The Evolution of Evidence-Based Practice in Nursing

Florence Nightingale

Nightingale has been described as a reformer, reactionary, and researcher who has influenced nursing specifically and health care in general. Nightingale’s book, Notes on Nursing (1859), described her initial research activities, which focused on the importance of a healthy environment in promoting the patient’s physical and mental well-being. She identified the need to gather data on the environment, such as ventilation, cleanliness, temperature, purity of water, and diet, to determine their influence on the patient’s health (Herbert, 1981).

Nightingale is most noted for her data collection and statistical analyses during the Crimean War. She gathered data on soldier morbidity and mortality rates and the factors influencing them and presented her results in tables and pie charts, a sophisticated type of data presentation for the period (Palmer, 1977). Nightingale’s research enabled her to instigate attitudinal, organizational, and social changes. She changed the attitudes of the military and society toward the care of the sick. The military began to view the sick as having the right to adequate food, suitable quarters, and appropriate medical treatment. These interventions drastically reduced the mortality rate from 43% to 2% in the Crimean War (Cook, 1913). Nightingale improved the organization of army administration, hospital management, and hospital construction. Because of Nightingale’s research evidence and influence, society began to accept responsibility for testing public water, improving sanitation, preventing starvation, and decreasing morbidity and mortality rates (Palmer, 1977).

Early 1900s

From 1900 to 1950, research activities in nursing were limited, but a few studies advanced nursing education. These studies included the Nutting Report, 1912; Goldmark Report, 1923; and Burgess Report, 1926 (Abdellah, 1972; Johnson, 1977). On the basis of recommendations of the Goldmark Report, more schools of nursing were established in university settings. The baccalaureate degree in nursing provided a basis for graduate nursing education, with the first master of nursing degree offered by Yale University in 1929. Teachers College at Columbia University offered the first doctoral program for nurses in 1923 and granted a degree in education (Ed.D.) to prepare teachers for the profession. The Association of Collegiate Schools of Nursing, organized in 1932, promoted the conduct of research to improve education and practice. This organization also sponsored the publication of the first research journal in nursing, Nursing Research, in 1952 (Fitzpatrick, 1978).

A research trend that started in the 1940s and continued in the 1950s focused on the organization and delivery of nursing services. Studies were conducted on the numbers and kinds of nursing personnel, staffing patterns, patient classification systems, patient and personnel satisfaction, and unit arrangement. Types of care such as comprehensive care, home care, and progressive patient care were evaluated. These evaluations of care laid the foundation for the development of self-study manuals, which are similar to the quality assurance manuals of today (Gortner & Nahm, 1977).

Nursing Research in the 1950s and 1960s

In 1950, the American Nurses Association (ANA) initiated a 5-year study on nursing functions and activities. The findings were reported in Twenty Thousand Nurses Tell Their Story, and this study enabled the ANA to develop statements on functions, standards, and qualifications for professional nurses in 1959. Also during this time, clinical research began expanding as specialty groups, such as community health, psychiatric, medical-surgical, pediatrics, and obstetrics, developed standards of care. The research conducted by ANA and the specialty groups provided the basis for the nursing practice standards that currently guide professional nursing practice (Gortner & Nahm, 1977).

Educational studies were conducted in the 1950s and 1960s to determine the most effective educational preparation for the registered nurse. A nurse educator, Mildred Montag, developed and evaluated the 2-year nursing preparation (associate degree) in the junior colleges. Student characteristics, such as admission and retention patterns and the elements that promoted success in nursing education and practice, were studied for both associate- and baccalaureate degree–prepared nurses (Downs & Fleming, 1979).

In 1953, an Institute for Research and Service in Nursing Education was established at Teacher’s College, Columbia University, which provided research-learning experiences for doctoral students (Werley, 1977). The American Nurse’s Foundation, chartered in 1955, was responsible for receiving and administering research funds, conducting research programs, consulting with nursing students, and engaging in research. In 1956, a Committee on Research and Studies was established to guide ANA research (See, 1977).

A Department of Nursing Research was established in the Walter Reed Army Institute of Research in 1957. This was the first nursing unit in a research institution that emphasized clinical nursing research (Werley, 1977). Also in 1957, the Southern Regional Educational Board (SREB), the Western Interstate Commission on Higher Education (WICHE), and the New England Board of Higher Education (NEBHE) were developed. These organizations are actively involved in promoting research and disseminating the findings. The ANA sponsored the first of a series of research conferences in 1965, and the conference sponsors required that the studies presented be relevant to nursing and conducted by a nurse researcher (See, 1977). These ANA conferences continue to be an important means of disseminating nursing research findings.

In the 1960s, a growing number of clinical studies focused on quality care and the development of criteria to measure patient outcomes. Intensive care units were being developed, which promoted the investigation of nursing interventions, staffing patterns, and cost-effectiveness of care (Gortner & Nahm, 1977).

Nursing Research in the 1970s

In the 1970s, the nursing process became the focus of many studies, with the investigations of assessment techniques and guidelines, goal-setting methods, and specific nursing interventions. In 1973, the first Nursing Diagnosis Conference was held; these conferences continue to be held every 2 to 3 years. Studies have focused on identifying appropriate diagnoses for nursing and generating an effective diagnostic process (Carlson-Catalano & Lunney, 1995). Many of the studies conducted in the 1970s were not being used in practice, so Stetler and Marram (1976) developed a model to promote the communication and use of research findings in practice.

The educational studies of the 1970s evaluated teaching methods and student learning experiences. A number of studies were conducted to differentiate the practices of nurses with baccalaureate and associate degrees. These studies, which primarily measured abilities to perform technical skills, were ineffective in differentiating between the two levels of education.

In the service setting, primary nursing care, which involves the delivery of patient care predominantly by registered nurse, was the trend of the 1970s. Studies were conducted to examine the implementation and outcomes of primary nursing care delivery models. The number of nurse practitioners (NPs) and clinical nurse specialists (CNSs) with master’s degrees increased rapidly during the 1970s. Limited research has been conducted on the CNS role; however, the NP and nurse midwifery roles have been researched extensively to determine their positive impact on productivity, quality, and cost of health care (Brown & Grimes, 1995; Mundinger et al., 2000). In addition, those clinicians with master’s degrees were provided the background to conduct research and to use research findings in practice.

In the 1970s, nursing scholars began developing models, conceptual frameworks, and theories to guide nursing practice. The works of these nursing theorists also directed future nursing research. In 1978, a new journal, Advances in Nursing Science, began publishing the works of nursing theorists and the research related to their theories. The number of doctoral programs in nursing and the number of nurses prepared at the doctoral level greatly expanded in the 1970s (Jacox, 1980). Some of the nurses with doctoral degrees increased the conduct and complexity of nursing research; however, many doctorally prepared nurses did not become actively involved in research. In 1970, the ANA Commission on Nursing Research was established; in turn, this commission established the Council of Nurse Researchers in 1972 to advance research activities, provide an exchange of ideas, and recognize excellence in research. The commission also prepared position papers on subjects’ rights in research and on federal guidelines concerning research and human subjects, and it sponsored research programs nationally and internationally (See, 1977).

Federal funds for nursing research increased significantly, with a total of slightly more than $39 million awarded for research in nursing from 1955 to 1976. Even though federal funding for nursing studies rose, the funding was not comparable to the $493 million in federal research funds received by those doing medical research in 1974 alone (de Tornyay, 1977).

The dissemination of research findings was a major focus in the 1970s. Sigma Theta Tau, the International Honor Society for Nursing, sponsored national and international research conferences, and the chapters of this organization sponsored many local conferences to promote the dissemination of research findings. Image, a journal initially published in 1967 by Sigma Theta Tau, contains many nursing studies and articles about research methodology. A major goal of Sigma Theta Tau is to advance scholarship in nursing by promoting the conduct, communication, and utilization of research in nursing. The addition of two new research journals in the 1970s, Research in Nursing & Health in 1978 and Western Journal of Nursing Research in 1979, also increased the communication of nursing research findings.

Professor Archie Cochrane originated the concepts of evidence-based practice with a book he published in 1972 titled Effectiveness and Efficiency: Random Reflections on Health Services. Cochrane advocated the provision of health care based on research to improve the quality of care and patient outcomes. To facilitate the use of research evidence in practice, the Cochrane Center was established in 1992 and the Cochrane Collaboration in 1993. The Cochrane Collaboration and Library house numerous resources to promote EBP, such as systematic reviews of research and evidence-based guidelines for practice (discussed later in this chapter) (see the Cochrane Collaboration at www.cochrane.org).

Nursing Research in the 1980s and 1990s

The conduct of clinical nursing research was the focus in the 1980s and 1990s. A variety of clinical journals (Cancer Nursing; Cardiovascular Nursing; Dimensions of Critical Care Nursing; Heart & Lung; Journal of Obstetric, Gynecologic, and Neonate Nursing; Journal of Neurosurgical Nursing; Oncology Nursing Forum; Pediatric Nursing; and Rehabilitation Nursing) published an increasing number of studies. One new research journal was published in 1987, Scholarly Inquiry for Nursing Practice, and two in 1988, Applied Nursing Research and Nursing Science Quarterly.

Even though the body of empirical knowledge generated through clinical research grew rapidly in the 1970s and 1980s, little of this knowledge was used in practice. Two major projects were launched to promote the use of research-based nursing interventions in practice: the Western Interstate Commission for Higher Education (WICHE) Regional Nursing Research Development Project and the Conduct and Utilization of Research in Nursing (CURN) Project. In these projects, nurse researchers, with the assistance of federal funding, designed and implemented strategies for using research findings in practice. The WICHE Project participants selected a research-based intervention for use in practice and then functioned as change agents to implement the selected intervention in a clinical agency. Because of the limited amount of research that had been conducted, the project staff and participants had difficulty identifying adequate clinical studies with findings ready for use in practice (Krueger, Nelson, & Wolanin, 1978).

The CURN Project was a 5-year venture (1975–1980) directed by Horsley, Crane, Crabtree, and Wood (1983) to increase the utilization of research findings by (1) disseminating findings, (2) facilitating organizational modifications necessary for implementation, and (3) encouraging collaborative research that was directly transferable to clinical practice. Research utilization was seen as a process to be implemented by an organization rather than by an individual practitioner. Activities of the research utilization included (1) identification and synthesis of multiple studies in a common conceptual area (research base), (2) transformation of the knowledge derived from a research base into a solution or clinical protocol, (3) transformation of the clinical protocol into specific nursing actions (innovations) that are administered to patients, and (4) clinical evaluation of the new practice to ascertain whether it produced the predicted result (Horsley et al., 1983). The clinical protocols developed during the project were published to encourage nurses in other health care agencies to use these research-based intervention protocols in their practice (CURN Project, 1981–1982).

To ensure that the studies were incorporated into nursing practice, the findings needed to be synthesized for different topics. In 1983, the first volume of the Annual Review of Nursing Research was published (Werley & Fitzpatrick, 1983). This annual publication contains experts’ reviews of research in selected areas of nursing practice, nursing care delivery, nursing education, and the profession of nursing. The Annual Review of Nursing Research continues to be published each year to (1) expand the synthesis and dissemination of research findings, (2) promote the use of research findings in practice, and (3) identify directions for future research.

Many nurses obtained master’s and doctoral degrees during the 1980s and 1990s, and postdoctoral education was encouraged for nurse researchers. The ANA Cabinet on Nursing Research identified the research participation for various levels of educational preparation. As indicated in Figure 2-1, nurses at all levels of education have a role in research (ANA, 1989). The nursing educational preparation provides a background for nurses at the following levels:

These research expectations for each level of nursing education were supported by the American Association of Colleges of Nursing’s (AACN’s) 1999 position statement on nursing research (AACN, 1999).

Another priority of the 1980s and 1990s was to obtain greater funding for nursing research. Most of the federal funds in the 1980s were designated for studies involving the diagnosis and cure of diseases. Therefore, nursing received a small percentage of the federal research and development (R&D) funds (approximately 2% to 3%) compared with medicine (approximately 90%), even though nursing personnel greatly outnumber medical personnel (Larson, 1984). However, the ANA achieved a major political victory for nursing research with the creation of the National Center for Nursing Research (NCNR) in 1985. This center was created after years of work and two presidential vetoes (Bauknecht, 1986). The purpose of the NCNR was to support the conduct of basic and clinical nursing research and the dissemination of findings. The NCNR was established under the National Institutes of Health (NIH) and provided visibility for nursing research at the federal level. In 1993, during the tenure of its first director, Dr. Ada Sue Hinshaw, the NCNR became the National Institute of Nursing Research (NINR). This change in title enhanced the recognition of nursing as a research discipline and expanded the funding for nursing research.

Outcomes research emerged as an important methodology for documenting the effectiveness of health care services in the 1980s and 1990s. This type of research evolved from the quality assessment and quality assurance functions that originated with the professional standards review organizations (PSROs) in 1972. During the 1980s, William Roper, the director of the Health Care Finance Administration (HCFA), promoted outcomes research for determining the quality and cost-effectiveness of patient care (Johnson, 1993).

In 1989, the Agency for Health Care Policy and Research (AHCPR) was established to facilitate the conduct of outcomes research (Rettig, 1991). The AHCPR also had an active role in communicating research findings to health care practitioners and was responsible for publishing the first clinical practice guidelines in 1989. Several of these guidelines, including the latest research findings with directives for practice, were published in the 1990s. The Healthcare Research and Quality Act of 1999 reauthorized the AHCPR, changing its name to the Agency for Healthcare Research and Quality (AHRQ). This significant change positioned the AHRQ as a scientific partner with the public and private sectors to improve the quality and safety of patient care by promoting the use of the best research evidence available in practice (see www.ahcpr.gov).

Building on the process of research utilization, physicians, nurses, and other health care professions focused on the development of EBP for health care during the 1990s. A research group led by Dr. David Sackett at McMaster University in Canada developed explicit research methodologies to determine the “best evidence” for practice. The term evidence based was first used by David Eddy in 1990 with the focus on providing EBP for medicine (Craig & Smyth, 2007; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised the accreditation policies for hospitals to support the implementation of evidence-based health care. To facilitate the movement of nursing toward EBP, Stetler (2001) develop the “Research Utilization to Facilitate EBP” model (see Chapter 27 for a description of this model).

Nursing Research in the Twenty-First Century

The vision for nursing in the twenty-first century includes conducting quality studies, synthesizing the study findings into the best research evidence available, and using that research evidence effectively in practice (Brown, 1999; Craig & Smyth, 2007; Malloch & Porter-O’Grady, 2006; Melnyk & Fineout-Overholt, 2005; Pearson, Field, & Jordan, 2007). This vision is consistent with the mission of the NINR, which is to support the conduct of biological and clinical research and facilitate the communication of this research to promote an EBP for nursing (NINR, 2007, at www.nih.gov/ninr). With the conduct of biological research a priority for the NINR, the journal Biological Research for Nursing was initiated in 2000. The focus on EBP in nursing was supported with the initiation of the Worldviews on Evidence-Base Nursing journal in 2004.

The AHRQ has been designated the lead agency supporting research designed to improve the quality of health care, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. The AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes, quality, cost, use, and access. This research information promotes effective health care decision making by patients, clinicians, health system executives, and policy makers. The three future goals of the AHRQ are to (1) support improvements in health outcomes; (2) strengthen quality measurements and improvements; and (3) identify strategies to improve access, foster appropriate use of health care resources, and reduce unnecessary expenditures (AHRQ, 2007, www.ahrq.gov). Currently, the AHRQ and NINR work collaboratively to promote funding for nursing studies. These agencies often jointly call for proposals for studies of high priority to both agencies.

The focus of health care research and funding is expanding from the treatment of illness to include health promotion and illness prevention interventions. Healthy People 2000 and Healthy People 2010, government documents published by the U.S. Department of Health and Human Services (1992, 2000), have increased the visibility of and identified priorities for health promotion research. In the twenty-first century, nurses can have a major role in the development of interventions to promote health and prevent illness in individuals, families, and communities.

To ensure an effective research enterprise in nursing, the discipline must do the following:

Comparison of Quantitative and Qualitative Research

The quantitative and qualitative types of research complement each other because they generate different kinds of knowledge that are useful in nursing practice. The problem and purpose to be studied determines the type of research to be conducted, and the researcher’s knowledge of both types of research promotes accurate selection of the methodology for the problem identified (McPherson & Leydon, 2002). Quantitative and qualitative research methodologies have some similarities, because both require researcher expertise, involve rigor in implementation, and result in the generation of scientific knowledge for nursing practice. Some of the differences between the two methodologies are presented in Table 2-2.

Classification for the Research Methodologies Presented in This Text

Research methods used frequently in nursing have been classified in different ways, so a classification system was developed for this text and is presented in Table 2-3. The quantitative research methods are classified into four categories: (1) descriptive, (2) correlational, (3) quasi-experimental, and (4) experimental. Types of quantitative research are used to test theories and generate and refine knowledge for nursing practice. Quantitative research methods are introduced in this section and described in more detail in Chapter 3.

The qualitative research methods included in this textbook are (1) phenomenological research, (2) grounded theory research, (3) ethnographic research, (4) historical research, (5) philosophical inquiry, and (6) critical social theory. These approaches, all methodologies for discovering knowledge, are introduced in this section and described in depth in Chapters 4 and 23. Unit Two of this textbook focuses on understanding the research process and includes discussions of both quantitative and qualitative research.

Outcomes Research

The spiraling cost of health care has generated many questions about the quality and effectiveness of health care services and the patient outcomes. Consumers want to know what services they are buying and whether these services will improve their health. Health care policy makers want to know whether the care is cost-effective and high quality. These concerns have promoted the development of outcomes research, which examines the results of care and measures the changes in health status of patients (AHRQ, 2007; Doran, 2003). Key ideas related to outcomes research are addressed throughout the text, and Chapter 12 contains a detailed discussion of this methodology.

Intervention Research

Intervention research investigates the effectiveness of a nursing intervention in achieving the desired outcome or outcomes in a natural setting. “Interventions are defined as treatments, therapies, procedures, or actions implemented by health professionals to and with clients, in a particular situation, to move the clients’ condition toward desired health outcomes that are beneficial to the clients” (Sidani & Braden, 1998, p. 8). An intervention can be a specific treatment implemented to manage a well-defined patient problem or a program. A program intervention, such as a cardiac rehabilitation program, consists of multiple nursing actions that are implemented as a package to improve the health conditions of the participants (Brown, 2002). The goal of intervention research is to generate sound scientific knowledge for actions that nurses can use to provide evidence-based nursing care. The details of intervention research are presented in Chapter 13. In summary, nurse researchers conduct a variety of research methodologies (quantitative, qualitative, outcomes, and intervention research) to develop the research evidence needed for practice.

Definition of Best Research Evidence

Best research evidence is a summary of the highest quality, current empirical knowledge in a specific area of health care that is developed from a synthesis of quality studies (quantitative, qualitative, outcomes, and intervention) in that area. The synthesis of study findings is a complex, highly structured process that is best conducted by at least two or even a team of expert researchers and health care providers. There are various types of research synthesis, and the type of synthesis conducted varies based on the quality and types of research evidence available.

The quality of the research evidence available in an area depends on the number and strength of the studies. Replicating or repeating of studies with similar methodology adds to the quality of the research evidence. The strengths and weaknesses of the studies are determined by critically appraising the validity or credibility of the study outcomes (see Chapter 26). The types of research commonly conducted in nursing were identified earlier in this chapter as quantitative, qualitative, outcomes, and intervention. The research synthesis process used to summarize knowledge varies for quantitative and qualitative research. In building the best research evidence for practice, the quantitative experimental study, such as a randomized controlled trial (RCT), has been identified as producing the strongest research evidence for practice (Craig & Smyth, 2007; Institute of Medicine, 2001; Malloch & Porter-O’Grady, 2006; Melnyk & Fineout-Overholt, 2005; Pearson et al., 2007; Sackett et al., 2000).

Research evidence in nursing and health care is synthesized by using the following processes: (1) systematic review, (2) meta-analysis, (3) integrative review, (4) metasummary, and (5) methasynthesis. Depending on the research findings available, the best research evidence might be synthesized by one or more of these five processes. Table 2-4 identifies the processes used in research evidence synthesis, the purpose of each synthesis process, the types of research included in the synthesis (sampling frame), and the analysis techniques used to achieve the synthesis of research evidence (Whittemore, 2005). A systematic review is a structured, comprehensive synthesis of quantitative studies in a particular health care area to determine the best research evidence available for expert clinicians to use to promote an EBP. Systematic reviews are conducted to synthesize research evidence from numerous, high-quality quantitative studies with similar methodologies (Craig & Smyth, 2007). These reviews are often conducted by teams or panels of expert researchers and clinicians, who use the results of these reviews to produce the national and international standardized guidelines for managing health care problems such as hypertension (Chobanian et al., 2003). These standardized guidelines are made available online, published in articles and books, and presented at conferences and professional meetings. Some of the common sources for these standardized guidelines are presented at the end of this chapter.

Meta-analysis is a type of study that statistically pools the results from previous, similar studies into a single quantitative analysis that provides one of the highest levels of evidence for an intervention’s efficacy (Conn & Rantz, 2003). The studies synthesized are usually quasi-experimental or experimental types of studies. In addition, a meta-analysis can be performed on correlational studies to determine the type (positive or negative) or strength of relationships among selected variables (see Table 2-4). Because meta-analyses involve statistical analysis to combine study findings, it is possible to be objective rather than subjective in synthesizing research evidence. Some of the strongest evidence for using an intervention in practice is generated from a meta-analysis of multiple, controlled quasi-experimental and experimental studies. Thus, many systematic reviews conducted to generate evidence-based guidelines include meta-analyses. The process for conducting a meta-analysis is presented in Chapter 27.

An integrative review of research identifies, analyzes, and synthesizes research findings from independent quantitative and qualitative studies to determine the current knowledge (what is known and not known) in a particular area. Most of the studies synthesized in an integrative review are quantitative (descriptive, correlational, quasi-experimental, and experimental), but some reviews also include important findings from qualitative studies and theoretical literature (see Table 2-4). Integrative reviews of research direct future studies and are sometimes included in systematic reviews. The value of an integrative review depends on the standards used to the conduct the review, which is similar to the standards of clarity, rigor, and replication required for conducting primary research. The process for conducting an integrative review of research is presented in Chapter 27.

Qualitative research synthesis is the process and product of systematically reviewing and formally integrating the findings from qualitative studies (Sandelowski & Barroso, 2007). Qualitative research synthesis includes two categories: qualitative metasummary and qualitative metasynthesis (see Table 2-4). Qualitative metasummary is the synthesis or summing of the findings across qualitative reports to determine the current knowledge in an area. Metasummary can be an end in itself to identify current knowledge or can provide a foundation for conducting qualitative metasynthesis. Qualitative metasynthesis provides a fully integrated, novel description or explanation of a target event or experience verses a summary view of that event or experience. Metasynthesis requires more complex, integrative thought in developing a new perspective or theory based of the findings of previous qualitative studies. These qualitative research synthesis processes have been used to generate research evidence that contributes to the knowledge needed for EBP. Sandelowski and Barroso (2007) have developed a book that focuses on the synthesis of qualitative research, and their processes for conducting metasummary and metasynthesis are addressed in Chapter 27.

Levels of Research Evidence

The strength or validity of the best research evidence in an area depends on the quality and quantity of the studies conducted in the area. Quantitative studies, especially experimental studies like the RCT, are thought to provide the strongest research evidence. Also the replication or repetition of studies with similar methodology increases the strength of the research evidence generated. The levels of the research evidence can be thought of as a continuum with the highest quality of research evidence at one end and weakest research evidence at the other (see Figure 2-2) (Craig & Smyth, 2007; Malloch & Porter-O’Grady, 2006; Melnyk & Fineout-Overholt, 2005; Pearson et al., 2007). The systematic research reviews and meta-analyses of high-quality experimental studies provide the strongest or best research evidence for use by expert clinicians in practice. Meta-analyses and integrative reviews of quasi-experimental and experimental studies also provide strong research evidence for managing practice problems. Correlational, descriptive, and qualitative studies direct further research and provide some useful findings for practice (see Figure 2-2). The weakest evidence comes from expert opinions, which can include expert clinicians’ opinions or the opinions expressed in committee reports. When making a decision in your clinical practice, be sure to base that decision on the best research evidence available.

The levels of research evidence identified in Figure 2-2 will help nurses to determine the quality and validity of the evidence that is available for them to use in practice. Advance practice nurses must seek out the best research knowledge available in an area to ensure that they manage patients’ acute and chronic illnesses with a high quality of care (Kania-Lachance, Best, McDonah, & Ghosh, 2006). This best research evidence generated from systematic reviews, meta-analyses, and integrative reviews is used most often to develop standardized or evidence-based guidelines for practice.

Introduction to Evidence-Based Guidelines

Evidence-based practice guidelines are rigorous, explicit clinical guidelines that are based on the best research evidence available in that area. These guidelines are usually developed by a team or panel of expert researchers; expert clinicians (physicians, nurses, pharmacists, and other health professionals); and sometimes consumers, policy makers, and economists. The expert panel seeks consensus on the content of the guideline to provide clinicians with the best information for making clinical decisions in practice. There has been a dramatic growth in the production of evidence-based guidelines to assist health care providers in building an EBP and in improving health care outcomes for patients, families, providers, and health care agencies.

Every year, new guidelines are developed, and some of the existing guidelines are revised based on new research evidence. These guidelines have become the gold standard (or standard of excellence) for patient care, and nurses and other health care providers are encouraged to incorporate these standardized guidelines into their practice. Many of these evidence-based guidelines have been made available online by expert national and international government agencies, professional organizations, and centers of excellence. When selecting a guideline for practice, be sure that a credible agency or organization developed the guideline and that the reference list reflects the synthesis of extensive research evidence.

An extremely important source for evidence-based guidelines in the United States is the National Guideline Clearinghouse (NGC), which was initiated in 1998 by the Agency for Healthcare Research and Quality (AHRQ). The NGC started with 200 guidelines and has expanded to more than 1000 evidence-based guidelines (see www.guideline.gov). Another excellent source of systematic reviews and evidence-based guidelines is the Cochrane Collaboration and Library in the United Kingdom, which can be accessed at www.cochrane.org. Professional nursing organizations, such as the Oncology Nursing Society (www.ons.org) and the National Association of Neonatal Nurses (www.nann.org), have also developed evidence-based guidelines for nursing practice. These websites will introduce you to some of evidence-based guidelines that exist nationally and internationally. Chapter 27 will help you to critically appraise the quality of an evidence-based guideline and implement that guideline in your practice.

• Florence Nightingale initiated nursing research more than 150 years ago; this was followed by years of limited research until the 1950s. During the 1950s and 1960s, research became a higher priority, with the development of graduate programs in nursing that increased the number of nurses with doctorates and master’s degrees. In the 1970s and 1980s, the major focus was on the conduct of clinical research to improve nursing practice.

• Outcomes research emerged as an important methodology for documenting the effectiveness of health care service in the 1980s and 1990s. In 1989, the Agency for Health Care Policy and Research (AHCPR) was established to facilitate the conduct of outcomes research.

• The vision for nursing in the twenty-first century is the development of a scientific knowledge base that enables nurses to implement an evidence-based practice (EBP).

• Nursing research incorporates both quantitative and qualitative research and two relatively new methodologies, outcomes research and intervention research.

• Quantitative research is classified into four types for this textbook: descriptive, correlational, quasi-experimental, and experimental.

• Qualitative research is classified into six types for this textbook: phenomenological research, grounded theory research, ethnographic research, historical research, philosophical inquiry, and critical social theory.

• Outcomes research focuses on determining the end results of care or a measure of the change in health status of the patient and family.

• Intervention research involves the investigation of the effectiveness of a nursing intervention in achieving the desired outcomes in a natural setting.

• Best research evidence is a summary of the highest quality, current empirical knowledge in a specific area of health care that is developed from a synthesis of high-quality studies (quantitative, qualitative, outcomes, and intervention) in that area. Research evidence in nursing and health care is synthesized using the following processes: (1) systematic review, (2) meta-analysis, (3) integrative review, (4) metasummary, and (5) methasynthesis.

• The levels of the research evidence can be thought of as a continuum with the highest quality of research evidence at one end and the weakest at the other. The best research evidence is synthesized by a team or panel of experts to develop evidence-based guidelines for clinicians in practice.

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