control_Appraisal_Checklist_14oct10.pdf.
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4. Etiology-causation-harm category: If the question concerns
determining whether or not one thing is related to or caused by
another, select studies with:Nonexperimental, usually
longitudinal or retrospective (ex post facto) study designs over
a clinically relevant period of time Assessment of whether or
not the patient has been exposed to the independent variableUse
a harm appraisal tool to evaluate the article. A harm appraisal
tool can be accessed at

Tool #2: Searching the Literature
Consult librarian
Tutorial for PubMed at
www.nlm.nih.gov/bsd/disted/pubmed.html#qt
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Consult your academic research librarian for assistance.
You can also learn how to effectively search PubMed through a
Web-based tutorial located at
http://www.nlm.nih.gov/bsd/disted/pubmed.html#qt.
Tool #3: Screening Your Findings
Peer-reviewed journal?
Similar setting and sample?
Study sponsorship?
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*Is this article from a peer-reviewed journal? Articles published
in a peer-reviewed journal have had an extensive review and

editing process Are the setting and sample of the study similar
to mine so that results, if valid, would apply to my practice or
to my patient population?Is the study sponsored by an
organization that might influence the study or the design or
results?
Tool #4: Appraise Each Article’s Findings
Therapy studies
Is there a difference between two or more treatments?
Numerical values are either continuous or discrete.
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Therapy studiesAttempt to determine whether a difference
exists between two or more treatments. Numeric values in these
studies are either continuous or discrete.
Continuous and Discrete Variables
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*ObjectiveVariableOutcomeCONTINUOUS
VARIABLESChange after exposure to interventionPain score
Levels of distress Blood pressure WeightMeasures of central
tendencyDISCRETE VARIABLES“Event” occurred or did not
occurDeath
Diarrhea
Pressure ulcer PregnancyMeas ures of event probability

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CONTINUOUS VARIABLES Researcher objective: Researcher
is interested in degree of change after exposure to an
intervention.Examples of variables: Pain score, levels of
distress, blood pressure, weight How the outcome is
described: Measures of central tendency (e.g., mean, median, or
standard deviation)
DISCRETE VARIABLES Researcher objective: Researcher
is interested in whether or not an “event” occurred or did not
occur.Examples of variables: Death, diarrhea, pressure ulcer,
pregnancy. How the outcome is described: Measures of
event probability (e.g., relative risk, odds ratio or number
needed to treat)
Diagnosis Articles

Sensitivity is the proportion of those with disease who test
positive; that is, sensitivity is a measure of how well the test
detects disease when it is really there—a highly sensitive test
has few false negatives.
Specificity is the proportion of those without disease who test
negative. It measures how well the test rules out disease when it
is really absent; a specific test has few false positives.
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*If a trial were repeated many times, results would be expected
to differ slightly from trial to trial. However, results would also
be expected to fall within a certain range that would lie around
the “true” result. In reality, trials are usually done only once.
The confidence interval (95% CI is most widely used) is an
estimate of the range within which the “true” result is likely to
fall.
Sensitivity
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*Measure of Accuracy
Definition
CommentsSensitivityAbility of the test to detect the proportion
of people with the disease or disorder of interestTP/(TP + FN),
where TP and FN are number of true-positive and false-negative
results, respectively

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Sensitivity: A characteristic of a diagnostic test. It is the ability
of the test to detect the proportion of people with the disease or
disorder of interest. For a test to be useful in ruling out a
disease, it must have a high sensitivity.
Specificity
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*Measure of Accuracy
Definition
CommentsSpecificityAbility of the test to detect the proportion
of people without the disease or disorderTN/(TN + FP), where
TN and FP are number of true-negative and false-positive
results, respectively
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Specificity: A characteristic of a diagnostic test. It is the ability
of the test to detect the proportion of people without the dise ase
or disorder of interest. For a test to be useful at confirming a
disease, it must have a high specificity. Formula for sensitivity:
TN/(TN + FP), where TN and FP are number of true-negative
and false-positive results, respectively.
Prognosis Articles
Odds ratio: Probability of developing the outcome or a
particular disease.
Indicates how much more likely certain independent variables
(factors) predict the probability of developing the dependent
variable (outcome or disease).
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fall.
Odds Ratio

Odds ratio
The odds ratio (OR) best describes the data in case-control
studies.
The OR = probability of an event
Calculated by dividing the odds in the treated or exposed group
by the odds in the control group
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*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Harm studies:The odds ratio (OR) is the measure of association
that best describes the analyzed data in case-control studies.The
OR communicates the probability of an event. OR is calculated
by dividing the odds in the treated or exposed group by the odds
in the control group.
Harm Articles
Used to determine if an individual has been harmed by being
exposed to a particular event
Case-control design: investigators select the outcome they are
interested in (e.g., pressure ulcers), and examine if any one
factor explains those who have and do not have the outcome of
interest.
The measure of association that best describes the analyzed data
in case-control studies is the odds ratio.
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*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986

fall.
Meta-analysis
A research method that statistically combines the results of
multiple studies (usually randomized clinical trials) to answer a
focused clinical question through an objective appraisal of
carefully synthesized research evidence
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Meta-analysis
Terms “meta-analysis,” “systematic review,” and “integrative
review” are used interchangeably.
Meta-analysis is a quantitative approach to a systematic review,
whereas an integrative review uses a nonquantitative approach.
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986

*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Meta-analysis
Meta-analyses and integrative reviews are both considered
systematic reviews and provide level I evidence.
Each uses a standardized process, which has a set of
preestablished criteria that guide its implementation.
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*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Steps in a Meta-analysis
Clinical question
Search for all relevant studies
What studies are included
Assess the quality of each study
Studies statistically combined
Conclusion
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*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*A clinical question is formulated. A team of at least two
investigators search for all relevant studies, published and
unpublished, on the topic or question Using pre-established
inclusion and exclusion criteria team determines the studies that
will be used in the meta-analysisAt least two individuals
independently assess the quality of each study, include or
exclude studies based on preestablished criteriaThe results of
individual studies are statistically combinedA balanced and
impartial quantitative and narrative evidence summary is
prepared representing a “state of the science” conclusion about
the strength, quality, and consistency of evidence
Measures in Meta-analysis Systematic Review
The OR is the statistic of choice for use in a meta-analysis.
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
*
Interpreting Odds Ratios

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*Odds ratioType of OutcomeAdverse outcomeBeneficial
outcomeLess than 1Intervention betterIntervention worse = to 1
(null)Intervention no better or worseIntervention no better or
worseGreater than 1Intervention worseIntervention better
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*
What is the most important step in applying evidence to
practice?
PICO (population, intervention, comparison, and outcome)
Critically reviewing the literature
Putting the research into practice
Evaluating efficacy of the new practice
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*
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ANSWER: A
RATIONALE: All are important, but a focused clinical question
using PICO (population, intervention, comparison, and
outcome) lays the foundation.

*
Which EBP clinical category would the nurse be using in the
following scenario?
A clinical nurse has noticed an increased incidence in urinary
tract infections and would like to find the best practice to
minimize this.
Therapy
Diagnosis
Prognosis
Harm
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*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
ANSWER: D
RATIONALE: Harm; the nurse wants to determine whether or
not one thing is related to or caused by another.
*
When completing a literature search for a clinical question,
what is the first resource the nurse should use?
Evidence-based nursing
CINAHL
PUBMED
Cochrane review
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*

Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
ANSWER: A
RATIONALE: Evidence-based nursing is a prefiltered source
and is available online at http://ebn.bmjjournals.com/ and in
print.
*
For the nurse who has limited time to review a research article,
where would be the best place to find the answer to the clinical
question?
Abstract
Method
Conclusion
Table
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*
Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986
ANSWER: D
RATIONALE: When evaluating whether or not you should
spend time reviewing an article, examine the article’s tables.
The information you need to answer your clinical question
should be contained in one or more of the tables.
*
NRSE 4550 – Evidence-Based Nursing

August 2012 Ohio University© Page 1 of 1
Quantitative Research
Sample Literature Review Critique
Learning to critique a literature review is an important aspect of
understanding research. This optional activity can
provide you with additional practice as you learn more about
what you should expect to find in a literature review
in a research study. Although various literature reviews may
differ, some general expectations about things you
will find exist. Consult chapter #4 of your text to familiarize
yourself with these ideas. Look at the criteria that
should be considered when critiquing a literature review. Take a
look at the activities in the accompanying
workbook to identify more about the key components of a
literature review.
In your textbook are a number of research studies (see
Appendices) that you can use to compare the way different
literature reviews are written. What are the similarities and
differences in the ways different researchers present
their literature to support the study? Does one style seem better
than another? If so, what is it that makes it seem

better?
Use the critiquing criteria for literature reviews found in
chapter #4 of the textbook. After you have read the
literature review below, then consider these questions:
1. Does the literature provide you with a good perspective of
the topic?
2. Does the review of literature uncover new knowledge?
3. Are there other things you think should have been included in
this review? Why?
4. Did the review of the literature provide strong bases for
research in the clinical practice setting?
As you study and try to understand more about what makes a
good literature review, you will need to look at a
variety of different literature review sections of research
papers. Think of this as the foundation for the study.
Without a good foundation, the entire study may prove shaky.
Researchers need to know what has already been
done in research related to a topic and have clear
understandings about what is already known prior to beginning
a
new research study. Research should build on previous
knowledge and a new study should add to what is known.
Learning to critique literature reviews takes practice. However,

if the research is about a topic that you are
unfamiliar with, you may find yourself feeling somewhat like a
fish out of water. While it is difficult to critique
things when you are less familiar, the use of the critiquing
criteria provides you with some excellent tools for
thinking about the content and identifying the quality of
information provided. As novice researchers, we have to
trust the expertise of those who were peer-reviewers of the
article, those that made the decision to publish the
study. When things are published in high quality nursing
journals and have been peer-reviewed, then even if we
are novices we can still have some confidence in the quality of
the work.
You may want to spend some time working through the
activities in the Rose-Grippa & McGorney workbook for
additional experience in understanding the various aspects of
literature reviews. Literature reviews supply the
assumptions and knowledge upon which research studies are
developed.
1

THE NIGHTINGALE LEGACY
CHILD HEALTH 2000
International Pediatric Nursing Conference
Friday, June 2, 1995
Heather F. Clarke, RN, PhD
Nursing Research Consultant
Registered Nurses Association of British Columbia,
Vancouver, B.C., Canada
2
INTRODUCTION
"The time has come the walrus said to talk of many things, of
sailing ships and sealing
wax and cabbages and kings". Indeed the time has come - and

its a time of reform - not just a
tinkering around the edges - but of rule breaking; not just
reducing/maintaining costs but of
reengineering - doing more with less; not just developing new
technologies but of their creative
use. Albert Einstein's wisdom is as relevant today as it was
decades ago "The significant
problems we face cannot be solved at the same level of thinking
we were at when we created
them."
The clues that it is a time for calling in the chits include: -
evidence-based practice is "in"
- ritual and intuition are "out" - inappropriate/ineffective
diagnostic and therapeutic interventions
are not being tolerated - evidence-based tools for decision-
making in practice (e.g. CPGs, Care
Maps, Critical Paths) are proliferating and being made widely
accessible (e.g. on-line, internet) -
accountability for outcomes is demanded of each and every
health care profession - the "lone
ranger" practitioner is neither effective nor tolerated -
"collaborative" practice is taking on many
shapes and sizes - consumer participation in decision making is
not an option - the medical

model (paradigm) has been replaced (by many if not most) by
the consumer model (paradigm) -
In this era of shared responsibility and cost-consciousness,
patient preferences are a key element
of health care decisions and should be considered in the
development of practice guidelines.
How come it is taking us so long to recognize these clues - to
re-conceptualize our world
of professional nursing - to clearly demonstrate how nursing
care makes a difference - how
health care resources and therapeutic nursing interventions are
effectively and efficiently utilized
3
to improve the health status of clients of our health care
system? Clearly, there is a need to
improve the research and evidence bases of our practice. This is
the Nightingale Legacy -
Research and Practice. In Nightingale's view, nursing should be
a search for truth. She held that
the ability to collect accurate information and make correct
observations is essential. "If you

cannot get the habit of observation one way or other, you had
better give up being a nurse, for it
is not your calling, however kind and anxious you might be"(1)
However, promoting and implementing research-based practice
is not a simple task; nor
is it solely reliant upon nurses in clinical practice. There are
forces affecting the advancement of
research-based practice within both the health care and nursing
systems.
I know Dr. Ritchie is going to address this as well, so I am
going to focus more on some
"how come" questions related to research-based nursing practice
and discuss two interrelated
processes which must be attended to if the "how come"
questions are to be turned into "why not"
questions - or "just do it" approaches. And I am going to
address this with particular emphasis on
research utilization.
HOW COME?
How come there is a gap between knowledge generation and
application? Is it that
research is not seen to be relevant to practice? If so, how come
we aren't getting the relevant

research done? Are we not asking the right or relevant
questions? We know nurs es have
questions - consider those generated through the provincial
Agency Challenge and agency
dinosaur and sacred cow challenges. There are relevant
questions. So - How come they are not
being explored? Are researchers not listening to those
questions? And even if they are to some
4
extent - How come clinicians are not more engaged in
answering those questions? Furthermore
sometimes there are answers to the practice relevant questions.
How come we're not using the
research?
Example: Internet - IM Injection Sites
In the clinical arena the challenges of promoting research-based
practice require a
different view of our world - they require us to create a new
future. How we shape our future will
depend to great extent on how we perceive the clues I
mentioned earlier - do we see them as

threats? or opportunities? do we see this as a loss? or a gain?
I believe it is time to turn our nursing system upside down:
From one that is currently-
-making
(promotes evaporation instead)
to one that is -
-based knowledge
5
educators, administrators and
researchers)
Let's go back to one of the "how come" questions.

How come we're not using the research-based knowledge that
we have in our practice?
- or do we
either not believe the research
findings - or not believe that we have "permission" to use them?
all facts before a piece of
research is deemed usable(2)
rastructure and/or competencies to support
such activity?
process?
In this section of the presentation I will focus on two processes
- diffusion and adoption
of innovations and use of research utilization
models/frameworks - processes that have the
potential to facilitate the use of research in nursing. I will tell
you a couple of success stories to
illustrate my point.
We know that neither the mere existence or dissemination of

knowledge nor enforced
behavior change ensure that attitudes, values and behaviors will
change (3). Using research
findings in nursing practice can be thought of as adoption of an
innovation - a complex process
which involves several stages.
6
Rogers'(4) (1983) theory of diffusion of innovations with its
four successive stages is a
good place to start. The first stage - knowledge - occurs as
nurses become aware of the
innovation. Next, in the persuasion stage, they form a favorable
or unfavorable attitude toward
the innovation. Thirdly, nurses make decisions to adopt or reject
the innovation, at least on a trial
basis. If a new practice is mandated without practitioners
moving through these appropriate
stages, it is unlikely that the innovation w ill be implemented
consistently or as intended.
Consistent application with evaluation occurs in the fourth
confirmation stage - if progress has

been successful through the previous stages.
A number of researchers have found that the source for new
knowledge influences the
rate at which individuals pass through the first stage. Print-
media and interpersonal contacts
(research-oriented conferences and inservice programs and role
models) are most influential in
solving clinical problems and adopting innovations (Brett(5),
Coyle and Sokop(6), Means(7),
Salasin and Cedar(8), Stinson and Mueller(9)). Although
educational programs are suggested as
important methods of research dissemination, few studies have
examined the extent to which
research findings are incorporated into nursing curricula.
In 1995, Barta(10) reported on a study that investigated
pediatric nurse educators'
inclusion of evidence-based pain management techniques in the
curriculum. Practices most
highly diffused among pediatric nurse educators were use of
pain scales, providing sensory
information and teaching self-comforting strategies. However,
only the use of pain scales was in
the "include always" range. The least diffused innovation in this
sample was the use of TENS

(transcutaneous electrical nerve stimulation). It's interesting to
note that at the 1992 International
Pediatric Nursing Conference at Child Health 2000, Dr. Leora
Kutner11 spoke about desirability
7
(in fact predicted) that physical methods to ease pain would
become more commonplace -
including therapeutic touch, massage and TENS - and that this
would reflect the growing
appreciation of the research that shows that pain can be shifted
by means other than
pharmacological. However, sadly in a 1994 report from Alberta,
Williams'12 study of nurse
educators in that province we learn that there is a significant
lack of fundamental know-how
about the pharmacological management of acute pain - that little
time is spent on pain
management in nursing curricula and that content is often
spontaneous rather than planned. In
Barta's study the educators chose nursing journals, nursing texts
and Cumulated Index of

Nursing Literature, as most useful sources of information for
updating instruction of
baccalaureate degree students. One has to seriously question the
currency of texts and their
appropriateness as a source of update!
Factors influencing nurses in the persuasion stage are agency
policy, procedure manuals,
and the opinions of other professionals. Rather than actual
agency policy about research-based
nursing practice, Brett(13) found that it was perceived policy
that influenced innovation adoption
behavior among her sample of hospital nurses. In the last two
innovation adoption stages, the
most common barriers identified by clinicians were
organizational barriers. Nurses' perception
that they lack authority and support of administration to change
nursing practice inhibits
innovation adoption.
Romano's (14) identified five attributes of the innovation, as
perceived by potential users
that affect the rate of its adoption. Innovations which have an
obvious advantage to the
patient/client; are compatible with nurses' values and
experiences; are relatively simple to

understand and implement; can be tested and evaluated; and
demonstrate results are likely to be
8
adopted relatively quickly - with nurses passing through each of
the four stages quickly and
without much angst. However, problems are sure to arise when
at least one of these attributes
differ and when attention is not paid to assisting nurses move
through the four stages in a logical
and timely fashion.
PCA Example
In 1991 members of the RNABC Nursing Research Committee
Network questioned why
their staff nurses were not using the Patient Controlled
Analgesia approach, including the pump,
as intended and supported by research. Subsequently an 11 site
research study w as carried out
by 13 nurse-investigators. The purpose of the study was to
determine nurses' learning needs to
bring about effective and efficient implementation of a PCA
approach within the complexity of

decision-making about pain management. We used Rogers'(15)
innovation adoption framework,
paying special attention to two of the five attributes of PCA
(the innovation) not previously
investigated - compatibility of PCA with nurses' existing values
and experiences and complexity
of the approach.
We found that nurses' beliefs related to PCA changed in varying
degrees depending upon
the accumulation of positive or negative forces in their
agencies. Positive forces included
planned implementation, education/clinical experience and
positive outcomes for most patients,
even the chemically dependent. Nurse-involvement in patient
selection for PCA was another
positive force, as was the ease of pump use and safety features.
The timing of learning and
clinical application of new information and skills was as
important as the availability of
knowledgeable peer supported clinical experience. The positive
forces enhanced nurses' ability to
9

adopt a new perception of the PCA approach and supported
them in the transformation of their
pain management beliefs.
Negative forces were opposite of the positive forces and
included increased workload
during early phases of PCA implementation. These negative
forces inhibited the implementation
of PCA and changes in pain management beliefs.
Our findings support the need to systematically address five
issues when embarking on
the innovation adoption process:
1. availability of research-based knowledge - Is it available in
clinically focused journals,
conferences, or electronic communication systems?
2. acceptability and readability of that knowledge - is it worded
in jargon that only a
researcher can understand?
3. credibility of the study - do nurses believe the findings, given
their understanding of the
research methods?
4. relevancy of the findings - how relevant are the findings to

clinical practice, the
sociocultural context of practice and clients, and organizational
structures?
5. support and reinforcement to adopt and maintain the
innovation - are there supportive
persons and materials to assist nurses to adopt and practice
innovations?
WHY NOT?
Why not change this how come into a "just do it"? What
resources/processes are there to
assist moving through the innovation adoption process? One is a
research utilization framework.
10
A research utilization framework can facilitate the research
adoption process and the
resolution of some of the above mentioned issues. The four
best-known frameworks are the
Western Interstate Commission for Higher Education in
Nursing, also called WICHEN(16); the
Conduct and Utilization of Research in Nursing or CURN(17),
NCAST(18) and

Stetler/Marram(19). WICHEN and CURN frameworks are both
based on the concepts of
diffusion of innovation and planned change; NCAST focusses
solely on diffusion of innovations;
and the refined Stetler/Marram framework is an interactive,
staged model.
Based on the work of Stetler (20) and the expressed needs of
nurses and health care
agencies in British Columbia, a decision-making model for
utilization of research findings in
practice was developed and published in the workbook Nursing
Research: From Question to
Funding(21). Application of this framework requires
partnerships among nurses with clinical
expertise, research experience, and administrative
responsibilities. Each of the four phases
requires particular nurses to be involved, decisions to be made,
and resources to be accessed. The
framework can be modified by individual agencies, thus making
it relevant to both staff needs
and the organizational structure. <PExample: Vancouver Health
Department
The Vancouver Health Department Nursing Research Committee
- a sub-committee of

their Nursing Council - decided that their focus would be on
assisting staff nurses in research
utilization. Based on the work of RNABC an agency-specific
research utilization framework was
developed and a supporting manual written. During this process
the committee members
critiqued the RNABC model, identified their agency's needs and
resources, articulated their
agency's culture, philosophy, and mission statement, and
consulted with Nursing Council and the
11
Quality Improvement Program. The result - a widely accepted
framework and manual that are
user-friendly and "owned" by each of the health units in the
department.
How well a given framework will serve a situation or agency
depends on the framework's
efficacy, the type of problem, and the congruence of the
framework's theoretical based with
nurses' decision making22. As well, the framework must fit with
the organization's structure,
philosophy of nursing practice, and available resources.

SUMMARY
Each stage of the innovation adoption process is critical to
appropriate implementation of
research-based nursing practice. Change is rarely easy, but can
be facilitated by addressing
known organizational and individual factors and using a
research utilization framework.
Other individuals and organizations have tackled the "how
comes" head on - and turned
them into "why nots" - "why not do it?" or "just do it". The
"why nots" have included:
1. Why not be explicit about the responsibilities and
accountability of every nurse for
evidence-based practice - in job descriptions and performance
appraisals, in agency
philosophy and mission statements, in educational courses and
programs?
2. But the changes required to solve today's problems won't
come about unless there is a
supportive Infrastructure - why not tackle the various elements
to determine which can be
expanded, coordinated with others, or developed?
3. Why not create opportunities for staff nurses to participate in

evidence-based practice?
Agency challenge in the workplace; interdisciplinary research-
based projects;
nursing/agency research committees; utilization frameworks;
etc.
12
4. Why not build on what we know about discouragers and
facilitators?
o Discouragers - lack of time, lack of support from nursing
administration, lack of
nursing staff support, lack of support from other disciplines
o Encourages - methods to keep informed about study findings,
research
newsletters, research meetings, continuing education programs,
computer
networks, research study guides
5. Why not focus on the positive rather than overlooking or
ignoring it and focusing on the
negative? Why not give praise for small and large
accomplishments - for taking on the
challenge? Praise is the oil that greases the wheels of

performance. It helps us to see the
good, build on success, overcome difficulties and not feel
defeated by failure.
Putting our efforts into mobilizing a supportive environment for
quality nursing care -
care that uses research findings appropriately - can have far
reaching effects in promoting the
health of children and their families - that's what we are all
about.
13
References
Barta, K.M> (1995). Information-seeking, research utilization,
and barriers to research utilization
of pediatric nurse educators. Journal of Professional Nursing,
11, 1, 49-57.
Brett, J.L. (1987). Use of nursing practice research findings.
Nursing Research, 36, 6, 344-349.
Coyle, L.A. & Sokop, A.G. (1990). Innovation adoption
behavior among nurses. Nursing
Research, 39, 3, 176-180.
Horsely, J., Crane, J. & Bingle, J. (1978). Research utilization

as an organization process.
Journal of Nursing Administration, 8, 4-6.
King, D., Barnard, K., & Hoehn, R. (1981). Disseminating the
results of nursing research.
Nursing Outlook, 3, 164-169.
Krueger, J., Nelson, A., & Wolanin, M. (1978). Nursing
research: Development, collaboration,
and utilization. Germantown, MD: Aspen.
Kutner, L. (1992). Pain management at BC's Children's
Hospital. In H.F. Clarke and B. Davies
(eds) Shaping the Future of Child Health: Challenges for
Nurses. Vancouver, BC. p. 92-
95.
Larson, E., Kent, L, & Larson, J.S. (1984). Effects of enforced
behavior change on attitudes.
Journal of Continuing Education in Nursing, 15, 4, 143-145.
Means, R.P.(1979/1980). Information seeking behaviors of
Michigan Family Physicians.
Unpublished doctoral dissertation. University of Illinois at
Urbana-Champaign.
14

Nightingale, F. (1969). Notes on Nursing. New York: Dover
Publications. (Original work
published 1860). p. 113
Registered Nurses Association of British Columbia (1990).
Nursing research: From question to
funding. Vancouver: Author.
Rogers, E.M. (1983). Diffusion of Innovations (3rd ed.). New
York: The Free Press.
Romano, C.A. (1991). Diffusion of technology innovation.
Advances in Nursing Science, 13, 2,
11-21. 15. Rogers op cit
Salasin, J. & Cedar, T. (1985). Information-seeking behavior in
an applied research/service
delivery setting. Journal of the American Society for
Information Science, 36, 2, 94-102.
Stetler, C. (1983). Nurses and research: Responsibility and
involvement. National Intravenous
Therapy Association, 6, 3, 207-212.
Stetler, C. (1985). Research utilization: Defining the concept.
IMAGE: The Journal of Nursing
Scholarship, 17, 2, 40-44.

Stetler, C. (1994). Refinement of the Stetler/Marram Model for
application of research findings
to practice. Nursing Outlook, 42, 1, 15-25.
Stinson, E.R. & Mueller, E. A. (1980). Survey of health
professionals information habits and
needs. Journal of the American Medical Association, 243, 2,
140-143.
Williams, B. (1994). A painful lack of knowledge. Canadian
Nurse, November, 19-20. 13. Brett
Op cit
15
Wood, M. (1992). Shaping practice through research. Clinical
Nursing Research, 1, 2, 123-126.
Quantitative Research

Written Critique of a Nursing Research Article
The criteria listed below are less detailed than what you will
find in the chapters of your textbook. However, this
is an excellent list of some of the main aspects to consider when
doing a critique. You may want to make a copy
of this handout so that you can use it as a worksheet when
reading the various textbook chapters. You could think
about these criteria as some of the main points about research
that you should understand.
Introduction
1. Is the purpose of the study presented?
2. Is the significance (importance) of the problem discussed?
3. Does the investigator provide a sense of what he or she is
doing and why?
Problem statement
1. Is the problem statement clear?
2. Does the investigator identify key research questions and
variables to be examined?
3. Does the study have the potential to help solve a problem that
is currently faced in clinical practice?
Literature review
1. Does the literature review follow a logical sequence leading

to a critical review of supporting and conflicting
prior work?
2. Is the relationship of the study to previous research clear?
3. Does the investigator describe gaps in the literature and
support the necessity of the present study?
Theoretical framework and hypotheses
1. Is a rationale stated for the theoretical/conceptual
framework?
2. Does the investigator clearly state the theoretical basis for
hypothesis formulation?
3. Is the hypothesis stated precisely and in a form that permits it
to be tested?
Methodology
1. Are the relevant variables and concepts clearly and
operationally defined?
2. Is the design appropriate for the research questions or
hypotheses?
3. Are methods of data collection sufficiently described’?
4. What are the identified and potential threats to internal and
external validity that were present in the study?
5. If there was more than one data collector, was inter-rater
reliability adequate?

Sample
1. Are the subjects and sampling methods described?
2. Is the sample of sufficient size for the study, given the
number of variables and design?
3. Is there adequate assurance that the rights of human subjects
were protected?
Instruments
1. Are appropriate instruments for data collection used?
2. Are reliability and validity of the measurement instruments
adequate’?
Data analysis
1. Are the statistical tests used identified and the values
reported?
2. Are appropriate statistics used, according to level of
measurement, sample size, sampling method, and
hypotheses/research questions?
Results

1. Are the results for each hypothesis clearly and objectively
presented?
2. Do the figures and tables illuminate the presentation of
results’?
3. Are results described in light of the theoretical framework
and supporting literature?
Conclusions/discussion
1. Are conclusions based on the results and related to the
hypotheses’?
2. Are study limitations identified?
3. Are generalizations made within the scope of the findings?
4. Are implications of findings discussed (i.e., for practice,
education, and research)?
5. Are recommendations for further research stated?
Research utilization implications
1. Is the study of sufficient quality to meet the criterion of
scientific merit’?
2. Does the study meet the criterion of replicability?
3. Is the study of relevance to practice?
4. Is the study feasible for nurses to implement?
5. Do the benefits of the study outweigh the risks?

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