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CHAPTER 1Introduction to Nursing Research

in an Evidence-Based Practice Environment
NURSING RESEARCH IN PERSPECTIVE
In all parts of the world, nursing has experienced a profound culture change. Nurses are increasingly
expected to understand and conduct research, and to base their professional practice, in part, on
research evidence—that is, to adopt an evidence-based practice (EBP). EBP involves using the best
evidence (as well as clinical judgment and patient preferences and circumstances) in making patient
care decisions, and “best evidence” typically comes from research conducted by nurses and other
healthcare professionals.
What is Nursing Research?
Research is systematic inquiry that relies on disciplined methods to answer questions or solve
problems. Nurses are increasingly engaged in disciplined studies that benefit nursing and its clients.
Nursing research is systematic inquiry designed to generate evidence about issues of importance to
the nursing profession, including nursing practice, education, administration, and informatics. In
this book, we emphasize clinical nursing research aimed at guiding nursing practice and improving
the health and quality of life of nurses’ clients.
Nursing research has experienced remarkable growth in the past few decades, providing nurses with
a growing evidence base from which to practice. Yet many questions persist, and mechanisms for
incorporating research innovations into nursing practice still are in development.
[Examples of Nursing Research Questions:
- How effective is a web-based intervention in improving parent-adolescent communication about
sexuality and sexual health? (Varas-Diaz et al., 2019)
- What are the experiences of college students who are newly diagnosed with type 1 diabetes
mellitus? (Saylor et al., 2019)]
The Importance of Research in Nursing
Findings from rigorous research provide evidence for informing nurses’ decisions. Nurses have
come to accept the desirability of incorporating research evidence into their actions, if the evidence
shows that the actions are clinically appropriate and result in positive patient outcomes.
In some countries, research plays an important role in nursing credentialing and status. For example,
the American Nurses Credentialing Center— an arm of the American Nurses Association and a
prestigious credentialing organization in the United States—developed a Magnet Recognition
Program to acknowledge healthcare organizations that provide high-quality nursing care. The 2019
Magnet application manual incorporates revisions that strengthen evidence-based requirements
(Graystone, 2017).
Indeed, applicants must now submit at least three nursing studies, indicating that Magnet hospitals
must not only be involved in EBP but also in the creation of new practice knowledge. The good
news is that there is growing evidence that the focus on research and EBP may have important
payoffs. For example, Barnes and coresearchers (2016) found that Magnet hospitals had lower rates
of central line-associated bloodstream infection than non-Magnet hospitals, even when differences
in other hospital characteristics were taken into account. And McCaughey et al. (2019) found that
patients treated at a Magnet hospital were more satisfied with their care than patients in non-Magnet
hospitals.
Changes to nursing practice now occur regularly because of EBP efforts. Practice changes often are
local initiatives that are not publicized, but broader clinical changes are also occurring based on
accumulating research evidence about beneficial practice innovations.
[Example of Evidence-Based Practice:
“Kangaroo care” (the holding of diaper-clad infants skin-to-skin by parents) is now routinely
practiced in neonatal intensive care units (NICUs), but before 2000, only a minority of NICUs
offered kangaroo care options. Expanded adoption of this practice reflects mounting evidence that
early skin-to-skin contact has benefits without negative side effects (e.g., Johnston et al., 2017;

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Moore et al., 2016). Some of that evidence came from rigorous studies conducted by nurse
researchers (e.g., Bastani et al., 2017; Billner-Garcia et al., 2018; Cho et al., 2016).]
The Consumer-Producer Continuum in Nursing Research
Most nurses are likely to engage in research activities along a continuum of participation. At one
end are consumers of nursing research, who read research reports or research summaries to keep up-
to-date on findings that might affect their practice. EBP depends on well-informed research
consumers.
At the other end of the continuum are producers of nursing research: nurses who conduct research.
At one time, most nurse researchers were academics who taught in nursing schools, but research is
increasingly being conducted by clinical nurses who seek solutions to recurring problems in patient
care.
Between these end points on the continuum lie a variety of research activities that are undertaken by
nurses. Even if you never personally carry out a study, you may (1) contribute to an idea for a
clinical study; (2) gather information for a study; (3) advise clients about participating in research;
(4) seek answers to a clinical problem by searching for and appraising research evidence; or (5)
discuss the implications of a study in a journal club in your practice setting, which involves
meetings (in groups or online) to discuss research articles. Understanding research can improve the
depth and breadth of every nurse’s professional practice.
[TIP The Cochrane Collaboration, an important organization for EBP, offers an online journal club
resource with podcasts, slides, and discussion questions (http://www.cochranejournalclub.com).
Journal clubs can help to create an environment of lifelong learning and can foster a commitment to
EBP (Gardner et al., 2016). Links to some articles about journal clubs are provided in the Toolkit in
the accompanying Resource Manual.]
Nursing Research in Historical Perspective
Table 1.1 summarizes some of the key events in the historical evolution of nursing research. An
expanded summary of the history of nursing research appears in the Supplement to this chapter on
thePoint.
Most people would agree that research in nursing began with Florence Nightingale in the 1850s.
Her most well-known research contribution involved an analysis of factors affecting soldier
mortality and morbidity during the Crimean War. Based on skillful analyses, she was successful in
effecting changes in nursing care—and, more generally, in public health. After Nightingale’s work,
research was absent from the nursing literature until the early 1900s, but most early studies
concerned nurses’ education rather than patient care.
TABLE 1.1 - Historical Landmarks in Nursing Research

YEAR EVENT

1859 Nightingale’s Notes on Nursing is published.

1900 American Journal of Nursing begins publication.

Columbia University establishes first doctoral program for nurses. Goldmark Report with
1923
recommendations for nursing education is published.

1936 Sigma Theta Tau awards first nursing research grant in the United States.

1948 Brown publishes report on inadequacies of nursing education.

1952 The journal Nursing Research begins publication.

1955 Inception of the American Nurses’ Foundation to sponsor nursing research.

1957 Establishment of nursing research center at Walter Reed Army Institute of Research.

1963 International Journal of Nursing Studies begins publication.

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1965 American Nurses’ Association (ANA) sponsors nursing research conferences.

1969 Canadian Journal of Nursing Research begins publication.

1972 ANA establishes a Commission on Research and Council of Nurse Researchers.

Stetler and Marram publish guidelines on assessing research for use in practice. Journal of
1976
Advanced Nursing begins publication.

1982 Conduct and Utilization of Research in Nursing (CURN) project publishes report.

1983 Annual Review of Nursing Research begins publication.

1985 ANA Cabinet on Nursing Research establishes research priorities.

National Center for Nursing Research (NCNR) is established within U.S. National Institutes
1986
of Health.

1988 Conference on Research Priorities is convened by NCNR.

1989 The U.S. Agency for Health Care Policy and Research (AHCPR) is established.

NCNR becomes a full institute, the National Institute of Nursing Research (NINR). The
1993
Cochrane Collaboration is established. Magnet Recognition Program makes first awards.

1995 Joanna Briggs Institute, an EBP collaborative, is established in Australia.

1997 Canadian Health Services Research Foundation is established with federal funding.

1998 The European Academy of Nursing Science (EANS) is launched.

1999 AHCPR is renamed Agency for Healthcare Research and Quality (AHRQ).

NINR’s annual funding exceeds $100 million.

2000 The Canadian Institute of Health Research is launched.
Council for the Advancement of Nursing Science (CANS) is established.

2005 The Quality & Safety Education for Nurses (QSEN) initiative is inaugurated.

2006 NINR issues strategic plan for 2006-2010.

The Institute of Medicine publishes a report, The Future of Nursing, that includes research
2010
priorities and recommendations for lifelong learning.

2011 NINR celebrates 25th anniversary and issues a new strategic plan.

2016 NINR issues The NINR Strategic Plan: Advancing Science, Improving Lives.

2019 NINR budget exceeds $145 million.

In the 1950s, research by nurses began to accelerate. For example, the American Nurses’
Foundation, which is devoted to the promotion of nursing research, was founded. The surge in the
number of studies conducted in the 1950s created the need for a new journal; Nursing Research
came into being in 1952. As shown in Table 1.1. dissemination opportunities in professional
journals grew steadily thereafter.
In the 1960s, nursing leaders expressed concern about the shortage of research on practice issues.
Professional nursing organizations, such as the Western Interstate Council for Higher Education in

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Nursing, established research priorities, and practice-oriented research on various clinical topics
began to emerge in the literature.
During the 1970s, improvements in client care became a more visible research priority, and
guidance on assessing research for application in practice settings emerged. Also, nursing research
expanded internationally. For example, the Workgroup of European Nurse Researchers was
established in 1978 to develop greater communication and opportunities for partnerships among 25
European National Nurses Associations.
In the United States, the National Center for Nursing Research (NCNR) at the National Institutes of
Health (NIH) was established in 1986. Several forces outside of nursing also helped to shape the
nursing research landscape in the 1980s. A group from the McMaster Medical School in Canada
designed a clinical learning strategy that was called evidence-based medicine (EBM). EBM, which
promulgated the view that research findings were superior to the opinions of authorities as a basis
for clinical decisions, constituted a profound shift for medical education and practice, and has had a
major effect on all healthcare professions.
Nursing research was strengthened and given more visibility when NCNR was promoted to full
institute status within the NIH. In 1993, the National Institute of Nursing Research (NINR) was
established, helping to put nursing research more into the mainstream of health research. Funding
opportunities for nursing research expanded in other countries as well.
Current and Future Directions for Nursing Research
Nursing research continues to develop at a rapid pace and will undoubtedly flourish throughout the
21st century. Broadly speaking, the priority for future nursing research will be the promotion of
excellence in nursing science. Toward this end, nurse researchers and practicing nurses will be
sharpening their research skills and using those skills to address emerging issues of importance to
the profession and its clientele. Among the trends we foresee for the early 21st century are the
following:
- Continued focus on EBP. Encouragement for nurses to engage in evidence-based patient care and
lifelong learning is sure to continue. In turn, improvements will be needed both in the quality of
studies and in nurses’ skills in locating, understanding, critically appraising, and using relevant
study results. Relatedly, there is an emerging interest in translational research, which involves
research on how findings from studies can best be translated into practice.
- Accelerating emphasis on research synthesis. Research syntheses that integrate research evidence
across studies are the cornerstone of EBP. Of particular importance is a type of synthesis called
systematic reviews, which rigorously integrate research information on a research question. Clinical
practice guidelines typically rely on such systematic reviews. We offer some guidance on how to
create, as well as how to appraise, research syntheses in this book.
- Expanded local research and quality improvement efforts in healthcare settings. Projects designed
to solve local problems are increasing. This trend will be reinforced as more hospitals apply for (and
are recertified for) Magnet status in the United States and in other countries. Mechanisms need to be
developed to ensure that evidence from these projects becomes available to others facing similar
problems.
- Strengthening of interprofessional collaboration. Collaboration of nurses with researchers in
related fields has expanded in the 21st century as researchers address fundamental healthcare
problems.
In turn, such collaborative efforts could lead to nurse researchers playing a more prominent role in
national and international healthcare policies. One major recommendation in the Institute of
Medicine’s influential 2010 report The Future of Nursing was that nurses should be full partners
with physicians and other healthcare professionals in redesigning health care.
Increased emphasis on patient-centeredness. Patient centeredness has become a central concern in
health care, as well as in research. In the United States, the Patient-Centered Outcomes Research
Institute (PCORI) funds research focused on assisting patients and their caregivers to make well-
informed healthcare decisions. Efforts are increasing to ensure that research is relevant to patients
and that patients play a role in setting research priorities. Comparative effectiveness research, which
involves direct comparisons of alternative treatments, has emerged as an important tool for patient-
centered research.

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Relatedly, greater interest in the applicability of research. More attention is being paid to figuring
out how study results can be applied to individual patients or groups of patients. A limitation of the
current EBP model is that standard strategies offer evidence on average effects of healthcare
interventions under ideal circumstances. Ideas are emerging about how best to enhance the
applicability of research in real-world settings. Growing interest in defining and ascertaining
clinical significance. Research findings increasingly must meet the test of being clinically
significant, and patients have taken center-stage in efforts to define clinical significance. Growing
interest in precision health care and symptom science. NINR has embraced research in these areas
(Cashion & Grady, 2015). Symptom science involves research to study the underlying behavioral
and molecular mechanisms of symptoms, irrespective of the health disorder. The Precision
Healthcare Initiative is helping to advance nursing omic research (e.g., genomic, microbiomic).
What are nurse researchers likely to be studying in the future? Although there is rich diversity in
research interests—as we illustrate throughout this book in our research examples—research
priorities have been articulated by several nursing organizations, including NINR, Sigma Theta Tau
International, and other nursing organizations throughout the world. For example, the primary areas
of interest articulated in the 2016 NINR strategic plan were Symptom Science: Promoting
Personalized Health Strategies; Wellness: Promoting Health and Preventing Disease; Self-
Management: Improving Quality of Life for Individuals with Chronic Illness; and End-of-Life and
Palliative Care: The Science of Compassion. Two cross-cutting areas of emphasis were promoting
innovation and developing innovative strategies for research careers (NINR, 2016). And in 2017,
the Science Committee of the Council for the Advancement of Nursing Science (CANS) in the
United States identified four priorities: precision science, big data and data analytics, determinants
of health, and global health (Eckardt, 2017).
SOURCES OF EVIDENCE FOR NURSING PRACTICE
Nurses make clinical decisions based on knowledge from many sources, including coursework,
textbooks, and their own clinical experience. Because evidence is constantly evolving, learning
about best practice nursing will persist throughout your career.
Some of what you have learned is based on systematic research, but some is not. What are the
sources of evidence for nursing practice? Until recently, knowledge primarily was handed down
from one generation to the next based on experience, trial and error, tradition, and expert opinion. A
brief discussion of some alternative sources of evidence shows how research-based information is
different.
Tradition and Authority
Decisions are sometimes based on custom or tradition. Certain “truths” are accepted as given, and
such “knowledge” is so much a part of a common heritage that few seek validation.
Some nursing interventions are based on custom and “unit culture” rather than on sound evidence.
Indeed, one analysis suggested that some “sacred cows” (ineffective traditional habits) persisted
even in a healthcare center recognized as a leader in EBP (Hanrahan et al., 2015).
Another common source of information is an authority, a person with specialized expertise.
Reliance on authorities (such as faculty or textbook authors) is unavoidable but imperfect:
authorities are not infallible, particularly if their expertise is based primarily on personal experience
or out-of-date materials.
Clinical Experience and Trial and Error
Clinical experience is a functional source of knowledge and plays an important role in EBP Yet
personal clinical experience has some limitations as a knowledge source because each nurse’s
experience is too narrow to be generally useful. Moreover, the same objective event is often
perceived differently by different nurses.
Trial and error involves trying alternatives successively until a solution to a problem is found. Trial
and error may offer a practical means of securing knowledge, but the method tends to be haphazard
and solutions may be idiosyncratic.
Logical Reasoning
Solutions to some problems are developed by logical reasoning, which combines experience, the
intellect, and formal systems of thought. Inductive reasoning involves developing generalizations
from specific observations. For example, a nurse may observe the anxious behavior of (specific)

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hospitalized children and conclude that (in general) children’s separation from their parents is
stressful. Deductive reasoning involves developing specific predictions from general principles. For
example, if we assume that separation anxiety occurs in hospitalized children (in general), then we
might predict that (specific) children in a hospital whose parents do not room-in will manifest
symptoms of stress. Both types of reasoning are useful for understanding phenomena, and both play
a role in research. Logical reasoning by itself, however, is limited because the validity of reasoning
depends on the accuracy of the initial premises.
Assembled Information
In making clinical decisions, healthcare professionals rely on information that has been assembled
for a various purposes. For example, local, national, and international benchmarking data provide
information on such issues as infection rates or the rates of various procedures (e.g., cesarean births)
and can facilitate evaluations of clinical practices. Cost data—information on the costs associated
with certain procedures, policies, or practices—are sometimes used as a factor in clinical decision-
making. Quality improvement and risk data, such as medication error reports, can be used to assess
the need for practice changes. Such sources are useful, but they do not provide a mechanism for
making clinical decisions or guiding improvements.
Disciplined Research
Research conducted in a disciplined framework is the best method of acquiring knowledge. Nursing
research combines logical reasoning with other features to create evidence that, although fallible,
tends to be especially reliable. Carefully synthesized findings from rigorous research are especially
valuable. The current emphasis on EBP requires nurses to base their clinical practice to the greatest
extent possible on research-based findings rather than on tradition, authority, intuition, or personal
experience—although nursing will always remain a rich blend of art and science.
PARADIGMS AND METHODS FOR NURSING RESEARCH
A paradigm is a world view, a general perspective on the complexities of the world. Paradigms for
human inquiry are often characterized in terms of the ways in which they respond to basic
philosophical questions, such as, “What is the nature of reality?” and “What is the relationship
between the inquirer and those being studied?”
Disciplined inquiry in nursing has been conducted mainly within two broad paradigms, positivism
and constructivism. This section describes these two paradigms and outlines the research methods
associated with them. In later chapters, we describe the transformative paradigm that underpins
critical theory research (Chapter 22) and a pragmatism paradigm that underlies mixed methods
research (Chapter 27).
The Positivist Paradigm
The paradigm that dominated healthcare research for decades is called positivism (or logical
positivism). Positivism is rooted in 19th century thought, guided by such philosophers as Newton
and Locke. Positivism reflects a broader cultural phenomenon (modernism) that emphasizes the
rational and the scientific.
A fundamental assumption of positivists is that there is a reality out there that can be studied and
known. (An assumption is a basic principle that is believed to be true without proof.) Adherents of
positivism assume that nature is basically ordered and regular and that reality exists independent of
human observation (Table 1.2). The related assumption of determinism refers to the positivists’
belief that phenomena are not haphazard but rather have antecedent causes. If a person has a
cerebrovascular accident, a positivist assumes that there must be a reason that can be potentially
identified. Within this paradigm, much research activity is aimed at understanding the underlying
causes of phenomena.
Positivists value objectivity and attempt to hold personal beliefs and biases in check. The
positivists’ scientific approach involves using orderly procedures with tight controls of the research
situation to test hunches about the phenomena being studied.
Strict positivist thinking has been challenged, and few researchers adhere to the tenets of pure
positivism. In the postpositivist paradigm, there is a belief in reality and a desire to understand it,
but postpositivists recognize the impossibility of total objectivity. They do, however, see objectivity
as a goal and strive to be as neutral as possible. Postpositivists also recognize the obstacles to
knowing reality with certainty and therefore seek probabilistic evidence—i.e., learning what the

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true state of a phenomenon probably is. This modified positivist position remains a dominant force
in healthcare research. For the sake of simplicity, we refer to it as positivism.
The Constructivist Paradigm
The constructivist paradigm (also called the naturalistic paradigm) began as a countermovement to
positivism with writers such as Weber and Kant. Just as positivism reflects the cultural phenomenon
of modernism that burgeoned after the industrial revolution, naturalism is an outgrowth of the
cultural transformation called postmodernism. Postmodern thinking emphasizes the value of
deconstruction, taking apart old ideas and structures, and reconstruction, putting ideas and
structures together in new ways. The constructivist paradigm represents a major alternative system
for conducting disciplined research in nursing. Table 1.2 compares the major assumptions of the
positivist and constructivist paradigms.
For the naturalistic inquirer, reality is not a fixed entity but rather is a construction of the people
participating in the research; reality exists within a context, and many constructions are possible.
Naturalists thus take the position of relativism: if there are multiple interpretations of reality that
exist in people’s minds, then there is no process by which the ultimate truth or falsity of the
constructions can be determined.
The constructivist paradigm assumes that knowledge is maximized when the distance between the
researcher and those under study is minimized. The voices and interpretations of study participants
are crucial to understanding the phenomenon of interest. Findings in a constructivist inquiry are the
product of the interaction between the inquirer and the participants.
Paradigms and Methods: Quantitative and Qualitative Research
Research methods are the techniques researchers use to structure a study and to gather and analyze
information relevant to the research question. The two alternative paradigms correspond to different
approaches to developing evidence.
TABLE 1.2 - Major Assumptions of the Positivist and Constructivist Paradigms

PHILOSOPHICAL POSITIVIST PARADIGM CONSTRUCTIVIST PARADIGM

QUESTION ASSUMPTION ASSUMPTION

What is the nature of Reality exists; there is a real world Reality is multiple and subjective,
reality? driven by real natural causes mentally constructed by individuals

In what way is the

The researcher is independent from The researcher interacts with those
researcher related to
those being researched; findings are being researched; findings are the
those being
not influenced by the researcher creation of the interactive process
researched?

What is the role of Values and biases are to be held in Subjectivity and values are inevitable
values in the inquiry? check; objectivity is sought and desirable

What are the best

Deductive processes→ hypothesis Inductive processes → hypothesis
methods for obtaining
testing generation
evidence?

Emphasis on discrete, specific Emphasis on entirety of a

concepts phenomenon, holistic

Focus on the objective and Focus on the subjective and

quantifiable nonquantiflable

Outsider knowledge—researcher is Insider knowledge—researcher is

external, separate part of the process

Fixed, prespecified design Flexible, emergent design

Controls over context Context-bound

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Large, representative samples Small, information-rich samples

Measured (quantitative) information Narrative (unstructured) information

Statistical analysis Qualitative analysis

Seeks generalizations Seeks in-depth understanding

A key methodologic distinction is between quantitative research, which is most closely allied with
positivism, and qualitative research, which is associated with constructivist inquiry—although
positivists sometimes undertake qualitative studies and constructivist researchers sometimes collect
quantitative information. This section provides an overview of the methods associated with the two
paradigms.
The Scientific Method and Quantitative Research
The traditional scientific method refers to a set of orderly, disciplined procedures used to acquire
information. Quantitative researchers use deductive reasoning to generate predictions that are tested
in the real world. They typically move in a systematic fashion from the definition of a problem and
the selection of concepts on which to focus, to the solution of the problem.
By systematic, we mean that the investigator progresses logically through a series of steps,
according to a prespecified plan of action.
Quantitative researchers use various control strategies. Control involves imposing conditions on the
research situation so that biases are minimized and validity is maximized. Control mechanisms are
discussed at length later in this book.
Quantitative researchers gather empirical evidence—evidence that is rooted in objective reality and
gathered through the senses (e.g., through sight or hearing). Observations of the presence or absence
of skin inflammation, patients’ agitation, or infant birth weight are all examples of empirical
observations. Reliance on empirical evidence means that findings are grounded in reality rather than
in researchers’ personal beliefs.
Evidence for a study in the positivist paradigm is gathered according to an established plan, using
structured methods to collect needed information. Usually the information gathered is quantitative
—that is, numeric information that is obtained through a formal measurement and is analyzed
statistically.
A traditional scientific study strives to go beyond the specifics of a research situation. For example,
quantitative researchers are typically not as focused on understanding why a particular person has a
stroke as in understanding what factors influence its occurrence in people generally. The degree to
which research findings can be generalized to individuals other than those who participated in a
study is called generalizability.
The scientific method has enjoyed considerable stature as a method of inquiry and has been used
productively by nurse researchers studying a wide range of nursing problems. This approach cannot,
however, solve all nursing problems. One important limitation—common to both quantitative and
qualitative research—is that research cannot be used to answer moral or ethical questions. Many
intriguing questions about humans fall into this area—questions such as whether euthanasia should
be practiced or abortion should be legal.
The traditional research approach also must address measurement challenges. To study a
phenomenon, quantitative researchers try to measure it using numeric values that express quantity.
For example, if the phenomenon of interest is patient stress, researchers would want to assess if
patients’ stress is high or low. Physiologic phenomena like blood pressure can be measured with
great accuracy and precision, but measuring psychological phenomena (e.g., stress, resilience,
depression) is challenging.
Another issue is that nursing research focuses on humans, who are inherently complex and diverse.
Quantitative studies typically concentrate on relatively few concepts (e.g., weight gain, fatigue,
pain). Complexities tend to be controlled and, if possible, eliminated, rather than studied directly,
and this narrowness of focus can sometimes obscure insights. Quantitative research within the
positivist paradigm has been accused of an inflexibility of vision that fails to capture the full breadth
of human experience.

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Constructivist Methods and Qualitative Research

Researchers in constructivist traditions emphasize the inherent complexity of humans, their ability
to shape and create their own experiences, and the idea that truth is a composite of realities.
Constructivist studies are thus focused on understanding the human experience as it is lived, usually
through the collection and analysis of qualitative materials that are narrative and subjective.
Researchers who criticize the scientific method believe that it is overly reductionist—that is, it
reduces human experience to the few concepts under investigation, and those concepts are defined
in advance by the researcher rather than emerging from the perspective of those under study.
Constructivist researchers tend to emphasize the dynamic and holistic aspects of human life and
attempt to capture those aspects in their entirety.
Flexible, evolving procedures are used to capitalize on findings that emerge during the study.
Constructivist inquiry often takes place in the field (i.e., in naturalistic settings), sometimes over an
extended time period. In constructivist research, the collection of information and its analysis
typically progress concurrently; as researchers sift through
information, insights are gained, new questions emerge, and further evidence is sought to amplify or
confirm the insights. Through an inductive process, researchers integrate information to develop a
theory or description that helps illuminate the phenomenon of interest.
Constructivist studies yield rich, in-depth information that can elucidate varied dimensions of a
complicated phenomenon. Findings from qualitative research are typically grounded in the real-life
experiences of people with first-hard knowledge of a phenomenon. Nevertheless, the approach has
several limitations. Human beings are used directly as the instrument through which information is
gathered, and humans are extremely intelligent and sensitive—but fallible—tools. The subjectivity
that enriches the analytic insights of skillful researchers can yield trivial and obvious “findings”
among less competent ones.
Another potential limitation involves the subjectivity of constructivist inquiry, which sometimes
raises concerns about the idiosyncratic nature of the conclusions. Would two constructivist
researchers studying the same phenomenon in similar settings arrive at similar conclusions? The
situation is further complicated by the fact that most constructivist studies involve a small group of
participants. Thus, the generalizability of findings from constructivist inquiries is sometimes a
potential concern.
Multiple Paradigms and Nursing Research
Paradigms should be viewed as lenses that help to sharpen our focus on phenomena, not as blinders
that limit intellectual curiosity. Nursing knowledge would be thin if there were not a rich array of
methods available within the two paradigms—methods that are often complementary in their
strengths and limitations. We believe that intellectual pluralism is advantageous.
We have emphasized differences between the two paradigms and associated methods so that
distinctions would be easy to understand. Subsequent chapters of this book elaborate further on
differences in terminology, methods, and research products. It is equally important to note, however,
that the two main paradigms have many features in common, only some of which are mentioned
here:
- Ultimate goals. The aim of disciplined research, regardless of paradigm, is to answer questions
and solve problems. Both quantitative and qualitative researchers seek to capture the truth about an
aspect of the world in which they are interested, and both groups can make meaningful
contributions to evidence for nursing practice.
- External evidence. Although the word empiricism has come to be associated with the classic
scientific method, researchers in both traditions gather and analyze evidence empirically, that is,
through their senses.
- Reliance on human cooperation. Human cooperation is essential in both qualitative and
quantitative research. To understand people’s circumstances and experiences, researchers must
persuade them to participate in the investigation and to speak and act candidly.
- Ethical constraints. Research with human beings is guided by ethical principles that sometimes are
at odds with research goals. Ethical dilemmas sometimes confront researchers, regardless of
paradigm or method.

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- Fallibility of disciplined research. Virtually all studies have limitations. Every research question
can be addressed in many ways, and inevitably there are tradeoffs. The fallibility of any single study
makes it important to understand and critically appraise researchers’ methodologic decisions when
evaluating evidence quality.
Thus, despite philosophic and methodologic differences, researchers using traditional scientific or
constructivist methods face many similar challenges. The selection of an appropriate method
depends on researchers’ personal philosophy and on the research question. If a researcher asks,
“What are the effects of cryotherapy on nausea and oral mucositis in patients undergoing
chemotherapy?” the researcher needs to study effects by carefully measuring patient outcomes. On
the other hand, if a researcher asks, “What is the process by which parents learn to cope with the
death of a child?” the researcher would be hard pressed to quantify such a process.
Personal world views of researchers help to shape their questions.
In reading about the alternative paradigms for nursing research, you likely were more attracted to
one of the two paradigms. It is important, however, to learn about both approaches to disciplined
inquiry and to recognize their respective strengths and limitations. In this textbook, we describe
methods associated with both qualitative and quantitative research to assist you in becoming
methodologically bilingual. This is especially important because large numbers of nurse researchers
are now undertaking mixed methods research that involves the collection and analysis of both
qualitative and quantitative data (Chapters 27-29).
THE PURPOSES OF NURSING RESEARCH
The general purpose of nursing research is to answer questions and solve problems of relevance to
nursing. Specific purposes can be classified in various ways. For example, a distinction sometimes
is made between basic and applied research. Basic research is undertaken to discover general
principles of human behavior and biophysiologic processes. Some basic research (bench research)
is performed in laboratory settings and focuses on the molecular and cellular mechanisms that
underlie disease. Applied research is aimed at examining how basic principles can be used to solve
practice problems. Nurse researchers undertake both types of research.
Another way to classify research purposes concerns the extent to which studies provide explanatory
information. Specific study goals can range along a descriptive/explanatory continuum, but a
fundamental distinction is between studies whose primary intent is to describe phenomena and those
that are cause-probing—that is, designed to illuminate the underlying causes of phenomena. The
descriptive/explanatory continuum includes studies whose purposes are identification, description,
exploration, prediction/control, and explanation of health-related phenomena. For each purpose,
various types of question are addressed—some more amenable to qualitative than to quantitative
inquiry, and vice versa. Table 1.3 gives examples of questions asked for these purposes.
In both nursing and medicine, several books have been written to facilitate evidence-based practice,
and these books categorize studies in terms of the types of information needed by clinicians (Guyatt
et al., 2015; Melnyk & Fineout-Overholt, 2015). These writers focus on several types of clinical
purposes: Therapy/intervention; Diagnosis/assessment; Prognosis; Etiology (causation)/prevention
of harm; Description; and Meaning/process.
Therapy/Intervention
Therapy/intervention questions are addressed by healthcare researchers who want to learn about the
effects of specific actions, products, or processes. Typically, researchers addressing this type of
question are evaluating whether a new treatment or a practice change has beneficial effects.
The name “Therapy” for this category originates from promoters of EBP in medicine who focused
on studies of the effects of “therapeutic” medical interventions, such as new drugs or surgical
procedures. However, this category should be thought of more broadly to include research on the
effects of alternative ways of doing things, usually with the intent of testing strategies for making
improvements. Therapy questions are foundational for evidence-based decision-making. Evidence
for changes to nursing practice, nursing education, and nursing administration comes from studies
that have specifically tested the effects of intervening in a particular way. Table 1.4 provides some
examples of studies in which nurse researchers addressed diverse Therapy/intervention questions. If
such questions are answered in a rigorous fashion, the evidence might suggest a practice change or
the implementation of an institutional innovation.

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Studies in this category range from evaluations of highly specific treatments (e.g., comparing two
types of cooling blankets for febrile patients) to assessments of complex multisession interventions
designed to change behaviors (e.g., nurse-led health promotion programs). Intervention research is
essential for evidence-based practice, and nurses are increasingly engaging in this type of research.
TABLE 1.3 - Research Purposes and Questions on the Description/Explanation Continuum

TYPES OF QUESTIONS: QUANTITATIVE TYPES OF QUESTIONS:

PURPOSE
RESEARCH QUALITATIVE RESEARCH

What is this phenomenon? What is its

Identification
name?

What are the dimensions or

How prevalent is the phenomenon? How characteristics of the phenomenon?
Description often does the phenomenon occur? How
intense is the phenomenon? What is important about the
phenomenon?

What is the full nature of the

What factors are related to the phenomenon? What is really going on
phenomenon? here?
Exploration
What are the antecedents of the How is the phenomenon experienced?
phenomenon? What is the process by which the
phenomenon evolves?

What is the underlying cause of the How does the phenomenon work? What
Explanation phenomenon? does the phenomenon mean? How did
Does the theory explain the phenomenon? the phenomenon occur?

If phenomenon X occurs, will phenomenon

Y follow?
Prediction -
What will happen if we modify a
phenomenon or introduce an intervention?

Can the occurrence of the phenomenon be

Control -
prevented or controlled?

Research addressing Therapy questions is inherently cause-probing: the researcher wants to know if
a certain intervention will cause improved outcomes.
Diagnosis/Assessment
A burgeoning number of nursing studies concern the rigorous development and evaluation of formal
instruments to screen, diagnose, and assess patients and to measure important clinical outcomes—
that is, they address Diagnosis/assessment questions. High-quality instruments with documented
accuracy are essential for both clinical practice and research. Typically, the question being
addressed is: Does this new instrument yield reliable and valid information about an outcome,
situation, or condition of importance to nursing? Studies addressing Diagnosis questions are not
cause-probing.
Example of a Study Aimed at Diagnosis/ Assessment
Kang and colleagues (2018) developed and evaluated the Automated Medical Error Assessment
System, which was incorporated into an electronic health record system.
Prognosis
Researchers who ask Prognosis questions strive to understand the outcomes that are associated with
a disease or a health problem (i.e., its consequences), to estimate the probability they will occur, and
to predict the types of people for whom the outcomes are most likely.
TABLE 1.4 - Examples of Therapy/Intervention Questions

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THERAPY/INTERVENTION QUESTION AREA OF

FOCUS

Does an education intervention improve teenagers’ knowledge and behaviors

Nursing practice
relating to contraception? (Pivatti et al., 2019)

Do muscle relaxation or nature sounds reduce fatigue in patients with heart

Nursing practice
failure? (Seifi et al., 2018)

Does a nurse-led phone follow-up education program reduce cardiovascular risk

Nursing practice
among patients with cardiovascular disease? (Zhou et al., 2018)

Does a simulation-based palliative care communication skill workshop improve

Interprofessional
self-perception of skills in expressing empathy and discussing spiritual issues
education
among healthcare workers and students? (Brown et al., 2018)

Does simulation improve the ability of first year nursing students to learn vital Nursing
signs? (Eyikara & Baykara, 2018) education

Does a bundle of interventions to support nurses’ engagement in evidence-based

Nursing
practice (EBP) increase their knowledge, attitudes, and use of library resources?
administration
(Carter et al., 2018)

Such studies facilitate the development of long-term care plans for patients and can suggest the need
for appropriate interventions. For example, Prognosis studies provide valuable information for
guiding patients to make lifestyle choices or to be vigilant for key symptoms. Prognosis questions
are typically cause-probing; the researcher wants to know if, for example, a certain disease or
behavior causes subsequent adverse outcomes.
[Example of a Study Aimed at Prognosis
Galazzi and colleagues (2018) studied the long-term quality of life outcomes of patients with severe
respiratory failure who had undergone extracorporeal membrane oxygenation.]
Etiology (Causation)/Prevention of Harm
Nurses encounter patients who face potentially harmful exposures as a result of environmental
agents or because of personal behaviors or characteristics. Providing information to patients about
such harms and how best to avoid them depends on the availability of accurate evidence about
factors that contribute to health risks. For example, there would be no smoking cessation programs
if research had not provided strong evidence that smoking cigarettes causes or contributes to a wide
range of health problems. Thus, identifying factors that affect or cause illness, mortality, or
morbidity is an important purpose of many nursing studies. Etiology questions tire inherently cause-
probing—the purpose is to understand factors that cause health problems.
[Example of a Study Aimed at Identifying and Preventing Harm
Philpott and Corcoran (2018) did a study to identify factors that put men at risk of paternal postnatal
depression in Ireland. The risk factors examined included a prior history of depression, economic
circumstances, marital status, and availability of paternity leave.]
Description
Description questions are not in a category typically identified in EBP-related classification
schemes, but so many nursing studies have a descriptive purpose that we include it here.
Examples of phenomena that nurse researchers have described include patients’ pain, physical
function, confusion, and levels of depression. Quantitative description focuses on the prevalence,
size, intensity, and measurable attributes of phenomena. Qualitative researchers, by contrast,
describe the dimensions or the evolution of phenomena.
[Example of a Quantitative Study Aimed at Description
Schoenfisch and colleagues (2019) did a study to describe hospital nursing staff’s use of lift or
transfer devices. They found that only 40% of the nurses used equipment for at least half of
lifts/transfers.]

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[Example of a Qualitative Study Aimed at Description

Dose and Rhudy (2018) undertook a study to describe what was important to patients newly
diagnosed with advanced cancer and receiving dignity therapy during cancer treatment.]
Meaning/Process
Designing effective interventions, motivating people to comply with treatments and health
promotion activities, and providing sensitive advice to patients are among the many healthcare
activities that can benefit from understanding clients’ perspectives. Research that provides evidence
about what health and illness mean to clients, what barriers to positive health practices they face,
and what processes they experience in a transition through a healthcare crisis are important to
evidence-based nursing practice. Studies that address Meaning/process questions are seldom
focused on identifying the underlying causes of phenomena but might offer important clues.
[Example of a Study Aimed at Understanding Meaning/Process
Qin and coresearchers (2019) studied the process by which women experienced a cognitive-
behaviora transition after undergoing pregnancy termination for fetal anomaly.]
Study Purposes and Evidence-Based Practice
Studies that address Therapy/intervention questions provide the most direct evidence for EBP. If we
want to know, for example, whether wedge-shaped foam cushions are more effective in preventing
heel pressure ulcers than standard foam pillows, we would need to look for rigorous studies that
have addressed this Therapy question. However, other questions also play a role in improving the
quality of nursing care, albeit in different ways.
Table 1.5 presents examples of different types of questions relating to cigarette smoking, using the
study purpose categories we just described. The findings from studies relating to only one of these
questions is directly actionable—the Therapy question. If there is strong evidence that nurse-led
smoking cessation programs are effective in reducing smoking among young adults, we might
consider initiating such a program in our own community
If the other questions in Table 1.5 were answered in rigorous studies, the evidence could also play a
role in guiding efforts to improve nursing practice—but not as directly. Answers to some of these
questions might help to target those most in need of an intervention. For example, based on studies
addressing the Diagnosis question, we could launch a prevention effort aimed at teenagers with high
scores on the evidence-based Smoking Susceptibility Index, or results from an Etiology study might
lead us to offer a smoking-cessation initiative in low-income neighborhoods. Evidence from the
Prognosis question might prompt us to develop a strong program of emotional support for patients
with lung cancer. We might be motivated to implement an intervention for high school students if
we knew that rates of smoking were high (the Description question). And, if we knew that a high
percentage of smokers in our community had been unsuccessful in efforts to quit, we might design
an intervention with that information in mind. The stories from long-term smokers who failed to
quit despite efforts to do so (the Meaning question) could lead us to involve them in the design of an
intervention for hardened smokers.
TABLE 1.5 - Different Categories of Questions Related to Cigarette Smoking

TYPE OF EXAMPLE OF A RELATED RESEARCH QUESTION ON CIGARETTE

QUESTION SMOKING

Therapy/
Does a nurse-led smoking cessation program for young adults reduce smoking?
intervention

Is our Smoking
Diagnosis/
assessment Susceptibility Index a valid and reliable measure of propensity to initiate
smoking in teenagers?

Is a diagnosis of smoking-related lung cancer associated with increased risk of

Prognosis
suicidal ideation?

Etiology Does being poor increase the risk that a person will smoke cigarettes?

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(causation)/
prevention of harm

What percentage of high school students smoke 1+ packs of cigarettes/ week,

Description
and what percentage of smokers have tried to quit?

Meaning/process What is it like for long-term smokers to attempt and fail at quitting?

Nurse researchers are making strides in addressing all types of questions about important health
problems—but evidence regarding what “works” to address problems comes from studies focused
on Therapy questions. Evidence about the scope of a problem, factors affecting the problem, the
consequences of the problem, and the meaning of the problem can, however, play a crucial role in
efforts to design better interventions, to aim our resources at those in greatest need, and to provide
appropriate guidance to clients in everyday practice.
ASSISTANCE FOR USERS OF NURSING RESEARCH
This book is designed primarily to help you develop skills for conducting research, but in an
environment that stresses EBP, it is extremely important to hone your skills in reading, evaluating,
and using nursing studies. We provide specific guidance to consumers in most chapters by including
guidelines for critically appraising aspects of a study covered in the chapter. The questions in Box
1.1 are designed to assist you in using the information in this chapter in an overall preliminary
assessment of a research report.
[TIP The Resource Manual (RM) for this book offers rich opportunities to practice your critical
appraisal skills. The RM’s Toolkit on thePoint includes Box 1.1 as a Word document, which will
allow you to adapt these questions, if desired, and to input answers to them directly in a Word
document without having to retype the questions.]
RESEARCH EXAMPLES
Each chapter of this book presents brief descriptions of studies conducted by nurse researchers,
focusing on aspects emphasized in the chapter. Read the full journal articles to learn more about the
methods and results of these studies.
Research Example of a Quantitative Study
Study: Promoting heart health among rural African Americans (Abbott et al., 2018)
Study purpose: The purpose of the study, which addressed a Therapy question, was to evaluate a
culturally relevant health promotion intervention designed to reduce cardiovascular disease risk in
rural African American adults—the “With Every Heartbeat is Life” program.
BOX 1.1 Questions for a Preliminary Overview of a Research Report
1. How relevant is the research question in this study to the actual practice of nursing? Does the
study focus on a topic that is a priority area for nursing research?
2. Was the research quantitative or qualitative?
3. What was the underlying purpose (or purposes) of the study—identification, description,
exploration, explanation, or prediction and control? Does the purpose correspond to an EBP focus
such as Therapy/ intervention, Diagnosis/assessment, Prognosis, Etiology (causation)/prevention of
harm, Description, or Meaning/process?
4. Is this study fundamentally cause-probing?
5. What might be some clinical implications of this research? To what type of people and settings is
the research most relevant? If the findings are valid, how might / use the results of this study in my
clinical work?
Study methods: Twelve rural churches in two counties of northern Florida were assigned, at random,
to either receive the intervention (six churches) or not receive it (the other six churches). Pastors and
community members from the churches then recruited people to participate in the study. A total of
115 adults were in the intervention group, and 114 were in the group not receiving the intervention
(the control group). Those in the intervention group received the weekly, 90-minute cardiovascular
health promotion intervention for 6 weeks, whereas those in the control group did not receive any
health promotion education. Everyone who participated in the study completed questionnaires
before the start of the study and 6 weeks later at the end of the study. The questionnaires were used

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to gather information about participants’ attitudes, intentions, and self-efficacy to increase the
consumption of produce, reduce dietary saturated fat intake, and increase exercise.
Key findings: Those in the intervention group had significantly greater improvements than those in
the control group on most of the outcomes. For example, participants who received the program had
significantly greater intentions to increase produce consumption and reduce dietary fat intake. Self-
efficacy for healthy choices also increased significantly more among participants in the intervention
group.
Conclusions: Abbott and colleagues concluded that nurse-led interventions in community settings
can potentially reduce cardiovascular disease risk.
Research Example of a Qualitative Study
Study: “I can never be too comfortable”—Race, gender, and emotion at the hospital bedside
(Cottingham et al., 2018)
Study purpose: The purpose of this descriptive study was to explore how gender and race intersect
to shape the emotion practice of nurses as they experience, manage, and reflect on their emotions in
the workplace.
Study methods: As part of a larger study of nurses and emotional labor, audio diaries were elicited
from a sample of 48 nurses who were diverse with respect to gender (both women and men) and
race (white, black, and Asian). Study participants were given a digital voice recorder and were
instructed to make a recording after six consecutive shifts. They were asked to reflect on how they
felt during and after their last shift, to describe things that influenced their emotions, and to explain
how they responded to their own emotions. Participants were not asked to specifically reflect on
experiences related to race. Each recording was transcribed for analysis.
Key findings: Analysis of the audio diary data revealed “a disproportionate emotional labor that
emerges among women nurses of color in the white institutional space of American health care” (p.
145). Women of color were found to experience an emotional “double shift” in negotiating
interactions between patients, coworkers, and supervisors. These women were found to have
experiences that added to job-related stress and that resulted in depleted emotional resources that
negatively influenced patient care.
Conclusions: The researchers expressed the hope that their study would help to make more visible
the toll of the intersection of race and gender on emotional labor in nursing.
SUMMARY POINTS
- Nursing research is systematic inquiry undertaken to develop evidence on problems of importance
to nurses. Nurses are adopting an evidence-based practice (EBP) that incorporates research findings
into their clinical decisions.
- Nurses can participate in a range of research-related activities that span a continuum from being
consumers of research (those who read and evaluate studies) to being producers of research (those
who design and undertake studies). Engagement with research often occurs in practice settings
through participation in a journal club.
- Nursing research began with Florence Nightingale but developed slowly until its rapid acceleration
in the 1950s. Since the 1980s, the focus has been on clinical nursing research—that is, on problems
relating to clinical practice.
- The National Institute of Nursing Research (NINR), established at the U.S. National Institutes of
Health in 1993, affirms the stature of nursing research in the United States.
- Contemporary issues in nursing research include the growth of EBP, expansion of local research
and quality improvement efforts, research synthesis through systematic reviews, interprofessional
studies, patient-centeredness in both clinical care and in research, interest in the applicability of
research to individual patients or groups, interest in precision health care and symptom science, and
efforts to measure the clinical significance of research results.
- Disciplined research stands in contrast to other knowledge sources for nursing practice, such as
tradition, authority, personal experience, trial and error, and logical reasoning.
Nursing research is conducted mainly within one of two broad paradigms—world views with
underlying assumptions about reality: the positivist and the constructivist paradigms. In the
positivist paradigm, it is assumed that there is an objective reality and that natural phenomena are

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orderly. The assumption of determinism is the belief that phenomena result from prior causes and
are not haphazard. In the constructivist (naturalistic) paradigm, it is assumed that reality is not
fixed, but it is a construction of human minds; “truth” is a composite of multiple constructions of
reality. The positivist paradigm is associated with quantitative research—the collection and analysis
of numeric information. Quantitative research is typically conducted within the traditional scientific
method, which is a systematic, controlled process. Quantitative researchers gather and analyze
empirical evidence (evidence collected through the human senses) and strive for generalizability of
their findings.
Researchers within the constructivist paradigm emphasize understanding the human experience as it
is lived through the collection and analysis of subjective, narrative materials using flexible
procedures that evolve in the field; this paradigm is associated with qualitative research.
Basic research is designed to extend the knowledge base for the sake of knowledge itself. Applied
research focuses on discovering solutions to immediate problems. A fundamental distinction,
especially relevant in quantitative research, is between studies whose primary intent is to describe
phenomena and those that are cause-probing—i.e., designed to illuminate underlying causes of
phenomena. Specific research purposes on the description/explanation continuum include
identification, description, exploration, prediction/control, and explanation. Nursing studies can be
classified in terms of several EBP-related aims: Therapy/intervention; Diagnosis/assessment;
Prognosis; Etiology (causation)/prevention of harm; Description; and Meaning/process. Rigorous
answers to Therapy questions are foundational for EBP.
STUDY ACTIVITIES
Study activities are available to instructors on Point.
REFERENCES CITED IN CHAPTER 1
**Abbott, L., Williams, C., Slate, E., & Gropper, S. (2018). Promoting heart health among rural
African Americans. Journal of Cardiovascular Nursing, 33. E8-E14.
*Barnes, H., Reardon, J., & McHugh, M. (2016). Magnet® hospital recognition linked to lower
central line-associated bloodstream infection rates. Research in Nursing & Health, 39, 96-104.
Bastani, F., Rajai, N., Farsi, Z., & AIs, H. (2017). The effects of kangaroo care on the sleep-wake
states of preterm infants. Journal of Nursing Research, 25, 231-239.
Billner-Garcia, R., Spilkerm, A., & Goyak, D. (2018). Skin to skin contact: newborn temperature
stability in the operating room. MCN: American Journal of Maternal-Child Nursing, 43, 158-163.
Brown, C., Back, A., Ford, D., Kross, E., Downey, L., Shannon, S., … Engelberg, R. (2018). Self-
assessment scores improve after simulation-based palliative care communication skill workshop.
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Carter, E., Rivera, R., Gallagher, K., & Cato, K. (2018). Targeted interventions to advance a culture
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*Cashion, A. K., & Grady, P. (2015). The National Institutes of Health/National Institutes of
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infant attachment, and maternal stress. Journal of Pediatric Nursing, 31, 430-438.
Cottingham, M., Johnson, A., & Erickson, R. (2018). “I can never be too comfortable”: race,
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Dose, A., & Rhudy, L. (2018). Perspectives of newly diagnosed advanced cancer patients receiving
dignity therapy during cancer treatment. Supportive Care in Cancer, 26, 187-195.
Eckardt, P., Culley, J., Corwin, E., Richmond, T., Dougherty, C, Pickler, R., … DeVon, H. (2017).
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Eyikara, E., & Baykara, Z. (2018). Effect of simulation on the ability of first year nursing students
to learn vital signs. Nurse Education Today, 60, 101-106.

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Galazzi, A., Brambilla, A., Grasselli, G., Pesenti, A., Fumagali, R., & Lucchini, A. (2018). Quality
of life of adult survivors after extra corporeal membrane axygenation (ECMO). Dimensions of
Critical Care Nursing, 37, 12-17.
Gardner, K., Kanaskie, M., Knehans, A., Salisbury, S., Doheny, K., & Schirm, V. (2016).
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Graystone, R. (2017). The 2014 Magnet® Application Manual: nursing excellence standards
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Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C, Greiner, J.,… Williamson, A.
(2015). Sacred cows gone to pasture: a systematic evaluation and integration of evidence-based
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*Institute of Medicine. (2010). The future of nursing: leading change, advancing health.
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Johnston, C., Campbell-Yeo, M., Disher, T., Benoit, B., Femandes, A., Streiner, D.,… Zee, R.
(2017). Skin-to-skin care for procedural pain in neonates. Cochrane Database of Systematic
Reviews, CD0008435.
Kang, M., Jin, Y., Jin, T., & Lee, S. (2018). Automated medication error risk assessment system
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McCaughey, D., McGhan, G., Rathert, C., Williams, J., & Hearld, K. (2019). Magnetic work
environments: patient experience outcomes in Magnet versus non-Magnet hospitals. Health Care
Management Review (in press).
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare:
a guide to best practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
Moore, E. R., Bergman, N., Anderson, G., & Medley, N. (2016). Early skin-to-skin contact for
mothers and their health newborn infants. Cochrane Database of Systematic Reviews, CD0003519.
*National Institute of Nursing Research. (2016). The NINR strategic plan: advancing science,
improving lives. Bethesda, MD: NINR.
Philpott, L., & Corcoran, P. (2018). Paternal postnatal depression in Ireland: prevalence and
associated factors. Midwifery, 56, 121-127.
Pivatti, A., Osis, M., & deMorales Lopes, M. (2019). The use of educational strategies for
promotion of knowledge, attitudes and contraceptive practice among teenagers: a randomized
clinical trial. Nurse Education Today, 72, 18-26.
Qin, C., Chen, W., Deng, Y., Li, Y., Mi, C, Sun, L., & Tang, S. (2019). Cognition, emotion, and
behaviour in women undergoing pregnancy termination for foetal anomaly: a grounded theory
analysis. Midwifery, 68, 84-90.
Saylor, J., Hanna, K., & Calamaro, C. (2019). Experiences of students who are newly diagnosed
with type 1 diabetes mellitus. Journal of Pediatric Nursing, 44, 74-80.
Schoenfisch, A., Kucera, K., Lipscomb, EL, Mcllvaine, J., Becherer, L., James, T., & Avent, S.
(2019). Use of assisteive devices to lift/transfer, and reposition hospital patients. Nursing Research,
68, 3-12.
Seifi, L., Najafi Ghezeljeh, T., & Haghani, H. (2018). Comparison of the effects of Benson muscle
relaxation and nature sounds on the fatigue of patients with heart failure. Holistic Nursing Practice,
32, 27-34.
Varas-Diaz, N., Betancourt-Diaz, E., Lozano, A., Huang, L., DiNapoli, L., Hanlon, A., & Villaruel,
A. (2019). Testing the efficacy of a web-based parent-adolescent sexual communication intervention
among Puerto Ricans. Family & Community Health, 42, 30-43.
Zhou, Y., Liao, J., Feng, F., Ji, M., Zhao, C., & Wang, X. (2018). Effects of a nurse-led phone
follow-up education program based on the self-efficacy among patients with cardiovascular disease.
Journal of Cardiovascular Nursing, 33, E15-E23.

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[Footnote: *A link to this open-access article is provided in the Toolkit for Chapter 1 in the
Resource Manual.]
[Footnote: **This journal article is available on thePoint for this chapter.]

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