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Evidence for nursing practice comes from research and other sources.

Evidence for nursing practice comes from research and other sources.

Evidence for nursing practice comes from research and other sources. Evidence-based prac- tice requires an understanding of how research findings and other evidence inform and guide practice. In this chapter, you will learn the importance of conducting nursing research and the connection between research and evidence-based nursing practice. We start by providing definitions for research and nursing research. We continue with a dis- cussion of the reason research is conducted and add definitions for evidence and evidence- based practice. We also provide an overview of different sources of knowledge that are used as evidence, a definition of theory, and a discussion of the evidence provided by five dif- ferent types of theories.

Chapter 1

Research and Evidence-Based Nursing Practice

KEYWORDS

Aesthetic Nursing Theories

Applied Research

A Priori

Authority

Basic Research

Clinical Research

Concepts

Data

Descriptive Nursing Theories

Empirical Nursing Theories

Ethical Nursing Theories

Evidence

Evidence-Based Nursing Practice

Explanatory Nursing Theories

Knowledge

Metaparadigm

Metaparadigm of Nursing

Nursing Research

Predictive Nursing Theories

Propositions

Research

Sociopolitical Theories

Tenacity

Theories of Personal Knowing

Theory

Utilization of Research

WHAT IS RESEARCH?

Research can be defined in various ways. Some definitions of research found in the Oxford English Dictionary (OED) (2005) are:

• the act of searching (closely or carefully) for or after a specified thing or person

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• a search or investigation directed to the discovery of some fact by careful consideration or study of a subject; a course of critical or scientific inquiry

• an investigation; an inquiry into things

The dictionary definitions draw our attention to research as a thorough search, an investi- gation, or a critical inquiry. The goal of the search, investigation, or inquiry is the discovery of something.

Definitions of research found in textbooks, such as the definitions listed below, underscore the thorough and critical nature of research and draw attention to the discovery or develop- ment of knowledge as the specific goal. The definitions indicate that research is:

• “A diligent, systemic inquiry or study that validates and refines existing knowledge and develops new knowledge” (Burns & Grove, 2007, p. 3)

• “Systematic inquiry that uses disciplined methods to answer questions or solve problems” (Polit & Beck, 2006, p. 4)

• “A rigorous process of inquiry designed to provide answers to questions about things of concern in an academic discipline or profession” (Anders, Daly, Thompson, Elliott, & Chang, 2005, p. 155)

• A formal, systematic, and rigorous process used to generate and test theories (Fawcett, 1999)

Although Polit and Beck (2006) refer to research as a way to solve problems, it is important to point out that research is not the same as problem-solving. Research focuses on developing knowledge to enhance understanding, whereas problem-solving focuses on using existing knowledge to resolve practical problems (Fain, 2004). More precisely, knowledge developed by means of research does not provide answers to problems but rather helps us to think differently about the problems we encounter in practice.

Knowledge,Theory, and Research

Fawcett (1999) mentions theories in her definition of research, whereas Burns and Grove (2007) mention knowledge, as did Hunt (1981), who also pointed out that “research increases the body of knowledge” (p. 190).

Knowledge is a very broad term that encompasses all that is known about something (OED, 2005). The spectrum of knowledge ranges from very broad statements to very precise statements.

A theory is regarded as knowledge that is at the relatively precise end of the knowledge spectrum. Theories are made up of one or more ideas and statements about those ideas. When discussing theories, ideas are referred to as concepts, and statements are referred to as propositions. Examples of theory concepts are functional status and physical energy. One type of proposition is a statement that defines a concept. An example is:

Functional status is defined as the performance of usual activities of daily living.

Another type of proposition is a statement about the association between two concepts. An example is:

Physical energy is related to functional status.

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Our definition of theory given below identifies the number of concepts (one or more) and the type of concepts (concrete and specific), as well as the type of propositions (descriptions of concepts and associations between concepts) that make up a theory.

• A theory is made up of one or more relatively concrete and specific concepts, the propositions that narrowly describe those concepts, and the propositions that state relatively concrete and specific associations between two or more of the concepts.

Research is the process used to gather and convert words and numbers—which are referred to as data—into theories. The definition of research we prefer combines the idea that research is a rigorous and systematic type of inquiry with the idea that research is directed toward the development of knowledge through the generation and testing of theories.

• Research is a formal, systematic, and rigorous process of inquiry used to generate and test theories.

Unfortunately, in some cases, the theory that is generated or tested through the use of data is not always obvious, and the research appears to be what Chinn and Kramer (2004) called “theory-isolated” (p. 123). They explained that the contribution of research that is not expli- citly directed toward theory development is very limited.

WHAT IS NURSING RESEARCH?

Nursing research “provides the scientific basis for the practice of the profession” (American Association of Colleges of Nursing, 2005, p. 1). Definitions of nursing research tend to be circular, requiring an understanding of the meaning of research and the meaning of nursing. For example, Nieswiadomy (2008) defined nursing research as “the systematic, objective process of analyzing phenomena of importance to nursing” (p. 54). Burns and Grove (2007) pointed out that the definition of nursing research requires an understanding of what knowl- edge is relevant for nursing, and specifically what knowledge is needed to improve nursing practice.

The meaning of nursing and the identification of categories of knowledge that are rele- vant for nursing practice are summarized in what is called the metaparadigm of nursing. A metaparadigm is a global statement that identifies the subject matter of each discipline or field of study (Fawcett, 2005b). The metaparadigm of nursing identifies human beings, the environment, health, and nursing as the subject matter of interest to nurses. The distinctive focus of the discipline of nursing is on nursing actions and processes directed toward human beings that take into account the environment in which human beings reside and in which nursing practice occurs.

We have already defined research. Based on that definition and the metaparadigm of nurs- ing, we offer this definition of nursing research:

• Nursing research is a formal, systematic, and rigorous process of inquiry used to generate and test theories about the health-related experiences of human beings within their environments and about the actions and processes that nurses use in practice.

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WHY CONDUCT RESEARCH?

We believe that one of the most compelling reasons to conduct research is to develop theories. Sometimes research is conducted to generate theories, while at other times research is conducted to test theories.

Basic,Applied, and Clinical Research

Research designed to generate or test theories is considered basic research. Tests of the limits of the applicability of theories in different situations with diverse populations are considered applied research (Donaldson & Crowley, 1978). Tests of theories about the effectiveness of interventions are considered clinical research (Donaldson & Crowley).

Research and Theory Development

The product of research is always theory. In Box 1–1, we deliberately use equal signs (�) to signify the equivalence of the terms. Thus, we believe that research does not lead to theory development but rather that research is the process of theory development. Similarly, theory does not lead to evidence but instead is the evidence. And practice does not lead to research, but rather practice and research are the same process. Appreciating the equivalence of practice and research highlights the practicing nurse’s ability to be a “knowledge producer” as well as a “knowledge consumer or user” (Reed, 2006, p. 36).

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BOX 1-1

Research,Theory, Evidence, and Practice

• Research � Theory development

• Theory � Evidence

• Practice � Research

Theories as Evidence

Theories can be thought of as evidence (see Box 1–1), which is something that serves as proof (OED, 2005). When theories are used as evidence, the “proof ” should be considered tentative or uncertain, because no theory is absolutely true and actually may be false (Popper, 1965). In other words, a theory can never be proved to be true, so it should never be considered final or absolute. It is always possible that additional tests of the theory will yield findings that would contradict it or that other theories will provide a better fit with the data (Hoyle, Harris, & Judd, 2002). In nursing, evidence in the form of theory is used to guide practice.

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WHAT IS EVIDENCE-BASED NURSING PRACTICE?

In recent years, a great deal of attention has been paid to the need to base practice on evidence. The term evidence-based nursing practice refers to the use of evidence to guide nurs- ing practice. Some discussions of evidence-based nursing practice reflect an atheoretical,

Practice and Research

When theories are thought of as evidence, it becomes clear that the evidence needed for practice actually is theory (Walker & Avant, 2005). It may not be surprising, therefore, to learn that prac- tice and research are essentially the same process (see Box 1–1). This means that the nursing prac- tice process and the nursing research process involve the same critical thinking skills and actions. When professional practice is as rigorous and systematic as we expect research to be, the nursing practice process “mirrors” the nursing research process (Cipriano, 2007, p. 27). In each process, a problem is identified and then a plan is developed, implemented, and evaluated.

As can be seen in Table 1–1, the results of assessment of a person’s health-related experiences can be considered the statement of the research problem—that is, the purpose of the research. Sometimes, the results of the assessment are summarized with a label or diagnosis that specifies a health-related experience and influencing factors. The label or diagnosis used in practice becomes a more elaborate statement of the problem in research. Planning in nursing practice, or developing a plan of care for a person, a family, or a community, is the same as identifica- tion of the methods for research. Implementation in practice comprises the nursing interven- tions; in research, implementation refers to the actual conduct of research, including recruiting research participants and collecting and analyzing data. Evaluation in practice can be consid- ered the same as the interpretation of research results. Written or computerized documentation of each step of the nursing process in practice is equivalent to the research report.

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Table 1–1 The Parallel Between the Nursing Practice Process and the Nursing Research Process

NURSING PRACTICE PROCESS NURSING RESEARCH PROCESS

Assessment

Planning

Implementation

Evaluation

Documentation

Statement of the problem

Research methods

Conduct of the research

Interpretation of results

Research report

Adapted from Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (2nd ed., p. 595). Philadelphia: F.A. Davis, with permission.

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biomedically dominated, empirical perspective in which the randomized clinical trial—a very rigorous type of experimental research—is the only legitimate source of evidence. Along with Fawcett and colleagues (2001) and Ingersoll (2000), we believe that such a narrow viewpoint detracts from thinking about theories as the evidence for practice. A broader viewpoint, but one that does not explicitly include theory, was given by Pearson, Wiechula, Court, and Lockwood (2007), who are associated with the Joanna Briggs Institute, an Australian organi- zation devoted to advancement of evidence-based nursing care. They stated, “The Joanna Briggs Institute (JBI) model of evidence-based healthcare conceptualizes evidence-based prac- tice as clinical decision-making that considers the best available evidence, the context in which the care is delivered, client preference, and the professional judgment of the health professional” (p. 85). Similarly, Porter-O’Grady (2006) defined evidence-based practice as “simply the inte- gration of the best possible research . . . evidence with clinical expertise and with patient needs” (p. 1).

The definitions of evidence-based practice given here highlight theory as central. These definitions assert that evidence-based practice is:

• “Conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in con- sideration of individual needs and preferences” (Ingersoll, 2000, p. 152)

• “Conscious and intentful use of research- and theory-based information to make deci- sions about patient care delivery” (Macnee, 2004, p. 5)

• “Explicit and judicious decision making about health care delivery for individuals or groups of patients based on the consensus of the most relevant and supported evidence derived from theory-derived research and data-based information to respond to con- sumers’ preferences and societal expectations” (Driever, 2002, p. 593)

Our definition of evidence-based nursing practice draws from those definitions, as well as from our emphasis on research as theory development, theory as evidence, and practice as research (see Box 1–1).

• Evidence-based nursing practice is the deliberate and critical use of theories about human beings’ health-related experiences to guide actions associated with each step of the nursing process.

At times, evidence-based practice is equated with research utilization (Hasseler, 2006), which has been the focus of a great deal of literature and many projects during the past 30 years. At other times, evidence-based practice is regarded as different from or broader than research utilization. Stetler (2001b) viewed evidence-based practice and research utilization as different but acknowledged that the connection between them “is somewhat murky in the literature” (p. 272). She pointed out that research utilization “provides the requisite prepara- tory steps for research-related actions that, when implemented and sustained, result in [evidence-based practice]” (p. 272). Polit and Beck (2006) regard evidence-based practice as broader than research utilization, claiming that evidence-based practice involves basing nurs- ing care decisions on the best available evidence, whereas research utilization involves the translation of the results of research into the real world of practice. Brown (1999) referred to “research-based practice,” which can be thought of as a bridge between research utilization and evidence-based practice. She defined research-based practice as “healthcare practitioners’ use

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of research findings and collective research evidence to shape general approaches to care, spe- cific courses of action, and recommendations made to individual patients” (p. 4). In this book, we focus on evidence-based practice.

WHAT ARE THE SOURCES OF KNOWLEDGE USED AS EVIDENCE FOR PRACTICE?

We believe that theory is the very best source of knowledge used as evidence for nursing practice. We acknowledge, however, that other sources of knowledge exist and sometimes are evidence for practice. For example, knowledge that serves as evidence for practice may come from medical record data, quality improvement and infection control reports, health- care professionals’ clinical expertise and judgment, and patient preferences based on values and culture (Driever, 2002; Macnee & McCabe, 2008; Pearson et al., 2007).

Other sources of knowledge are various methods of knowing. The philosopher Charles Sanders Peirce (1839–1914) identified four methods of knowing—tenacity, authority, a priori, and science—as sources of knowledge that sometimes are used as evidence for practice (Cohen & Nagel, 1934; Kerlinger & Lee, 2000). We have substituted “theory” for “science” because “[t]he basic aim of science is theory” (Kerlinger & Lee, p. 11). Understanding the meaning and the limitations of each method of knowing can help increase our commitment to develop the theories that are needed to guide nursing practice (Table 1–2).

Tenacity

One method of knowing is tenacity, which has also been called tradition (Dzurec, 1998; Polit & Beck, 2006). Tenacity refers to persistent, unsubstantiated, personal opinions about things in the world. Tenacious opinions are those that people believe to be true because they know that they are true on the basis of their always having known that they are true (Kerlinger & Lee, 2000). In practice, tenacity guides us to do certain things in a certain way just because we have always done them that way. Tenacity is evident in the many habits, rit- uals, and customs we find in practice. For example, it is customary to bathe a patient from head to toe.

A major limitation of tenacity is that any opinion that contradicts the tenaciously held opinion is ignored as unworthy of attention or regarded as disloyal. Another limitation is that there is no way for a person to decide which one of various conflicting opinions might be best. Still another limitation is that reliance on tenacity as evidence “sometimes [leads] to unantic- ipated outcomes” that may be harmful (Thompson, McCaughan, Cullum, Sheldon, & Reynor, 2005, p. 438).

Authority

Another method of knowing is authority. This method, which is similar to faith, involves appeal to a highly respected source—the authority—for evidence. The authority might be a

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book, a journal article, a governmental agency, or a person who is considered an expert. The words written in the book, article, or agency report or uttered by the person are accepted as the truth because the book, article, report, or person is highly respected. Authority is evident in the laws, rules, and procedures of daily life and practice. Authority, in the form of the opinions of people regarded by their peers as experts, also is evident in organizational or national standards for practice that are not based on theory (Panfil & Wurster, as cited in Hasseler, 2006).

Use of authority as evidence may be justified because authorities may be correct or because people do not have the time or adequate knowledge and skills to find the evi- dence themselves. Reliance on authoritative sources may, however, ignore the potential fallibility of written or spoken words. For example, errors may be found in a textbook; a teacher may present evidence that has been discredited by new research results; or a nurse manager may hold atheoretical opinions. And because some authorities sometimes rely on other persons who also are thought to be authorities or on their own tenacious opinions, their words cannot always be regarded as accurate evidence. A teacher, for example, may not notice an error on a particular page in a textbook before referring students to that page.

10 Part 1 ■ Introduction to Research

Table 1–2 Description and Limitations of Four Methods of Knowing Used as Evidence

DESCRIPTION LIMITATIONS

Tenacity

“We’ve always done it that way; it’s the custom.”

“It’s the traditional way to do it here.”

Authority

“The textbook tells us to do it that way.”

“My teacher told me to do it this way.”

A Priori

“It seems reasonable.”

Theory

“The theory guides me to do it.”

Ignores contradictory evidence and opinions.

There is no way to decide between con- flicting opinions.

There are unanticipated negative outcomes.

Authoritative sources are not infallible.

There is no way to decide which authori- tative source is correct.

One person’s idea of reasonable is not the same as another’s.

There is no way to decide whether rea- sonableness depends on the current way of thinking or previous education.

Must be developed through rigorous inquiry.

Theories can be false.

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A Priori

Still another method of knowing is a priori—that is, “the use of reason alone, without exper- imental evidence” (Payton, 1994, p. 11). This method, which is also referred to as intuition or common sense, involves reliance on the obviously true or self-evident nature of the evidence. The evidence may agree with reason, although it may not agree with experience. The a priori method often involves trial and error or “isolated and unsystematic clinical experiences” (Stetler, 2001a, p. 186) that are never formalized as procedures, although a procedure that seems to be effective may be passed from one practitioner to others. For example, one nurse may tell other nurses that all patients experience good outcomes when they walk a short distance on the first postoperative day.

A limitation of the a priori method is that what one person regards as reasonable may not be the same as what another person regards as reasonable. Another limitation is that the self- evident nature of something may reflect a way of thinking that is popular at a particular time or that was learned at an earlier time.

Theory

The best method of knowing used for evidence is theory. Others have identified science or research, which is the method of science, as the best way to acquire evidence in the form of theory because it is much more reliable and self-corrective than the tenacity, authority, and a priori methods (Cohen & Nagel, 1934; Kerlinger & Lee, 2000). We agree with Polit and Beck (2006) that research “is the most sophisticated method of acquiring evidence that humans have developed” (p. 13). Research can be regarded as sophisticated because it requires the researcher to consider alternatives. Researchers, as Cohen and Nagel pointed out, are “never too certain about [their] results” (p. 195). Consequently, as the product of research, theory is not regarded as the truth but rather as the best currently available evidence. A theory that represents the best available evidence may, for example, indicate that words of encourage- ment from nurses and family members hasten patients’ recovery from surgery.

A limitation of theory as evidence is that it must be developed through careful and system- atic research, which typically takes a long time. Thus, a theory may not yet be available to guide a particular practice action. Another limitation is that a theory may be false (Popper, 1965). The geocentric theory, which asserts that the planet Earth is the center of our solar sys- tem, is an example of a theory about the physical world that currently is regarded as false.

WHAT TYPES OF THEORIES ARE USED AS EVIDENCE FOR NURSING PRACTICE?

Many nursing actions are very complex and “are based to a very large degree on interaction, communication, and human care, [which] cannot be measured at all, nor can they be stan- dardized or shown to be effective” (Hasseler, 2006, p. 227). Nursing actions may also be based on “clinical expertise, patient choices, and critical evaluation of the literature” (Cumulative

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Index of Nursing and Allied Health Literature, 2005). Consequently, our thinking about the- ory as evidence for evidence-based nursing practice has to account for all of the complex human care actions performed by nurses.

Five types of theories can be used as evidence for evidence-based nursing practice— empirical, aesthetic, ethical, personal knowing, and sociopolitical (Carper, 1978; Chinn & Kramer, 2004; White, 1995). Each type of theory is developed by means of a different type of inquiry, and each is a different type of evidence.

Empirical Theories

Empirical nursing theories are publicly verifiable factual descriptions, explanations, or pre- dictions based on subjective or objective data about groups of people. The data used for empir- ical theories are summarized as group averages. Empirical theories make up the science of nursing (Table 1–3).

Chinn and Kramer (2004, p. 10) identified two critical questions that are answered by empirical theories:

• “What is this?” • “How does it work?”

We add two other questions that are answered by empirical theories:

• How do I know what my own best practices are? • How do I know how to get desired outcomes?

Three types of empirical theories are used as evidence for nursing practice—descriptive the- ories, explanatory theories, and predictive theories. Each type of empirical theory is developed by means of a particular type of empirical research (see Table 1–3).

Descriptive Nursing Theories

Descriptive nursing theories are detailed descriptions of people’s health-related experiences; they are developed by means of descriptive research. Descriptive theories are the evidence needed to develop tools that nurses can use to assess people’s health-related experiences. A the- ory about the concept of empathy, called the Theory of Personal System Empathy, is an exam- ple of a descriptive nursing theory (Alligood & May, 2000). This theory is a description of what nurses do when they feel empathy for a patient. Specifically, the theory “proposes that empathy organizes perceptions; facilitates awareness of self and others; increases sensitivity; promotes shared respect, mutual goals, and social awareness; cultivates understanding of individuals with- in a historical and social context; and affects learning” (p. 243). This theory is the evidence needed for development of a nursing practice tool to assess nurses’ empathy for patients.

Explanatory Nursing Theories

Explanatory nursing theories are explanations of the relation between people’s health- related experiences and environmental factors that influence those experiences; they are

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developed by means of correlational research. Explanatory theories are the evidence nurses need to link assessments of health-related experiences with assessments of environmental factors and to understand which environmental factors influence which aspects of health- related experiences. The Theory of Chronic Pain is an example of an explanatory nursing theory (Tsai, Tak, Moore, & Palencia, 2003). The theory indicates that pain, disability, and social support are related to daily stress and that daily stress is related to depression in older individuals with arthritis. This theory is the evidence needed to link assessments of pain, dis- ability, and social support with assessment of daily stress and assessment of daily stress with assessment of depression in older people who have arthritis.

Predictive Nursing Theories

Predictive nursing theories are predictions about the effects of some nursing intervention on people’s health-related experiences; they are developed by means of experimental research.

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Table 1–3 Types of Nursing Theories and Modes of Inquiry with Examples: Empirical Theories

TYPE OF MODE OF THEORY DESCRIPTION INQUIRY EXAMPLES

Empirical theories

The science of nursing

Descriptive theories

Explanatory theories

Predictive theories

Publicly verifiable factual descrip- tions, explanations, or predictions based on subjec- tive or objective group data

Descriptions of people and situations

Explanations of environmental factors that influ- ence people and situations

Predictions about the effects of some actions or processes on people and situations

Empirical research

Descriptive research

Correlational research

Experimental research

Scientific data

Descriptions of people’s health experiences

Explanations of factors that influ- ence health experiences

Outcomes of nursing interven- tions

Adapted from Fawcett, J.,Watson, J., Neuman, B., Hinton-Walker, P., & Fitzpatrick, J. J. (2001). On theories and evidence. Journal of Nursing Scholarship, 33, 115–119, with permission.

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Predictive theories are the evidence needed to link nursing interventions to outcomes experi- enced by people with diverse health conditions. The Theory of Dependent Care is an exam- ple of a predictive nursing theory (Arndt & Horodynski, 2004). This theory predicts that group and individual education for parents about child development, feeding, food, nutrition, and parent mealtime practices will result in toddlers’ self-regulation of feeding and mealtime interactions. The theory is the evidence needed for the development of group and individual educational programs for parents that are targeted to toddlers’ feeding behaviors and interac- tions during meals.

Knowledge progresses from descriptive theories developed by means of descriptive research to explanatory theories developed by means of correlational research to predictive theories developed by means of experimental research. Although researchers sometimes are tempted to omit the crucial steps of descriptive and explanatory theory development in their haste to test predictive theories of the effects of interventions, we agree with Lobo (2005) that “[w]e must value and support the descriptive research that helps us understand individuals, families, and groups of people with specific needs. . . . We must encourage the logical development of nurs- ing knowledge, starting with descriptive, foundational research that must be completed before specific interventions can be developed and tested” by means of experimental research (p. 6).

Aesthetic Nursing Theories

Aesthetic nursing theories focus on individuals, rather than groups. They emphasize the nurse’s perception of what is significant in an individual’s behavior. This type of theory high- lights the nurse’s ability to know what is happening to a particular patient in a subjective, intuitive way, without relying on objective information, such as vital signs. Aesthetic theories also address the “artful” performance of manual and technical skills. They make up the art of nursing (Table 1–4).

Chinn and Kramer (2004, p. 10) identified two critical questions that are answered by aes- thetic theories:

• What does this mean?” • “How is this significant?”

We add one other question:

• How do I know what each individual needs?

Aesthetic theories are developed by means of envisioning the possibilities about nursing practice with each individual and rehearsing the art and acts of nursing, with emphasis on developing an appreciation of aesthetic meanings in practice and inspiration for the develop- ment of the art of nursing. This type of theory is expressed in philosophical essays about nurs- ing as an art, in aesthetic criticism of the performance of the art of nursing through manual and technical skills, and in works of art, such as paintings, drawings, sculpture, poetry, fiction and nonfiction, music, acting, and dance. An example of an aesthetic nursing theory is the Theory of Nursing Art (Chinn, 2001). This theory “offers a conceptual definition of the art of nursing—explanations as to how nursing art evolves as a distinct aspect of nursing practice and explanations of artistic validity in nursing” (p. 287). Chinn emphasized that the theory is

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not empirical and therefore “is not intended to be subjected to empirical testing but rather to be considered from a logical, philosophic, and aesthetic perspective” (p. 287). Another exam- ple of an aesthetic nursing theory is Masson’s (2001) poem about her experiences with a sister who had breast cancer.

Ethical Theories

Ethical nursing theories, which are descriptions of obligations, values, and desired outcomes, also are used for practice. This type of theory is made up of concepts and propositions about nurses’ personal beliefs and values and the collective values of the professional discipline of nursing. Ethical theories make up the ethics of nursing (Table 1–5).

Chinn and Kramer (2004, p. 10) identified two critical questions that are answered by ethical theories:

• “Is this right?” • “Is this responsible?”

We add two other questions:

• How do I know what I should do? • How do I know what the right things to do are?

Ethical theories are developed by means of ethical inquiries that focus on identification and analysis of the beliefs and values held by individuals and groups, dialogue about and

Chapter 1 ■ Research and Evidence-Based Nursing Practice 15

Table 1–4 Types of Nursing Theories and Modes of Inquiry with Examples:Aesthetic Theories

TYPE OF MODE OF THEORY DESCRIPTION INQUIRY EXAMPLES

Aesthetic theories

The art and act of nursing

Expressions of the nurse’s perception of what is signifi- cant in the individ- ual patient’s behavior

Performance of nursing actions in an artful manner

Envisioning the possibilities of practice with an individual

Rehearsing nursing art and acts and observing or per- forming nursing art

Philosophical essays

Works of art

Aesthetic criticism

Adapted from Fawcett, J.,Watson, J., Neuman, B., Hinton-Walker, P., & Fitzpatrick, J. J. (2001). On theories and evidence. Journal of Nursing Scholarship, 33, 115–119, with permission.

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clarification of beliefs and values, and establishment of justification for beliefs and values. Sometimes, ethical inquiry and empirical research overlap. As Chinn and Kramer (2004) pointed out, descriptive ethics is an empirical endeavor, in that people are asked about their beliefs and values.

Codes of ethics, standards of practice, and philosophical essays about how nurses should behave can be considered ethical theories. An example is the American Nurses’ Association (ANA) (2001) Code of Ethics. The Code of Ethics is a statement of professional goals and values that guide nurses’ conduct (ANA’s Code of Ethics Project Task Force, 2000).

Theories of Personal Knowing

Nursing theories of personal knowing are another type of theory used as evidence for prac- tice. This type of theory is concerned with the nurse’s knowing, encountering, and actualizing the authentic self. This means that personal knowing theories focus on how each nurse knows how to be authentic in relationships with patients—that is, how he or she knows how to express concern and caring for another human being. Personal knowing is not “knowing one’s self,” but rather knowing how to be authentic with others, what can be thought of as know- ing one’s own personal style of being with another person. Personal knowing is what we mean when we talk about therapeutic nurse/patient relationships and when we discuss the quality and authenticity of the interpersonal process between each nurse and each patient. Personal knowing theories are the interpersonal relationships of nursing (Table 1–6).

Chinn and Kramer (2004, p. 10) identified two critical questions that are answered by per- sonal knowing theories:

• “Do I know what I do?” • “Do I do what I know?”

16 Part 1 ■ Introduction to Research

Table 1–5 Types of Nursing Theories and Modes of Inquiry with Examples: Ethical Theories

TYPE OF MODE OF THEORY DESCRIPTION INQUIRY EXAMPLES

Ethical theories

The ethics of nursing

Descriptions of moral obligations, moral and non- moral values, and desired ends

Identification, analy- sis, and clarifica- tion of beliefs and values

Dialogue about and justification of beliefs and values

Standards of practice

Codes of ethics

Philosophies of nursing

Adapted from Fawcett, J.,Watson, J., Neuman, B., Hinton-Walker, P., & Fitzpatrick, J. J. (2001). On theories and evidence. Journal of Nursing Scholarship, 33, 115–119, with permission.

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We add two other questions:

• How do I know how to be with people who come to me for nursing? • How do I know how to be therapeutic?

Personal knowing theories are developed as nurses open and center themselves in their work with patients, as they think about how they are or can be authentic, and as they listen to responses from others and reflect on those responses. This type of theory requires the nurse to draw on “personal qualities . . . [such as] self-awareness, sensitivity, warmth, and a positive non-blaming attitude” to develop effective and authentic relationships with patients (Hewitt & Coffey, 2005, p. 563). Theories of personal knowing are found in nurses’ autobiographical stories about the genuine, authentic self, as well as in essays about personal knowing. Diers’ (2005) description of her work as a nurse is an example of a nursing theory of personal know- ing presented as a short autobiographical story. Meisenhelder’s (2006) discussion of personal knowledge of spirituality is an example of a personal knowing nursing theory presented as an essay. The theory proposes that nurses’ personal self-knowledge of spirituality is required to address patients’ spiritual needs.

Sociopolitical Theories

Sociopolitical nursing theories help nurses to understand the context of nursing practice and facilitate acceptance of multiple perspectives of a situation. This type of theory provides the context or cultural location for nurse/patient interactions and the broader context in which nursing and health care take place. They focus on exposing and exploring alternate constructions of reality (Table 1–7).

The question we think is relevant for sociopolitical knowing is:

• How do I know what is “real” in practice situations?

Chapter 1 ■ Research and Evidence-Based Nursing Practice 17

Table 1–6 Types of Nursing Theories and Modes of Inquiry with Examples:Theories of Personal Knowing

TYPE OF MODE OF THEORY DESCRIPTION INQUIRY EXAMPLES

Theories of per- sonal knowledge

The interpersonal relationships of nursing

Expressions of the quality and authen- ticity of the inter- personal process between each nurse and each patient

Opening, centering, thinking, listening, and reflecting

Essays

Nurses’ autobio- graphical stories

Adapted from Fawcett, J.,Watson, J., Neuman, B., Hinton-Walker, P., & Fitzpatrick, J. J. (2001). On theories and evidence. Journal of Nursing Scholarship, 33, 115–119, with permission.

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Sociopolitical theories are generated and tested by means of critiques of situations and of alternate constructions of reality, as well as by hearing and attending to the voices of all who are concerned with a particular situation, the stakeholders. Henderson (2005) pointed out that a combination of methods, including description of “the ‘stage’ upon which practice occurs, . . . shared implicit meanings within an interaction, . . . and . . . beliefs and values ascribed to symbolic acts and objects inherent in the hospital” or other health-care organiza- tion, can be used to describe the context of health care (p. 555). This type of theory is found in documents and statements that indicate that the many voices involved in nursing practice are heard and acknowledged. For example, a sociopolitical theory is evident in Browne’s (2001) discussion of the influence of liberal political ideology on nursing science. Browne proposed that the development of empirical nursing theories is strongly influenced by the beliefs and values of liberal political philosophy, including individualism, egalitarianism, individual freedom and tolerance, neutrality, and a free-market economy. Her theory is a cri- tique of nursing’s “implicit political allegiances” and the implications of those allegiances on nursing knowledge development that “help us to understand whether our science disrupts or inadvertently helps to maintain social inequities” (Browne, p. 129). Daiski’s (2004) response to Browne brings other viewpoints and voices to our attention. She cited Carper’s (1978) and White’s (1995) contributions to our understanding of nonempirical nursing theories, as well as Silva and Rothbart’s (1984) discussion of historicism as a strong influence on nursing the- ory development. Historicism, Daiski explained, is “concerned with whole persons and their experiences . . . [and acknowledges] multiple realities” (p. 117). Browne (2004) later acknowledged that “a diversity of paradigms, theories and perspectives are required to inform knowledge development in nursing” (p. 123). She also pointed out, “Studies of health and illness are not neutral scholarly activities; they are loaded with social, political and economic consequences for individuals and society” (p. 123).

18 Part 1 ■ Introduction to Research

Table 1–7 Types of Nursing Theories and Modes of Inquiry with Examples: Sociopolitical Theories

TYPE OF MODE OF THEORY DESCRIPTION INQUIRY EXAMPLES

Sociopolitical theories

The politics and policies of nursing

Descriptions and expressions of the context or cultural location for nurse/ patient interac- tions and the broader context in which nursing and health care take place

Critique of situations

Critique of alter- nate constructions of reality

Hearing and attend- ing to all relevant views

Written or oral criticism

Written or oral criticism

Written or oral documentation of voices heard and acknowledged

Adapted from Fawcett, J.,Watson, J., Neuman, B., Hinton-Walker, P., & Fitzpatrick, J. J. (2001). On theories and evidence. Journal of Nursing Scholarship, 33, 115–119, with permission.

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HOW ARE NURSING THEORIES USED IN NURSING PRACTICE?

Nursing’s distinctive body of knowledge includes empirical, aesthetic, ethical, personal knowing, and sociopolitical theories. Each type of theory is an essential component of the integrated knowledge base for evidence-based nursing practice, so no one type of theory should be used in isolation from the others. As Carper (1978) pointed out, “Nursing [practice] depends on the scientific knowledge of human behavior in health and in illness, the aesthetic perception of sig- nificant human experiences, a personal understanding of the unique individuality of the self and the capacity to make choices within concrete situations involving particular moral judgments” (p. 22). White (1995) added that sociopolitical theories are “essential to an understanding of all the [other types of theories]” (p. 83). Furthermore, Hallberg (2003) mentioned the need for the- ories about clinical expertise and patient choices, as well as empirical theories, for evidence-based nursing practice. Aesthetic theories and theories of personal knowing address clinical expertise, and ethical and sociopolitical theories address patient choices.

No one type of theory should be regarded as superior or inferior to another. Rather, each type of theory is useful for understanding particular aspects of nursing practice. When nurses integrate specific empirical, aesthetic, ethical, personal knowing, and sociopolitical theories, they combine them to form a new, interactive, and unified base of knowledge for practice (Westra & Rodgers, 1991). Nurses then use the unified knowledge to help people attain their health-related goals. An example of the integration of multiple types of theories is Schwartz’s (2001) commentary about the presence of family members when a patient is receiving inva- sive procedures or is being resuscitated. Pointing out that nurses frequently know when a patient’s family members should be present and when they should not be present, Schwartz stated, “Nursing will always entail the balance of art [aesthetic theory] and science [empirical theory]” (p. 11), as well as ethical, personal knowing, and sociopolitical theories.

Another example is Andrews and Waterman’s (2005) description of the knowledge nurses use to report patients’ physiological deterioration to physicians. They developed an Early Warning Score (EWS), which “packages” the nurse’s objective (empirical) and subjective (aesthetic, ethical, personal, and sociopolitical) knowledge about a patient’s deteriorating physiological condition. The EWS “gives nurses a precise, concise, and unambiguous means of communicating deterioration” (p. 473) to physicians.

Conclusion

In this chapter, you have learned how research, theory, evidence, and evidence-based practice are defined. You also have learned why research is conducted and the links between research and theory and theory and evidence, as well as the link between the nursing practice process and the nursing research process. And you have learned about various sources of knowledge used as evidence for practice, various types of theories, and the type of evidence that each source of evidence and each type of theory provides.

The remainder of this book focuses on how empirical research provides the evidence needed for evidence-based nursing practice. Although we recognize and value the contributions of all

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five types of theories—empirical, aesthetic, ethical, personal knowing, and sociopolitical—as evidence, we will focus on empirical theories and empirical research throughout the rest of the book.

Three questions about information contained in published research reports provide the organizing framework for the remaining chapters in this book (Box 1–2).

You will be able to answer the question, “Where is the information?” when you learn how to identify where in research reports you can find each component of conceptual-theoretical- empirical (C-T-E) structures for research. We introduce C-T-E structures in Chapter 2 and discuss where to find the information about each of the components in research reports in Chapter 3. We then discuss each component in detail in Chapters 5 through 15.

You will be able to answer the question, “What is the information?” when you learn how to identify what the information is. In Chapter 3, we explain not only where to find the infor- mation but also what information is contained in each section of a research report. We discuss that information in much more detail in subsequent chapters.

Finally, you will be able to answer the question, “How good is the information?” when you learn how to determine whether the information meets certain criteria. We identify those cri- teria in Chapter 4 and discuss them in more detail in Chapters 5 through 15.

References

Full citations for all references cited in this chapter are provided in the Reference section at the end of the book.

Learning Activities

Activities to supplement what you have learned in this chapter, along with practice examina- tion questions, are provided on the CD that comes with this book.

20 Part 1 ■ Introduction to Research

BOX 1-2

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