Sr. Callista Roy, PhD, RN, FAAN Professor and Nurse Theorist Boston College Connell School of Nursing

Council Advancement Nursing Science Washington , DC September 14, 2012

Generating Cumulative Knowledge: Evidence for

Practice

Purpose-Discovery through Innovation

To purpose a pathway to cumulative knowledge as a basis for evidence for practice by:

Synthesizing research based on one conceptual model

Deriving middle-range theories based on the cumulative knowledge

Providing a broad definition for evidence for practice and demonstrate the evidence for the derived theories

Presenting an exemplar of how cumulative knowledge can create change for practice

Cumulative Knowledge Annual Review of Nursing Research—started in

1983, H. WerleyPublishes state of the science papers—integrated review on one topic

Metaanalysis—usually of clinical trials

Critique of Use as Evidence—Move from focus on empirics to focus on diverse patterns of knowing and use of theory-guided, evidence-based holistic nursing practice

Fawcett, Watson, Neuman, Walker & Fitzpatrick, 2001

Cumulative Knowledge Based on One Theoretical Model—Roy Adaptation Model

Have common concepts close to practiceConcepts cross clinical areas, based on

adapting people and groups; can be generalized

Large number of studiesMultiple methodsMeasurements may be the sameBasis within heritage of nursing perspective

Results of Literature Review 1995-2010

178 studies met research and links to model criteria

106 were referred journal publications and 72 were dissertations

Articles published in 47 English-language journals

Dissertations completed at 32 different universities in the United States

Studies Organized by MethodQuantitative Studies (n=127) Descriptive (59) Explaining, Predicting and Prescribing (43) Interventions (25) Qualitative Studies (n=40) Content Analysis (n=8) Grounded Theory (n=4) Ethnography (n=3) Phenomenology (n=17) Mixed Methods (n=6) Case Study (n=2)

350 Research Studies in Data Base from 1970-2010 by 5-year Intervals

Process of Using Studies to Create MRT

1. Observations (studies) are clustered together

2. Similarities identified3. Major concepts identified-Critics,

Conceptual clarity needed,RAM concepts developed over 42 years of publications, with definitions/theoretical basis

4. Concepts interrelated in theoretical statements-RAM has set of generic propositions

5. Even with 178 plus researchers, still commonalities for cumulative knowledge are great

Middle-range Theories

Significant milestone that marks considerable progress in knowledge development beginning 1991-1995

Have a transformational effect on entire discipline of nursing

Help to answer questions about overall mission, goals and nature of discipline of nursing and differentiate from other disciplines

Clear indication that nursing discipline has undergone a turning point toward producing more accessible and functional theories that guide productive research programs and provide theory and research-based evidence for practice

Meleis, 2007

Major Clusters of Studies-Developing Middle range Theories General copingCoping with life eventsCoping with lossCoping with chronic health conditionsCoping with family health

Coping with Life Events Examples of Studies--Quantitative

1. Descriptive survey. 300 women identified common postpartum problems and adaptation strategies to cope with these problems during the first 2 to 8 weeks following delivery of full term healthy newborns (Martin, 1995)

2. Multivariate –to explain. Public data set used to test a model of decision-making responses related to Advance Directives (ADS) with 938 aging subjects. Results were analyzed using causal modeling and path analysis (Zhang, 2004)

Intervention study. 105 preschool children having immunization injections. The aim was to examine the effects distraction and cutaneous stimulation on the pain of having the injection (Sparks, 1999)

Phenomenological study. Described the experience of five emergency nurses who routinely handle traumatic and violent events (Wright, 2007)

Examples of Studies–Quantitative and Qualitative

Coping with Life Events: Concepts

1. Developmental, expected postpartum, menopause, advanced

directives, immunizations

2. Situational Events, unexpected, specific—verbal abuse or observing trauma-nurses; date violence Challenges of health changes

—mother and child, e.g. NICU, cerebral palsy, cancer

Statements from Studies that Relate Coping Strategies to Outcomes

1. Cognator processes of taking direct action, planning ahead, handling systematically and use of resources and experience can affect adaptive responses in self-esteem, role transition, sensation, and health attitudes.

2. In new role development or an unexpected role event expanding input can lead to effective role transition or role effectiveness.

3.When life event or health challenges involve too many or unfamiliar challenges selective attention can help integrate the experience.

4. For nurses facing specific event challenges problem-focused behaviors, use of knowledge and skill and humor can lead to role effectiveness, teamwork, and protected mental health.

5. Time perspective can be useful in resolving moral distress.

6. Use of personal and spiritual self, particularly seeing moral ends can protect mental health.

7. Relating to others during developmental challenges is used for help, support and emotional sharing.

8. Relating to others during life challenges is used for support and empathy.

9. Relating to others in health challenges is needed but may be lacking, leaving the person with a duty to be strong.

10. The use of a common language between those dealing with health challenges and the nurse can lessen anxiety and fear.

11. The pooled effect of contextual stimuli such as context, age, and socioeconomic status and residual stimuli such as childhood abuse and witness of violence affect the mental health outcomes of abuse.

12. The unique bonding and connecting of mothers of ill children does not eliminate the craving for normalacy

Middle Range Theory of Coping with Life Events, Developmental Events

Middle Range Theory of Coping with Life Events, Situational Events

Views of Evidence for Practice1. Sometimes evidence means, reduced to biomedical,

empirical and positivistic variables and criteria2. Critical dialogue about eclectic views of evidence

that may incorporate more components more congruent with nursing science and emanate from how nursing knowledge and knowing how been defined

3. Included widening meaning of evidence to make it more pluralistic, to incorporate humanistic experience as evidence of models of care used

4. We have not explored criteria for judging evidence within this framework—no definite ideas reached

Meleis, 2007

Level 1 EBP: High Potential for Implementation in Practice Proposition supported by more than one studyUnequivocal support of hypothesisLow riskHigh clinical need

Level 2 EBP: Needs Further Clinical Evaluation Before Implementation

Proposition supportedGeneralizability not clearRisk not clearHigh clinical needLevel 3 EBP: Needs Further Testing Before

Implementation

Translational ResearchNational Institutes of Health made translational research a

priorityClinical and Translational Science Award (CTSA) program

began in 2006; in 2008 were 60 such centers; in 2012 expect 60

T1 means bench to bedside; e.g. harnessing knowledge from basic sciences to produce new drugs, devices, and treatment s

T2 seeks to close the gap and improve quality by improving access, reorganizing and coordinating system care, helping clinicians and patients to exchange behaviors, make more informed choices, providing reminders and point –of-care decision support tools, and strengthening patient-clinician relationship

Take clinical studies into everyday clinical practice and health decision making Wolfe, 2011

Coping is Significant for Health: Recommendations for Practice

Intervention: We propose that a major responsibility for every nurse in practice is to coach each patient in the use of ones’ own coping strategies; when to use one and when another; what coping strategies works best for them in a given situation and what situations call for learning new strategies

Change for Practice: Add a nurse-discharge planner for every inpatient unit. This nurse would not be concerned primarily with finding long-term placements for patients across many settings. Rather the nurse in this re-defined role would work with the primary care nurses on a given unit from the time the patient is admitted to plan for coordinating the patient’s ability to cope with their developmental and situational life events across settings.

Pathway to Cumulative Knowledge as Evidence for Practice, the Basis of Change