Acquisitions Editor: Christina C. Burns Product Director: Jennifer K. Forestieri Development Editor: Meredith L. Brittain Production Product Manager: Marian Bellus Design Coordinator: Joan Wendt Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Prepress Vendor: Absolute Service, Inc. 9th edition




Acquisitions Editor: Christina C. Burns Product Director: Jennifer K. Forestieri Development Editor: Meredith L. Brittain Production Product Manager: Marian Bellus Design Coordinator: Joan Wendt Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Prepress Vendor: Absolute Service, Inc. 9th edition

Copyright 2018 © Wolters Kluwer

Fifth Edition © 2011 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Fourth Edition © 2006 by LIPPINCOTT WILLIAMS & WILKINS Third Edition © 2001 by LIPPINCOTT WILLIAMS & WILKINS

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at, or via our website at (products and services).

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Library of Congress Cataloging-in-Publication Data

Names: Polit, Denise F., author. | Beck, Cheryl Tatano, author. Title: Essentials of nursing research : appraising evidence for nursing practice / Denise

F. Polit, Cheryl Tatano Beck. Description: Ninth edition. | Philadelphia : Wolters Kluwer Health, [2018] | Includes

bibliographical references and index. Identifiers: LCCN 2016043994 | ISBN 9781496351296 Subjects: | MESH: Nursing Research | Evidence-Based Nursing Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available at

This work is provided “as is,” and the publisher disclaims any and all warranties,



express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.




Our Families—Our Husbands, Our Children (and Their Spouses/Fiancés), and Our Grandchildren

Husbands: Alan and Chuck

Children: Alex (Maryanna), Alaine (Jeff), Lauren (Vadim), Norah (Chris), Curt, and Lisa

Grandchildren: Maren, Julia, Cormac, Ronan, and Cullen





Denise F. Polit, PhD, FAAN, is an American health care researcher who is recognized internationally as an authority on research methods, statistics, and measurement. She received her Bachelor’s degree from Wellesley College and her Ph.D. from Boston College. She is the president of a research consulting company, Humanalysis, Inc., in Saratoga Springs, New York, and professor at Griffith University, Brisbane, Australia. She has published in numerous journals and has written several award-winning textbooks. She has recently written a ground-breaking book on measurement in health, Measurement and the Measurement of Change: A Primer for the Health Professions. Her research methods books with Dr. Cheryl Beck have been translated into French, Spanish, Portuguese, German, Chinese, and Japanese. She has been invited to give lectures and presentations in many countries, including Australia, India, Ireland, Denmark, Norway, South Africa, Turkey, Sweden, and the Philippines. Denise has lived in Saratoga Springs for 29 years and is active in the community. She has assisted numerous nonprofit organizations in designing surveys and analyzing survey data. Currently, she serves on the board of directors of the YMCA, Opera Saratoga, and the Saratoga Foundation.




Cheryl Tatano Beck, DNSc, CNM, FAAN, is a distinguished professor at the University of Connecticut, School of Nursing, with a joint appointment in the Department of Obstetrics and Gynecology at the School of Medicine. She received her master’s degree in maternal–newborn nursing from Yale University and her doctor of nursing science degree from Boston University. She has received numerous awards such as the Association of Women’s Health, Obstetric and Neonatal Nursing’s Distinguished Professional Service Award, Eastern Nursing Research Society’s Distinguished Researcher Award, the Distinguished Alumna Award from Yale University School of Nursing, and the Connecticut Nurses’ Association’s Diamond Jubilee Award for her contribution to nursing research. Over the past 30 years, Cheryl has focused her research efforts on developing a research program on postpartum mood and anxiety disorders. Based on the findings from her series of qualitative studies, Cheryl developed the Postpartum Depression Screening Scale (PDSS), which is published by Western Psychological Services. She is a prolific writer who has published over 150 journal articles. In addition to co-authoring award-winning research methods books with Denise Polit, Cheryl coauthored with Dr. Jeanne Driscoll Postpartum Mood and Anxiety Disorders: A Clinician’s Guide, which received the 2006 American Journal of Nursing Book of the Year Award. In addition, Cheryl has published two other books: Traumatic Childbirth and Routledge International Handbook of Qualitative Nursing Research. Her most recent book is Developing a Program of Research in Nursing.





Essentials of Nursing Research, ninth edition, helps students learn how to read and critique research reports and to develop an appreciation of research as a path to enhancing nursing practice.

We continue to enjoy updating this book with important innovations in research methods and with nurse researchers’ use of emerging methods. Feedback from our loyal adopters has inspired several important changes to the content and organization. We are convinced that these revisions introduce important improvements—while retaining many features that have made this book a classic best-selling textbook throughout the world. The ninth edition of this book, its study guide, and its online resources will make it easier and more satisfying for nurses to pursue a professional pathway that incorporates thoughtful appraisals of evidence.

LEGACY OF ESSENTIALS OF NURSING RESEARCH This edition, like its predecessors, is focused on the art—and science—of research critique. The textbook offers guidance to students who are learning to appraise research reports and use research findings in practice.

Among the basic principles that helped to shape this and earlier editions of this book are as follows:

1. An assumption that competence in doing and appraising research is critical to the nursing profession

2. A conviction that research inquiry is intellectually and professionally rewarding to nurses

3. An unswerving belief that learning about research methods need be neither intimidating nor dull

Consistent with these principles, we have tried to present research fundamentals in a way that both facilitates understanding and arouses curiosity and interest.


New Organization




In the previous edition, we separated chapters on quantitative and qualitative designs and methods into two separate parts. In this edition, we organized the parts by methodologic content. So, for example, Part 3 in this edition covers designs and methods for quantitative, qualitative, and mixed methods research, and Part 4 is devoted to analysis and interpretation in quantitative and qualitative studies. (Please see “The Text” later in this preface for more information.) We think this new organization offers greater continuity of methodologic concepts and will facilitate better understanding of key methodologic differences between quantitative and qualitative research. We are confident that this new organization will better meet the needs of students and faculty.

Manageable Text for One-Semester Course We have streamlined the text to make it more manageable for use in a one-semester course. We reduced the length by organizing content differently and by keeping essential information in the text while moving background/advanced content online, making this an 18-chapter book rather than the previous 19 chapters in the eighth edition.

Enhanced Accessibility To make this edition even more user-friendly than in the past, we have made a concerted effort to simplify the presentation of complex topics. Most importantly, we have reduced and simplified the coverage of statistical information. We eliminated the chapter on measurement, opting to present a shorter, more digestible section on this topic in our chapter on quantitative data collection, which is supplemented by information in the chapter on statistical analysis. In addition, throughout the book we have used more straightforward, concise language.

New Content In addition to updating the book with new information on conventional research methods, we have added content on the following topics:

Quality improvement projects, describing how they are distinct from research studies and evidence-based practice (EBP) projects. This new content is found in Chapter 13.

Clinical significance, a seldom-mentioned but important topic that has gained prominence among researchers in other health care fields but has only recently gained traction among nurse researchers. This new content is found in Chapter 15.

THE TEXT The content of this edition is as follows:

Part 1, Overview of Nursing Research and Its Role in Evidence-Based Practice,




introduces fundamental concepts in nursing research. Chapter 1 summarizes the background of nursing research, discusses the philosophical underpinnings of qualitative research versus quantitative research, and describes major purposes of nursing research. Chapter 2 offers guidance on using research to build an evidence- based practice. Chapter 3 introduces readers to key research terms and presents an overview of steps in the research process for both quantitative and qualitative studies. Chapter 4 focuses on research journal articles, explaining what they are and how to read them. Chapter 5 discusses ethics in nursing studies.

Part 2, Preliminary Steps in Quantitative and Qualitative Research, further sets the stage for learning about the research process by considering aspects of a study’s conceptualization. Chapter 6 focuses on the development of research questions and the formulation of research hypotheses. Chapter 7 discusses how to retrieve research evidence (especially in electronic bibliographic databases) and the role of research literature reviews. Chapter 8 presents information about theoretical and conceptual frameworks.

Part 3, Designs and Methods for Quantitative and Qualitative Nursing Research, presents material on the design and conduct of all types of nursing studies. Chapter 9 describes fundamental design principles and discusses many specific aspects of quantitative research design, including efforts to enhance rigor. Chapter 10 introduces the topics of sampling and data collection in quantitative studies. Concepts relating to quality in measurements—reliability and validity—are introduced in this chapter. Chapter 11 describes the various qualitative research traditions that have contributed to the growth of constructivist inquiry and presents the basics of qualitative design. Chapter 12 covers sampling and data collection methods used in qualitative research, describing how these differ from approaches used in quantitative studies. Chapter 13 emphasizes mixed methods research, but the chapter also discusses other special types of research such as surveys, outcomes research, and quality improvement projects.

Part 4, Analysis and Interpretation in Quantitative and Qualitative Research, presents tools for making sense of research data. Chapter 14 reviews methods of statistical analysis. The chapter assumes no prior instruction in statistics and focuses primarily on helping readers to understand why statistics are useful, what test might be appropriate in a given situation, and what statistical information in a research article means. Chapter 15 discusses approaches to interpreting statistical results, including interpretations linked to assessments of clinical significance. Chapter 16 discusses qualitative analysis, with an emphasis on ethnographic, phenomenologic, and grounded theory studies. Chapter 17 elaborates on criteria for appraising trustworthiness and integrity in qualitative studies. Finally, Chapter 18 describes systematic reviews, including how to understand and appraise both meta-analyses and metasyntheses.




At the end of the book, we offer students additional critiquing support. In the appendices, we offer full-length research articles —two quantitative, one qualitative, and one mixed methods—that students can read, analyze, and critique. Students can model their critiques on the full critiques of two of those studies provided or compare their work to the ones provided. A glossary at the end of the book provides additional support for those needing to look up the meaning of a methodologic term.

FEATURES OF THE TEXT We have retained many of the classic features that were successfully used in previous editions to assist those learning to read and apply evidence from nursing research:

Clear, User-Friendly Style. Our writing style is easily digestible and nonintimidating —and we have worked even harder in this edition to write clearly and simply. Concepts are introduced carefully, difficult ideas are presented thoughtfully, and readers are assumed to have no prior knowledge of technical terms.

Critiquing Guidelines. Each chapter includes guidelines for conducting a critique of various aspects of a research report. The guidelines sections provide a list of questions that walk students through a study, drawing attention to aspects of the study that are amenable to appraisal by research consumers.

Research Examples and Critical Thinking Exercises. Each chapter concludes with one or two actual research examples designed to highlight critical points made in the chapter and to sharpen the reader’s critical thinking skills. In addition, many research examples are used to illustrate key points in the text and to stimulate students’ thinking about areas of research inquiry. We have chosen many international examples to communicate to students that nursing research is growing in importance worldwide. Some of the Critical Thinking Exercises focus on the full-length articles in Appendix A (a quantitative study) and Appendix B (a qualitative study).

Tips for Students. The textbook is filled with practical guidance and tips on how to translate the abstract notions of research methods into more concrete applications. In these tips, we have paid special attention to helping students read research reports, which are often daunting to those without specialized research training.

Graphics. Colorful graphics—in the form of supportive tables, figures, and examples —reinforce the text and offer visual stimulation.

Chapter Objectives. Learning objectives are identified in the chapter opener to focus students’ attention on critical content.

Key Terms. Each chapter opener includes a list of new terms, and we have made the list more focused and less daunting by including only key new terms. In the text, new terms are defined in context (and bolded) when used for the first time; terms of lesser




importance are italicized. Key terms are also defined in our glossary.

Bulleted Summary Points. A succinct list of summary points that focus on salient chapter content is provided at the end of each chapter.

Essentials of Nursing Research: Appraising Evidence for Nursing Practice, ninth edition, has ancillary resources designed with both students and instructors in mind, available on website.

Student Resources Available on Supplements for Each Chapter further students’ exploration of specific topics. A full

list of the Supplements appears on page xxii. These supplements can be assigned to provide additional background or to offer advanced material to meet students’ specific needs.

Interactive Critical Thinking Activity brings the Critical Thinking Exercises from the textbook (except those focused on studies in the appendices) to an easy-to-use interactive tool that enables students to apply new skills that they learn in each chapter. Students are guided through appraisals of real research examples and then ushered through a series of questions that challenge them to think about the quality of evidence from the study. Responses can be printed or e-mailed directly to instructors for homework or testing.




Hundreds of Student Review Questions help students to identify areas of strength and areas needing further study.

Answers to Critical Thinking Exercises are provided for questions related to the studies in Appendices A and B of the textbook.

Journal Articles—18 full articles from Wolters Kluwer journals (one corresponding to each chapter)—are provided for additional critiquing opportunities. Many of these are the full journal articles for studies used as the end-of-chapter Research Examples. All journal articles that appear on are identified in the text with and are called out in the References lists for appropriate chapters with a double asterisk (**).

Internet Resources with relevant and useful websites related to chapter content can be clicked on directly without having to retype the URL and risk a typographical error. This edition also includes links to all open-access articles cited in the textbook; these articles are called out in the References lists for appropriate chapters with a single asterisk (*).

Critiquing Guidelines and Learning Objectives from the textbook are available in Microsoft Word for your convenience.

Nursing Professionals Roles and Responsibilities.

Instructor’s Resources Available on NEW! Test Generator Questions are completely new and written by the book’s

authors for the ninth edition. Hundreds of multiple-choice questions aid instructors in assessing their students’ understanding of the chapter content.

An Instructor’s Manual includes a preface that offers guidance to improve the teaching experience. We have recognized the need for strong support for instructors in teaching a course that can be quite challenging. Part of the difficulty stems from students’ anxiety about the course content and their concern that research methods might not be relevant to their nursing practice. We offer numerous suggestions on how to make learning about—and teaching—research methods more rewarding. The contents of the Instructor’s Manual include the following for each chapter:

Statement of Intent. Discover the authors’ goals for each chapter. Special Class Projects. Find numerous ideas for interesting and meaningful class

projects. Check out the icebreakers and activities relating to the Great Cookie Experiment with accompanying SPSS files.

Test Questions and Answers. True/false questions, plus important application questions, test students’ comprehension and their ability to put their new critiquing skills to use. The application questions focus on a brief summary of a study and include several short-answer questions (with our answers), plus essay questions. These application questions are intended to assess students’ knowledge




about methodologic concepts and their critiquing skills.

Answers to the Interactive Critical Thinking Activity. Suggested answers to the questions in the Interactive Critical Thinking Activity are available to instructors. Students can either print or e-mail their responses directly to the instructor for testing or as a homework assignment.

Two sets of PowerPoint Slides: “Test Yourself!” PowerPoint Slides. For each chapter, a slide set of five

multiple-choice “Test Yourself!” questions relating to key concepts in the chapter are followed by answers to the questions. The aim of these slides is not to evaluate student performance. We recommend these slides be given to students for self- testing, or they can be used in the classroom with i>clickers to assess students’ grasp of important concepts. To enhance the likelihood that students will see the relevance of the concepts to clinical practice, all the questions are application-type questions. We hope instructors will use the slides to clarify any misunderstandings and, just as importantly, to reward students with immediate positive feedback about newly acquired skills.

PowerPoint Presentations offer traditional summaries of key points in each chapter for use in class presentations. These slides are available in a format that permits easy adaptation and also include audience response questions that can be used on their own or are compatible with i>clicker and other audience response programs and devices.

An Image Bank includes figures from the text.

QSEN Map shows how the book content integrates QSEN competencies.

BSN Essentials Competencies Map shows how the book content integrates American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice competencies.

Strategies for Effective Teaching offer creative approaches for engaging students.

Learning Management System Course Cartridges.

Access to all student resources previously discussed.

STUDY GUIDE The accompanying Study Guide for Essentials of Nursing Research, ninth edition, is available for purchase and augments the text, providing students with opportunities to apply their learning.

Critiquing opportunities abound in the Study Guide, which includes eight research articles in their entirety. The studies represent a range of nursing topics and research approaches, including a randomized controlled trial, a correlational/mixed




methods study, an EBP project, three qualitative studies (ethnographic, phenomenologic, and grounded theory), a meta-analysis, and a metasynthesis. The Application Exercises in each chapter guide students in reading, understanding, and critiquing these eight studies.

Answers to the “Questions of Fact” section in the Application Exercises in each chapter are presented in Appendix I of the Study Guide so that students can get immediate feedback about their responses.

Although critiquing skills are emphasized in the Study Guide, other included activities support students’ learning of fundamental research terms and principles, such as fill- in-the-blank exercises, matching exercises, and focused Study Questions. Answers to those questions that have an objective answer are provided in Appendix I.

COMPREHENSIVE, INTEGRATED DIGITAL LEARNING SOLUTIONS We are delighted to introduce an expanded suite of digital solutions to support instructors and students using Essentials of Nursing Research, ninth edition. Now for the first time, our textbook is embedded into two integrated digital learning solutions— one specific for prelicensure programs and the other for postlicensure—that build on the features of the text with proven instructional design strategies. To learn more about these solutions, visit or contact your local Wolters Kluwer representative.

Our prelicensure solution, Lippincott CoursePoint, is a rich learning environment that drives course and curriculum success to prepare students for practice. Lippincott CoursePoint is designed for the way students learn. The solution connects learning to real-life application by integrating content from Essentials of Nursing Research with video cases, interactive modules, and evidence-based journal articles. Ideal for active, case-based learning, this powerful solution helps students develop higher level cognitive skills and asks them to make decisions related to simple-to-complex scenarios.

Lippincott CoursePoint for Nursing Research features the following:

Leading Content in Context. Digital content from Essentials of Nursing Research, ninth edition, is embedded in our Powerful Tools, engaging students and encouraging interaction and learning on a deeper level.

The complete interactive eBook features annual content updates with the latest EBPs and provides students with anytime, anywhere access on multiple devices.

Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical dictionary available.

Powerful Tools to Maximize Class Performance. Additional course-specific tools provide case-based learning for every student:



Video Cases show how nursing research and evidence-based practice relates to real-life nursing practice. By watching the videos and completing related activities, students will flex their evidence-based practice skills and build a spirit of inquiry.

Interactive Modules help students quickly identify what they do and do not understand, so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the digital textbook are integrated throughout.

Curated Collections of Journal Articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences practice.

Data to Measure Students’ Progress. Student performance data provided in an intuitive display lets instructors quickly assess whether students have viewed interactive modules and video cases outside of class as well as see students’ performance on related NCLEX-style quizzes, ensuring students are coming to the classroom ready and prepared to learn.

To learn more about Lippincott CoursePoint, please visit

Lippincott RN to BSN Online: Nursing Research is a postlicensure solution for online and hybrid courses, marrying experiential learning with the trusted content in Essentials of Nursing Research, ninth edition.

Built around learning objectives that are aligned to the BSN Essentials and QSEN



nursing curriculum standards, every aspect of Lippincott RN to BSN Online is designed to engage, challenge, and cultivate postlicensure students.

Self-Paced Interactive Modules employ key instructional design strategies— including storytelling, modeling, and case-based and problem-based scenarios—to actively involve students in learning new material and focus students’ learning outcomes on real-life application.

Pre- and Postmodule Assessments activate students’ existing knowledge prior to engaging with the module, then assess their competency after completing the module.

Discussion Board Questions create an ongoing dialogue to foster social learning. Writing and Group Work Assignments hone students’ competence in writing and

communication, instilling the skills needed to advance their nursing careers. Collated Journal Articles acquaint students to the body of nursing research ongoing

in recent literature. Case Study Assignments, including unfolding cases that evolve from cases in the

interactive modules, aid students in applying theory to real-life situations. Best Practices in Scholarly Writing Guide covers APA formatting and style


Used alone or in conjunction with other instructor-created resources, Lippincott RN to BSN Online adds interactivity to courses. It also saves instructors time by keeping both textbook and course resources current and accurate through regular updates to the content.

To learn more about Lippincott RN to BSN Online, please visit




CLOSING NOTE It is our hope and expectation that the content, style, and organization of this ninth edition of Essentials of Nursing Research will be helpful to those students who want to become skillful, thoughtful readers of nursing studies and to those wishing to enhance their clinical performance based on research findings. We also hope that this textbook will help to develop an enthusiasm for the kinds of discoveries and knowledge that research can produce.

Denise F. Polit, PhD, FAAN Cheryl Tatano Beck, DNSc, CNM, FAAN





Learning Objectives focus students’ attention on critical content Key Terms alert students to important terminology

Examples help students apply content to real-life research

Tip boxes describe what is found in actual research articles

How-to-Tell Tip boxes explain confusing issues in actual research articles




Critiquing Guidelines boxes lead students through key issues in a research article

Research Examples highlight critical points made in the chapter and sharpen critical thinking skills

Critical Thinking Exercises provide opportunities to practice critiquing actual research articles

Summary Points review chapter content to ensure success

Special icons alert students to important content found on and in the




accompanying Study Guide





Lisa Aiello-Laws, RN, MSN, AOCNS, APN-C Assistant Clinical Professor College of Nursing and Health Professions Drexel University Philadelphia, Pennsylvania

Elizabeth W. Black, MSN, CSN Assistant Professor Gwynedd Mercy University Gwynedd Valley, Pennsylvania

Lynn P. Blanchette, RN, PhD Program Director Rhode Island College Providence, Rhode Island

Anne Watson Bongiorno, PhD, APHN-BC, CNE Associate Professor State University of New York at Plattsburgh Plattsburgh, New York

Katherine Bowman, PhD, RN Assistant Teaching Professor Sinclair School of Nursing University of Missouri Columbia, Missouri

Barb Braband, EdD, RN, CNE Master’s Program Director University of Portland Portland, Oregon

Vera Brancato, EdD, MSN, RN, CNE Professor of Nursing




Alvernia University Reading, Pennsylvania

Jennifer Bryer, PhD, RN, CNE Chairperson and Associate Professor Department of Nursing Farmingdale State College Farmingdale, New York

Wendy Budin, PhD, RN-BC, FACCE, FAAN Adjunct Professor New York University New York, New York

Carol Caico, PhD, CS, NP Associate Professor New York Institute of Technology New York, New York

Mary Ann Cantrell, PhD, RN, CNE, FAAN Assistant Professor Villanova University Villanova, Pennsylvania

Ruth Chaplen, RN, MSN, DNP, ACNS BC, AOCN Associate Professor of Nursing Rochester College Rochester Hills, Michigan

Lori Ciafardoni, RN, MSN/ED Assistant Professor State University of New York at Delhi Delhi, New York

Leah Cleveland, EdD, RN, CNS, PHN, CDE Lecturer California State University, Fullerton Fullerton, California

Susan Davidson, EdD, APN, NP-C Professor School of Nursing Coordinator Gateway RN-BSN Program




School of Nursing University of Tennessee at Chattanooga Chattanooga, Tennessee

Pamela de Cordova, PhD, RN-BC Assistant Professor Rutgers University New Brunswick, New Jersey

Josephine DeVito, PhD, RN Undergraduate Chair and Associate Professor College of Nursing Seton Hall University South Orange, New Jersey

Nancy Ann C. Falvo, BSN, MSN, PhD Assistant Professor Clarion University of Pennsylvania Clarion, Pennsylvania

Jeanie Flood, PhD, RN-C, IBCLC RN to BSN Faculty Advisor University of Hawaii at Hilo Hilo, Hawaii

Deborah Hunt, PhD, RN Associate Professor College of New Rochelle New Rochelle, New York

Linda Johanson, EdD, RN Associate Professor Appalachian State University Boone, North Carolina

Lucina Kimpel, PhD, RN Associate Professor Mercy College of Health Sciences Des Moines, Iowa

Pamela Kohlbry, PhD, RN, CNL Associate Professor Med/Surg Lead and CNL Program Coordinator California State University San Marcos




San Marcos, California

Leann Laubach PhD, RN Professor Career Advancement Coordinator University of Central Oklahoma Edmond, Oklahoma

Hayley Mark, PhD, MSN, MPH, RN Chairperson Department of Nursing Towson University Towson, Maryland

Donna Martin, DNP, MSN, RN-BC, CDE Assistant Professor Lewis University Romeoville, Illinois

Ditsapelo McFarland, PhD, MSN, EdD Associate Professor Adelphi University Garden City, New York

Kristina S. Miller, DNP, RN, PCNS-BC Instructor of Maternal Child Nursing College of Nursing University of South Alabama Mobile, Alabama

Kathy T. Morris, EdD, MSN, RN Assistant Professor Armstrong State University Savannah, Georgia

Elizabeth Murray, PhD, RN, CNE Assistant Professor Florida Gulf Coast University Fort Myers, Florida

Sarah Newton, PhD, RN Associate Professor School of Nursing Oakland University




Rochester, Michigan

Mae Ann Pasquale, RN, BSN, MSN Assistant Professor of Nursing Cedar Crest College Allentown, Pennsylvania

Kim L. Paxton DNP, APRN, ANP-BC, LIHT-C Assistant Professor Cardinal Stritch University Milwaukee, Wisconsin

Janet Reagor, PhD, RN Interim Dean and Assistant Professor of Nursing Director RN-BSN Program Avila University Kansas City, Missouri

Elizabeth A. Roe, PhD, RN Acting Assistant Dean College of Human and Health Sciences Saginaw Valley State University Saginaw, Michigan

Cathy Rozmus, PhD, RN Professor Associate Dean for Academic Affairs University of Texas Health Science Center at Houston Houston, Texas

Milena P. Staykova, EdD, FNC-BC Director Post-Licensure Bachelor of Science in Nursing Jefferson College of Health Sciences Roanoke, Virginia

Amy Stimpfel, PhD, RN Assistant Professor College of Nursing New York University New York, New York

Yiyuan Sun, DNSc




Associate Professor Adelphi University Garden City, New York

Annie Thomas, PhD, RN Assistant Professor Loyola University Chicago Chicago, Illinois

Elizabeth VandeWaa, PhD Professor of Adult Health Nursing University of South Alabama Mobile, Alabama

Adrienne Wald, BSN, MBA, EdD Assistant Professor College of New Rochelle New Rochelle, New York

Camille Wendekier, PhD, CRRN, CSN, RN Assistant Professor Saint Francis University Loretto, Pennsylvania

Kathleen Williamson, RN, PhD Chair Wilson School of Nursing Midwestern State University Wichita Falls, Texas

Roxanne Wilson, PhD, RN Assistant Professor St. Cloud State University St. Cloud, Minnesota

Paige Wimberley, RN, CNS, CNE Assistant Professor of Nursing Arkansas State University Jonesboro, Arkansas

Charlotte A. Wisnewski, PhD, RN, CDE, CNE Associate Professor University of Texas Medical Branch Galveston, Texas





This ninth edition, like the previous eight editions, depended on the contribution of many generous people. To all of the many faculty and students who used the text and have made invaluable suggestions for its improvement, we are very grateful. Suggestions were made to us both directly in personal interactions (mostly at the University of Connecticut and Griffith University in Australia) and via e-mail correspondence. We would like in particular to thank Valori Banfi, nursing librarian at the University of Connecticut, and John McNulty, a faculty member at the University of Connecticut. We would also like to acknowledge the reviewers of the ninth edition of Essentials.

Other individuals made specific contributions. Although it would be impossible to mention all, we note with thanks the nurse researchers who shared their work with us as we developed examples, including work that in some cases was not yet published. We also extend our warm thanks to those who helped to turn the manuscript into a finished product. The staff at Wolters Kluwer has been of tremendous assistance in the support they have given us over the years. We are indebted to Christina C. Burns, Emily Lupash, Meredith L. Brittain, Marian Bellus, and all the others behind the scenes for their fine contributions. Thanks also to Rodel Fariñas for his patience and good humor in turning our manuscript into this textbook.

Finally, we thank our families, our loved ones, and our friends, who provided ongoing support and encouragement throughout this endeavor and who were tolerant when we worked long into the night, over weekends, and during holidays to get this ninth edition finished.





Part 1 Overview of Nursing Research and Its Role in Evidence-Based Practice

1 Introduction to Nursing Research in an Evidence-Based Practice Environment 2 Fundamentals of Evidence-Based Nursing Practice 3 Key Concepts and Steps in Quantitative and Qualitative Research 4 Reading and Critiquing Research Articles 5 Ethics in Research

Part 2 Preliminary Steps in Quantitative and Qualitative Research

6 Research Problems, Research Questions, and Hypotheses 7 Finding and Reviewing Research Evidence in the Literature 8 Theoretical and Conceptual Frameworks

Part 3 Designs and Methods for Quantitative and Qualitative Nursing Research

9 Quantitative Research Design 10 Sampling and Data Collection in Quantitative Studies 11 Qualitative Designs and Approaches 12 Sampling and Data Collection in Qualitative Studies 13 Mixed Methods and Other Special Types of Research

Part 4 Analysis and Interpretation in Quantitative and Qualitative Research

14 Statistical Analysis of Quantitative Data 15 Interpretation and Clinical Significance in Quantitative Research 16 Analysis of Qualitative Data 17 Trustworthiness and Integrity in Qualitative Research




18 Systematic Reviews: Meta-Analysis and Metasynthesis

Appendix A Swenson et al.’s (2016) Study: Parents’ Use of Praise and Criticism in a Sample of Young Children Seeking Mental Health Services

Appendix B Beck and Watson’s (2010) Study: Subsequent Childbirth After a Previous Traumatic Birth

Appendix C Wilson et al.’s (2016) Study: A Randomized Controlled Trial of an Individualized Preoperative Education Intervention for Symptom Management After Total Knee Arthroplasty

Critique of Wilson and Colleagues’ Study

Appendix D Sawyer et al.’s (2010) Study: Differences in Perceptions of the Diagnosis and Treatment of Obstructive Sleep Apnea and Continuous Positive Airway Pressure Therapy Among Adherers and Nonadherers

Critique of Sawyer and Colleagues’ Study




Supplement for Chapter 1 The History of Nursing Research

Supplement for Chapter 2 Evaluating Clinical Practice Guidelines—AGREE II

Supplement for Chapter 3 Deductive and Inductive Reasoning

Supplement for Chapter 4 Guide to an Overall Critique of a Quantitative Research Report and Guide to an Overall Critique of a Qualitative Research Report

Supplement for Chapter 5 Informed Consent

Supplement for Chapter 6 Simple and Complex Hypotheses

Supplement for Chapter 7 Finding Evidence for an EBP Inquiry in PubMed

Supplement for Chapter 8 Prominent Conceptual Models of Nursing Used by Nurse Researchers

Supplement for Chapter 9 Selected Experimental and Quasi-Experimental Designs: Diagrams, Uses, and Drawbacks

Supplement for Chapter 10 Vignettes and Q-Sorts

Supplement for Chapter 11 Qualitative Descriptive Studies




Supplement for Chapter 12 Transferability and Generalizability

Supplement for Chapter 13 Other Specific Types of Research

Supplement for Chapter 14 Multivariate Statistics

Supplement for Chapter 15 Research Biases

Supplement for Chapter 16 A Glaserian Grounded Theory Study: Illustrative Materials

Supplement for Chapter 17 Whittemore and Colleagues’ Framework of Quality Criteria in Qualitative Research

Supplement for Chapter 18 Publication Bias in Meta-Analyses




Part 1 Overview of Nursing Research and Its Role in Evidence-Based Practice

1 Introduction to Nursing Research in an Evidence-Based Practice Environment

Learning Objectives On completing this chapter, you will be able to:

Understand why research is important in nursing Discuss the need for evidence-based practice Describe broad historical trends and future directions in nursing research Identify alternative sources of evidence for nursing practice Describe major characteristics of the positivist and constructivist paradigm Compare the traditional scientific method (quantitative research) with constructivist

methods (qualitative research) Identify several purposes of quantitative and qualitative research Define new terms in the chapter

Key Terms Assumption Cause-probing research Clinical nursing research Clinical significance Constructivist paradigm Empirical evidence Evidence-based practice (EBP) Generalizability Journal club




Nursing research Paradigm Positivist paradigm Qualitative research Quantitative research Research Research methods Scientific method Systematic review

NURSING RESEARCH IN PERSPECTIVE We know that many of you readers are not taking this course because you plan to become nurse researchers. Yet, we are also confident that many of you will participate in research-related activities during your careers, and virtually all of you will be expected to be research-savvy at a basic level. Although you may not yet grasp the relevance of research in your career as a nurse, we hope that you will come to see the value of nursing research during this course and will be inspired by the efforts of the thousands of nurse researchers now working worldwide to improve patient care. You are embarking on a lifelong journey in which research will play a role. We hope to prepare you to enjoy the voyage.

What Is Nursing Research? Whether you know it or not, you have already done a lot of research. When you use the Internet to find the “best deal” on a laptop or an airfare, you start with a question (e.g., Who has the best deal for what I want?), collect the information by searching different websites, and then come to a conclusion. This “everyday research” has much in common with formal research—but, of course, there are important differences, too.

As a formal enterprise, research is systematic inquiry that uses disciplined methods to answer questions and solve problems. The ultimate goal of formal research is to gain knowledge that would be useful for many people. Nursing research is systematic inquiry designed to develop trustworthy evidence about issues of importance to nurses and their clients. In this book, we emphasize clinical nursing research, which is research designed to guide nursing practice. Clinical nursing research typically begins with questions stemming from practice problems—problems you may have already encountered.

Examples of nursing research questions Does a text message notification process help to reduce follow-up time for women

with abnormal mammograms? (Oakley-Girvan et al., 2016) What are the daily experiences of patients receiving hemodialysis treatment for




end-stage renal disease? (Chiaranai, 2016)

TIP You may have the impression that research is abstract and irrelevant to practicing nurses. But nursing research is about real people with real problems, and studying those problems offers opportunities to solve or address them through improvements to nursing care.

The Importance of Research to Evidence-Based Nursing Nursing has experienced profound changes in the past few decades. Nurses are increasingly expected to understand and undertake research and to base their practice on evidence from research—that is, to adopt an evidence-based practice (EBP). EBP, broadly defined, is the use of the best evidence in making patient care decisions. Such evidence typically comes from research conducted by nurses and other health care professionals. Nurse leaders recognize the need to base specific nursing decisions on evidence indicating that the decisions are clinically appropriate and cost-effective and result in positive client outcomes.

In some countries, research plays an important role in nursing credentialing and status. For example, the American Nurses Credentialing Center—an arm of the American Nurses Association—has developed a Magnet Recognition Program to recognize health care organizations that provide high-quality nursing care. To achieve Magnet status, practice environments must demonstrate a sustained commitment to EBP and nursing research. Changes to nursing practice are happening every day because of EBP efforts.

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