Running head: REVIEW OF REFERENCES

Guidance for Nursing Practice Decisions: The Roles of Nursing Research and Evidence Review Ronda A. Mott Ferris State University

REVIEW OF REFERENCES Abstract The practice of nursing has finally evolved from its historical roots as a vocation to a bona-fide profession. Central to this transformation is the advent and introduction of formal nursing research as a cornerstone that defines, refines and buttresses the profession in the eyes of the general scientific community. The standardization of what constitutes nursing research, the development of tools to scrutinize evidence and the establishment of benchmarks to gauge the

impact of research work and that which deserves incorporation into clinical practice is now being realized. The following is a review of two sources of evidence and the application of nursing specific rules for evidence analysis and a rationale for defining the value of the selected works to clinical nursing practice.

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Guidance for Nursing Practice Decisions: The Roles of Nursing Research and Evidence Review Nursing research develops knowledge to build a scientific foundation for nursing practice. Identification of research, conducted by nurses, to build scientific knowledge is an important step in the communication of nursing knowledge. According to the syllabus, the purpose of this assignment is to re-evaluate references used to guide practice decisions, using knowledge gained from the first few weeks of class (Ferris State University, 2014, p. 8). This assignment also provides an opportunity to receive feedback on writing skills and APA format before completion of a final paper (Ferris State University, 2014). Credibility The credibility of the source of research is the linchpin that defines the value and usefulness of research work product and the ability to translate this work into clinical practice. The deluge of research material available today results in an ever-increasing mass of data, much of which may be irrelevant to nursing practice. Nurses demand strategies and clues in sifting through the weight of materials to assess the quality of the source material. On even cursory review, credible sources should be able to answer important questions for the discerning reader. According to Fitzpatrick (2007, p. 32) attributes of dependable sources include a track record of being established over time in the industry and unlikely to suddenly change; are authored by researchers with suitable, verifiable credentials; and are backed by academic institutions, societies or government departments whose trustworthiness is staked in the integrity of the work product. Further, a credible source should have been reviewed and sanctioned by experts in the field and enjoy the backing of renowned publishers free of bias or agenda. Lastly, a credible source should impose burdens upon research authors and editors to check their work comport with accepted statistical standards and reflect an appreciation for other well established dogma in

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the field (Fitzpatrick, 2007). According to Nieswiadomy (2012, p. 265) factors such as these are illustrated in a works publication in either a refereed or non-refereed nursing journal, in which selected subject experts or the publishers editorial staff evaluate a manuscript. Fitzpatricks (2007) credibility criteria however, according to Nieswiadomy (2012), are best illustrated in manuscripts that are peer reviewed, typically by unpaid discipline experts and notables in various nursing fields, which are considered the top standard of review for scientific works (Nieswiadomy, 2012, p. 265). According to Polit and Beck (2008) nursing research has been defined as a systematic inquiry designed to develop knowledge about issues of importance to the nursing profession, including nursing practice, education, administration and infomatics. In contrast, Nieswiadomy (2012, p. 3) defines nursing research more liberally as the systematic, objective process of analyzing phenomena of importance to nursing. Further, according to Nieswiadomy (2012, p. 5) the goals for conducting research are to promote evidence-based nursing practice, ensure credibility of the nursing profession, provide accountability for nursing practice and document the cost effectiveness of nursing care and that research has been determined to be the most reliable means of obtaining knowledge (Nieswiadomy, 2012, p.5). However, according to Burns and Grove (2009, p. 711) nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences the delivery of evidence-based nursing practice. Given the variety of evidentiary sources, research methodologies, statistical methods and conclusion types in analytical and clinical research, a reliable and practical means to dissect, authenticate and classify the research literature is vital to the practicing nurse. The nursing levels of evidence are a universally accepted criteria and tool to assist practitioners in determining

REVIEW OF REFERENCES whether statements and conclusions found in the scientific literature are based on research or other reliable evidence. The current level of evidence tool defines six tiers of research sources that define the strength of evidence from strongest to weakest (Armola et al., 2009). These measures and definitions are outlined on Armola et al. (2009, p. 72).

Evidenced-based practice has become the catchword in the health care industry. Though evidence is usually supported by research, other evidence forms, such as case studies and expert opinion, can be sufficient when empirical research is absent (Armola et al., 2009, p. 70). The strength of the evidence has become a new area of scrutiny, as now, more than ever, it is clear that research work product varies in quality (Armola et al., 2009, p. 70). The newly proposed system of levels of evidence to valuate research studies and manuscripts offers practitioners a profession-endorsed benchmark to determine the evidentiary strength of a research work (Armola et al., 2009, p. 72). Though the levels used in evidence ranking are a good start for comparing the strength of conclusions across various forms of evidence, readers must assess the quality of the evidence before incorporating conclusions into clinical practice. With the growth in the evidence-based practice movement, nurses are inundated with evidence sources. Subsequently, practitioners require these and perhaps other tools to assist them in examining and considering the best evidence worthy of clinical practice (Armola et al., 2009). Article 1 This article, O'Leary-Kelley, Puntillo, Barr, Stotts, and Douglas (2005) investigated enteral nutrition in sixty mechanically ventilated, intensive care unit (ICU) patients over three consecutive days. Several factors thought to impact nutritional outcomes and enteral feeding success were studied. During the study period, the amount of calories received and the rationale and duration for interference with feedings were recorded. The study identified a significant

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difference in the calculated caloric requirements and the mean calories actually received for each patient, indicating that most patients received far less than the required needs, typically due to feeding interruptions, the most significant and consistent of which were interruptions due to care related procedures. The research references used in this study work product included prior studies by several expert, tenured, repeatedly published researchers, whose work if reproduced over a decade in other notable peer-reviewed sources in the field of nutritional practices in ICU medicine, including sources specific to nursing. This article, O'Leary-Kelley et al. (2005) was published in a peer reviewed journal and authored by PhD level, nurse academicians specifically for nurses in clinical ICU practice. This research was endorsed by the National Institute of Nursing Research. The study also received a pre-doctoral award sponsored by the National Research Service, and received the Sigma Theta Tau, Alpha Eta chapter, Dissertation Research Award. This articles (O'Leary-Kelley et al., 2005) level of evidence is most consistent with Level B. According to the AACNs new evidence-leveling system, Level B evidence is identified by research that demonstrates well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention or treatment (Armola et al., 2005, p.72). As such, this article qualifies as nursing research according to criteria proposed by (O'Leary-Kelley et al., 2005, p. 231) due to its attributes of 1) being authored by nurses for nurses; 2) being directly applicable to a specific area of nursing practice; 3) providing evidence intended to shape guidelines for nursing advocacy for patients in the ICU setting and 4) serving as a future research spring-board for evidence-based feeding practice in ICU patients. Article 2

REVIEW OF REFERENCES This article, Pruitt and Jacobs (2005) is an editorial synopsis of the authors personal experience and anecdotal views on how pulmonary secretions can impair ventilation predispose to infection and threaten the survival outcome of patients with pulmonary conditions, including those receiving mechanical ventilation. The article summarizes the disease processes that may contribute to pulmonary secretions and weakened respiratory host defenses, patient populations they believe are most at risk for morbidity and what constitutes an adequate nursing assessment and response to such patients. Finally, the authors list their deductions on how to mitigate patient risks and summarize the modalities available to for the treatment of these patients.

The authors include a part-time respiratory therapist who serves as a clinical instructor in a university cardiorespiratory sciences department and a practicing emergency department staff nurse, who serves as a clinical assistant professor a state universitys College of Nursing. This review article was published in a nursing specialty magazine which is neither peer-reviewed nor professionally critiqued by experts in the field of nursing or nursing research organizations. The levels of evidence in this articles references include four works from two peer-reviewed journals in the field of general respiratory care, two sources of which originate from the same single publication and encompass work from only three researchers in the field. This articles (Pruitt & Jacobs, 2005) level of evidence is most consistent with Level E. According to the AACNs new evidence-leveling system, Level E evidence is defined as theory-based evidence from expert opinion or multiple case reports (Armola et al., 2009, p. 72). This article does not constitute nursing research in that it restates knowledge regurgitated from borrowed sources, is not grounded in meta-analysis or a synthesis of qualitative studies, includes no designed controlled study upon which conclusions are drawn and reflects no peer-reviewed organizational standards but merely reflects the authors opinions. Further, the article does not

REVIEW OF REFERENCES reach the threshold of nursing research in that according to Nieswiadomy (2012, p. 5) the manuscript does not 1) provide any credibility to the nursing profession; 2) does not serve as a resource that provides accountability specific to nursing practice, 3) offers perspectives on care to professionals outside of, (i.e. respiratory therapists), rather than within the scope of nursing and 4) provides no recommendations nor documents the cost-effectiveness of nursing care for the referenced patient population (Nieswiadomy, 2012, p.5). Significance of Nursing The significance of using and incorporating research and evidence that is specific to the field of nursing and developing specific theory, knowledge and a skills set of singular import to nurses is necessary to furthering the discipline and solidifying nursing practice as a true profession, rather than its historical definition merely a vocation (Chitty & Black, 2011, p.62). In its essence, a profession is defined by a unique set of qualifications or licensure, attitudes,

behaviors and language, actions and vocational benchmarks guided by a specific knowledge base and shaped by specific standards not shared by any other discipline (Chitty & Black, 2011, p.61). As nurses devise theories of nursing, test their validity in actual practice, have them critiqued by colleagues in a standardized and disciplined peer-review process and promulgate findings in nursing literature, the profession moves forward as a system of exclusive knowledge. As an example, when the voice of bedside nurses swelled, articulating the consensus of a collective identity to unmask the risks and shortcomings in understaffing that contributed to unsafe care, a sense of mission and responsibility to the public was born. Subsequently, as educational, practice and policy changes were studied and refined, this groundswell of consensus led to the adoption of nursing birthed patient safety standards and goals by the Joint Accreditation of the Healthcare Organizations (JCAHO), in 2005 (Chitty & Black, 2011) and is consistent with

REVIEW OF REFERENCES Bixler and Bixlers Criteria for defining a profession as an entity that applies its body of knowledge in practical services which are vital to human and social welfare (Chitty and Black, p.66). To the extent that nurses query, study, validate and write about nursing practice, they advance nursing theory, solidify principles that govern the profession, and construct a stable framework for professional accountability. In doing so, the value and impact of the nursing

evidence base on the scientific community is recognized and are more likely to enjoy publication in journals and work with highest impact factor scores (Nieswiadomy, 2012, p. 265). An excellent, nursing literature example of the concepts of advancing theory, creating accountability and defining the profession through research, is the development of the Quality and Safety Education for Nurses (QSEN) initiative for nursing education (Cronenwett et al., 2007). This nursing-proposed agenda seeks 1) to characterize specific core nursing competencies, such as patient safety, and quality of care improvement; 2) undertake correction of the inconsistencies in such competencies among practitioners across the profession; 3) and draft the direction of future nursing education to provide the knowledge, skillsets and attitudes necessary to acquire and maintain proficiency in these areas of focus for all nurses. Further, the utilization of nursing research, from bona-fide nursing sources, such as QSEN, shapes nursing practice and education. Such an initiative illustrates how specific nursing research, applied to direct bedside care, allows nurses to justify the decisions they make and the care they give (Nieswiadomy, 2012, p. 267). This process of research utilization is significant to nursing, whereby it contributes to both theory and a code of ethics for nurses, not based solely on nostalgia but on criteria that defines nursing as a profession as outlined by O'Leary-Kelley et al. where there is a specialized body of knowledge that is continually enlarged through research (Chitty and Black, p.66).

REVIEW OF REFERENCES Notwithstanding the levels used in evidence ranking, nurses must assess the quality of the

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evidence before incorporating conclusions into clinical practice. As the evidence-based practice movement continues to define contemporary clinical care, nurses, like every other professional, will be expected to scrutinize and separate the myriad of evidence sources that contribute to the rationale for their actions (Nieswiadomy, 2012, pp. 5-6). Subsequently, nurses must devise and validate the tools to assist them in examining and considering the best evidence worthy of clinical practice.

REVIEW OF REFERENCES References Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L.,...Medina, J. (2009). AACN levels of evidence: What's not? Critical Care Nurse, 29(4), . Retrieved from http://www.ccnonline.org Burns, N., & Grove, S. K. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence (6th ed.). St. Louis, MO: Saunders Elsevier. Chitty, K. K., & Black, B. P. (2011). Profession nursing: Concepts and challenges (6 ed.). Maryland Heights, MO: Saunders Elsvier.

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Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., & Mitchell, P.,...Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. doi:10.1016/j.outlook.2007.02.006 Ferris State University (2014). NURS 350 Research in nursing, [Syllabus] School of Nursing, Big Rapids, Michigan. Fitzpatrick, J. (2007). Finding the research for evidence-based practice - part two: Selecting credible evidence. Nursing Times, 103(17), 32-33. Retrieved from http://www.nursingtimes.net Nieswiadomy, R. M. (2012). Foundations of nursing research. Upper Saddle River, NJ: Pearson Education, Inc. . O'Leary-Kelley, C. M., Puntillo, K. A., Barr, J., Stotts, N., & Douglas, M. K. (2005). Nutritional adequacy in patients receiving mechanically ventilation who are fed enterally. American Journal of Critical Care, 14(3), 222-231. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

REVIEW OF REFERENCES Pruitt, B., & Jacobs, M. (2005). Clearing away pulmonary secretions. Nursing, 35(7), 36-42. Tingen, M. S., Burnett, A. H., Murchison, R. B., & Zhu, H. (2009). The importance of nursing research. Journal of Nursing Education, 48, 167-170.

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