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2019v1.0
Fifth Edition
LoBiondo-Wood and Haber’s
NURSING RESEARCH
IN CANADA
Methods, Critical Appraisal, and Utilization
MINA D. SINGH, RN, RP, BSc, BScN, LORRAINE M. THIRSK, RN, PhD
MEd, PhD, I-FCNEI Assistant Professor
Professor Faculty of Health Disciplines
School of Nursing Athabasca University
Faculty of Health, York University Athabasca, Alberta
Toronto, Ontario
Canada
Associate Editors
SARAH STAHLKE, BScN, MHSA, PhD RAMESH VENKATESA PERUMAL, RN,
Adjunct Professor/Associate Lecturer MSc(N), CCNE, CNCC®, PhD(c)
Department of Sociology Professor
University of Alberta; Edmonton, Alberta School of Community and Health Studies
Sessional Instructor Centennial College;
Faculty of Health Disciplines Assistant Professor
Athabasca University School of Nursing
Athabasca, Alberta Faculty of Health
York University
Toronto, Ontario
US Authors
GERI LOBIONDO-WOOD, PhD, RN, FAAN JUDITH HABER, PhD, RN, FAAN
Professor, Director of PhD Nursing Program The Ursula Springer Leadership Professor in Nursing
University of Texas Health Sciences Center Rory Meyers College of Nursing
School of Nursing, Nursing Systems and Technology New York University
Houston, Texas New York, New York
Elsevier
LOBIONDO-WOOD AND HABER’S NURSING RESEARCH IN CANADA:

METHODS, CRITICAL APPRAISAL, AND UTILIZATION, FIFTH EDITION ISBN: 978-0-323-77898-5
Copyright © 2022 Elsevier Inc. All Rights Reserved.
Previous editions copyrighted 2018, 2013, 2009, and 2005 by Elsevier Canada, a division of Reed Elsevier
Canada, Ltd.
Adapted from Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice, 10th edition, by
Geri LoBiondo-Wood and Judith Haber. Copyright © 2022 Elsevier Inc. All Rights reserved. Previous editions
copyrighted 2018, 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986.
ISBN: 978-0-323-76291-5 (softcover).
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Reproducing passages from this book without such written
permission is an infringement of copyright law.
Requests for permission to make copies of any part of the work should be mailed to: College Licensing Officer,
access ©, 1 Yonge Street, Suite 1900, Toronto, ON, M5E 1E5. Fax: (416) 868-1621. All other inquiries should
be directed to the publisher. www.elsevier.com/permissions.
Every reasonable effort has been made to acquire permission for copyright material used in this text and to
acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will
be corrected in future printings.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances in
the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for
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Library of Congress Control Number: 2021946978

Managing Director, Global ERC: Kevonne Holloway
Senior Content Strategist (Acquisitions, Canada): Roberta A. Spinosa-Millman
Content Development Specialist: Theresa Fitzgerald
Publishing Services Managers: Shereen Jameel/Deepthi Unni
Project Managers: Rukmani Krishnan/Manchu Mohan
Design Direction: Renee Duenow
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contents
PART ONE PART TWO
Research Overview, 1 Indigenous Peoples: Research,
RESEARCH VIGNETTE: Nursing research to improve Knowledges, and Ways of
immunization in Canada, 2
Shannon MacDonald
Knowing, 133
RESEARCH VIGNETTE: An Interview with
1 The Role of Research in Nursing, 5 Dr. Evelyn Voyageur, 134
Lorraine Thirsk Caroline Foster-Boucher & Evelyn Voyageur
2 Theoretical Frameworks, 20 7 Indigenous Peoples: Research,

Sarah Stahlke Knowledges, and Ways of Knowing, 138
Caroline Foster-Boucher & Lorraine Thirsk
3 Critical Appraisal Strategies: Reading
Research, 37
Lorraine Thirsk PART THREE
4 Developing Research Questions, Qualitative Research, 165
Hypotheses, and Clinical Questions, 57 RESEARCH VIGNETTE: Public Health Nursing and the
Mina D. Singh & Ramesh Venkatesa Perumal
Social Construction of Mothering, 166
Megan Aston
5 Finding and Appraising the Literature, 82
Lorraine Thirsk
8 Introduction to Qualitative Research, 168
Sarah Stahlke & Lorraine Thirsk
6 Legal and Ethical Issues, 104
9 Qualitative Approaches to Research, 186
Lorraine Thirsk & Sarah Stahlke
iii

iv CONTENTS
PART FOUR 17 Quantitative Data Analysis, 367

Mina D. Singh
Quantitative Research, 209
RESEARCH VIGNETTE: Why I Focus on Violence Against
18 Presenting the Findings, 400
Mina D. Singh
Women and Girls (VAWG), 210
Ruth Rodney
10 Introduction to Quantitative Research, 212 PART SIX

Ramesh Venkatesa Perumal & Mina D. Singh Critiquing Research, 413
11 Experimental and Quasiexperimental RESEARCH VIGNETTE: Rural and Remote Nursing
Designs, 230 Research, 414
Ramesh Venkatesa Perumal & Mina D. Singh Martha MacLeod
12 Nonexperimental Designs, 249 19 Critiquing Qualitative Research, 416

Lorraine Thirsk
20 Critiquing Quantitative Research, 462

Ramesh Venkatesa Perumal & Mina D. Singh
PART FIVE
Processes Related to PART SEVEN
Research, 275 Application of Research:
RESEARCH VIGNETTE: Nursing Workforce, 276
Evidence-Informed Practice, 495
Mélanie Lavoie-Tremblay
RESEARCH VIGNETTE: The Influence of NP Program
13 Sampling, 278 Students in My Current Research Portfolio:
Mina D. Singh & Ramesh Venkatesa Perumal Exploring Medical Cannabis and Applying It to
Clinical Practice, 496
14 Data-Collection Methods, 308 Luisa Barton
21 Developing an Evidence-Informed
15 Rigour in Research, 328 Practice, 498
Mina D. Singh & Lorraine Thirsk Lorraine Thirsk
RESEARCH VIGNETTE: Cancer Survivorship Program:
16 Qualitative Data Analysis, 350 Cancer, Work, Fear of Cancer Recurrence, 526
Lorraine Thirsk & Sarah Stahlke Christine Maheu
CONTENTS v
Appendices D How Does Simulation Impact Building

Competency and Confidence in
Recognition and Response to the
A The Rocks and Hard Places of MAiD: Adult and Paediatric Deteriorating
A Qualitative Study of Nursing Practice Patient Among Undergraduate Nursing
in the Context of Legislated Assisted Students?, 575
Death, 533 Sandra Goldsworthy, J. David Patterson, Martie Dobbs,
Barbara Pesut, Sally Thorne, Catharine J. Schiller, Arfan Afzal & Shelley Deboer
Madeleine Greig & Josette Roussel
E Prenatal Maternal Anxiety as a Risk
B Lanolin for the Treatment of Nipple Pain Factor for Preterm Birth and the Effects
in Breastfeeding Women: A Randomized of Heterogeneity on This Relationship: A
Controlled Trial, 552 Systematic Review and Meta-Analysis, 585
Kimberley T. Jackson & Cindy-Lee Dennis M. Sarah Rose, Gianella Pana & Shahirose Premji
C Mâmawoh Kamâtowin, “Coming GLOSSARY, 611

Together to Help Each Other in
Wellness”: Honouring Indigenous Nursing ANSWERS AND RATIONALES TO THE
Knowledge, 563 CRITICAL JUDGEMENT QUESTIONS, 623
R. Lisa Bourque Bearskin, Brenda L. Cameron, Malcolm
King, Cora Weber-Pillwax, Madeleine Dion Stout, Evelyn
Voyageur, Alice Reid, Lea Bill & Rose Martial INDEX, 630
Author Biographies
Mina D. Singh, RN, RP, BSc, BScN, MEd, in acute care, mainly in the operating room and
PhD, I-FCNEI, is a Professor at the School of intensive care. After moving into leadership and
Nursing, York University. She has a long career administrative roles, she worked in program de-
in nursing, having worked in acute care, mental velopment, hospital management, and professional
health, psychotherapy, and public health. Her regulation. She is currently an adjunct professor and
expertise is as a research methodologist, statisti- lecturer in sociology at the University of Alberta
cian, and program evaluator. In addition, she is and an instructor in the nursing/health studies mas-
a psychotherapist. She won the 2012 National ter’s degree program at Athabasca University. Her
Nursing Research Scholar award and the 2014 research and teaching interests relate to nursing
Accreditation Reviewer Excellence award, both roles, nursing practice environments, employee
granted by the Canadian Association of Schools engagement, organizational studies, professional
of Nursing (CASN). She was an Accreditation regulation, and interprofessional relationships.
Reviewer for CASN for over 18 years and has Sarah is an internationally recognized qualitative
travelled internationally and nationally reviewing methodologist and has taught numerous courses
nursing education programs. and workshops on qualitative research methods.
Lorraine M. Thirsk, RN, PhD, is an Assistant Ramesh Venkatesa Perumal, RN, MSc(N),
Professor in the Faculty of Health Disciplines, CCNE, CNCC®, PhD(c), is a Professor at
Athabasca University. Over the last 20 years, Centennial College and an Assistant Professor at
she has worked in rural and tertiary hospitals, York University. In addition to being a Critical
home care, and palliative care. In advanced Care Nurse, Ramesh has more than 20 years of
practice, she worked as a community therapist, experience in teaching, research, and community
nurse consultant, and a clinical nurse specialist. service. He has served on the editorial boards of
Her research program focuses on family nursing nursing journals and has been a peer reviewer
interventions in adult populations facing seri- of nursing journals. He won a prestigious award
ous illness. As an educator, she is interested in for the best teacher (Award for Excellence in
supporting undergraduate nursing students to Teaching) in 2009 at a public university in
develop competencies in working with families Muscat, Sultanate of Oman. His research and
and supporting graduate students from across teaching interests relate to mentorship in nurs-
the health disciplines in the research process. In ing, Internationally Educated Nurses (IEN), and
addition, she is passionate about supporting and Relational Care in intensive care units.
advancing evidence-informed nursing practice.
Methodologically, she is interested in mixed Geri LoBiondo-Wood, PhD, RN, FAAN, is
methods and using qualitative research to under- Professor and Director of the PhD in Nursing
stand complex interventions. Program at the University of Texas Health Science
Center at Houston, School of Nursing (UTHSC-
Sarah Stahlke, BScN, MHSA, PhD, is a sociolo- Houston) and former Director of Research
gist and a nurse. As a clinician, her experience is and Evidence-Based Practice Planning and
vi
AUTHOR BIOGRAPHIES vii
Development at the MD Anderson Cancer Center, Rory Meyers College of Nursing, at New York
Houston, Texas. She received her Diploma in University. She received her undergraduate
Nursing at St. Mary’s Hospital School of Nursing nursing education at Adelphi University in New
in Rochester, New York; Bachelor’s and Master’s York, and she holds a Master’s degree in Adult
degrees from the University of Rochester; and a Psychiatric–Mental Health Nursing and a PhD
PhD in Nursing Theory and Research from New in Nursing Theory and Research from New York
York University. Dr. LoBiondo-Wood teaches re- University. Dr. Haber is internationally recog-
search and evidence-based practice principles to nized as a clinician and educator in psychiatric–
undergraduate, graduate, and doctoral students. At mental health nursing. She has extensive clinical
MD Anderson Cancer Center, she developed and experience in psychiatric nursing, having been
implemented the Evidence-Based Resource Unit an advanced practice psychiatric nurse in private
Nurse (EB-RUN) Program, a hospital-wide pro- practice for over 30 years, specializing in treat-
gram that involves all levels of nurses in the ap- ment of families coping with the psychosocial se-
plication of research evidence to practice. She has quelae of acute and chronic catastrophic illness.
extensive national and international experience Her NIH-funded program of research addressed
guiding nurses and other health care profession- physical and psychosocial adjustment to illness,
als in the development and utilization of research. focusing specifically on women with breast can-
Dr. LoBiondo-Wood is an editorial board mem- cer and their partners and, more recently, breast
ber of Progress in Transplantation and a reviewer cancer survivorship. Dr. Haber is also committed
for Nursing Research, Oncology Nursing Forum, to an interprofessional program of clinical schol-
Oncology Nursing, and Nephrology Nursing arship related to improving oral-systemic health
Journal. Her research and publications focus on outcomes and leads the Oral Health Nursing
chronic illness and oncology nursing. Education and Practice (OHNEP) program
Dr. LoBiondo-Wood has been active locally funded by the DentaQuest Foundation, as well
and nationally in many professional organiza- as the HRSA-funded Teaching Oral Systemic
tions, including the Oncology Nursing Society, Health (TOSH) program.
Southern Nursing Research Society, the Midwest Dr. Haber has been active locally and nation-
Nursing Research Society, and the North American ally in many professional organizations, including
Transplant Coordinators Organization. She has re- the American Nurses Association, the American
ceived local and national awards for teaching and Psychiatric Nurses Association, and the American
contributions to nursing. In 1997, she received Academy of Nursing. She has received numerous
the Distinguished Alumnus Award from New local, state, and national awards for public policy,
York University, Division of Nursing Alumni clinical practice, and research, including the APNA
Association. In 2001, she was inducted as a Fellow Psychiatric Nurse of the Year Award in 1998 and
of the American Academy of Nursing and in 2007 2005 and the APNA Outstanding Research Award
as a Fellow of the University of Texas Academy in 2005. She received the 2007 NYU College of
of Health Science Education. In 2012, she was ap- Nursing Distinguished Alumnus Award, the 2011
pointed as a Distinguished Teaching Professor of NYU Distinguished Teaching Award, and the 2013
the University of Texas System. NYU Alumni Meritorious Service Award. In 1993,
she was inducted as a Fellow of the American
Judith Haber, PhD, RN, FAAN, is the Ursula Academy of Nursing and in 2012 as a Fellow in
Springer Leadership Professor in Nursing at the the New York Academy of Medicine.
Contributors
Megan Aston, RN, PhD Martha MacLeod, RN, PhD
Professor Professor
School of Nursing School of Nursing & School of Health Sciences
Dalhousie University University of Northern British Columbia
Halifax, Nova Scotia Prince George, British Columbia
Luisa Barton, NP-PHC, BScN, MN, DNP Christine Maheu, PN, PhD
Assistant Professor Associate Professor
Faculty of Health Disciplines Ingram School of Nursing
Athabasca University McGill University
Athabasca, Alberta Montreal, Quebec
Caroline Foster-Boucher, RN, MN Ruth Rodney, RN, PhD

Assistant Professor Assistant Professor
Department of Nursing Science School of Nursing
MacEwan University York University
Edmonton, Alberta Toronto, Ontario
Mélanie Lavoie-Tremblay, BScN, MScN, PhD Evelyn Voyageur, RN, PhD (psychology)
Associate Professor Elder in Residence, Aboriginal Education
Ingram School of Nursing North Island College, Comox Valley Campus
McGill University Courtney, British Columbia
Montréal, Quebec
Shannon MacDonald, RN, PhD

Assistant Professor
Faculty of Nursing
University of Alberta
Edmonton, Alberta
viii
Reviewers
Miranda Bevilacqua, RN, BScN, MN, PhD(c) Catherine (Cathy) Doreen MacDonald, BScN, RN,
Professor MN, PhD
School of Health, Negahneewin, & Community Services Associate Dean Academic Affairs, Arts & Science
Confederation College Arts & Science & Nursing
Thunder Bay, Ontario Rankin School of Nursing
Saint Francis Xavier University
Ellen Buck-McFadyen, RN, MScN, PhD Antigonish, Nova Scotia
Assistant Professor
Trent/Fleming School of Nursing Elise J. Matthews, BScN, BA, RN, PhD
Trent University Assistant Professor
Peterborough, Ontario Faculty of Nursing
University of Regina
Tracy M. Christianson, RN, BSN, MN, DHEd, CCNE Regina, Saskatchewan
Assistant Professor
School of Nursing Christie Pettipas, BSW, MPA, EdD
Thompson Rivers University Instructor
Kamloops, British Columbia School of Community Studies
Bow Valley College
Calgary, Alberta
Angela J. Gillis, RN, PhD
Professor Emeritus
Cheryl Pollard, RPN, RN, PhD
School of Nursing
Dean
Saint Francis Xavier University
Faculty of Nursing
Antigonish, Nova Scotia
University of Regina
Regina, Saskatchewan
Tracy Hoot RN, BScN, MSN, DHEd
Associate Dean Nancy A. Sears, RN, BNSc, MPA, CHE, PhD
School of Nursing Professor
Thompson Rivers University School of Baccalaureate Nursing
Kamloops, British Columbia St. Lawrence College (Laurentian University
collaborative BScN program)
Laura Anne Killam, BScN, RN, MScN Kingston, Ontario
Professor
Health Sciences, Nursing & Emergency Services Candice Waddell, RPN, BScPN, MPN, PhD(c)
Cambrian College Assistant Professor
Sudbury, Ontario Department of Psychiatric Nursing
Faculty of Health Studies
Tsorng-Yeh Lee, RN, PhD Brandon University
Associate Professor Brandon, Manitoba
School of Nursing
York University Karla L. Wolsky, RN, PhD
Toronto, Ontario Nursing Instructor
Nursing Centre for Health and Wellness
Lethbridge College
Lethbridge, Alberta
ix

Acknowledgements
THIS MAJOR UNDERTAKING WAS ACCOMPLISHED WITH writing during the pandemic would mean ex-
the help of many people, some of whom made tending deadlines
direct contributions to this new edition and some • Our vignette contributors, whose willingness
of whom contributed indirectly. We acknowledge to share their wisdom and evidence of their in-
with deep appreciation and our warmest thanks novative research made a unique contribution
the following people who made this fifth Cana- to this edition
dian edition possible: • All of the reviewers, who provided thoughtful
• The Inuit, First Nations, and Métis people who feedback not only on the previous four edi-
first lived on these lands and whose ancestors tions but also on the fifth Canadian edition
shared their knowledge with the settlers manuscript
• Nursing educators across Canada who provided • Our families, who supported us and picked up
valuable and insightful comments that helped the “loose ends” while we wrote and revised.
to direct the revisions featured in this edition
and contributed to improving the content To my husband Neranjan, my daughter Sandhya,
• Our students, particularly past and present and my parents Ram and Betty Laljie, for their
nursing students at York University, University support and encouragement.
of Alberta, and Athabasca University, who in- Mina D. Singh
spired us with their feedback and ideas
• Roberta A. Spinosa-Millman, Senior Content To my husband Reidar Hagtvedt, my sons
Strategist, who got us started with encourage- Benjamin and Alexander, and my parents Theo
ment, a sense of humour, and great insight and Margot Thirsk. Completing this fifth edition,
• Theresa Fitzgerald, Content Development Spe- during the pandemic, would not have been pos-
cialist, who encouraged us with positive feed- sible without your support.
back, made sense of the process, and understood Lorraine M. Thirsk
x
Preface
THE FOUNDATION OF THE FIFTH CANADIAN edition of
evident not only in the undergraduate nursing
LoBiondo-Wood and Haber’s Nursing Research
research course but also throughout the curric-
in Canada: Methods, Critical Appraisal, and
ulum. The research role of nurses calls for ev-
Utilization continues to be the belief that nursing
idence-informed practice competencies; central
research is integral to all levels of nursing edu-
to this are critical appraisal skills—that is, nurses
cation and practice. Since the first edition of this
should be competent in using research.
textbook, we have seen the depth and breadth of
Preparing students for this role involves de-
nursing research grow. More nurses are conduct-
veloping their critical thinking and reading
ing research and using research evidence to shape
skills, thereby enhancing their understanding of
clinical practice, education, administration, and
the research process and their ability to appraise
health policy.
research critically. An undergraduate course in
The Canadian Nurses Association promotes
nursing research should develop this basic level
the notion that nurses must provide care that is
of competence, which is an essential requirement
based on the best available scientific evidence.
if students are to engage in evidence-informed
This is an exciting challenge to meet. Nurses are
clinical decision-making and practice. This con-
using the best available evidence, combined with
trasts with a graduate-level research course, in
their clinical judgement and patient preferences,
which the emphasis is on conducting research, as
to influence the nature and direction of health care
well as understanding and appraising it.
delivery and to document outcomes related to the
The primary audience for this textbook remains
quality and cost-effectiveness of patient care. As
undergraduate students who are learning the steps
nurses continue to develop a unique body of nurs-
of the research process, as well as how to develop
ing knowledge through research, decisions about
clinical questions, critically appraise published
clinical nursing practice will be increasingly evi-
research literature, and use research findings to
dence informed.
inform evidence-informed clinical practice. This
As editors, we believe that all nurses not only
book is also a valuable resource for students at the
need to understand the research process but also
Master’s and doctoral levels who want a concise
need to know how to critically read, evaluate,
review of the basic steps of the research process,
and apply research findings in practice. We real-
the critical appraisal process, and the principles
ize that understanding research, as a component
and tools for evidence-informed practice.
of evidence-informed practice, is a challenge for
This text is also a key resource for health
every student, but we believe that the challenge
care leaders who are preparing to be experts at
can be accomplished in a stimulating, lively, and
evidence-informed initiatives in clinical settings.
learner-friendly manner.
Furthermore, it is an important resource for
Consistent with this perspective is a com-
practising nurses who strive to use research evi-
mitment to advancing implementation of the
dence as the basis for clinical decision-making
evidence-informed practice paradigm. Under-
and development of evidence-informed poli-
standing and applying nursing research must
cies, protocols, and standards, rather than rely
be an integral dimension of nursing education,
on tradition, authority, or trial and error. It is an
xi
xii PREFACE
important resource for nurses who collaborate producers, they must become knowledgeable
with nurse-scientists in the conduct of clinical research consumers.
research and evidence-informed practice. • Emphasizing the role of evidence-informed
Building on the success of the fourth edition, practice as the basis for informing clinical de-
we maintain our commitment to introduce evi- cision-making and nursing interventions that
dence-informed practice and research principles support nursing practice, demonstrating qual-
to baccalaureate students, thereby providing a ity and cost-effective outcomes of nursing care
cutting-edge research consumer foundation for delivery.
their clinical practice. • Presenting numerous examples of recently
Knowledge and language concerning sex, gen- published research studies that illustrate and
der, and identity are fluid and continually evolv- highlight each research concept in a manner
ing. The language and terminology presented in that brings abstract ideas to life for students
this text endeavours to be inclusive of all people new to the research and critical appraisal pro-
and reflects what is to the best of our knowledge cess.
current at the time of publication. • These examples are a critical link for reinforce-
LoBiondo-Wood and Haber’s Nursing Research ment of evidence-informed concepts and the
in Canada: Methods, Critical Appraisal, and related research and critiquing process.
Utilization prepares nursing students and practis- • Showcasing, in Research Vignettes, the work
ing nurses to become knowledgeable nursing re- of renowned nurse researchers whose careers
search consumers in the following ways: exemplify the links among research, education,
• Addressing the evidence-informed practice and practice.
role of the nurse, thereby embedding evidence- • Providing numerous pedagogical chapter fea-
informed competence in the clinical practice of tures, including Learning Outcomes, Key
every baccalaureate graduate. Terms, Key Points, new Critical Think-
• Demystifying research, which is sometimes ing Challenges, Research Hints, Evidence-
viewed as a complex process. Informed Practice Tips, new Practical Appli-
• Using an evidence-informed approach to teach- cations, revised Critical Thinking Decision
ing the fundamentals of the research process. Paths, and Critical Judgement Questions, as
• Teaching the critical appraisal process in a well as numerous tables, boxes, and figures. At
user-friendly but logical and systematic pro- the end of each chapter that presents a step of
gression. the research process, we feature a section titled
• Promoting a lively spirit of inquiry that devel- Appraising the Evidence, which reviews how
ops critical thinking and critical reading skills, each step of the research process should be
facilitating mastery of the critical appraisal evaluated from a consumer’s perspective. This
process. section is accompanied by an updated Critiqu-
• Developing information literacy, searching, ing Criteria box.
and evidence-informed practice competencies • Providing a Study Guide that promotes active
that prepare students and nurses to effectively learning and assimilation of nursing research
locate and evaluate the best available research content.
evidence. • Offering an Evolve site presenting free Evolve
• Elevating the critical appraisal process and Resources for Instructors that includes a Test
research appreciation to a position of im- Bank, TEACH, PowerPoint slides, critiqu-
portance comparable to that of producing ing exercises, an Image Collection, and criti-
research. Before students become research cal appraisal activities. There are also Evolve
PREFACE xiii
resources for both the student and faculty that students and nurses with the tools necessary to ef-
include an audio glossary. fectively search, retrieve, manage, and evaluate
The fifth Canadian edition of LoBiondo-Wood research studies and their findings. This chapter
and Haber’s Nursing Research in Canada: also develops research consumer competencies
Methods, Critical Appraisal, and Utilization is that prepare students and nurses to critically read,
organized into seven parts. Each part is preceded understand, and appraise a study’s literature re-
by an introductory section and opens with an ex- view and framework. The final chapter in this
citing “Research Vignette” by a renowned nurse section, Chapter 6, “Legal and Ethical Issues,”
researcher. provides an overview of the increased emphasis
Part One, Research Overview, contains six on the legal and ethical issues facing researchers
chapters. Chapter 1, “The Role of Research in in Canada.
Nursing,” provides an excellent overview of re- Part Two, Indigenous Peoples: Research,
search and evidence-informed practice processes Knowledges, and Ways of Knowing, is an ex-
that shape clinical practice. This chapter introduces citing, brand-new section in this fifth edition. We
the role that research plays in practice and educa- were honoured to be able to include an interview
tion, the roles of nurses in research activities, a his- with Elder Evelyn Voyageur, and to work with
torical perspective, and future directions in nursing Caroline Foster-Boucher, to develop Chapter 7,
research. The style and content of this chapter are “Indigenous Peoples: Research, Knowledges, and
designed to make subsequent chapters more user- Ways of Knowing.” This section will introduce
friendly. Chapter 2, “Theoretical Framework,” fo- students to the history and significance of colo-
cuses specifically on how theoretical frameworks nization as it relates to how Indigenous peoples
guide and inform knowledge generation through have been affected by, and are affecting, nursing
the research process. Chapter 3, “Critical Appraisal and health research. The chapter highlights the
Strategies: Reading Research,” addresses students relevant recommendations from the Truth and
directly and highlights critical thinking and critical Reconciliation Commission and offers a begin-
reading concepts and strategies, thereby facilitat- ning exploration of Indigenous Methodologies.
ing students’ understanding of the research process Part Three, Qualitative Research, contains
and its relationship to the critical appraisal process. two interrelated qualitative research chapters.
This chapter introduces a model evidence hierar- Chapter 8, “Introduction to Qualitative Research,”
chy that is used throughout the text. provides a framework for understanding qualita-
The next two chapters address foundational tive research designs and literature, as well as
components of the research process. Chapter 4, the significant contribution of qualitative re-
“Developing Research Questions, Hypotheses, search to evidence-informed practice. Chapter 9,
and Clinical Questions,” focuses on how research “Qualitative Approaches to Research,” presents,
questions, hypotheses, and evidence-informed illustrates, and, in examples from the literature,
practice questions are derived, operationalized, showcases major qualitative methods. This chap-
and critically appraised. Numerous clinical ex- ter highlights the questions most appropriately
amples illustrating different types of research answered using qualitative methods.
questions and hypotheses maximize student un- Part Four, Quantitative Research, con-
derstanding. Students are also taught how to de- tains Chapter 10 (“Introduction to Quantitative
velop clinical questions that are used to guide Research”), 11 (“Experimental and Quasiex-
evidence-informed inquiry. Chapter 5, “Finding perimental Designs”), and 12 (“Nonexperimental
and Appraising the Literature,” showcases cut- Designs”). These chapters delineate the essential
ting-edge information literacy content, providing steps of the quantitative research process, with
xiv PREFACE
published, current clinical research studies used to frameworks for implementing and evaluating the
illustrate each step. Links between the steps and outcomes of evidence-informed health care.
their relationship to the total research process are The Evolve website that accompanies the fifth
examined. Canadian edition provides interactive learning activ-
Part Five, Processes Related to Research, de- ities that promote the development of critical think-
scribes the specific steps of the research process for ing, critical reading, and information literacy skills
qualitative and quantitative studies. The chapters designed to develop the competencies necessary to
make the case for linking an evidence-informed produce informed consumers of nursing research.
approach with essential steps of the research pro- Instructor resources are available at a passcode-
cess by teaching students how to critically ap- protected website that gives faculty access to all in-
praise the strengths and weaknesses of each step structor materials online, including the TEACH for
of the research process. Students learn how to se- Nurses Lesson Plans, Image Collection, PowerPoint
lect participants (Chapter 13, “Sampling”), gather Slides, a Test Bank that allows faculty to create ex-
data (Chapter 14, “Data-Collection Methods”), aminations through the use of the ExamView test
analyze the results (Chapter 16, “Qualitative Data generator program, and more.
Analysis,” and Chapter 17, “Quantitative Data The development and refinement of an evi-
Analysis”), and present their results (Chapter 18, dence-informed foundation for nursing practice is
“Presenting the Findings”). Chapter 15, “Rigour an essential priority for the future of professional
in Research,” gives students the tools for assess- nursing practice. The fifth Canadian edition of
ing the quality and trustworthiness of a study. LoBiondo-Wood and Haber’s Nursing Research
Part Six, Critiquing Research, makes the case in Canada: Methods, Critical Appraisal, and
for linking an evidence-informed approach with Utilization will help students develop a basic
essential steps of the research process by teaching level of competence in understanding the steps of
students how to critically appraise the strengths and the research process that will enable them to criti-
weaknesses of each step of the research process. cally analyze research studies, evaluate their mer-
Each chapter critiques two examples of actual pub- it, and judiciously apply evidence in practice. To
lished research. Chapter 19, “Critiquing Qualitative the extent that this goal is accomplished, the next
Research Articles,” focuses on qualitative research, generation of nursing professionals will include a
whereas Chapter 20, “Critiquing Quantitative cadre of clinicians who inform their practice by
Research,” is based on the quantitative research using theory and research evidence, combined
process. with their clinical judgement, and specific to the
Part Seven, Application of Research: health care needs of patients and their families in
Evidence-Informed Practice, contains the final health and illness.
chapter in the book. Chapter 21, “Developing Mina D. Singh
an Evidence-Informed Practice,” provides a dy- [email protected]
namic review of evidence-informed models. Lorraine M. Thirsk
These models can be applied—step by step, at [email protected]
the organizational or individual patient level—as
To the Student
EVIDENCE-INFORMED PRACTICE is integral to meet- Remember that evidence-informed practice
ing the challenge of providing quality health care skills are used in every clinical setting and can
in partnership with patients and their families be applied to every patient population or nursing
and significant others, as well as with the com- practice issue. Whether your practice involves
munities in which they live. As you read this primary care or specialty care and provides inpa-
fifth Canadian edition of LoBiondo-Wood and tient or outpatient treatment in a hospital, clinic,
Haber’s Nursing Research in Canada: Methods, or home, you will be challenged to use research
Critical Appraisal, and Utilization, we hope you as the foundation for your evidence-informed
develop an appreciation of the importance of practice. The fifth Canadian edition of LoBiondo-
nursing research to practice. Whether you are a Wood and Haber’s Nursing Research in Canada:
student or a practising nurse whose goal is to use Methods Critical Appraisal, and Utilization will
research evidence as the foundation of your prac- guide you as you discover your ability to play
tice, you will discover that nursing research and a a vital role in contributing to the building of an
commitment to evidence-informed practice posi- evidence-informed professional nursing practice.
tions our profession at the forefront of change. As Mina D. Singh
you learn about nursing research and evidence- [email protected]
informed practice, you will develop a foundation Lorraine M. Thirsk
of knowledge and skills that will equip you for [email protected]
clinical practice today and into the future.
The fifth Canadian edition of LoBiondo-Wood
and Haber’s Nursing Research in Canada: Meth- A NOTE ABOUT THE
ods, Critical Appraisal, and Utilization reflects NEXT-GENERATION NCLEX
cutting-edge trends for developing evidence- The National Council for the State Boards of
informed nursing practice. The seven-part or- Nursing (NCSBN) is a not-for-profit organiza-
ganization and special features in this text are tion whose members include nursing regulatory
designed to help you develop your critical think- bodies. In empowering and supporting nursing
ing, critical reading, information literacy, and regulators in their mandate to protect the pub-
evidence-informed clinical decision-making while lic, the NCSBN is involved in the development
providing a user-friendly approach to learning of nursing licensure examinations, such as the
that expands your competence to deal with these NCLEX-RN®. In Canada, the NCLEX-RN® was
new and challenging experiences. The compan- introduced in 2015 and is, as of the writing of this
ion Study Guide, with its chapter-by-chapter ac- text, the recognized licensure exam required for
tivities, will serve as a self-paced learning tool to practising RNs in Canada.
reinforce the content of the text. The accompa- The NCLEX-RN® will, as of 2023, be changing
nying Evolve website offers “summative” review in order to ensure that its item types adequately
material to help you reinforce the concepts dis- measure clinical judgement, critical thinking, and
cussed throughout the book. problem-solving skills on a consistent basis. The
xv

xvi TO THE STUDENT
NCSBN will also be incorporating into the ex- • All new item types are accompanied by mini
amination what they call the Clinical Judgement case studies with comprehensive patient infor-
Measurement Model (CJMM), which is a frame- mation—some of it relevant to the question,
work that the NCSBN has created to measure a and some of it not.
novice nurse’s ability to apply clinical judgement • Case information may present a single, un-
in practice. changing moment in time (a “single-episode”
These changes to the examination come as a re- case study) or multiple moments in time as a
sult of research findings that indicated that novice patient’s condition changes (an “unfolding”
nurses have a much higher than desirable error rate case study).
with patients (i.e., errors that cause patient harm) • Single-episode case studies may be accompa-
and, upon NCSBN’s investigation, the discovery nied by one to six questions; unfolding case
that the overwhelming majority of these errors studies are accompanied by six questions.
were caused by failures of clinical judgement. For more information (and detail) regarding the
Clinical judgement has been a foundation un- NCLEX-RN® and changes coming to the exam,
derlying nursing education for decades, based on visit the NCSBNs website: https://www.ncsbn
the work of a number of nursing theorists. The .org/11447.htm and https://ncsbn.org/Building_a_
theory of clinical judgement that most closely Method_for_Writing_Clinical_Judgment_It.pdf.
aligns to what NCSBN is basing their CJMM is For further NCLEX-RN® examination prepara
the work by Christine A. Tanner. tion resources, see Silvestri’s Canadian Compre-
The new version of the NCLEX-RN® is loosely hensive Review for the NCLEX-RN® Examination,
being identified as the “Next-Generation NCLEX” Second Edition, ISBN 9780323709385.
or “NGN” and will feature the following: Prior to preparing for any nursing licensure
• Six key skills in the CJMM: recognizing cues, examination, please refer to your provincial
analyzing cues, prioritizing hypotheses, gener- or territorial nursing regulatory body to deter-
ating solutions, taking actions, and evaluating mine which licensure examination is required
outcomes. in order for you to practise in your chosen
• Approved item types as of June 2020: multiple jurisdiction.
response, extended drag and drop, cloze (drop- Next-Generation NCLEX™ (NGN)-Style Case
down), enhanced hotspot (highlighting), and Studies can be found on this text’s accompanying
matrix/grid. More question types may be added. Evolve site.
PA RT ON E
Research Overview
1 The Role of Research in
Nursing
2 Theoretical Frameworks
3 Critical Appraisal Strategies:
Reading Research
4 Developing Research
Questions, Hypotheses,
and Clinical Questions
5 Finding and Appraising the
Literature
6 Legal and Ethical Issues
focus my research on identifying
RESEARCH VIGNETTE and improving system-level fac-
tors that influence convenience,
Nursing Research to Improve such as immunization access,
Immunization in Canada accurate immunization records,
and reminder systems. Through
our research, my team has found
Shannon MacDonald, PhD, RN decided not to give them the vac- that these system-level barriers
Assistant Professor cine. Later in my nursing career, I disproportionately impact vulner-
Faculty of Nursing
travelled to less developed regions able populations, including chil-
University of Alberta
Edmonton, Alberta of the world, where it wasn’t un- dren receiving child intervention
common for mothers to report los- services (Hermann et al., 2019),
ing multiple children to vaccine- First Nations children (MacDon-
We have all seen social media posts preventable diseases. In those ald et al., 2016), and children in
that try to scare people about vac- cases, it wasn’t due to a choice single-parent, low-income fami-
cines. There are claims that vaccines not to vaccinate, but instead due lies that have unstable housing
are unnecessary, ineffective, or to limited access to health ser- (Bell et al., 2015). Identifying
unsafe. Unfortunately, the average vices. The cumulative effect of these at-risk populations allows
Canadian doesn’t see the other side those clinical experiences led to us as nurses to develop strategies
of the story, namely the people who my lifelong passion and program to reach them, and to advocate for
have come to harm because they of research focused on improving public health policies to provide
weren’t protected from vaccine- immunization practices, policies, system-level supports for these
preventable diseases. As nurses, we and parent decision-making. populations. I will share with you
see both sides because we are the The World Health Organization two examples of my research that
ones caring for people infected with (WHO, 2014) has a conceptual seeks to achieve these goals.
these diseases. We also have the sci- framework to explain the influ- Under-immunization of chil-
entific literacy to critically read and ences on vaccine hesitancy and dren receiving child intervention
evaluate the evidence on this topic. uptake. They identify ‘the 3 Cs’: services: Children who receive
Thus, nurses are in the ideal posi- Complacency (vaccines are not intervention from the child wel-
tion to promote vaccine uptake; to perceived as necessary), Con- fare system (sometimes referred
advocate for equitable vaccine ac- fidence (lack of trust in the vac- to as “children in care”) typically
cess; and to ask important research cines/providers/policy-makers), do so to ensure their safety and
questions that ensure that safe and and Convenience (physical avail- security (Canadian Child Welfare
effective vaccine programs contin- ability, affordability, geographical Research Portal, 2020). However,
ue to be provided to Canadians. accessibility, ability to understand, the circumstances in their home,
My own interest in the immuni- and appeal/ease of immunization the processes of removal from
zation field started when I worked services). Any one, or a combina- their home, and their subsequent
as a nurse in the Pediatric Inten- tion, of these factors can act as an placement in one or more other
sive Care Unit. I cared for children impediment to someone accepting care settings (e.g., foster care
who were on ventilators as a result vaccines for themselves or their homes) may result in interrup-
of a whooping cough infection children. tions in provision of their immu-
contracted because they were too When considering the WHO nizations (Hermann et al., 2019).
young to be vaccinated; teenagers ‘3 Cs’ framework, I have al- In our study (Hermann et al.,
who lost hands or legs to menin- ways found it striking that ‘con- 2019), we wanted to assess vac-
gococcemia because the vaccine venience’ can prevent someone cine coverage (i.e., the proportion
wasn’t yet available to them; and from vaccinating, even if com- of the eligible population who
children who had measles enceph- placency or confidence are not a have received a vaccine) of chil-
alopathy because their parents had concern. Thus, I have chosen to dren who had spent time in care of
2
the child welfare system. What we coverage for rotavirus vaccine, the largest groups of health care
discovered was that children in in order to identify areas for im- providers, and the most trusted
care have consistently lower vac- proved service delivery. What by the public (Milton, 2018), we
cine coverage than children who we found was that pre-term in- are in a prime position to provide
had never been in care. For infants were less likely to be vac- clear, evidence-informed guid-
stance, at age 2, vaccination cov- cinated, despite being at higher ance to families who are strug-
erage for children in care ranged risk of becoming seriously ill gling with the immunization de-
from 54.3% to 81.4%, depend- from a rotavirus infection. Other cision. In many provinces and
ing on vaccine, while coverage studies from the USA (Fathima territories of Canada, nurses are
for those not in care ranged from et al., 2019; Dahl et al., 2018), also the main provider of immu-
74.2% to 87.4%. So, our study re- found similarly that infants that nizations. Thus, the role we can
vealed that vaccine coverage for were pre-term and/or low birth play is significant. Nurses are also
this already vulnerable popula- weight had low rotavirus vaccine ideally positioned to lead research
tion was significantly below the coverage, and that these infants in the field of immunization. We
rest of the population and vastly were more likely to have spent have the clinical perspective, the
below the target level for vaccine their first days/weeks/months in experience of interacting with
coverage (target levels for most a Neonatal Intensive Care Unit families, and the education to en-
vaccines are >95%). As a result (NICU). Our study raised a red gage in critical inquiry. Currently,
of our study, we have advocated flag in Alberta regarding whether there are only a handful of nurses
for improvements in tracking im- infants in the NICU were receiv- in Canada who are working in this
munizations for children in care, ing their recommended vaccines field. My dream is for nurses and
as well as increased collaboration while hospitalized. It led us to emerging nurse researchers to ac-
between health and children’s collaborate with public health and cept the challenge to improve the
services ministries to ensure hospital-based clinicians to assess care provided to families in Cana-
these vulnerable children are bet- and remedy the situation. da and beyond through improved
ter served. We also identified the These are just two examples evidence-informed immunization
need to conduct more research on of the type of research that I and services. ■
this topic, specifically, qualitative my research team have engaged
REFERENCES
studies to identify the specific bar- in to improve immunization ser-
Bell, C. A., Simmonds, K. A., & MacDon-
riers that are preventing equitable vice delivery, and to improve the
ald, S. E. (2015). Exploring the het-
access to immunizations for this convenience for parents seeking erogeneity among partially vaccinated
population. immunizations for their children. children in a population-based cohort.
Rotavirus immunization for The fact that I am a nurse leads Vaccine, 33(36), 4572–4578.
pre-term infants: Rotavirus vac- me to approach this research Canadian Child Welfare Research Portal
(2020). Frequently Asked Questions
cine is provided to infants, start- through a nursing lens. I also
(FAQs). http://cwrp.ca/faqs.
ing when they are 2 months old, approach research from a very Dahl, R. M., Curns, A. T., Tate, J. E.,
with additional booster doses applied, rather than theoretical, & Parashar, U. D. (2018). Effect of
provided before the child turns 8 perspective. I am always eager rotavirus vaccination on acute diarrheal
months old. Unlike some other to move beyond acquisition of hospitalizations among low and very
low birth weight us infants, 2001-
vaccines, there is an upper age knowledge, to identify ways that
2015. The Pediatric Infectious Disease
limit to when children can receive this new knowledge can improve Journal, 37(8), 817–822. https://doi.
the vaccine, due to safety con- clinical care and health policies org/10.1097/INF.0000000000001930.
cerns for older children (Parashar in the real world. Fathima, P., Gidding, H. F., Snelling,
et al., 2018). Our team conducted Nurses, and nurse researchers, T. L., McIntyre, P. B., Blyth, C. C.,
Sheridan, S., & Moore, H. C. (2019).
a study (Rafferty et al., 2019) to have the potential to play impor-
Timeliness and factors associated with
determine whether there were tant roles in supporting immuni- rotavirus vaccine uptake among Aus-
some sub-populations of children zation best practices, policies, and tralian Aboriginal and non-Aboriginal
in Alberta that had lower vaccine parent decision-making. As one of children: A record linkage cohort study.
3

Vaccine, 37(39), 5835–5843. https://doi MacDonald, S. E., Bell, C. A., & Sim- Rafferty, E., Guo, X., McDonald, B.,
.org/10.1016/j.vaccine.2019.08.013. monds, K. A. (2016). Coverage and Svenson, L. W., & MacDonald, S. E.
Hermann, J. S., Featherstone, R. M., Rus- determinants of uptake for privately (2019). Measurement of coverage,
sell, M. L., & MacDonald, S. E. (2019). funded rotavirus vaccine in a Canadian compliance and determinants of
Immunization coverage of children birth cohort, 2008–2013. The Pediatric uptake in a publicly funded rotavirus
in care of the child welfare system in Infectious Disease Journal, 35(6), vaccination programme: A retrospec-
high-income countries: A systematic e177–e179. https://doi.org/10.1097 tive cohort study. BMJ Open, 9(11).
review. American Journal of Preventive /INF.0000000000001125. http://dx.doi.org/10.1136/bmjopen
Medicine, 56(2), e55–e63. https://doi Milton, C. L. (2018). Will nursing con- -2019-031718.
.org/10.1016/j.amepre.2018.07.026. tinue as the most trusted profession? World Health organization (WHO) (2014).
Hermann, J. S., Simmonds, K. A., Bell, C. A., An ethical overview. Nursing Science Report of the SAGE working group on
Rafferty, E., & MacDonald, S. E. (2019). Quarterly, 31(1), 15–16. https://doi.org vaccine hesitancy. http://www.who.int
Vaccine coverage of children in care of the /10.1177/2F0894318417741099. /immunization/sage/meetings/2014
child welfare system. Canadian Journal Parashar, U. D., Cortese, M. M., & Offit, /october/SAGE_working_group_revised
of Public Health, 110(1), 44–51. https://doi P. A. (2018). Rotavirus vaccines _report_vaccine_hesitancy.pdf?ua=1.
.org/10.17269/s41997-018-0135-5. (7th ed.). Philadelphia: Elsevier. Accessed May 14, 2020.
4
C H APT ER 1
The Role of Research in Nursing

Lorraine Thirsk
LEARNING OUTCOMES
After reading this chapter, you will be able to do the following:
• State the significance of research to the practice of nursing.
• Recognize that theory, research, and practice are related.
• Describe the history of nursing research.
• Identify the roles of the research user and producer.
• Identify trends and priorities in health care research.
KEY TERMS
critical appraisal evidence-based practice quality improvement
data evidence-informed practice research
dissemination phenomena
STUDY RESOURCES
Go to Evolve at http://evolve.elsevier.com/Canada/LoBiondo/Research
for the Audio Glossary.
HOW DO YOU KNOW WHAT YOU know? Is it less own experiences, from our family, culture, tradi-
painful for a patient if you remove a burn dress- tions, and authorities. Historically, many nursing
ing slowly or quickly? What are the challenges that practices were based on received wisdom or tra-
pregnant women face in obtaining prenatal care, and dition. Some of the first documentation discuss-
how is this complicated if they lack transportation ing the importance of research evidence in nurs-
or housing? How do you assess pain in someone ing practice is from Florence Nightingale, who, in
with cognitive impairment like dementia? What is the 1850s, noted there was a connection between
the best way to talk with a family who is hesitant to poor sanitary conditions and death rates among
vaccinate their child? Does cannabis have a thera- wounded soldiers (Nightingale, 1863).
peutic effect for the treatment of anxiety? These are In Europe, in the early 20th century, a move-
all questions that can be answered with research and ment began to define criteria that would separate
are important to nurses. science from non-sciences such as pseudoscience,
Research is a systematic way to acquire knowl- metaphysics, ideology, and religion (Hansson,
edge. We also acquire knowledge through our 2017). The scientific method was developed as a
5

6 PART ONE Research Overview
systematic way to determine knowledge and un- skills in relation to the steps of the research pro-
derstand the world. While human beings have an cess. Research Hints, designed to reinforce your
incredible capacity for thinking and understand- understanding and critical thinking, appear at
ing the world around them, the mind does some- various points throughout the chapters. Evidence-
times make mistakes and is influenced by beliefs Informed Practice Tips will help you apply
and ideology that do not always reflect reality. evidence-informed practice strategies in your
Over the last century, psychological studies have clinical practice. Finally, Practical Application
revealed that people have biases in their thought boxes offer examples of translating principles and
processes that can be problematic and give us an methods of nursing research into real-life nursing
incorrect or a skewed view of the world around situations and interventions.
us (Buetow, 2019; Kahneman, 2011; Paley et al., Your critical thinking, critical reading, and
2007). Our hunches about patterns and probabili- clinical decision-making skills will expand as you
ties are insufficient to ensure good decision-mak- develop clinical questions, search the research lit-
ing. Health care resources are scarce, and thus it erature, evaluate the research evidence found in
is prudent for nurses and other health care profes- the literature, and make clinical decisions about
sionals to ensure that scarce resources are used applying the best available evidence. In this
wisely. In other words, we need to know that our book you will discover the “who, what, where,
decisions are based on the best evidence available when, why, and how” of research and develop
(Melnyk & Fineout-Overholt, 2011). a foundation of knowledge, evidence-informed
Research is integral to achieving the goal of practice, and competencies that will equip you
providing quality outcomes in partnership with for 21st-century nursing practice. To begin, this
patients, their families and significant others, chapter provides an overview of the importance
and the communities in which they live. As you of research to evidence-informed practice, the
progress through your educational program you role that research plays in practice, the roles of
will be taught how to ensure quality and safety nurses in research activities, and future directions
in practice by acquiring knowledge of various of health care research.
sciences and health care principles. Research is a
critical foundation of an evidence-informed ap-
proach to nursing practice, positioning nurses at SIGNIFICANCE OF RESEARCH AND
the cutting edge of change and improvement in EVIDENCE-INFORMED PRACTICE
patients’ outcomes. The health care environment is changing at an in-
The aim of this book is to prepare you to criti- creasingly rapid pace. The challenges associated
cally appraise research and incorporate research with these changes and with nursing’s rapid pace
into your practice. Throughout this text you will of growth can best be met by integrating evidence-
find special features that will help refine and de- informed knowledge into nursing practice. Nurs-
velop your competence in using research. Each ing research provides scientific knowledge that
chapter contains a Critical Thinking Decision enables nurses to keep up with these changes.
Path related to each step of the research process; In learning about research, it is important
these will sharpen your decision-making skills as to differentiate between the terms research,
you critique research articles. Internet resources evidence-based practice, and evidence-informed
in the chapters will also enhance your research practice. Research is systematic, rigorous, logi-
user skills. Critical Thinking Challenges, which cal investigation with the aim of answering ques-
appear at the end of each chapter, are designed tions about nursing phenomena. Phenomena can
to reinforce your critical thinking and judgment be defined as occurrences, situations, or facts that
CHAPTER 1 The Role of Research in Nursing 7
are perceptible by the senses. Although the ori- more inclusive and interactive process of decision-
gin of the term phenomena refers to events that making that pertains to all nurses—whether they
are observable and/or measurable, nurses are also are clinicians, educators, researchers, administra-
interested in experiences that are not easily ob- tors, or policy-makers (CNA, 2018). Building on the
served, such as the experiences of pain, loss, or foundation of evidence-based practice, evidence-
anxiety. informed practice also involves acknowledging
In the past 25 years, many health care dis- and considering the myriad factors that constitute
ciplines have adopted the tenets of evidence- decision-making, taking into account patient pref-
informed practice to provide better health care erence, culture, history, and local context.
for their patients. The roots of modern evi- When you first read about the research and the
dence-informed practice stem from Dr. Archie evidence-informed practice process, you will no-
Cochrane’s investigation of the efficacy of health tice that both processes may seem similar. Each
care interventions, particularly in medicine. begins with a question. The difference is that in
His work resulted in the establishment of the a research study, the question is tested with a de-
Cochrane Collaboration, which provides system- sign appropriate for the question and with specific
atic reviews of health care interventions. methods (sample, instruments, procedures, and
In 1996, Sackett and colleagues defined data analysis). In the evidence-informed practice
“evidence-based medicine” as the “conscientious, process, a question is used to search the literature
explicit, and judicious use of current best evidence for studies already completed and then you criti-
in making decisions about the care of individual cally appraise this literature in order to answer
patients” (p. 312). This was considered the be- your clinical question.
ginning of evidence-based practice, which most Broadly, there are two types of research: quanti-
health professions have now adopted. Research is tative and qualitative. Increasingly, many research-
completed, published in academic journals, and ers use mixed methods—in other words, they
then assessed to determine application to clinical utilize both types of research in one project, or in
practice—this results in practice that is evidence- examination of one phenomenon in a program of
based. The evidence-based practice movement research. You will be introduced to these types of
has not been without challenges and problems. research in more depth in Chapter 2. In addition,
The strict application of algorithms and guide- the Research Vignettes included throughout the
lines, along with selective trials that overlook text will introduce you to nurses who use a variety
multiple morbidities, means that individual pa- of research methods to study phenomenon impor-
tients are not always receiving the most appropri- tant to health care and nursing practice. The meth-
ate care (Greenhalgh et al., 2014). Evidence-based ods used by nurse researchers are the same meth-
practice can become rigid and not consider patient ods used in other disciplines; the difference is that
preferences, individuality, and contexts. nurses study questions relevant to nursing practice.
Evidence-informed practice extends beyond Nurse researchers also conduct research collab-
the early definitions of evidence-based practice. oratively with researchers from other disciplines.
With evidence-informed practice, the methods for Through the conducting of research, they produce
gathering evidence are the same as the processes knowledge that is reliable and useful for nursing
used for evidence-based practice; however, the practice. The methods and findings of studies pro-
evidence also incorporates expert opinion, clini- vide evidence that is evaluated, and their applica-
cal expertise, patient preference, and other re- bility to practice is used to inform decisions.
sources (CNA, 2018). It is important to remem- Throughout this text, the steps of the research
ber that evidence-informed practice focuses on a and evidence-informed practice processes are
described. Understanding the step-by-step pro-

cess that researchers use will help you develop Practical Application
the assessment skills necessary to judge the Dan Ariely was badly burned when he was
18 years old (Ariely, 2009)—70% of his body experi-
soundness of research studies and participate in
1234567890-=qwertyuiop[]\asdfghjkl;’zx-
enced 3rd degree burns. During daily dressing changes,
or lead research projects someday. Chapter 21
cvbnm,./
he noticed that most of the nurses would grab the
will further describe how you can implement evi- bandages and rip them off as quickly as possible. He
dence into practice to improve patient outcomes. recalls thinking the nurses had theorized that quick,
sharp bursts of pain were better for the patient than
slowly pulling off the bandages. In addition, he noticed
RESEARCH: THE ELEMENT THAT LINKS that there was no rationale as to whether the dressing
changes were started at the most painful part of his
THEORY, EDUCATION, AND PRACTICE body or the least painful part. As a patient, he had opin-
Research links theory, education, and practice. ions about which methods were better, but there did
not seem to be any evidence to help guide the nurses
Theoretical formulations supported by, or devel- on the best methods. When he later attended univer-
oped from, research findings may become the sity, Ariely began working as a research assistant and
foundations of theory-informed practice in nurs- eventually started to test some of his theories about
ing and inform further research studies. Your edu- pain and the removal of burn dressings. The research he
conducted showed that slowly removing burn dressings
cational setting, whether a nursing program or the would result in the least amount of pain for the patient.
health care organization where you are employed, He wondered how these kind and experienced nurses
provides an environment in which you, as a stu- could be so wrong. “I knew that their behaviour was
not due to maliciousness, stupidity, or neglect. Rather,
dent or an employee, can learn about the research they were most likely the victims of inherent biases in
process. In the setting of a nursing program or their perceptions of their patients’ pain—biases that ap-
a health care organization, you can also explore parently were not altered even by their vast experience”
(Ariely, 2009, p. xvi). Interestingly, when he reported his
different theories and practices and begin to evalu- results back to the nurses at the burn unit, one nurse
ate them based on research findings. The knowl- explained that perhaps removing the dressings quickly
edge you gain through your educational program, lessened the nurse’s psychological pain, which they ex-
whether theory or research based, will inform the perienced when they inflicted pain on patients.
decisions that you make in your practice. See the Source: Based on Ariely, D. (2009). Predictably Irrational: The Hidden
Forces That Shape Our Decisions. New York:. Harper Perennial.
Practical Application box for an example of how
theory and research influence health care practices.
The example in the Practical Application box through research, and then this new evidence needs
is an attempt to answer a question that you may to be incorporated into practice. Often in the ab-
have asked before taking this course: “How will the sence of evidence, theoretical knowledge will guide
theory and research content of this course relate to practice. Research can also be used to generate new
my nursing practice?” This example demonstrates theory. The relationships between theory, practice,
how theory informs practice, how knowledge based and research will be further explored in Chapter 2.
only on experience can be biased and limited, and
how approaching clinical problems with system- Evidence-Informed Practice Tip
atic, scientific research methods can improve pa- What is the current evidence on how to remove
tient outcomes. Dan Ariely was not a nurse, but this burn dressings? Given that the example provided was
anecdote demonstrates how nursing practice could over a decade old, has this research been incorporated
be drastically changed by research. In this example into practice? Has more recent research been done?
Health care leaders have an important role to play in
you can see how theory, research, and practice are implementing research in practice areas. Implementing
connected. Theory is used to explain causal rela- research in practice requires support from leaders who
tionships (e.g., if I remove the dressing quickly, are champions of evidence (see Chapter 21 for more
about implementing evidence-informed practice).
it will be less painful). Theory needs to be tested
Learning about research will provide you reviewed journals that summarize valid and clinically
with an appreciation and understanding of the useful published studies. (CNA, 2018, p. 1)
research process so that you can more easily Therefore, to use research for evidence-
become a participant in research activities and informed practice, you may not necessarily be
an intelligent consumer of research. A research conducting research, but you can understand
user actively uses and applies research. To be and appraise the steps of the research process in
a knowledgeable research user, you must have order to read the research literature critically and
knowledge about the relevant subject matter, use it to inform your clinical decisions. Even as
the ability to discriminate and to evaluate in- students you can participate by completing sur-
formation logically, and the ability to apply the veys, attending research conferences, and asking
knowledge gained. You need not actually con- questions.
duct research to be able to appreciate and use At a provincial level, each province in Canada
research findings in practice. Rather, you must has its own standards for entry into nursing prac-
understand the research process and develop tice, and many of these standards have specific
the critical evaluation skills needed to judge the related research competencies. For example, the
merit and relevance of evidence before applying College and Association of Registered Nurses of
it to practice. The success of evidence-informed Alberta (2019) outlined the following competen-
practice depends on your ability to understand cies for nurses in their role as scholars:
the research process and to evaluate the evidence. Registered nurses are scholars who demonstrate a
Nurses in practice, who understand research and lifelong commitment to excellence in practice through
its contribution to knowledge, are ideally suited critical inquiry, continuous learning, application of
to identify phenomena and issues to be studied evidence to practice, and support of research activities.
(p. 15)
by asking relevant research questions.
Nurses must be intelligent users of research;
ROLES OF THE NURSE IN THE RESEARCH that is, they must understand all steps of the re-
PROCESS search process and their interrelationships. Frisch
et al. (2013) have developed a useful description
Every nurse practising in the 21 century has a role
of a Health Services Researchers Pathway that ex-
to play in the research process.
plains the five levels of nurses’ roles in research
The Canadian Nurses Association (2017) de-
(Table 1.1). The nurse interprets, evaluates, and
clares that “nurses support, use and engage in
determines the credibility of research findings.
research and other activities that promote safe,
The nurse discriminates between interesting find-
competent, compassionate and ethical care, and
ings for which further investigation is required and
they use guidelines for ethical research that are
those that are sufficiently supported by evidence
in keeping with nursing values” (p. 9). What does
before applying findings to practice. The nurse
this mean for you? There is a consensus that ef-
should then use these competencies to advance
fective use of research calls for the skills of criti-
nursing or interdisciplinary evidence-informed
cal appraisal; that is, you can appraise research
practice projects (e.g., developing clinical stan-
evidence and use existing standards to determine
dards, tracking quality improvement data, or co-
the merit and readiness of research for use in clin-
ordinating implementation of a pilot project to test
ical practice:
the efficacy of a new wound care protocol) of the
Sources of evidence need to be critically appraised
before their findings are incorporated into decision- workplace committees to which he or she belongs.
making and practice. Sources that meet this standard Nurses are also responsible for generating clinical
include systematic reviews, research studies and peer- questions to identify nursing issues that necessitate
TABLE 1.1
HEALTH SERVICES RESEARCHER PATHWAY
RESEARCH PROCESS DATA ANALYSIS LITERACY KNOWLEDGE TRANSLATION
Level 1 Research User: • Defines and distinguishes • Understands and values • Identifies credible and
Learning about between research and statistics and quantitative reliable resources
research use in care quality improvement and qualitative research
delivery settings methods
• Follows agency policy • Reads research reports • Performs literature
and clinical practice searches, integrating
guidelines; collaborates evidence into EIP
on QI activities
• Curious and willing to • Interested in and
learn about research advocates for practice
improvement
Level 2 Research User: • Describes research and • Understands application • Identifies opportunities
Using research in care QI processes; explains QI of statistics and steps of for knowledge sharing,
delivery settings processes and models research process understands concept of
strength of evidence,
distinguishing between
single studies and
systematic reviews
• Interprets protocols for • Collects and uses accurate • Collaborates with team
relevancy, conducts litera- data, uses basic statistics to change practice and
ture reviews, participates and qualitative methods support KT
in policy development
and QI
• Appreciates relationship • Appreciates the process of • Aware of and appreciates
between research and conducting research research activities in the
practice, values active workplace and willing to
engagement of front-line lead KT activities
staff in QI and research
Level 3 Research User: • Describes emerging • Interprets qualitative and • Describes KT practices
Facilitating and knowledge, best practices quantitative data and can and facilitates KT projects,
leading research and priorities; facilitates conduct simple analysis translates projects
use in care delivery research
settings
Level 4 Research • Understands research • Understands advanced • Uses research findings
Producer: Beginning designs and theoretical analysis techniques, to support policy and
researcher frameworks, manages critically and accurately practice, carries out KT
research projects, analyzes research data plans
contributes to research
teams
Level 5 Research • Expertise in at least one • Expert in analysis • Builds and implements KT
Producer: Research method, understands methods in own research as part of own research
scientist leading a various research program, manages and program
program of research approaches supervises use of data,
values rigorous analysis
• Leads a program of
research
Source: Adapted from Frisch & Hamilton (2013). Health Services Researcher Pathway. Michael Smith Foundation for Health Research and the BC Nursing
Research Initiative.
investigation and for participating in the imple- master’s-level training also facilitate the investi-
mentation of scientific studies. Nurses often gen- gation of clinical problems by enabling a climate
erate research ideas or questions from hunches, that is open to nursing research and by engaging
gut-level feelings, intuition, or observations of pain evidence-informed practice projects. A clinical
tients or nursing care. These ideas often become nurse specialist prepared with a master’s or doc-
the seeds of research investigations. toral degree in nursing who has clinical expertise
Nurses may participate in research projects as in a specific practice area can be the primary re-
members of research teams in one or more phases searcher or act as a collaborator to “ensure their
of a project. For example, a staff nurse may work practice applies evidence-based care most effec-
on a clinical research unit in which a research tively while being a leader in every aspect of re-
project is underway to test a new type of nurs- search” (CNA, 2020, Roles section).
ing care (e.g., for pain management, prevention To achieve the greatest expertise in appraising,
of falls, or treatment of urinary incontinence). designing, and conducting research, nurses must
In situations such as these, the nurse administers complete PhDs. Nurses with doctoral degrees de-
care according to the format described in the re- velop theories for phenomena relevant to nursing,
search protocol. The nurse may also be involved develop methods of scientific inquiry, and use a
in collecting and recording data relevant to the variety of methods to modify or extend existing
administration of, and the patient’s response to, knowledge so that it is relevant to nursing (or to
nursing care. other areas of health care). In addition to their role
After new knowledge is generated, it is im- as researchers, nurses with doctoral-level training
portant to share findings widely. This is called act as role models and mentors to guide, stimu-
dissemination. Examples of dissemination in- late, and encourage other nurses who are devel-
clude publishing an article or presentation at a oping their research skills. Nurses with doctoral
conference. It may involve joining a health care degrees also collaborate and consult with social,
agency’s research committee or its quality assur- educational, and health care institutions or gov-
ance or quality improvement committee, in which ernmental agencies in their respective research
research articles, integrative reviews of the litera- endeavours. These nurses then disseminate their
ture, and clinical practice guidelines are evaluated research findings to the scientific community, cli-
for evidence-informed clinical decision-making. nicians, and—as appropriate—the general public
Nurses who have graduate degrees are fur- through scientific journal articles and presenta-
ther prepared to conduct research as co-investi- tions at research conferences.
gators or primary investigators. With a master’s An essential responsibility of all nurses is to
degree, nurses can focus on being more active pay special regard to the ethical principles of re-
members of research teams. Although master’s search, especially the protection of human par-
degrees may focus on advanced clinical practice, ticipants (see Chapter 6). For example, nurses car-
advanced practice nurses are still champions for ing for patients who are participating in research
research. They can assume the role of clinical ex- on antinausea chemotherapy must ensure that
pert, collaborating with an experienced research- patients have signed the informed consent form
er in proposal development, data collection, data and that all their questions are answered by the
analysis, and interpretation. Nurses with mas- research team before they begin participation.
ter’s degrees enhance the quality and relevance Furthermore, if patients have an adverse reaction
of nursing research by providing clinical exper- to the medication, nurses must not administer
tise and evidence-informed knowledge about the more doses until they have notified an appropri-
way clinical services are delivered. Nurses with ate member of the research team. Regardless of
their role, nurses need to view the research pro- 1991. Another was established at the University
cess as integral to the growing professionalism in of British Columbia School of Nursing later
nursing. that year, and programs at McGill University
As a professional, you must take time to read and the University of Toronto followed in 1993.
research studies and evaluate them, using the Now there are many doctoral nursing programs
current standards for scientific research. Also, in universities across Canada. In addition, there
you will need to use the critiquing process to has been growth of university-based Registered
identify the strengths and weaknesses of each Psychiatric Nursing programs, with the first mas-
study. Bearing in mind that each study has its ter’s degree established at Brandon University in
limitations, you should consider whether sound 2011.
and relevant evidence from one study can be Growing awareness of the importance of nurs-
used in other settings as well. Chapter 21 will ex- ing research gradually led to the availability of
pand on how to bring research into your nursing research funds. The year 1964 marked the first
practice. time that a federal granting agency funded nurs-
ing research in Canada (Good, 1969). In 1999,
HISTORICAL PERSPECTIVE1 the Canadian government established the Nursing
Research Fund, budgeting $25 million for nursing
During the Crimean War, Florence Nightingale’s
research ($2.5 million over each of the following
detailed and systematic observation of nursing
10 years). The research areas targeted for support
actions and outcomes resulted in major changes
included nursing policies, management, human
in nursing practice. Her work demonstrated the
resources, and nursing care. Although this fund-
importance of systematic observational research
ing is no longer available, nurse researchers have
to nursing practice.
been successful at obtaining Tri-Council fund-
In Canada, the establishment of univer-
ing nationally and international funding to sup-
sity nursing courses starting in 1918, followed
port their programs of research. Tri-Council is a
by master’s degree programs in the 1950s and
term referring to three federal research agencies:
1970s and by doctoral programs in the 1990s
Canadian Institutes of Health Research, National
and 2000s, was crucial to the development of
Science and Engineering Research Council of
nursing research. Since the 1970s and 1980s, the
Canada, and the Social Sciences and Humanities
two major factors in the development of nurs-
Research Council.
ing research have been the establishment of re-
search training through doctoral programs and
the establishment of funding to support nurs- CURRENT STATE AND FUTURE DIRECTIONS
ing research. Throughout the 1970s and 1980s, While the last 30 years has seen an increase
university faculties and schools of nursing built in the number of nurse researchers in Canada,
their research resources so that they could estab- there are still challenges. A global shortage of
lish doctoral programs. The first provincially ap- nursing faculty, particularly of nurses who hold
proved doctoral nursing program was established PhDs, impacts the education of the next genera-
at the University of Alberta Faculty of Nursing in tion of nurses as well as the capacity for nurs-
ing research (Vandyk et al., 2017). In Canada,
1
This section (i.e. Historical Perspectives p. 12) is adapted
there are numerous faculty vacancies and an in-
with permission from Duggleby, W., & Astle, B.J. (2019).
The development of nursing in Canada. In Potter, P., sufficient number of PhD graduates every year
Duggleby, W., Stockert, P. Astle, B., Perry A., & Hall, A. to fill these spaces; recruitment and retention
(Eds.), Canadian fundamental of nursing (6th ed., pp. 75–80). of faculty is a concern with an aging nursing
Elsevier. faculty workforce (Canadian Association of
Schools of Nursing, 2016). Nursing faculty are

needed to teach in undergraduate and gradu- Practical Application
ate programs and mentor the new generation of Dr. Kelli Stajduhar is a professor at the Institute
for Aging and Lifelong Health and the School of Nursing
nurse researchers. To further the body of 1234567890-=qwertyuiop[]\asdfghjkl;’zx-
nurs- at the University of Victoria. With a research career span-
ing knowledge, nurses will need to developcvbnm,./
pro- ning more than 20 years, Dr. Stajduhar leads a team of
grams of research, increase research on nursing researchers studying palliative and end-of-life care is-
interventions and outcomes, and be aware of sues. The work of this team of researchers spans from
palliative care in vulnerable populations (Stajduhar
national and international trends and issues in et al., 2019), supporting family caregivers (Sutherland
health and health care. et al., 2016), and understanding family’s experiences
(Stajduhar et al., 2017). Dr. Stajduhar collaborates with
researchers from around the world, as well as policy
Developing Programs of Research makers and health care providers. This work has influ-
To build robust research knowledge, nurses need enced and will continue to shape a palliative approach
to care in Canada.
to be recruited early in their careers to pursue
graduate education and develop programs of re-
search. Developing a program of research can the importance of research teams. A large cadre
take years. Researchers need time in their careers of nurse researchers, who begin their research
to establish their expertise and develop the neces- careers at a young age, is important for the
sary collaborations and funding streams to sup- development of research programs like Dr.
port their investigations. Stajduhar’s. The goal is to increase the longevity
Research programs that include a series of of research careers, enhance the discipline’s sci-
studies in a similar area, each of which builds entific development, promote mentoring oppor-
on a prior investigation, promote depth and tunities, prepare the next generation of research-
credibility in nursing science. An example of ers, and provide leadership in health care. The
a research program can be seen in the Practical Research Vignettes included in this book have fur-
Application box. To maximize use of resources ther examples of Canadian nurse researchers who
and to prevent duplication, researchers must have developed programs of research addressing
develop intradisciplinary, interdisciplinary, and a variety of current health care trends and issues.
international networks in similar areas of study.
Researchers from a variety of health profes-
sions (e.g., medicine, nursing, and respiratory Interventions and Outcomes
therapy) and other disciplines such as psychol- Globally, there is a need for more research on
ogy, law, and business can come together to de- nursing interventions (Richards, Hanssen, & Bor-
lineate common and unique aspects of patient glin, 2018) and fundamental nursing care (Kitson
care. Interdisciplinary health research may be et al., 2019). Quality research is still needed to
“a team of researchers who come together to re- address essential nursing care tasks including
search an important and challenging health is- managing elimination, hygiene, nutrition, and
sue” (Hall et al., 2006, p. 764). Interdisciplinary mobility with patients (Richards, Hilli, et al.,
research is increasingly becoming a mandate of 2018).
research funders, as it is recognized that exper- Strategies that enhance nurses’ focus on out-
tise is required from many disciplines to solve comes management through evidence-informed
complex health and social problems (Clarke quality improvement activities and the use of
et al., 2012). research findings for effective clinical deci-
Dr. Stajduhar’s work illustrates the value of sion making also are being refined and iden-
building a program of research and highlights tified as research priorities (see Chapter 21).
Evidence-informed practice guidelines, stan- logistical limitations of this method, the number
dards, protocols, decision tools, and critical path- of international collaborative research projects
ways are becoming benchmarks for cost-effec- has increased. Nurse researchers participating in
tive, high-quality clinical practice. For example, collaborative international research projects are
the Registered Nurses’ Association of Ontario well positioned to play a large role in improving
(RNAO) (2016) has developed 50 best practice health care globally (CNA, 2012; Grady, 2015).
guidelines to support nurses in their efforts to pro- An example of international collaboration can be
vide the best possible patient care. seen in Chapter 19 (Harvey et al., 2019).
International organizations committed to the
goal of health care for all help create natural
Evidence-Informed Practice Tip
research partnerships. For example, the World
The COVID-19 pandemic in 2020 created many
challenges and opportunities for nursing research. Health Organization (WHO, n.d.) has established
While delaying the conduct of some research projects a series of collaboration centres to advance health
and funding decisions, the pandemic also resulted in care for the global community. One such centre
a plethora of research on new topics. For example, re-
search is examining the impact of personal protective works toward maximizing the contribution of
equipment on nursing workflow in emergency depart- nursing and midwifery and provides relevant re-
ments (Government of Canada, 2020), standardized search and clinical training to nurses worldwide.
nursing care models for COVID-19 patients (Richards,
2020), and nursing leadership in acute and long term
care settings during the pandemic (Baxter, 2020). Research Priorities Reflecting Trends
and Issues
Funding agencies often determine research pri-
An International Perspective orities based on their needs and interests. These
The continuing development of a national and priorities are often reflective of trends and issues
international research environment is essential in health and health care. In 2018, the Canadian
to the nursing profession’s mission to “improve Association of Schools of Nursing identified seven
the health and well-being of all world citizens” priorities for nursing research:
(National Institute of Nursing Research, 2015, • Indigenous and other vulnerable and/or equity
n.p.). The CNA has been partnering with many seeking communities
international networks in more than 45 countries • Chronic disease management and care delivery
to strengthen the nursing profession’s contribu- across space and time
tion to global health through study, research, and • Home care and primary health care nursing
practice (CNA, 2012). Because of nursing’s em- • Care of older adults across diverse care contexts
phasis on the cultural aspects of care and the in- • Roles, scopes of practice, and value of RNS,
fluence of such factors on practice, international and/or NPs to health care
research is likely to increase. Access to multiple • Nursing care, quality improvement, and patient
populations as a function of globalization allows safety
the testing of nursing science from various per- • Nursing education outcomes
spectives. The Canadian Foundation for Healthcare Im
International research projects are often fo- provement (CFHI, 2020a) supports spreading
cused on comparative research in which a phe- health care innovations throughout Canada by
nomenon is studied in more than one country. bringing together patients, families, health and
Ideally, relationships are formed with researchers social services providers, governments, and other
from the international sites, resulting in collabor- organizations from across the country to solve
ative research projects. Despite the financial and persistent health care problems. Two priority
health challenges that have been identified are sustained life-threatening illnesses will live with
improving access to addiction and mental health the help of new life-sustaining technology that
services, and home and community care (CFHI, will in turn create new demands for self-care and
2020b). These two areas were identified by the family support. Cancer, heart disease, arthritis,
Government of Canada as shared health priorities asthma, chronic pulmonary disease, diabetes, and
between federal, provincial, and territorial gov- Alzheimer’s disease, prevalent during middle age
ernments (Health Canada, 2018). and later life, will be responsible for expendi-
The Canadian Institute for Health Research tures of large proportions of the available health
(CIHR) is one of the largest funders of health re- care resources. The impacts of the COVID-19
search, although the application process is highly pandemic on the health of individuals and com-
competitive, with as few as 13% of applicants be- munities will likely not be fully understood for
ing successful in procuring funding (Semeniuk, years. HIV/AIDS, a chronic illness that affects
2016). men, women, and children, will continue to have
In 2016, CIHR developed a strategy for a significant effect on health care delivery. Access
patient-oriented research to help engage patients to quality palliative care services and ground-
in research as more than just participants and to breaking research on medical assistance in dying
promote research that addressed patients’ con- will be prevalent.
cerns (CIHR, 2018). This resulted in research
Another vulnerable population, persons with
units being developed across the country to
mental health illness and addictions, will be
help researchers increase and improve patient-
served by a better understanding of mental disor-
oriented research. It has impacted how research-
ders, which will emerge because of advancements
ers get funding for research and offers support to
in psychobiological knowledge and research ini-
help facilitate research that is focused on patient
tiatives. Mental health illnesses will continue to
outcomes.
be a major public health issue; “depression is
Reducing health disparities in underserviced
a leading cause of disability and a major con-
communities and vulnerable populations is an-
tributor to the overall global burden of disease”
other major topic that will shape the focus of
future nursing- and interdisciplinary-related re- (WHO, 2020, Key Facts). Alcohol and drug abuse
search agendas, particularly among Indigenous will continue to be responsible for significant in-
peoples. The CIHR (2020) has an Institute dividual suffering and health care expenses as
of Indigenous Peoples’ Health and the health well as significant social and economic losses
of First Nations, Inuit and Metis Peoples is a (WHO, 2018).
priority for the other institutes of CIHR that Nurse researchers will have an increasingly
offer research funding. In 2019, CIHR created strong voice in shaping public policy relating to
six research awards for Indigenous Research health care. Disciplines such as nursing—because
Chairs in Nursing. These awards, totalling close of its focus on treatment of chronic illness, health
to $6 million, support Indigenous and non- promotion, independence in health, and care of
indigenous nurses to conduct research focused the acutely ill, all of which are heavily emphasized
on Indigenous health. values for the future—will be central to the shap-
Health research will continue to occur across ing of health care policy in the future. Research
the lifespan. For example, the health concerns of evidence that supports or refutes the merit of
mothers and infants will continue to spur research health care needs and programs focusing on these
that deals effectively with the maternal–neonatal issues will be timely and relevant. Thus, nurs-
mortality rate. Individuals of all ages who have ing and its scientific base is well placed to shape
health policy decisions (Turale & Kunaviktikul,

2019). CRITICAL THINKING CHALLENGES
Data analytics has incredible potential to im- ■ What research roles are you interested in?
prove health care. Nurse leaders will need com- ■ What effects will evidence-informed patient out-
petencies in analyzing, managing, and using data come studies have on the practice of nursing?
analysis tools. Using this unprecedented amount ■ Have you had any experiences, like Dan Ariely’s,
of information, nurses can improve patient care that make you question nursing practice?
and mitigate risk by informing decisions about ■ Why is it important to have interdisciplinary and
patient flow, interventions, workforce model- international research perspectives?
ling, cost drivers, and workplace safety (Solman,
■ What topics in nursing do you think require fur-
2017). Knowing how to ethically access and suc-
ther research?
cessfully analyze this data will be key if nurses—
regardless of their role—are to make the best use
out of this increase in technology and computing CRITICAL JUDGEMENT QUESTIONS
power.
1. What is the most appropriate source of informa-
Communication of nursing research has also tion for evidence-informed practice?
become increasingly important. Research find-
ings continue to be disseminated in professional A. Charge nurse
arenas (e.g., international, national, regional, and B. Attending physician
local electronic and print publications and con- C. Clinical practice guideline
ferences) as well as in consultations and staff D. Nightingale’s notes on nursing
development programs implemented on site 2. Why are interdisciplinary networks important in
through webinars and websites. Dissemination research?
of research findings in the public sector has also A. Collaboration can help solve complex prob-
gained importance. lems
Increasingly, nurse researchers are being asked B. Nurses do not do independent research
to testify at governmental hearings and to serve C. Research funding needs to be spread across
on commissions and task forces related to health disciplines
care. Nurses are quoted in the media when health D. There is overlap in the scopes of practice
care topics are addressed, and their visibility has 3. What drives the priorities for health care research?
expanded significantly. A. Political agenda
As opportunities are recognized and gaps in B. Changes in values in society
science are observed, nurses will conduct, cri- C. Trends and issues in health care
tique, and use nursing research in ways that pub- D. The United Nations
licly demonstrate how nursing care makes a dif-
ference in patients’ lives. Nurses have a research
heritage to be proud of. They also have a chal-
lenging and exciting future ahead of them. Both KEY POINTS
researchers and users of research need to engage
• Nursing research expands the body of scien-
in a united effort to gather and assess research tific knowledge that forms the foundation of
findings that make a difference in the care that evidence-informed nursing practice.
is provided and in the lives that are touched by • Nurses gain research literacy through educa-
their commitment to evidence-informed nursing tion and practical experience. As users of
practice.
Canadian Foundation for Healthcare Improvement

research, nurses must have a basic under- [CFHI]. (2020a). About us. Retrieved from https://
standing of the research process and must www.cfhi-fcass.ca/AboutUs.aspx.
demonstrate critical appraisal skills to evaluate Canadian Foundation for Healthcare Improvement
the strengths and weaknesses of research be- [CFHI]. (2020b). Priority health innovation
fore applying the research to clinical practice. challenge. Retrieved from https://www.cfhi-fcass.ca
• All nurses, whether they possess baccalaure- /WhatWeDo/challenges/priority-challenge.
Canadian Institutes of Health Research [CIHR]. (2018).
ate, master’s, or doctoral degrees, have a
About SPOR. Retrieved from https://cihr-irsc
responsibility to participate in the research
.gc.ca/e/51036.html.
process. Canadian Institutes of Health Research [CIHR]. (2020).
• Programs of research studies and replication of Indigenous health research at CIHR. Retrieved from
studies will become increasingly valuable. https://cihr-irsc.gc.ca/e/50339.html.
• Research studies will emphasize clinical issues, Canadian Nurses Association [CNA]. (2012). CNA global
problems, and outcomes. Priority will be health partnerships retrospective. Retrieved from https://
given to research studies that focus on health nurseone.ca/, http://media/cna/page-content/pdf-fr
promotion, care for the health needs of vulner- /global_health_partnership_program_2012_e.pdf?la=en.
able groups, and the development of cost- Canadian Nurses Association [CNA]. (2017). Code of
effective health care systems. ethics for registered nurses. Retrieved from https://
www.cna-aiic.ca/html/en/Code-of-Ethics-2017
• Both users of research and nurse researchers
-Edition/files/assets/basic-html/page-1.html.
will engage in a collaborative effort to further
Canadian Nurses Association [CNA]. (2018). Evidence-
the growth of nursing research and accomplish informed decision-making and nursing practice.
the profession’s research objectives. Retrieved from https://www.cna-aiic.ca/-/media/cna
/page-content/pdf-en/evidence-informed-decision
FOR FURTHER STUDY -making-and-nursing-practice-position-statement
_dec-2018.pdf.
Go to Evolve at http://evolve.elsevier.com/Canada/ Canadian Nurses Association [CNA]. (2020). Clinical
LoBiondo/Research for the Audio Glossary. nurse specialists,.Retrieved from https://www.cna
-aiic.ca/en/nursing-practice/the-practice-of-nursing
/advanced-nursing-practice/clinical-nurse-specialists.
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CHAPTE R 2
Theoretical Frameworks
Sarah Stahlke
LEARNING OUTCOMES
After reading this chapter, you will be able to do the following:
• Define key concepts in the philosophy of science.
• Identify and differentiate between theoretical/empirical, aesthetic, personal, sociopolitical, and ethical
ways of knowing.
• Identify assumptions underlying the post-positivist, critical social, and interpretive/constructivist views
of research.
• Compare inductive and deductive reasoning.
• Describe how a framework guides research.
• Differentiate between conceptual and operational definitions.
• Describe the relationships among theory, research, practice, and leadership.
• Discuss levels of abstraction related to frameworks guiding research.
• Describe the points of critical appraisal used to evaluate the appropriateness, cohesiveness, and
consistency of a framework guiding research.
KEY TERMS
aim of inquiry epistemology post-positivism
concept hypothesis qualitative research
conceptual definition inductive reasoning quantitative research
conceptual framework methodology text
constructivism model theoretical framework
constructivist paradigm ontology theory
context operational definition values
critical social theory paradigm worldview
critical social thought philosophical beliefs
deductive reasoning positivism
STUDY RESOURCES
Go to Evolve at http://evolve.elsevier.com/Canada/LoBiondo/Research
for the Audio Glossary.
20
CHAPTER 2 Theoretical Frameworks 21
THE NATURE OF KNOWLEDGE becomes outdated. In this chapter, we focus spe-

AS YOU LEARNED IN CHAPTER 1, NURSES DEVISE clini-
cifically on theoretical frameworks and how they
cal questions, based on their daily practice experi- guide and inform knowledge generation.
ences, that, if answered, can improve the care they Nursing knowledge is created and interpreted
provide to individuals, families, and communities. at various levels of abstraction, ranging from the
Each question requires that clinicians and nurse most abstract to the most concrete thinking (Butts,
researchers engage in a knowledge development 2015). Fawcett has identified five components of
process (Fig. 2.1). The process begins with the nursing knowledge, which span a range of ab-
identification of knowledge gaps: the absence of straction levels. These include metaparadigm,
theoretical or scientific knowledge relevant to the philosophy, conceptual model, theory, and em-
phenomenon of interest. Knowledge generation pirical indicator (Butts, 2015). The metaparadigm
occurs next, with the conduct of research that pro- is the most abstract level of knowledge in nurs-
vides answers to well-thought-out research ques- ing. It is the worldview of the discipline, which
tions. This knowledge is then distributed through distinguishes its focus (Butts, 2015). Philosophy
journal articles, textbooks, and public presenta- addresses questions about existence, reality,
tions to nurses. Next, the knowledge is adopted, knowing, and ethics as they pertain to nursing
as nurses alter their practice based on published (Butts, 2015). Conceptual models are a set of con-
information or as health care organizations de- cepts that address broad, general ideas of interest
velop policies and protocols that are informed by to the discipline, while theories translate concepts
newly generated knowledge. Finally, knowledge into testable questions that can be explored using
is reviewed and revised as new health issues arise, empirical indicators such as instruments, experi-
advances in clinical practice occur, or knowledge ments, or procedures (Butts, 2015).
Knowledge Gap
• Nurses ask questions that require
answers from experts in the field.
• Absence of theoretical/empirical
knowledge.
Knowledge Review and Knowledge Generation

Revision
• Research questions are devised
• New health issues lead to the asking about a phenomenon.
of new questions. • Qualitative and quantitative
• Old knowledge is revised or excluded. methods are used to answer the
• New questions prompt the need for questions.
new research.
Knowledge Distribution
Knowledge Adoption
• Knowledge is shared with profession
• New knowledge is used to alter
through formal (presentation, journal
practice.
publications, reports) and informal
• New knowledge is used to
(media, Internet, social networks)
develop policies and protocols.
reporting methods.
FIG. 2.1 Knowledge development process.

Knowledge that comes from the inner

experiences and maturation of the nurse
Encompasses becoming a whole, aware,
genuine, and authentic self
Continual life process that occurs with
deep reflection
Scientific knowledge Allows for interpersonal relationships
Development and testing of
theories/theoretical models Theoretical/ Personal
Observation and measurement of Empirical Knowledge
case-specific issues and phenomena Knowledge
Quantitative and qualitative research
Knowledge that comes from
repeated exposure to
Contextual knowledge that situations that lead to the
moves beyond nurse– refining of earlier ideas and
patient relationship and the thoughts
profession Experiential Involves movement along a
Understanding of culture, Sociopolitical Culture Knowledge continuum of novice
society, and politics Knowledge competent expert
Awareness of how society practitioner
is organized and its Expert practitioner is fully
implications for health engaged and attuned to
each situation and responds
on the basis of past learning
The art of nursing
The expressive, intuitive, and Ethical
Aesthetic Moral component of nursing knowledge
creative aspect of nursing Knowledge
Knowledge Encompasses the moral principles, codes,
Practice that incorporates poetry, art,
music, and stories, allowing a deep and theories of ethical conduct
understanding of the human The moment-to-moment judgement of
experience what is “right” and “responsible”
Involves confrontation and resolution of
ethical conflicts
FIG. 2.2 Nursing knowledge.

(Adapted from Chapter 2 of the previous edition of this book, written by Cherylyn Cameron.)
Figure 2.2 outlines the various ways by which in nursing (Zander, 2007). Understanding the so-
nurses inform their practice. These include theo- ciopolitical context of practice is an overarching
retical/empirical, personal, experiential, ethical, way of knowing; nurses can situate their practice
aesthetic, and sociopolitical/cultural ways of and knowledge within a societal context (Zander,
knowing (Chinn & Kramer, 2015; Zander, 2007). 2007).
Empirical knowing is acquired through the sci- It is important to remember that the way we
entific process, which results in tested and justi- understand these aspects of knowledge is based
fiable knowledge for practice (Zander, 2007). In on our cultural perspectives, such as Western
contrast, aesthetics is the art of nursing in which ideologies or Indigenous ways of knowing.
the nurse interprets the patient’s behaviour and Indigenous perspectives are covered in depth in
needs and addresses the bigger picture of pa- Chapter 7, but a brief introduction is warranted
tient care (Zander, 2007). Ethical knowing is the here. Indigenous knowledge is “a learned way
moral component of nursing and is concerned of looking at the world that may have very dif-
with justifying and judging actions. This know- ferent forms of acquisitions, transmission, and
ing depends on an understanding of philosophi- manifestation for Indigenous peoples” (Battiste
cal concepts about what is good as well as rights & Henderson, 2000, p. 48). Indigenous knowl-
and obligations (Zander, 2007). Personal know- edge is transmitted through oral traditions, which
ing involves an existential awareness of self and provides a way of understanding Indigenous
others in relationship (Zander, 2007). Experience people’s experiences and promotes a continued
and intuition constitute other forms of knowing existence of their culture. Battiste (2000) rightly
notes that Indigenous knowledge is essential for pretations to develop theories about health
transformation toward a just society that will “en- service delivery for that population
gage with and react to multiple circumstances and 3. Delivering an intervention (e.g., a school
shapes of oppression, exploitation, assimilation, health program for obese children) and as-
colonization, racism, genderism, ageism, and the sessing changes in health care–related be-
many other strategies of marginalization” (p. xxi). haviours (e.g., type of foods consumed,
Battiste (2002) claimed that Indigenous episte- amount of daily exercise, weight and other
mology is located in theories, philosophies, histo- biomedical parameters) after the delivery of
ries, ceremonies, and stories as ways of knowing. the intervention
The guiding tenets of Indigenous epistemology 4. Using surveys or a questionnaire to ask a
encompass a legitimate way of knowing, story- large group of people questions about health
telling as a method for sharing knowledge, and experiences or their current symptom levels
the relationship between the researcher and par- with regard to, for example, pain, digestive
ticipants as a natural component of the research problems, or depression.
process (Kovach, 2005). Indigenous epistemol- Taking an example of published work, Nahm
ogy is derived from multiple sources including and colleagues (2010) hypothesized that using
traditional knowledge from previous generations, social cognitive theory (involving self-efficacy,
empirical knowledge from careful observation, mastery, and modelling) as the foundation for a
personal knowledge and experiences, oral trans- hip fracture prevention website would be more
mission, holistic knowledge, and experimental effective in changing individuals’ health behav-
knowledge (Castellano, 2000). iours than conventional educational strategies;
From the Western perspective that is common this hypothesis is an example of theoretical
in Canada, theoretical/empirical knowledge is knowing. However, it was only through develop-
most commonly referred to as scientific knowl- ing a clinical trial that tested the intervention that
edge. Recently, theoretical/empirical knowledge Nahm and colleagues could observe the effec-
has gained prominence in nursing with the in- tiveness of the theory-based educational website
creasing focus on evidence-informed practice. (e.g., differences in knowledge and health behav-
Theoretical and empirical knowledge really can- iours) compared to the effectiveness of a conven-
not be separated; however, theoretical knowing tional prevention website. Their results provided
is concerned with developing or testing theories support for the hypothesis; this support is an ex-
(possible explanations or ideas) that nurse re- ample of empirical knowing.
searchers have about how the world operates.
Theoretical knowing is informed by empirical PHILOSOPHIES OF RESEARCH
knowing, which involves observations of reality. Thus far, we have used a number of terms that may
Observations may include the following: be new to you. Every discipline has characteristic
1. Speaking with people about their life experi- terminology for communicating important features
ences (e.g., living with Alzheimer’s disease) of the work in that field. Learning new terminology
and using their responses to specific and gen- is part of what nursing students do when they learn
eral questions to understand the phenomenon research methods and skills. Each research method
2. Observing social or cultural interactions and all philosophies of science have specialized
(e.g., homeless individuals interacting with language that nursing students will encounter in
service providers) as they naturally occur, the literature. Thus, to help you comprehend the
interpreting what the interactions might research you will read, it is important to clarify a
mean for both parties, and using those inter- few terms.
All research is based on philosophical beliefs the science or study of being or existence and its
about the world; these beliefs are the motivat- relationship to nonexistence. Ontology addresses
ing values, concepts, principles, and the nature two primary questions: (1) What exists or what
of human knowledge of an individual, group, or is real? and (2) Into what categories can existing
culture, and they are the basis of a worldview, things be sorted? Epistemology addresses four
or paradigm. Paradigm is from the Greek word key questions: (1) What is knowledge? (2) What
paradeigma, meaning “pattern.” Paradigms are are the sources of knowledge? (3) What are the
“different ways of viewing the world and often ways we come to know something, in contrast to
form the foundation from which research is un- believing, wondering, guessing, or imagining?
dertaken. They consist of a set of assumptions and (4) What is truth and what role does it play
about what is reality, how knowledge is created in knowledge? Methodology refers to the princi-
and what is valuable to learn” (Davies & Fisher, ples, rules, and procedures that guide the process
2018, p. 21). Therefore, knowing and compre- through which knowledge is acquired. The aim of
hending these views and practices is important inquiry refers to the goals or specific objectives
in understanding and using research findings. of the research. Context refers to the personal, so-
They are not right or wrong; rather, they repre- cial, organizational, cultural and/or political envi-
sent different ways of viewing the world and the ronment in which a phenomenon of interest (that
way things operate within it. Nursing researchers “thing of interest”) occurs. The context of research
may tend to gravitate toward a particular world- studies can include physical settings, such as the
view but it is important to remember that differ- hospital or home, or less concrete “environments,”
ent kinds of research questions call for different such as the context that cultural understandings
approaches to understanding and studying reality, bring to an experience. Values are the things that
so it is possible for researchers to value different the nurse researcher holds to be important.
worldviews at different times. For example, a re- Positivism is a philosophical orientation that
searcher can know that a certain drug has side ef- arose in the 18th century, as part of a movement
fects or that turning bedridden patients regularly away from religious knowing to reasoning and sci-
will reduce the risk of skin breakdown but also ence. Positivistic research aims for objectivity and
understand that people’s narratives about their impartiality, with a goal of producing unbiased,
experiences will yield multiple and sometimes generalizable research. Post-positivism emerged
conflicting explanations. This shows how differ- in response to the realization that such objectiv-
ent paradigms can be held simultaneously. ity is usually not possible and our observations
It is important to note that there can be overlap cannot always be relied upon because they are
between paradigms and they are not always ex- subject to error and human bias—we all have dif-
clusive of one another (Davies & Fisher, 2018), ferent values, cultures, and life experiences and,
although categorizations can simplify learning thus, generate different interpretations.
about the basic worldviews. In nursing, there are Constructivism, which is also referred to as in-
three key paradigmatic perspectives that are com- terpretivism or relativism, points to the centrality of
monly held and that generally underpin various human experiences, social and cultural constructs,
approaches to research. These are positivism/post- values, perspectives, and language (Clark, 2008). It
positivism, constructivism, and critical theory. is a philosophical orientation that suggests that real-
These three paradigms are compared in Table 2.1; ity and the way in which we understand our world
however, first you need to understand the philo- are largely dependent on our perceptions and con-
sophical language used in the table. Ontology text. Truth about life experience is regarded as rela-
(from the Greek word onto, meaning “to be”) is tive and multiple rather than absolute. The value of
knowledge development lies in the ability to under- It harnesses the strengths and addresses the weak-
stand how people perceive their world. Knowledge nesses of positivism and constructivism (Clark,
development occurs through observation, dialogue 2008) by acknowledging that, although there is a
with people, or both, and as a result of paying at- single reality, we cannot know it for sure (Davies
tention to the language people use to describe life & Fisher, 2018). This perspective offers a middle
experiences. Constructivists tap into personal expe- ground that “does not reduce the world to unknow-
rience rather than seeking measurement and elusive able chaos [as might be the case with relativism]
objectivity. This form of research is aimed at creat- or a positivistic universal order” (Clark, 2008,
ing an understanding of people and their life experi- p. E68). In critical realism, social entities exist in-
ences from their point of view. dependently of human understanding. For example,
Critical realism is a philosophical orientation that discrimination and power imbalances exist regard-
has become of great interest in nursing research. less of whether humans recognize their influence.
TABLE 2.1
BASIC RESEARCH PARADIGMS
ITEM/QUESTIONS POST-POSITIVISM CRITICAL THEORY CONSTRUCTIVISM
ONTOLOGY
What can be said to A material world exists. Reality is constructed by those Reality is constructed by
exist? Not all things can be with the most power at individual perception within
Into what categories understood, sensed, or particular points in history. a social context.
can we sort existing placed into a cause-and- Over time, reality is shaped by Truth is relative and based
things? effect relationship. numerous social, political, on perception or some
The senses provide us with an economic, and cultural forces. particular frame of
imperfect understanding of Stories/discourses shaped by the reference.
the external/material world. powerful become accepted
reality.
EPISTEMOLOGY
What is knowledge? Researchers are naturally Research is a transaction that Research is a transaction
How is knowledge biased. occurs between the researcher that occurs between the
acquired? Objectivity (controlled bias) is and research participant. researcher and research
How do we know the ultimate goal, although The perceptions (standpoint) of participant.
what we know? pure objectivity is not the researcher and the research Research emphasizes the
attainable. participants naturally influence meaning ascribed to human
Uses triangulation and knowledge generation/creation. experiences.
replication of findings across Perceptions (standpoints) are Objectivity is not possible;
multiple perspectives. determined by context, and so knowledge is co-created.
contextual awareness and its
relationship to the participant’s
understanding of reality is the
focus of the research.
RESEARCHER’S VALUES
How do the All attempts are made to Researcher perspectives are Researcher perspectives,
researcher’s exclude researcher bias. acknowledged and recognized values, experiences are
values influence Influence is denied. as influential. recognized as potentially
the knowledge Researcher values drive research influential.
development questions and purpose; Influence is managed with
process? researcher manages own reflection and bracketing.
perspectives.
Continued
TABLE 2.1
BASIC RESEARCH PARADIGMS—cont’d
ITEM/QUESTIONS POST-POSITIVISM CRITICAL THEORY CONSTRUCTIVISM
METHODOLOGY
Within a particular Inquiry generally involves Inquiry requires dialogue between Inquiry requires dialogue
discipline, what quantitative methods and the investigator and research between the investigator
principles, rules, and is viewed as a series of participant. and research participant.
procedures guide logically related steps. Research purposes are Focus is on interpretation of
the process through Research questions/hypotheses transformative, emancipatory, interview data, documents,
which knowledge is are proposed and subjected or consciousness raising. and artifacts, including
acquired? to empirical testing. Dialogue brings to the forefront written texts, art, pictures.
Research is characterized by the historical context behind Interpretation brings to the
careful accounting for and experiences of suffering, conflict, forefront the varying ways
control of factors that may and collective struggles. in which people construct
influence research findings. Dialogue increases participants’ their understanding of their
Qualitative research may be awareness of actions required social world and how their
used to develop hypotheses. to incite change. interpretation shifts as they
interact with others.
AIM OF INQUIRY
What is the goal of Explanation, prediction, and Critique, change, reconstructed Understanding of
research? control. reality, and emancipation. social realities and
interpretations of
meaning.
CONTEXT
What biographical, Attempt is made to set Focus is on historical, social, and Focus is on life context,
life, social, and aside researcher histories, political context. including significant
political factors politics, ideologies, and Context refers to the social and conditions and demands
may influence the experiences. political climate in which an that provide greater
research findings? event or process occurred. understanding of the
Social context highlights phenomena being
how structural, economic, studied; focus also
representational, and emphasizes time and
institutional factors of the place.
past influence how people
understand an issue today.
Political context highlights
how political dialogue and
opinions, legal directives, and
government policies of the
past influence how people
understand an issue.
SUB-PARADIGMS/ Critical realism Feminism Symbolic Interactionism
THEORIES/ Mixed methods Critical Race Theory Philosophy
METHODS Intersectionality Qualitative approaches
Disability Studies
Critical Policy Analysis
Adapted from Denzin, N. K., & Lincoln, Y. S. (2000). Handbook of Qualitative Research. SAGE Publications Inc.
However, human perceptions and experiences can the subjects of most research about cardiovascu-
still be incorporated into an understanding of re- lar disease; they call for more women-focused
ality (Clark, 2008). From a research perspective, studies to inform nursing practice more broadly.
truth and reality are ascertained through varied ap- Critical race theory provides a foundation
proaches to data collection and analysis to increase for “studying and transforming the relation-
the accuracy with which social phenomena are un- ship among race, racism, and power” (Delgado
derstood (Davies & Fisher, 2018). & Stefancic, 2001, p. 2). Critical race theorists
Critical social theory emphasizes that reality point out that racism is an everyday experience
and our understanding of reality are constructed that is difficult to address because it is not ac-
by people with the most power in a particular time knowledged. They also note that race is an idea
and place. This perspective supports the under- that benefits the dominant group so they have no
standing that health and other aspects of reality are incentive to eliminate racism (Wesp et al., 2018).
shaped by numerous social, political, economic, Wesp and colleagues (2018) evaluated models
and cultural factors. Such factors include gender, and guidelines for cultural competency in nursing
sexual orientation, class and economic status, race from a critical race perspective. They noted that
and ethnicity, ability, and geographic location. In most nurses would agree that there is a need to
nursing research, a strong emphasis is placed on reduce culturally based disparities in health care,
understanding how power imbalances associated which cultural competency guidelines seek to ad-
with these factors influence health and well-being, dress. However, they show that these guidelines
access to health care, and patient experiences and are flawed because they fail to consider the preju-
outcomes. The goal of critical research is emanci- dicial attitudes and imbalances of power that af-
pation and social change (Davies & Fisher, 2018). fect patient care and nursing practice. Instead of
Some specific types of critical theory include promoting cultural competence, these guidelines
feminist theory, critical race theory, queer theory, can ironically perpetuate stereotypes and fail to
disability theory, and intersectionality. Feminist produce change.
theories are numerous and varied (e.g., Marxist, Queer theory offers a critique of normative un-
poststructuralist, cultural, eco) but generally fo- derstandings of sex, gender, and sexuality, com-
cus on the experiences of women, although this bining these with other aspects of social differ-
can be broadened to study the experiences and ence such as race and class (Hall & Jagose, 2013).
perspectives of all genders, especially in terms Disability theory critiques the medical view of
of stereotyping, marginalization (exclusion), and disability as an individual defect that requires cure
emancipation. The primary intent of feminist the- or elimination. Critical disability theories allow
ories is to dismantle systems of oppression and scholars to explore and challenge social injustice
to raise awareness of gender disparities in a more and oppression, which equate ability with human
meaningful way. Rolls and Young (2012) assert worth (Siebers, 2008). Intersectionality is a criti-
that feminist nursing research ought to benefit cal theoretical perspective that combines various
women; value women’s experiences, ideas, and critical theories. This shifts the focus from single
needs; recognize the structural, interpersonal, and aspects of identity (such as gender or race) toward
ideological conditions that oppress women; and a recognition that these aspects work together in
include a portrayal of women’s strengths (p. 18). people’s lived experience. The way that these
To apply this, they conducted a review of the re- social forces, identities, and ideologies combine
search literature about older women’s experiences in people’s lives has an impact on how much
of heart failure. They found that there were very power they have or lack (Crenshaw, 2017). This
few studies on this topic because men have been has implications for people’s expectations and
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Iloks kansan tään paras laatia ois
runotekstejä katkismuksiin,
myös kuutamoiltoina puhjeta vois
ah, lemmenhuokauksiin…
Hyvä ois, vähän myöskin jos kutkuttais

isänmaallista ihramahaa:
pian kunniatohtorin miekan sais,
tukun täyteläisen rahaa.
Runon työ on vienosti kuiskuttaa

poven tyhjyyttä eleegistä.
— Mut lehmän häntiä huiskuttaa
runoss' on epäesteettistä!
Niin kai se on, enkä minäkään

kovin lehmän häntää kiitä.
Mut lammaskuorohon määkyvään
voi määkyä myöskin siitä.
Niin aattelin, mutta sen aatoksen

oli siittänyt järki lyhä.
Minä viisastuin ja nyt aattelen:
On lehmän häntä pyhä;
maholehmän hännän ainiaan tulis rauhoitettu olla: se on

tehtaanmerkkinä paikallaan monen laulajan tuotannolla.
IV
SATU MEISTÄ KAIKISTA.
Olen kävellyt kaiken iltaa puiston teitä ja ajatellut itseäni: mitä

olen ja mitä voisin olla.
Olen katsellut tähtiä ja ihmetellyt, kuinka niiden silmät ovat

suuret tänä iltana. Minä melkein näen, kuinka ne kaikki istuvat
suuressa kristallisalissa sinisellä matolla Jumalan jalkojen
juuressa — pienien lasten parvi, valkoiset mekot yllä. Ja
Jumala katsoo kaikkia heitä aurinkoisilla silmillä, joissa on
isällistä hymyä. Ja Jumala miettii satua, minkä hän kertoisi
heille.
Ja silloin Isä Jumala muistaa, kuinka hän itse oli lapsi:

kuinka hän leikki kerran suuressa vihreässä puistossa ihanien
puiden alla.
Hän oli katsellut huvikseen, kuinka hänen hymynsä putosi

kukkina maahan, kuinka hänen naurunsa lehahti perhosina
ilmaan. Ja kun hän väsyi siihen, keksi hän tyhmän leikin:
Hän oli yksin, leikkitoveria vailla, ja hänen oli ikävä. Hän
teki sentähden savesta pojan, ihan kaltaisensa, puhalsi
siihen: ja katso! se hymyili hänelle. Ja Jumala katseli poikaa
suurella ilolla.
Mutta hän saikin jo aamulla tuta, että oli pahoin tehnyt: hän
tuli leikkitoverin luokse — ja säikähti tätä: Hän oli outo ja ruma
ja vanha. Puisto oli mykkä ja surullinen, kukkaset vapisivat
kovin ja kauniit linnut ja perhoset pakenivat vieroen kauas.
Ja Jumala itsekin tunsi, miten hänen ilonsa äkisti kuoli,

miten hänen lapsenmieltänsä puistatti vieras ja paha tunne,
hänelle käsittämätön. Ja hän oli kääntynyt pois. Ja hän oli
itkenyt silloin ensimmäisen kerran.
ATLANTIS.
Oli onnellisten saari mun sydämeni kerta, ja auringossa kylpi

se keskellä merta.
Ja linnassa siellä monin jalokivin hohti Maan prinsessa

kaunein ja prinsessa nuorin — mut sielua vailla ja peikotar
siksi.
Meren äärillä kultaisin pähkinänkuorin unet soutivat

vehmaita rantoja kohti: ihanaisinten huulien kostuttimiksi Ilon
maasta ne noutivat ruusujen mettä.
Jos kuinkakin valtiatarta ne palvoi, jano prinsessan julmilla
huulilla valvoi: — Ei sammu se ihmisen kyynelettä!
Hän kyyneltä pyys — mereks ei sitä tiennyt. Sen sai:

tuhotulvana saaren se peitti, kuin simpukan aaltojen kohtuun
sen heitti — merenpohjainen peikkojen luola se lie nyt.
SANOJA YÖSSÄ.
Yö on noussut mustin äänettömin kasvoin vuoren alta,

sydämestä maan. Yö on niellyt auringon ja maan ja metsän,
meren, joita rakastamme niinkuin elämää. Yö on niinkuin
peikon paha katse, josta joka hetki lentää lepakot.
Yö on tullut meille. Tunnetko? — kuin vieras kylmä käsi

lepäis silmillämme, jotka äsken vielä niinkuin kukanterät
paisuvaiset tulta, tulta joivat auringosta, jok' on silmä kaikkein
tulisin.
Yö on tullut meille.
Sanat lakastuvat huulillemme.
Emme nähdä, tuntea voi toisiamme,
emme itseämme yöltä pelastaa.
VERKOSSA.
Olen verkon silmässä kala. En pääse pois:
ovat viiltävät säikeet jo syvällä lihassa mulla.
Vesi päilyvä, selvä ja syvä minun silmäini edessä ois.
Vesiaavikot vapaat, en voi minä luoksenne tulla!
Meren silmiin vihreisiin vain loitolta katsonut oon:

mikä autuus ois lohen kilpaveikkona olla! —
Sameassa ken liejussa uupuu, hän pian uupukoon!
Omat sammuvat silmäni kuoletan auringolla.
PURJEHTIJAT.
On syvyys allamme kuin lohikäärmeen suu,

kuin syli Atlantin — me kohta vajoamme.
Niin kiiluu alta pilvipäärmeen kuu
kuin paholaisen silmä. Kaukana on meistä jumalamme.
Ja jokin maston lailla meissä katkeaa

kuin veitsi leikkais meidät irti juuristamme.
Lyö salama. Ja taivas päämme päällä ratkeaa.
Me tyhjin silmäkuopin syvään pimeyteen tuijotamme.
Ja kaikki elonlaivan purjehtijat hullut on:

söi myrsky niinkuin skorpiooni pään ja tunnon heistä.
Ja sydän jokainen koht' aronkaltaiseksi tullut on.
Ja elo putoaa kuin kimmeltävä kalansuomus meistä.
Kuin olisimme kahlein kiinni vuoressa

niin käsiämme ylös kurkoitamme.
Olemme toukanruoka mätänevän ruumiin kuoressa.
Ja aavelaiva kantaa varjojamme.
VANHA MAA.
Maata katso, Äiti, katso tytärtäsi: myöhä rintalapses käynyt

onhan vanhemmaksi itseäsi!
Itse synnyt, sytyt joka aamu hehkuun uuteen, uuteen

nuoruuteen ja häikäisevään valonihanuuteen. Maa, sun
tyttäres, on vanhuutensa runtelema, taudin lyömä, syksyn-
kuumehinen, kaikelt' ytimeltään madonsyömä.
Tähtirakkautes hyljäten ja kupeeltasi luopuin Maa on

syvään langennut, Kuun peikonhyväilyihin juopuin; raiskattu
on, vereen, tuskan-syntiin tahrattu on nuoruus tyttäresi —
itke, Äiti jumalallinen, tai nouskoon pilvi häpeän sun otsallesi.
Lahjaas kalleintakin — kulmillansa laulun kimmellystä —

hylki tyttäres: niin vihas sydämensä hengitystä.
Älä katso, avaruutta syleilevä Äiti, tytärtäsi:

häntä kiroten myös kirota sun täytyis itseäsi!
DELUGE.
Minun silmieni rovio on syttynyt, kätenikin palavat ja vereni
vapisee. Minun sanani tukehtuvat tai ovat tuiki mielettömät
niinkuin samum, jossa koko erämaa puhuu ja kaikki hiekan
henget taistelevat.
Olen tullut enkä päästä sinua, ennenkuin vereni

maanjäristys määrättömien tuhon ja hukkumisen sekuntien
jälkeen asettuu.
Minun äitini on suudellut kaikkina päivinä Jumalan otsaa,

kun hän minua kantoi. Olen tuli sinun tultasi, aurinko, ja minä
tahdon polttaa ja palaa.
APHELIUM.
Mun vuosmyriaadeja sitten avaruuksihin yöpyvän nähtiin. Ah,

arvaamattoman pitkä tie täältä on muihin tähtiin.
Mun taattoni aurinko, turhaan

tulinuolias jälkeeni ammuit:
yön, äitini, tahto mun voitti;
jo aikoja taakseni sammuit.
Edes kaikuna tänne ei kuulu

elon rannalta aaltojen pauhu,
tääll' yön kivikasvoilla viihtyy
iankaikkinen tyhjyys, kauhu.
Olen kylmä, mun vertani hyytää
tämä äänetön kuoleman aatto.
Ylt'ympäri jäässä on lapses —
mua lämmitä, lämmitä, taatto!
Tule leimuten, suurena saavu,

yön sielussa soihtusi nostain.
Olen arvoton armohos, taatto,
tule kuitenkin, vaikkapa kostain.
Tue, kutsu ja luoksesi ohjaa, kun nöyränä tieltäni palaan.

Jos kuoleva oon, minä kuolla sinun liekkihis, aurinko, halaan!
(1921.)
V
HUOMISPÄIVÄ.
Tämänpäiväinen aurinko ei ole sinua varten: se näkee vielä

ranteissasi kahleenjälkien häpeän ja otsallasi eilispäivän
polttomerkit.
Tänään — erämaa
joka nielee kaikki keitaat:
unet ilosta ja auringosta.
Tuulen tuomaa lentohiekkaa
janon runtelemille huulille.
Mutta:
rautaristikon takaa
katse,
ihmisen katse —
niinkuin liekki joka syttyy tuhkaan.
Vielä täynnä
tuskan ja ilon taistelua,
mutta voitonvarma,
huomisen-altis,
juopunut syntymättömästä valosta.
Niinkuin huuto
etäisyydestä toiseen:
— Nähkää naulanjäljet käsissämme, jotka ovat kohonneet

jaoittamaan tämänpäivän vankilaa. Kuulkaa sielujemme
salamaa: se on tuli taivaasta ja sytyttää esiuhrin
huomispäivän auringolle, joka tulee — on pian tuleva — ja
suutelee kaikkia rikkaita sydämiä.
OLIN NUORI.
Olin nuori. Ja kasvoin harmajin, sinipunervin silmänaluksin

minä arkana kouluun kuljin.
Oli rehtori vanha ja viisas mies.

Minä usein pelkäsin, että hän ties,
mikä syy minun mieltäni painoi.
Ja kotona täti, hän katsoi niin

minun silmäini lastenkamariin,
että pakenin pois ja itkin.
Kun nuoria kasvoja muita näin,

miten vihasin omaa itseäin
ja kipeää elämääni.
— Ah, silloin vielä mä tiennyt en,
että kukaan, kukaan ihminen
ei tääll' ole parempi toista.
Tuta sai sen poika. Ja rakastamaan

mies sitten on oppinut nuoruuttaan
ja omia arpiansa.
SYDÄN JA KUOLLEEN MEREN APINAT.
Kuolleen meren rannalla jossakin — maailmahan on kuolleita

meriä täynnä — asui jolloinkin ajan varrella suku, joka oli
unohtanut sydämensä jonnekin.
Ja katso, nämä ihmiset menestyivät hyvin ja lihoivat hyvin.

Heidän vehnänsä kypsyi ja rypäleensä paisuivat.
He tekivät viekkaasti kauppaa ja kävivät julmasti sotaa. Ja

kameelit kantoivat ryöstösaaliina kotiin kultaa ja kalliita kiviä
vuorten takaa.
He olivat onnelliset. Ja lihavin kaikista papeista puhui: —

Kiitetty olkoon Allah! Nyt hänen siunauksensa on vuotanut
ylitsemme runsaampana kuin koskaan. Tietkää, oi uskovaiset
kaikki, että tämä Allahin ylenpalttinen suosio johtuu siitä, että
tuo kärkäs rauhanrikkoja, Sydän, alati tyytymätön, alati
kapinoiva Sydän on vihdoinkin keskuudestamme poissa. Eikö
hän riistänyt meiltä öittemme unta ja päivällä virittänyt ansoja
kaikille teillemme. Eikö hän napissut aina lempeitä lakejamme
vastaan. Eikö hän solvannut aina, tuo niskuri Sydän, pyhää
esivaltaa ja jaloja tuomareita, että he muka olisivat pyöveleitä.
Jos me ryhdyimme sotaan tahi jos solmimme rauhan, eikö
hän syyttänyt, että me teimme väärin. Eikö hän saattanut
meidät alati häpeään.
Nyt hän on poissa. Allah, hän joka Kuolleessa meressä

nukkuu, hän ei katsellut Sydäntä suopein silmin: tämähän
häiritsi alati hänenkin untaan. Iloitkaatte, oi uskovaiset kaikki:
Allah on vienyt hänet keskelle erämaata, että hän menehtyisi
nälkään ja janoon, että me olisimme alati onnelliset! Kiitetty
olkoon Allah!
Allah, hän joka Kuolleessa meressä nukkuu, heräsi eräänä

yönä: hän oli kuullut jonkun huutavan nimeään. Ja katso,
Kuolleessa meressä paloi elävä liekki. Se lähestyi niinkuin
lentävä tähti ja lankesi jumalan jalkojen juureen. Se oli palava
Sydän. Se puhui: — Isäni, en ole löytänyt kotia ihmisten luota!
Ja Allah katseli häntä

ja kuunteli häntä
ja itki.
Ja Allah kohotti päätänsä Kuolleesta merestä.
Silloin kuuli hän sen,
mitä lihavin kaikista papeista puhui.
Ja Allah vihastui kovin.

Ja Allah kohotti kätensä:
ja katso, ihmiset olivat aamulla niinkuin apinat.
Mutta Sydän jäi Allahin luokse. Ja lempeä jumala otti hänet

käteensä, nosti hänet huulilleen ja suuteli häntä.
SANA.
Alussa oli Sana.

Ja muuta ollut ei.
Ja Ylimmäisest' oli synty sen.
Ja alkuyöhön kauas
sen Luojan sormi vei:
niin luotiin maa ja meri, ihminen.
Sana luomistyönsä päätti

ja palas Isän luo.
Ja Henki kantoi sitä huulillaan.
Mut kerran keskiyöllä

Kyy, valheen henki tuo
sen varkain otti, vei sen maailmaan.
Ja Sana, kaiken luoja,

oli hedelmätön nyt,
kun ihminen sen nosti huulilleen;
vain lasten leikkikalu,

vain malja särkynyt,
vain mykkä ääni, kaiku tyhjyyteen.
Se näki paljon nälkää

ja paljon tahraantui;
sen kimmellyksen peitti tomu maan.
— Mut joskus, ihmisistä

kun paras uneksui,
se lensi jälleen kotiin, jumalaan.
Ja Isä huulillensa
sen virvoittaen vei,
ja siihen tarttui Luojan hengitys.
Ja ihmiset, he koskaan
sitä unohtaneet ei.
Ja sydämissä kävi väristys.
SYYLLINEN MIES.
Hänet ammutaan. Hän on syyllinen mies.
Hän katsoo ääneti meihin ja meistä pois.

Hän antaa silmänsä minulle ja käskee: katso!
Ja silloin näen, kuka myöskin on syyllinen mies.
Syyn kahleen rautaisen näen ranteessa kaikkien meidän.

Syyn käärme on purrut jo kehdossa lapsen kantapäätä.
Syyn hämähäkki on kutonut verkkonsa kaikkien sydänten teille.
Syy nielee kaikki ihmiset niinkuin hete suossa.
Mutta yksi meistä on murtanut kuoleman renkaan.

Näen kuinka hän riisuu likaset vaatteet yltään,
syyn varjojen kehästä pois hän astuu valoon.
Näen uudet kasvot nuo: hän on ryöväri ristinpuussa.

hän on veljeni, syyllinen mies, joka ammutaan.
RUNO RISTIINNAULITUISTA.
Ristinpuiden varjo lankeaa mittaamattomana maailman yli.

Nähkää se pilvien hartioilla ja kaikkien vuosituhansien
kasvoilla.
Näettekö: ristiinnaulittuna maailman sydän ja elämän

nuoruus, jokainen uusi ääni, joka huomenna on kaikkien
uskonto, jokaisen uuden päivän aurinko, jokainen uusi
vapahtaja — vain messiaita ristiinnaulitaan, ei epäjumalia.
He rakensivat ristinpuita maan kuninkaille.

Mutta heidän lapsensa suutelevat ristejä.
Pian kuolevat heidän askeleensa pimeään.
Mutta valo ei ole pakeneva ristinpuiden ympäriltä,
sillä jokainen ristiinnaulittu sydän oli tähti.
PAIMENET.
Voi paimenten öitä erämaassa.
Haaskalta, kaukaa korpin viimeinen huuto. Pimeys, pimeys

vyöryi maailman yli niinkuin musta meri.
Skorpionit vaanivat hietikolla. Yö oli pantterin silmiä täynnä

ja shakaalin ulvonta leikkasi ilmaa niinkuin nuoli. Nuotiomme
kitui ja laumamme vapisi sen luona.
— Sinäkin vapisit, sydän.
Tunsithan
pahojen henkien hiipivän yössä.
Aavistit:
tuhannen pahaa tahtoa vaani
raatelu-valmiina
— niinkuin tuhannen
julmaa, korpinkyntistä mustaa kouraa
tai pedon hammasta —
ympärilläsi erämaassa,
pimeän meressä, kaikkialla,
lämmintä vertasi janoten
niinkuin pantteri janoo
nuoren karitsan verta.
Ei ole koskaan nähty tällaista yötä erämaassa. Taivas: —

tähdistä kudottu kangas. Ja kaikki tähdet kiertävät suurinta,
kauneinta tähteä, jota ei koskaan ennen mikään silmä nähnyt.
Erämaan hiekkaan sataa pieniä tähtiä lukemattomasti.
Nähkää:
ei ole varjoja, yötä.
Tunnemme:
ei ole enää pelkoa, vihaa,
paha on kuollut,
maa on kaunis ja nuori
ja ihmeitä täynnä:
pantteri nuolee nuorimman vuonan kaulaa,
jännitetyn jousensa laskee metsästäjä,
huulilla lapsen hymy.
Silmämme näkevät unta: tähdistä astuu enkeli niinkuin
kaunis Jumala itse. Siunaa maata ja siunaa meitä: — Hetki on
tullut, rauha on maanpäällä syntynyt, hyvyys astunut ihmisten
joukkoon, maa on ihmisen koti.
(Jouluna 1923.)
ME.
Me, tomun tomu, saimme elämän. Suin, sieraimin ja silmin

yhä juomme sitä kuin mehiläinen yrtin mettä juo, vaikk' yrtin
okaat punertuvat verestämme.
Ah, suurin kipumme on täynnä siunausta,

tuo syvä arpi meissä, kallis todistus:
me suutelimme suulle polttavalle
hänt', Ainoata, joka on ja jota rakastamme.
Ja kun me lähestymme sydänt' Elämän kuin pisarainen

hänen suonissaan, koht' oma valtimomme täys' on elämää, ja
oomme rikkaat lailla jumalan.
Me sormin kosketamme maata, ja se kukkii. Ja

ihmisveljiemme tomusydämiin me puhallamme, ja ne ihanasti
värähtävät kuin sydän ensi ihmisen, kun sieraimissaan hän
tunsi hengityksen jumalallisen.
MINÄ NÄEN.
Näkysarjojen vaihtuva leikki. Ah, näin ei silmillä nähdä.

Sisempään, syvemmälle ja kauemmaksi ma nään.
Minä tiedän: nyt mieleni katsoo kuulevin, tuntevin silmin.
Näyt syntyvät, kuolevat silmässä itsessään.
On silmäni leili. Sen viinillä täytin. Ja viini on käynyt.

Ihanampana leilistä juon saman viinin nyt.
Oli poutaa ja pilviä, tuulta ja taivasta mielessä mulla.
Hedelmöittyvät nyt nämä siemenet kätketyt.
Näen mieleni unta. Kuin auringon säihkyssä kotka se nousee

tomust' irti ja maasta ja myös ajan piiristä pois.
Salamalla se ratsastaa elon maallisen rannasta rantaan.
On kuin joka ihmisen silmäni tuntea vois.
Hedelmist' olen tiedon puun minä syönyt kai: tämä uusi

elontietoni siks yli parhaan tietoni käy.
Mato pieni on suurin. Ja köyhimmällä on enkelin kasvot.
Erämaissamme eikö nyt jumalan askelet näy.
Näen: ihminen kirkastuu. Hänet jumalan veljeksi tunnen.

Ota kuoleman taittuu, ja kuollehet käy elämään.
Minä nään: paratiisin portti on auki, on taivahat auki.
Joka kohtalon yllä mä sateenkaaria nään.
LENTÄVÄN HOLLANTILAISEN NÄKY.

Hän ruorissa seisoi ja katsoi veteen.
Ja kuoleman-tyyneltä ulapalta, jolla pilvien kummitusvarjot

makaa, kuva nous, kuva kaukainen, silmien eteen kuin
jostakin satojen vuosien takaa kovan uhman ja paatumuksen
alta.
Näki itsensä mies: soman poikasen, ruson poskilla, silmissä

päivänsäteen. Näki pojan poimivan kukkasen ja sen vievän
äitinsä vanhaan käteen.
Ja niinkuin emonsa rinnalla vuona hän kirkkoon äitinsä

kanssa kulki somiss' ensimmäisissä saappaissaan. Pojun
hellästi syliinsä äiti sulki, kun he olivat kivisen portin luona ja
näkivät kirkon ja hautausmaan.
Näin äiti: "Kas, kultainen katolla tuolla on risti, ja risti on

haudoillakin. Se on elävän Jumalan merkki ja vala:
iankaikkisen tuskan ei lieskassa pala, kenen voi sydän lailla
Mestarin oman ristinsä kantaa, sen nimessä kuolla."
Saman äänen kummituslaivaan kuuli uros harmaapartainen

kaukaa jostain kuin kaikuna esirukousten. Ja hän luuli
silmänsä hourailevan: ah, keskellä pilvikummitusten kuin
kirkastettuna siltaa veen kävi äiti, merestä ristiä nostain!
Kovin kalpeni Hollantilaisen huuli. Hänen nähtiin rajusti

vapisevan kuin vuoren huipulla vanha puu, johon ukkosen
vasama kohdistuu. Käsin päähänsä harmaatukkaiseen nyt
tarttui mies, joka tyynenä kesti satavuotiset kauhuntaipaleet,
jota uhmasta uhmaan jäisimpään viha taivaan paadutti
ikuisesti, jota ihmiset olivat sylkeneet, joka itse Jumalan
nimeä sylki.
Kova, uhman kallio murtui, suli.

Ja hän painoi kädellä sydäntään.
Söi silmiä liekki kuin taulaa tuli.
Ja vavahti kummituslaivan kylki,
kun Lentävän Hollantilaisen ääni
parahduksena sielun pohjalta soi:
"Mua nuolevat liekit, ne lyö yli pääni!
Kirouksesta irti en päästä voi.
Tule, äiti, mun ristiä suudella anna!
Pois täältä sun poikasi kauas kanna!"
Heti, niinkuin rautainen piikki-ies, kirous hänen kirposi

otsaltansa. Vavistuksella tunsi hän, sokea mies, miten Jumala
itse ristinmerkin hänen otsalleen teki, suuteli sitä. Nyt oli hän
taaskin poikanen herkin, syli äidin jolla on suojanansa. — —
Nyt missä on, Hollantilainen, laivas! Täys aamua kirkasta,

nuorta on itä; meren silmäkalvossa toistuu taivas.
LAPSEN SILMÄ.
Ei mitään puhtaampaa kuin silmäs sun: mä niiden kautta

katson kadotettuun paratiisiin ja aikaan ennen
syntiinlankeemusta.

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Caroline Foster-Boucher, RN, MN Ruth Rodney, RN, PhD

Shannon MacDonald, RN, PhD

The Role of Research in Nursing

described. Understanding the step-by-step pro-

Schools of Nursing, 2016). Nursing faculty are

health policy decisions (Turale & Kunaviktikul,

Canadian Foundation for Healthcare Improvement

THE NATURE OF KNOWLEDGE becomes outdated. In this chapter, we focus spe-

Knowledge Review and Knowledge Generation

FIG. 2.1 Knowledge development process.

Knowledge that comes from the inner

FIG. 2.2 Nursing knowledge.

Hyvä ois, vähän myöskin jos kutkuttais

Runon työ on vienosti kuiskuttaa

Niin kai se on, enkä minäkään

Niin aattelin, mutta sen aatoksen

maholehmän hännän ainiaan tulis rauhoitettu olla: se on

SATU MEISTÄ KAIKISTA.

Olen kävellyt kaiken iltaa puiston teitä ja ajatellut itseäni: mitä

Olen katsellut tähtiä ja ihmetellyt, kuinka niiden silmät ovat

Ja silloin Isä Jumala muistaa, kuinka hän itse oli lapsi:

Hän oli katsellut huvikseen, kuinka hänen hymynsä putosi

Ja Jumala itsekin tunsi, miten hänen ilonsa äkisti kuoli,

Oli onnellisten saari mun sydämeni kerta, ja auringossa kylpi

Ja linnassa siellä monin jalokivin hohti Maan prinsessa

Meren äärillä kultaisin pähkinänkuorin unet soutivat

Hän kyyneltä pyys — mereks ei sitä tiennyt. Sen sai:

Yö on noussut mustin äänettömin kasvoin vuoren alta,

Yö on tullut meille. Tunnetko? — kuin vieras kylmä käsi

Meren silmiin vihreisiin vain loitolta katsonut oon:

On syvyys allamme kuin lohikäärmeen suu,

Ja jokin maston lailla meissä katkeaa

Ja kaikki elonlaivan purjehtijat hullut on:

Kuin olisimme kahlein kiinni vuoressa

Maata katso, Äiti, katso tytärtäsi: myöhä rintalapses käynyt

Itse synnyt, sytyt joka aamu hehkuun uuteen, uuteen

Tähtirakkautes hyljäten ja kupeeltasi luopuin Maa on

Lahjaas kalleintakin — kulmillansa laulun kimmellystä —

Älä katso, avaruutta syleilevä Äiti, tytärtäsi:

Olen tullut enkä päästä sinua, ennenkuin vereni

Minun äitini on suudellut kaikkina päivinä Jumalan otsaa,

Mun vuosmyriaadeja sitten avaruuksihin yöpyvän nähtiin. Ah,

Mun taattoni aurinko, turhaan

Edes kaikuna tänne ei kuulu