Methods and Critical Appraisal for Evidence-
Based Practice


Geri LoBiondo-Wood, PhD, RN, FAAN
Professor and Coordinator, PhD in Program, University of Texas Health Science Center at Houston,
School of , Houston, Texas

Judith Haber, PhD, RN, FAAN
The Ursula Springer Leadership Professor in , New York University, Rory Meyers College of
, New York, New York


Table of Contents

Cover image

Title page


About the authors



To the faculty

To the student

I. Overview of Research and Evidence-Based Practice



1. Integrating research, evidence-based practice, and quality improvement processes

2. Research questions, hypotheses, and clinical questions


3. Gathering and appraising the literature


4. Theoretical frameworks for research

II. Processes and Evidence Related to Qualitative Research





5. Introduction to qualitative research


6. Qualitative approaches to research

7. Appraising qualitative research

Critique of a qualitative research study



III. Processes and Evidence Related to Quantitative Research



8. Introduction to quantitative research


9. Experimental and quasi-experimental designs


10. Nonexperimental designs

11. Systematic reviews and clinical practice guidelines


12. Sampling


13. Legal and ethical issues

14. Data collection methods


15. Reliability and validity


16. Data analysis: Descriptive and inferential statistics



17. Understanding research findings


18. Appraising quantitative research
Critique of a quantitative research study

Critique of a quantitative research study




IV. Application of Research: Evidence-Based Practice



19. Strategies and tools for developing an evidence-based practice


20. Developing an evidence-based practice

21. Quality improvement


Example of a randomized clinical trial (Nyamathi et al., 2015) case management peer
coaching and hepatitis A and B vaccine completion among homeless men recently released on

Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and
mental health at 1 and 3 months after their infant schild s death in an intensive care unit

Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating
pain: A qualitative study

Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic
growth and coping in parents and siblings of adolescent cancer survivors

Example of a systematic Review/Meta analysis (Al mallah et al., 2015) The impact of nurse led
clinics on the mortality and morbidity of patients with cardiovascular diseases




Special features



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N o t i c e s
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
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Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986.

Library of Congress Cataloging-in-Publication Data

Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor.
Title: research : methods and critical appraisal for evidence-based


Justin Mouchayad

 practice / [edited by] Geri LoBiondo-Wood, Judith Haber.
Other titles: research (LoBiondo-Wood)
Description: 9th edition. | St. Louis, Missouri : Elsevier, [2018] | Includes
 bibliographical references and index.
Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper)
Subjects: | MESH: Research—methods | Research Design |
 Evidence-Based —methods
Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available

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Content Development Manager: Lisa Newton
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Publishing Services Manager: Jeff Patterson
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Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1


Justin Mouchayad

About the authors

Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator of the PhD in
Program at the University of Texas Health Science Center at Houston, School of (UTHSC-
Houston) and former Director of Research and Evidence-Based Practice Planning and Development
at the MD Anderson Cancer Center, Houston, Texas. She received her Diploma in at St.
Mary’s Hospital School of in Rochester, New York; Bachelor’s and Master’s degrees from
the University of Rochester; and a PhD in Theory and Research from New York University.
Dr. LoBiondo-Wood teaches research and evidence-based practice principles to undergraduate,
graduate, and doctoral students. At MD Anderson Cancer Center, she developed and implemented
the Evidence-Based Resource Unit Nurse (EB-RUN) Program. She has extensive national and
international experience guiding nurses and other health care professionals in the development and
utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress in
Transplantation and a reviewer for Research, Oncology Forum, and Oncology .
Her research and publications focus on chronic illness and oncology nursing. Dr. Wood has
received funding from the Robert Wood Johnson Foundation Future of Scholars program
for the past several years to fund full-time doctoral students.

Dr. LoBiondo-Wood has been active locally and nationally in many professional organizations,
including the Oncology Society, Southern Research Society, the Midwest
Research Society, and the North American Transplant Coordinators Organization. She has received
local and national awards for teaching and contributions to nursing. In 1997, she received the
Distinguished Alumnus Award from New York University, Division of Alumni
Association. In 2001 she was inducted as a Fellow of the American Academy of and in 2007
as a Fellow of the University of Texas Academy of Health Science Education. In 2012 she was
appointed as a Distinguished Teaching Professor of the University of Texas System and in 2015
received the John McGovern Outstanding Teacher Award from the University of Texas Health
Science Center at Houston School of .

Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership Professor in at the Rory
Meyers College of at New York University. She received her undergraduate nursing
education at Adelphi University in New York, and she holds a Master’s degree in Adult
Psychiatric–Mental Health and a PhD in Theory and Research from New York
University. Dr. Haber is internationally recognized as a clinician and educator in psychiatric–
mental health nursing. She was the editor of the award-winning classic textbook, Comprehensive


Psychiatric , published for eight editions and translated into five languages. She has
extensive clinical experience in psychiatric nursing, having been an advanced practice psychiatric
nurse in private practice for over 30 years, specializing in treatment of families coping with the
psychosocial impact of acute and chronic illness. Her NIH-funded program of research addressed
physical and psychosocial adjustment to illness, focusing specifically on women with breast cancer
and their partners and, more recently, breast cancer survivorship and lymphedema prevention and
risk reduction. Dr. Haber is also committed to an interprofessional program of clinical scholarship
related to interprofessional education and improving oral-systemic health outcomes and is the
Executive Director of a national nursing oral health initiative, the Oral Health Education and
Practice (OHNEP) program, funded by the DentaQuest and Washington Dental Service

Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA Psychiatric
Nurse of the Year Award, the 2005 APNA Outstanding Research Award, and the 1998 ANA
Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae Award, the 2011
Distinguished Teaching Award, and the 2014 NYU Meritorious Service Award. In 2015, Dr. Haber
received the Sigma Theta Tau International Marie Hippensteel Lingeman Award for Excellence in
Practice. Dr. Haber is a Fellow in the American Academy of and the New York
Academy of Medicine. Dr. Haber has consulted, presented, and published widely on evidence-
based practice, interprofessional education and practice, as well as oral-systemic health issues.



Terri Armstrong, PhD, ANP-BC, FAANP, Senior Investigator, Neuro-oncology Branch, Center
for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

Julie Barroso, PhD, ANP, RN, FAAN, Professor and Department Chair, Medical University of
South Carolina, Charleston, South Carolina

Carol Bova, PhD, RN, ANP, Professor of and Medicine, Graduate School of ,
University of Massachusetts, Worcester, Massachusetts

Dona Rinaldi Carpenter, EdD, RN, Professor and Chair, University of Scranton, Department of
, Scranton, Pennsylvania

Maja Djukic, PhD, RN, Assistant Professor, Rory Meyers College of , New York
University, New York, New York

Mei R. Fu, PhD, RN, FAAN, Associate Professor, Rory Meyers College of , New York
University, New York, New York

Mattia J. Gilmartin, PhD, RN, Senior Research Scientist , Executive Director, NICHE Program,
Rory Meyers College of , New York University, New York, New York

Deborah J. Jones, PhD, MS, RN, Margaret A. Barnett/PARTNERS Professorship , Associate
Dean for Professional Development and Faculty Affairs , Associate Professor, University of Texas
Health Science Center at Houston, School of , Houston, Texas

Carl Kirton, DNP, RN, MBA, Chief Officer, University Hospital, Newark, New
Jersey; , Adjunct Faculty, Rory Meyers College of , New York University, New York,
New York

Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN, Professor, Rory Meyers
College of , New York University, New York, New York

Elaine Larson, PhD, RN, FAAN, CIC, Anna C. Maxwell Professor of
Research , Associate Dean for Research, Columbia University School of , New York, New

Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center
at Houston, School of , Houston, Texas


Gail D’Eramo Melkus, EdD, ANP, FAAN, Florence & William Downs Professor in
Research, Associate Dean for Research, Rory Meyers College of , New York University,
New York, New York

Susan Sullivan-Bolyai, DNSc, CNS, RN, FAAN, Associate Professor, Rory Meyers College of
, New York University, New York, New York

Marita Titler, PhD, RN, FAAN, Rhetaugh G. Dumas Endowed Professor , Department Chair,
Department of Systems, Populations and Leadership, University of Michigan School of ,
Ann Arbor, Michigan

Mark Toles, PhD, RN, Assistant Professor, University of North Carolina at Chapel Hill, School
of , Chapel Hill, North Carolina


Karen E. Alexander, PhD, RN, CNOR, Program Director RN-BSN, Assistant Professor,
Department of , University of Houston Clear Lake-Pearland, Houston, Texas
Donelle M. Barnes, PhD, RN, CNE, Associate Professor, College of , University of Texas,
Arlington, Arlington, Texas

Susan M. Bezek, PhD, RN, ACNP, CNE, Assistant Professor, Division of , Keuka
College, Keuka Park, New York
Rose M. Kutlenios, PhD, MSN, MN, BSN, ANCC Board Certification, Adult Psychiatric/Mental
Health Clinical Specialist, ANCC Board Certification, Adult Nurse Practitioner,
Program Director and Associate Professor, Department of , West Liberty University, West
Liberty, West Virginia

Shirley M. Newberry, PhD, RN, PHN, Professor, Department of , Winona State
University, Winona, Minnesota
Sheryl Scott, DNP, RN, CNE, Assistant Professor and Chair, School of , Wisconsin
Lutheran College, Milwaukee, Wisconsin


To the faculty
Geri LoBiondo-Wood, [email protected], Judith Haber, [email protected]

The foundation of the ninth edition of Research: Methods and Critical Appraisal for Evidence-
Based Practice continues to be the belief that nursing research is integral to all levels of nursing
education and practice. Over the past three decades since the first edition of this textbook, we have
seen the depth and breadth of nursing research grow, with more nurses conducting research and
using research evidence to shape clinical practice, education, administration, and health policy.

The National Academy of Medicine has challenged all health professionals to provide team-based
care based on the best available scientific evidence. This is an exciting challenge. Nurses, as
clinicians and interprofessional team members, are using the best available evidence, combined
with their clinical judgment and patient preferences, to influence the nature and direction of health
care delivery and document outcomes related to the quality and cost-effectiveness of patient care.
As nurses continue to develop a unique body of nursing knowledge through research, decisions
about clinical nursing practice will be increasingly evidence based.

As editors, we believe that all nurses need not only to understand the research process but also to
know how to critically read, evaluate, and apply research findings in practice. We realize that
understanding research, as a component of evidence-based practice and quality improvement
practices, is a challenge for every student, but we believe that the challenge can be accomplished in
a stimulating, lively, and learner-friendly manner.

Consistent with this perspective is an ongoing commitment to advancing implementation of
evidence-based practice. Understanding and applying research must be an integral dimension of
baccalaureate education, evident not only in the undergraduate nursing research course but also
threaded throughout the curriculum. The research role of baccalaureate graduates calls for
evidence-based practice and quality improvement competencies; central to this are critical appraisal
skills—that is, nurses should be competent research consumers.

Preparing students for this role involves developing their critical thinking skills, thereby
enhancing their understanding of the research process, their appreciation of the role of the critiquer,
and their ability to actually critically appraise research. An undergraduate research course should
develop this basic level of competence, an essential requirement if students are to engage in
evidence-informed clinical decision making and practice, as well as quality improvement activities.

The primary audience for this textbook remains undergraduate students who are learning the
steps of the research process, as well as how to develop clinical questions, critically appraise
published research literature, and use research findings to inform evidence-based clinical practice
and quality improvement initiatives. This book is also a valuable resource for students at the
master’s, DNP, and PhD levels who want a concise review of the basic steps of the research process,
the critical appraisal process, and the principles and tools for evidence-based practice and quality

This text is also an important resource for practicing nurses who strive to use research evidence
as the basis for clinical decision making and development of evidence-based policies, protocols, and
standards or who collaborate with nurse-scientists in conducting clinical research and evidence-
based practice. Finally, this text is an important resource for considering how evidence-based
practice, quality improvement, and interprofessional collaboration are essential competencies for
students and clinicians practicing in a transformed health care system, where nurses and their
interprofessional team members are accountable for the quality and cost-effectiveness of care
provided to their patient population. Building on the success of the eighth edition, we reaffirm our
commitment to introducing evidence-based practice, quality improvement processes, and research
principles to baccalaureate students, thereby providing a cutting-edge, research consumer
foundation for their clinical practice. Research: Methods and Critical Appraisal for Evidence-
Based Practice prepares nursing students and practicing nurses to become knowledgeable nursing


research consumers by doing the following:

• Addressing the essential evidence-based practice and quality improvement role of the nurse,
thereby embedding evidence-based competencies in clinical practice.

• Demystifying research, which is sometimes viewed as a complex process.

• Using a user-friendly, evidence-based approach to teaching the fundamentals of the research

• Including an exciting chapter on the role of theory in research and evidence-based practice.

• Providing a robust chapter on systematic reviews and clinical guidelines.

• Offering two innovative chapters on current strategies and tools for developing an evidence-
based practice.

• Concluding with an exciting chapter on quality improvement and its application to practice.

• Teaching the critical appraisal process in a user-friendly progression.

• Promoting a lively spirit of inquiry that develops critical thinking and critical reading skills,
facilitating mastery of the critical appraisal process.

• Developing information literacy, searching, and evidence-based practice competencies that
prepare students and nurses to effectively locate and evaluate the best research evidence.

• Emphasizing the role of evidence-based practice and quality improvement initiatives as the basis
for informing clinical decisions that support nursing practice.

• Presenting numerous examples of recently published research studies that illustrate and highlight
research concepts in a manner that brings abstract ideas to life for students. These examples are
critical links that reinforce evidence-based concepts and the critiquing process.

• Presenting five published articles, including a meta-analysis, in the Appendices, the highlights of
which are woven throughout the text as exemplars of research and evidence-based practice.

• Showcasing, in four new inspirational Research Vignettes, the work of renowned nurse
researchers whose careers exemplify the links among research, education, and practice.

• Introducing new pedagogical interprofessional education chapter features, IPE Highlights and IPE
Critical Thinking Challenges and quality improvement, QSEN Evidence-Based Practice Tips.

• Integrating stimulating pedagogical chapter features that reinforce learning, including Learning
Outcomes, Key Terms, Key Points, Critical Thinking Challenges, Helpful Hints, Evidence-
Based Practice Tips, Critical Thinking Decision Paths, and numerous tables, boxes, and figures.

• Featuring a revised section titled Appraising the Evidence, accompanied by an updated
Critiquing Criteria box in each chapter that presents a step of the research process.

• Offering a student Evolve site with interactive review questions that provide chapter-by-chapter
review in a format consistent with that of the NCLEX® Examination.

• Offering a Student Study Guide that promotes active learning and assimilation of nursing
research content.

• Presenting Faculty Evolve Resources that include a test bank, TEACH lesson plans, PowerPoint
slides with integrated audience response system questions, and an image collection. Evolve
resources for both students and faculty also include a research article library with appraisal
exercises for additional practice in reviewing and critiquing, as well as content updates.


The ninth edition of Research: Methods and Critical Appraisal for Evidence-Based Practice is
organized into four parts. Each part is preceded by an introductory section and opens with an
engaging Research Vignette by a renowned nurse researcher.

Part I, Overview of Research and Evidence-Based Practice, contains four chapters: Chapter 1,
“Integrating Research, Evidence-Based Practice, and Quality Improvement Processes,” provides an
excellent overview of research and evidence-based practice processes that shape clinical practice.
The chapter speaks directly to students and highlights critical reading concepts and strategies,
facilitating student understanding of the research process and its relationship to the critical
appraisal process. The chapter introduces a model evidence hierarchy that is used throughout the
text. The style and content of this chapter are designed to make subsequent chapters user friendly.
The next two chapters address foundational components of the research process. Chapter 2,
“Research Questions, Hypotheses, and Clinical Questions,” focuses on how research questions and
hypotheses are derived, operationalized, and critically appraised. Students are also taught how to
develop clinical questions that are used to guide evidence-based inquiry, including quality
improvement projects. Chapter 3, “Gathering and Appraising the ,” showcases cutting-
edge information literacy content and provides students and nurses with the tools necessary to
effectively search, retrieve, manage, and evaluate research studies and their findings. Chapter 4,
“Theoretical Frameworks for Research,” is a user-friendly theory chapter that provides students
with an understanding of how theories provide the foundation of research studies and evidence-
based practice projects.

Part II, Processes and Evidence Related to Qualitative Research, contains three interrelated
qualitative research chapters. Chapter 5, “Introduction to Qualitative Research,” provides an
exciting framework for understanding qualitative research and the significant contribution of
qualitative research to evidence-based practice. Chapter 6, “Qualitative Approaches to Research,”
presents, illustrates, and showcases major qualitative methods using examples from the literature as
exemplars. This chapter highlights the questions most appropriately answered using qualitative
methods. Chapter 7, “Appraising Qualitative Research,” synthesizes essential components of and
criteria for critiquing qualitative research reports using published qualitative research study.

Part III, Processes and Evidence Related to Quantitative Research, contains Chapters 8 to
18Chapter 8Chapter 9Chapter 10Chapter 11Chapter 12Chapter 13Chapter 14Chapter 15Chapter
16Chapter 17Chapter 18. This group of chapters delineates essential steps of the quantitative
research process, with published clinical research studies used to illustrate each step. These
chapters are streamlined to make the case for linking an evidence-based approach with essential
steps of the research process. Students are taught how to critically appraise the strengths and
weaknesses of each step of the research process in a synthesized critique of a study. The steps of the
quantitative research process, evidence-based concepts, and critical appraisal criteria are
synthesized in Chapter 18 using two published research studies, providing a model for appraising
strengths and weaknesses of studies, and determining applicability to practice. Chapter 11, a
unique chapter, addresses the use of the types of systematic reviews that support an evidence-based
practice as well as the development and application of clinical guidelines.

Part IV, Application of Research: Evidence-Based Practice, contains three chapters that
showcase evidence-based practice models and tools. Chapter 19, “Strategies and Tools for
Developing an Evidence-Based Practice,” is a revised, vibrant, user-friendly, evidence-based toolkit
with exemplars that capture the essence of high-quality, evidence-informed nursing care. It “walks”
students and practicing nurses through clinical scenarios and challenges them to consider the
relevant evidence-based practice “tools” to develop and answer questions that emerge from clinical
situations. Chapter 20, “Developing an Evidence-Based Practice,” offers a dynamic presentation of
important evidence-based practice models that promote evidence-based decision making. Chapter
21, “Quality Improvement,” is an innovative, engaging chapter that outlines the quality
improvement process with information from current guidelines. Together, these chapters provide
an inspirational conclusion to a text that we hope motivates students and practicing nurses to
advance their evidence-based practice and quality improvement knowledge base and clinical
competence, positioning them to make important contributions to improving health care outcomes
as essential members of interprofessional teams.

Stimulating critical thinking is a core value of this text. Innovative chapter features such as
Critical Thinking Decision Paths, Evidence-Based Practice Tips, Helpful Hints, Critical Thinking
Challenges, IPE Highlights, and QSEN Evidence-Based Practice Tips enhance critical thinking,
promote the development of evidence-based decision-making skills, and cultivate a positive value


about the importance of collaboration in promoting evidence-based, high quality and cost-effective
clinical outcomes.

Consistent with previous editions, we promote critical thinking by including sections called
“Appraising the Evidence,” which describe the critical appraisal process related to the focus of the
chapter. Critiquing Criteria are included in this section to stimulate a systematic and evaluative
approach to reading and understanding qualitative and quantitative research and evaluating its
strengths and weaknesses. Extensive resources are provided on the Evolve site that can be used to
develop critical thinking and evidence-based competencies.

The development and refinement of an evidence-based foundation for clinical nursing practice is
an essential priority for the future of professional nursing practice. The ninth edition of
Research: Methods and Critical Appraisal for Evidence-Based Practice will help students develop a basic
level of competence in understanding the steps of the research process that will enable them to
critically analyze research studies, judge their merit, and judiciously apply evidence in clinical
practice. To the extent that this goal is accomplished, the next generation of nursing professionals
will have a cadre of clinicians …

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