Health & Medical Question
Hi I need help writing a discussion post, all citations are in APA and is based on the attached article, I will attach the course text for help as well
respond to the following:
Identify the clinical question and describe each portion of the question.
Population – (introduction section)
Comparison (Methods section)
How will you apply this information in your practice setting?
P atient Safety Issues
S
KIN PREPARATION AND
ELECTRODE REPLACEMENT
TO REDUCE ALARM FATIGUE
IN A COMMUNITY HOSPITAL
INTENSIVE CARE UNIT
By Debbie Leigher, BSN, RN, CNML, Paula Kemppainen, BSN, RN, and
David M. Neyens, PhD, MPH
This article is followed by an AJCC Patient Care Page on
page 396.
©2020 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2020120
390
Background Nurses in intensive care units are exposed
to hundreds of alarms during a shift, and research shows
that most alarms are not clinically relevant. Alarm fatigue
can occur when a nurse becomes desensitized to alarms.
Alarm fatigue can jeopardize patient safety, and adverse
alarm events can lead to patients dying.
Objective To evaluate how a process intervention affects
the number of alarms during an 8-hour shift in an intensive care unit.
Methods A total of 62 patients from an intensive care unit
were included in the study; 32 of these patients received
the intervention, which included washing the patient’s
chest with soap and water and applying new electrocardiography electrodes at the start of a shift. The number
of alarms, clinical diagnoses, and demographic variables
were collected for each patient. A Poisson regression
model was used to evaluate the impact of the intervention on the overall number of clinical alarms during the
shift, with no adjustments to the alarm settings or other
interventions.
Results After relevant covariates are controlled for, the
results suggest that patients in the intervention group
presented significantly fewer alarms than did patients in
the control group.
Conclusions Managing clinical alarms is a main issue in
terms of both patient safety and staff workload management. The results of this study demonstrate that a relatively simple process-oriented strategy can decrease the
number of alarms. (American Journal of Critical Care.
2020;29:390-395)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
www.ajcconline.org
W
ithin intensive care units (ICUs), most equipment has safety alarms embedded that alert staff of changes in various patient parameters and situations.1
This technology can increase the already large number of alarms—sometimes
hundreds—nurses encounter during shifts1,2; many of those alarms are not
clinically relevant.3 Frequent auditory alarms can result in unintended consequences that have implications for patient safety (eg, patient injuries, fatalities) and quality
of care.4 Managing these clinical alarms has been identified as a “top 10” safety concern.5
Although all alarms must be acknowledged or
dismissed, clinically relevant alarms require nursing
intervention, whereas false alarms do not. Various
factors can create false or nonactionable alarms: the
patient’s motion, incorrect alarm parameter settings,
the patient’s condition, care being provided to the
patient (eg, bathing or turning), improper skin preparation or electrocardiography (ECG) electrode placement, or faulty connections of leads or electrodes.
Here we use the term false alarms to describe both
false alarms and nonactionable alarms.
In its 2013 Sentinel Alert, the Joint Commission
reported that between January 2009 and June 2012,
alarm-related events led to the death of 80 patients
and to a permanent loss of function in 13 patients.6
Because of the critical importance of patient safety
and the rising number of alarm-related events, the
Joint Commission issued a national patient safety
goal related to alarm management, mandating that
hospitals make establishing an alarm safety system a
hospital priority and identify the most important
alarms to manage.6 In addition, the Joint Commission required accredited hospitals to implement
policies and procedures to manage alarms and
appropriately educate staff.7 When clinical alarms are
more likely to be false than clinically relevant, a
work culture can emerge wherein nurses may delay
responding to alarms, especially when the setting
has a large patient census or a high patient to nurse
ratio, and thus may miss critical alarms.8-10
The ever-increasing number of alarms can lead
to a phenomenon known as alarm fatigue.7,11 Alarm
fatigue can occur when a nurse is exposed to frequent
About the Authors
Debbie Leigher is a nurse manager and Paula Kemppainen
is an assistant nurse manager, Greer Memorial Hospital,
Prisma Health System, Greer, South Carolina. David M.
Neyens is an associate professor, Department of Industrial Engineering, Clemson University, Clemson, South
Carolina.
Corresponding author: David M. Neyens, PhD, MPH, Department of Industrial Engineering, Clemson University,100
Freeman Hall, Clemson, SC 29634 (email: dneyens@
clemson.edu).
www.ajcconline.org
alarms and becomes desensitized to them.8 Alarm
fatigue has been described as the most common
factor contributing to alarm-related events,3,7,12,13
and it is well known that alarm fatigue can jeopardize patient safety and that adverse alarm-related
events can lead to patient fatalities3,7,12 and staff
workload management issues.13 A recent study
showed that alarm management and nuisance
alarms remain problems.14
Much of the previous research on alarm fatigue
has examined the issue from the perspective of
technology and alarm parameters.8,15,16 A technologyonly intervention will not, however, completely
alleviate alarm fatigue because factors related to
organizational best practices and nursing best practices influence alarm management and subsequent
alarm fatigue. The literature focuses on specialized ICUs and ICUs in
large academic hospitals,2,3,7,15,17 but the
patient population in a
community hospital’s ICU is typically more diverse
than that in specialty ICUs at larger facilities. Common diagnoses and conditions among patients in a
community ICU—like the one included in this
study—include congestive heart failure, pneumonia,
gastrointestinal bleeding, sepsis, cardiac arrhythmia,
alcohol withdrawal, suicide attempt, postoperative
complications, diabetic ketoacidosis, and chronic
obstructive pulmonary disease. This diversity makes
managing alarm fatigue through technology-centric
strategies (eg, by adjusting alarm parameters) a challenge for nurses.8,16,18,19 Therefore, alternative strategies are needed to reduce the number of false
alarms and to address and reduce the effects of
alarm fatigue and increase patient safety.
One possible way to reduce the number of false
alarms is to improve skin preparation before placing
ECG electrodes. Cvach et al20 reported that daily
electrode changes reduced by 46% the number of
alarms per bed day in 2 acute care units. Hermens
et al21 recommended changes in sensor placement
procedures in an effort to reduce the number of false
Alarm events can lead to
potential harm for patients.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
391
alarms related to surface electromyography, and they
proposed that preparing patients’ skin could improve
electrode–skin contact, thereby resulting in fewer nonrelevant alarms. In addition, an American Association
of Critical-Care Nurses Practice Alert outlined 7 nursing actions related to false alarms that may reduce the
number of such alarms22: properly preparing the skin
for ECG electrodes, changing ECG electrodes daily,
customizing alarm parameters and levels on ECG monitors, customizing delay and threshold settings for
oxygen saturation via pulse oximetry, providing initial
and ongoing nursing education about devices with
alarms, establishing interprofessional teams to address
issues related to alarms (eg, developing policies and
procedures), and monitoring only those patients who
present clinical indications for
monitoring.1,22 Several of these
clinical decision–related or
technology-mediated interventions can affect the number of
alarms that occur in an ICU,
and they are well documented
in the literature.5,8,15,16,18 We
must, however, further evaluate how preparing the skin
for ECG electrodes and changing the electrodes
affect the number of alarms while accounting for specific patient types and characteristics. Therefore, the
objective of this study was to evaluate how a process
intervention of preparing the skin (ie, washing a
patient’s chest with soap and water) and changing
electrodes at the start of each shift affected the number
of alarms throughout an 8-hour day shift in an ICU.
Methods
Data Collection
The study included 100 patients, with 50 patients
in each group. Each patient was included in the
study for a single 8-hour shift, and no individual
patient was included in both groups. If a patient
experienced no alarms during the 8-hour period,
they were excluded from the analysis. After exclusions, the study included 62 patients. We counted
alarms hourly during the 8-hour period to calculate
the total number of alarms during the work shift.
Several demographics were collected for each patient:
age, primary and secondary diagnoses, body mass
index, activity level, and alertness. Prisma Health’s
clinical engineering department automatically
extracted the hourly counts for red, yellow, and blue
alarms for each patient during the study, but we
included only red and yellow cardiac alarms in the
analyses. A yellow alarm is a low-priority patient
alarm and a red alarm is a high-priority patient
alarm. According to the Philips IntelliVue MP70
Patient Monitors documentation, a blue alarm is a
technical alarm that indicates that the monitor cannot reliably measure or detect alarm conditions.
Study Design
This study included 2 groups. For patients in
the intervention group, a nurse prepared their skin
for electrode placement (by washing the patient’s
chest with soap and water) and changed the electrodes daily (before 8:00 AM). The same clinical staff
member prepared the skin and changed electrodes
throughout the entire study. We collected data only
on weekdays to ensure that the intervention was
consistent and done by the same provider. Patients
in the control group received standard care that
included changing electrodes only as needed, per
standard hospital procedure. We used 3M Red Dot
monitoring electrodes with foam tape and sticky gel
and Philips IntelliVue MP70 Patient Monitors for all
patients. Throughout the study, we did not modify
or adjust any parameters (eg, alarm thresholds) for
the equipment and monitors for any patient.
Statistical Analysis
We conducted all analyses in R statistical software version 3.3.2 (The R Foundation for Statistical Computing). Poisson regression is used when
the dependent variable is a count variable, and in
this study the dependent variable was the number
of alarms during an 8-hour work shift. Thus we
used a Poisson regression model to examine the
impact of skin preparation on the patient alarms.
We included in the model 2 covariates: the age of
the patient and a binary variable that indicated
whether the patient was active and alert during the
8-hour study period. We also created binary covariates as indicator variables for the presence of several diagnoses including alcohol withdrawal,
pulmonary disease, gastrointestinal disease, sepsis,
and cardiac disease.
Red and yellow alarms
were counted for an
8-hour shift in an
intensive care unit at
a community hospital.
392
Study Setting and Sample
This study was conducted after we obtained
approval through the Prisma Health institutional
review board (no. Pro00049513). The study took
place in the ICU at a community hospital. The ICU
is not specialized and is similar to a medical-surgical
ICU in that the patient population varies daily and
can include patients with diagnoses of cardiac, respiratory, or gastrointestinal diseases, sepsis, alcohol
withdrawal, postsurgical complications, suicide
attempt, and others.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
www.ajcconline.org
Table 1
Characteristics of patients in the
intervention and control groupsa
Results
www.ajcconline.org
Intervention group
(n = 32)
Control group
(n = 30)
66.47 (15.41)
65.43 (17.21)
Female
53
57
Body mass indexb
Normal or underweight (≤ 24.9)
Overweight (25-29.9)
Obese (≥ 30)
34
19
47
40
13
47
Conditions
Alcohol withdrawal
Pulmonary disease
Cardiac disease
Gastrointestinal disease
Sepsis
16
63
69
31
31
3
37
33
33
17
Alert and oriented
66
77
Variable
Age, mean (SD), y
a Data are percentages unless otherwise indicated.
b Calculated as weight in kilograms divided by height in meters squared.
15
No. of patients
After exclusion, this study included 32 patients
in the intervention group (receiving skin preparation
and new electrodes) and 30 in the control group
(receiving standard care). The patients’ characteristics are described in Table 1. As mentioned, the
patients’ primary and secondary diagnoses were
separated into binary variables for several conditions, including some disease categories. A patient
was defined as experiencing alcohol withdrawal when
a physician had documented alcohol dependence in
the patient’s electronic health record. Pulmonary
diseases were identified broadly and included
respiratory failure, chronic obstructive pulmonary
disease, and pneumonia. The intervention group
had more patients with pulmonary disease than
did the control group. Cardiac diseases included
hypertension, hypotension, and cardiac dysrhythmia; these were distributed among the study population in a way similar to the pulmonary diseases.
Gastrointestinal diseases also had a similar prevalence between the groups and included all diagnoses related to the gastrointestinal system. Patients
with sepsis were identified in both of the groups.
Patients were defined as being alert if they were
alert and oriented (eg, not confused about person,
place, or time).
The number of alarms across all patients is
shown in the Figure. For most patients, between 1
and 10 alarms occurred during the 8-hour shift,
but more than 20 alarms occurred for 16 patients
during that period. One patient experienced 70
alarms during the 8-hour shift—the maximal
number of alarms during a shift within this study.
Because we automatically extracted from the system
all alarms for each patient, we do not know how
many of the alarms were clinically relevant and
how many were not.
We constructed a Poisson regression model to
predict the number of clinical alarms that would
occur for each patient during the 8-hour study
period (Table 2). We included all demographic and
diagnosis indicator variables in the initial model.
We used stepwise deletion to identify the best-fit
model. In that model, older patients were more
likely to have more alarms than were younger
patients. Patients who were alert and oriented were
more likely to have more alarms than if they were
not alert and oriented. Finally, patients in the intervention group were less likely to have more alarms
than if they were in the control group. No other
demographic or diagnostic indicator variables were
included in the final best-fit model.
10
5
0
0
10
20
Condition:
30
40
No. of alarms
Control
50
60
70
Intervention
Figure Histogram of the alarms during an 8-hour shift for all
patients in both the control and the intervention groups. The purple shading indicates where the alarms between groups overlap.
Discussion
In this study, we evaluated how preparing the
skin and changing ECG electrodes affected the number of alarms that occurred during a work shift in an
ICU at a community hospital. Some of the literature
suggests that this approach is one of several strategies
that might affect the number of alarms that occur in
this setting and thereby affect the likelihood of
alarm fatigue.9,22 When patient age and alertness are
controlled for, preparing the skin and changing electrodes did significantly reduce the total number of
alarms that occurred during the 8-hour work shift,
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
393
Table 2
Poisson regression model predicting the likelihood of more alarmsa
Parameter
Regression coefficient
SE
Z statistic
Odds ratio (95% CI)
Intercept
Intervention: wash condition
Patient’s age
Alert and oriented
1.826
−0.484
0.014
0.296
0.185
0.065
0.002
0.077
9.887
−7.457
6.527
3.837
6.210 (4.302-8.874)
0.616 (0.542-0.700)
1.015 (1.010-1.019)
1.344 (1.158-1.566)
Null deviance
Residual deviance
1187.3
1074.0
df = 61
df = 58
a All model parameters were significant at P < .001.
consistent with the types of reductions Cvach et al20
identified in their previous study.
Reducing alarm fatigue is critical in terms of
patient safety and nurse workload management.1
Many studies have been focused on technological
interventions related to alarm management and alarm
fatigue,15 but more straightforward and simple interventions may be beneficial, as organizational and
process factors also affect alarm management. Given
the Joint Commission’s suggestion to prioritize managing alarms6 and the need for effective strategies to
address alarm fatigue, our relatively simple intervention can help meet the goal of reducing the number
of alarms that occur. Given that
our team used no other interventions during this study, that
they did not adjust parameters,
and that this intervention did
not influence the clinical relevance of alarms, we expect that
nurses missed no clinically
important alarm. Rather, this
intervention most likely reduced
the number of alarms related to connection issues
and movement of patients.
Several limitations are associated with this study
and can be addressed in future research. Our study
sample was relatively small and included only 1 shift
per day. Skin preparation and electrode changes for
a full 24 hours may have implications that differ
from skin preparation and electrode changes within
an 8-hour shift, so future work should investigate
the effects of this practice when 24 hours go by
between intervention events. We included only
uninterrupted monitoring, and we excluded from
the study any patient who was moved for a procedure or imaging. Although we did not select any
particular patients within the patient census for
inclusion in or exclusion from the study, patients
with specific diagnoses were unequally represented
in each group. It may be possible to address this
limitation in future research by focusing on specific
diagnoses and populations of patients. We were not
able to identify any statistical outliers or any impact
Some practice-based
interventions may
reduce the number
of alarms in an
intensive care unit.
394
of diagnoses, but unobserved variables might exist
that could affect these results. Future researchers
should examine more homogeneous populations
of patients, including pediatric patients and patients
in other telemetry units.
We conducted the intervention first and did not
randomize assignment to the intervention and control groups because of operational restrictions in
implementing the interventions. With targeted populations or adequate samples from groups with specific diagnoses, future research might indicate an
interaction between a diagnosis and the intervention. Finally, we did not document a distinction
between the alarms that were and were not clinically
relevant, but we do not believe that skin preparation
and new electrodes would have limited or reduced
the number of clinically relevant alarms. False
alarms and nonactionable alarms, however, can
result from various causes in different contexts and
for different patients.
Conclusion
Alarm fatigue is dangerous, and organizations
should implement practices that minimize the effect
of an excessive number of alarms that are not clinically relevant on patient safety. Intensive care nurses
need to be aware of the potential risks for patients
associated with alarm fatigue. Our study focused on 2
nursing actions: preparing the skin for and changing
ECG electrodes daily. Our results showed that the
number of alarms was reduced during a shift when
these nursing actions were implemented in the ICU
at a community hospital. Future work should evaluate these interventions in other clinical settings.
ACKNOWLEDGMENTS
The authors acknowledge the students in the Ergonomics
and Applied Statistics Laboratory at Clemson University
for reviewing the manuscript, and Puneeth Kalavagunta
for his early work on this project. This work was conducted
at Greer Memorial Hospital within the Prisma Health
System (Greer, South Carolina) and at Clemson University
(Clemson, South Carolina).
FINANCIAL DISCLOSURES
None reported.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
www.ajcconline.org
SEE ALSO
For more about alarm management, visit the Critical Care
Nurse website, www.ccnonline.org, and read the article
by Nguyen et al, “Double Trouble: Patients With Both True
and False Arrhythmia Alarms” (April 2020).
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3. Lawless ST. Crying wolf: false alarms in a pediatric intensive
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4. Harris RM, Manavizadeh J, McPherson DJ, Smith L. Do you
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5. Keller JP Jr. Clinical alarm hazards: a “top ten” health technology safety concern. J Electrocardiol. 2012;45(6):588-591.
6. The Joint Commission. Sentinel event alert 50: medical
device alarm safety in hospitals. Published April 8, 2013.
Accessed May 14, 2019. https://www.jointcommission.org/
resources/patient-safety-topics/sentinel-event/sentinelevent-alert-newsletters/sentinel-event-alert-issue-50medical-device-alarm-safety-in-hospitals/
7. Sendelbach S, Funk M. Alarm fatigue: a patient safety concern. AACN Adv Crit Care. 2013;24(4):378-386.
8. Graham KC, Cvach M. Monitor alarm fatigue: standardizing
use of physiological monitors and decreasing nuisance
alarms. Am J Crit Care. 2010;19(1):28-34.
9. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily
electrode change and effect on cardiac monitor alarms: an
evidence-based practice approach. J Nurs Care Qual. 2013;
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10. Welch J. Alarm fatigue hazards: the sirens are calling. Patient
Safety Qual Healthc. 2012;9(3):26-33.
11. Bell L. Monitor alarm fatigue. Am J Crit Care. 2010;19(1):38-38.
12. Korniewicz DM, Clark T, David Y. A national online survey on the
effectiveness of clinical alarms. Am J Crit Care. 2008;17(1):36-41.
13. Honan L, Funk M, Maynard M, Fahs D, Clark JT, David Y. Nurses’
perspectives on clinical alarms. Am J Crit Care. 2015;24(5):387-395.
14. Ruppel H, Funk M, Clark JT, et al. Attitudes and practices related to
clinical alarms: a follow-up survey. Am J Crit Care. 2018;27(2):114-123.
15. Allan SH, Doyle PA, Sapirstein A, Cvach M. Data-driven implementation of alarm reduction interventions in a cardiovascular
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16. Imhoff M, Kuhls S, Gather U, Fried R. Smart alarms from medical devices in the OR and ICU. Best Pract Res Clin Anaesthesiol.
2009;23(1):39-50.
17. Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C,
Boniface B. Multicentric study of monitoring alarms in the adult
intensive care unit (ICU): a descriptive analysis. Intensive Care
Med. 1999;25(12):1360-1366.
18. Schoenberg R, Sands DZ, Safran C. Making ICU alarms meaningful: a comparison of traditional vs. trend-based algorithms. Proc
AMIA Symp. 1999:379-383.
19. Edworthy J, Hellier E. Fewer but better auditory alarms will improve
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20. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: an evidencebased practice approach. J Nurs Care Qual. 2013;28(3):265-271.
21. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development
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EVIDENCE-BASED
NURSING
The Research-Practice
Connection
FOURTH
EDITION
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Consultant Emeritus
Evidence-Based Practice
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Contents
Lead-In
xi
PART I
NURSING RESEARCH
1
Chapter 1
The Research–Practice Connection
7
Research to Practice
Clinical Care Protocols
Evidence
Evidence-Based Practice
Short History of Evidence-Based Nursing Practice
Your Path to Evidence-Based Practice
References
7
8
9
10
12
14
15
Research Evidence
17
Building Knowledge for Practice
Findings from an Original Study
Conclusions of a Systematic Review
Recommendations of an Evidence-Based Clinical
Practice Guideline
Going Forward
References
18
19
22
Chapter 2
23
25
26
iii
iv
CONTENTS
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Reading Research Articles
27
Starting Point
Format of Study Reports
Reading Approach
Wading In
References
28
29
37
37
38
Qualitative Research
39
Research Traditions
Qualitative Description
Uniqueness of Qualitative Studies
Exemplar
Profile & Commentary
References
40
43
46
47
48
51
Quantitative Descriptive Research
53
Methods
Study Variables
Good Data
Extraneous Variables
Target Population and Sampling
Surveys
Results
Exemplar
Profile & Commentary
References
53
55
58
62
64
70
71
73
74
81
Correlational Research
83
Defining Relationship
Measuring a Relationship
Correlational Design
Profile & Commentary
References
83
84
94
99
103
Contents
Chapter 7
Chapter 8
Chapter 9
v
Experimental Research
105
Chapter Map
Section 1: Experimental Methods
Key Features of Experimental Studies
Measurement of the Outcome Variables
Limitations of Randomized Experiments
Quasi-Experimental Designs
Exemplar
Profile & Commentary: Why and How
Section 2: Study Results
More Effective?
Outcome Reported as a Mean
Attainment of an Outcome
Both Perspectives
Opinion Regarding Reporting of Outcomes
Exemplar
Profile & Commentary: Results
References
105
106
106
119
119
120
121
133
137
137
137
145
147
149
150
150
151
Cohort Research
153
Design
Data Analysis and Results
Confounding
Other Limitations
Case-Control Studies
Wrap-Up
Exemplar
Profile & Commentary
References
153
155
155
155
156
157
158
166
173
Systematic Reviews
175
Types of Systematic Reviews
Close and Distant Relatives of SRwNS
The SR Production Process
175
177
178
vi
CONTENTS
Chapter 10
Use of SRwNS
Umbrella SRs
Exemplar
Profile & Commentary
References
186
188
188
206
208
Evidence-Based Clinical Practice Guidelines
211
Forerunners to Care Protocols
EbCPG Production
Guideline Formats
Comorbidity
Guideline Producers
Profile & Commentary
References
212
214
222
223
223
239
241
PART II
EVIDENCE-BASED PRACTICE
243
Chapter 11
Asking Clinical Questions
249
Triggers
Questions Not Answerable by Research Evidence
Forming a Useful Project Question
References
249
251
253
257
Searching for Research Evidence
259
Health Science Databases
Nonprofit, International Organizations
Professional Specialty Organizations
Wrap-Up
260
262
263
264
Appraising Research Evidence
265
Appraisal Systems
Appraisal in General
Practical Considerations
Already Appraised Evidence
Resources
266
267
272
273
274
Chapter 12
Chapter 13
Contents
Chapter 14
Chapter 15
Chapter 16
Chapter 17
vii
Appraising Recommendations of
Clinical Practice Guidelines
275
Synopsis
Credibility
Clinical Significance
Applicability
Appraisal Guide Format
Your Turn
References
276
276
278
279
280
280
281
Appraising Conclusions of Systematic Reviews
with Narrative Synthesis
283
Synopsis
Credibility
Clinical Significance
Applicability
Your Turn
References
284
284
286
286
286
287
Appraising Findings of Original Studies
289
Is This a Qualitative or Quantitative Study?
Broad Credibility Issues
Appraisal of the Findings of a Qualitative Study
Appraisal of the Findings of a Quantitative Study
Your Turn
Across-Studies Analysis
Wrap-Up
References
289
290
292
293
297
297
300
300
Evidence-Based Practice Strategies
303
Research–Practice Lag
Embedding Evidence-Based Practice in
Quality Improvement
Translating Evidence into Practice
Evaluate the Impact
303
305
307
312
viii
CONTENTS
Information Technology
Present and Future
Recap
References
313
315
315
316
Evidence-Based Practice Participation
319
Capstone Project
Contribute to a Patient Care Conference
Join a Project Team
Make a Poster
Present an Idea or Concern
Build Your EBP Knowledge and Skills
Reference
319
320
322
323
324
325
326
Point-of-Care Adaptations
327
Individualized Care Story
Point-of-Care Evidence-Based Practice Story
From Mobile Devices
The Information Intersection
My Ending—Your Beginning
References
327
329
330
333
334
335
Appendix A
Appraisal Guide: Recommendations
of a Clinical Practice Guideline
337
Appendix B
Completed Appraisal: Recommendations
of a Clinical Practice Guideline
341
Appendix C
Appraisal Guide: Conclusions of a Systematic
Review with Narrative Synthesis
347
Appendix D
Completed Appraisal of a Systematic Review
with Narrative Synthesis
351
Chapter 18
Chapter 19
Contents ix
Appendix E
Appraisal Guide: Findings of a Qualitative
Study
357
Appendix F
Appraisal Guide: Findings of a Quantitative
Study
361
Appendix G
Completed Appraisal of the Findings
of a Quantitative Study
365
Appendix H
Completed Findings Table
369
Glossary
373
Index
385
Lead-In
“Evidence is stronger than argument.”
—from The Celebrity
by Winston Churchill, 1897
H
ealthcare professionals apply specialized knowledge and skills
in the interest of patients. This text is about the production and
use of new knowledge produced by research. As a professional
nurse, you should know something about how knowledge for practice is
produced and how to use that knowledge in what you do every day.
Aims
In the first part of the text, the focus is on how clinical knowledge is
produced—from original studies, to research summaries, to the translation
of research evidence into practice guidelines. Just enough of the basics of
conducting research are explained so you can understand research reports,
research reviews, and evidence-based guidelines published in clinical journals. Then in the second part of the book, the use of research in practice
settings is examined. This includes locating, appraising, and translating research evidence into clinical protocols and standards of care.
Features of Note
■■ Emphasis on Using Research Evidence Systematic research reviews
and evidence-based clinical practice guidelines receive considerable
attention as the most ready-to-go forms of research evidence. Basing
care on one or even several individual studies is viewed as the fallback
xi
xii LEAD-IN
position—for reasons that are explained early on. In the second part
of the text there is a strong emphasis on developing skills in appraising
the quality and applicability of the various forms of research evidence.
■■ Easy to Read An online reviewer of the third edition said it was easy to
understand because it was written almost like a blog. Although some
persons may view these descriptions as an indication that the book is
not “academic,” I feel good about them because I have made considerable effort to write so that complex information is conveyed in a clear
and de-jargonized way. I hope you find it readable and clear—even
interesting.
■■ Format In Part I, a profile and discussion is provided for each exemplar research report you read; this material is presented in a consistent
WHY-HOW-WHAT format to assist you in breaking a research article down into its key parts.
■■ Exemplars As in previous editions, actual research reports are used to
illustrate the different types of research evidence. Careful reading of
these exemplars is essential to acquiring understanding of how nursing research is conducted and reported. Four exemplars are printed
in full, whereas the citation and abstract are provided for the other
three. We are unable to print these three in full here due to copyright
restrictions. The full reports should be easily obtained through college, university, and medical center libraries.
■■ Statistics You will note that there is not a chapter about statistics;
instead specific statistical tests and their interpretations are incorporated into the explanations of results of the exemplar reports. Students have told me that learning about a statistical test in the context
of an actual study is quite helpful. The index indicates the page(s) on
which each statistic is explained.
■■ Gender References As with all texts that include examples with unknown persons, there is the she-her/he-him conundrum. There are
various ways to deal with it, but I have chosen to sometimes refer to
the nurse as she and other times as he—the same with references to
an individual patient.
Sarah Jo Brown, PhD, RN
P A R T
I
Nursing Research
1
2
3
4
5
6
7
8
9
10
The Research–Practice Connection
Research Evidence
Reading Research Articles
Qualitative Research
Quantitative Descriptive Research
Correlational Research
Experimental Research
Cohort Research
Systematic Reviews
Evidence-Based Clinical Practice Guidelines
1
PART I Nursing Research
T
he level of knowledge required to understand research reports published in clinical journals is somewhat akin to being a savvy computer user. To be a competent computer user,
you do not have to understand binary arithmetic, circuitry, program
architecture, or how central processing units work. You just need to
know some basic computer language and be familiar with the features of the hardware and software programs you use. Similarly, as
a professional nurse in clinical care, you do not need to know all the
different ways of obtaining samples, how to choose an appropriate
research design, or how to decide on the best statistical test. But you
do need to be able to read study reports with basic understanding of
the methods used and what the results mean.
The goal of the first part of the text is to introduce you to research
methods and different kinds of research evidence. To accomplish this,
seven research articles have been chosen as exemplars of each major
research method. The use of exemplar articles allows me to explain
research methods and results by pointing them out in the context of
an actual study. For reasons explained in the Lead-In, an abstract and
citation is provided for the first three exemplars; the next four are
reprinted in full.
I strongly recommend that you read all the articles in full, whether
they are reprinted in full herein or not. Getting to the full articles for
the first three articles using your college or university library access
should not be difficult. Admittedly, you might get by reading just the
abstract. But if you really want to acquire the knowledge and skills
needed to become a nurse who is able to read and put into practice
professional health literature, you will have to read the exemplar articles in full. Doing so will help you acquire: (1) understanding of research methods and results, (2) the ability to extract key information
3
4
PART I Nursing Research
from research reports; and (3) skill in evaluating whether the research
evidence is trustworthy and applicable to your practice. The abstract
is just a sketch and lacks the details needed to acquire the needed
knowledge and skills.
Courtesy of Abby Laux, Landscape Artist of Indiana, U.S.A.
One other advisory: Research and evidence-based practice knowledge
is built piece by piece from the simple to the more complex across the
text. If you don’t master early information, you will struggle when
more complex information is presented later in the text.
For readers who like to know where their learning will take them,
an overview of the text’s learning progression is graphically displayed
in F
igure PI-1. The main learning goals are in the chevrons on the left
side. More specific learning issues associated with each goal are shown
to the right.
PART I Nursing Research 5
• Why
Goal:
Understand
research
• How
Synopsis
• What
• Credibility
Goal:
How to appraise
research
evidence
• Clinical significance
Decision re: Use
• Applicability
• Clinical protocols
Goal:
How to use
evidence
Figure PI-1
• EBP-QI projects
Evaluate outcomes
• Individual practice
Overview of the Text’s Learning Progression
C H A P T E R
O N E
The Research–Practice
Connection
E
ffective nursing practice requires the application of knowledge,
information, judgment, skills, caring, and art to take care of patients in an effective and considerate way. An important part of the
knowledge used in making decisions about care is produced by research
findings. Ideally, all key decisions about how patients are cared for should
be based on research evidence (Institute of Medicine, 2001). Although this
is not a completely attainable goal, large bodies of healthcare research provide considerable guidance for care. This text introduces you to the basics
of how knowledge is produced by conducting research studies and to the
application of that knowledge to nursing practice.
Research to Practice
In the healthcare professions, research is conducted to develop, refine, and
expand clinical knowledge about how to promote wellness and care for
persons with illness. The development of clinical knowledge about a clinical issue plays out over time proceeding from a single study about the issue, to several similar and related studies, to a systematic summary of the
finding of the several studies, to a translation of the summary conclusions
into a clinical action or decision recommendation. Thus, research evidence
develops as a progression from knowledge that has limited certainty to
greater certainty and from limited usefulness to greater usefulness. Actually, clinical nursing knowledge is quite variable with some issues having
been examined by only one or two studies and other issues having been
7
8
CHAPTER 1 The Research–Practice Connection
studied and summarized sufficiently that research-based recommendations
have been issued by respected organizations and associations.
The end users of research evidence are healthcare delivery organizations
and individual care providers. The healthcare delivery organization could
be nurses on a particular unit or ward of a hospital, a nursing department,
a multidisciplinary clinical service line, a home care agency, a long-term
care facility, or a rehabilitation team; in short: a group of providers or an
organization with a commitment to basing the care they deliver on research
evidence.
Use of research evidence by provider groups and organizations often
takes the form of clinical protocols that are developed using the research
evidence available. In contrast, individuals use research evidence in a softer,
less prescribed way—meaning that they incorporate it into their own
practice as a refinement or slight change in how they do something. After
reading a research summary about patient education methods for children
learning to give themselves insulin, a nurse might alter her teaching approach; or after reading a study about sleep deprivation in hospitalized
adults, a nurse working the night shift might pay more attention to how often patients are being awakened and try to cluster care activities to reduce
interruptions of sleep.
Clinical Care Protocols
Clinical protocols are standards of care for a specified population that
are set forth by caregiving organizations with the expectation that providers will deliver care accordingly. A population is a group of patients who
have the same health condition, problem, or treatment. A population can
be defined broadly, for example, as persons having surgery; or narrowly,
as elderly persons having hip replacement surgery. Some clinical protocols
set forth a comprehensive plan of care for the specified population; for
example, perioperative and postoperative care of elderly persons having
hip surgery, whereas others address just one aspect of care such as body
temperature maintenance in the elderly having hip surgery. Still others are
even narrower and could be called a clinical procedure, for example, blood
salvage and transfusion during hip surgery. Generally, multidisciplinary
groups produce protocols that address many aspects of care, whereas nursing staff members produce protocols that address clinical issues that nurses
manage, such as preventing delirium in ICU patients.
Evidence
9
Clinical protocols are set forth in various formats: standardized plans
of care, standard order sets, clinical pathways, care algorithms, decision
trees—all are guides for clinicians regarding specific actions that should be
taken on behalf of patients in the specified population.
PROTOCOLS
■■ Standardized plans of care
■■ Standard order sets
■■ Clinical pathways
■■ Care algorithms
■■ Decision trees
■■ Care bundles
Evidence
To produce effective and useful clinical protocols, project teams combine
research evidence with other forms of evidence, including:
■■ Internal quality monitoring data
■■ Data from national databases
■■ Expert opinion
■■ Scientific principles
■■ Patient/family preferences
There is wide agreement among healthcare providers that research findings are the most trustworthy sources of evidence and that clinical protocols should be based on research evidence to the extent possible. However,
when research evidence is not available or does not address all aspects of
a clinical issue, the other forms of evidence come into play. In recognition
of the fact that multiple sources of knowledge and information are used to
develop clinical protocols, they are commonly called evidence-based protocols. Research evidence is an essential ingredient, although, as you will
learn, the strength of the research evidence will vary. From here forward
I will use the descriptor evidence-based, often abbreviated e-b, to describe
protocols and care actions that are based to a major degree, but maybe not
entirely, on research findings.
10 CHAPTER 1 The Research–Practice Connection
Evidence-Based Practice
When research findings are used to develop a protocol and the protocol
is followed in daily practice, everyone involved (patients, healthcare professionals, the caregiving organization, third-party payers, and accrediting
agencies) can have confidence that patients are receiving high-quality care.
This is the case because the recommended actions have been scientifically
studied, and people with expertise in the field have considered their application. In addition, the consistency of care achieved with standardized e-b
protocols reduces variability and omissions in care, which enhance even
further the likelihood of good patient outcomes.
Research
Evidence
EvidenceBased
Protocol
EvidenceBased
Practice
Using Clinical Protocols
In any care setting, care protocols do not exist for every patient population and every care situation. Healthcare organizations develop protocols
to promote effective clinical management and to reduce variability in the
care of their high-volume and high-risk patient groups. If a protocol exists,
it should be followed unless there is good reason for not doing so. Protocols should be adhered to but with attentiveness to how they are affecting
individual patients. Nurses are patient advocates and as such look out for
patients’ welfare; this requires that nurses be constantly aware of patients’
responses to protocols. If a nurse observes that a protocol is not producing
effective results with a patient, a clinical leader should be consulted to help
determine whether a different approach to care should be used. A protocol
may be evidence-based and may work well for most patients; however, it
may not be right for every patient.
Scenario Suppose you are providing care to a patient 2 days after he had a
lumbar spinal fusion and you observe that he does not seem as comfortable
Evidence-Based Practice
11
as he should be even though the postoperative protocol is being followed;
he has no neurological deficit and the surgeon’s notes indicate that there
are no signs of complications. You should then ask yourself questions such
as, “Why isn’t he getting good pain relief? Should we get a different pain
medication approach? Would applying ice packs to his lower back reduce
muscle spasm that could cause his pain? Is he turning in bed and getting up
using proper technique? Should he be sitting less? Should he use his brace
more?” The advisable course of action would be to talk with the patient
and then with your nurse manager or a clinical leader about how to supplement or change some aspect of his care.
Protocols Þ Recipes
So, now you know a bit about how research evidence contributes to good
patient care. In the rest of Part I of this text, I will walk you through the
methods used to develop clinical practice knowledge. In later chapters of
Part II, I will turn your thinking once again to e-b protocols and to how
you as an individual can locate research evidence when there is no protocol
for a clinical condition or situation.
As a Staff Nurse
After you have been in the staff nurse role for a while, you may be asked to
participate in a project to develop or update a care protocol or procedure.
Often, your organization will be adapting an evidence-based guideline that
was issued by a professional association, leading healthcare system, or government organization. Other times, an evidence-based guideline will not
be available, but a research summary relative to the clinical issue will have
been published, and its conclusions will be used in developing the protocol.
To contribute to a protocol project, you will need to know how to read and
understand research articles published in professional nursing journals and
on trustworthy healthcare Internet sites.
Scenario You are working in a pediatric, urgent care clinic and are asked
to be a member of a work group revising the protocol for evaluating and
treating children with fever who are suspected of a having a urinary tract
infection. You may be asked to read, appraise, and report to the group
about an evidence-based clinical guideline produced by a leading pediatric
12 CHAPTER 1 The Research–Practice Connection
hospital. To fulfill this assignment, you should be able to formulate a reasonably informed opinion as to the extent to which the guideline recommendations are evidence based (e-b) and were produced in a sound manner.
If the recommendations are deemed credible, then the protocol work group
will rely heavily on them while developing their protocol.
In this anecdote, do note that the protocol project team was building on
the works of others who had produced an e-b guideline on the issue. E-b
guidelines and protocols may sound similar but they are different in an
important way. E-b guidelines (1) draw directly on the research evidence,
(2) are produced by experts from a variety of work settings, and (3) consist
of a set of e-b recommendations that are not intended for a particular setting. In contrast, clinical protocols are produced by providers in a healthcare setting for that setting; often they are translations of an e-b guideline
that keep the essential nature of the guideline recommendations but tweak
them to fit into the routines and resources of the particular setting.
GUIDELINE: A set of recommendations for the care of a patient population that is issued by a professional association, leading healthcare
center, or government organization. Guidelines are not setting specific.
PROTOCOL: A set of care actions for a patient population that has
been endorsed by the hospital, agency, clinic, or healthcare facility. Protocols are setting specific.
Short History of Evidence-Based Nursing Practice
The nursing profession has been conducting scientific research since the
1920s, when case studies were first published, and calls for research about
nursing practice were first issued in the American Journal of Nursing. Now,
nursing research is being conducted in countries around the world, and
reports of clinical research studies are published in research journals and
clinical journals in many languages. In many countries, nursing research
is funded by the government, and over 50 countries have doctoral programs in nursing. The growing cadre of nurses with doctoral degrees has
propelled both the quantity and quality of clinical nursing research being
conducted. In the United States, the National Institute of Nursing Research
(www.ninr.nih.gov), a component of the National Institutes of Health, is a
Short History of Evidence-Based Nursing Practice
13
major source of funding for nursing research. Many other countries have
similar organizations.
In the mid-1970s, visionary nurse leaders realized that even though
clinical research was producing new knowledge indicating which nursing
methods were effective and which were not, practicing nurses were not
aware of the research. As a result, several projects were started to increase
the utilization of research-supported actions by practicing nurses. These
projects gathered together the research that had been conducted on issues
such as preoperative teaching, constipation in nursing home residents,
management of urinary drainage systems, and preventing decubitus ulcers.
Studies were critiqued, evidence-based guidelines were developed, and considerable attention was paid to how the guidelines were introduced into
nursing departments (Horsley, Crane, & Bingle, 1978; Krueger, Nelson, &
Wolanin, 1978). These projects stimulated interest in the use of nursing
research in practice throughout the United States; at the same time, nurses
in other countries were also coming to the same recognition. By the 1980s
and 1990s, many research utilization projects using diverse approaches to
making nurses aware of research findings were under way.
During this time, interest in using research findings in practice was also
proceeding in medicine. In the United Kingdom, the Cochrane Collaboration at Oxford University was formed in 1992 to produce rigorous research summaries with the goal of making it easier for clinicians to learn
what various studies found regarding the effectiveness of particular healthcare interventions. At the McMaster Medical School in Montreal, Canada,
a faculty group started the evidence-based practice movement. This movement brought to the forefront the responsibility of the individual clinicians
to seek out the best evidence available when making clinical decisions in
everyday practice. The evidence-based practice (EBP) movement in medicine flowed over into nursing and reenergized the use of research by nurses.
Three other things were happening in the late 1990s and early 2000s:
■■ Considerably more clinical nursing research was being conducted.
■■ The EBP movement was proceeding in a somewhat multidisciplinary
way.
■■ National
governments in the United States, the United Kingdom,
anada, and many other countries funded efforts to promote the
C
translation of research into practice.
Today, high-quality evidence-based clinical practice guidelines and research summaries are being produced by healthcare organizations around
14 CHAPTER 1 The Research–Practice Connection
the world, and nursing staffs are increasingly developing clinical protocols
based on those guidelines and summaries. Also, individual clinicians are
increasingly seeking out the best available evidence to use as a guide for
the care they provide to patients. The most recent development is an area
of research called implementation research or translational research. These
studies examine how to implement evidence-based innovations in various
practice settings so the changes are taken up by direct care providers and
become part of routine care.
Your Path to Evidence-Based Practice
I want to emphasize that the point of this text and of the course you are
taking is not to prepare you to become a nurse researcher, but rather to
help you be an informed consumer of nursing research, i.e., a true professional clinician. The exemplar research articles you will be reading were
published in clinical journals, not research journals. They were written for
clinicians; thus they do not go into the fine points of research methodology. In Part I you will start by learning about individual studies, then about
research summaries, and last about clinical practice guidelines—the three
major forms of research evidence. Your goal in reading about them will be
to grasp why the study/summary/guideline was done, how it was done, and
what was found.
Because this text is a primer, only the most widely used and important
types of research are presented. Also, the information provided is selective,
which means that it is not a comprehensive reference source regarding research methodology. It does not delve deeply into methodological issues; it
does not explain all research designs, methods, and statistics. However, it
does provide an introduction to research methods and results that serves
as a foundation for making a judgment about the credibility of a study/
summary/guideline.
In Part II you will learn about using research evidence in nursing practice. You will revisit the studies/summaries/guidelines you read in Part I,
to learn how to critically appraise their soundness, and consider their
applicability to a particular setting. You will also learn about how organizations use research evidence to develop clinical protocols and how to use
research evidence in your own individual clinical practice.
References
15
You, the Learner
The exploration of evidence-based nursing in this text assumes that you
(1) have had an introduction to statistics course; (2) have some experience
in clinical settings; and (3) are committed to excellence in your professional
practice.
Other Learning Resources
In reading this text, and indeed in your reading of research articles once
you have graduated, you may want to have a statistics book handy to look
up statistical terms and tests you have forgotten or never learned. Your
statistics text need not be new. Earlier editions are often available very inexpensively—and statistics do not change much from edition to edition. Do
make sure you use a basic book, not an advanced one written for researchers. If in doubt, ask your instructor for a suggestion.
For a full suite of learning activities and resources, use the access code
located in the front of your text to visit this exclusive website: http://
go.jblearning.com/brown4e. If you do not have an access code, you can
obtain one at the site.
References
Horsley, J. A., Crane, J., & Bingle, J. (1978). Research utilization as an organizational process. Journal of Nursing Administration, 8, 4–6.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for
the 21st century. Washington, DC: National Academy of Sciences. Retrieved
from http://www.nap.edu/html/quality_chasm/reportbrief.pdf
Krueger, J. C., Nelson, A. H., & Wolanin, M. O. (1978). Nursing research: Development, collaboration, and utilization. Germantown, MD: Aspen.
C H A P T E R
T W O
Research Evidence
T
he term research evidence needs to be defined. First, perhaps obvious, scientific research is the methodical study of phenomena
that are part of the reality that humans can observe, detect, or
infer; it is conducted to understand what exists and to acquire knowledge
about how things work. More particularly, nursing research is the study of
phenomena in and relevant to the world of nursing practice; nursing phenomena can be grouped into five categories (adapted from Kim, 2000). The
categories and examples of phenomena within each are:
■■ The Client as a Person (motivation, anxiety, hope, exercise level, and
adherence to treatments)
■■ The Client’s Environment (social support, financial resources, and
peer group values)
■■ Nursing Interventions (risk assessment for skin breakdown, patient
teaching, and wound care)
■■ Nurse–patient Relationship and Communication (person-centered talk,
collaborative decision making)
■■ The Healthcare System (access to health care, quality of care, cost)
In brief, nursing phenomena are personal, social, physical, and system realities that exist or occur within the realm with which nursing is concerned.
As a student new to the science of nursing, when mention is made of
research evidence, you will naturally think of the findings of a scientific
17
18 CHAPTER 2 Research Evidence
study. However, as you proceed through this course, you will come to see
that research evidence can take several forms, namely:
■■ Findings from a single, original study
■■ Conclusions from a summary of several (or many) original studies
■■ Research-based recommendations of a clinical practice guideline
Building Knowledge for Practice
A finding of a single original study is the most basic form of research evidence. Most studies produce several findings, but each finding should be
considered as a separate piece of evidence because one finding may be well
supported by the study whereas another finding may be on shaky ground.
Although a finding from an original study is the basic building block of scientific knowledge, clinical knowledge is really more like a structure made
up of many different kinds of blocks.
E-B
Guidelines
Systematic
Research Reviews
Findings from Individual Studies
Building Practice Knowledge
Building Practice Knowledge
Findings from several/many soundly conducted studies are necessary to
build reliable knowledge regarding a clinical issue. Insistence on confirmation of a finding from more than one study ensures that a knowledge claim
(or assertion) is not just a fluke unique to the patients, setting, or research
methods of one study. If a finding is confirmed in several different studies, clinicians have confidence in that knowledge because it held up across diverse
settings, research methods, patient participants, and clinician participants.
Findings from an Original Study
19
There are several recognized ways of summarizing findings from two
or more studies; as a group these methods are called systematic research
reviews, most often shortened to systematic reviews. Conclusions from
systematic reviews may then be translated into evidence-based recommendations by expert panels. A group of e-b recommendations is called an
evidence-based clinical practice guideline. Although one could make a case
that evidence-based recommendations are technically derivations of research evidence, when they are true to the underlying research results they
are considered research evidence for practical purposes. In this chapter,
each of these forms of research evidence is introduced briefly in turn. Later
in the text, each is considered in depth.
Findings from an Original Study
Most people think of a research study as involving (1) a large number of
subjects who are (2) randomly assigned to be in one of several intervention
groups; (3) research environments that are tightly controlled; and (4) data
that are meticulously obtained and then analyzed using statistics to produce results. In fact, research using these methods is common and valuable;
however, it is only one type of scientific study—there are many other kinds.
The most common way of thinking about research methods is to categorize
them as qualitative and quantitative.
Qualitative Research
Qualitative research can be used to study what it is like to have a certain
health problem or healthcare experience. Qualitative research methods are
also used to study care settings and patient–provider interaction. The following are examples of phenomena a nurse researcher might study using
qualitative methods:
1. The experience of being a physically disabled parent or the experience of recovery from a disability.
2. The interpersonal support dynamics at a social center for persons
with chronic mental illness.
3. How intensive care unit (ICU) staff members interact with family
members of unconscious patients.
4. How a family who has entered a family weight loss program makes
changes in eating and physical activity over time.
20 CHAPTER 2 Research Evidence
These kinds of social experiences and situations are typically tangles of
issues, forces, perceptions, values, expectations, and aims. They can be understood and sorted out best by methods of inquiry that will get at participants’ perceptions, feelings, daily thoughts, beliefs, expectations, and
behavior patterns.
Qualitative researchers have an overall plan for how they will approach
potential informants and position themselves in situations of interest.
However, they are also committed to going where the data leads them and
following up leads suggested by prior informants. Data collection methods
such as in-depth interviewing, extended observation, diary keeping, and
focus groups are used to acquire insights regarding subjective and social
realities. Qualitative data consists of what people say, observational notes,
and written material. The data are analyzed in ways that preserve the meanings of the stories, opinions, and comments participants offer. The goal of
qualitative research is understanding—not counting, measuring, averaging,
or quantifying in any way. Qualitative research is described in more depth
in Chapter 4.
Quantitative Research
Quantitative research methods provide a different perspective on how the
world works. Quantitative researchers assume a basic understanding of
phenomena that allows numerical measurement of them. They then use numerical measurements to confirm the level at which phenomena are present
and explore the nature of relationships among them under various conditions. For instance, the quantitative measurement of body temperature using a degree scale on a thermometer is a precise way of determining body
temperature at a point in time and tracking it over time. It is also makes
possible the study of the relationship between body temperature and blood
alcohol level by 2-axis graphing and by statistical analysis. Measurement
is also used to test how well a nursing intervention works compared to another intervention by measuring the outcomes achieved by both intervention groups to determine if there is a difference.
Quantitative researchers have specific study questions they want to examine; most often the questions involve several phenomena. For example,
a researcher whose main interest is preoperative anxiety may ask a research question pertaining to how patients’ levels of perceived risk for a
bad outcome affect anxiety. Perceived risk and preoperative anxiety are
the phenomena that make up the research question. In research lingo,
Findings from an Original Study
21
however, the phenomena of interest are called variables because they are
not constants—they exist at more than one level and vary in time, place,
person, and context.
Variables are phenomenon that exist
at more than one level
The following are examples of study purposes that could be studied using quantitative research methods:
■■ The strength of relationship between health-related phenomena (e.g.,
between mothers’ hours worked outside the home and mothers’ level
of fatigue).
■■ Test a hypothesis about the effectiveness of an intervention (e.g.,
A smoking cessation program delivered to small groups of sixth graders by a school nurse will result in a lower level of smoking in 3 years
than will an interactive computer program delivered and evaluated
in the same time frame. The intervention in this study is one variable
(it is a variable because it has two forms); level of smoking at 3 years
is the other variable.
■■ Predict good or bad health outcomes (e.g., Determine predictors of
re-hospitalization within 30 days for persons discharged on newly
prescribed anticoagulants. Several predictor variables could be tested,
such as: type of anticoagulant, frequency of blood level monitoring,
age, or lives alone. Re-hospitalization (yes/no) is the outcome variable).
Researchers then choose a research design that will produce answers to
their questions. A research design is a framework or general guide regarding how to structure studies conducted to answer a certain type of research
question. The four quantitative research designs used most often in nursing
research are:
1. Descriptive designs
2. Correlation designs
3. Experimental designs
4. Quasi-experimental designs (Burns & Grove, 2009)
After choosing a design that will answer their research questions and
is feasible given their resources, they develop a detailed study plan that
spells out specifically how their study will be conducted—sample size, how
22 CHAPTER 2 Research Evidence
participants will be recruited, data to be collected, statistical analysis that
will be done, etc.
Mixed Methods Research
Researchers sometimes use qualitative and quantitative methods in combination with one another. Using mixed methods may produce a more
complete portrayal of an issue than can one method alone. For instance,
researchers used mixed methods to identify health concerns in an African
American community; they conducted focus groups and analyzed the results of a community health survey. They concluded that “Although quantitative approaches yield concrete evidence of community needs, qualitative
approaches provide a context for how these issues can be addressed”
(Weathers et al., 2011, p. 2087).
Conclusions of a Systematic Review
Systematic reviews are an important and useful form of research evidence.
A systematic review is a research summary that produces conclusions by
bringing together and integrating the findings from all available original
studies. The process is often referred to as synthesis because it involves
making a new whole out of the parts. The integration of findings from
several or many studies can be done using tables and logical reasoning
and/or with statistics. To reduce bias resulting from the process used to
produce the conclusions, the methods used for conducting a systematic
review are rigorous and widely agreed upon.
Systematic reviews, when well done, bring to light trends and nuances
regarding the clinical issue that are not evident in the findings of individual
studies. I suggest that now you take a look at an abstract of a systematic
review, because reading and using the conclusions of systematic reviews is
one of the destinations on your learning path, and looking at one will give
you a sense of this important learning destination.
1. Go to the CINAHL database in your library’s website or go online
to PubMed (http://www.ncbi.nlm.nih.gov/pubmed). PubMed is a
free, online database of healthcare articles.
2. Type the following text in the search box: “facilitated tucking
Obeidat” and click on the Search button. (Facilitated tucking
involves holding or swaddling an infant so his arms and legs are
slightly flexed and close to his body.)
Recommendations of an Evidence-Based Clinical Practice Guideline 23
3. That should bring up the citation and abstract for a systematic
review of five studies about facilitated tucking of preterm infants
during invasive procedure to modulate their responses to pain; the
review was conducted by Obeidat, Kahalaf, Callister, & Froelicher
and published in 2009.
4. Note that the abstract provides information about how many articles were included in the review, the outcomes that were examined,
and the main conclusion of the review. Remember: You are reading
a very short synopsis of the review, not the entire report.
From this quick look at the abstract of a systematic review, you should
get a sense of the groundwork that has been done by the persons who did
this review. In the process of doing the review, they did the following:
■■ Searched for articles
■■ Sifted through them for relevant studies
■■ Extracted information from each study report
■■ Brought the findings together in a coherent way
Clearly, this saves clinical nurses a great deal of time when they are looking for the research evidence about an issue in care. You will delve more
deeply into systematic reviews in later chapters.
Recommendations of an Evidence-Based
Clinical Practice Guideline
The third form of research evidence is the recommendations of an
evidence-based clinical practice guideline. A clinical practice guideline
consists of a set of recommendations, and when the recommendations
are based on research evidence, the whole guideline is referred to as an
evidence-based clinical practice guideline. These guidelines are most often
developed by organizations with the resources (money, expertise, time) required to produce them. I think it will be informative for you to now briefly
look at a guideline to get a feel for how the recommendations and supporting research evidence are linked. (You will be examining a guideline in
more depth in Chapter 10.)
1. Go to the website of the Registered Nurses’ Association of Ontario
(RNAO; http://www.rnao.org ).
2. Click the Best Practice Guidelines tab; scroll down to the search box,
enter “dyspnea,” and click Search. The search result will bring up the
24 CHAPTER 2 Research Evidence
guideline Nursing Care of Dyspnea: The 6th Vital Sign in Individuals
with Chronic Obstructive Pulmonary Disease.
3. Double click to open the page for the guideline.
4. Low on the page under Related File(s), you will see COPD Summary. Open that by double clicking and you will see a list of recommendations.
The developers of this guideline looked at the research evidence regarding
nursing assessment and management of stable, unstable, and acute dyspnea
associated with COPD. Based on the evidence, they derived the recommendations listed. (I suggest that you look at the Practice Recommendations
[1–5] and ignore the Education Recommendation and Organization &
Policy Recommendations that follow.)
The strength of the evidence supporting each recommendation is indicated in the right column, and definitions of those levels are provided at
the end of the table; do not get caught up in that right now, although you
should know that level Ia is very strong research evidence whereas level IV
evidence was obtained from expert opinion evidence (i.e., no research exists, so consensus of an expert panel was the best available evidence). The
evidence levels that support the recommendations are mostly either Ia or
IV, indicating that considerable research evidence is available for some issues but none for quite a few others.
Remember that you are looking at part of a much larger report. The
other document, the complete 166-page guideline (viewable by clicking on
Free Download tab), presents more specific guidance and detailed review
of the evidence that led to each recommendation. It also informs the reader
how the search for evidence was conducted and how the 2010 update of
the original 2005 guideline was done.
As you can see, evidence-based clinical practice guidelines are even more
ready to go for use in practice than systematic reviews and definitely more
ready to go than tracking down the original research articles and trying to
get an overall sense of them. For time-pressed protocol development teams,
evidence-based clinical practice guidelines and systematic reviews are the
short roads to evidence-based protocols, as portrayed in Figure 2-1. If starting the development of a care protocol by retrieving individual research
articles is like baking a cake from scratch, and systematic reviews are like
using a cake mix, then starting with an evidence-based clinical practice
Going Forward
25
E-B Protocol
Develop
Develop
Adapt
E-B Guideline
Summarize
Retrieve
Original
Studies (1–?)
Systematic
Review
Start
Figure 2-1
Roads to E-B Protocols
guideline is like buying a cake at the bakery and adding a personalized topping or presentation.
Going Forward
In Chapter 3, you will begin to learn how to read research reports of individual studies. Then in Chapters 4 through 8, you will be guided through
reading of exemplary articles reporting five different types of research (one
qualitative study and four types of quantitative studies). After that, you
will read a systematic review and learn how one type of systematic review
is conducted, and then you will read an evidence-based clinical practice
guideline and learn how they are produced.
Note that this order is the reverse of the order in which care design project teams search for research evidence—they first look for evidence-based
guidelines and systematic reviews. If they exist and are well done, the team
can build on them rather than reinventing the wheel. The order of presentation in this book is reversed because proceeding from original studies to
systematic reviews to evidence-based clinical practice guidelines is a more
natural learning order.
26 CHAPTER 2 Research Evidence
References
Burns, N., & Grove, S. K. (2009). Practice of nursing research: Conduct, critique,
and utilization (6th ed.). St. Louis, MO: Elsevier Saunders.
Kim, H. S. (2000). The nature of theoretical thinking in nursing (2nd ed.). New
York, NY: Springer.
Obeidat, H., Kahalaf, I., Callister, L. C., & Froelicher, E. S. (2009). Use of facilitated tucking for nonpharmacological pain management in preterm infants: A
systematic review. Journal of Perinatal and Neonatal Nursing, 23(4), 372–377.
Weathers, B., Barg, F. K., Bowman, M., Briggs, V., Delmoor, E., Kumanyika, S., . . .
Halbert, C. H. (2011). Using a mixed-methods approach to identify health concerns in an African American community. American Journal of Public Health,
101(11), 2087–2092.
C H A P T E R
T H R E E
Reading Research Articles
T
o get the most out of a research article one has to be intellectually
engaged. One way to be intellectually engaged is to annotate or
mark your copy of the article: underline, circle phrases, highlight,
or jot comments in the margin—whatever helps you keep track of important information and connect the various parts of the study. When reading
a pdf file in Acrobat Reader, you can click “Comment” on the tool bar and
use the Comment and Annotation tools. Also, some people prefer to make
notes in a file on their computer—fine, whatever works for you.
I tend to annotate right on my paper copy of articles. I write something
like “n = 54” in the margin so I can quickly locate the sample size, underline important definitions, outcomes or findings, circle abbreviations that
will be used in the report and the parts of a table that are most important
or unexpected. I put question marks where a statement does not fit with
what was said earlier or does not make sense. When reading a pdf file electronically, I use the sticky note feature and/or the highlight and underline
tools. Of course, it is possible to over-annotate and in so doing produce
clutter. However, if you annotate selectively, you will be able to find important information easily when you return to the article at a later time.
In this chapter, I make suggestions about how to read reports of individual studies. At this point in your learning, the goals in reading a research
article about a study are to identify (1) why the study was done, (2) how it
was conducted, and (3) what was found. After you are have mastered extracting these aspects of a study, you will add the goals of (4) determining
whether the study was soundly conducted, and (5) relevant to the care of
patients to whom your agency or unit provides care.
27
28 CHAPTER 3 Reading Research Articles
GOALS IN READING A RESEARCH ARTICLE
1. Determine the purpose of the study
2. Understand how the study was done
3. Understand what was found
4. Appraise the credibility of the findings
5. Determine if the findings are relevant to the care of your patients
The emphasis in this chapter and in all of Part I of the book is on understanding the why, how, and what of a study (goals 1–3). As you read you
may wonder whether the data really showed what the researcher claimed it
did or think about the patients to whom the results would and would not
apply. That’s fine—just put your thinking about credibility and applicability (goals 4 and 5) on the back burner for now and we’ll take them up in
Part II when we revisit the studies with the aim of appraising them. Also,
in reading this chapter, you may see a few terms that are unfamiliar to you.
For now, just look them up in the glossary to get a sense of what they mean;
they are explained in full as you proceed through the first part of the text.
Starting Point
Is this a report of an original research study? This seems like it should be
an easy question to answer, but at times it is not. Some articles read like
research articles, but they are in fact other kinds of reports. An article with
tables and percentages may lead you to think you are reading a research
study, but the article may just be providing numerical data to describe a
clinical program. Such data is anecdotal and naturally occurring with no
control over its quality or the conditions under which it was collected. As
you will learn, it takes more than numerical data to call an evaluation report research.
Most often, the author of a research report, which is often referred to
as a research article, will refer to “the study” early in the report, but sometimes you have to read quite far into an article to determine that it has the
essential elements of a study. The essential elements of a research study
include the following:
■■ A specified research question, hypothesis, or purpose
■■ Specified, systematic methods of data collection
■■ Data analysis and results
Format of Study Reports
29
■■ Findings (interpreted results)
■■ Conclusions
If all these elements are present, then the likelihood that you are reading a
research study report is very high. Remember, however, that there are many
types of research methods and designs, and the essential elements of each
type look quite different. Most quantitative studies address specific research
questions or hypotheses, whereas qualitative studies may have a broad aim
or purpose. Quantitative studies report results with tables, graphs, and statistics, whereas the data of qualitative studies consist of extended quotes
and narrative descriptions. Qualitative studies often have small sample
sizes (e.g., N = 6); most quantitative nursing studies use moderate sample
sizes (e.g., N = 40–200). In short, research articles are diverse but should
include at a minimum a clear purpose statement, a description of methods
used to collect and analyze data, results and/or findings, and conclusions.
Format of Study Reports
Research reports of original studies are organized in a very logical way, and
the formats used are similar from one journal to another. This standardization of format helps you as a reader because you will learn where to expect,
and later locate, various kinds of information about the study. The following is a brief orientation to the format of research reports.
Title and Abstract
The title tells the reader what the study examined and often the patient
group of interest. These are your first clues as to whether the report is likely
to be of interest to you. However, titles can be misleading because a phrase
or term used in the title may be different from the one used in your practice
setting.
Abstracts almost always precede the main body of the article. An abstract provides a brief summary of the study—typically 300 words or less.
The section headings used in the abstract are similar but not identical to
those used in the full report. The abstract distills the main points of the
study, and after reading it you should know whether the study is of interest.
Let us assume that you have decided to read the whole study. Rather
than read straight through the first time, you might want to read the introduction and then jump to the discussion section. The discussion summarizes the important findings and places them in the context of findings
30 CHAPTER 3 Reading Research Articles
from earlier studies. Having read the introduction and the discussion, you
should have a sense for the context of the study—and be ready to read the
article from start to finish in its entirety.
Introduction
In the introduction of a research study report, the researcher presents a view
of the current state of knowledge regarding the issue or problem being investigated; this includes what is known and what are the gaps in knowledge.
Study purposes are often set forth in the introduction section. Mark them in
some way because they are important and you will want to refer to them.
Theoretical Framework In the introduction section of a research study
report, a theory that has been used to organize thinking about the issue
and that serves as a conceptual context for the study may be specified.
A theory is made up of assumptions, concepts, definitions, and/or propositions that provide a cohesive, although often tentative, explanation of
how a phenomenon in the physical, psychological, or social world works.
Propositions are suggested linkages among the concepts of the theory that
have not yet been proven.
THEORY
Concept
Definition
Concept
Definition
Concept
Definition
Concept
Definition
Propositions
Assumptions
To make the preceding paragraph a bit more rooted in the real world,
consider the following illustration. The theory of community empowerment
was developed to provide direction for improving health in communities
(Persily & Hildebrandt, 2008). Consider two propositions from this theory:
1. Involving lay workers in a community health promotion program
extends access to health promotion opportunities.
2. Access to health promotion information leads to adoption of healthy
behaviors.
Format of Study Reports
31
Lay workers, access, health promotion opportunities, and adoption of
healthy behaviors are concepts of the theory.
A researcher conducting a study about improving the health of elders
living in their own homes might use the theory of community empowerment as a source of ideas for the study. By translating the two theoretical
propositions into more concrete terms, the following two study hypotheses
are formed:
1. Trained volunteers who collect healthy living questions from elders
once a month at the weekly senior lunch and deliver answers the following week will increase access to health promotion information.
2. Health promotion information of personal interest will produce
changes in health-related behaviors.
The questions submitted are given to a nurse practitioner who answers
them via video recording shown at the next week’s lunch. Adoption of new
health behavior outcomes will then be measured at 3-month intervals for
1 year. Thus, the theory has served the research by bringing into a trial
program a component that otherwise might not have been included and
by providing a knowledge context for the findings. At the same time, the
study acts as a test of the theory because the study has translated the abstract concepts of the theory into concrete realities that can be examined.
If the study hypotheses are supported, the theory is supported because the
hypotheses represent the theory.
THEORETICAL
PROPOSITIONS
Lay workers
Health promotion
opportunity
Adoption of
healthy behavior
RESEARCH
HYPOTHESES
Trained
volunteers
at lunch
Opportunity to ask
healthy living
questions
Performance of
healthy behaviors
Not all study reports stipulate a theoretical framework; many researchers, particularly those testing physiological hypotheses, do not locate their
studies within a theoretical framework; instead, they locate their study in
a review of what is known from previously conducted research and what
32 CHAPTER 3 Reading Research Articles
is still not known with certainty. Clearly, much more could be said about
the relationship between theory and research; however, doing so would be
a diversion from the topic of this chapter, which is how research articles
are formatted.
Study Purposes
A reason for doing a study may be stated as a purpose statement, aims,
objectives, research questions, or as hypotheses that will be tested by the
study. Purpose words and phrases you will encounter in nursing study reports include:
■■ Acquire insights about . . .
■■ Understand
■■ Explore
■■ Examine
■■ Describe
■■ Compare
■■ Examine the relationship/association between . . .
■■ Predict
■■ Test the hypothesis that . . .
In the early stages of studying an issue, research is directed at acquiring
understanding of the various aspects of the issue—the problems people
with the condition are experiencing, social or psychological forces at work,
and what the condition or experience means to individuals. Generally, these
early studies use qualitative research methods. The following are study purposes from qualitative studies:
■■ “The research question in this qualitative study was: How do women
experience miscarriage, conception, and the early pregnancy waiting
period, and what types of coping strategies do they use during these
periods” (Ockhuijsen, van den Hoogen, Boivins, Macklon, & de Boes,
2014, p. 267)?
■■ “The objective of this study was to examine how skilled nursing facility nurses transition the care of individuals admitted from hospitals,
the barriers they experience, and the outcomes associated with variation in the quality of transitions” (King et al., 2013, p. 1095).
Note how both purposes set forth issues that will be examined, but they
do not get highly specific about what they are looking for because they
Format of Study Reports
33
want the study participants to highlight the important aspects of their situation and experiences.
After the condition or situation is well understood at the experiential or
social process level, subsequent studies may determine the frequency with
which it occurs in different populations or measure the degree to which
aspects of the condition or situation are present. Later, when several studies have been done and the situation is fairly well mapped, researchers will
propose and quantitatively test associations between aspects of the situation or effectiveness of interventions directed at it.
The following examples illustrate several ways of stating quantitative
research purposes:
■■ “The specific research question was ‘What patient characteristics, clin-
ical conditions, nursing unit characteristics, medical pharmacy, and
nursing interventions are associated with falls during hospitalization
of older adults’” (Titler, Shever, Kanak, Picone, & Qin, 2011, p. 129)?
■■ “The purpose of this study was to compare the time needed to reach
a specified temperature and the efficiency of two warming methods—
warm cotton blankets and a radiant warmer—for hypothermia patients
in a postanesthesia care unit after spinal surgery” (Yang et al., 2012, p. 2).
■■ “The hypothesis is that the outcomes from nurse-led clinics will not
be inferior to those obtained by the rheumatologist-led clinics, but
at a lower cost and greater patient satisfaction” (Ndosi et al., 2011,
p. 996).
■■ In a study of the association between depression and health-risk behaviors in high school students, two competing explanations became
the hypotheses that were tested in the study: (1) Early depressive
symptoms predict increases in risk behaviors over time; and (2) Early
participation in health-risk behaviors predicts increases in depressive
symptoms over time (Hooshmand, Willoughby, & Good, 2012).
Methods
In the methods section, the author describes how the study was conducted,
including information about the following:
1. The overall arrangements and logistics of the study
2. The setting or settings in which the study was conducted
3. The institutional review board (IRB) that gave ethical approval
to the study
34 CHAPTER 3 Reading Research Articles
4. How the sample was obtained
5. How data were collected
6. Any measurement instruments that were used (i.e., scales, questionnaires, physiologic measurements)
7. How the data were analyzed
Each of these steps will be discussed in detail specific to different research designs later. Briefly here, I will just say that the information about
the sample should be sufficient to inform the reader about the likelihood
that the sample is a good representation of the target population or provide
enough profile information about the sample to let readers decide to whom
the results would likely apply.
The information about how the data were obtained includes a statement
about the organization that gave ethical approval to the study, procedures
used to collect data, and descriptions of the measurement instruments used.
For now, you should come away from reading the methods section of the
reports with an understanding of the characteristics of the people who
were included in the study, the sequence of steps in the study, and the data
collected.
Results/Findings
In the results/findings section, a profile of the sample and the results of the
data analysis are reported. The profile of the sample lists characteristics
of the sample as its composition determines the population to whom the
results can be generalized. Results are the outcomes of the analyses. In
quantitative studies, results are shown in tables, graphs, percentages, frequencies, and statistics. There should be results related to each of the research questions, hypotheses, or aims. To illustrate, consider the following
hypothetical statement that might be found in the results section of a quantitative study: “The t-test comparing the functional status scores of those
in intervention group A and intervention group B indicated a significant
difference (mean A = 8.4; mean B = 6.1; p = .038).” This is a result statement; it reports the results of the statistical analysis.
The interpretation of a result is called a finding. A finding for the result
statement just given would be stated something like, “The group who received nursing intervention A had a significantly higher functional level
than did the group who received intervention B.” Note how the findings
statement interprets the statistical result but does not claim anything more
Format of Study Reports
35
than the statistical result indicated. Findings statements are usually found
in the conclusions or discussion section of quantitative study reports.
To illustrate further, consider the results and findings of a hypothetical
quantitative study comparing the effects of a new method for osteoporosis
prevention education to standard education among high school students.
A t-test was used to compare the scores of the two groups on an osteoporosis prevention questionnaire; the result of that test was t = 1.99, p = .025.
This result indicates that the statistical calculation comparing the scores of
the two groups resulted in a t-value of 1.99, which is statistically significant
at the p = .025 level. The finding was this: The new educational method on
average produced higher osteoporosis knowledge levels than standard education did, and there is a very low chance that this claim would not hold
up in other similar situations. The concept of p-values will be explained in
detail in Chapters 6 and 7.
Results → Findings → Conclusions
In qualitative research reports, data (observations, quotes) and findings
(e.g., themes) are often intermingled. Generally, qualitative study reports
do not have a results section; rather, they have a findings section in which
themes, narrative descriptions, or theoretical statements are presented
along with examples of data that led to them. Chapter 4 provides more
explanation of the analytical processes used by qualitative researchers.
When you first begin reading research articles, you may have a tendency
to skip over the tables and figures. However, you really should pay attention to them because that is where you will find the real meat of the results.
Most authors highlight or summarize in the text what is in the tables, but
others assume the reader will get the information from the tables, thus
they do not restate that information. In examining tables and figures, it is
important to carefully read their titles so you know exactly what you are
looking at. Also, within tables, the column and row labels are critical to
understanding the data provided. Reading tables is a bit like dancing with
a new partner—with a bit of practice, you will quickly get good at it.
Discussion and Conclusions
In the discussion section, the researcher ties together several aspects of
the study and offers possible applications of the findings. The researcher
36 CHAPTER 3 Reading Research Articles
will usually open this section by stating the most important findings and
placing them in the context of what other studies on the topic or question have found. In discussing the findings, many researchers describe
what they think are the clinical implications of the findings. Here, they
are allowed some latitude in saying what they think the findings mean.
In the osteoporosis education for high school students example just
given, the researcher might say, “The findings indicate that a short educational session is effective in increasing high school students’ knowledge regarding osteoporosis prevention.” This conclusion statement is
close to the findings. On the other hand, if the researcher said, “Short
educational sessions are an effective way of increasing osteoporosis prevention behaviors in high school students,” the findings statement would
be beyond the results. Because the study only measured the outcome of
knowledge, not behaviors, the author is adding an assumption to the
results, namely, that knowledge produces behavior change—and that is
a big assumption.
Authors are also expected to consider alternative explanations for their
findings. This would include noting how research methods may have influenced the results, such as “The sample size may have been too small to
detect a difference in the treatment groups” or...
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