Do not summarize the chapter, nor make lengthy discourses on what is in the chapter. The comments should reflect your comprehension and take-a-aways from the readings. Or you may pose a question to the class. Review Grove, Gray, &
Burns Chapter 2 Please come up with some questions on chapter 2 also
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1 Introduction to Nursing Research
and Evidence-Based Practice, 1
2 Introduction to Quantitative Research, 31
Introduction to Qualitative Research, 66
Examining Ethics in Nursing Research, 93
Research Problems, Purposes, and Hypotheses, 129
Understanding and Critically Appraising
the Literature Review, 162
7 Understanding Theory and Research Frameworks, 189
8 Clarifying Quantitative Research Designs, 210
9 Examining Populations and Samples in Research, 248
10 Clarifying Measurement and Data Collection
in Quantitative Research, 281
11 Understanding Statistics in Research, 317
12 Critical Appraisal of Quantitative and Qualitative
Research for Nursing Practice, 361
13 Building an Evidence-Based Nursing Practice, 414
14 Outcomes Research, 466
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Building an Evidence-Based Practice
Susan K. Grove, PhD, RN, ANP-BC, GNP-BC
College of Nursing
The University of Texas at Arlington
Adult Nurse Practitioner
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
Nancy Burns, PhD, RN, FCN, FAAN
College of Nursing
The University of Texas at Arlington
Faith Community Nurse
St. Matthew Cumberland Presbyterian Church
3251 Riverport Lane
St. Louis, Missouri 63043
UNDERSTANDING NURSING RESEARCH: BUILDING
AN EVIDENCE-BASED PRACTICE, EDITION SIX
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).
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become
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
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Content Development Specialist: Charlene Ketchum
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Project Manager: Bridget Healy
Design Direction: Maggie Reid
Printed in China
Last digit is the print number: 9 8
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4 3 2
C O N T R I B U TO R A N D
Diane Doran, RN, PhD, FCAHS
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Revised Chapter 14
Lisa D. Brodersen, EdD, MA, RN
Professor, Coordinator of Institutional Research
Sara L. Clutter, PhD, RN
Associate Professor of Nursing
Jacalyn P. Dougherty, PhD, RN
Nursing Research Consultant
JP Dougherty LLC
Joanne T. Ehrmin, RN, COA-CNS, PhD,
University of Toledo, College of Nursing
Betsy Frank, PhD, RN, ANEF
Indiana State University College of Nursing
Health, and Human Services
Terre Haute, Indiana
Tamara Kear, PhD, RN, CNS, CNN
Assistant Professor of Nursing
Sharon Kitchie, PhD, RN
Keuka Park, New York
Madelaine Lawrence, PhD, RN
University of North Carolina at Wilmington
Wilmington, North Carolina
Robin Moyers, PhD, RN-BC
Carl Vinson VA Medical Center
Sue E. Odom, DSN, RN
Professor of Nursing
Clayton State University
Teresa M. O’Neill, PhD, APRN, RNC
Our Lady of Holy Cross College
New Orleans, Louisiana
Sandra L. Siedlecki, PhD, RN, CNS
Senior Nurse Scientist
Sharon Souter, PhD, RN, CNE
Dean and Professor
University of Mary Hardin Baylor
CONTRIBUTOR AND REVIEWERS
Molly J. Walker, PhD, RN, CNS, CNE
Angelo State University
San Angelo, Texas
Cynthia Ward, DNP, RN-BC, CMSRN,
Surgical Clinical Nurse Specialist
Carilion Roanoke Memorial Hospital
Angela Wood, PhD, RN, Certified High-Risk
Associate Professor and Chair
Department of Nursing
Jefferson City, Tennessee
Fatma A. Youssef, RN, DNSc, MPH
School of Health Professions
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.
To my husband Randy Gray who is my love and my cheerleader.
To my husband Jerry who has supported all of my academic endeavors
through 58 years of marriage.
P R E FAC E
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.
Chapter 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, meta-analysis, meta-synthesis, and mixedmethods 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
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
Chapter 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
Chapter 8, Clarifying Quantitative Research Designs, addresses descriptive, correlational, quasiexperimental, 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, meta-synthesis, and mixed-method systematic
review). These guidelines were used to critically appraise current research syntheses to assist students in examining the quality of published research syntheses and the potential use of research
evidence in practice. The chapter includes theories to assist nurses and agencies in moving toward
EBP. Translational research is introduced as a method for promoting the use of research evidence in
Chapter 14, Introduction to Outcomes Research, was significantly revised by Dr. Diane Doran,
one of the leading authorities in the conduct of outcomes research. The goal of this chapter is to
increase students’ understanding of the impact of outcomes research on nursing and health care.
Content and guidelines are provided to assist students in reading and critically appraising the outcomes studies appearing in the nursing literature.
The sixth edition is written and organized to facilitate ease in reading, understanding, and critically appraising studies. The major strengths of the text are as follows:
• State-of-the art coverage of EBP—a topic of vital importance in nursing.
• Balanced coverage of qualitative and quantitative research methodologies.
• Rich and frequent illustration of major points and concepts from the most current nursing
research literature from a variety of clinical practice areas.
• Study findings implications for practice and link to QSEN competencies were provided.
• A clear, concise writing style that is consistent among the chapters to facilitate student
• Electronic references and websites that direct the student to an extensive array of information that is important in reading, critically appraising, and using research knowledge in
This sixth edition of Understanding Nursing Research is appropriate for use in a variety of undergraduate research courses for both RN and general students because it provides an introduction to
quantitative, qualitative, and outcomes research methodologies. This text not only will assist students in reading research literature, critically appraising published studies, and summarizing
research evidence to make changes in practice, but it also can serve as a valuable resource for practicing nurses in critically appraising studies and implementing research evidence in their clinical
LEARNING RESOURCES TO ACCOMPANY UNDERSTANDING NURSING
RESEARCH, 6TH EDITION
The teaching/learning resources to accompany Understanding Nursing Research have been
expanded for both the instructor and student to allow a maximum level of flexibility in course
design and student review.
Evolve Instructor Resources
A comprehensive suite of Instructor Resources is available online at http://evolve.elsevier.com/
Grove/understanding/ and consists of a Test Bank, PowerPoint slides, an Image Collection, Answer
Guidelines for the Appraisal Exercises provided for students, and new TEACH for Nurses Lesson
Plans, which replace and enhance the Instructor’s Manual provided for previous editions.
The Test Bank consists of approximately 550 NCLEX® Examination–style questions, including
approximately 10% of questions in alternate item formats. Each question is coded with the correct
answer, a rationale from the textbook, a page cross-reference, and the cognitive level in the new
Bloom’s Taxonomy (with the cognitive level from the original Bloom’s Taxonomy in parentheses).
The Test Bank is provided in ExamView and Evolve LMS formats.
The PowerPoint slide collection contains approximately 800 slides, now including seamlessly integrated Audience Response System Questions, images, and new Unfolding Case Studies. The
PowerPoints have been simplified and converted into bulleted-list format (using less narrative).
Content details in the slides have been moved as appropriate into the Notes area of the slides.
New Unfolding Case Studies focus on practical EBP/PICO questions, such as a nurse on a unit
needing to perform a literature search or to identify a systematic review or meta-analysis. PowerPoint presentations are fully customizable.
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