Sr. Callista Roy, PhD, RN, FAAN

1
Generating Cumulative Knowledge Evidence for
Practice

• 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

2
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

3
Cumulative Knowledge

• Annual Review of Nursing Researchstarted in
  1983, H. Werley
• Publishes state of the science papersintegrated
  review on one topic
• Metaanalysisusually of clinical trials
• Critique of Use as EvidenceMove 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
4
Cumulative Knowledge Based on One Theoretical
ModelRoy Adaptation Model

• Have common concepts close to practice
• Concepts cross clinical areas, based on adapting
  people and groups can be generalized
• Large number of studies
• Multiple methods
• Measurements may be the same
• Basis within heritage of nursing perspective

5
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

6
Studies Organized by Method

• Quantitative Studies (n127)
• Descriptive (59)
• Explaining, Predicting and Prescribing (43)
• Interventions (25)
• Qualitative Studies (n40)
• Content Analysis (n8)
• Grounded Theory (n4)
• Ethnography (n3)
• Phenomenology (n17)
• Mixed Methods (n6)
• Case Study (n2)

7
350 Research Studies in Data Base from 1970-2010
by 5-year Intervals
8
Process of Using Studies to Create MRT

• 1. Observations (studies) are clustered together
• 2. Similarities identified
• 3. Major concepts identified-Critics, Conceptual
  clarity needed,RAM concepts developed over 42
  years of publications, with definitions/theoretica
  l 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

9
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

10
Major Clusters of Studies-Developing Middle range
Theories

• General coping
• Coping with life events
• Coping with loss
• Coping with chronic health conditions
• Coping with family health

11
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)

12
Examples of StudiesQuantitative and Qualitative

• 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)

13
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

14
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.

15

• 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

16
Middle Range Theory of Coping with Life Events,
Developmental Events
17
Middle Range Theory of Coping with Life Events,
Situational Events
18
Views of Evidence for Practice

• 1. Sometimes evidence means, reduced to
  biomedical, empirical and positivistic variables
  and criteria
• 2. 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 frameworkno definite ideas
  reached
• 
  
  
  
  
  
• Meleis, 2007
• 
  

19
Level 1 EBP High Potential for Implementation
in Practice

• Proposition supported by more than one study
• Unequivocal support of hypothesis
• Low risk
• High clinical need
• Level 2 EBP Needs Further Clinical Evaluation
  Before Implementation
• Proposition supported
• Generalizability not clear
• Risk not clear
• High clinical need
• Level 3 EBP Needs Further Testing Before
  Implementation

20
Translational Research

• National Institutes of Health made translational
  research a priority
• Clinical 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

21
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 patients ability to
  cope with their developmental and situational
  life events across settings.

22
Pathway to Cumulative Knowledge as Evidence
for Practice, the Basis of Change