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9™ EDITION

Methods and Critical Appraisal

for Evidence-Based Practice

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

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Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986.

Library of Congress Cataloging-in-Publication Data

Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor.

Title: Nursing research : methods and critical appraisal for evidence-based practice / [edited by] Geri LoBiondo-Wood, Judith Haber.

Other titles: Nursing research (LoBiondo-Wood)

Description: 9th edition. | St. Louis, Missouri : Elsevier, [2018] | Includes bibliographical references and index.

Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper) Subjects: | MESH: Nursing Research—methods | Research Design | Evidence-Based Nursing—methods

Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available at https://Iccn.loc.gov/2017008727

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ABOUT THE AUTHORS

Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator

of the PhD in Nursing Program at the University of Texas Health

Science Center at Houston, School of Nursing (UTHSC-Houston) and

former Director of Research and Evidence-Based Practice Planning

and Development at the MD Anderson Cancer Center, Houston, Texas.

She received her Diploma in Nursing at St. Mary’s Hospital School of

Nursing in Rochester, New York; Bachelor’s and Master’s degrees from

the University of Rochester; and a PhD in Nursing Theory and

Research from New York University. Dr. LoBiondo-Wood teaches

research and evidence-based practice principles to undergraduate, graduate, and doctoral

students. At MD Anderson Cancer Center, she developed and implemented the Evidence-

Based Resource Unit Nurse (EB-RUN) Program. She has extensive national and interna-

tional experience guiding nurses and other health care professionals in the development

and utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress

in Transplantation and a reviewer for Nursing Research, Oncology Nursing Forum, and

Oncology Nursing. Her research and publications focus on chronic illness and oncology

nursing. Dr. Wood has received funding from the Robert Wood Johnson Foundation

Future of Nursing Scholars program for the past several years to fund full-time doctoral

students.

Dr. LoBiondo-Wood has been active locally and nationally in many professional organiza-

tions, including the Oncology Nursing Society, Southern Nursing Research Society, the

Midwest Nursing Research Society, and the North American Transplant Coordinators Organi-

zation. She has received local and national awards for teaching and contributions to nursing.

In 1997, she received the Distinguished Alumnus Award from New York University, Division

of Nursing Alumni Association. In 2001 she was inducted as a Fellow of the American Acad-

emy of Nursing and in 2007 as a Fellow of the University of Texas Academy of Health Science

Education. In 2012 she was appointed as a Distinguished Teaching Professor of the University

of Texas System and in 2015 received the John McGovern Outstanding Teacher Award from

the University of Texas Health Science Center at Houston School of Nursing.

Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership

Professor in Nursing at the Rory Meyers College of Nursing at

New York University. She received her undergraduate nursing

education at Adelphi University in New York, and she holds a Master’s

degree in Adult Psychiatric-Mental Health Nursing and a PhD in

Nursing Theory and Research from New York University. Dr. Haber is

internationally recognized as a clinician and educator in psychiatric—

mental health nursing. She was the editor of the award-winning

classic textbook, Comprehensive Psychiatric Nursing, published for eight editions and

translated into five languages. She has extensive clinical experience in psychiatric nurs-

ing, having been an advanced practice psychiatric nurse in private practice for over

30 years, specializing in treatment of families coping with the psychosocial impact of

acute and chronic illness. Her NIH-funded program of research addressed physical and

Vv

a ABOUT THE AUTHORS

psychosocial adjustment to illness, focusing specifically on women with breast cancer

and their partners and, more recently, breast cancer survivorship and lymphedema

prevention and risk reduction. Dr. Haber is also committed to an interprofessional

program of clinical scholarship related to interprofessional education and improving

oral-systemic health outcomes and is the Executive Director of a national nursing oral

health initiative, the Oral Health Nursing Education and Practice (OHNEP) program,

funded by the DentaQuest and Washington Dental Service Foundations. Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA

Psychiatric Nurse of the Year Award, the 2005 APNA Outstanding Research Award, and the

1998 ANA Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae

Award, the 2011 Distinguished Teaching Award, and the 2014 NYU Meritorious Service

Award. In 2015, Dr. Haber received the Sigma Theta Tau International Marie Hippensteel

Lingeman Award for Excellence in Nursing Practice. Dr. Haber is a Fellow in the American

Academy of Nursing and the New York Academy of Medicine. Dr. Haber has consulted,

presented, and published widely on evidence-based practice, interprofessional education

and practice, as well as oral-systemic health issues.

CONTRIBUTORS

Terri Armstrong, PhD, ANP-BC, FAANP

Senior Investigator, Neuro-oncology Branch

Center for Cancer Research

National Cancer Institute

National Institutes of Health

Bethesda, Maryland

Julie Barroso, PhD, ANP, RN, FAAN

Professor and Department Chair

Medical University of South Carolina

Charleston, South Carolina

Carol Bova, PhD, RN, ANP Professor of Nursing and Medicine

Graduate School of Nursing

University of Massachusetts

Worcester, Massachusetts

Dona Rinaldi Carpenter, EdD, RN

Professor and Chair

University of Scranton

Department of Nursing

Scranton, Pennsylvania

Maja Djukic, PhD, RN

Assistant Professor

Rory Meyers College of Nursing

New York University

New York, New York

Mei R. Fu, PhD, RN, FAAN Associate Professor

Rory Meyers College of Nursing

New York University

New York, New York

Mattia J. Gilmartin, PhD, RN

Senior Research Scientist

Executive Director, NICHE Program

Rory Meyers College of Nursing

New York University

New York, New York

Deborah J. Jones, PhD, MS, RN

Margaret A. Barnett/PARTNERS Professorship

Associate Dean for Professional Development

and Faculty Affairs

Associate Professor

University of Texas Health Science Center at

Houston

School of Nursing

Houston, Texas

Carl Kirton, DNP, RN, MBA

Chief Nursing Officer

University Hospital

Newark, New Jersey;

Adjunct Faculty

Rory Meyers College of Nursing

New York University

New York, New York

Barbara Krainovich-Miller, EdD, RN,

PMHCNS-BC, ANEF, FAAN

Professor

Rory Meyers College of Nursing

New York University

New York, New York

Elaine Larson, PhD, RN, FAAN, CIC

Anna C. Maxwell Professor of Nursing Research

Associate Dean for Research

Columbia University School of Nursing

New York, New York

Melanie McEwen, PhD, RN, CNE, ANEF

Professor

University of Texas Health Science Center at

Houston

School of Nursing

Houston, Texas

Gail D’Eramo Melkus, EdD, ANP, FAAN Marita Titler, PhD, RN, FAAN

Florence & William Downs Professor in Nursing —Rhetaugh G. Dumas Endowed Professor

Research Department Chair

Associate Dean for Research Department of Systems, Populations and

Rory Meyers College of Nursing – Leadership

New York University University of Michigan School of Nursing

New York, New York Ann Arbor, Michigan

Susan Sullivan-Bolyai, DNSc, CNS, Mark Toles, PhD, RN

RN, FAAN Assistant Professor

Associate Professor University of North Carolina at Chapel Hill

Rory Meyers College of Nursing School of Nursing

New York University Chapel Hill, North Carolina

New York, New York

Karen E. Alexander, PhD, RN, CNOR

Program Director RN-BSN

Assistant Professor

Department of Nursing

University of Houston Clear Lake-Pearland

Houston, Texas

Donelle M. Barnes, PhD, RN, CNE

Associate Professor

College of Nursing

University of Texas, Arlington

Arlington, Texas

Susan M. Bezek, PhD, RN, ACNP, CNE

Assistant Professor

Division of Nursing

Keuka College

Keuka Park, New York

REVIEWERS

Rose M. Kutlenios, PhD, MSN, MN, BSN

ANCC Board Certification, Adult Psychiatric/

Mental Health Clinical Specialist

ANCC Board Certification, Adult Nurse

Practitioner

Nursing Program Director and Associate Professor

Department of Nursing

West Liberty University

West Liberty, West Virginia

Shirley M. Newberry, PhD, RN, PHN

Professor

Department of Nursing

Winona State University

Winona, Minnesota

Sheryl Scott, DNP, RN, CNE Assistant Professor and Chair

School of Nursing

Wisconsin Lutheran College

Milwaukee, Wisconsin

10 THE FACULTY

The foundation of the ninth edition of Nursing Research: Methods and Critical Appraisal for

Evidence-Based Practice continues to be the belief that nursing research is integral to all

levels of nursing education and practice. Over the past three decades since the first edition

of this textbook, we have seen the depth and breadth of nursing research grow, with

more nurses conducting research and using research evidence to shape clinical practice,

education, administration, and health policy.

The National Academy of Medicine has challenged all health professionals to provide

team-based care based on the best available scientific evidence. This is an exciting challenge.

Nurses, as clinicians and interprofessional team members, are using the best available

evidence, combined with their clinical judgment and patient preferences, to influence the

nature and direction of health care delivery and document outcomes related to the quality

and cost-effectiveness of patient care. As nurses continue to develop a unique body of nurs-

ing knowledge through research, decisions about clinical nursing practice will be increas-

ingly evidence based.

As editors, we believe that all nurses need not only to understand the research process

but also to know how to critically read, evaluate, and apply research findings in practice.

We realize that understanding research, as a component of evidence-based practice and

quality improvement practices, is a challenge for every student, but we believe that the

challenge can be accomplished in a stimulating, lively, and learner-friendly manner.

Consistent with this perspective is an ongoing commitment to advancing implementa-

tion of evidence-based practice. Understanding and applying research must be an integral

dimension of baccalaureate education, evident not only in the undergraduate nursing

research course but also threaded throughout the curriculum. The research role of

baccalaureate graduates calls for evidence-based practice and quality improvement

competencies; central to this are critical appraisal skills—that is, nurses should be com-

petent research consumers.

Preparing students for this role involves developing their critical thinking skills, thereby

enhancing their understanding of the research process, their appreciation of the role of

the critiquer, and their ability to actually critically appraise research. An undergraduate

research course should develop this basic level of competence, an essential requirement if

students are to engage in evidence-informed clinical decision making and practice, as well as quality improvement activities.

The primary audience for this textbook remains undergraduate students who are learn-

ing the steps of the research process, as well as how to develop clinical questions, critically

appraise published research literature, and use research findings to inform evidence-based

clinical practice and quality improvement initiatives. This book is also a valuable resource

for students at the master’s, DNP, and PhD levels who want a concise review of the basic

steps of the research process, the critical appraisal process, and the principles and tools for

evidence-based practice and quality improvement.

This text is also an important resource for practicing nurses who strive to use research

evidence as the basis for clinical decision making and development of evidence-based

policies, protocols, and standards or who collaborate with nurse-scientists in conducting

clinical research and evidence-based practice. Finally, this text is an important resource for

TO THE FACULTY pe

considering how evidence-based practice, quality improvement, and interprofessional

collaboration are essential competencies for students and clinicians practicing in a trans-

formed health care system, where nurses and their interprofessional team members

are accountable for the quality and cost-effectiveness of care provided to their patient

population. Building on the success of the eighth edition, we reaffirm our commitment

to introducing evidence-based practice, quality improvement processes, and research

principles to baccalaureate students, thereby providing a cutting-edge, research consumer

foundation for their clinical practice. Nursing Research: Methods and Critical Appraisal

for Evidence-Based Practice prepares nursing students and practicing nurses to become

knowledgeable nursing research consumers by doing the following:

– Addressing the essential evidence-based practice and quality improvement role of the

nurse, thereby embedding evidence-based competencies in clinical practice.

– Demystifying research, which is sometimes viewed as a complex process.

* Using a user-friendly, evidence-based approach to teaching the fundamentals of the

research process.

* Including an exciting chapter on the role of theory in research and evidence-based

practice.

* Providing a robust chapter on systematic reviews and clinical guidelines.

– Offering two innovative chapters on current strategies and tools for developing an

evidence-based practice.

* Concluding with an exciting chapter on quality improvement and its application to

practice.

– Teaching the critical appraisal process in a user-friendly progression.

* Promoting a lively spirit of inquiry that develops critical thinking and critical reading

skills, facilitating mastery of the critical appraisal process.

* Developing information literacy, searching, and evidence-based practice competencies that

prepare students and nurses to effectively locate and evaluate the best research evidence.

* Emphasizing the role of evidence-based practice and quality improvement initiatives as the

basis for informing clinical decisions that support nursing practice.

+ Presenting numerous examples of recently published research studies that illustrate and

highlight research concepts in a manner that brings abstract ideas to life for students.

These examples are critical links that reinforce evidence-based concepts and the critiquing

process. * Presenting five published articles, including a meta-analysis, in the Appendices, the

highlights of which are woven throughout the text as exemplars of research and

evidence-based practice.

* Showcasing, in four new inspirational Research Vignettes, the work of renowned nurse

researchers whose careers exemplify the links among research, education, and practice.

* Introducing new pedagogical interprofessional education chapter features, IPE Highlights

and IPE Critical Thinking Challenges and quality improvement, QSEN Evidence-

Based Practice Tips.

+ Integrating stimulating pedagogical chapter features that reinforce learning, including

Learning Outcomes, Key Terms, Key Points, Critical Thinking Challenges, Helpful

Hints, Evidence-Based Practice Tips, Critical Thinking Decision Paths, and numerous

tables, boxes, and figures.

* Featuring a revised section titled Appraising the Evidence, accompanied by an updated

Critiquing Criteria box in each chapter that presents a step of the research process.

a _ SOOTHE. FACULTY en ee

* Offering a student Evolve site with interactive review questions that provide chapter-

by-chapter review in a format consistent with that of the NCLEX” Examination.

* Offering a Student Study Guide that promotes active learning and assimilation of nurs-

ing research content. – Presenting Faculty Evolve Resources that include a test bank, TEACH lesson plans,

PowerPoint slides with integrated audience response system questions, and an image

collection. Evolve resources for both students and faculty also include a research article library with appraisal exercises for additional practice in reviewing and critiquing, as

well as content updates. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-

Based Practice is organized into four parts. Each part is preceded by an introductory section

and opens with an engaging Research Vignette by a renowned nurse researcher.

Part I, Overview of Research and Evidence-Based Practice, contains four chapters:

Chapter 1, “Integrating Research, Evidence-Based Practice, and Quality Improvement

Processes,’ provides an excellent overview of research and evidence-based practice

processes that shape clinical practice. The chapter speaks directly to students and highlights

critical reading concepts and strategies, facilitating student understanding of the research

process and its relationship to the critical appraisal process. The chapter introduces a

model evidence hierarchy that is used throughout the text. The style and content of this

chapter are designed to make subsequent chapters user friendly. The next two chapters

address foundational components of the research process. Chapter 2, “Research Questions,

Hypotheses, and Clinical Questions,” focuses on how research questions and hypotheses

are derived, operationalized, and critically appraised. Students are also taught how to

develop clinical questions that are used to guide evidence-based inquiry, including quality

improvement projects. Chapter 3, “Gathering and Appraising the Literature,” showcases

cutting-edge information literacy content and provides students and nurses with the tools

necessary to effectively search, retrieve, manage, and evaluate research studies and their

findings. Chapter 4, “Theoretical Frameworks for Research,” is a user-friendly theory

chapter that provides students with an understanding of how theories provide the founda-

tion of research studies and evidence-based practice projects.

Part II, Processes and Evidence Related to Qualitative Research, contains three inter-

related qualitative research chapters. Chapter 5, “Introduction to Qualitative Research,”

provides an exciting framework for understanding qualitative research and the significant

contribution of qualitative research to evidence-based practice. Chapter 6, “Qualitative

Approaches to Research,” presents, illustrates, and showcases major qualitative methods

using examples from the literature as exemplars. This chapter highlights the questions most

appropriately answered using qualitative methods. Chapter 7, “Appraising Qualitative Re-

search,’ synthesizes essential components of and criteria for critiquing qualitative research reports using published qualitative research study.

Part III, Processes and Evidence Related to Quantitative Research, contains Chapters 8

to 18. This group of chapters delineates essential steps of the quantitative research process,

with published clinical research studies used to illustrate each step. These chapters are

streamlined to make the case for linking an evidence-based approach with essential steps

of the research process. Students are taught how to critically appraise the strengths and

weaknesses of each step of the research process in a synthesized critique of a study. The

steps of the quantitative research process, evidence-based concepts, and critical appraisal

criteria are synthesized in Chapter 18 using two published research studies, providing a