Nurses prepared in research and practice focused doctoral programs make important contributions to the development and implementation of the science that shapes nursing practice. This article explores the different, yet complementary roles that PhD and DNP prepared nurses make to the scholarship of discovery within the discipline of nursing. The impact of translational research, implementation science, and improvement science on the quality of healthcare is explored, along with the possibilities presented by big data. Examples of successful collaborations are highlighted, including opportunities for DNP and PhD faculty to advance scholarship and research. The authors consider the context of these roles in both research and practice and academia.
Key Words: Nursing research, nursing science, PhD in nursing, Doctor of Nursing Practice (DNP), PhD-DNP collaboration, scholarship of discovery, implementation science, translational research, improvement science, nurse faculty
In March 2018, leaders from the nation’s nursing schools voted to endorse a position statement advanced by the American Association of Colleges of Nursing (AACN) on Defining Scholarship for Academic Nursing. The task force that prepared this document was charged with capturing the profession’s current consensus related to the scholarship of discovery or scientific inquiry; the scholarship of practice or application and integration; and the scholarship of teaching. Though often considered the domain of research scientists, the AACN position (2018a) recognizes that “in today’s academic setting, scholarship should be inclusive and applicable to scientists, as well as practice, education, and policy scholars” (para. 1). As a significant focus of healthcare research shifts toward translational research, it is important for faculty, graduate students, and other stakeholders within academic nursing to consider how the profession’s two terminal degrees incorporate this into their scholarship.
...nurses prepared at the doctoral level must serve as stewards of the profession with a responsibility to develop and disseminate scholarship. In keeping with the expectations of academia, and other health disciplines, nurses prepared at the doctoral level must serve as stewards of the profession with a responsibility to develop and disseminate scholarship. In today’s workforce, nurses with doctoral degrees represent only about 2% of the nursing population (Budden, Zhong, Moulton, & Cimiotti, 2013) despite great demand for these individuals to serve as Advanced Practice Registered Nurses (APRNs), assume faculty roles, embark on careers as research scientists, and pursue leadership roles (Howard & Williams, 2016).
Those considering a terminal degree in nursing must make a choice... Those considering a terminal degree in nursing must make a choice: focus on a career devoted to intellectual inquiry and conducting original research studies or concentrate on developing practice expertise and implementing evidence-based practice innovations at the macro or microsystems level. In the realm of translational research, nurses focus on either original research (PhD) or actual translation of evidence into practice (DNP).
In particular, PhD implementation scientists, implementation researchers, and translational research experts are seeking to understand: “1). What concepts predict better implementation?; 2) Which implementation metrics are reliable and valid?; 3) How should baseline assessments be conducted?; and 4) What system antecedents and readiness predict better adoption of evidence-based practices?” (Newhouse, Bobay, Dykes, Stevens, & Titler, 2013, p. S38). DNP prepared evidence based practice experts are implementing evidence into practice when systems demonstrate readiness, conducting assessments driven by data, applying research concepts to better implement evidence into practice, and evaluating implementation using reliable and valid metrics. Understanding the academic differences and individual attributes of DNP and PhD nurses, as well as areas for collaboration related to translation research, can help nurses both identify the correct academic path and, for those in the field, ways to incorporate scholarship into their career.
Complementary Approaches to Scholarship by Degree
PhD Prepared Nurse
The Doctor of Philosophy (PhD) in nursing represents the highest level of formal education for a career in research and the scholarship of discovery. Program graduates develop new nursing science, serve in leadership capacities, and educate the next generation of nurses. Designed to prepare nurse scholars, these programs focus heavily on scientific content and research methodology and typically require an original research project as well as the completion and defense of a dissertation. Attainment of the PhD (or the Doctor of Nursing Science/DNS at some institutions) requires a strong scientific emphasis within the discipline, an understanding of the science of related disciplines and translation science, dissemination of findings, and interprofessional collaboration. Currently, 136 nursing schools in the U.S. offer a research-focused doctorate (AACN, 2018b).
PhD prepared nurses are well versed in research methods. PhD prepared nurses are well versed in research methods. This includes not just design but also collecting, analyzing, and interpreting data to best answer questions about an identified phenomenon that informs implementation science and translational research (Williams, 2011). Qualitative, quantitative, and mixed methods research each have their own unique advantages, challenges, and data that support scientific inquiry (McCusker & Gunaydin, 2015). Each method is more or less appropriate, based on the phenomenon and question under investigation.
Quantitative research seeks to explain a phenomenon by collection of numerical data to test a theory or hypothesis. This method of research has its foundations in a positivist philosophy that advocates that there is one truth that can be tested by collecting this numerical data (Claydon, 2015). Qualitative research encompasses a broad range of inquiry that utilizes a wide variety of approaches and methods. A fundamental component of qualitative research is the focus on “what, why, and how” questions, as opposed to “how many,” that captures unique data that does not fit with traditional analysis strategies (Ormston, Spencer, Barnard, & Snape, 2014). Designing and evaluating studies that have strong reliability, validity, and generalizability, or in the case of qualitative research, measures of trustworthiness, are crucial components of the PhD nurses role as a nurse scientist.
In today’s complex healthcare system, utilization of big data is driving changes in practice. However, nurse researchers are filling roles in clinical and industry related fields as well. In today’s complex healthcare system, utilization of big data is driving changes in practice. Doctorally-prepared nurses with a full understanding of research methods and data analysis are uniquely qualified to fill roles as nursing administrators (Lewallen & Kohlenberg, 2011) to best answer practice problems and develop solutions that will improve quality and contain cost. The participation of nurses in big data science initiatives “is essential to ensure that the discoveries not only be shaped by our profession’s unique understanding of the patient experience but also that the discoveries lead to knowledge that is useful to nursing” (Brennan & Bakken, 2015, p. 477).
Big data serves the functions of initial inquiry and secondary analysis. Big data is complex in not just size, but also in characteristics such as alphanumeric, image, and continuous flow data, such as streamed video. These complex data require a unique understanding of clinical and practice relevance and impact, as well as the statistical implications. Big data serves the functions of initial inquiry and secondary analysis. The nurse researcher has the knowledge to be sure that the data collection, analysis, and reporting are accurate and valid to assure that all decision making is made based on the best possible evidence (Englebright & Caspers, 2016).
As an example of the importance that big data is playing in healthcare is the Patient-Centered Outcomes Research Institute (PCORI), which has funded two types of data collaboratives to advance the use of electronic health data (Fleurence et al., 2014). The first, Clinical Data Research Networks (CDRNs), are based on the electronic sources of very large populations receiving care within an integrated delivery system such as an electronic health record (EHR). The other collaborative is a Patient-Centered Research Network (PCRN), which is comprised of communities of patients with similar motivation who are interested in forming partnerships with researchers.
DNP Prepared Nurse
The Doctor of Nursing Practice (DNP) represents the highest level of preparation in nursing practice for those seeking careers focused on the scholarship of clinical practice, application, and integration. In 2004, nursing schools affiliated with AACN voted to move the level of education necessary for advanced nursing practice from the master's degree to the doctorate. This action elevated the expected level of educational preparation from the master’s degree to the doctorate for the four APRN roles—Nurse Practitioners, Clinical Nurse Specialists, Nurse Anesthetists, and Nurse-Midwives—as well as for other nurses engaged in advanced specialty practice.
DNP programs focus heavily on practice that is innovative and evidence-based, reflecting the application of credible research findings. DNP programs focus heavily on practice that is innovative and evidence-based, reflecting the application of credible research findings. As a practice discipline, nursing scholarship informs science, enhances clinical practice, influences policy, and impacts best practices for educating nurses as clinicians, scholars, and leaders. Both post-baccalaureate and post-master’s DNP programs are available with 336 nursing schools nationwide currently offering the practice doctorate (AACN, 2018b).
... nurses with DNP preparation use their skills to assure that the best evidence reaches the bedside in the most effective and efficacious ways. DNP prepared nurses hold a variety of roles with the healthcare system. As described in the DNP Essentials, nurses who complete a DNP program are prepared in either in an advanced practice nursing role (APRN) or with an aggregate/systems/organizational focus (AACN, 2006). In the healthcare arena, DNP-prepared APRNs also often serve in dual roles, concurrently practicing at the systems level to have a broader impact on patient and systems outcomes. With DNP preparation, APRNs are prepared to address complex issues that face patients and healthcare today. DNP-prepared nurses are also rapidly assuming roles focusing on leadership, nursing informatics, public health, knowledge translation, application of implementation science, application of improvement science, and quality improvement. Roles such as chief nurse officer (CNO), director of quality improvement, director of evidence-based practice, and chief information officer (CIO) are common positions where nurses with DNP preparation use their skills to assure that the best evidence reaches the bedside in the most effective and efficacious ways.
... improvement science, implementation science, and implementation research are relatively new disciplines. Focused on determining which interventions best support the integration of knowledge into routine practice, improvement science, implementation science, and implementation research are relatively new disciplines (Newhouse et al., 2013). While the disciplines themselves are research disciplines, the concepts are foundational to high level nursing practice. DNP-prepared nurses often find themselves involved with teams of researchers in this arena or in the application of this research. Nurses with DNP preparation are uniquely qualified to bridge the gap between research and the bedside, in part, because they have an in-depth understanding of key concepts in organizational systems, translation of evidence into practice, implementation science, and research.
DNP-prepared nurses possess the breadth and depth of knowledge to answer these questions and lead translational research efforts launched to improve care. Many DNP-prepared nurses oversee and oftentimes implement hospital quality improvement initiatives. According to the Institute for Healthcare Improvement (IHI) “the science of improvement is an applied science that emphasizes innovation, rapid-cycle testing in the field, and spread in order to generate learning about what changes, in which contexts, produce improvements” (2018, para. 2). With knowledge of implementation theories, frameworks, and process models, DNP nurses are leading quality improvement (QI) initiatives. They bring knowledge of complex adaptive systems, stakeholder engagement, project charters, logic models, driver diagrams, rapid cycle models, measurement, and data which are critical to the success of QI.
Many DNP-prepared nurses oversee and oftentimes implement hospital quality improvement initiatives. There are many examples of how DNP-prepared nurses use data to translate research into evidence-based practice innovations at the systems level. Data has become an integral part of any large healthcare organization and with growing electronic medical record use, big data is a new reality. Understanding how to effectively use big data, big data analytics, and big data tools to drive system improvement is now imperative for healthcare executives in the “c-suite” (Englebright & Caspers, 2016). Dr. Mary Blankson is a DNP prepared nurse who is the CNO of The Community Health Center (CHC) Inc. In her role as CNO, she is a leader in improvement within the organization’s more than 200 sites. Leading an organization with a $100 million-dollar annual budget and nearly 100,000 annual visits generates an immense data set (Blankson, 2017). One endeavor involved supporting primary care providers to improve the care of patients in pain. She used her expertise to develop a multipronged approach, which included: 1) developing and implementing standards of care; 2) employing electronic health record (EHR) solutions; 3) using data tools to measure progress and outcomes; 4) implementing technology and telehealth to improve care; and 5) educating and collaborating with providers, and putting in place oversight of the process from the beginning.
PhD and DNP Collaboration
PhD- and DNP-prepared nurses are natural allies when it comes to accelerating the pace at which new nursing interventions are translated from the bench to the bedside. Though nursing’s two terminal degrees differ in focus and prepare graduates with distinct sets of competencies, these programs represent complementary, alternative approaches to the highest level of educational preparation in nursing. PhD- and DNP-prepared nurses are natural allies when it comes to accelerating the pace at which new nursing interventions are translated from the bench to the bedside. In part, the relationship between a PhD-prepared nurse and a DNP-prepared nurses is reflected in this quote from Louis Pasteur, “To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications” (Dubos, 1951, p. 85).
In practice, there is often a dependence on each other to best use unique skills to meet the overall goal of improving health. Both programs prepare graduates to develop new knowledge that will shape how nurses practice and advance scholarship in nursing. In a variety of settings, DNP graduates are serving as health system and hospital leaders who work collaboratively with nurse researchers to implement new nursing science and practice innovations. Together these leaders are ensuring that contemporary nursing practice remains relevant and pliable enough to meet evolving patient needs.
The collaboration that results when nurse researchers join with practice leaders is redefining the discipline’s approach to translational research and implementation science. The collaboration that results when nurse researchers join with practice leaders is redefining the discipline’s approach to translational research and implementation science. According to the National Institute of Nursing Research, translational research improves patient care and promotes public health by “[transforming] scientific findings or discoveries from basic laboratory, clinical, or population studies into new clinical tools, processes, or applications” (Grady, 2010, p.164). By working together, academic and practice leaders can accelerate the dissemination of shared knowledge, scientific inquiry, translational research, and policy advocacy that affect health and health outcomes (AACN, 2004; 2016). The new AACN’s position statement on scholarship underscores the need for nurses holding a PhD or DNP to partner in order to translate newly generated knowledge into practices that improve health and healthcare.
To facilitate the translation of new science into practice, implementation science seeks to “identify barriers (personal, economic, and management) to effective evidence translation and examines the causal relationships of the interventions and the outcomes” (AACN, 2018a, p. 4). This branch of research inquiry seeks to understand the facilitators and barriers to incorporating new science into healthcare innovations. Taken together, implementation science informs best practices when translating new evidence in a manner that is most effective and most likely to lead to sustainable change in patient care delivery.
Research and Practice
DNP- and PhD-prepared nurses can use their individual skills to advance each other’s work. The power of research and practice collaboration in nursing is emerging throughout the U.S. healthcare system. A group of clinicians in Michigan, including a PhD- and DNP-prepared nurse, developed a regional collaborative to reduce 30-day heart failure readmissions, demonstrating that intra- and interprofessional teams can have a large-scale impact on quality (Pollard et al., 2015). DNP- and PhD-prepared nurses can use their individual skills to advance each other’s work. For example, a DNP-prepared nurse in a system level leadership role may be focused on using data to improve patient 30-day readmission rates. This individual may notice discrepancies between 30-day readmission rates between like-units or like-institutions. While novice nurse leaders might believe they have a clear understanding of the practices used to prevent 30-day readmission, an experienced doctorally prepared practice leader understands that there are often hidden nuances that may strongly impact outcomes. What are the specific practices used in various areas? To answer this query, a PhD nurse colleague could then design a study collecting data (both qualitative and quantitative) to describe variations in practice.
With knowledge of current practice, the DNP-prepared nurse can look to the literature to determine what interventions are supported by quality research. Knowledge of complex adaptive systems, leadership strategies, financial considerations, and interprofessional dynamics that the DNP-prepared nurse possesses can provide the PhD nurse researcher with informed insight into which interventions may or may not be deployable within their organization. This collaboration will strengthen the design of any research project that attempts to answer this practice inquiry. While a great deal of current research exists on interventions associated with this clinical issue, it may not be clear which interventions are best suited for this health system. These differently educated nurses may collaborate to answer the question, “which interventions work best within our unique healthcare system?”
The Plan, Do, Study, Act (PDSA) cycle ensures that including a collaborative effort between the two expert nurses will occur to evaluate change. As previously described, the use of big data increasingly contributes to understanding health phenomena and policy development. Early descriptive exploration and study to understand clinical problems and knowledge of tactics used throughout a complex system guides the work of the PhD-prepared nurse, who designs an interventional study or completes secondary data analysis to determine which interventions used in various system units and departments are most likely to reduce 30-day readmission. The DNP-prepared nurse is an appropriate person to lead an institutional shift in practice based on expertise in implementation frameworks and implementation process models, as well as specific intervention data from implementation researchers. The Plan, Do, Study, Act (PDSA) cycle ensures that including a collaborative effort between the two expert nurses will occur to evaluate change. This pilot work may develop into a larger scale, multi-center study, using implementation science as framework.
Collaboration is one of many strategies to increase productivity. Many PhD- and DNP-prepared nurses have careers in academia, contributing to research, practice, service, and education. In addition to collaboration with the more traditional roles in academia (e.g., teaching, course coordination, advising/mentoring students, serving on school or university committees and in professional organizations), DNP and PhD faculty collaborate on scholarship and research (Agger, Oermann, & Lynn, 2016). The work of designing practice projects and studies; writing grants; conducting practice change and research; and disseminating findings can be challenging for even the skilled academician. Collaboration is one of many strategies to increase productivity.
Together PhD- and DNP-prepared faculty can use their skills sets to grow and strengthen their practice and research portfolios. The role of primary researcher often hinders the ability of a nurse clinician to continue clinical practice. Likewise, clinical practice by a faculty member often hinders a highly productive research career. Together PhD- and DNP-prepared faculty can use their skills sets to grow and strengthen their practice and research portfolios. A faculty member practicing in an emergency room may identify a practice problem related to opioid use in patients presenting with dental pain. As an expert in research implementation, the DNP-prepared nurse may implement evidence-based practice guidelines for the setting. As the practice changes, the DNP clinician may gain a curiosity about the impact on recidivism or the impact of the practice guidelines on provider prescribing patterns. Together, they design a research study to gain a better understanding using several years of data to describe the phenomena.
Simply describing a change is valuable information, but other key data may help implementation researchers gather and design further research to improve health. For example, are there time points, critical events, or national policy changes that impact the prescribing practice of clinicians? Together these nurses write up the practice change and research. Rather than one individual serving in the often-overwhelming role of clinician researcher, they become a clinician researcher team.
Examples of how PhD- and DNP-prepared nurses are transforming research and practice are emerging throughout the landscape of academic nursing. The University of Maryland Baltimore serves as one example where this synergistic relationship is producing real results. Dr. Roseann Velez and colleagues, for instance, have studied appropriate prescribing of antibiotics for methicillin-resistant Staphylococcus aureus infections in an urgent care center (Velez, Becker, Davidson, & Sloand, 2014). This work helped to inform a group of academicians about the need to better prepare healthcare providers, including nurse practitioners, pharmacists, and medical students, on the topic of antibiotic use and prescribing practices. This interprofessional group is currently investigating the use of gamification to engage students in learning about antimicrobial management.
Nurses with doctoral preparation avidly pursue scholarship in a variety of forms. Nurses with doctoral preparation avidly pursue scholarship in a variety of forms. PhD-prepared nurses are skilled in and gravitate to the scholarship of discovery, or research to create new knowledge or refine existing knowledge that can be translated to practice (2018a). DNP-prepared nurses typically focus on a scholarship of practice, or translating evidence to practice, often using quality improvement methodologies, with an aim to improve and transform healthcare delivery and patient outcomes (2018a). Both groups of scholars share in the scholarship of teaching in the academic environment and often find collaborative and synergistic roles in the practice and research environments.
Deborah E. Trautman, PhD, RN, FAAN
Deborah Trautman is the President and Chief Executive Officer of the American Association of Colleges of Nursing (AACN). Formerly the Executive Director of the Center for Health Policy and Healthcare Transformation at Johns Hopkins Hospital, Dr. Trautman has served in leadership positions at the University of Pittsburgh Medical Center and the Johns Hopkins Medical Institutions. She also held a joint appointment at the Johns Hopkins University School of Nursing. Dr. Trautman received a BSN from West Virginia Wesleyan College, an MSN from the University of Pittsburgh, and a PhD in health policy from the University of Maryland, Baltimore County. She has authored publications on health policy, intimate partner violence, pain management, clinical competency, change management, cardiopulmonary bypass, and consolidating emergency services. Dr. Trautman is a 2007/2008 Robert Wood Johnson Health Policy Fellow who worked for the Honorable Nancy Pelosi, then Speaker of the U.S. House of Representatives.
Shannon Idzik, DNP, CRNP, FAANP, FAAN
Shannon Idzik is the Associate Dean of the DNP Program and an Associate Professor at the University of Maryland. In addition, she is a practicing nurse practitioner at the University of Maryland Upper Chesapeake Medical Center. In her role as Associate Dean of the DNP program, she led the development and implementation of the first DNP APRN programs in Maryland and continues to oversee all APRN programs at UMSON. A member of the AACN taskforce on the implementation of the DNP, she co-wrote the recently published white paper, The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations, which resulted from the work of the task force. Dr. Idzik received her DNP, a post-master certificate in Teaching in Nursing and Health Professions, and an MS Adult Nurse Practitioner from the University of Maryland, Baltimore. She holds a BS in Nursing from York College of Pennsylvania.
Margaret Hammersla, PhD, CRNP-A
Margaret Hammersla is an Assistant Professor and Senior Director for the DNP Program at University of Maryland School of Nursing and an Adult Nurse Practitioner. She has had extensive experience in both simulation development, interprofessional education and curriculum development. Dr. Hammersla was a member of a project to develop 6 simulation-based learning experiences to provide healthcare students (medicine, nursing, pharmacy, dental, social work, and law) with the opportunity to learn both about each other’s discipline as well as how to better communicate utilizing a TEAMSTEPPS based approach funded by the Maryland Higher Education Commission. In addition, she has work on many individual projects to provide students APRN programs with IPE opportunities with other schools on the UMB campus such as pharmacy and dental students. Dr. Hammersla received her PhD, a post-master certificate in Teaching in Nursing and Health Professions, and an MS Adult Nurse Practitioner from the University of Maryland, Baltimore.
Robert Rosseter, MBA, MS
Robert Rosseter is the Chief Communications Officer for the American Association of Colleges of Nursing. In this role, he directs all public affairs efforts for the association and oversees several program areas, including communications, data collection, publications, and student services. Previously, Mr. Rosseter served as marketing director for the University of Virginia’s satellite campus in Northern Virginia. He currently teaches graduate business courses online for the University of Virginia and has co-authored a chapter in the textbook Teaching Nursing: The Art and Science. Mr. Rosseter earned both an MBA and an MS in Marketing from the University of Maryland, and a BA in Journalism from The George Washington University.
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