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Consider a patient centered issue you have observed recently. Formulate a research question related to that issue. Identify the independent and dependent variable, hypothesis and type of hypothesis. What type of research study design would you use to address that issue, what type of sampling or sampling strategy would you use? Defend your choices with support from your textbook or other peer-reviewed journal source..

EVIDENCE-BASED PRACTICE
FOR NURSES
Appraisal and Application of Research

2

THE PEDAGOGY

Evidence-Based Practice for Nurses: Appraisal and Application of Research,
Third Edition, drives comprehension through various strategies that meet the
learning needs of students, while also generating enthusiasm about the topic. This
interactive approach addresses different learning styles, making this the ideal text
to ensure mastery of key concepts. The pedagogical aids that appear in most

chapters include the following:

3

Chapter Objectives
These objectives provide instructors and students with a snapshot of the key
information they will encounter in each chapter. They serve as a checklist to
help guide and focus study.

Key Terms

Found in a list at the beginning of each chapter and in bold within the chapter,
these terms will create an expanded vocabulary in evidence-based practice.

Critical Thinking Exercises An integral part of the learning process, critical-
thinking scenarios and questions are presented by the authors to spark insight into
situations you may face in practice.

4

FYI

Quick tidbits and facts are pulled out in chapter margins to highlight important
aspects of the chapter topic.

Test Your Knowledge

These questions serve as benchmarks for the knowledge you are acquiring as
you move throughout the chapter.

5

Rapid Review This succinct list at the end of the chapter compiles the most
pertinent and key information for quick review and later reference.

6

Apply What You Have Learned

With this outstanding feature, you will be challenged to apply your newly
acquired knowledge to specific evidence-based practice scenarios and
research studies.

7

Case Examples Found in select chapters, these vignettes illustrate research
questions and studies in actual clinical settings and provide critical-thinking
challenges for students.

8

Keeping It Ethical

Relevant ethical content concludes each chapter to ensure ethics are kept at the
forefront of every step of the nursing process.

9

10

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Library of Congre s s Cataloging-in-Publication Data Evidence-based practice for nurses : appraisal and
application of research / [edited by] Nola A. Schmidt and Janet M. Brown. — 3rd.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-284-05330-2 (pbk.) I. Schmidt, Nola A., editor. II. Brown, Janet M. (Janet Marie), 1947– editor.

[DNLM: 1. Nursing Research—methods. 2. Evidence-Based Nursing. WY 20.5]

RT81.5

610.73072—dc23

2014017978

6048

Printed in the United States of America 18 17 16 15 14 10 9 8 7 6 5 4 3 2 1

12

DEDICATION
For Mom, whose love and support are endless.

—N. A. S.

To my husband, my children, and my granddaughters, who enrich my life in every
way.

—J. M. B.

13

CONTENTS
Contributors

Reviewers

Preface

Acknowledgments

UNIT 1
Introduction to Evidence-Based
Practice

CHAPTER
1

What Is Evidence-Based Practice?

Nola A. Schmidt and Janet M. Brown

1.1 EBP: What Is It?

1.2 What Is Nursing Research?

1.3 How Has Nursing Evolved as a Science?

1.4 What Lies Ahead?

1.5 Keeping It Ethical

CHAPTER
2

Using Evidence Through Collaboration to
Promote Excellence in Nursing Practice

Emily Griffin and Marita G. Titler

2.1 The Five Levels of Collaboration

14

2.2 Keeping It Ethical

UNIT 2 Acquisition of Knowledge

CHAPTER
3

Identifying Research Questions

Susie Adams

3.1 How Clinical Problems Guide Research Questions

3.2 Developing Hypotheses

3.3 Formulating EBP Questions

3.4 Keeping It Ethical

CHAPTER
4

Finding Sources of Evidence

Patricia Mileham

4.1 Purpose of Finding Evidence

4.2 Types of Evidence

4.3 How Sources Are Organized

4.4 How to Search for Evidence

4.5 Keeping It Ethical

CHAPTER

15

5 Linking Theory, Research, and Practice

Elsabeth Jensen

5.1 How Are Theory, Research, and Practice Related?

5.2 Keeping It Ethical

UNIT 3 Persuasion

CHAPTER
6

Key Principles of Quantitative Designs

Rosalind M. Peters

6.1 Chart the Course: Selecting the Best Design

6.2 What Is Validity?

6.3 Categorizing Designs According to Time

6.4 Keeping It Ethical

CHAPTER
7

Quantitative Designs: Using Numbers to
Provide Evidence

Rosalind M. Peters

7.1 Experimental Designs

7.2 Quasi-Experimental Designs

16

7.3 Nonexperimental Designs

7.4 Specific Uses for Quantitative Designs

7.5 Keeping It Ethical

CHAPTER
8

Epidemiologic Designs: Using Data to
Understand Populations

Amy C. Cory

8.1 Epidemiology and Nursing

8.2 Infectious Diseases and Outbreak Investigations

8.3 Measures of Disease Frequency

8.4 Descriptive Epidemiology

8.5 Descriptive Study Designs

8.6 Analytic Study Designs

8.7 Screening

8.8 Evaluating Health Outcomes and Services

8.9 Keeping It Ethical

CHAPTER
9

Qualitative Designs: Using Words to Provide
Evidence

Kristen L. Mauk

17

9.1 What Is Qualitative Research?

9.2 The Four Major Types of Qualitative Research

9.3 Keeping It Ethical

CHAPTER
10

Collecting Evidence

Jan Dougherty

10.1 Data Collection: Planning and Piloting

10.2 Collecting Quantitative Data

10.3 Validity and Reliability

10.4 Collecting Qualitative Data

10.5 Keeping It Ethical

CHAPTER
11

Using Samples to Provide Evidence

Ann H. White

11.1 Fundamentals of Sampling

11.2 Sampling Methods

11.3 Sample Size: Does It Matter?

11.4 Keeping It Ethical

18

CHAPTER
12

Other Sources of Evidence

Cynthia L. Russell

12.1 The Pyramid of Evidence: The 5 Ss

12.2 Using the Pyramid for Evidence-Based Practice

12.3 Keeping It Ethical

UNIT 4 Decision

CHAPTER
13

What Do the Quantitative Data Mean?

Rosalind M. Peters, Nola A. Schmidt, and Moira Fearncombe

13.1 Using Statistics to Describe the Sample

13.2 Using Frequencies to Describe Samples

13.3 Measures of Central Tendency

13.4 Distribution Patterns

13.5 Measures of Variability

13.6
Inferential Statistics: Can the Findings Be Applied to the
Population?

13.7 Reducing Error When Deciding About Hypotheses

13.8
Using Statistical Tests to Make Inferences About
Populations

19

13.9 What Does All This Mean for EBP?

13.10 Keeping It Ethical

CHAPTER
14

What Do the Qualitative Data Mean?

Kristen L. Mauk

14.1 Qualitative Data Analysis

14.2 Qualitative Data Interpretation

14.3 Qualitative Data Evaluation

14.4 Keeping It Ethical

CHAPTER
15

Weighing In on the Evidence

Carol O. Long

15.1 Deciding What to Do

15.2 Appraising the Evidence

15.3
Clinical Practice Guidelines: Moving Ratings and
Recommendations into Practice

15.4 Keeping It Ethical

UNIT 5 Implementation

20

UNIT 5 Implementation

CHAPTER
16 Transitioning Evidence to Practice

Maria Young

16.1 Evidence-Based Practice Models to Overcome Barriers

16.2 Creating Change

16.3 Keeping It Ethical

CHAPTER
17

Developing Oneself as an Innovator

Diane McNally Forsyth

17.1 Who Is an Innovator?

17.2 Developing Oneself

17.3 Professionalism

17.4 Keeping It Ethical

UNIT 6 Confirmation

CHAPTER
18

Evaluating Outcomes of Innovations

21

18.1 What Is an Outcome?

18.2 Choosing Outcomes

18.3 Evaluating the Outcomes

18.4 Keeping It Ethical

CHAPTER
19

Sharing the Insights with Others

Janet M. Brown and Nola A. Schmidt

19.1 Dissemination: What Is My Role?

19.2 The 3 Ps of Dissemination

19.3 Using Technology to Disseminate Knowledge

19.4 Making the Most of Conferences

19.5 Keeping It Ethical

Glossary

Index

22

CONTRIBUTORS
Susie Adams, PhD, RN, PMHNP, FAANP

Professor and Director PMHNP Program School of Nursing

Vanderbilt University

Nashville, Tennessee

Janet M. Brown, PhD, RN

Dean and Professor

College of Nursing and Health Professions Valparaiso University

Valparaiso, Indiana

Amy C. Cory, PhD, RN, CPNP

Associate Professor

College of Nursing and Health Professions Valparaiso University

Valparaiso, Indiana

Jan Dougherty, MS, RN

Director

Family and Community Services Banner Alzheimer’s Institute Phoenix, Arizona

Moira Fearncombe

Associate Professor

The Illinois Institute of Art Schaumburg, Illinois

Diane McNally Forsyth, PhD, RN

Professor

Graduate Programs in Nursing Winona State University

Rochester, Minnesota

Emily Griffin, MSN, ARNP, FNP-C

Lecturer

23

College of Nursing

University of Iowa

Iowa City, Iowa

Elsabeth Jensen, PhD, RN

Associate Professor and Graduate Program Director School of Nursing

Faculty of Health

York University

Toronto, Ontario

Carol O. Long, PhD, RN, FPCN

Geriatric and Palliative Care Educator and Researcher Capstone Healthcare Group

Adjunct Faculty

College of Nursing and Health Innovation Arizona State University

Phoenix, Arizona

Kristen L. Mauk, PhD, DNP, RN, CRRN, GCNS-BC, GNP-BC, FAAN

Professor Kreft Endowed Chair for the Advancement of Nursing Science College
of Nursing and Health Professions Valparaiso University

Valparaiso, Indiana

Patricia Mileham, MA Associate Professor of Library Services, Director of
Public Service Christopher Center for Library & Information Resources
Valparaiso University

Valparaiso, Indiana

Rosalind M. Peters, PhD, RN, FAAN

Associate Professor

College of Nursing

Wayne State University

Detroit, Michigan

Kathleen A. Rich, PhD, RN, CCNS-CSC, CNN

Cardiovascular Clinical Specialist Patient Care Services

Indiana University Health La Porte Hospital La Porte, Indiana

Cynthia L. Russell, PhD, RN, ACNS-BC, FAAN

24

Professor

School of Nursing and Health Studies University of Missouri—Kansas City Kansas
City, Missouri

Nola A. Schmidt, PhD, RN, CNE

Professor

College of Nursing and Health Professions Valparaiso University

Valparaiso, Indiana

Marita G. Titler, PhD, RN, FAAN

Associate Dean for Practice and Clinical Scholarship Rhetaugh G. Dumas
Endowed Chair Division Chair Health Systems and Effectiveness Sciences
University of Michigan School of Nursing Ann Arbor, Michigan

Ann H. White, PhD, MBA, RN, NE-BC

Dean

College of Nursing and Health Professions University of Southern Indiana
Evansville, Indiana

Maria Young, PhD, RN, ACNS-BC

Cardiac Care Clinical Nurse Specialist Franciscan St. Elizabeth Health West
Lafayette, Indiana

25

REVIEWERS
Carol Beltz, MSN, RN

26

Lecturer

27

Kent State University

Kent, Ohio

Susan Weber Buchholz, PhD, ANP-BC

28

Professor

Department of Adult Health and Gerontological Nursing Rush University

Chicago, Illinois

Nathania A. Bush, MSN, APRN, BC

Assistant Professor of Nursing Morehead State University

Morehead, Kentucky

Janie Canty-Mitchell, PhD, RN

University of North Carolina—Wilmington Wilmington, North Carolina

Kim Clevenger, MSN, RN

Assistant Professor of Nursing Morehead State University

Morehead, Kentucky

Suzanne Edgett Collins, PhD, RN, MPH, JD

29

Associate Professor

30

Department of Nursing

31

University of Tampa

Tampa, Florida

Marianne Curia, PhD, MSN, RN

32

Assistant Professor

University of St. Francis College of Nursing and Allied Health Joliet, Illinois

Maureen B. Doyle, PhD, APRN

33

Assistant Professor

Fairleigh Dickinson University Henry P. Becton School of Nursing and Allied
Health Teaneck, New Jersey

Catherine M. Jennings, RN, MSN, APN-C

34

Felician College

Lodi, New Jersey

Jane Kapustin, PhD, CRNP

University of Maryland—Baltimore Baltimore, Maryland

Cathy Leahy, MSN, MEd, RN

35

Department of Nursing

36

Xavier University

Cincinnati, Ohio

Cheryl Martin, PhD

37

BSN Programs Director

38

Associate Professor

39

University of Indianapolis

Indianapolis, Indiana

Mary A. Megel, PhD, RN

40

Associate Professor

41

College of Nursing

Family & Systems Department University of Nebraska Medical Center Omaha,
Nebraska

Arlene Morris, EdD, RN, CNE

42

Associate Professor

43

Department of Nursing

Auburn University Montgomery School of Nursing Montgomery, Alabama

Iris Mullins, PhD, RN

44

Assistant Professor

45

School of Nursing

New Mexico State University Las Cruces, New Mexico

Jenenne P. Nelson, PhD, RN, CNS

Associate Professor and Kaiser Permanente Professorship in Nursing Beth-El
College of Nursing and Health Sciences Colorado Springs, Colorado

Katherine Peck, MSN, RN, CNS

46

Instructor

New Mexico State University Las Cruces, New Mexico

Michael Perlow, DNS, RN

47

Murray State University

Murray, Kentucky

Ginger Raterink, DNSc, ANP-C

48

School of Nursing

49

University of Colorado

Denver, Colorado

Jacquelyn Reid, EdD

50

Associate Professor

51

School of Nursing

Indiana University Southeast New Albany, Indiana

Linda S. Rieg, PhD, RN

52

Associate Professor

53

Xavier University

Cincinnati, Ohio

Kandy K. Smith, DNS, RN

54

Associate Professor

55

College of Nursing

University of South Alabama Mobile, Alabama

Claudette Spalding, PhD, ARNP, CNAA Associate Dean for Graduate Education
Associate Professor

Barry University School of Nursing Miami Shores, Florida

Nancy Wilk, DNS, WHNP

St. John Fisher College

Rochester, New York

56

PREFACE

We are most pleased to offer the third edition of this text. For this revision,
chapter authors have paid particular attention to updating information and
references. Of special note is a new chapter about statistics used in epidemiology.
We consider this an important addition because evidence-based practice (EBP) and
epidemiology are closely aligned. As more nursing literature involves
epidemiology, it is important for nurses to understand the methods used in order to
interpret information and apply it to their practices.

We are even more committed to the premise that baccalaureate-prepared nurses,
given the emphasis on leadership, critical thinking, and communication in their
curricula, are ideally positioned to advance best practices. Therefore, nursing
faculty must create educational strategies for students that develop a lifelong
commitment to critically examining nursing practice in light of scientific advances.
Although many texts and references deal with the principles, methods, and
appraisal of nursing research, few sources address the equally important aspect of
integrating evidence into practice. Because there is a growing expectation by
accrediting bodies that patient outcomes are addressed through best practice, it is
imperative that books be available to prepare nurses for implementing best
practices. This nursing research textbook provides substantive strategies to assist
students with applying evidence at the point of care.

The American Association of Colleges of Nursing (AACN) charges nursing
programs to prepare baccalaureate nurses with the basic understanding of the
processes of nursing research. This book includes content related to methods,
appraisal, and utilization, which is standard in many other texts. Furthermore, the
AACN expects BSN-prepared nurses to apply research findings from nursing and
other disciplines in their clinical practice. The framework for this text is the model
of diffusion of innovations (Rogers, 2003), which gives readers a logical and
useful means for creating an EBP. Readers are led step by step through the process
of examining the nursing practice problem of medication errors using the
innovation–decision process (IDP). It is recommended that faculty use this text with
students to guide them through assignments that might effect actual change in patient
care at a healthcare facility. Schmidt and Brown (2007) described this teaching
strategy more fully. Because students typically express that research content is
uninteresting and lacks application to real life, we have tried to create a textbook
that is less foreboding and more enjoyable through the use of friendly language and
assignments to make content more pertinent for students.

57

The primary audience for this textbook is baccalaureate undergraduate nursing
students and their faculty in an introductory nursing research course. All
baccalaureate nursing programs offer an introductory research course, for which
this text would be useful. Because the readership has grown, we recognize that
nursing graduate programs are also using this textbook. The addition of the chapter
about epidemiology may be especially pertinent to this audience.

In this third edition, input from students and feedback from faculty has been
incorporated. We are most grateful for their time and thoughtful critique. This
edition continues to follow the five steps of the IDP: knowledge, persuasion,
decision, implementation, and confirmation. This organizational approach allows
the research process to be linked with strategies that promote progression through
the IDP. The chapters follow a consistent format: chapter objectives, key terms,
major content, test your knowledge, case study, rapid review, and reference list.
Critical thinking exercises and user-friendly tables and charts are interspersed
throughout each chapter to allow readers to see essential information at a glance.
Textbook users will be pleased to find that efforts to provide consistency between
chapters have been made. The evidence hierarchy and questions to consider when
appraising nursing studies are printed inside the back cover for easy reference. The
chapter about qualitative methods was expanded to include more detail about the
philosophic underpinning of various methods. Additionally, content about the role
of technology in dissemination has also been enhanced.

The case study continues to be a significant feature of this textbook. More
recent evidence has been provided to challenge students to make decisions about
practice related to the elimination of medication errors. The case study unfolds in a
manner that integrates chapter content with each step of the EBP process. Concrete
strategies, in the form of exemplars and checklists, allow readers to master
competencies needed to perform these activities in the clinical setting.

The unique feature of integrating ethical content throughout the chapters
remains. Organizing content in this manner assists students to integrate ethical
principles into each step of the research process.

As a learning strategy, chapters are subdivided so that content is presented in
manageable “bites.” Students commented that they liked this feature. As in the
second edition, chapters begin with a complete list of all objectives addressed in
the chapter. Objectives are repeated for each subsection and are followed by
content, and the chapter ends with a section called Test Your Knowledge. Multiple-
choice and true-or-false questions, with an answer key, reinforce the objectives and
content. Chapters also include critical thinking exercises that challenge readers to
make decisions based on the content. Users will find significant alterations to the
digital resources available to readers.

58

New challenges arose while we wrote this third edition. Publishers are
becoming less inclined to allow their materials to be reproduced. Therefore, we
are disappointed that we can no longer offer the full-text reference articles within
this text’s digital resources. In response to this challenge, the Apply What You
Have Learned exercise for Chapter 4 was significantly transformed. Directions
have been provided for students so that they can search for the articles themselves,
thereby reinforcing behaviors that will be required of baccalaureate-prepared
nurses, who need to keep up with the ever-changing healthcare environment. We are
pleased with the result because this alteration has actually strengthened the
exercise. For readers’ convenience, following is a table containing the evidence
used throughout the Apply What You Have Learned exercises.

Articles to Search in CINAHL

Citation Chapter(s) Search Terms (Limiters)

Anthony, K., Wiencek, C., Bauer,
C., Daly, B., & Anthony, M. K.
(2010). No interruptions please.
Impact of a no interruption zone on
medication safety in intensive care
units. Critical Care Nurse, 30(3),
21–29.

6, 7, 10, 11, 13,
15

Anthony (author) “no
interruptions” (all fields)

Ausserhofer, D., Schubert, M.,
Desmedt, M., Blegen, M. A.,
DeGeest, S., & Schwendimann, R.
(2013). The association of patient
safety climate and nurse-related
organizational factors with selected
patient outcomes: A cross-sectional
survey. International Journal of
Nursing Studies, 50, 240–252.

8, 11, 13, 15
Ausserhofer (author) Schubert
(author) “safety climate” (title)

Biron, A. D., Loiselle, C. G., &
Lavoie-Tremblay, M. (2009). Work
interruptions and their contribution
to medication errors: An evidence
review. World Views on Evidence-
Based Nursing, 6, 70–86.

12, 13, 15 Biron (author) “evidence review”
(all fields)

Cohen, H., & Shastay, D. (2008).
Getting to the root of medication
errors. Nursing, 38(12), 39–49.

4
Cohen (author) Shastay (author)
2008 (publication date)

59

Flanagan, J. M., Carroll, D. L., &
Hamilton, G. A. (2010). The long-
term lived experience of patients
with implantable cardioverter
defibrillators. MEDSURG Nursing,
19, 113–119.

1
“lived experience” (title)
“implantable cardioverter
defibrillators” (title)

Flynn, L., Liang, Y., Dickson, G.
L., Xie, M., & Suh, D. (2013).
Nurses’ practice environments,
error interpretation practices, and
inpatient medication errors. Journal
of Nursing Scholarship, 44(2),
180–186.

10, 11, 13, 15
Flynn (author) Liang (author)
“Journal of Nursing Scholarship”
(publication name)

Kliger, J., Blegen, M. A., Gootee,
D., & O’Neil, E. (2009).
Empowering frontline nurses: A
structured intervention enables
nurses to improve medication
administration accuracy. The Joint
Commission Journal on Quality
and Patient Safety, 35, 604–612.

4, 6, 7, 10, 11,
13, 15

Kliger (author) Gootee (author)

Pipe, T. B., Kelly, A., LeBrun, G.,
Schmidt, D., Atherton, P., &
Robinson, C. (2008). A prospective
descriptive study exploring hope,
spiritual well-being, and quality of
life in hospitalized patients.
MEDSURG Nursing, 17, 247–257.

1
Pipe (author) hope (all fields)
“spiritual well-being” (all fields)

Rich, V. L. (2005). How we think
about medication errors: A model
and a charge for nurses. American
Journal of Nursing, 105(3 Suppl.),
10–11.

5, 10, 11, 12, 13,
15

Rich (author) “model” (title)
“American Journal of Nursing”
(publication name)

Schwappach, D. L. B.,
Hochreutener, M. A., & Wernli, M.
(2010). Oncology nurses’
perceptions about involving patients
in the prevention of chemotherapy
administration errors. Oncology
Nursing Forum, 37, E84–E91.

9, 11, 14, 15
Schwappach (author) “oncology“
(all fields) “qualitative“ (all fields)

60

Tomietto, M., Sartor, A.,
Mazzocoli, E., & Palese, A.
(2012). Paradoxical effects of a
hospital-based, multi-intervention
programme aimed at reducing
medication round interruptions.
Journal of Nursing Management,
20(3), 335–343.

4 Tomietto (all fields)

Evidence to Obtain from Web

Citation Chapters Web Link

Institute of Medicine. (2006).
Preventing medication errors.
Retrieved from
http://www.iom.edu/~/media/Files/
Report%20Files/2006/
Preventing-Medication-Errors-
Quality-Chasm-Series/
medicationerrorsnew.ashx

3

http://www.iom.edu/~/
media/Files/Report%20Files/
2006/Preventing-Medication-Errors
-Quality-Chasm-Series/
medicationerrorsnew
.ashx

Murphy, K. (2006, October 31).
What pilots can teach hospitals
about patient safety. New York
Times. Retrieved from
http://www.nytimes.com/2006/
10/31/health/31safe.html?
ex=1319950800&en=a
64123f3e689ea9f&
ei=5088&partner=rssnyt&emc=rss

12, 13, 15

http://www.nytimes.com/2006/
10/31/health/31safe.
html?ex=1319950800&en=
a64123f%203e689ea9f&
ei=5088&partner=rssnyt&
emc=rss&_r=0

National Cancer Institute. (n.d.).
Human participant protections
education for research teams.
Retrieved from
http://phrp.nihtraining.com/
users/login.php

2 http://phrp.nihtraining.com/
users/login.php

Xue, Y. (2013). Medication errors:
Double checking. Joanna Briggs 12, 13, 15

Connect to JBI website and sign in.
You will probably have to access
this site through your university’s
library. Enter the following phrase

61

in the search box: Medication
Errors: Double Checking.

Emotional Intelligence (EQ)
Assessment

17 http://www.ihhp.com/?
page=freeEQquiz

The New Enneagram Test 17 http://www.9types.com/
newtest/index.php)

Available in the Digital Resources

Resource Chapter

Grid 4
Visit this text’s accompanying
digital resources to find links to
these materials.

Table of Error Rates 18

Poster guideline for making an EBP
poster presentation

19

We hope that the variety of strategies incorporated in this textbook meet your
learning needs and generate enthusiasm about EBP. We wish you the best as you
begin your professional career as an innovator who provides care …

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