Background and Descriptors. The first main category in Table 2, background and descriptors, explores differences between QI, EBP, and research along five dimensions. These dimensions include historical evolution, definition, commonalities and distinctions, rigor, and key features.
QI, EBP, and research have different historical evolutions. QI comes from the business world, EBP derives from medicine, and early research in nursing is credited to Florence Nightingale. Despite their different historical origins, QI, EBP, and research together produce a solid foundation for nursing practice. To illustrate the important interrelationship between QI, EBP, and research, Hedges (2006) uses a three-legged stool as a model. In imagining the three-legged stool, nursing practice is the stool’s seat and QI, EBP, and research each represent a leg of the stool. Without all three legs (QI, EBP, and research) intact, the stool’s seat (nursing practice) cannot remain stable and strong.
Although the definitions of QI, EBP, and research suggest they are all systematic approaches to problem solving, each possesses different intents. QI analyzes existing data to improve systems related to business processes and outcomes (i.e., cost, productivity, quality). EBP analyzes existing data for purposes of ranking evidence that will be used to answer burning clinical, education, or administrative questions that guide practice. Research, on the other hand, validates and refines existing data or generates new knowledge to influence nursing practice, systems, and policies.
Whereas QI uses existing knowledge to address internal organizational systems and improve performance, research influences outcomes through a more rigorous scientific process that generates new knowledge. EBP integrates best evidence (often derived from research) into practice to produce desired outcomes. All three approaches have an important, yet different, relationship with knowledge: research generates it, EBP translates it, and QI incorporates it. Answering the unanswered questions (inquiry) drives research, whereas existing evidence usually directs both EBP and QI efforts.
Uses and Applications. The second main category in Table 2, uses and applications, explores differences between QI, EBP, and research along 14 dimensions. These dimensions include purpose, beneficiaries, use of protocols, data collection, Institutional Review Board (IRB) approval, and funding. Also included are dimensions related to oversight, limitations, overlaps, challenges, risks and burdens, tools and instruments, methodology, and application examples.
Although the complete comparative table (Table 2) captures 26 dimensions to help decipher differences between QI, EBP, and research, the literature (Kring, 2008; Newhouse et al., 2006) considers the purpose of a study or project to be the definitive distinguishing dimension. The purpose of QI is to improve internal processes and practices within a specific patient group or organization (Kring, 2008; Reinhardt & Ray, 2003). The purpose of EBP is to evaluate evidence along a continuum (DiCenso, Guyatt, & Ciliska, 2005) to identify the strongest or best evidence to guide nursing practice within an organizational setting and with a specific patient population. The purpose of research is to generate new knowledge within the broader scientific community (Kring, 2008; Reinhardt & Ray, 2003) to produce knowledge that is generalizable beyond the study sample. Determining the purpose of a study guides whether to undertake a QI, EBP, or research project.
QI, EBP, and research all benefit patients, families, health care professionals, and institutions. Given its greater rigor and potential for generalizability, research benefits the broader scientific community. Although QI, EBP, and research may all use protocols, the conduct of research follows strict federal regulations (U.S. Department of Health and Human Services, 2002) and necessitates a priori IRB approval for such protocols. A common misconception related to QI data is that these data produce evidence of nursing’s engagement in active research and thus meet the Magnet designation’s research requirement (Newhouse et al., 2006). Although this belief may be widely held, it is based on a flawed assumption and presents a “slippery slope” for nursing (Newhouse et al., 2006). Because QI does not generally meet federally mandated design requirements and human subject protection, QI cannot and should not be referred to as research. Accordingly, institutions pursuing Magnet designation must understand and respect the distinctions between QI, EBP, and research and not confuse one approach for the other. Similarly, leaders within these organizations should facilitate distinct, yet collaborative, venues to cultivate QI, EBP, and research initiatives.
QI, EBP, and research all use distinct protocols. QI protocols are less formal and rigorous and may change throughout the course of a QI project. EBP protocols are stricter and more prescriptive than QI protocols, yet they are not as strict as research protocols. QI protocols do not generally control for extraneous variables, whereas EBP projects may or may not control for these same variables. Research protocols generally have tight controls for extraneous variables to provide confidence that outcomes occur as a result of defined interventions and not chance. An IRB must approve a research project’s original protocol. If the researcher wants to change the original study protocol, a formal amended protocol necessitating new IRB approval must be submitted.
Data collection in QI is usually rapid cycle and uses minimal to moderate time and resources. EBP data collection may not be rapid cycle and involves varying resources. Research is not rapid cycle and involves the use of resources that may vary according to project scope. Because research project protocols are generally more complicated and precise, research data collection may be more time intensive and rigorous.
All research activity requires IRB approval. QI and EBP projects do not generally require IRB approval. QI and EBP projects that are intended for publication and could potentially expose patients to risks and burdens should be considered research and have IRB approval. Individuals involved in QI and EBP must understand if and when IRB approval may be needed and proceed accordingly (Lynn, 2004).
Funding for QI and EBP projects is generally internal within the sponsoring institution. Funding for research, however, may be either internal or external to the institution where the research is conducted. Oversight for QI and EBP may be institutional, whereas research requires external oversight that entails compliance with local, state, and federal laws.
QI and EBP have one major limitation: they do not establish cause-and-effect relationships. Also, QI and EBP may not be theoretically based and thus may not be consistent with tested theoretical frameworks. Although research can establish causal relationships and be theoretically based, research takes time and is not as quickly integrated into practice as are QI and EBP. Independent of their individual limitations, QI, EBP, and research collectively provide beneficial overlaps and synergies. QI and research inform EBP, whereas EBP informs QI.
A unique challenge relative to QI, EBP, and research is that for these approaches to be successfully implemented, they require infrastructure investment. All approaches benefit from human, financial, and technological resource allocation. Specifically needed are mentors with experience and advanced educational preparation to build QI, EBP, and research capacity. For QI, EBP, and research to be conducted effectively, employee release time is essential. Given their different purposes and methodologies, QI, EBP, and research projects take time to complete and thus require realistic time lines and supportive structures.
QI, EBP, and research use different tools, instruments, and methodologies. Whereas research follows the scientific method, QI and EBP follow one of many discipline-accepted methodologies (Table 2). The purpose of the study and the questions being asked guide methodology selection. An extensive discussion of methodology selection for QI, EBP, and research is beyond the scope of this article.
Scholarship Integration. The third and last main category in Table 2, scholarship integration, explores differences between QI, EBP, and research along seven dimensions. These dimensions include theoretical underpinnings, generalizability, expectations and potential for knowledge dissemination, examples of venues for publications and presentations, and foundational scholarly resources.
Much research is theory based, whereas QI is not generally based on theory and EBP may or may not have theoretical underpinnings. Depending on the research design used (experimental designs using random samples are best), research findings may be generalizable beyond the individuals and organizations studied. In the case of QI and EBP, study results are not usually generalizable beyond the organization in which the projects were undertaken.
There is learning to be gained from QI, EBP, and research. For this reason, knowledge dissemination related to QI, EBP, and research may be valuable. Although there are scientific purists who argue that QI findings “ordinarily are not publishable in peer reviewed literature” (Lynn, 2004, p. 69), QI peer-reviewed scholarly journals do exist (e.g., Journal of Healthcare Quality). EBP peer-reviewed journals (e.g., Worldviews on Evidence-Based Practice) and research journals (e.g., Nursing Research) also exist. Table 2 identifies available scholarly venues for oral and poster presentations to share QI, EBP, and research findings.
It is commonly expected that knowledge dissemination will follow research. This same expectation has not always applied to EBP and QI. The recent National Institutes of Health (NIH) road map emphasizes translation science (NIH, 2008). The nursing profession’s increasing focus on EBP, the emphasis on patient safety and ongoing process improvement, and the national growth of DNP programs are building additional momentum for knowledge dissemination and translation science. Knowledge dissemination through publications and presentations is increasingly becoming a professional nursing expectation independent of practice setting. No longer does knowledge dissemination fall within the exclusive domain of researchers and academics.
Although generalizability of QI, EBP, and research findings may vary, they each have value and limitations. Accordingly, selecting the proper venue to disseminate knowledge is crucial to building scholarly nursing practice and advancing the profession. Knowledge dissemination activities may also provide a competitive advantage for individuals and institutions. Using Table 2 as a resource may help to build knowledge dissemination across multiple settings.