Research, evidence-based practice (EBP), and quality improvement support the three main goals of the Magnet Recognition Program^® and the Magnet Model component of new knowledge, innovation, and improvements. The three main goals of the Magnet Recognition Program are to: 1) Promote quality in a setting that supports professional practice 2) Identify excellence in the delivery of nursing services to patients or residents 2) Disseminate best practices in nursing services.

The Magnet Model includes five components:

• transformational leadership
• structural empowerment
• exemplary professional practice
• new knowledge, innovation, and improvements
• empirical quality outcomes.

To achieve the goals of the Magnet Recognition Program and the “new knowledge innovation and improvements” component of the Magnet Model, nurses at all levels of healthcare organizations must be involved. Many nurses may be unaware of the importance of their contributions to developing new knowledge, innovations, and improvements and may not be able to differentiate among those processes. This article explains the basic differences among research, EBP, and quality improvement (QI.) (See Comparing research, evidence-based practice, and quality improvement.)

Understanding research

The purpose of conducting research is to generate new knowledge or to validate existing knowledge based on a theory. Research studies involve systematic, scientific inquiry to answer specific research questions or test hypotheses using disciplined, rigorous methods. While research is about investigation, exploration, and discovery, it also requires an understanding of the philosophy of science. For research results to be considered reliable and valid, researchers must use the scientific method in orderly, sequential steps.

The process begins with burning (compelling) questions about a particular phenomenon, such as: What do we know about the phenomenon? What evidence has been developed and reported? What gaps exist in the knowledge base?

The first part of investigation involves a systematic, comprehensive review of the literature to answer those questions. Identified knowledge gaps typically provide the impetus for developing a specific research question (or questions), a hypothesis or hypotheses, or both. Next, a decision can be made on the underlying theory that will guide the study and aid selection of type of method to be used to explore the phenomenon.

The two main study methods are quantitative (numeric) and qualitative (verbal), although mixed methods using both are growing. Quantitative studies tend to explore relationships among a set of variables related to the phenomenon, whereas qualitative studies seek to understand the deeper meaning of the involved variables.

• Quantitative studies typically involve scientific methodology to determine appropriate sample size, various designs to control for potential errors during data collection, and rigorous statistical analysis of the data.
• Qualitative studies tend to explore life experiences to give them meaning.

In all research, discovery occurs as data are collected and analyzed and results and outcomes are interpreted.

A final important step in the research process is publication of study results with a description of how they contribute to the body of knowledge. Examples of potential nursing research include conducting a systematic review of studies on preventing catheter-associated urinary tract infections (CAUTI), a randomized controlled trial exploring new wound care methods, and a qualitative study to investigate the lived experiences of patients with a specific chronic disease.

Understanding EBP

Unlike research, EBP isn’t about developing new knowledge or validating existing knowledge. It’s about translating the evidence and applying it to clinical decision-making. The purpose of EBP is to use the best evidence available to make patient-care decisions. Most of the best evidence stems from research. But EBP goes beyond research use and includes clinical expertise as well as patient preferences and values. The use of EBP takes into consideration that sometimes the best evidence is that of opinion leaders and experts, even though no definitive knowledge from research results exists. Whereas research is about developing new knowledge, EBP involves innovation in terms of finding and translating the best evidence into clinical practice.

Steps in the EBP process

The EBP process has seven critical steps:

1. Cultivate a spirit of inquiry.

2. Ask a burning clinical question.

3. Collect the most relevant and best evidence.

4. Critically appraise the evidence.

5. Integrate evidence with clinical expertise, patient preferences, and values in making a practice decision or change.

6. Evaluate the practice decision or change.

7. Disseminate EBP results.

Cultivating a spirit of inquiry means that individually or collectively, nurses should always be asking questions about how to improve healthcare delivery. The burning clinical question commonly is triggered through either a problem focus or a knowledge focus. Problem-focused triggers may arise from identifying a clinical problem or from such areas as risk management, finance, or quality improvement. Knowledge-focused triggers may come from new research results or other literature findings, new philosophies of care, or new regulations.

Regardless of the origin, the next step in the EBP process is to review and appraise the literature. Whereas a literature review for research involves identifying gaps in knowledge, a literature review in EBP is done to find the best current evidence.

Hierarchy of evidence

In searching for the best available evidence, nurses must understand that a hierarchy exists with regard to the level and strength of evidence. All of the various hierarchies of evidence are similar to some degree.

• The highest (strongest) level of evidence typically comes from a systematic review, a meta-analysis, or an established evidence-based clinical practice guideline based on a systematic review.
• Other levels of evidence come from randomized controlled trials (RCTs), other types of quantitative studies, qualitative studies, and expert opinion and analyses.

Critical appraisal

Once the evidence is gathered, the researcher must critically appraise each study to ensure its credibility and clinical significance. Critical appraisal often is thought to be tedious and time-consuming. But it’s crucial to determine not only what was done and how, but how well it was done. An easy method for conducting critical appraisal is to answer these three key questions:

• What were the results of the study? (In other words, what is the evidence?)
• How valid are the results? (Can they be trusted?)
• Will the results be helpful in caring for other patients? (Are they transferable?)

Final steps of EBP

The final steps of the EBP process include integrating the evidence with one’s clinical expertise, taking into account patient preferences, and evaluating the effectiveness of applying the evidence. Disseminating or reporting the results of EBP projects may help others learn about and apply the best evidence. Examples of potential EBP projects include implementing an evidence-based clinical practice guideline to reduce or prevent CAUTIs, evaluating an evidence-based intervention to improve wound healing, and applying an EBP to improve compliance with a specific treatment for a chronic disease.

Understanding QI

The purpose of QI is to use a systematic, data-guided approach to improve processes or outcomes. Principles and strategies involved in QI have evolved from organizational philosophies of total quality management and continuous quality improvement.

While the concept of quality can be subjective, QI in healthcare typically focuses on improving patient outcomes. So the key is to clearly define the outcome that needs to be improved, identify how the outcome will be measured, and develop a plan for implementing an intervention and collecting data before and after the intervention.

QI methods

Various QI methods are available. A common format uses the acronym FOCUS-PDSA:

Find a process to improve.

Organize an effort to work on improvement.

Clarify current knowledge of the process.

Understand process variation and performance capability.

Select changes aimed at performance improvement.

Plan the change; analyze current data and predict the results.

Do it; execute the plan.

Study (analyze) the new data and check the results.

Act; take action to sustain the gains.

Unlike research and EBP, QI typically doesn’t require extensive literature reviews and rigorous critical appraisal. Therefore, nurses may be much more involved in QI projects than EBP or research. Also, QI projects normally are site specific and results aren’t intended to provide generalizable knowledge or best evidence. Examples of QI projects include implementing a process to remove urinary catheters within a certain time frame, developing a process to improve wound-care documentation, and improving the process for patient education for a specific chronic disease.

Take-away points

• Research, EBP, and QI support the three main goals of the Magnet Recognition Program and the Magnet Model components of new knowledge, innovation, and improvements.
• Research applies a methodology (quantitative or qualitative) to develop new knowledge.
• EBP seeks and applies the best clinical evidence, often from research, toward making patient-care decisions.
• QI uses systematic processes to improve patient outcomes.

All nurses should know and understand the differences among these three concepts.

Brian T. Conner is an assistant professor and undergraduate program director in the College of Nursing at the Medical University of South Carolina in Charleston.

Selected references

American Nurses Credentialing Center. Magnet Program Overview. www.nursecredentialing.org/Magnet/ProgramOverview. Accessed April 21, 2014.

Brown SJ Evidence-Based Nursing: The Research-Practice Connection. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2013.

Burns N, Grove SK, Gray JR. The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. 7th ed. St. Louis, MO: Elsevier Saunders; 2012.

Harris JL, Roussel L, Walters SE, et al. Project Planning and Management: A Guide for CNLs, DNPs, and Nurse Executives. Sudbury, MA: Jones & Bartlett Learning; 2011.

Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. London: Churchill Livingstone; 2000.

Tappen RM. Advanced Nursing research: From Theory to Practice. Sudbury, MA: Jones & Bartlett Learning; 2011.

Titler MG, Kleiber D, Steelman VJ, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509.