1. Chapter 4 Evidence-Based Practice and Ethics in Community Health Nursing

2. Evidence-Based Practice
Research: systematic collection and analysis of data related to a particular problem or phenomenon
Use of evidence or research findings along with clinical judgment and patients’ wishes in making decisions about how to care for patients
Clinical reasoning is an important component
Commonalities between evidence-based practice and critical thinking

4. Evidence-Based Practice (cont.)
Sources of information: Integrative or systematic reviews
Cochrane Collaboration (
AHRQ evidence-based practice centers (
Worldviews on Evidence-Based Nursing from Sigma Theta Tau International (
Evidence-Based Nursing, a British online journal (
RAND Corporation research briefs (

5. Evidence-Based Practice (cont.)
Correctly compose a clinical question.
Find an appropriate database to search for systematic reviews.
Critically review the evidence.
Consult practice guidelines and expert practitioners.
Work with clients to develop an appropriate plan of action.

6. Question Is the following statement true or false?
Evidence-based practice involves clinical reasoning.

7. Answer
True
Clinical reasoning is an important component of evidence-based practice.

8. Quantitative and Qualitative Research
Quantitative Research
Data can be quantified or measured objectively.
Helpful in identifying problem or relationship between two or more variables
Qualitative Research
Emphasis on subjectivity and the meaning of experiences to individuals
Possible use of both approaches in research studies
Meta-analysis: statistical procedure to analyze research; involves evaluating the results of many similar quantitative research studies in an attempt to integrate findings and combine sample sizes of many small studies to obtain a “single effect measure”

9. Steps in the Research Process
Identify an area of interest (specificity, feasibility, and relevance).
Formulate a research question or statement (population of interest, variables, interventions).
Review the literature (primary and secondary sources).
Select a conceptual model (framework of ideas providing structure and direction for research activities).

10. Steps in the Research Process (cont.)
Choose a research design (experimental [true experiments, randomized control trials, quasi- experimental]; nonexperimental or descriptive).
Obtain IRB or Human Subjects Committee approval.
Collect and analyze data (instrument, instrument validity and reliability; statistical procedures [descriptive, inferential]).
Interpret results.
Communicate findings.

11. Impact of Research on Community Health and Nursing Practice
Public policy and community’s health
Effectiveness of community health nursing practice
Status and influence of nursing as a profession

12. Question
When preparing to perform research, which of the following would the nurse do first?
Choose a research design
Review the literature
Formulate a research question
Select a conceptual model

13. c. Formulate a research question
Answer
c. Formulate a research question
After identifying an area of interest, the next step would be to formulate a research question or statement. This is followed by a review of literature, selection of a conceptual model, and then selection of a research design.

14. Values
Something perceived as desirable or a personally held abstract belief about the truth and worth of thoughts, objects, or behavior
Motivation to behave in certain ways
Derived from societal norms, family and/or religious beliefs
Value system resulting from experiences with others
Function as standards that guide actions and behavior in daily situations; code of conduct

15. Qualities of Values Endurance: relatively stable over time
Hierarchical arrangement: certain values have more weight or importance than others
Prescriptive-proscriptive belief: descriptive (capable of being true or false); evaluative (judgments of good and bad)
Reference: terminal (end states of existence [spiritual salvation, peace of mind]; instrumental (modes of conduct [confidentiality, keeping promises, honesty])
Preference: one mode of behavior over another

16. Value Systems Organizations of beliefs guiding behaviors
Systems of ordered priority allowing for change over time based on changes in society, environment, or personal experience
Conflict in values is part of decision-making processes.
Persistence in some values (i.e., individual vs. community) has effects on efforts to achieve “health care for all.”

17. Values Clarification
Process of identifying the personal and professional values that guide one’s actions by prompting person to examine what he or she believes about worth, truth, or beauty of any object, thought, or behavior and where this belief ranks compared with other values
Helpful in guaranteeing that any course of action chosen is consistent with their beliefs and values

18. Process of Valuing Choose the value freely and individually.
Choose the value from among alternatives.
Carefully consider the consequences of the choice.
Cherish or prize the value.
Publicly affirm the value.
Incorporate the value into behavior so that it becomes a standard.
Consciously use the value in decision making.

19. Question Is the following statement true or false?
The endurance of a value means that the value has more importance than another.

20. Answer
False
The endurance of a value refers to the fact that the value is relatively stable over time.

21. Value Clarification Strategies
Values Clarification Strategy I: Name tag exercise (see Fig. 4.4)
Values Clarification Strategy II: Patterns (see Fig. 4.5)
Values Clarification Strategy III: Forced choice ranking (see Fig. 4.6)

22. Ethics
Set of moral principles; theory or system of moral values; principles of conduct of a group; guiding philosophy
Ethical decision making: making a choice that is consistent with a moral code or that can be justified from an ethical perspective
Bioethics: use of ethical principles and methods of decision making that involve biological, medical, or health care issues
Ethical situations: typically involving issues with words such as want, desire, refer, should, or ought or benefit, harm, duty, responsibility, right, or obligation.

23. Ethical Decision-Making Frameworks
Key steps:
Separate questions of fact from questions of value.
Identify both clients’ and nurse’s value systems.
Consider ethical principles and concepts.
Clarify the ethical dilemma.

25. DECIDE Model D—Define the problem (or problems) E—Ethical review
C—Consider the options
I—Investigate outcomes
D—Decide on action
E—Evaluate results

26. Values that Guide Decision Making
Self-determination
Individual autonomy
Possible deterioration to self-interest
Well-being (state of positive health)
Equity (justice, fair or equal treatment)

27. Ethical Principles Respect Autonomy Beneficence Nonmaleficence
Justice (distributive, egalitarian, restorative)
Veracity
Fidelity

28. Question
Which ethical principle is applied when the nurse ensures the group’s involvement in decision making?
Beneficence
Autonomy
Respect
Justice

29. Answer
b. Autonomy
Autonomy is applied when the nurse promotes a group’s right to be involved in decision making. Beneficence is demonstrated when the nurse makes decisions that actively promote the community’s best interests and well-being. Respect is demonstrated by acknowledging the clients as participants in shaping their own and the community’s health outcomes. Justice is demonstrated when clients are treated fairly and equally.

30. Application of Ethical Principles to Decision Making
Related to value of self-determination
Respect the choices of clients.
Protect privacy.
Provide for informed consent.
Protect diminished capacity for self- determination.

31. Application of Ethical Principles to Decision Making (cont.)
Related to value of well-being
Reduce or prevent harm and provide benefits to client populations.
Measure the effectiveness of nursing services.
Balance costs of services against real client benefits.

32. Application of Ethical Principles to Decision Making (cont.)
Related to the value of equity
Broadly distributing health goods (macroallocation issues)
Deciding which populations will obtain available health goods and services (microallocation issues)

33. Internet Resources
American Nurses Association:
Healthy People 2010:
International Council of Nurses:
United Nations:
U.S. Department of Health and Human Services:
World Health Organization: