Fluent Essays

Quantitative Critical Appraisal Guide 1. The Research Question/Purpose of Study a. Is the research question/purpose of study stated clearly? b. Does the research question express a relationship between two or more variables? c. How has the significance of the research question been identified? 2. The Hypothesis a. Is there a hypothesis and if so, is it concisely stated in a declarative form? b. Is the hypothesis stated in such a way that it is testable? 3. Review of the Literature a. Are all of the relevant concepts and variables included in the review? b. Does the critique of each reviewed study include strengths, weaknesses, or limitations of the design, conflicts, and gaps in information related to the area of interest? c. Is the literature review presented in an organized format that flows logically (e.g., chronologically, clustered by concept or variables), enhancing the readers ability to evaluate the need for the research study or evidence-based practice project? 4. Theoretical Framework a. Is the framework for research clearly identified? b. Is the framework consistent with a nursing perspective? c. Is the framework appropriate to guide research on the subject of interest? 5. Research Design a. Does the design used seem to flow from the proposed research question, theoretical framework, literature review, and hypothesis? b. What level of evidence is the research design? 6. Type of Design-use the questions below that are applicable to your study a. What design is used in the study, and is it appropriate? b. What are the most common threats to internal and external validity of the findings of this design? c. Are the findings generalizable to the larger population of interest? 7. Sampling a. How was the sample selected? Is the method of sample selection appropriate? b. What kind of bias, if any, is introduced by this sampling method? c. Are their indications that rights of subjects have been ensured? 8. Data-Collection Methods a. Are all of the data-collection instruments clearly identified and described? b. Is the method used appropriate to the problem being studied? c. Were all data collectors adequately trained and supervised? 9. Descriptive and Inferential Statistics a. Are their appropriate statistics for each major variable, for example, demographic variables, and any other relevant data? b. If tables and graphs are used, do they agree with the text and extend it, or do they merely repeat it? c. Are the results understandable? 10. Research Findings a. Are the results interpreted considering the hypotheses and theoretical framework and all the other steps that preceded the results? b. How does the investigator attempt to identify the studys weaknesses, that is, threats to internal and external validity, and strengths, as well as suggest possible solutions for the research area? c. Does the researcher discuss the studys clinical relevance? Critical Appraisal Assignment Grading Criteria/Rubric Name: Criteria Not present or included Not Acceptable Needs improvement Satisfactory Excellent Points Critique of areas/ coverage relevant to question #1 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage Critique of areas/ coverage relevant to question #2 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage Critique of areas/ coverage relevant to question #3 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage Critique of areas/ coverage relevant to question #4 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage Critique of areas/ coverage relevant to question #5 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage Critique of areas/ coverage relevant to question #6 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage Critique of areas/ coverage relevant to question #7 0 Not present or included 2 Inadequate Many important things missing 4 Adequate Some gaps 6 Good All areas 8 Excellent coverage You will select a quantitative nursing research article from a peer-reviewed nursing journal within the last 5 years.The study’s main components should be summarized. A critical appraisal also contains comments about the positive and negative aspects of the study and the report of the study. The critical appraisal should be written as concisely as possible, typewritten, double-spaced, and no more than six pages excluding title and reference pages. The paper should address all parts of the report equally, with strengths and weaknesses outlined where appropriate. Where possible, include suggestions for improvement. Papers must follow correct APA format for in-text citations and references and should include an introduction and a conclusion. The critical appraisal must be submitted electronically by the assigned due date and time. O R I G I N A L A R T I C L E Delirium in ICU patients following cardiac surgery: An observational study Silvio Simeone PhD, RN, MSN, Lecturer of Nursing1 | Gianluca Pucciarelli PhD, RN, MSN, Post Doctoral Research Fellow2 | Marco Perrone RN, Ward Manager1 | Rea Teresa PhD, RN, MSN, Lecturer of Nursing3 | Gianpaolo Gargiulo RN, MSN, Lecturer of Nursing4 | Assunta Guillari RN, MSN, PhD Student, Lecturer of Nursing3 | Gaetano Castellano MD, Anesthetist5 | Luigi Di Tommaso MD, Lecturer of Medical Science6 | Massimo Niola MD, Professor7 | Gabriele Iannelli MD, Professor8 1Department of Cardiology, Cardiac Surgery and Emergency, University of Naples Federico II, Naples, Italy 2Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy 3Department of Hygiene, University of Naples Federico II, Naples, Italy 4Pediatric Cardiac Surgery, University of Naples Federico II, Naples, Italy 5Department of Clinical Neuroscience, Anaesthesiology, University of Naples Federico II, Naples, Italy 6Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy 7Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy 8Department of Cardiology, Cardiac Surgery and Cardiovascular Emergency, University of Naples Federico II, Naples, Italy Correspondence Gianluca Pucciarelli, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy. Email: [email protected] Aims and objectives: To observe the clinical and structural factors that can be asso- ciated with the post-operative onset of delirium in patients who have undergone heart surgery. Background: Several risk factors could contribute to the development of delirium, such as the use of some sedative drugs and a patient’s history with certain types of acute chronic disease. However, in the literature, there is little knowledge about the association between delirium in patients who have undergone cardiac surgical inter- vention and their clinical and environmental predictors. Design: We used an observational design. Methods: We enrolled 89 hospitalised patients in the ICU. Patients were first eval- uated using the Richmond Agitation Sedation Scale and subsequently using the Con- fusion Assessment Method for the ICU. A linear model of regression was used to identify the predictors of delirium in patients. Results: The patients had an average age of 89 years (SD = 6.9), were predomi- nantly male (84.3\%) and were mostly married (79.8\%). The majority of patients had been subjected to bypass (80.9\%), while 19.1\% had undergone the intervention of endoprosthesis. The logistic regression model showed that patient age, the duration of mechanically assisted ventilation, continuous exposure to artificial light and the presence of sleep disorders were predictors of the onset of delirium. Conclusion: This study further confirms that clinical aspects such as insomnia and one’s circadian rhythm as well as structural elements such as exposure to artificial light are variables that should be monitored in order to prevent and treat the onset of severe post-operative delirium. Relevance to clinical practice: Identifying the possible factors that predispose a patient to the onset of delirium during intensive therapy following cardiac surgery, it is fundamental to implement interventions to prevent this syndrome. K E Y W O R D S cardiosurgery, delirium, environment, ICU, patient, predictors Accepted: 18 February 2018 DOI: 10.1111/jocn.14324 1994 | © 2018 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:1994–2002. http://orcid.org/0000-0001-9266-0185 http://orcid.org/0000-0001-9266-0185 http://orcid.org/0000-0001-9266-0185 http://orcid.org/0000-0001-6915-6802 http://orcid.org/0000-0001-6915-6802 http://orcid.org/0000-0001-6915-6802 http://wileyonlinelibrary.com/journal/JOCN http://crossmark.crossref.org/dialog/?doi=10.1111\%2Fjocn.14324&domain=pdf&date_stamp=2018-04-25 1 | INTRODUCTION Delirium is an acute cognitive disorder that manifests itself via fluc- tuations in cognition and disorganised thoughts (Shadvar, Baastani, Mahmoodpoor, & Bilehjani, 2013). In the literature, several terms have been used to describe this syndrome, and it is often incorrectly defined as intensive therapy syndrome (Pun & Ely, 2007), psychosis resulting from intensive therapy (Justic, 2000), an acute state of con- fusion or confusion with an encephalopathy or with neurological def- icits (McGuire, Basten, Ryan, & Gallagher, 2000). Despite being a common disorder during intensive therapies (Koster, Hensens, Schuurmans, & van der Palen, 2011; Salluh et al., 2010), the literature showed conflicting data regarding its prevalence rate (Barr et al., 2013; Cavallazzi, Saad, & Marik, 2012; Salluh et al., 2010) with values between 16\%–80\% (Barr et al., 2013). This differ- ence is mainly due to the different investigated populations and to the different rating scales that are used (Allen & Alexander, 2012). While this condition remains significantly underdiagnosed (Spronk, Riekerk, Hofhuis, & Rommes, 2009), it is known that the prevalence of delirium during the administration of intensive therapies following cardiac surgery ranges between 23\%–52\% (Brown, 2014; Koster et al., 2011), while the incidence between 8\%–52\% (Brown, 2014; Rudolph et al., 2010; Schoen et al., 2011). Associated with disorders of psychomotor activity, delirium can be classified into several types: (i) hyperactive, (ii) hypoactive or (iii) mixed (Heriot et al., 2017). Symptoms are used to differentiate between the several types of delirium; for example, agitation, rest- lessness and hallucinations can be present in patients with severe hyperactive delirium (Barr et al., 2013). However, in cases of hypoactive delirium, the patient often shows an apathetic attitude that is accompanied by lethargy and drowsiness (Allen & Alexan- der, 2012), while subjects who demonstrate both attitudes fall into the category of displaying mixed delirium (Allen & Alexander, 2012). These events, especially in the case of hyperactive delirium, are strongly associated with various complications, such as the possibility of a patient self-removing his/her gold-tracheal probe or the risk of accidentally removed drains, central venous catheters or bladder catheters (Arumugam et al., 2017; Crimi & Bigatello, 2012). More- over, hyperactive delirium can create nonsynchronicity between the patient and the mechanically assisted ventilation (VAM) system, thus contributing to a consequent negative prognosis (Bakker, Osse, Tulen, Kappetein, & Bogers, 2012; Chaput & Bryson, 2012). In the specific case of cardiac surgery, delirium can be related to such post- operative complications as respiratory insufficiency (Ely et al., 2004), sternal problems (Bucerius et al., 2004) and the possibility that the patient will require further surgery (Horacek, Krnacova, Prasko, & Latalova, 2016). Complications could have an important impact on the patient’s quality of life (Basinski, Alfano, Katon, Syrjala, & Fann, 2010). In addition, it could increase the patient’s hospitalisation (She- habi et al., 2010), healthcare costs (Leslie & Inouye, 2011) and mor- tality (Brummel & Girard, 2013; Kiely et al., 2009). 2 | BACKGROUND The early detection, treatment and prevention of delirium are impor- tant elements of rapid post-operative recovery (Lundstrom et al., 2005). In a recent literature review (Kalabalik, Brunetti, & El-Srougy, 2014), the authors described several risk factors that may contribute to the development of delirium, such as the use of some sedative drugs and a patient’s past history with certain types of acute chronic dis- eases. Dasgupta and Dumbrell (2006) further identified the following circumstances to be risk factors: older age, elevated serum levels of cortisol, poor renal function, a history of diabetes, presurgical demen- tia, a long-duration intervention and complications during surgery. Moreover, Bakker et al. (2012) described the following as predisposing factors of delirium: advanced patient age, a history of diabetes and the presence of pre-existing cerebrovascular disease. They also argued that the duration of mechanical ventilation was a possible risk factor. Other authors have also observed a significant association between the development of delirium and the duration of heart surgery (Koster, Hensens, Schuurmans, & van der Palen, 2013), the administration of an improper sedative and/or the incorrect management of arterial blood pressure (Brown, 2014). Because of the significantly associated stress and the complexity of the operational procedure (Ogawa et al., 2017), patients undergoing cardiac surgery may be at greater risk of developing delirium during their post-operative care. However, it is essential to observe that certain risk factors are not modifiable (e.g., such predisposing factors as the past occurrence of cognitive deficits), while others are modifiable (e.g., immobility). This represents an opportunity for intervention. In fact, while non- modifiable predisposing factors can be used for risk assessment prior to surgery, causative factors (i.e., those that are modifiable) may be What is already known about the topic? • Delirium is a common disorder among patients in ICU. • Delirium could increase hospitalisation, healthcare cost and mortality. • Older age, a history of diabetes, presurgical dementia, a long-duration intervention and complications during sur- gery could be risk factors for delirium. What does this paper contribute to the wider global clinical community? • This study further confirms that clinical aspects such as insomnia and one’s circadian rhythm as well as structural elements such as exposure to artificial light are variables that should be monitored in order to prevent and treat the onset of severe post-operative delirium. • Identifying clinical and environmental predictors, it is fun- damental to implement specific intervention to prevent delirium disorder. SIMEONE ET AL. | 1995 taken into consideration to improve clinical care and to avoid the onset of delirium. The recognition of risk factors, then, is a crucial key to prevention and early identification of delirium. The identifica- tion of risk factors would allow for the implementation of health interventions that can improve the post-operative care of a patient subjected to heart surgery (Jones & Pisani, 2012; Pun & Boehm, 2011). For these reasons, several studies (Bakker et al., 2012; Brown, 2014; Dasgupta & Dumbrell, 2006; Kalabalik et al., 2014; Koster et al., 2013) have identified various predictors that may affect the onset of delirium during post-operative care. Although these studies have identified risk factors and strategies for improving the management of delirium in general ICU population, specific studies are needed to translate these findings into improved management of delirium in the cardiac surgical ICU. In the literature, there is little knowledge about the association between delirium in patients who have undergone cardiac surgical intervention and their clinical and environmental predictors. Some studies (Brown, 2014; Hollinger, Siegemund, Goettel, & Steiner, 2015; Kim, Kim, Oh, Park, & Park, 2017; Kumar, Jayant, Arya, Magoon, & Sharma, 2017; Zhang et al., 2015), conducted on cardiac post-operative population, have identi- fied several predictors of delirium, such as atrial fibrillation, cognitive impairment, prolonged surgery duration, post-operative poor quality of sleep and electrolyte disturbance were associated with delirium. However, the same authors suggested future research to examine delirium among this population. Future studies should be focused to investigate the association between patient’s comorbidities, environ- mental factors, shortening mechanical ventilation time and delirium. As suggested by literature (Kukull & Ganguli, 2012), it is not possible to generalise the prior studies’ results when the subpopulation changes. Being both general and cardiac ICU population similar but different at the same time, further studies are needed to identify delirium predictors in this specific population. The identification of factors that are not linked solely to the patient but also to the struc- ture of the operating unit is essential in order to prevent the occur- rence of this event in patients subjected to cardiac surgery. For this reason, the aim of this study was to observe the clinical and structural factors that can be associated with the post-operative onset of delirium in cardiac surgery patients. 3 | METHODS 3.1 | Ethics committee Members of the ethics committee of the Federico II Hospital Univer- sity from which participating patients were recruited approved this study according to protocol no. 139/17. The study was also approved by the director of the operating unit where patients were hospitalised. 3.2 | Design, participants and setting We used a correlational design. In this study, we enrolled 89 hospi- talised patients in the ICU Post-Operative Cardiac Surgery unit of the Federico II Hospital University (Naples). The operating unit was composed of 12 adult stations, including four stations located near windows that allowed natural lighting to flow into the patient’s unit. The other eight stations, however, did not allow for the inflow of natural light. In these rooms, artificial light was present approxi- mately 18–20 of 24 hr, while for the remaining 4–6 hr, the artificial light inside the room was dimmed. Each station was identical, as was the distance between them and the nurse station. To be enrolled in this study, the patients had to meet the follow- ing inclusion criteria: (i) they were ≥18 years old; (ii) have undergone a heart surgery; (iii) have stayed in the ICU Post-Operative Cardiac Surgery unit for more than 24 hr; and (iv) correctly speak and under- stand the Italian language. The following exclusion criteria were also considered: patients were not included in this study if they (i) had a history of psychological pathology and/or psychogenic drug use; (ii) had visual disturbances; (iii) had hearing disorders; or (iv) had a Rich- mond Agitation Sedation Scale (RASS) score of equal to or less than four. Following heart surgery, all patients were evaluated by the trained nurses. Their consciousness state was daily assessed with simple and standardised questions that were drawn up in coopera- tion with the medical staff. Patients who showed signs of disorgan- ised thoughts were first evaluated using the RASS and subsequently using the Confusion Assessment Method for the ICU (CAM-ICU). Patients who had RASS scores between �1 and �3 were cate- gorised into hypoactive delirium. Patients with floating RASS scores between +4 and �3 in conjunction with a positive screening for delirium were defined as having mixed or alternating delirium. Patients with a RASS score of �5 (unresponsive to physical and ver- bal stimulus) and �4 (responsive only to physical stimulus) are classi- fied ineligible. If patient’s score ranged between �3 and +4, patient was evaluated with CAM-ICU assessment. The criteria of CAM-ICU are as follows: (i) an acute change in any cognitive status; (ii) inatten- tion; (iii) disorganised thoughts; and (iv) an altered level of conscious- ness. Delirium was considered present when features 1 and 2 were both present, while at the same time either feature 3 or 4 were dis- played. Patients with CAM-ICU positive (+) and RASS score positive (+) were categorised into hyperactive delirium, while patients with CAM-ICU positive (+) and RASS score negative (�) were categorised into hypoactive delirium. 3.3 | Instruments In this study, we used the Confusion Assessment Method for the ICU (Ely et al., 2001) and the RASS (Sessler et al., 2002). The CAM-ICU is a version of the CAM tool (Inouye et al., 1990), which was developed on the basis of the DSM-IIIR. It is a tool that facilitates the rapid exchange of four key criteria. An algorithm allows for the rapid detection of delirium. These key criteria are as follows: (i) an acute change in any cognitive status; (ii) inattention; (iii) disorganised thoughts; and (iv) an altered level of consciousness (detected via RASS). The CAM-ICU is the most frequently utilised screening tool that aims to detect delirium in subjects who are both 1996 | SIMEONE ET AL. mechanically and nonmechanically ventilated (Guenther et al., 2010). Originally developed to recognise delirium in mechanically ventilated patients, the CAM-ICU is limited to the context of intensive therapy and utilises nonverbal means of identification, such as the recogni- tion of figures, simple logical questions that require a dichotomic answer (yes or not) and simple controls that facilitate the following of a very precise algorithm. The CAM-ICU has demonstrated high sensitivity (93\%) and specificity (89\%) during the diagnosis of delir- ium. This instrument is also recommended within the guidelines (Wei, Fearing, Sternberg, & Inouye, 2008) and by the National Insti- tute for Health and Care Excellence (NICE, 2010) as the diagnostic tool of choice for the detection of delirium during intensive therapy. Valid and reliable tool (Boot, 2012), the scale has also been validated and translated into the Italian language (Gaspardo et al., 2014). After a minimum of training, the CAM-ICU could be used by nurses in the Intensive Care Post-Operative Cardiac Surgery (Inouye et al., 1990). The RASS (RASS; Ely et al., 2003; Sessler et al., 2002) is used by physicians who seek to assess the level of consciousness/sedation and agitation of patients in ICU. The scale is based on an evaluation of verbal and physical stimuli and thus assesses 10 elements of compo- sure, each of which is given a specific attribute score. Before one car- ries out an assessment using the CAM-ICU, it is essential that one assesses the patient’s level of consciousness via the RASS. RASS score ranges between �5 (unarousable) and + 4 (combative). Patients with positive RASS score (from +1 to +4) were considered to have hyperac- tive delirium, while patients with a RASS score ranged between �3 and �1 were considered as having hypoactive delirium. Only patients with a RASS score of ≥�3 can be evaluated using the CAM-ICU, as they have been assessed to show signs of responsiveness. Patients with a RASS score of �5 (unresponsive to physical and verbal stimu- lus) and �4 (responsive only to physical stimulus) are considerate comatose, and for this reason, as suggested by the authors, these patients were classified ineligible for delirium evaluation. This allows to evaluate their clarity of thought and, possibly, the presence of delir- ium. This detail could explain some of the variations in terms of the sensitivity of the instrument (Neto et al., 2012). 3.4 | Data analysis The data were analysed using procedures of descriptive and inferen- tial statistics. Descriptive statistics were used to calculate the means, standard deviations, frequencies and percentages of patient sociode- mographic characteristics as well as the clinical features of the patients. Demographic and clinical characteristics of the patients that involved categorical variables were summarised using counts and percentages (e.g., gender, type of intervention, blood pressure, loca- tion with regard to sunlight, comorbidities and sleep disorder), while for continuous variables mean and standard deviation (e.g., age, VAM duration and length of ICU stay) were used to describe data distribution. An independent sample t test was used to analyse the significant differences between delirium/no delirium group and con- tinuous variables (such as age, the duration of VAM and the length of hospitalisation). Categorical variables were compared using chi- square test. The significant continuous and categorical variables were used in the regression model. Delirium was used as dependent vari- able, while age, duration of VAM, length of ICU stay, blood pressure (BP), location with regard to sunlight and sleep disorder were used as independent variables. The independent variables were adjusted according to the logistic regression model. A logistic model of regres- sion was used to identify the predictors of delirium in patients. Results from logistic regression model are reported in adjusted rela- tive risk ratios (RRR), 95\% confidence intervals and p-values. 4 | RESULTS 4.1 | Sociodemographic characteristics and clinical features of patients In this study, 89 patients were enrolled. Their sociodemographic and clinical characteristics are reported in Table 1. The patients had an average age of 89 years (SD = 6.9), were predominantly male (84.3\%) and were mostly married (79.8\%). The majority of patients had been subjected to bypass (80.9\%), while 19.1\% had undergone the intervention of endoprosthesis. Moreover, patients exhibited comorbidities such as diabetes (39.3\%), arrhythmia (37.1\%) and renal disease (6.7\%). Additionally, more than half of the recruited sample also experienced sleep disorders (62.9\%). On average, patients expe- rienced 5.5 days (SD = 2.0) of hospitalisation and were subjected to VAM for 5.4 hr (SD = 1.6). TABLE 1 Sociodemographic and clinical characteristics of patients (n = 89) Characteristics N (\%) \% Age (mean, SD) 89 (SD = 6.9) Gender Male 75 84.3 Female 14 15.7 Marital status Married 71 79.8 Widowed 18 20.2 Type of intervention Bypass 72 80.9 Endoprosthesis 17 19.1 Comorbidities Diabetes 35 39.3 Arrhythmia 33 37.1 Renal insufficiency 6 6.7 Sleep disorder 56 62.9 VAM duration, in hr (mean, SD) 5.4 (SD = 1.6) Length of ICU stay, in days (mean, SD) 5.5 (SD = 2.0) Delirium 65 73.0 Hypoactive delirium 17 26.2 Hyperactive delirium 48 73.8 SIMEONE ET AL. | 1997 4.2 | Differences between patients with and patients without delirium In Table 2, it is possible to observe the differences in age, duration of VAM and length of hospitalisation between patients who mani- fested delirium and those who did not. For instance, patients who exhibited delirium were significantly older than those who did not (M = 68.1 years old vs. M = 62.3 years old; p < .001). We also observed that the duration of VAM (M = 6.0 hr vs. M = 4.9 hr; p = .003) and the length of hospitalisation (M = 6.1 days vs. M = 4.9 days; p = .005) were significantly higher in patients who manifested delirium than in those who did not present with such a condition. As described in Table 3, no significant differences were observed regard to gender between patient with and without delirium (86.1\% vs. 83.0\%, p = .774). More Patients with delirium showed higher blood pressure than 140/90 pressure compared with patients with- out delirium (66.7\% vs. 32.1\%, p = .002). In addition, compared to patients without delirium, more patients with delirium experienced sleep disorder (86.1\% vs. 47.2\%, p < .001) and had location with regard to sunlight (80.6\% vs. 67.9\%, p = .032). The variables that were significantly more prevalent between patient with and without delirium were incorporated into logistic regression models. Age, duration of VAM and length in ICU stay were incorporated as continuous variables, while blood pressure, location with regard to sunlight and sleep disorder as categorical variables. The regression model showed that patient age (p = .001), the duration of VAM (p = .025), continuous exposure to artificial light (p = .034) and the presence of sleep disorders (p = .024) were predictors of the onset of delirium. The results of the logistic regres- sion model are reported in Table 4. 5 | DISCUSSION This study identified not only clinical but also environmental risk fac- tors that may be responsible for the onset of delirium during inten- sive therapy following cardiac surgery. Delirium is a frequent phenomenon that could occur during such treatment (Koster et al., 2013). Importantly, the onset of this disorder may significantly wor- sen the patient’s health (Arumugam et al., 2017). In fact, patients who have this disorder are more likely to self-removing their gold- tracheal probes and to the accidental removal of drains, central venous catheters and bladder catheters. Furthermore, such delirium can create nonsynchronicity between the patient and the mechani- cally assisted ventilation system. As reported in the literature (Brown, 2014; Koster et al., 2013), we observed that delirium manifested in 40.4\% of the recruited patients. Several important results have been emphasised in our study. Firstly, we observed that age is a risk factor for the onset of delirium. Differently from our study, other authors (Ouimet, Kava- nagh, Gottfried, & Skrobik, 2007; Van Rompaey et al., 2009) did not observe a significant association between delirium and age. It is important to note, however, that in our study, the sample had a higher average age. This could explain the differences between our results and those of the above-mentioned studies. This is confirmed in the literature, wherein authors (Wass, Webster, & Nair, 2008) have observed that the likelihood of delirium rises with increasing age. As described by Wass et al. (2008), in fact, the prevalence of delirium ranged between 1\% in patients with 55 years of age and 14\% in patients older than 85 years. With regard to gender, our findings are in line with those of other studies (Van Rompaey et al., 2009). There is no significant dif- ference between male and female patients. In contrast to our find- ings, however, Kolanowski et al. (2014) observed that women had a higher chance than men to develop a more severe form of delirium. Men, as described by authors, may be more resistant to this particu- lar disorder because they have more cognitive reserve than do women (Kolanowski et al., 2014). Moreover, Barnes et al. (2005) showed that due to the greater physiological size of the brain and greater number and density of neurons, men are more likely than women to use compensating mechanisms in the face of delirium. Another element that may predict the delirium is the duration of VAM. In the literature, however, this is not an unknown phe- nomenon (Leite et al., 2014; Salluh et al., 2010; Serafim et al., 2012; Tsuruta et al., 2010). In fact, as described by various authors (Leite et al., 2014; Ouimet et al., 2007), one complication seen in patients who have been admitted to an intensive care unit, particularly in TABLE 2 Independent sample t test for delirium (n = 89) Characteristics Delirium M (SD) No delirium M (SD) p-Value Age (mean, SD) 68.1 (5.6) 62.3 (6.7) <.001*** VAM duration, in hr (mean, SD) 6.0 (1.5) 4.9 (1.5) .003** Length of ICU stay, in days (mean, SD) 6.1 (2.2) 4.9 (1.7) .005** **p < .01; ***p < .001. TABLE 3 Differences between delirium/no delirium (n = 89) Characteristics Delirium N (\%) No delirium N (\%) v2 p Value Gender (male) 31 (86.1) 44 (83.0) 0.155 .774 Marital status 22 (61.1) 49 (92.5) 13.052 <.001** Type of intervention (bypass) 27 (75.0) 45 (84.9) 1.361 .280 Blood Pressure (>140/90) 24 (66.7) 17 (32.1) 10.325 .002* Diabetes 15 (41.7) 20 (37.7) 0.139 .826 TC 14 (38.9) 16 (30.2) 0.726 .846 Location with regard to sunlight 29 (80.6) 36 (67.9) 9.737 .032* Arrhythmia 16 (44.4) 17 (32.1) 1.406 .269 Sleep disorder 31 (86.1) 25 (47.2) 13.934 <.001** TC, temperature. Comparison were made using chi-square tests for categorical variables. *p < .01; **p < .001. 1998 | SIMEONE ET AL. those patients who receive mechanical ventilation, is delirium. In addition, other authors (Shehabi et al., 2010) observed that delirium is often associated with a slower weaning from mechanical ventila- tion and an increase in the length of a patient’s stay in the intensive care unit. The delirium’s incidence is often lower in those patients who do not receive mechanical ventilation (Tsuruta et al., 2010; Van Rompaey et al., 2008). However, the development of delirium in patients who receive mechanical ventilation has been poorly described. In several studies (Serafim et al., 2012; Shehabi et al., 2010), the assessment of delirium was carried out through a single assessment (and only after the patient had been extubated). How- ever, this may not be enough to detect the exact moment of delir- ium’s onset. Leite et al. (2014) observed that roughly 20.6\% of delirium diagnoses occur prior to extubation while only 14.7\% occur after extubation. It must be emphasised that in our study, the aver- age duration of VAM was definitely low, equal to 5.4 hr after sur- gery, differently from other studies, wherein the average length of extubation was between 3 (Shehabi et al., 2010)–6 days (Leite et al., 2014). Despite the fact that our sample was subjected to a VAM duration that was shorter than that described in the literature, the onset of delirium is still statistically associated with the duration of VAM. In fact, we observed that patients who showed delirium had an average VAM duration that was significantly higher than those who did not manifest delirium. Additionally, in our study, we observed that … Nursing Research Methods and Critical Appraisal for Evidence- Based Practice NINETH EDITION Geri LoBiondo-Wood, PhD, RN, FAAN Professor and Coordinator, PhD in Nursing Program, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas Judith Haber, PhD, RN, FAAN The Ursula Springer Leadership Professor in Nursing, New York University, Rory Meyers College of Nursing, New York, New York 2 Table of Contents Cover image Title page Copyright About the authors Contributors Reviewers To the faculty To the student Acknowledgments I. Overview of Research and Evidence-Based Practice Introduction References 1. Integrating research, evidence-based practice, and quality improvement processes References 2. Research questions, hypotheses, and clinical questions References 3. Gathering and appraising the literature References 4. Theoretical frameworks for research References II. Processes and Evidence Related to Qualitative Research Introduction 3 kindle:embed:0006?mime=image/jpg References 5. Introduction to qualitative research References 6. Qualitative approaches to research References 7. Appraising qualitative research Critique of a qualitative research study References References III. Processes and Evidence Related to Quantitative Research Introduction References 8. Introduction to quantitative research References 9. Experimental and quasi-experimental designs References 10. Nonexperimental designs References 11. Systematic reviews and clinical practice guidelines References 12. Sampling References 13. Legal and ethical issues References 14. Data collection methods References 15. Reliability and validity References 16. Data analysis: Descriptive and inferential statistics 4 References 17. Understanding research findings References 18. Appraising quantitative research Critique of a quantitative research study Critique of a quantitative research study References References References IV. Application of Research: Evidence-Based Practice Introduction References 19. Strategies and tools for developing an evidence-based practice References 20. Developing an evidence-based practice References 21. Quality improvement References Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer coaching and hepatitis A and B vaccine completion among homeless men recently released on parole Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and mental health at 1 and 3 months after their infant schild s death in an intensive care unit Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating pain: A qualitative study Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic growth and coping in parents and siblings of adolescent cancer survivors Example of a systematic Review/Meta analysis (Al mallah et al., 2015) The impact of nurse led clinics on the mortality and morbidity of patients with cardiovascular diseases Glossary Index 5 Special features 6 Copyright 3251 Riverport Lane St. Louis, Missouri 63043 NURSING RESEARCH: METHODS AND CRITICAL APPRAISAL FOR EVIDENCE-BASED PRACTICE, NINTH EDITION ISBN: 978-0-323-43131-6 Copyright © 2018 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). N o t i c e s Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986. Library of Congress Cataloging-in-Publication Data Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor. Title: Nursing research : methods and critical appraisal for evidence-based 7 http://www.elsevier.com/permissions Justin Mouchayad  practice / [edited by] Geri LoBiondo-Wood, Judith Haber. Other titles: Nursing research (LoBiondo-Wood) Description: 9th edition. | St. Louis, Missouri : Elsevier, [2018] | Includes  bibliographical references and index. Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper) Subjects: | MESH: Nursing Research—methods | Research Design |  Evidence-Based Nursing—methods Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available at https://lccn.loc.gov/2017008727 Executive Content Strategist: Lee Henderson Content Development Manager: Lisa Newton Content Development Specialist: Melissa Rawe Publishing Services Manager: Jeff Patterson Book Production Specialist: Carol O’Connell Design Direction: Renee Duenow Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 8 https://lccn.loc.gov/2017008727 Justin Mouchayad About the authors Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator of the PhD in Nursing Program at the University of Texas Health Science Center at Houston, School of Nursing (UTHSC- Houston) and former Director of Research and Evidence-Based Practice Planning and Development at the MD Anderson Cancer Center, Houston, Texas. She received her Diploma in Nursing at St. Mary’s Hospital School of Nursing in Rochester, New York; Bachelor’s and Master’s degrees from the University of Rochester; and a PhD in Nursing Theory and Research from New York University. Dr. LoBiondo-Wood teaches research and evidence-based practice principles to undergraduate, graduate, and doctoral students. At MD Anderson Cancer Center, she developed and implemented the Evidence-Based Resource Unit Nurse (EB-RUN) Program. She has extensive national and international experience guiding nurses and other health care professionals in the development and utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress in Transplantation and a reviewer for Nursing Research, Oncology Nursing Forum, and Oncology Nursing. Her research and publications focus on chronic illness and oncology nursing. Dr. Wood has received funding from the Robert Wood Johnson Foundation Future of Nursing Scholars program for the past several years to fund full-time doctoral students. Dr. LoBiondo-Wood has been active locally and nationally in many professional organizations, including the Oncology Nursing Society, Southern Nursing Research Society, the Midwest Nursing Research Society, and the North American Transplant Coordinators Organization. She has received local and national awards for teaching and contributions to nursing. In 1997, she received the Distinguished Alumnus Award from New York University, Division of Nursing Alumni Association. In 2001 she was inducted as a Fellow of the American Academy of Nursing and in 2007 as a Fellow of the University of Texas Academy of Health Science Education. In 2012 she was appointed as a Distinguished Teaching Professor of the University of Texas System and in 2015 received the John McGovern Outstanding Teacher Award from the University of Texas Health Science Center at Houston School of Nursing. Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership Professor in Nursing at the Rory Meyers College of Nursing at New York University. She received her undergraduate nursing education at Adelphi University in New York, and she holds a Master’s degree in Adult Psychiatric–Mental Health Nursing and a PhD in Nursing Theory and Research from New York University. Dr. Haber is internationally recognized as a clinician and educator in psychiatric– mental health nursing. She was the editor of the award-winning classic textbook, Comprehensive 9 Psychiatric Nursing, published for eight editions and translated into five languages. She has extensive clinical experience in psychiatric nursing, having been an advanced practice psychiatric nurse in private practice for over 30 years, specializing in treatment of families coping with the psychosocial impact of acute and chronic illness. Her NIH-funded program of research addressed physical and psychosocial adjustment to illness, focusing specifically on women with breast cancer and their partners and, more recently, breast cancer survivorship and lymphedema prevention and risk reduction. Dr. Haber is also committed to an interprofessional program of clinical scholarship related to interprofessional education and improving oral-systemic health outcomes and is the Executive Director of a national nursing oral health initiative, the Oral Health Nursing Education and Practice (OHNEP) program, funded by the DentaQuest and Washington Dental Service Foundations. Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA Psychiatric Nurse of the Year Award, the 2005 APNA Outstanding Research Award, and the 1998 ANA Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae Award, the 2011 Distinguished Teaching Award, and the 2014 NYU Meritorious Service Award. In 2015, Dr. Haber received the Sigma Theta Tau International Marie Hippensteel Lingeman Award for Excellence in Nursing Practice. Dr. Haber is a Fellow in the American Academy of Nursing and the New York Academy of Medicine. Dr. Haber has consulted, presented, and published widely on evidence- based practice, interprofessional education and practice, as well as oral-systemic health issues. 10 Contributors Terri Armstrong, PhD, ANP-BC, FAANP, Senior Investigator, Neuro-oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Julie Barroso, PhD, ANP, RN, FAAN, Professor and Department Chair, Medical University of South Carolina, Charleston, South Carolina Carol Bova, PhD, RN, ANP, Professor of Nursing and Medicine, Graduate School of Nursing, University of Massachusetts, Worcester, Massachusetts Dona Rinaldi Carpenter, EdD, RN, Professor and Chair, University of Scranton, Department of Nursing, Scranton, Pennsylvania Maja Djukic, PhD, RN, Assistant Professor, Rory Meyers College of Nursing, New York University, New York, New York Mei R. Fu, PhD, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York University, New York, New York Mattia J. Gilmartin, PhD, RN, Senior Research Scientist , Executive Director, NICHE Program, Rory Meyers College of Nursing, New York University, New York, New York Deborah J. Jones, PhD, MS, RN, Margaret A. Barnett/PARTNERS Professorship , Associate Dean for Professional Development and Faculty Affairs , Associate Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas Carl Kirton, DNP, RN, MBA, Chief Nursing Officer, University Hospital, Newark, New Jersey; , Adjunct Faculty, Rory Meyers College of Nursing, New York University, New York, New York Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN, Professor, Rory Meyers College of Nursing, New York University, New York, New York Elaine Larson, PhD, RN, FAAN, CIC, Anna C. Maxwell Professor of Nursing Research , Associate Dean for Research, Columbia University School of Nursing, New York, New York Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas 11 Gail D’Eramo Melkus, EdD, ANP, FAAN, Florence & William Downs Professor in Nursing Research, Associate Dean for Research, Rory Meyers College of Nursing, New York University, New York, New York Susan Sullivan-Bolyai, DNSc, CNS, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York University, New York, New York Marita Titler, PhD, RN, FAAN, Rhetaugh G. Dumas Endowed Professor , Department Chair, Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan Mark Toles, PhD, RN, Assistant Professor, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina 12 Reviewers Karen E. Alexander, PhD, RN, CNOR, Program Director RN-BSN, Assistant Professor, Department of Nursing, University of Houston Clear Lake-Pearland, Houston, Texas Donelle M. Barnes, PhD, RN, CNE, Associate Professor, College of Nursing, University of Texas, Arlington, Arlington, Texas Susan M. Bezek, PhD, RN, ACNP, CNE, Assistant Professor, Division of Nursing, Keuka College, Keuka Park, New York Rose M. Kutlenios, PhD, MSN, MN, BSN, ANCC Board Certification, Adult Psychiatric/Mental Health Clinical Specialist, ANCC Board Certification, Adult Nurse Practitioner, Nursing Program Director and Associate Professor, Department of Nursing, West Liberty University, West Liberty, West Virginia Shirley M. Newberry, PhD, RN, PHN, Professor, Department of Nursing, Winona State University, Winona, Minnesota Sheryl Scott, DNP, RN, CNE, Assistant Professor and Chair, School of Nursing, Wisconsin Lutheran College, Milwaukee, Wisconsin 13 To the faculty Geri LoBiondo-Wood, [email protected], Judith Haber, j[email protected] The foundation of the ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence- Based Practice continues to be the belief that nursing research is integral to all levels of nursing education and practice. Over the past three decades since the first edition of this textbook, we have seen the depth and breadth of nursing research grow, with more nurses conducting research and using research evidence to shape clinical practice, education, administration, and health policy. The National Academy of Medicine has challenged all health professionals to provide team-based care based on the best available scientific evidence. This is an exciting challenge. Nurses, as clinicians and interprofessional team members, are using the best available evidence, combined with their clinical judgment and patient preferences, to influence the nature and direction of health care delivery and document outcomes related to the quality and cost-effectiveness of patient care. As nurses continue to develop a unique body of nursing knowledge through research, decisions about clinical nursing practice will be increasingly evidence based. As editors, we believe that all nurses need not only to understand the research process but also to know how to critically read, evaluate, and apply research findings in practice. We realize that understanding research, as a component of evidence-based practice and quality improvement practices, is a challenge for every student, but we believe that the challenge can be accomplished in a stimulating, lively, and learner-friendly manner. Consistent with this perspective is an ongoing commitment to advancing implementation of evidence-based practice. Understanding and applying research must be an integral dimension of baccalaureate education, evident not only in the undergraduate nursing research course but also threaded throughout the curriculum. The research role of baccalaureate graduates calls for evidence-based practice and quality improvement competencies; central to this are critical appraisal skills—that is, nurses should be competent research consumers. Preparing students for this role involves developing their critical thinking skills, thereby enhancing their understanding of the research process, their appreciation of the role of the critiquer, and their ability to actually critically appraise research. An undergraduate research course should develop this basic level of competence, an essential requirement if students are to engage in evidence-informed clinical decision making and practice, as well as quality improvement activities. The primary audience for this textbook remains undergraduate students who are learning the steps of the research process, as well as how to develop clinical questions, critically appraise published research literature, and use research findings to inform evidence-based clinical practice and quality improvement initiatives. This book is also a valuable resource for students at the master’s, DNP, and PhD levels who want a concise review of the basic steps of the research process, the critical appraisal process, and the principles and tools for evidence-based practice and quality improvement. This text is also an important resource for practicing nurses who strive to use research evidence as the basis for clinical decision making and development of evidence-based policies, protocols, and standards or who collaborate with nurse-scientists in conducting clinical research and evidence- based practice. Finally, this text is an important resource for considering how evidence-based practice, quality improvement, and interprofessional collaboration are essential competencies for students and clinicians practicing in a transformed health care system, where nurses and their interprofessional team members are accountable for the quality and cost-effectiveness of care provided to their patient population. Building on the success of the eighth edition, we reaffirm our commitment to introducing evidence-based practice, quality improvement processes, and research principles to baccalaureate students, thereby providing a cutting-edge, research consumer foundation for their clinical practice. Nursing Research: Methods and Critical Appraisal for Evidence- Based Practice prepares nursing students and practicing nurses to become knowledgeable nursing 14 research consumers by doing the following: • Addressing the essential evidence-based practice and quality improvement role of the nurse, thereby embedding evidence-based competencies in clinical practice. • Demystifying research, which is sometimes viewed as a complex process. • Using a user-friendly, evidence-based approach to teaching the fundamentals of the research process. • Including an exciting chapter on the role of theory in research and evidence-based practice. • Providing a robust chapter on systematic reviews and clinical guidelines. • Offering two innovative chapters on current strategies and tools for developing an evidence- based practice. • Concluding with an exciting chapter on quality improvement and its application to practice. • Teaching the critical appraisal process in a user-friendly progression. • Promoting a lively spirit of inquiry that develops critical thinking and critical reading skills, facilitating mastery of the critical appraisal process. • Developing information literacy, searching, and evidence-based practice competencies that prepare students and nurses to effectively locate and evaluate the best research evidence. • Emphasizing the role of evidence-based practice and quality improvement initiatives as the basis for informing clinical decisions that support nursing practice. • Presenting numerous examples of recently published research studies that illustrate and highlight research concepts in a manner that brings abstract ideas to life for students. These examples are critical links that reinforce evidence-based concepts and the critiquing process. • Presenting five published articles, including a meta-analysis, in the Appendices, the highlights of which are woven throughout the text as exemplars of research and evidence-based practice. • Showcasing, in four new inspirational Research Vignettes, the work of renowned nurse researchers whose careers exemplify the links among research, education, and practice. • Introducing new pedagogical interprofessional education chapter features, IPE Highlights and IPE Critical Thinking Challenges and quality improvement, QSEN Evidence-Based Practice Tips. • Integrating stimulating pedagogical chapter features that reinforce learning, including Learning Outcomes, Key Terms, Key Points, Critical Thinking Challenges, Helpful Hints, Evidence- Based Practice Tips, Critical Thinking Decision Paths, and numerous tables, boxes, and figures. • Featuring a revised section titled Appraising the Evidence, accompanied by an updated Critiquing Criteria box in each chapter that presents a step of the research process. • Offering a student Evolve site with interactive review questions that provide chapter-by-chapter review in a format consistent with that of the NCLEX® Examination. • Offering a Student Study Guide that promotes active learning and assimilation of nursing research content. • Presenting Faculty Evolve Resources that include a test bank, TEACH lesson plans, PowerPoint slides with integrated audience response system questions, and an image collection. Evolve resources for both students and faculty also include a research article library with appraisal exercises for additional practice in reviewing and critiquing, as well as content updates. 15 The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice is organized into four parts. Each part is preceded by an introductory section and opens with an engaging Research Vignette by a renowned nurse researcher. Part I, Overview of Research and Evidence-Based Practice, contains four chapters: Chapter 1, “Integrating Research, Evidence-Based Practice, and Quality Improvement Processes,” provides an excellent overview of research and evidence-based practice processes that shape clinical practice. The chapter speaks directly to students and highlights critical reading concepts and strategies, facilitating student understanding of the research process and its relationship to the critical appraisal process. The chapter introduces a model evidence hierarchy that is used throughout the text. The style and content of this chapter are designed to make subsequent chapters user friendly. The next two chapters address foundational components of the research process. Chapter 2, “Research Questions, Hypotheses, and Clinical Questions,” focuses on how research questions and hypotheses are derived, operationalized, and critically appraised. Students are also taught how to develop clinical questions that are used to guide evidence-based inquiry, including quality improvement projects. Chapter 3, “Gathering and Appraising the Literature,” showcases cutting- edge information literacy content and provides students and nurses with the tools necessary to effectively search, retrieve, manage, and evaluate research studies and their findings. Chapter 4, “Theoretical Frameworks for Research,” is a user-friendly theory chapter that provides students with an understanding of how theories provide the foundation of research studies and evidence- based practice projects. Part II, Processes and Evidence Related to Qualitative Research, contains three interrelated qualitative research chapters. Chapter 5, “Introduction to Qualitative Research,” provides an exciting framework for understanding qualitative research and the significant contribution of qualitative research to evidence-based practice. Chapter 6, “Qualitative Approaches to Research,” presents, illustrates, and showcases major qualitative methods using examples from the literature as exemplars. This chapter highlights the questions most appropriately answered using qualitative methods. Chapter 7, “Appraising Qualitative Research,” synthesizes essential components of and criteria for critiquing qualitative research reports using published qualitative research study. Part III, Processes and Evidence Related to Quantitative Research, contains Chapters 8 to 18Chapter 8Chapter 9Chapter 10Chapter 11Chapter 12Chapter 13Chapter 14Chapter 15Chapter 16Chapter 17Chapter 18. This group of chapters delineates essential steps of the quantitative research process, with published clinical research studies used to illustrate each step. These chapters are streamlined to make the case for linking an evidence-based approach with essential steps of the research process. Students are taught how to critically appraise the strengths and weaknesses of each step of the research process in a synthesized critique of a study. The steps of the quantitative research process, evidence-based concepts, and critical appraisal criteria are synthesized in Chapter 18 using two published research studies, providing a model for appraising strengths and weaknesses of studies, and determining applicability to practice. Chapter 11, a unique chapter, addresses the use of the types of systematic reviews that support an evidence-based practice as well as the development and application of clinical guidelines. Part IV, Application of Research: Evidence-Based Practice, contains three chapters that showcase evidence-based practice models and tools. Chapter 19, “Strategies and Tools for Developing an Evidence-Based Practice,” is a revised, vibrant, user-friendly, evidence-based toolkit with exemplars that capture the essence of high-quality, evidence-informed nursing care. It “walks” students and practicing nurses through clinical scenarios and challenges them to consider the relevant evidence-based practice “tools” to develop and answer questions that emerge from clinical situations. Chapter 20, “Developing an Evidence-Based Practice,” offers a dynamic presentation of important evidence-based practice models that promote evidence-based decision making. Chapter 21, “Quality Improvement,” is an innovative, engaging chapter that outlines the quality improvement process with information from current guidelines. Together, these chapters provide an inspirational conclusion to a text that we hope motivates students and practicing nurses to advance their evidence-based practice and quality improvement knowledge base and clinical competence, positioning them to make important contributions to improving health care outcomes as essential members of interprofessional teams. Stimulating critical thinking is a core value of this text. Innovative chapter features such as Critical Thinking Decision Paths, Evidence-Based Practice Tips, Helpful Hints, Critical Thinking Challenges, IPE Highlights, and QSEN Evidence-Based Practice Tips enhance critical thinking, promote the development of evidence-based decision-making skills, and cultivate a positive value 16 about the importance of collaboration in promoting evidence-based, high quality and cost-effective clinical outcomes. Consistent with previous editions, we promote critical thinking by including sections called “Appraising the Evidence,” which describe the critical appraisal process related to the focus of the chapter. Critiquing Criteria are included in this section to stimulate a systematic and evaluative approach to reading and understanding qualitative and quantitative research and evaluating its strengths and weaknesses. Extensive resources are provided on the Evolve site that can be used to develop critical thinking and evidence-based competencies. The development and refinement of an evidence-based foundation for clinical nursing practice is an essential priority for the future of professional nursing practice. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice will help students develop a basic level of competence in understanding the steps of the research process that will enable them to critically analyze research studies, judge their merit, and judiciously apply evidence in clinical practice. To the extent that this goal is accomplished, the next generation of nursing professionals will have a cadre of clinicians …