overcome these barriers are discussed later in this chapter.

another essential step, once articles have been obtained, is the critical appraisal of the research. EVALUATING THE SCIENTIFIC MERIT OF RESEARCH FINDINGS Research findings that are to serve as a base for clinical practice must be sound. The developers of the CURN model identified there criteria of determining the validity of research findings, scientific merit, replication, and risk (haller, Reynold, and Horsley, !"!#. The evaluation of the scientific merit has been discussed in the previous chapter. Replication and risk are criteria that are highly relevant to the clinical usefulness of findings. Replication may be either an e$act or literal replication follo%ing the details of the original design, or it may be a construct replication in %hich a similar hypothesis os tested using a ne% method or design ( &lom'uist, !()* haller and Reynolds, !() #. The latter helps to establish the validity of the construct across different situation and populations, increasing the generali+ability of result. Replication provide the substantiating evidemce that research conclusion are sound ( ,ettler and -arram, !"! #. .n either from the process is critical for research/based practice because it enhances scientific merit and helps to prevent both type . and type .. errors ( Haller, et al., !"! #. type . errors or fals positive , are potentially ha+ardous to client, so building practice on the basis of one study %ould be unethical. The rigor %ith %hich the criterion of replication is applied is to some e$tend dependent on the risk factor. Risk can include both the potential ha+ard to the client and the potential costs to the organi+ation. in a situation %here the risk is small, the findings may be applied more liberally. .f an innovation can be safety and cost effectively implemented and clinically evaluated, the decision to try it prior to rigorous replication may be appropriate. 0or e$ample , a study of the effect of offering choices to mildly to moderately demented nursing ho,e resident found that resident made decisions %hen given the opportunity ( 1epler and 2oesner, !!3 #. 1articipant %ith the last cognitive ability. %hose 0olstesin -ini -ental ,tatus score %ere less than 3, %here able to make a choice bet%een

alternatives %ithout an$iety, although they %ere less able to respond to open/ended choices. The intervention is simple, virtually cost free, and the effect can be closely monitored for a careful clinical evaluation. ASSESING THE CLINICAL MERIT OF THE RESEARCH FINDINGS 4nce these three criteria have been considered, relevance to clinical practice can be evaluated. appraising clinical merit involves e$amination of the follo%ing 5 . The significant of the problem or phenomenon. 3. The relative advantages of the innovation, including cost 6. The fit %ith the setting. 7. The feasibility of evaluating the innovation ( Horsley, et al., !(6 #. .n determining %hether to use an innovation in practice. the clical %ill %eigh the significant of the problem or phenomenon against the relative advantage of the innovation over current practice. .f an innovation relates to a minor or rarely encountered problem or involves a change in %hich human and finance costs are e$cessive, the costs of changing current practice may not be %orth%hile. The advantages need to be e$amined in relation to %ho benefits and ho% much. 8 ne% approach that benefits Client significantly might %ell be %orthy of adoption, even if costs the nurse in terms of effort or the agency in terms of dollars. 8dvantages that are visible or tangible are more readily recogni+ed and can be more convincing than those that are abstract or 9soft:. 0ortunately, better measure of variables such as 'uality of life are becoming available and their significance is more %idely recogni+ed. 4bviously the ideal innovation is beneficial in terms of client and nursing outcomes and costs less than present practice. 8 good 9fit: %ith the organi+ation in is other important consideration ( Horsley, et al., !(6 #. This does not imply that an organi+ation cannot change to the fit an innovation, but a change that is consistent %ith the philosophy and policies of an agency is more likely to occur. 0or e$ample, if the philosophy is one of patient autonomy and collaborative

practice among different health professionals, the instruction of patient/controlled analgesia (1C8# is likely to fit %ith nurses and physicians beliefs. 1C8 is much more liable to be effectively implemented in such a setting than one in %hich either nurse or physicians believe that patient %ill take too much analgesia. 4ther factors in the organi+ation to be considered, as %ell as philosophy and policy, are the structure, the decision/making processes, and the personnel. 8ssessing the feasibility of adopting an innovation involves comparing the needed resources %ith those available or obtainable. .t may be possible to modify either the innovation or the resource %ithin budgetary and other constrainst, but sometimes the innovation may have to be re;ected for the particular setting despite its clinical merit. 0or instance a change calling for a different location of bathrooms may not be possible at a given time, but the research should be considered %hen renovation s are planned. another aspect of feasibility assessment, is the consideration of the comple$ity, reversibility, and divisibility of the innovation. 8 ne% techni'ue or strategy that is relatively straightfor%ard or easily learned may be attainable %ithin limited resource and more readily adopted than one that is comple$ and involves a ma;or training program for staff. .f an innovation can be introduced temporalily and can be readily reserved if it does not have the desired outcomes, staff %ill be more %illing to give it a try. ,imilarly, if it can be introduce gradually, unit by unit or section by section, it %ill be less threatening as a ma;or change. <valuation of the clinical merit of the findings is as essential as evaluation of the scientific merit. .t is a comple$ re'uiring clinical kno%ledge and skills and a thorough understanding of the particular setting. 1art of the assessment of clinical merit includes the necessary step of testing innovation in terms of desired outcomes and costs. The ease %ith %hich a ne% idea or techni'ues can be tested and the cost and political reality of the impact of that tasting %ill have important implications for its clinical merit.

TESTING THE FINDINGS IN PRACTICE 8 ne% approach or idea must be tested in practice before is adoption. This evaluative process should be carried out systematically and rigorously, but the process different from the conduct of research. .ts purpose is to e$amine the feasibility of using the innovation in a particular setting. .t serves as the base for decision making about the adoption of the innovation. The CURN model for developing research based practice calls for a clinical trial comparing baseline measure %ith actual outcomes after the introduction of the innovation ( Horsley, et al., !(6 #. The innovation should be carried out %ithin the scientific limits of the independent variable in the original study, possibly %ith minor ad;ustments relevant to the setting. 0or e$ample, if a trial of positioning of premature neonates %ere to be conducted, parameter of gestational age, birth age, %eigh, and diagnosis in the original studies (0o$ and -olesky, !!=# %ould have to be respected, but the particular type of mattress used in the neonatal intensive care unit might be different. The outcomes should include as many as possible of the dependent variables in the research and should be measured %ith the same instrument %hen clinically feasible. The use of some research instrument a laboratory, and direct invasive measure may not be possible. Reliable indirect measure may be used, such as measuring blood pressure %ith a sphygmomanometer rather than having an intraarterial line. The trial is planned in detail, including identification of needed resourch and costs. .t is essential to involve the nursing staff and other health professional in early discussion and to obtain the necessary sanctions and approval. The staff involved in implementing the innovation %ill need to learn the techni'ue, and separate group independent of those implementing the innovation, %ill need to learn ho% to use the dependent measure. The political reality of the agency or institution may have significant effect on the trial and need to be considered. ,upose a long/term care institution of a no/restraint policy based on the evidence of the potential harm of the use of restraint and the effectiveness of alternative methods of maintaining resident safety resident safety ( -acioro%ski, -unro,

>ietrick/?allagher, and @anich, !((#. .f the nursing staff is skeptical about the research evidence, the nursing department %ill have to consider not only the effect of alternative interventions, but also the political outcomes of the process. .f the test is carried out on a unit %here the staff are perceived by staff on other units to be more enthusiastic or vigilant, a successful outcome may not convince staff on other unit. 4n the other hand, there may be a risk conducting the test on a unit %here the staff are less enthusiastic, as the outcome may not be positive. 4ther factor to be appraised %hen planning a trial are concurrent phenomena and surrounding events. 4bvious occurrences such as seasonal change in staffing or client populations could effect the outcome of a trial, and since health care agencies are rarely static, fle$ibility and tracking of concurrent events are necessary. 8 trial may have to be discontinued if there are ma;or change in the environment. .n the revised ,tetler model ( ,tetler, !!7 # a different level of testing can be appropriate. @ith certain innovation a systematic test in individual nurseAs practice can precede a larger clinical trial, or the change may remain an individual change rather than an institutional one. 0or instance, based on study by Rosendahl and Ross ( !(3#, a nurse may decide to e$amine the purposeful us of specific attending behavior %hen interacting %ith client. 8 nurse manager might use data from a revie% of nurse turnover literature (Cavanagh, !(!# to test a particular strategy %ith the staff. These individual tests are not merely a matter of trial and error, because the innovation, the research base and the level of utili+ation, discussed in the follo%ing section. @hen a research base is e$pected to form policy and lead to a change in practice, the care taken in the evaluation phase can have a significant influence on ultimate use. systematic evaluation of a ne% approach of techni'ue not only affects decision making regarding the approachAs usefulness, but it also affect attitudes fundamental to successful change.