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Attachment PreviewUnderstanding Nursing Research Building an Evidence-Based Practice
SIXTH EDITION Susan K. Grove, PhD, RN, ANP-BC, GNP-BC Professor Emerita, College of
Nursing, The University of Texas at Arlington, Arlington, Texas Adult Nurse Practitioner,
Family Practice, Grand Prairie, Texas Jennifer R. Gray, PhD, RN, FAAN George W. and Hazel
M. Jay Professor, College of Nursing, Associate Dean, College of Nursing, The University of
Texas at Arlington, Arlington, Texas Nancy Burns, PhD, RN, FCN, FAAN Professor Emerita,
College of Nursing, The University of Texas at Arlington, Arlington, Texas Faith Community
Nurse, St. Matthew Cumberland Presbyterian Church, Burleson, Texas Table of Contents
Cover image Title page Inside Front Cover Copyright Contributor and Reviewers Dedication
Preface Acknowledgments Chapter 1: Introduction to Nursing Research and Evidence-
Based Practice What is Nursing Research? What is Evidence-Based Practice? Purposes of
Research for Implementing an Evidence-Based Nursing Practice Historical Development of
Research in Nursing Acquiring Knowledge in Nursing Acquiring Knowledge Through
Nursing Research Understanding Best Research Evidence for Practice What Is Your Role in
Nursing Research? Key Concepts Chapter 2: Introduction to Quantitative Research What is
Quantitative Research? Problem-Solving and Nursing Processes: Basis for Understanding
the Quantitative Research Process Identifying the Steps of the Quantitative Research
Process Reading Research Reports Practice Reading Quasi-Experimental and Experimental
Studies Key Concepts. Discussion: Understanding Nursing Research Building an Evidence-
Based PracticeChapter 3: Introduction to Qualitative Research Values of Qualitative
Researchers Rigor in Qualitative Research Qualitative Research Approaches Qualitative
Research Methodologies Data Collection Methods Data Management Data Analysis Key
Concepts Chapter 4: Examining Ethics in Nursing Research Historical Events Influencing the

Development of Ethical Codes and Regulations Protecting Human Rights Understanding
Informed Consent Understanding Institutional Review Examining the Benefit-Risk Ratio of a
Study Understanding Research Misconduct Examining the Use of Animals in Research Key
Concepts Chapter 5: Research Problems, Purposes, and Hypotheses What Are Research
Problems and Purposes? Identifying the Problem and Purpose in Quantitative, Qualitative,
and Outcomes Studies Determining the Significance of a Study Problem and Purpose
Examining the Feasibility of a Problem and Purpose Examining Research Objectives,
Questions, and Hypotheses in Research Reports Understanding Study Variables and
Research Concepts Key Concepts Chapter 6: Understanding and Critically Appraising the
Literature Review Purpose of the Literature Review Sources Included in a Literature
Review Critically Appraising Literature Reviews Reviewing the Literature Key Concepts
Chapter 7: Understanding Theory and Research Frameworks What is a Theory?
Understanding the Elements of Theory Levels of Theoretical Thinking Examples of Critical
Appraisal Key Concepts Chapter 8: Clarifying Quantitative Research Designs Identifying
Designs Used in Nursing Studies Descriptive Designs Correlational Designs Understanding
Concepts Important to Causality in Designs Examining the Validity of Studies Elements of
Designs Examining Causality Quasi-Experimental Designs Experimental Designs
Randomized Controlled Trials Introduction to Mixed-Methods Approaches Key Concepts
Chapter 9: Examining Populations and Samples in Research Understanding Sampling
Concepts Representativeness of a Sample in Quantitative and Outcomes Research
Probability Sampling Methods Nonprobability Sampling Methods Commonly Used in
Quantitative Research Sample Size in Quantitative Studies Sampling in Qualitative Research
Sample Size in Qualitative Studies Research Settings Key Concepts Chapter 10: Clarifying
Measurement and Data Collection in Quantitative Research Concepts of Measurement
Theory Accuracy, Precision, and Error of Physiological Measures. Discussion:
Understanding Nursing Research Building an Evidence-Based PracticeUse of Sensitivity,
Specificity, and Likelihood Ratios to Determine the Quality of Diagnostic AND Screening
Tests Measurement Strategies in Nursing Data Collection Process Key Concepts Chapter 11:
Understanding Statistics in Research Understanding the Elements of the Statistical Analysis
Process Understanding Theories and Concepts of the Statistical Analysis Process Using
Statistics to Describe Determining the Appropriateness of Inferential Statistics in Studies
Using Statistics to Examine Relationships Using Statistics to Predict Outcomes Using
Statistics to Examine Differences Interpreting Research Outcomes Key Concepts Chapter 12:
Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice When are
Critical Appraisals of Studies Implemented in Nursing? What are the Key Principles for
Conducting Intellectual Critical Appraisals of Quantitative and Qualitative Studies?
Understanding the Quantitative Research Critical Appraisal Process Example of a Critical
Appraisal of a Quantitative Study Understanding the Qualitative Research Critical Appraisal
Process Example of a Critical Appraisal of a Qualitative Study Key Concepts Chapter 13:
Building an Evidence-Based Nursing Practice Benefits and Barriers Related to Evidence-
Based Nursing Practice Searching for Evidence-Based Sources Critically Appraising
Research Syntheses Developing Clinical Questions to Identify Existing Research-Based
Evidence for Use in Practice Models to Promote Evidence-Based Practice in Nursing

Implementing Evidence-Based Guidelines in Practice Introduction to Evidence-Based
Practice Centers Introduction to Translational Research Key Concepts Chapter 14:
Outcomes Research Theoretical Basis of Outcomes Research Nursing-Sensitive Outcomes
Origins of Outcomes and Performance Monitoring Federal Government Involvement in
Outcomes Research Advanced Practice Nursing Outcomes Research Outcomes Research and
Nursing Practice Methodologies for Outcomes Studies Statistical Methods for Outcomes
Studies Critical Appraisal of Outcomes Studies Key Concepts Glossary Index Inside Back
Cover Inside Front Cover Copyright 3251 Riverport Lane St. Louis, Missouri 63043
UNDERSTANDING NURSING RESEARCH: BUILDING AN EVIDENCE-BASED PRACTICE,
EDITION SIX ISBN: 978-1-4557-7060-1 Copyright © 2015, 2011, 2007, 2003, 1999, 1995 by
Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be
reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher ’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions. This book and the individual
contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein). Notices Knowledge and best practice in this field are constantly
changing. Discussion: Understanding Nursing Research Building an Evidence-Based
PracticeAs 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. With respect to
any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor
the authors, contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or from any
use or operation of any methods, products, instructions, or ideas contained in the material
herein. International Standard Book Number: 978-1-4557-7060-1 Executive Content
Strategist: Lee Henderson Content Development Manager: Billie Sharp Content
Development Specialist: Charlene Ketchum Publishing Services Manager: Deborah L. Vogel
Project Manager: Bridget Healy Design Direction: Maggie Reid Printed in China Last digit is
the print number: 9 8 7 6 5 4 3 2 1 Contributor and Reviewers Contributor Diane Doran, RN,
PhD, FCAHS, Professor Emerita, Lawrence S. Bloomberg Faculty of Nursing, University of
Toronto, Toronto, Ontario Revised Chapter 14 Reviewers Lisa D. Brodersen, EdD, MA, RN ,

Professor, Coordinator of Institutional Research and Effectiveness, Allen College, Waterloo,
Iowa Sara L. Clutter, PhD, RN , Associate Professor of Nursing, Waynesburg University,
Waynesburg, Pennsylvania Jacalyn P. Dougherty, PhD, RN , Nursing Research Consultant, JP
Dougherty LLC, Aurora, Colorado Joanne T. Ehrmin, RN, COA-CNS, PhD, MSN, BSN ,
Professor, University of Toledo, College of Nursing, Toledo, Ohio Betsy Frank, PhD, RN,
ANEF , Professor Emerita, Indiana State University College of Nursing, Health, and Human
Services, Terre Haute, Indiana Tamara Kear, PhD, RN, CNS, CNN , Assistant Professor of
Nursing, Villanova University, Villanova, Pennsylvania Sharon Kitchie, PhD, RN , Adjunct
Instructor, Keuka College, Keuka Park, New York Madelaine Law rence, PhD, RN , Associate
Professor, University of North Carolina at Wilmington, Wilmington, North Carolina Robin
Moyers, PhD, RN-BC, Nurse Educator, Carl Vinson VA Medical Center, Dublin. Discussion:
Understanding Nursing Research Building an Evidence-Based Practice, Georgia Sue E.
Odom, DSN, RN , Professor of Nursing, Clayton State University, Morrow, Georgia Teresa M.
O’Neill, PhD, APRN, RNC, Professor, Our Lady of Holy Cross College, New Orleans, Louisiana
Sandra L. Siedlecki, PhD, RN, CNS, Senior Nurse Scientist, Cleveland Clinic, Cleveland, Ohio
Sharon Souter, PhD, RN, CNE, Dean and Professor, University of Mary Hardin Baylor, Belton,
Texas Molly J. Walker, PhD, RN, CNS, CNE, Professor, Angelo State University, San Angelo,
Texas Cynthia Ward, DNP, RN-BC, CMSRN, ACNS-BC, Surgical Clinical Nurse Specialist,
Carilion Roanoke Memorial Hospital, Roanoke, Virginia Angela Wood, PhD, RN, Certified
High-Risk Prenatal Nurse, Associate Professor and Chair, Department of Nursing, Carson-
Newman University, Jefferson City, Tennessee Fatma A. Youssef, RN, DNSc, MPH , Professor
Emerita, Marymount University, School of Health Professions, Arlington, Virginia Dedication
To all nurses who change the lives of patients through applying the best research evidence.
—Susan, Jennifer, and Nancy To my husband Jay Suggs who has provided me endless love
and support during my development of research textbooks over the last 30 years. —Susan
To my husband Randy Gray who is my love and my cheerleader. —Jennifer To my husband
Jerry who has supported all of my academic endeavors through 58 years of marriage. —
Nancy Preface Research is a major force in nursing, and the evidence generated from
research is constantly changing practice, education, and health policy. Our aim in
developing this essentials research text, Understanding Nursing Research: Building an
Evidence-Based Practice, is to create an excitement about research in undergraduate
students. The text emphasizes the importance of baccalaureate-educated nurses being able
to read, critically appraise, and synthesize research so this evidence can be used to make
changes in practice. A major goal of professional nursing and health care is the delivery of
evidence-based care. By making nursing research an integral part of baccalaureate
education, we hope to facilitate the movement of research into the mainstream of nursing.
We also hope this text increases student awareness of the knowledge that has been
generated through nursing research and that this knowledge is relevant to their practice.
Only through research can nursing truly be recognized as a profession with documented
effective outcomes for the patient, family, nurse provider, and healthcare system. Because of
this expanded focus on evidence-based practice (EBP), we have subtitled this edition
Building an Evidence-Based Practice. Developing a sixth edition of Understanding Nursing
Research has provided us with an opportunity to clarify and refine the essential content for

an undergraduate research text. The text is designed to assist undergraduate students in
overcoming the barriers they frequently encounter in understanding the language used in
nursing research. The revisions in this edition are based on our own experiences with the
text and input from dedicated reviewers, inquisitive students, and supportive faculty from
across the country who provided us with many helpful suggestions. Discussion:
Understanding Nursing Research Building an Evidence-Based PracticeChapter 1,
Introduction to Nursing Research and Evidence-Based Practice, introduces the reader to
nursing research, the history of research, and the significance of research evidence for
nursing practice. This chapter has been revised to include the most relevant types of
research synthesis being conducted in nursing—systematic review, metaanalysis, meta-
synthesis, and mixed-methods systematic review. The discussion of research methodologies
and their importance in generating an evidence-based practice for nursing has been
updated and expanded to include the exploratory-descriptive qualitative research method.
A discussion of the Quality and Safety Education for Nursing (QSEN) competencies and their
link to research has been included in this edition. Selected QSEN competencies are linked to
the findings from studies presented as examples throughout the text to increase students’
understanding of the importance in delivering quality, safe health care to patients and
families. Chapter 2, Introduction to Quantitative Research, presents the steps of the
quantitative research process in a concise, clear manner and introduces students to the
focus and findings of quantitative studies. Extensive, recent examples of descriptive,
correlational, quasi-experimental, and experimental studies are provided, which reflect the
quality of current nursing research. Chapter 3, Introduction to Qualitative Research,
describes five approaches to qualitative research and the philosophies upon which they are
based. These approaches include phenomenology, grounded theory, ethnography,
exploratory-descriptive qualitative, and historical research. Data collection and analysis
methods specific to qualitative research are discussed. Guidelines for reading and critically
appraising qualitative studies are explained using examples of published studies. Chapter 4,
Examining Ethics in Nursing Research, provides an extensive discussion of the use of ethics
in research and the regulations that govern the research process. Detailed content and
current websites are provided to promote students’ understanding of the Health Insurance
Portability and Accountability Act (HIPAA), the U.S. Department of Health and Human
Services Protection of Human Subjects, and the Federal Drug Administration regulations.
Guidelines are provided to assist students in critically appraising the ethical discussions in
published studies and to participate in the ethical review of research in clinical agencies.
Chapter 5, Research Problems, Purposes, and Hypotheses, clarifies the difference between a
problem and a purpose. Example problem and purpose statements are included from
current qualitative, quantitative, and outcome studies. Detailed guidelines are provided
with examples to direct students in critically appraising the problems, purposes,
hypotheses, and variables in studies. Discussion: Understanding Nursing Research Building
an Evidence-Based PracticeChapter 6, Understanding and Critically Appraising the
Literature Review, begins with a description of the content and quality of different types of
publications that might be included in a review. Guidelines for critically appraising
published literature reviews are explored with a focus on the differences in the purpose and

timing of the literature review in quantitative and qualitative studies. The steps for finding
appropriate sources, reading publications, and synthesizing information into a logical,
cohesive review are presented. Chapter 7, Understanding Theory and Research
Frameworks, briefly describes grand, middle range, physiological, and scientific theories as
the bases for study frameworks. The purpose of a research framework is discussed with the
acknowledgement that the framework may be implicit. Guidelines for critically appraising
the study framework are presented as well. The guidelines are applied to studies with
frameworks derived from research findings and from different types of theories. Chapter 8,
Clarifying Quantitative Research Designs, addresses descriptive, correlational, quasi-
experimental, and experimental designs and criteria for critically appraising these designs
in studies. The major strengths and threats to design validity are summarized in a table and
discussed related to current studies. This chapter has been expanded to include an
introduction to randomized controlled trials (RCT) and mixed-methods approaches being
conducted by nurses. Chapter 9, Examining Populations and Samples in Research, provides
a detailed discussion of the concepts of sampling in research. Different types of sampling
methods for both qualitative and quantitative research are described. Guidelines are
included for critically appraising the sampling criteria, sampling method, and sample size of
quantitative and qualitative studies. Chapter 10, Clarifying Measurement and Data
Collection in Quantitative Research, has been updated to reflect current knowledge about
measurement methods used in nursing research. Content has been expanded and uniquely
organized to assist students in critically appraising the reliability and validity of scales;
precision and accuracy of physiologic measures; and the sensitivity, specificity, and
likelihood ratios of diagnostic and screening tests. Chapter 11, Understanding Statistics in
Research, focuses on the theories and concepts of the statistical analysis process and the
statistics used to describe variables, examine relationships, predict outcomes, and examine
group differences in studies. Guidelines are provided for critically appraising the results and
discussion sections of nursing studies. The results from selected studies are critically
appraised and presented as examples throughout this chapter. Chapter 12, Critical
Appraisal of Quantitative and Qualitative Research for Nursing Practice, summarizes and
builds on the critical appraisal content provided in previous chapters and offers direction
for conducting critical appraisals of quantitative and qualitative studies. The guidelines for
critically appraising qualitative studies have been significantly revised and simplified. This
chapter also includes a current qualitative and quantitative study, and these two studies are
critically appraised using the guidelines provided in this chapter. Chapter 13, Building an
Evidence-Based Nursing Practice, has been significantly updated to reflect the current
trends in health care to provide evidence-based nursing practice. Detailed guidelines are
provided for critically appraising the four common types of research synthesis conducted in
nursing (systematic review, meta-analysis, metasynthesis, and mixed-method systematic
review). These guidelines were used to critically appraise current research syntheses to
assist studeDiscussion: Understanding Nursing Research Building an Evidence-Based
Practice