- Email: [email protected]
Understanding Qualitative Evidence for Emergency Nursing Practice
EVIDENCE-BASED PRACTICE
UNDERSTANDING QUALITATIVE EVIDENCE EMERGENCY NURSING PRACTICE
FOR
Author: Tania D. Strout, MS, BSN, RN, Portland, ME Section Editor: Nancy McGowan, RN, PhD, CEN
ackett and colleagues1,2 define evidence-based practice (EBP) as “the integration of best research evidence with clinical expertise and patient values,” presenting 3 essential ideas: a synergy between research evidence, the expertise of clinicians, and the values of the patients we serve. It acknowledges the tensions that exist in developing a balance between our clinical expertise, developed over years of practice at the bedside, and scientific evidence that may or may not be able to be generalized to our patients. This definition also gives credence to a voice formerly silent—that of our patients and their families. It takes into account their cultures, ethnicities, ideas about health and wellness, and all of the other unique attributes that make them who they are.3 The benefits of EBP are many and include benefits to patients, clinicians, organizations, and to the nursing profession. Patients experience improved outcomes when the care they receive is based on scientific evidence. They gain a sense of ownership of their health when their preferences and values are integrated into their plans of care, as called for in the definition by Sackett and colleagues. Nurses benefit by having a clinical practice that is based on sound evidence. We gain autonomy, experience tremendous professional growth, and personally benefit from the recognition of our critical thinking skills. Our organizations also experience benefits related to EBP, including improved patient outcomes and satisfaction, consistency in care delivery, and the nurturing of an environment supportive of professional nursing practice. EBP can serve as a stimulus for collaborative and interdisciplinary practices, can improve job satisfaction for involved practitioners, and is a useful retention and recruitment
S
Tania D. Strout, Member, Maine ENA, is Associate Director of Research, Maine Medical Center, Portland, ME. For correspondence, write: Tania D. Strout, MS, BSN, RN, Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102; E-mail: [email protected]. J Emerg Nurs 2010;36:483-5. Available online 8 June 2010. 0099-1767/$36.00 Copyright © 2010 by the Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.05.016
September 2010
VOLUME 36 • ISSUE 5
tool at a time when many organizations are faced with challenges in this area. In addition, EBP benefits our nursing profession by contributing to the professional image of nursing, providing vision for our future collective direction, providing opportunities for professional networking, and encouraging nurses to both use and contribute to the growth and development of our science. While nursing research and EBP are unique, their integration within a single setting has the potential to enhance the larger assimilation of research within the clinical arena. This larger degree of evidence integration is essential to advancing practice because we know that many of our current practices are based on outdated textbook knowledge, the practices of our peers, or what we learned as students, and the latter two sources may or may not be based on evidence. The explosion of information technology, including the availability of Web-based information, adds a layer of complexity to the already difficult task of keeping our nursing practices current. It is impossible to keep up with the sheer volume of new information being published each day. EBP models can provide ways for clinicians working in today’s fast-paced care delivery environments to synthesize and apply large volumes of research knowledge to their practices. Qualitative and Quantitative Research as Sources of Evidence
Many sources of evidence are useful for enhancing emergency nursing practice, including research findings, quality data, and internal institutional data. While certainly not the only valuable sources of evidence, research findings are widely used for this purpose. Research can be categorized into two main types based on their methods: quantitative and qualitative. In general we are most familiar with quantitative research, which is based on the “scientific method.”4 It is a “formal, objective, systematic process in which numerical data are used to obtain information about the world.”4 Quantitative methods allow us to describe variables, examine the relationships between variables, and determine cause-and-effect relationships between them.5 Quantitative research has yielded the majority of evidence currently applied to emergency nursing practice. The second major group of research methodologies is qualitative in nature. Qualitative research can be described
WWW.JENONLINE.ORG
483
EVIDENCE-BASED PRACTICE/Strout
as a “systematic, interactive, subjective approach used to describe life experiences and give them meaning.”4,6 The purposes of qualitative research are to describe, explore, and understand human phenomena and their meanings for the people who experience them.7,8 For example, when we want to know how many ED patients are physically restrained each year, we use a quantitative, statistically based approach. However, when we want to understand our patients’ experiences of being physically restrained and the meaning they attribute to those experiences, only a qualitative approach will help us. Because the phenomena of interest to nurses frequently are difficult to quantify (eg, coping and caring) and because qualitative methods focus on the unified person, the qualitative approach often is a good fit with the holistic approach of nursing. How Does Qualitative Research Provide Evidence?
the translation of qualitative findings into practice are more difficult to find.1,3,14 Morse, Penrod, and Hupcey15 fill this gap with their description of a method for qualitatively identifying intervention strategies and evaluating outcomes, which is called Qualitative Outcome Analysis.15 Qualitative Outcome Analysis is a systematic method of confirming the applicability of clinical interventions derived from a qualitative study, extending the number of clinical interventions available, and evaluating clinical outcomes related to those interventions. In addition, an excellent process for evaluating the level of evidence (strength of a study) of qualitative research studies has been developed.16 This process represents an important addition to evidence-based practice toolkits because traditional evidence-grading systems typically place all qualitative research into a single, low-level category, thereby inhibiting our ability to differentiate among the quality of multiple studies. These authors provide us with concrete strategies for incorporating qualitative evidence into emergency nursing practice.
Qualitative research provides evidence for nursing practice by providing the basis for nursing interventions. When we conduct research aimed at understanding our patients’ experiences of a particular event or experience, we are provided with information regarding where we can focus our interventions. For example, O’Brien and Fothergill-Bourbonnais9 conducted a qualitative study using interpretive phenomenology to understand patients’ perspectives on the experience of trauma resuscitation in the emergency department. They discovered that patients remembered their experiences, felt both scared and safe as a result of the resuscitation process and relationship with their caregivers, and believed that ultimately they would be okay and survive the experience. The investigators learned that behaviors exhibited by emergency nurses caring for the patients had an important impact on the patients’ feelings of being safe and knowing that they would survive. These behaviors included speaking in a soothing, calm tone of voice, addressing patients by name, and communicating frequently. As a result of this important work, we know that interventions designed to increase patient comfort during the resuscitation process should include components aimed at behaviors on the part of the emergency nurse. Additionally, many mid-range theories designed for practical use in clinical nursing practice are based on qualitative research findings. Examples include Swanson’s theory of caring, Beck’s theory of postpartum depression, the theory of chronic sorrow by Eakes, Burke, and Hainsworth, and Mishel’s theory of uncertainty in illness.10-13
Despite the utility of qualitative methods for understanding phenomena of interest for emergency nurses, there is a paucity of qualitative research in our literature. This situation may be the result of inaccurate perceptions of qualitative research as “soft” or lacking rigor, or our unfamiliarity with qualitative methods, or issues regarding the implementation of qualitative findings. Sadly, this lack of qualitative research impairs our ability to fully understand and address the complex needs of our patients. When undertaking evidence-based practice projects, writing policies and procedures, or planning nursing research, careful consideration should be given to the value added by qualitative work. In addition, we should work to incorporate more qualitatively focused work into our journals through publication of original research findings, syntheses of existing qualitative studies, and reviews of the literature that include articles from qualitative perspectives. Our conferences might offer sessions covering qualitative methods, evaluating qualitative evidence, and implementing qualitative findings in practice. The addition of qualitative research into current modes of EBP has the potential to add greatly to the body of emergency nursing knowledge and allow us to make further gains in caring holistically for our patients.
Using Qualitative Evidence in Practice
REFERENCES
Although methods of implementing quantitative evidence into practice are widely written about, practical guides to
484
JOURNAL OF EMERGENCY NURSING
Implications for Emergency Nursing
1.
Sackett DL, Straus E, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine— how to practice and teach EBP. New York, NY: Churchill Livingstone; 2000. p. 1.
VOLUME 36 • ISSUE 5
September 2010
Strout/EVIDENCE-BASED PRACTICE
2.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-2.
11. Mishel MH. Reconceptualization of the theory of uncertainty in illness. Image J Nurs Sch. 1990;22:256-62.
3.
Strout TD, Lancaster K, Schultz AA. Development and implementation of an inductive model for evidence-based practice: a grassroots approach for building evidence-based practice capacity in staff nurses. Nurs Clin North Am. 2009;44:93-102. Burns N, Grove SK. The practice of nursing research: conduct, critique, & utilization. St Louis, Mo: Elsevier; 2005. p. 23-30. Norbeck JS. In defense of empiricism. Image J Nurs Sch. 1987;19:28-30.
12. Eakes G, Burke ML, Hainsworth MA. Middle-range theory of chronic sorrow. Image J Nurs Sch. 1998;30:179-84.
4. 5. 6.
Munhall PL. Nursing research: a qualitative perspective. Sudbury, Mass: Jones and Bartlett; 2007. p. 65-90.
7.
Richards L, Morse JM. Read me first for a user’s guide to qualitative methods. Thousand Oaks, Calif: Sage; 2007. p. 25-51. Creswell JW. Qualitative inquiry & research design: choosing among five approaches. Thousand Oaks, Calif: Sage; 2007. p. 15-32. O’Brien J, Fothergill-Bourbonnais F. The experience of trauma resuscitation in the emergency department: themes from seven patients. J Emerg Nurs. 2004;30:216-24.
8. 9.
10. Swanson KM. Empirical development of a middle range theory of caring. Nurs Res. 1991;40:161-6.
September 2010
VOLUME 36 • ISSUE 5
13. Beck CT. Teetering on the edge: a substantive theory of postpartum depression. Nurs Res. 1993;42:42-8. 14. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005. p. 3-37. 15. Morse JM, Penrod J, Hupcey JE. Qualitative outcome analysis: evaluating nursing interventions for complex clinical phenomena. J Nurs Sch. 2000;32:125-30. 16. Cesario S, Morin K, Santa-Donato A. Evaluating the level of evidence of qualitative research. J Obstet Gynecol Neonat Nurs. 2001;31:708-14.
Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD, CEN [email protected]
WWW.JENONLINE.ORG
485
UNDERSTANDING QUALITATIVE EVIDENCE EMERGENCY NURSING PRACTICE
FOR
Author: Tania D. Strout, MS, BSN, RN, Portland, ME Section Editor: Nancy McGowan, RN, PhD, CEN
ackett and colleagues1,2 define evidence-based practice (EBP) as “the integration of best research evidence with clinical expertise and patient values,” presenting 3 essential ideas: a synergy between research evidence, the expertise of clinicians, and the values of the patients we serve. It acknowledges the tensions that exist in developing a balance between our clinical expertise, developed over years of practice at the bedside, and scientific evidence that may or may not be able to be generalized to our patients. This definition also gives credence to a voice formerly silent—that of our patients and their families. It takes into account their cultures, ethnicities, ideas about health and wellness, and all of the other unique attributes that make them who they are.3 The benefits of EBP are many and include benefits to patients, clinicians, organizations, and to the nursing profession. Patients experience improved outcomes when the care they receive is based on scientific evidence. They gain a sense of ownership of their health when their preferences and values are integrated into their plans of care, as called for in the definition by Sackett and colleagues. Nurses benefit by having a clinical practice that is based on sound evidence. We gain autonomy, experience tremendous professional growth, and personally benefit from the recognition of our critical thinking skills. Our organizations also experience benefits related to EBP, including improved patient outcomes and satisfaction, consistency in care delivery, and the nurturing of an environment supportive of professional nursing practice. EBP can serve as a stimulus for collaborative and interdisciplinary practices, can improve job satisfaction for involved practitioners, and is a useful retention and recruitment
S
Tania D. Strout, Member, Maine ENA, is Associate Director of Research, Maine Medical Center, Portland, ME. For correspondence, write: Tania D. Strout, MS, BSN, RN, Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102; E-mail: [email protected]. J Emerg Nurs 2010;36:483-5. Available online 8 June 2010. 0099-1767/$36.00 Copyright © 2010 by the Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.05.016
September 2010
VOLUME 36 • ISSUE 5
tool at a time when many organizations are faced with challenges in this area. In addition, EBP benefits our nursing profession by contributing to the professional image of nursing, providing vision for our future collective direction, providing opportunities for professional networking, and encouraging nurses to both use and contribute to the growth and development of our science. While nursing research and EBP are unique, their integration within a single setting has the potential to enhance the larger assimilation of research within the clinical arena. This larger degree of evidence integration is essential to advancing practice because we know that many of our current practices are based on outdated textbook knowledge, the practices of our peers, or what we learned as students, and the latter two sources may or may not be based on evidence. The explosion of information technology, including the availability of Web-based information, adds a layer of complexity to the already difficult task of keeping our nursing practices current. It is impossible to keep up with the sheer volume of new information being published each day. EBP models can provide ways for clinicians working in today’s fast-paced care delivery environments to synthesize and apply large volumes of research knowledge to their practices. Qualitative and Quantitative Research as Sources of Evidence
Many sources of evidence are useful for enhancing emergency nursing practice, including research findings, quality data, and internal institutional data. While certainly not the only valuable sources of evidence, research findings are widely used for this purpose. Research can be categorized into two main types based on their methods: quantitative and qualitative. In general we are most familiar with quantitative research, which is based on the “scientific method.”4 It is a “formal, objective, systematic process in which numerical data are used to obtain information about the world.”4 Quantitative methods allow us to describe variables, examine the relationships between variables, and determine cause-and-effect relationships between them.5 Quantitative research has yielded the majority of evidence currently applied to emergency nursing practice. The second major group of research methodologies is qualitative in nature. Qualitative research can be described
WWW.JENONLINE.ORG
483
EVIDENCE-BASED PRACTICE/Strout
as a “systematic, interactive, subjective approach used to describe life experiences and give them meaning.”4,6 The purposes of qualitative research are to describe, explore, and understand human phenomena and their meanings for the people who experience them.7,8 For example, when we want to know how many ED patients are physically restrained each year, we use a quantitative, statistically based approach. However, when we want to understand our patients’ experiences of being physically restrained and the meaning they attribute to those experiences, only a qualitative approach will help us. Because the phenomena of interest to nurses frequently are difficult to quantify (eg, coping and caring) and because qualitative methods focus on the unified person, the qualitative approach often is a good fit with the holistic approach of nursing. How Does Qualitative Research Provide Evidence?
the translation of qualitative findings into practice are more difficult to find.1,3,14 Morse, Penrod, and Hupcey15 fill this gap with their description of a method for qualitatively identifying intervention strategies and evaluating outcomes, which is called Qualitative Outcome Analysis.15 Qualitative Outcome Analysis is a systematic method of confirming the applicability of clinical interventions derived from a qualitative study, extending the number of clinical interventions available, and evaluating clinical outcomes related to those interventions. In addition, an excellent process for evaluating the level of evidence (strength of a study) of qualitative research studies has been developed.16 This process represents an important addition to evidence-based practice toolkits because traditional evidence-grading systems typically place all qualitative research into a single, low-level category, thereby inhibiting our ability to differentiate among the quality of multiple studies. These authors provide us with concrete strategies for incorporating qualitative evidence into emergency nursing practice.
Qualitative research provides evidence for nursing practice by providing the basis for nursing interventions. When we conduct research aimed at understanding our patients’ experiences of a particular event or experience, we are provided with information regarding where we can focus our interventions. For example, O’Brien and Fothergill-Bourbonnais9 conducted a qualitative study using interpretive phenomenology to understand patients’ perspectives on the experience of trauma resuscitation in the emergency department. They discovered that patients remembered their experiences, felt both scared and safe as a result of the resuscitation process and relationship with their caregivers, and believed that ultimately they would be okay and survive the experience. The investigators learned that behaviors exhibited by emergency nurses caring for the patients had an important impact on the patients’ feelings of being safe and knowing that they would survive. These behaviors included speaking in a soothing, calm tone of voice, addressing patients by name, and communicating frequently. As a result of this important work, we know that interventions designed to increase patient comfort during the resuscitation process should include components aimed at behaviors on the part of the emergency nurse. Additionally, many mid-range theories designed for practical use in clinical nursing practice are based on qualitative research findings. Examples include Swanson’s theory of caring, Beck’s theory of postpartum depression, the theory of chronic sorrow by Eakes, Burke, and Hainsworth, and Mishel’s theory of uncertainty in illness.10-13
Despite the utility of qualitative methods for understanding phenomena of interest for emergency nurses, there is a paucity of qualitative research in our literature. This situation may be the result of inaccurate perceptions of qualitative research as “soft” or lacking rigor, or our unfamiliarity with qualitative methods, or issues regarding the implementation of qualitative findings. Sadly, this lack of qualitative research impairs our ability to fully understand and address the complex needs of our patients. When undertaking evidence-based practice projects, writing policies and procedures, or planning nursing research, careful consideration should be given to the value added by qualitative work. In addition, we should work to incorporate more qualitatively focused work into our journals through publication of original research findings, syntheses of existing qualitative studies, and reviews of the literature that include articles from qualitative perspectives. Our conferences might offer sessions covering qualitative methods, evaluating qualitative evidence, and implementing qualitative findings in practice. The addition of qualitative research into current modes of EBP has the potential to add greatly to the body of emergency nursing knowledge and allow us to make further gains in caring holistically for our patients.
Using Qualitative Evidence in Practice
REFERENCES
Although methods of implementing quantitative evidence into practice are widely written about, practical guides to
484
JOURNAL OF EMERGENCY NURSING
Implications for Emergency Nursing
1.
Sackett DL, Straus E, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine— how to practice and teach EBP. New York, NY: Churchill Livingstone; 2000. p. 1.
VOLUME 36 • ISSUE 5
September 2010
Strout/EVIDENCE-BASED PRACTICE
2.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-2.
11. Mishel MH. Reconceptualization of the theory of uncertainty in illness. Image J Nurs Sch. 1990;22:256-62.
3.
Strout TD, Lancaster K, Schultz AA. Development and implementation of an inductive model for evidence-based practice: a grassroots approach for building evidence-based practice capacity in staff nurses. Nurs Clin North Am. 2009;44:93-102. Burns N, Grove SK. The practice of nursing research: conduct, critique, & utilization. St Louis, Mo: Elsevier; 2005. p. 23-30. Norbeck JS. In defense of empiricism. Image J Nurs Sch. 1987;19:28-30.
12. Eakes G, Burke ML, Hainsworth MA. Middle-range theory of chronic sorrow. Image J Nurs Sch. 1998;30:179-84.
4. 5. 6.
Munhall PL. Nursing research: a qualitative perspective. Sudbury, Mass: Jones and Bartlett; 2007. p. 65-90.
7.
Richards L, Morse JM. Read me first for a user’s guide to qualitative methods. Thousand Oaks, Calif: Sage; 2007. p. 25-51. Creswell JW. Qualitative inquiry & research design: choosing among five approaches. Thousand Oaks, Calif: Sage; 2007. p. 15-32. O’Brien J, Fothergill-Bourbonnais F. The experience of trauma resuscitation in the emergency department: themes from seven patients. J Emerg Nurs. 2004;30:216-24.
8. 9.
10. Swanson KM. Empirical development of a middle range theory of caring. Nurs Res. 1991;40:161-6.
September 2010
VOLUME 36 • ISSUE 5
13. Beck CT. Teetering on the edge: a substantive theory of postpartum depression. Nurs Res. 1993;42:42-8. 14. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005. p. 3-37. 15. Morse JM, Penrod J, Hupcey JE. Qualitative outcome analysis: evaluating nursing interventions for complex clinical phenomena. J Nurs Sch. 2000;32:125-30. 16. Cesario S, Morin K, Santa-Donato A. Evaluating the level of evidence of qualitative research. J Obstet Gynecol Neonat Nurs. 2001;31:708-14.
Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD, CEN [email protected]
WWW.JENONLINE.ORG
485