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(Download PDF) The Practice of Nursing Research Appraisal Synthesis and Generation Full Chapter PDF
(Download PDF) The Practice of Nursing Research Appraisal Synthesis and Generation Full Chapter PDF
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Burns & Grove's The Practice of Nursing Research 9th
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Contributors
vi
Reviewers
vii
Preface
R
esearch is a major force in the nursing profes- • A balanced coverage of qualitative and quantitative
sion that is used to change practice, education, research methodologies.
and health policy. Our aim in developing the • Electronic references and websites that direct the
seventh edition of The Practice of Nursing Research: student to an extensive array of information that is
Appraisal, Synthesis, and Generation of Evidence is to important for conducting studies and using research
increase excitement about research and to facilitate the findings in practice.
development of evidence-based practice for nursing. • Rich and frequent illustration of major points and
It is critically important that all nurses, especially those concepts from the most current nursing research
in advanced-practice roles (nurse practitioners, clini- literature from a variety of clinical practices areas.
cal nurse specialists, nurse anesthetists, and nurse mid- • A strong conceptual framework that links nursing
wives) and those assuming roles as administrators and research with EBP, theory, knowledge, and
educators, have a strong understanding of the research philosophy.
methods conducted to generate evidence-based knowl- Our text provides a comprehensive introduction to
edge for nursing practice. Graduate and undergraduate nursing research for graduate and practicing nurses.
nursing students and practicing nurses need to be For use at the master’s and doctoral level, the text
actively involved in critically appraising and synthe- provides not only substantive content related to
sizing research evidence for the delivery of quality, research but also practical applications based on the
cost-effective care. This text provides detailed content authors’ experiences in conducting various types of
and guidelines for implementing critical appraisal and nursing research, familiarity with the research litera-
synthesis processes. The text also contains extensive ture, and experience in teaching nursing research at
coverage of the research methods—quantitative, qual- various educational levels.
itative, outcomes, and intervention—commonly con- The seventh edition of this text is now organized
ducted in nursing. Doctoral students might use this text into 5 units and 29 chapters. Unit One introduces the
to facilitate their conduct of quality studies essential reader to the world of nursing research. The content
for generating nursing knowledge. and presentation of this unit have been designed to
The depth and breadth of content presented in this introduce EBP, quantitative research, and qualitative
edition reflect the increase in research activities and research.
the growth in research knowledge since the previous Unit Two provides an in-depth presentation of the
edition. Nursing research is introduced at the bacca- research process for both quantitative and qualitative
laureate level and becomes an integral part of graduate research. As with previous editions, this text provides
education (master’s and doctoral) and clinical practice. extensive coverage of the many types of quantitative
We hope that this new edition might raise the number and qualitative research.
of nurses at all levels involved in research activities Unit Three addresses the implications of research
to improve the outcomes for nursing practice. for the discipline and profession of nursing. Content
The seventh edition is written and organized to is provided to direct the student in conducting critical
facilitate ease in reading, understanding, and imple- appraisals of both quantitative and qualitative research.
menting the research process. The major strengths of A detailed discussion of types of research synthesis
this text are as follows: and strategies for promoting EBP is provided.
• State-of-the-art coverage of EBP—a topic of vital Unit Four gives students and practicing nurses the
and growing importance in a healthcare arena content they need for implementing studies. This unit
focused on quality, cost-effective patient care. includes chapters focused on data collection, statisti-
• A clear, concise writing style that is consistent cal analysis, interpretation of research outcomes, and
among the chapters to facilitate student learning. dissemination of research finding.
• Comprehensive coverage of quantitative, qualita- Unit Five addresses proposal development and
tive, outcomes, and intervention research methods. seeking support for research. Readers are given
viii
Preface ix
direction for developing quantitative and qualitative and Accountability Act (HIPAA), (2) U.S. Depart-
research proposals and seeking funding for their ment of Health and Human Services (DHHS) regu-
research. lations for protection of human subjects in research,
The changes in the seventh edition of this text and (3) U.S. Food and Drug Administration (FDA)
reflect the advances in nursing research and also incor- regulations for protection of research subjects. This
porate comments from outside reviewers, colleagues, chapter also details the escalating problem of
and students. Our desire to promote the continuing research misconduct in all healthcare disciplines
development of the profession of nursing was the and the actions that have been taken to manage this
incentive for investing the time and energy required problem.
to develop this new edition. • Chapter 10, “Understanding Quantitative Research
Designs,” provides new content on mixed-methods
designs that include both quantitative and qual
New Content itative research methods. Four common mixed-
The seventh edition provides current comprehensive method research strategies conducted in nursing
coverage of nursing research and is focused on the are discussed: sequential explanatory strategy,
learning needs and styles of today’s nursing students sequential exploratory strategy, sequential transfor-
and practicing nurses. Several exciting new areas of mative strategy, and concurrent triangulation strat-
content based on the changes and expansion in the egy. These strategies are presented using models,
field of nursing research are included in this edition. narrative descriptions, and examples.
Some of the major changes from the previous edition • Chapter 11, “Selecting a Quantitative Research
are as follows: Design,” describes many currently used designs
• Chapter 1, “Discovering the World of Nursing that are not covered in other leading texts but that
Research,” is a strong introduction to evidence- are important to the generation of nursing knowl-
based practice (EBP) that is linked to nursing edge. It contains a detailed discussion of random-
research using a revised framework model for this ized controlled trials (RCTs) along with the
edition of the text. Consolidated Standards for Reporting Trials
• Chapter 2, “Evolution of Research in Building Evi- (CONSORT, 2010) guidelines.
dence-Based Nursing Practice,” has a new title • Chapter 12, “Qualitative Research Methodology,”
and is focused on building an EBP for nursing. is completely reorganized to address each step of
This chapter introduces the most current processes the research process from writing the problem
for synthesizing research knowledge, which are statement to interpreting the findings for qualitative
systematic reviews, meta-analyses, meta-syntheses, studies. The data collection methods of observing,
and mixed-method systematic reviews. The chapter interviewing, and conducting focus groups are
includes a table that presents the purposes of these described in depth. In addition, examples of using
syntheses, the types of research they include (the photovoice, videos, and electronic communication
“sampling frame”), and the analysis for achieving are given. Methods specific to each philosophical
the different types of syntheses. A model of the approach are also discussed.
continuum of the levels of research evidence, from • Chapter 13, “Outcomes Research,” a unique feature
strongest to weakest evidence, is provided. of our text, was significantly rewritten to promote
• Chapter 4, “Introduction to Qualitative Research,” understanding of the history, significance, and
describes the philosophical perspectives that guide impact of outcomes research on nursing and health
the following five approaches to qualitative re- care, for both students and nurses in clinical prac-
search: (1) phenomenology, (2) grounded theory, tice. New content is included on nurse-sensitive
(3) ethnography, (4) exploratory-descriptive quali- patient outcomes, advanced-practice nursing out-
tative research, and (5) historical research. Excerpts comes, and databases used in conducting outcomes
from qualitative studies are provided to emphasize research. In addition, the methodologies for con-
the contributions researchers using each approach ducting outcomes research have been updated and
have made to nursing science. expanded. This chapter was revised by a leading
• Chapter 6, “Review of Relevant Literature,” pro- authority in the conduct of outcomes research,
vides current, comprehensive strategies for search- Dr. Diane Doran.
ing the literature to identify relevant sources. • Chapter 14, “Intervention-Based Research,” was
• Chapter 9, “Ethics in Research,” features updated extensively rewritten to focus on the conduct of
coverage of (1) the Health Insurance Portability intervention-based research. It offers students and
x Preface
practicing nurses detailed, current content and systematic reviews. Guidelines are also provided
guidelines for critically appraising and conducting to direct students in evaluating these research syn-
intervention studies. The chapter was revised by theses, which are appearing more frequently in the
Dr. Rosemary Polomano, an authority in the nursing and healthcare literature. Current informa-
conduct of intervention research. tion is given on the activities of Evidence-Based
• Chapter 15, “Sampling,” contains extensive cover- Practice Centers and the new initiative for funding
age of current sampling methods and the processes translation research through the National Institutes
for determining sample size for quantitative and of Health to increase the implementation of evi-
qualitative studies. This chapter includes formulas dence-based interventions in practice.
for calculating the acceptance and refusal rates for • Chapter 20, “Collecting and Managing Data,” now
potential study participants and the retention and covers practical aspects of developing a data collec-
attrition rates for subjects participating in a study. tion plan, including formatting instruments, creat-
Additional current content is provided to assist ing a data flow chart, and training data collectors. In
researchers in determining sample size for quanti- addition, common problems that occur during data
tative and qualitative research and for recruiting collection are described, with possible solutions.
and retaining subjects for their studies. • Major revisions have been made in the chapters
• Chapter 16, “Measurement Concepts,” features focused on statistical concepts and analysis tech-
detailed information for examining the reliability niques (Chapters 21 through 25). The content is
and validity of measurement methods and the pre- presented in a clear, concise manner and supported
cision and accuracy of physiological measures used with examples of analyses conducted on actual
in nursing studies. Students are provided a back- clinical data. Dr. Daisha Cipher, a noted statistician
ground for understanding sensitivity, specificity, and healthcare researcher, assisted with the revi-
and likelihood ratios used to determine the quality sion of these chapters.
of diagnostic tests. • Chapter 27, “Disseminating Research Findings,”
• Chapter 17, “Measurement Methods Used in features expanded and updated content on com-
Developing Evidence for Practice,” provides more municating study findings through oral and poster
detail on the use of physiological measurement presentations and publications.
methods in research. A growing number of nursing • Chapter 29, “Seeking Funding for Research,” pro-
studies are focused on the measurement of the vides current strategies to assist students and prac-
outcomes from interventions using physiological ticing nurses in obtaining funding for their studies.
measurement methods, and this chapter equips
the reader to understand and participate in these
studies. Student Ancillaries
• Chapter 18, “Critical Appraisal of Nursing Studies,” An Evolve Resources website, which is available at
has a more refined process for critically appraising http://evolve.elsevier.com/Grove/practice/, features a
quantitative studies that consists of the following wealth of assets, including the following:
steps: (1) identifying the steps of the research • Interactive Review Questions
process, (2) determining the study strengths and • Data Sets and Data Set Activities
weaknesses, and (3) evaluating the credibility and • Sample Research Proposals
meaning of a study for nursing knowledge and prac- An electronic Study Guide accompanies this
tice. The process of critically appraising qualitative edition of The Practice of Nursing Research. This
studies was revised to evaluate studies using the study guide is keyed chapter-by-chapter to the text. It
standards of philosophical congruence, method- includes the following:
ological coherence, intuitive comprehension, and • Relevant Terms activities that help students under-
intellectual contribution. stand and apply the language of nursing research
• Chapter 19, “Evidence Synthesis with Strategies • Key Ideas exercises that reinforce essential
for Promoting Evidence-Based Practice,” has concepts
undergone extensive revision to achieve a com- • Making Connections activities that give students
pletely new focus on how to conduct research practice in the higher-level skills of comprehension
syntheses and use the best research evidence and content synthesis
in practice. The chapter now contains extensive • Crossword Puzzles that serve not only as a clever
details for conducting systematic reviews, meta- learning activity but also as a welcome “fun” activ-
analyses, meta-syntheses, and mixed-method ity for busy adult learners
Preface xi
W
riting the seventh edition of this textbook College of Nursing at The University of Texas at
has allowed us the opportunity to examine Arlington, for their support during the long and some-
and revise the content of the previous times arduous experiences that are inevitable in devel-
edition based on input from a number of scholarly oping a book of this magnitude. We would also like
colleagues, the literature, and our graduate and under- to thank Dr. Julie Barroso for her suggestions regard-
graduate students. A textbook such as this requires ing the qualitative research content in this text. We
synthesizing the ideas of many people and resources. particularly value the questions raised by our students
For the first time, expert contributors have revised key regarding the content of this text, which allow us a
chapters of this textbook. These experts have added unique view of our learners’ perceptions.
invaluable content in critical areas of outcomes We would also like to recognize the excellent
research, intervention research, design, data collec- reviews of the colleagues who helped us make impor-
tion, and statistics. We thank these scholars for sharing tant revisions in this text. These reviewers are located
their expertise. in large and small universities across the United States
We have also attempted to extract from the nursing and provided a broad range of research expertise.
and healthcare literature the essence of knowledge Finally, we thank the people at Elsevier, who have
related to the conduct of nursing research. Thus we been extremely helpful to us in producing a scholarly,
would like to thank those scholars who shared their attractive, appealing text. We extend a special thank
knowledge with the rest of us in nursing and who have you to the people most instrumental in the develop-
made this knowledge accessible for inclusion in this ment and production of this book: Lee Henderson,
textbook. The ideas from the literature were synthe- Executive Content Strategist; and Julia Curcio, Asso-
sized and discussed with our colleagues and students ciate Content Development Specialist. We also want
to determine the revisions needed for the seventh to thank others involved with the production and mar-
edition. keting of this book—Antony Prince, Project Manager;
We would also like to express our appreciation to Karen Pauls, Designer; and Pat Crowe, Marketing
Dean Elizabeth Poster and faculty members of the Manager.
Susan K. Grove, Nancy Burns,
PhD, RN, ANP-BC, GNP-BC PhD, RN, FAAN
Jennifer Gray,
PhD, RN
xii
Contents
Glossary, 686
Unit Five
Proposing and Seeking Funding
for Research, 635 Index, 714
W
elcome to the world of nursing research. You research is the diligent, systematic inquiry or investi-
might think it is strange to consider research gation to validate and refine existing knowledge and
a “world,” but research is truly a new way of generate new knowledge. The concepts systematic and
experiencing reality. Entering a new world requires diligent are critical to the meaning of research because
learning a unique language, incorporating new rules, they imply planning, organization, and persistence.
and using new experiences to learn how to interact Many disciplines conduct research, so what distin-
effectively within that world. As you become a part of guishes nursing research from research in other disci-
this new world, your perceptions and methods of rea- plines? In some ways, there are no differences, because
soning will be modified and expanded. Understanding the knowledge and skills required to conduct research
the world of nursing research is critical to providing are similar from one discipline to another. However,
evidence-based care to your patients. Since the 1990s, when one looks at other dimensions of research within
there has been a growing emphasis for nurses— a discipline, it is clear that research in nursing must
especially advanced practice nurses (nurse practi be unique to address the questions relevant to the
tioners, clinical nurse specialists, nurse anesthetists, profession. Nurse researchers need to implement the
and nurse midwives), administrators, educators, and most effective research to develop a unique body of
nurse researchers—to promote an evidence-based knowledge for nursing.
practice in nursing (Brown, 2009; Craig & Smyth, The American Nurses Association (ANA, 2012)
2012; Melnyk & Fineout-Overholt, 2011). Evidence- developed the following definition of nursing that
based practice in nursing requires a strong body of identifies the unique body of knowledge needed by the
research knowledge that nurses must synthesize and profession: “Nursing is the protection, promotion, and
use to promote quality care for their patients, families, optimization of health and abilities, prevention of
and communities. We developed this text to facilitate illness and injury, alleviation of suffering through the
your understanding of nursing research and its con diagnosis and treatment of human response, and advo-
tribution to the implementation of evidenced-based cacy in the care of individuals, families, communities,
nursing practice. and populations.” On the basis of this definition,
This chapter broadly explains the world of research. nursing research is needed to generate knowledge
A definition of nursing research is provided followed about human responses and the best interventions to
by the framework for this textbook that connects promote health, prevent illness, and manage illness
nursing research to the world of nursing. The chapter (ANA, 2010b).
concludes with a discussion of the significance of Many nurses hold the view that nursing research
research in developing an evidence-based practice for should focus on acquiring knowledge that can be
nursing. directly implemented in clinical practice, which is
sometimes referred to as applied research or practical
research (Brown, 2009; Mackay, 2009). However,
Definition of Nursing Research another view is that nursing research should include
The root meaning of the word research is “search studies of nursing education, nursing administration,
again” or “examine carefully.” More specifically, health services, and nurses’ characteristics and roles
1
2 UNIT ONE Introduction to Nursing Research
identify researchable problems, design studies, and instruments have been developed to record sensory
interpret findings. Concrete thought is necessary in experiences more accurately. For example, does the
both planning and implementing the detailed steps of patient just feel hot or actually have a fever? Ther-
data collection and analysis. This back-and-forth flow mometers were developed to test this sensory percep-
between abstract and concrete thought may be one tion accurately. Through research, the most accurate
reason why nursing research seems complex and and precise measurement devices have been devel-
challenging. oped to assess the temperature of patients on the
basis of age and health status (Waltz, Strickland, &
Empirical World Lenz, 2010). Thus, research is a way to test reality
The empirical world is what we experience through and generate the best evidence to guide nursing
our senses and is the concrete portion of our existence. practice.
It is what we often call reality, and “doing” kinds of Nurses use a variety of research methods to
activities are part of this world. There is a sense of test their reality and generate nursing knowledge,
certainty about the empirical or real world; it seems including quantitative research, qualitative research,
understandable, predictable, controllable. Concrete outcomes research, and intervention research. Quan-
thinking focuses on the empirical world; words associ- titative research, the most frequently conducted
ated with this thinking include “practical,” “down-to- method, is a formal, objective, systematic meth
earth,” “solid,” and “factual.” Concrete thinkers want odology to describe variables, test relationships, and
facts. They want to be able to apply whatever they examine cause-and-effect interactions (Kerlinger &
know to the current situation. Lee, 2000; Shadish, Cook, & Campbell, 2002). Since
The practice of nursing takes place in the empirical the 1980s, nurses have been conducting qualitative
world, as demonstrated in Figure 1-1. The scope of research to generate essential theories and knowledge
nursing practice varies for the RN and the advanced for nursing. Qualitative research is a rigorous, inter-
practice nurse (APN). RNs provide care to and coor- active, holistic, subjective research approach used to
dinate care for patients, families, and communities describe life experiences and give them meaning
in a variety of settings. They initiate interventions (Marshall & Rossman, 2011; Munhall, 2012). Both
as well as carry out treatments authorized by other quantitative and qualitative research methods are
healthcare providers (ANA, 2010a). APNs, such important to the development of nursing knowledge
as nurse practitioners, nurse anesthetists, nurse mid- (Fawcett & Garity, 2009; Munhall, 2012; Shadish et
wives, and clinical nurse specialists, have an expanded al., 2002). Some researchers effectively combine these
practice. Their knowledge, skills, and expertise pro two methods in implementing mixed method research
mote role autonomy and overlap with medical prac- to address selected nursing research problems (Cre-
tice. APNs usually concentrate their clinical practice swell, 2009).
in a specialty area, such as acute care, pediatrics, ger- Medicine, healthcare agencies, and now nursing
ontology, adult or family primary care, psychiatric- are focusing on the outcomes of patient care. Out-
mental health, women’s health, maternal child, or comes research is an important scientific methodol-
anesthesia (ANA, 2010b). You can access the most ogy that has evolved to examine the end results of
current nursing scope and standards for practice from patient care and the outcomes for healthcare providers,
the ANA (2010a). Within the empirical world of such as RNs, APNs, and physicians, and for healthcare
nursing, the goal is to provide evidence-based practice agencies (Doran, 2011). Nurses are also engaged in
to improve the health outcomes of individuals, fami- intervention research, a methodology for investigat-
lies, and communities (see Figure 1-1). The aspects ing the effectiveness of nursing interventions in
of evidence-based practice and the significance of achieving the desired outcomes in natural settings
research in developing evidence-based practice are (Forbes, 2009). These different types of research are
covered later in this chapter. all essential to the development of nursing science,
theory, and knowledge (see Figure 1-1). Nurses have
Reality Testing Using Research varying roles related to research that include conduct-
People tend to validate or test the reality of their ing research, critically appraising research, and using
existence through their senses. In everyday activities, research evidence in practice.
they constantly check out the messages received from
their senses. For example, they might ask, “Am I Roles of Nurses in Research
really seeing what I think I am seeing?” Sometimes Generating a scientific knowledge base with imple-
their senses can play tricks on them. This is why mentation in practice requires the participation of all
4 UNIT ONE Introduction to Nursing Research
nurses in a variety of research activities. Some nurses The doctorate in nursing can be practice focused
are developers of research and conduct studies to gen- (doctorate of nursing practice [DNP]) or research
erate and refine the knowledge needed for nursing focused (doctorate of philosophy [PhD]). Nurses with
practice. Others are consumers of research and use DNPs are educated to have the highest level of clinical
research evidence to improve their nursing practice. expertise, with the ability to translate scientific knowl-
The American Association of Colleges of Nursing edge for use in practice. These doctorally prepared
(AACN, 2006) and ANA (2010a, 2010b) have pub- nurses have advanced research and leadership knowl-
lished statements about the roles of nurses in research. edge to develop, implement, evaluate, and revise
No matter their education or position, all nurses have evidence-based guidelines, protocols, algorithms, and
roles in research and some ideas about those roles are policies for practice (Clinton & Sperhac, 2006). In
presented in Table 1-1. The research role a nurse addition, DNP-prepared nurses have the expertise to
assumes usually expands with his or her advanced conduct and/or collaborate with clinical studies.
education, expertise, and career path. Nurses with a PhD-prepared nurses assume a major role in the
Bachelor of Science in Nursing (BSN) degree have conduct of research and the generation of nursing
knowledge of the research process and skills in reading knowledge in a selected area of interest (Brar, Boschma,
and critically appraising studies. They assist with the & McCuaig, 2010). These nurse scientists often coor-
implementation of evidence-based guidelines, proto- dinate research teams that include DNP-, MSN-, and
cols, algorithms, and policies in practice. In addition, BSN-prepared nurses to facilitate the conduct of
these nurses might provide valuable assistance in high-quality studies in a variety of healthcare agencies.
identifying research problems and collecting data for Postdoctorate nurses usually assume full-time re-
studies. searcher roles and have funded programs of research.
Nurses with a Master of Science in Nursing (MSN) They lead interdisciplinary teams of researchers and
have undergone the educational preparation to criti- sometimes conduct studies in multiple settings. These
cally appraise and synthesize findings from studies to scientists often are identified as experts in selected
revise or develop protocols, algorithms, or policies for areas of research and provide mentoring of new PhD-
use in practice. They also have the ability to identify prepared researchers (AACN, 2006) (see Table 1-1).
and critically appraise the quality of evidence-based
guidelines developed by national organizations. APNs Abstract Thought Processes
and nurse administrators have the ability to lead Abstract thought processes influence every element
healthcare teams in making essential changes in of the nursing world. In a sense, they link all the ele-
nursing practice and in the healthcare system on the ments together. Without skills in abstract thought, we
basis of current research evidence. Some MSN- are trapped in a flat existence; we can experience the
prepared nurses conduct studies but usually do so in empirical world, we cannot explain or understand it
collaboration with other nurse scientists (AACN, (Abbott, 1952). Through abstract thinking, however,
2006; ANA 2010a). we can test our theories (which explain the nursing
CHAPTER 1 Discovering the World of Nursing Research 5
world) and then include them in the body of scientific the level of evidence for possible use of the ideas in
knowledge (Smith & Liehr, 2008). Abstract thinking practice. If the findings are inadequate, perhaps other
also allows scientific findings to be developed into nurses would be interested in studying this situation
theories (Munhall, 2012). Abstract thought enables with you.
both science and theories to be blended into a cohesive
body of knowledge, guided by a philosophical frame- Intuition
work, and applied in clinical practice (see Figure 1-1). Intuition is an insight into or understanding of a situ-
Thus, abstract thought processes are essential for syn- ation or event as a whole that usually cannot be logi-
thesizing research evidence and knowing when and cally explained (Smith, 2009). Because intuition is a
how to use this knowledge in practice. type of knowing that seems to come unbidden, it may
Three major abstract thought processes— also be described as a “gut feeling” or a “hunch.”
introspection, intuition, and reasoning—are important Because intuition cannot be explained with ease sci-
in nursing (Silva, 1977). These thought processes are entifically, many people are uncomfortable with it.
used in critically appraising and applying best research Some even say that it does not exist. Sometimes,
evidence in practice, planning and implementing therefore, the feeling or sense is suppressed, ignored,
research, and developing and evaluating theory. or dismissed as silly. However, intuition is not the lack
of knowing; rather, it is a result of deep knowledge—
Introspection tacit knowing or personal knowledge (Benner, 1984;
Introspection is the process of turning your attention Polanyi, 1962, 1966). The knowledge is incorporated
inward toward your own thoughts. It occurs at two so deeply within that it is difficult to bring it con-
levels. At the more superficial level, you are aware of sciously to the surface and express it in a logical
the thoughts you are experiencing. You have a greater manner. One of the most commonly cited examples of
awareness of the flow and interplay of feelings and nurses’ intuition is their recognition of a patient’s
ideas that occur in constantly changing patterns. These physically deteriorating condition. Odell, Victor, and
thoughts or ideas can rapidly fade from view and Oliver (2009) conducted a review of the research lit-
disappear if you do not quickly write them down. erature and described nurses’ use of intuition in clini-
When you allow introspection to occur in more depth, cal practice. They noted that nurses have an intuition
you examine your thoughts more critically and in or a knowing that something is not right with their
detail. Patterns or links between thoughts and ideas patients by recognizing changes in behavior and phys-
emerge, and you may recognize fallacies or weak- ical signs. Through clinical experience and the use of
nesses in your thinking. You may question what intuition, nurses are able to recognize patterns of devi-
brought you to this point and find yourself really ations from the normal clinical course and to know
enjoying the experience. when to take action.
Imagine the following clinical situation. You have Intuition is generally considered unscientific and
just left John Brown’s home. John has a colostomy unacceptable for use in research. In some instances,
and has been receiving home health care for several that consideration is valid. For example, a hunch about
weeks. Although John is caring for his colostomy, he significant differences between one set of scores and
is still reluctant to leave home for any length of time. another set of scores is not particularly useful as an
You are irritated and frustrated with this situation. You analysis technique. However, even though intuition is
begin to review your nursing actions and to recall often unexplainable, it has some important scientific
other patients who reacted in similar ways. What were uses. Researchers do not always need to be able to
the patterns of their behavior? explain something in order to use it. A burst of intu-
You have an idea: Perhaps the patient’s behavior is ition may identify a problem for study, indicate impor-
linked to the level of family support. You feel unsure tant variables to measure, or link two ideas together
about your ability to help the patient and family deal in interpreting the findings. The trick is to recognize
with this situation effectively. You recall other nurses the feeling, value it, and hang on to the idea long
describing similar reactions in their patients, and you enough to consider it. Some researchers keep a journal
wonder how many patients with colostomies have this to capture elusive thoughts and hunches as they think
problem. Your thoughts jump to reviewing the charts about their phenomenon of interest. These intuitive
of other patients with colostomies and reading rele- hunches often become important later as they conduct
vant ideas discussed in the literature. Some research their studies.
has been conducted on this topic recently, and you Imagine the following situation. You have been
could critically appraise these findings to determine working in an oncology center for the past 3 years.
6 UNIT ONE Introduction to Nursing Research
You and two other nurses working in the center have nursing process to identify diagnoses and to imple-
been meeting with the acute care nurse practitioner to ment nursing interventions to resolve these problems.
plan a study to determine which factors are important Problematic reasoning is also evident when one identi-
for promoting positive patient outcomes in the center. fies a research problem and successfully develops a
The group has met several times with a nursing profes- methodology to examine it.
sor at the university, who is collaborating with the
group to develop the study. At present, the group is Operational Reasoning
concerned with identifying the outcomes that need to Operational reasoning involves the identification
be measured and how to measure them. of and discrimination among many alternatives and
You have had a busy morning. Mr. Green, a patient, viewpoints. It focuses on the process (debating alter-
stops by to chat on his way out of the clinic. You listen, natives) rather than on the resolution (Barnum,
but not attentively at first. You then become more 1998). Nurses use operational reasoning to develop
acutely aware of what he is saying and begin to have realistic, measurable health goals with patients and
a feeling about one variable that should be studied. families. Nurse practitioners use operational reason-
Although he didn’t specifically mention fear of break- ing to debate which pharmacological and nonphar-
ing the news about having cancer to his children, you macological treatments to use in managing patient
sense that he is anxious about conveying bad news to illnesses. In research, operationalizing a treatment
his loved ones. You cannot really explain the origin of for implementation and debating which measurement
this feeling, something in the flow of Mr. Green’s methods or data analysis techniques to use in a study
words has stimulated a burst of intuition. You suspect require operational thought (Kerlinger & Lee, 2000;
other patients diagnosed with cancer face similar fear Waltz et al., 2010).
and hesitation about informing their family members
of bad news, that they have cancer or that their cancer Dialectic Reasoning
has spread. You believe the variable “fear of breaking Dialectic reasoning involves looking at situations in
bad news to loved ones” needs to be studied. You feel a holistic way. A dialectic thinker believes that the
both excited and uncertain. What will the other nurses whole is greater than the sum of the parts and that the
think? If the variable has not been studied, is it really whole organizes the parts (Barnum, 1998). For
significant? Somehow, you feel that it is important to example, a nurse using dialectic reasoning would view
consider. a patient as a person with strengths and weaknesses
who is experiencing an illness, and not just as the
Reasoning “stroke in room 219.” Dialectic reasoning also involves
Reasoning is the processing and organizing of ideas examining factors that are opposites and making sense
in order to reach conclusions. Through reasoning, of them by merging them into a single unit or idea that
people are able to make sense of their thoughts and is greater than either alone. For example, analyzing
experiences. This type of thinking is often evident in studies with conflicting findings and summarizing
the verbal presentation of a logical argument in which these findings to determine the current knowledge
each part is linked together to reach a logical conclu- base for a research problem require dialectic reason-
sion. Patterns of reasoning are used to develop theo- ing. Analysis of data collected in qualitative research
ries and to plan and implement research. Barnum requires dialectic reasoning to gain an understanding
(1998) identified four patterns of reasoning as being of the phenomenon being investigated (Munhall,
essential to nursing: (1) problematic, (2) operational, 2012).
(3) dialectic, and (4) logistic. An individual uses all
four types of reasoning, but frequently one type of Logistic Reasoning
reasoning is more dominant than the others. Reason- Logic is a science that involves valid ways of relating
ing is also classified by the discipline of logic into ideas to promote understanding. The aim of logic is to
inductive and deductive modes (Chinn & Kramer, determine truth or to explain and predict phenomena.
2008). The science of logic deals with thought processes, such
as concrete and abstract thinking, and methods of rea-
Problematic Reasoning soning, such as logistic, inductive, and deductive.
Problematic reasoning involves (1) identifying a Logistic reasoning is used to break the whole into
problem and the factors influencing it, (2) selecting parts that can be carefully examined, as can the rela-
solutions to the problem, and (3) resolving the problem. tionships among the parts. In some ways, logistic rea-
For example, nurses use problematic reasoning in the soning is the opposite of dialectic reasoning. A logistic
CHAPTER 1 Discovering the World of Nursing Research 7
reasoner assumes that the whole is the sum of the In this example, deductive reasoning is used to move
parts and that the parts organize the whole. For from the two general premises about human beings
example, a patient states that she is cold. You logically experiencing loss and adolescents being human beings
examine the following parts of the situation and their to the specific conclusion, “All adolescents experience
relationships: (1) room temperature, (2) patient’s tem- loss.” However, the conclusions generated from deduc-
perature, (3) patient’s clothing, and (4) patient’s activ- tive reasoning are valid only if they are based on valid
ity. The room temperature is 65° F, the patient’s premises. Consider the following example:
temperature is 98.6° F, and the patient is wearing PREMISES:
lightweight pajamas and drinking ice water. You con- All health professionals are caring.
clude that the patient is cold because of external envi- All nurses are health professionals.
ronmental factors (room temperature, lightweight CONCLUSION:
pajamas, and drinking ice water). Logistic reasoning All nurses are caring.
is used frequently in quantitative, outcomes, and The premise that all health professionals are caring
intervention research to develop a study design, plan is not necessarily valid or an accurate reflection of
and implement data collection, and conduct statistical reality. Research is a means to test and confirm or
analyses. refute a premise so that valid premises can be used as
Inductive and Deductive Reasoning a basis for reasoning in nursing practice.
The science of logic also includes inductive and
deductive reasoning. People use these modes of rea- Science
soning constantly, although the choice of types of rea- Science is a coherent body of knowledge composed
soning may not always be conscious (Kaplan, 1964). of research findings and tested theories for a specific
Inductive reasoning moves from the specific to the discipline (see Figure 1-1). Science is both a product
general, whereby particular instances are observed (end point) and a process (mechanism to reach an end
and then combined into a larger whole or general point) (Silva & Rothbart, 1984). An example from the
statement (Chinn & Kramer, 2008). An example of discipline of physics is Newton’s law of gravity, which
inductive reasoning follows: was developed through extensive research. The knowl-
A headache is an altered level of health that is edge of gravity (product) is a part of the science of
stressful. physics that evolved through formulating and testing
A fractured bone is an altered level of health that theoretical ideas (process). The ultimate goal of
is stressful. science is to explain the empirical world and thus to
A terminal illness is an altered level of health that have greater control over it. To accomplish this goal,
is stressful. scientists must discover new knowledge, expand
Therefore, all altered levels of health are existing knowledge, and reaffirm previously held
stressful. knowledge in a discipline (Greene, 1979). Health pro-
In this example, inductive reasoning is used to fessionals integrate this evidence-based knowledge to
move from the specific instances of altered levels of control the delivery of care and thereby improve
health that are stressful to the general belief that all patient outcomes (evidence-based practice).
altered levels of health are stressful. By testing many The science of a field determines the accepted
different altered levels of health through research to process for obtaining knowledge within that field.
determine whether they are stressful, one can confirm Research is an important process for obtaining scien-
the general statement that all types of altered health tific knowledge in nursing. Some sciences rigidly limit
are stressful. the types of research that can be used to obtain knowl-
Deductive reasoning moves from the general to edge. A valued method for developing a science is the
the specific or from a general premise to a particular traditional research process, or quantitative research.
situation or conclusion. A premise or hypothesis is a According to this process, the information gained
statement of the proposed relationship between two or from one study is not sufficient for its inclusion in the
more variables. An example of deductive reasoning body of science. A study must be replicated several
follows: times and must yield similar results each time before
PREMISES: that information can be considered to be sound empiri-
All human beings experience loss. cal evidence (Fahs, Morgan, & Kalman, 2003).
All adolescents are human beings. Consider the research on the relationships between
CONCLUSION: smoking, lung damage, and cancer. Numerous studies
All adolescents experience loss. conducted on animals and humans over the past
8 UNIT ONE Introduction to Nursing Research
decades indicate causative relationships between theory of stress continues to be important in under-
smoking and lung damage and between smoking and standing the affects of health changes on patients and
lung cancer. Everyone who smokes experiences lung families. Extensive research has been conducted to
damage; and although not everyone who smokes gets detail the types, number, and severity of stressors
lung cancer, smokers are at a much higher risk for experienced in life and the effective interventions for
cancer. Extensive, quality research has been con- managing these stressful situations.
ducted to generate empirical evidence about the health A theory is developed from a combination of per-
hazards of smoking, and this evidence guides the sonal experiences, research findings, and abstract
actions of nurses in practice. We provide smoking thought processes. The theorist may use findings from
cessation education, emotional support, and drugs research as a starting point and then organize the find-
like nicotine patches and Chantix (Varenicline) to ings to best explain the empirical world. This is the
assist individuals to stop smoking. On the basis of this process Selye used to develop his theory of stress.
scientific evidence about the hazards of smoking, Alternatively, the theorist may use abstract thought
society has moved toward providing many smoke- processes, personal knowledge, and intuition to
free environments. develop a theory of a phenomenon. This theory then
Findings from studies are systematically related to requires testing through research to determine whether
one another in a way that seems to best explain the it is an accurate reflection of reality. Thus, research
empirical world. Abstract thought processes are used has a major role in theory development, testing, and
to make these linkages. The linkages are called laws refinement. Some forms of qualitative research focus
or principles, depending on the certainty of the facts on developing new theories or extending existing
and relationships within the linkage. Laws express the theories. Quantitative, outcomes, and intervention
most certain relationships and provide the best research methods of research are often implemented to test the
evidence for use in practice. The certainty depends on accuracy of theory. The study findings either support
the amount of research conducted to test a relationship or fail to support the theory, providing a basis for
and, to some extent, on the skills in abstract thought refining the theory (Chinn & Kramer, 2008; Fawcett
processes to link the research findings to form mean- & Garity, 2009).
ingful evidence. The truths or explanations of the
empirical world reflected by these laws and principles Knowledge
are never absolutely certain and may be disproved by Knowledge is a complex, multifaceted concept. For
further research. example, you may say that you know your friend John,
Nursing is in the beginning stages of developing a know that the earth rotates around the sun, know how
science for the profession, and additional original and to give an injection, and know pharmacology. These
replication studies are needed to develop the knowl- are examples of knowing—being familiar with a
edge necessary for practice (Fahs et al., 2003; Melnyk person, comprehending facts, acquiring a psychomo-
& Fineout-Overholt, 2011). As discussed earlier, tor skill, and mastering a subject. There are differences
nursing science is being developed with the use of a in types of knowing, yet there are also similarities.
variety of research methodologies, including quantita- Knowing presupposes order or imposes order on
tive, qualitative, outcomes, and intervention. The thoughts and ideas (Engelhardt, 1980). People have a
focus of this textbook is to increase your understand- desire to know what to expect. There is a need for
ing of these different types of research used in the certainty in the world, and individuals seek it by trying
development and testing of nursing theory. to decrease uncertainty through knowledge. Think of
the questions you ask a person who has presented
Theory some bit of knowledge: “Is it true?” “Are you sure?”
A theory is a creative and rigorous structuring of ideas “How do you know?” Thus, the knowledge that we
used to describe, explain, predict, or control a particu- acquire is expected to be an accurate reflection of
lar phenomenon or segment of the empirical world reality.
(Chinn & Kramer, 2008; Smith & Liehr, 2008). A
theory consists of a set of concepts that are defined Ways of Acquiring Nursing Knowledge
and interrelated to present a systematic view of a phe- We acquire knowledge in a variety of ways and expect
nomenon. A classic example is the theory of stress it to be an accurate reflection of the real world (White,
developed by Selye (1976) to explain the physical and 1982). Nurses have historically acquired knowledge
emotional affects of illness on peoples’ lives. This through (1) traditions, (2) authority, (3) borrowing,
CHAPTER 1 Discovering the World of Nursing Research 9
(4) trial and error, (5) personal experience, (6) role- Borrowing
modeling and mentorship, (7) intuition, (8) reasoning, As some nursing leaders have noted, knowledge in
and (9) research. Intuition, reasoning, and research nursing practice is partly made up of information that
were discussed earlier in this chapter; the other ways has been borrowed from disciplines such as medicine,
of acquiring knowledge are briefly described in this psychology, physiology, and education (McMurrey,
section. 1982; Walker & Avant, 2011). Borrowing in nursing
involves the appropriation and use of knowledge from
Traditions other fields or disciplines to guide nursing practice.
Traditions consist of “truths” or beliefs that are based Nursing practice has borrowed knowledge in two
on customs and past trends. Nursing traditions from ways. For years, some nurses have taken information
the past have been transferred to the present by written from other disciplines and applied it directly to
and verbal communication and role-modeling and nursing practice. This information was not integrated
continue to influence the present practice of nursing. within the unique focus of nursing. For example,
For example, some of the policies and procedures in some nurses have used the medical model to guide
hospitals and other healthcare facilities contain tradi- their nursing practice, thus focusing on the diagnosis
tional ideas. In addition, some nursing interventions and treatment of physiological diseases with limited
are transmitted verbally from one nurse to another attention to the patient’s holistic nature. This type of
over the years or by the observation of experienced borrowing continues today as nurses use technologi-
nurses. For example, the idea of providing a patient cal advances to focus on the detection and treatment
with a clean, safe, well-ventilated environment origi- of disease, to the exclusion of health promotion and
nated with Florence Nightingale (1859). illness prevention.
However, traditions can also narrow and limit the Another way of borrowing, which is more useful
knowledge sought for nursing practice. For example, in nursing, is the integration of information from other
tradition has established the time and pattern for pro- disciplines within the focus of nursing. Because disci-
viding baths, evaluating vital signs, and allowing plines share knowledge, it is sometimes difficult to
patient visitation on many hospital units. The nurses know where the boundaries exist between nursing’s
on these units quickly inform new staff members knowledge base and the knowledge bases of other
about the accepted or traditional behaviors for the unit. disciplines. Boundaries blur as the knowledge bases
Traditions are difficult to change because people with of disciplines evolve (McMurrey, 1982). For example,
power and authority have accepted and supported information about self-esteem as a characteristic of the
them for a long time. Many traditions have not been human personality is associated with psychology, but
tested for accuracy or efficiency and require research this knowledge also directs the nurse in assessing the
for continued use in practice. psychological needs of patients and families. However,
borrowed knowledge has not been adequate to answer
Authority many questions generated in nursing practice.
An authority is a person with expertise and power
who is able to influence opinion and behavior. A Trial and Error
person is thought of as an authority because she or he Trial and error is an approach with unknown out-
knows more in a given area than others do. Knowl- comes that is used in a situation of uncertainty when
edge acquired from authority is illustrated when one other sources of knowledge are unavailable. The
person credits another person as the source of informa- nursing profession evolved through a great deal of trial
tion. Nurses who publish articles and books or develop and error before knowledge of effective practices was
theories are frequently considered authorities. Stu- codified in textbooks and journals. The trial-and-error
dents usually view their instructors as authorities, and way of acquiring knowledge can be time-consuming,
clinical nursing experts are considered authorities because multiple interventions might be implemented
within their clinical settings. However, persons viewed before one is found to be effective. There is also a risk
as authorities in one field are not necessarily authori- of implementing nursing actions that are detrimental
ties in other fields. An expert is an authority only when to a patient’s health. Because each patient responds
addressing his or her area of expertise. Like tradition, uniquely to a situation, however, uncertainty in nursing
the knowledge acquired from authorities sometimes practice continues. Because of the uniqueness of
has not been validated through research and is not patient response and the resulting uncertainty, nurses
considered the best evidence for practice. must use trial and error in providing care. The
10 UNIT ONE Introduction to Nursing Research
trial-and-error approach to developing knowledge practice. The clinical expertise of the nurse is a critical
would be more efficient if nurses documented the component of evidence-based practice. It is the expert
patient and situational characteristics that provided the nurse who has the greatest skill and ability to imple-
context for the patient’s unique response. ment the best research evidence in practice to meet the
unique values and needs of patients and families.
Personal Experience
Personal experience is the knowledge that comes Role-Modeling and Mentorship
from being personally involved in an event, situation, Role-modeling is learning by imitating the behaviors
or circumstance. In nursing, personal experience of an exemplar. An exemplar or role model knows the
enables one to gain skills and expertise by providing appropriate and rewarded roles for a profession, and
care to patients and families in clinical settings. The these roles reflect the attitudes and include the stan-
nurse not only learns but is able to cluster ideas into dards and norms of behavior for that profession (ANA,
a meaningful whole. For example, students may be 2010a). In nursing, role-modeling enables the novice
told how to give an injection in a classroom setting, nurse to learn from interacting with expert nurses or
but they do not know how to give an injection until following their examples. Examples of role models are
they observe other nurses giving injections to patients admired teachers, expert practitioners, researchers,
and actually give several injections themselves. and illustrious individuals who inspire students, prac-
The amount of personal experience you have will ticing nurses, educators, and researchers through their
affect the complexity of your knowledge base as a examples.
nurse. Benner (1984) described five levels of experi- An intense form of role-modeling is mentorship.
ence in the development of clinical knowledge and In a mentorship, the expert nurse, or mentor, serves
expertise that are important today. These levels of as a teacher, sponsor, guide, exemplar, and counselor
experience are (1) novice, (2) advanced beginner, for the novice nurse (or mentee). Both the mentor and
(3) competent, (4) proficient, and (5) expert. Novice the mentee or protégé invest time and effort, which
nurses have no personal experience in the work that often result in a close, personal mentor-mentee rela-
they are to perform, but they have preconceived tionship. This relationship promotes a mutual exchange
notions and expectations about clinical practice that of ideas and aspirations relative to the mentee’s career
are challenged, refined, confirmed, or contradicted by plans. The mentee assumes the values, attitudes, and
personal experience in a clinical setting. The advanced behaviors of the mentor while gaining intuitive knowl-
beginner has just enough experience to recognize and edge and personal experience. Mentorship is essential
intervene in recurrent situations. For example, the for building research competence in nursing (Byrne &
advanced beginner nurse is able to recognize and inter- Keefe, 2002).
vene to meet patients’ needs for pain management. To summarize, in nursing, a body of knowledge
Competent nurses frequently have been on the job must be acquired (learned), incorporated, and assimi-
for 2 or 3 years, and their personal experiences enable lated by each member of the profession and collec-
them to generate and achieve long-range goals and tively by the profession as a whole. This body of
plans (Benner, 1984). Through experience, the com- knowledge guides the thinking and behavior of the
petent nurse is able to use personal knowledge to take profession and of individual practitioners. It also
conscious, deliberate actions that are efficient and directs further development and influences how
organized. From a more complex knowledge base, the science and theory are interpreted within the discipline
proficient nurse views the patient as a whole and as a (see Figure 1-1). This knowledge base is necessary in
member of a family and community. The proficient order for health professionals, consumers, and society
nurse recognizes that each patient and family have to recognize nursing as a science.
specific values and needs that lead them to respond
differently to illness and health. Philosophy
The expert nurse has had extensive experience and Philosophy provides a broad, global explanation of
is able to identify accurately and intervene skillfully the world. It is the most abstract and most all-
in a situation (Benner, 1984). Personal experience encompassing concept in the model (see Figure 1-1).
increases an expert nurse’s ability to grasp a situation Philosophy gives unity and meaning to the world of
intuitively with accuracy and speed. Lyneham, Parkin- nursing and provides a framework within which think-
son, and Denholm (2009) studied Benner’s fifth stage ing, knowing, and doing occur (Kikuchi & Simmons,
of practice development and noted the links of intu- 1994). Nursing’s philosophical position influences its
ition, science, knowledge, and theory to expert clinical knowledge base. How nurses use science and theories
CHAPTER 1 Discovering the World of Nursing Research 11
to explain the empirical world depends on their phi- them seek health from within those worldviews, an
losophy. Ideas about truth and reality, as well as approach that is a critical component of evidence-
beliefs, values, and attitudes, are part of philosophy. based practice.
Philosophy asks questions such as, “Is there an abso-
lute truth, or is truth relative?” and “Is there one
reality, or is reality different for each individual?”
Everyone’s world is modified by her or his philoso- Significance of Research in
phy, as a pair of eyeglasses would modify vision. Building an Evidence-Based
Perceptions are influenced first by philosophy and
then by knowledge. For example, if what you see is Practice for Nursing
not within your ideas of truth or reality, if it does not The ultimate goal of nursing is to provide evidence-
fit your belief system, you may not see it. Your mind based care that promotes quality outcomes for patients,
may reject it altogether or may modify it to fit your families, healthcare providers, and the healthcare
philosophy (Scheffler, 1967). For example, you might system (Craig & Smyth, 2012; Melnyk & Fineout-
believe that education is not effective in promoting Overholt, 2011). Evidence-based practice (EBP)
smoking cessation, so you do not provide your patients evolves from the integration of the best research evi-
this education. As you start to discover the world of dence with clinical expertise and patient needs and
nursing research, it is important for you to keep an values (Sackett, Straus, Richardson, Rosenberg, &
open mind to the value of research and your future Haynes, 2000). Figure 1-2 demonstrates the major
role in the development or use of research evidence in contribution of the best research evidence to the deliv-
practice. ery of EBP. Best research evidence is the empirical
Philosophical positions commonly held within the knowledge generated from the synthesis of quality
nursing profession include the view that human beings study findings to address a practice problem. A discus-
are holistic, rational, and responsible. Nurses believe sion of the levels of best research evidence and the
that people desire health, and health is considered to sources for this evidence is presented in Chapter 2. A
be better than illness. Quality of life is as important as team of expert researchers, healthcare professionals,
quantity of life. Good nursing care facilitates improved policy makers, and consumers often synthesizes the
patterns of health and quality of life (ANA, 2010a, best research evidence for developing standardized
2010b). In nursing, truth is relative, and reality tends guidelines for clinical practice. For example, research
to vary with perception (Kikuchi, Simmons, & Romyn, related to the chronic health problem of hypertension
1996; Silva, 1977). For example, because nurses (HTN) has been conducted, critically appraised, and
believe that reality varies with perception and that synthesized by experts to develop a practice guideline
truth is relative, they would not try to impose their for implementation by APNs, such as nurse practi
views of truth and reality on patients. Rather, they tioners, and physicians to ensure that patients with
would accept patients’ views of the world and help HTN receive quality, cost-effective care (Chobanian
Clinical
Expertise
Best
Research Evidence-Based
Practice Figure 1-2 Model of evidence-based practice.
Evidence
Patient
Needs and
Values
12 UNIT ONE Introduction to Nursing Research
Nurse
Practitioner
(Clinical expert)
JNC 7
Figure 1-3 Evidence-based practice for elderly Women with Normal
Hypertension
African-American women with hypertension Blood Pressure of
Guideline
(HTN). JNC, Joint National Committee on Less Than 120/80
(Best research
Prevention, Detection, Evaluation, and Treatment (Evidence-Based Practice)
evidence) Female, elderly,
of High Blood Pressure.
African-American
with HTN
(Patient needs
and values)
et al., 2003). The most current guidelines for the diag- Figure 1-3 provides an example of the delivery of
nosis and management of HTN, “The Seventh Report evidence-based care to women with HTN. In this
of the Joint National Committee on Prevention, Detec- example, the best research evidence on HTN is the
tion, Evaluation, and Treatment of High Blood Pres- JNC 7 National Standardized Guideline (Chobanian et
sure: The JNC 7 Report,” were published in 2003 al., 2003). An expert nurse practitioner translates this
(Chobanian et al., 2003) and are available online at guideline to meet the needs (chronic illness manage-
www.nhlbi.nih.gov/guidelines/hypertension. The JNC ment) and values of elderly African-American women
8 Report is currently under development, with pro- with HTN. In this case, the outcome of EBP is women
jected publication of the revised HTN guidelines with a normal blood pressure, less than 120 mm Hg
in 2012 or 2013 (see http://www.nhlbi.nih.gov/guide systolic/80 mm Hg diastolic (see Figure 1-3). A
lines/hypertension/jnc8). Many national standardized detailed discussion of how to locate, critically appraise,
guidelines are available through the Agency for and use national standardized guidelines in practice is
Healthcare Research and Quality (AHRQ) and profes- presented in Chapter 19.
sional organizations, which are discussed in more In nursing, the research evidence must focus on the
detail in Chapters 2 and 19. description, explanation, prediction, and control of
Clinical expertise is the knowledge and skills of phenomena important to practice. The following sec-
the healthcare professional providing care. A nurse’s tions address the types of knowledge that need to be
clinical expertise is determined by his or her years of generated in these four areas as nursing moves toward
practice, current knowledge of the research and clini- EBP.
cal literature, and educational preparation. The stron-
ger the nurse’s clinical expertise, the better his or her Description
clinical judgment is in the delivery of quality care Description involves identifying and understanding
(Craig & Smyth, 2012; Eizenberg, 2010). The patient’s the nature of nursing phenomena and, sometimes, the
need(s) might focus on health promotion, illness pre- relationships among them (Chinn & Kramer, 2008;
vention, acute or chronic illness management, or reha- Munhall, 2012). Through research, nurses are able to
bilitation (see Figure 1-2). In addition, patients bring (1) explore and describe what exists in nursing prac-
values or unique preferences, expectations, concerns, tice, (2) discover new information, (3) promote under-
and cultural beliefs to the clinical encounter. With standing of situations, and (4) classify information for
EBP, patients and their families are encouraged to take use in the discipline. Some examples of clinically
an active role in managing their health care. In important research evidence developed from research
summary, expert clinicians use the best research evi- focused on description include the following:
dence available to deliver quality, cost-effective care • Identification of the responses of individuals to a
to a patients and families with specific health needs variety of health conditions
and values to achieve EBP (Brown, 2009; Craig & • Description of the health promotion and illness pre-
Smyth, 2012; Sackett et al., 2000). vention strategies used by various populations
CHAPTER 1 Discovering the World of Nursing Research 13
• Determination of the incidence of a disease locally, for a sample of inpatient adults in acute care units. The
nationally, and internationally researchers found that the nurse characteristics and
• Identification of the cluster of symptoms for a par- staffing variables were significantly correlated with
ticular disease MRSA infections and reported patient falls. Thus, the
• Description of the effects and side effects of nursing characteristics and staffing were potential pre-
selected pharmacological agents in a variety of dictors of MRSA infections and patient falls. This
populations study illustrates how explanatory research can identify
For example, Imes, Daugherty, Pyper, and Sullivan relationships among nursing phenomena that are the
(2011, p. 208) conducted “a qualitative study to basis for future research focused on prediction and
describe the experience of living with heart failure control.
(HF) from the perspective of the partner.” These
researchers synthesized their findings as follows: “The Prediction
severity of the patient’s disease limited the partner’s Through prediction, one can estimate the probability
lifestyle, resulting in social isolation and difficulties in of a specific outcome in a given situation (Chinn &
planning for the future for both the patient and the Kramer, 2008). However, predicting an outcome does
partner. The partners were unprepared to manage the not necessarily enable one to modify or control the
disease burden at home without consistent information outcome. It is through prediction that the risk of illness
and assistance by healthcare providers. Moreover, is identified and linked to possible screening methods
end-of-life planning was neither encouraged by health- that will identify the illness. Knowledge generated
care providers nor embraced by patients or partners” from research focused on prediction is critical for EBP
(Imes et al., 2011, p. 208). and includes the following:
The findings from this study provide insights into • Prediction of the risk for a disease in different
the experience of HF by a loved one and their experi- populations
ences with healthcare providers. This type of research, • Prediction of the accuracy and precision of a
focused on description, is essential groundwork for screening instrument, such as mammogram, to
studies that will help to explain, predict, and control detect a disease
nursing phenomena. • Prediction of the prognosis once an illness is identi-
fied in a variety of populations
Explanation • Prediction of the impact of nursing actions on
Explanation clarifies the relationships among phe- selected outcomes
nomena and clarifies why certain events occur. • Prediction of behaviors that promote health and
Research focused on explanation provides the follow- prevent illness
ing types of evidence essential for practice: • Prediction of the health care required based on a
• Determination of the assessment data (both subjec- patient’s need and values
tive data from the health history and objective data For example, Scheetz and Kolassa (2007, p. 399)
from physical examination) needed to address a examined “crash scene variables to predict the need
patient’s health need for trauma center care in older persons.” The research-
• Link of assessment data to determine a diagnosis ers analyzed 26 crash scene variables and developed
(both nursing and medical) triage decision rules for managing persons with severe
• Link of causative risk factors or etiologies to and moderate injuries. Further research is needed to
illness, morbidity, and mortality determine whether the triage decision rules improve
• Determine the relationships among health risks, the health outcomes of the elderly following trauma.
health status, and healthcare costs Predictive studies isolate independent variables that
For example, Manojlovich, Sidani, Covell, and require additional research to ensure that their manip-
Antonakos (2011) conducted an outcomes study to ulation or control results in successful outcomes for
examine the links between a “nurse dose” (nurse char- patients, healthcare professionals, and healthcare
acteristics and staffing) and adverse patient outcomes. agencies.
The nurse characteristics examined were education,
experience, and skill mix. The staffing variables Control
included full-time employees, RN:patient ratio, and If one can predict the outcome of a situation, the next
RN hours per patient day. The adverse outcomes step is to control or manipulate the situation to produce
examined were methicillin-resistant Staphylococcus the desired outcome. Dickoff, James, and Wiedenbach
aureus (MRSA) infections and reported patient falls (1968) described control as the ability to write a
14 UNIT ONE Introduction to Nursing Research
prescription to produce the desired results. Using the adventure that holds much promise for the future prac-
best research evidence, nurses could prescribe specific tice of nursing.
interventions to meet the needs of patients. Nurses
need this type of research evidence to provide EBP
(see Figure 1-2). Research in the following areas is KEY POINTS
important for generating EBP in nursing:
• Testing interventions to improve the health status • This chapter introduces you to the world of nursing
of individuals, families, and communities research.
• Testing interventions to improve healthcare • Nursing research is defined as a scientific process
delivery that validates and refines existing knowledge and
• Determining the quality and cost-effectiveness of generates new knowledge that directly and indi-
interventions rectly influences the delivery of evidence-based
• Implementing an evidence-based intervention to nursing practice (EBP).
determine whether it is effective in managing a • This chapter presents a framework that links nursing
patient’s health need (health promotion, illness pre- research to the world of nursing and organizes the
vention, acute and chronic illness management, and content presented in this textbook (see Figure 1-1).
rehabilitation) and producing quality outcomes The concepts in this framework range from concrete
Yoo, Kim, Hur, and Kim (2011) conducted a study to abstract and include concrete and abstract think-
that examined the effect of a prescribed animation ing, the empirical world (evidence-based nursing
distraction intervention on the pain response of pre- practice), research, abstract thought processes,
school children during venipuncture. The intervention science, theory, knowledge, and philosophy.
or independent variable was a 3-minute animation • The empirical world is what we experience through
video that could be downloaded from the Internet and our senses and is the concrete portion of our exis-
shown to the child using a laptop computer. The pain tence where nursing practice occurs.
response was measured by the following dependent • Research is a way to test reality, and nurses use a
variables: “self-reported pain response, behavioral variety of research methods to test their reality and
pain response, blood cortisol, and blood glucose” (Yoo generate nursing knowledge, such as quantitative,
et al., 2011, p. 94). The researchers found a significant qualitative, outcomes, and intervention.
difference between the experimental and control • All nurses have a role in research—some are
groups for all four dependent variables of pain developers of research and conduct studies to gen-
response. Thus, the animation distraction intervention erate and refine the knowledge needed for nursing
was determined to be an effective method of managing practice, and others are consumers of research and
children’s pain during venipuncture. The researchers use research evidence to improve their nursing
concluded that this intervention required minimal practice.
effort and time and might be a convenient and cost- • Three major abstract thought processes—
effective intervention to be used in clinical settings to introspection, intuition, and reasoning—are impor-
reduce children’s pain. tant in nursing.
Many more studies need to be conducted to gener- • A theory is a creative and rigorous structuring of
ate the research evidence in the areas of prediction and ideas used to describe, explain, predict, or control
control (Brown, 2009; Craig & Smyth, 2012; Melnyk a particular phenomenon or segment of the empiri-
& Fineout-Overholt, 2011). This need for additional cal world.
nursing research provides you with many opportuni- • Reliance on tradition, authority, trial and error, and
ties to be involved in the world of nursing research. personal experience is no longer an adequate basis
This chapter introduced you to the world of nursing for sound nursing practice.
research and the significance of research in developing • The goal of nurses and other healthcare profession-
an EBP for nursing. The following chapters will als is to deliver evidence-based health care to
expand your understanding of different research meth- patients and their families.
odologies so you can critically appraise studies, syn- • EBP evolves from the integration of best research
thesize research findings, and use the best research evidence with clinical expertise and patient needs
evidence available in clinical practice. This text also and values (see Figure 1-2).
gives you a background for conducting research in • The best research evidence is the empirical knowl-
collaboration with expert nurse researchers. We think edge generated from the synthesis of quality studies
you will find that nursing research is an exciting to address a practice problem.
CHAPTER 1 Discovering the World of Nursing Research 15
• The clinical expertise of a nurse is determined by Creswell, J. W. (2009). Research design: Qualitative, quantitative,
his or her years of clinical experience, current and mixed methods approaches (3rd ed.). Los Angeles, CA: Sage.
knowledge of the research and clinical literature, Dickoff, J., James, P., & Wiedenbach, E. (1968). Theory in a prac-
tice discipline: Practice oriented theory (Part I). Nursing Research,
and educational preparation.
17(5), 415–435.
• The patient brings values—such as unique prefer- Doran, D. M. (2011). Nursing-sensitive outcomes: State of the
ences, expectations, concerns, and cultural beliefs, science. Sudbury, MA: Jones & Bartlett.
and health needs—to the clinical encounter, which Eizenberg, M. M. (2010). Implementation of evidence-based
are important to consider in providing evidence- nursing practice: Nurses’ personal and professional factors?
based care. Journal of Advanced Nursing, 67(1), 33–42.
• The knowledge generated through research is Engelhardt, H. T., Jr. (1980). Knowing and valuing: Looking for
essential for describing, explaining, predicting, and common roots. In H. T. Engelhardt & D. Callahan (Eds.), Knowing
controlling nursing phenomena. and valuing: The search for common roots (Vol. 4, pp. 1–17). New
• Nursing practice based on synthesized research York: Hastings Center.
Fahs, P. S., Morgan, L. L., & Kalman, M. (2003). A call for replica-
findings can have a powerful, positive impact on
tion. Journal of Nursing Scholarship, 35(1), 67–71.
patient outcomes and the healthcare system. Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-
based nursing practice. Philadelphia, PA: F. A. Davis.
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Byrne, M. W., & Keefe, M. R. (2002). Building research compe- (2011). Nurse dose: Linking staffing variables to adverse patient
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Livingstone. not. Philadelphia, PA: Lippincott.
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Odell, M., Victor, C., & Oliver, D. (2009). Nurses’ role in detecting Silva, M.C. (1977). Philosophy, science, theory: Interrelationships
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Polanyi, M. (1962). Personal knowledge. Chicago, IL: University Silva, M. C., & Rothbart, D. (1984). An analysis of changing trends
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Bobbs-Merrill. animation distraction intervention on pain response of preschool
Selye, H. (1976). The stress of life. New York, NY: McGraw-Hill. children during venipuncture. Applied Nursing Research, 24(2),
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http://evolve.elsevier.com/Grove/practice/
2 CHAPTER
I
nitially, nursing research evolved slowly, from research more than 150 years ago (Nightingale, 1859).
Florence Nightingale’s investigations of patient Following Nightingale’s work (1840-1910), nursing
mortality in the nineteenth century to the studies research received minimal attention until the mid-
of nursing education in the 1930s and 1940s. Nurses 1900s. In the 1960s, nurses gradually recognized the
and nursing roles were the focus of research in the value of research, but few had the educational back-
1950s and 1960s. However, in the late 1970s and ground to conduct studies until the 1970s. However,
1980s, many researchers designed studies aimed at in the 1980s and 1990s, research became a major force
improving nursing practice. This emphasis continued in developing a scientific knowledge base for nursing
in the 1990s with research focused on testing the practice. Today, nurses obtain federal, corporate, and
effectiveness of nursing interventions and examining foundational funding for their research, conduct
patient outcomes. The goal in this millennium is the complex studies in multiple settings, and generate
development of an evidence-based practice for sound research evidence for practice. Table 2-1 identi-
nursing, with the current best research evidence being fies key historical events that have influenced the
used to deliver quality health care. development of nursing research and the movement
Evidence-based practice (EBP) is the conscien- toward EBP. These events are discussed in the follow-
tious integration of best research evidence with ing section.
clinical expertise and patient values and needs in
the delivery of quality, cost-effective health care.
Chapter 1 presents a model depicting the elements Florence Nightingale
of EBP and provides an example (see Figures 1-2 and Nightingale has been described as a reformer, reac-
1-3). You probably have many questions about tionary, and researcher who influenced nursing spe-
EBP because it is an evolving concept in nursing and cifically and health care in general. Nightingale’s
health care. What does “best research evidence” book, Notes on Nursing (1859), described her initial
mean? How is research evidence developed? Are there research activities, which focused on the importance
levels of quality in the types of research evidence? of a healthy environment in promoting the patient’s
This chapter will increase your understanding of how physical and mental well-being. She identified the
nursing research has evolved over the past 150 years need to gather data on the environment, such as ven-
and of the current movement of the profession toward tilation, cleanliness, temperature, purity of water, and
EBP. The chapter describes the historical events rel- diet, to determine their influence on the patient’s
evant to nursing research in building an EBP, identifies health (Herbert, 1981).
the methodologies used in nursing to develop research Nightingale is also noted for her data collection and
evidence, and concludes with a discussion of the best statistical analyses during the Crimean War. She gath-
research evidence needed to build an EBP. ered data on soldier morbidity and mortality rates and
the factors influencing them and presented her results
in tables and pie charts, a sophisticated type of data
Historical Development presentation for the period (Cohen, 1984; Palmer,
1977). Nightingale was the first woman elected to the
of Research in Nursing Royal Statistical Society (Oakley, 2010), and her
Some people think that research is relatively new to research was highlighted in the periodical Scientific
nursing, but Florence Nightingale initiated nursing American in 1984 (Cohen, 1984).
17
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dread of what his demon-wife might take it into her head to do now
she was foiled in her cherished ambition for her child. He had
brought a beautiful basket of roses for Mrs. Lauriston, and he
insisted on paying for their tickets himself, to save poor Nouna what
he thought might be the shock of travelling second-class. When, as
the train started, Nouna saw that, on shaking hands with her
husband, the Colonel’s eyes grew moist and kindly, she relented,
and leaning far out of the carriage window, bestowed upon her
amazed and unwilling father a kiss which, being justified only by that
relationship which he was trying so hard to conceal, was scarcely
less unwelcome than a charge of grapeshot.
The train was out of sight before he recovered a degree of
serenity, which was shaken immediately afterwards by a glimpse he
caught, as he was leaving the station, of a tall, lean man wearing a
red fez, who came out by a different door, and crossing the inclosure
in front with quick strides, was lost to his sight among the crowd in
the Strand. Although George had not informed him of all he feared
from Rahas, he had told him enough about this dark-skinned agent
of Chloris White’s to make the Colonel suspect that with all their care
they had not succeeded in evading her evil vigilance. At first he
thought he would warn George, but reflecting how common foreign
headgear of all sorts is in London, he decided that he had not
enough grounds for disturbing so soon the poor fellow’s sense of
security.
With their arrival in Paris began the third era in the married life of
George and his wife. Nouna’s delight in the bright city was so great
that at first the fact of having to live in two small rooms on the fourth
floor of a house in a narrow street off the Boulevard Poissonnière
was of no account compared with the knowledge of the pleasures
that lay outside, the walks along the lighted boulevards in the
evening before the shops were shut, the expeditions in a tramcar to
the Bois de Boulogne or Saint Cloud, above all the Sunday trips
upon the Seine on a steamer, all joys within the reach of a most
modest purse, were delirious excitements to her susceptible
temperament, in the first ecstasy of which the handsome house at
Kensington, the tropical plants, the supper parties, even the services
of her servant Sundran, were for the time forgotten. On one
memorable Sunday they indulged in a drive round the Bois in a
fiacre, and in ices at the little châlet restaurant opposite the cascade,
where the lower middle-class brides come in all their bravery of white
satin and long veil and orange-blossom wreath, looking coquettish,
happy, and at ease in the unaccustomed attire which an English girl
of the same class wears with such shamefaced awkwardness. To
Nouna that day gave a glimpse of Paradise: the fiacre was more
comfortable than her victoria in London had been, Hyde Park could
not compare with the Bois, the passers-by amused, the ice
intoxicated her. When the sunshine had faded into twilight, and they
had driven back home through the lighted streets, she climbed up
the long flights of stairs, still in a silent ecstasy, and sat down in a
little low chair George had bought for her, seeing nothing in the
gloom but moving carriages, and small trees growing thickly round a
lake that glittered in sunshine, and pretty mock châlets and a
ridiculous little waterfall that fell from nothing into nowhere.
Presently she got up and went out on to the broad balcony which,
encroaching upon the size of the rooms, was yet the chief charm of
this little home under the roof. She had hung one corner of it with
curtains, and George had contrived a canvas awning under which,
when the weather was fine, she spent most of the hours of his
absence. Her husband watched without following her as she leaned
upon the rail and looked out at the yellow glow in the west which
could still be seen behind the housetops. Suddenly she turned and
came back to him. Standing just within the window with her back to
the fading light, her face could not be seen; but her voice rang out
with a strange vibration as she called to him, holding her arms
towards him:
“George, why don’t you come out to me?”
He was with her in a moment, found her trembling and dry-lipped,
and tried to persuade her to lie down while he called to the old
woman from whom they rented the rooms, to prepare their supper.
But Nouna shook her head, and insisted on his remaining with her by
the window. Yes, she was tired, she admitted, but she wanted the air;
she would go out on the balcony again if he would go with her. As
she seemed to desire it, he let her lead him out, all the time keeping
her eyes fixed in a remarkable manner immovably on his face.
“Look out,” she said, “at the sky—at the houses—at all you can
see.”
He let his gaze pass obediently from her face to the pale-starred
sky, the grey-blue of which was merging into the last red rays of the
disappearing sunset: to the house-roofs and chimney-pots, of which
they had a good though not an extensive view, to the street below,
with its little globes of yellow light, and the dark specks which were
all he could see of the moving passengers. Then he turned to her
curiously.
“Well, little one, I have looked at everything.”
“And you see nothing—nothing strange at all?”
“There’s a tabby cat two roofs off,” said the prosaic male
doubtfully.
“No, no,” she interrupted impatiently, still without moving her eyes
from his face. “Down below us—on the opposite side—a little to the
left—in the black shade.” Her voice had sunk gradually into a
whisper. Then she stopped.
“Well, I see nothing.”
“Not at the house where they have a floor shut up?”
George stepped forward and leaned over the rail of the balcony as
she had done, Nouna following closely and clinging to his hand. On
the opposite side, about three doors down, there was a flat on the
third floor which had borne during the first days of their residence in
Paris a large board inscribed ‘A louer.’ George saw that the board
was gone, and that one of the shutters was thrown back.
“Oh, I see they’ve let it. Well, there’s nothing to be frightened
about in that, my child.”
“You don’t notice anything else—anything strange—you don’t see
any—person?”
George started, and looked down again with searching eagerness
along the line of dead-eyed shuttered windows.
“No, child, there is nobody.”
Nouna heaved a long sigh, and looked timidly down through her
husband’s arm.
“No, it’s—gone,” she whispered.
“What is gone, dear? Tell me what you saw,” said George
caressingly, as he drew her back into the little sitting-room, where a
lamp now shed its soft light over the white table-cloth, and Madame
Barbier, who adored the picturesque young English couple, was
arranging the supper in a dainty and appetising fashion.
Nouna rubbed her eyes, and clinging to her husband’s arm, let the
words of her recital drop from her lips in a slow, hesitating and
faltering manner, as if she were fast asleep, and her brain were
working sluggishly under the half-paralysing influence of a will
stronger than her own.
“I was sitting in here,” she said, “and thinking of all the happiness
we have had to-day—the soft air and the warm sun, and your kind
eyes upon me, and all the lovely things we saw—the beautiful ladies
and the shining water, and the lights among the trees in the Champ
Elysées when we came back. And all at once,” her hands tightened
their hold upon his sleeve, “I felt that I must get up and go out—there
upon the balcony; and I looked out at the sky right in front where it
was yellow like flame, and all the pretty pictures of the day I saw
quite plainly still in my mind. But then—I don’t know how—I felt my
eyes drawn down from the bright sky, and there down below me—to
the left, I saw all black gloom, and in it I seemed to see Rahas’ room
in Mary Street, with all the pretty toys and bright shawls about just as
he used to put them for me to look at. And in the middle Rahas
himself, only not kind and gentle as he used to be, but with a wicked
cruel face, and burning eyes that frightened me. And I felt afraid, as
if I could have screamed. It seemed so strange, for even when he
used to look fierce, as he did sometimes, I never minded, and I was
never frightened. Was it a dream, George, that I saw? And if it was
only a dream, why was I afraid?”
Chiming in so appropriately with his own fears, this vision or fancy
of Nouna’s disturbed George a little. He calmed her excitement as
well as he could, and found some comfort in the fact that the crafty
Oriental had appeared to her, not as the kindly friend he had always
professed to be, but as a person inspiring horror. This seemed the
more remarkable as George had never mentioned the name of
Rahas to his wife since their wedding-day; he came, after a little
reflection, to look upon the vision as a proof of the new sympathy
which Nouna began to show with his own feelings, and to rejoice in
the fact that as the bond between him and his wife grew stronger
under the influence of his patient tenderness, the power of any
enemy to disturb their happiness was proportionately lessened. This
home peace, which was attaching Lauriston to his young wife more
strongly every day, was the more grateful to him, as his duties at the
Bank were rendered as irksome as possible to him through the
prejudice of his chief, Mr. Gurton, who never forgave the rejection of
his own candidate for the junior clerk’s post, and who scarcely
concealed his wish to find against him some lawful ground of
dissatisfaction. This George was careful not to give.
Mr. Gurton was one of those disagreeable brutes who seem to be
created as foils to show up the amiability and sweetness of ordinary
humanity. He was offensive to his few friends; he was unendurable
to the far greater number of people whom nothing but necessity
threw in his way. But as a man of business he was clear-headed,
shrewd, and enterprising, so exact and penetrating that even if he
drank, as his many detractors alleged, there seemed to be no
particular reason why he should not, as his business faculties could
not be said to be less keen at one time than at another. He hated
Lauriston from the first, bullied him on the smallest or on no
occasion, and did all in his power to induce the young fellow to throw
up his appointment. George took soft words and sour with dogged
quietness, and applied himself with all the energy of his character to
mastering every detail connected with his new profession, as
serenely as if incivility had been his daily bread for years. As a
matter of fact, the discourtesy and fault-finding of his chief did not
trouble him much; he looked upon Gurton, not without reason, as an
ill-bred brute whom one could only turn to account by noting the
methods by which he had attained such a splendid dexterity in the
management of affairs, and by thus considering him in the light of a
noisy machine it was easy to take the sting out of his insults. At the
same time this constant friction or avoidance of friction in his
business life made home and wife doubly dear and sweet to him.
On the day following Nouna’s strange vision on the balcony, he
came home at the usual time, and asked her whether she had had
any more “waking dreams.” She answered, reluctantly and shyly,
that she had not been on the balcony at all that day. George laughed
at her, and told her she should go with him, as the presence of such
a coarse creature as a man was a sure preventive of visions. She
allowed him to lead her out, being quite brave with the combined
forces of husband and sunlight. When they got on the balcony,
however, and looked to the left at the house where Nouna had
fancied she saw Rahas, a sight met their eyes which, whether a
coincidence or not, was strange enough to deepen the unpleasant
impression of the evening before.
For the shutters of the uninhabited third floor were now thrown
back, and outside the balcony hung a long strip of white calico with
this inscription in broad blue letters: “Bazar Oriental.”
George and Nouna read the words, and looked at each other in
troubled amazement.
“I’ll have this cleared up to-night,” thought George to himself.
CHAPTER XXVI.
When, true to his determination, George Lauriston visited the new
establishment that evening and insisted on seeing the proprietor, an
explanation offered itself which robbed Nouna’s vision of most of the
mystery attaching to it. For a dapper little Frenchman, who tried to
live up to his obviously assumed business title of Ben Hassan by
wearing a scarlet fez and a pair of Turkish slippers, immediately
appeared behind the servant who opened the door, and announcing
himself with a flourishing bow as the proprietor, thrust into
Lauriston’s hand a business card, and begged him to inspect his
stock, adding that perhaps Monsieur would do him the honour to
inaugurate his business and bring him good luck by purchasing
some trifle. George consented. The Oriental bazaar consisted of
three rooms fitted up with trestles on which were placed trays full of
trumpery, gilt sequin necklaces, cheap scarves, and other so-called
Eastern wares, such as may be bought for a very small sum in the
smaller shops along the Rue de Rivoli. George bought a little feather
hand-screen, obviously an “article de Paris,” and returned to his wife
quite satisfied that it was the sight of Monsieur Ben Hassan’s red fez
at one of the windows which had conjured up in her excited
imagination the ground-floor in Mary Street and its younger
occupant.
In order to convince his wife of her mistake, George took her next
day to the establishment of Monsieur Ben Hassan, and was pleased
to find that the nervous fear which had haunted her since her
supposed vision faded away in the amusement of turning over the
cheap trinkets and toys around her, as the obsequious proprietor, an
active and voluble little Parisian, who would have been invaluable as
a showman at a country fair, encouraged her to do. George asked
him, to satisfy Nouna, whether he had not had a friend with him on
the balcony two evenings before, a foreign gentleman, in whom, he
said, he thought he recognised an old acquaintance. Ben Hassan
said No, he had been working by himself to prepare his “Bazaar” for
opening on the following day, and he had been alone except for the
occasional assistance of the servant. He admitted also, with a
charmingly candid shrug of the shoulders, that his name of Ben
Hassan was assumed, that in private life he was simply Jules
Dubois, and that there was no gentleman in the business who came
from further East than the Faubourg Saint Antoine.
Nouna, to tell the truth, hardly listened to this explanation. She
was at heart still so much a child as to find, in trying on Tunisian
earrings at a franc and a half a pair, and gold crescent brooches that
could not be warranted to retain their colour a second time of
wearing, as much pleasure as she had felt, a few weeks back, in
decking herself with her wedding diamonds. Noticing this, the artful
Ben Hassan informed the lady that he expected, in the course of a
few days, a consignment of Indian jewellery which would be well
worthy of Madame’s attention, as it was the most marvellously cheap
and beautiful assortment that had ever been seen in France.
Nouna’s face glowed with interest, which was repressed for the
moment by her husband, who said coldly that Madame did not wear
imitation jewellery; a statement which seemed calculated to be
received with doubt, as Madame, now hung from head to foot with
gilt chains and spangled handkerchiefs, was evidently very well
satisfied with herself. However, the tactful Parisian bowed low and
apologised, humbly observing that the wares in question were
continually mounted, by desire of well-known ladies of the Boulevard
Saint Germains, with real gems of the highest value. Nouna divested
herself of the trinkets with manifest regret, and was with difficulty
persuaded by her husband to buy a string of sandalwood beads
instead of the barbaric rows of eye-dazzling brass on which her
choice had first fallen. George was rather shocked; a taste for cheap
finery in his wife seemed quite a new and startling development. As
soon as they got on the stairs outside he said, in a low and puzzled
voice:
“You wouldn’t really care to have those gimcrack things, would
you, Nouna?”
She wanted to sit down on the stairs and take the paper off her
beads: stopping in the act, she looked up at him with a laugh, but yet
showing a gleam of serious meaning in her red-brown eyes.
“Why not, if I can’t have real ones?” she said with a note of pathos
in her voice. “If I had rich things I should sell them to give you
money. But these poor ones I can keep and do you no harm.”
And George had a lump in his throat, as he often had now at
innocent speeches like this from his wife, which showed the
dawnings of a new womanly sympathy with him side by side with the
old childish love of finery and glitter.
She showed, by certain impulsive remarks in the course of the
next few days, a deep interest in the “marvellously cheap and
beautiful assortment of Indian jewellery,” of which the sham Arabian
had spoken; and when, towards the end of the week, Monsieur Ben
Hassan called one evening, not, as he assured the young
Englishman, with the intention of persuading him to buy the mock
gems which he had been informed Madame did not wear, but merely
to justify in the eyes of Monsieur the praises which he had lavished
on his own wares, Nouna showed so much eagerness to see them
that George had not the heart to deny her the pleasure. Ben Hassan
proceeded, by the light of the lamp which stood on the table amidst
the remnants of the dessert, to unfasten a little flat box which he
carried, to take out a layer of cotton-wool, and to display, against the
velvet lining, rows of flashing white gems which caused Nouna to cry
out with irrepressible admiration and longing.
“I flatter myself,” said the Parisian, laying the box on the table and
retreating a few paces with a bow, as if trusting his wares to speak
for themselves, “that there is not another firm in France which can
produce such a class of jewel for the same price.”
“Yes, yes,” said George hastily, with a shrewd guess that to see
these sparkling ornaments hidden away again in the little box and
carried off without leaving her so much as a single gem to remember
them by, would break Nouna’s heart. “But they are only sham jewels,
Monsieur Ben Hassan, and a lady who has had diamonds of her own
could not condescend to wear these.”
Nouna, who was leaning over the table, fingering the ornaments
delicately, and considering them with the intelligent interest of a
connoisseur, glanced up at her husband with a twinkle of demure
humour in her eyes, and instantly returned to her amusement with
condescension so infinite that it was not to be distinguished from the
most extravagant admiration. The astute Ben Hassan saw the look,
and bowed again with great humility.
“Monsieur, it is true an imitation is but a poor thing when you know
it is an imitation,” he said with shoulders raised and hands
outstretched in modest pleading. “But I appeal to Madame, who is
evidently a judge, if she would have known these stones from real
ones?”
Nouna hesitated, then quietly picked out a pair of diamond solitaire
earrings, and held them out under the lamp in her little pink palm.
“I should not have known these from real ones,” she said
doubtfully, and she looked up with an inquiring glance into the
Parisian’s face.
Ben Hassan drew himself up with much satisfaction.
“You hear, Monsieur,” he said proudly, “Madame would not have
known these earrings from real diamonds, and the cost of the pair is
only ten francs!”
“Ten francs!” echoed Nouna with incredulous delight.
And as she turned to her husband with a low murmur, “Oh,
George!” the paymaster saw that he was doomed. Without further
show of resistance he paid the ten francs, and signed to the bowing,
smirking Ben Hassan to pack up his traps and take himself off, which
the Parisian did, departing with a torrent of high-flown thanks for their
patronage and with every appearance of being highly satisfied with
the transaction. So contented did he seem indeed, that so soon as
the door closed behind him, and Nouna rushed into the bedroom to
try on her purchase, George instinctively took stock of all the
portable property which had been within the lively Ben Hassan’s
reach, to make sure that his ostensible occupation had not been a
cover for a predatory one. He had scarcely reassured himself on this
point when Nouna rushed in like a radiant little fire-fly, her new
ornaments twinkling in her ears, her eyes dancing with mysterious
excitement, her dress changed from a simple muslin to a ball-dress
of yellow gauzy material in honour of her brilliant bargain. She flitted
up to him almost breathlessly, and pulled his head down to her level
that she might whisper into his ear a communication which appeared
to be of vital importance.
“Do you think,” she suggested solemnly, “that he could have made
a mistake, and that they are real?”
George laughed, and said No, he did not think it at all likely,
whereupon she was silent for a little while, and then began again in
the same tone, but with much hesitation.
“You know, George, he told me that day we went to his bazaar that
he had some real diamonds in his stock, and said that, that——”
“Well, that what?” asked her husband, keeping his voice at a
gently subdued pitch, with a intuitive feeling that a confession was
coming.
“That if I would call in—some day—by myself—he would show
them to me.”
“By yourself!” cried George, all his blood on fire in a moment.
Nouna seemed at once to become a mere terror-struck heap, and
her husband saw his fatal mistake.
“Did you go? Did you ever go?” he asked in the softest tones he
could produce. But for a few minutes she was too much frightened
even to speak, except for a muttered, “No, no, no,” as she shook and
shivered. When at last by patient gentleness he had mastered her
fear, he extracted from her, little by little, the avowal that she had met
Ben Hassan one day outside the door of the house where he lived
as she was returning home from her marketing, and that he had
persuaded her to go up stairs and see some diamonds he had just
received. At the door, however, Nouna declared that she had been
frightened by hearing another man’s voice inside, and had refused to
go in, and that Ben Hassan had brought out some earrings to show
her, and had declared that if she would like to take a pair he would
be satisfied with only a small payment to start with, and she could
pay off the rest in instalments at her convenience.
“But I was frightened, and would not, and I tossed his hand up with
the diamonds, and they fell on the floor and on the stairs, and I ran
down and left him, and have never seen him since until this
evening,” finished Nouna, hurrying to the end of her confession. “And
I know it was wrong to go up, but I didn’t go in. And now I have done
all I could by telling you everything. And you can take the earrings
back if you like, only don’t be angry with me, because I can’t bear it.”
She burst out crying hysterically, and it was some time before she
was calm enough for her husband to be able to ask her one more
question. Did she know the voice of the man she heard talking inside
the bazaar? At first she professed she did not, but presently she
acknowledged, when asked whether it was like the voice of Rahas,
that she thought it was. Then George was very sweet to her, and
said she mustn’t trouble herself any more about the matter, that she
was a very good dear girl to tell him everything, and that it would
have been better still if she had told him at first; that she must give
up the earrings, as it was evident the man was a treacherous beast
who might get them into trouble. He added that she was tired, and
must go to bed, and fall asleep as fast as she could, and dream of
the real jewels she should have some day if she continued to be the
sweet and good little wife she now was. And so, amidst tears from
the wife and consoling kisses, the little shining ear-studs were taken
out, and George having become by this time a promising lady’s
maid, brushed out her curls for her, and tucked her up in bed, as
composedly as if nothing in the world had happened to disturb the
calm course of their daily life.
But no sooner was his wife thus disposed of than George, saying
he must write a letter and take it to the post, went out of the
bedroom, closed the door, and after waiting just long enough, as he
thought, to make Nouna think, if she was listening, that he had
written a letter, he went out and down the stairs. But Nouna had too
much native subtlety herself to be easily tricked. As soon as she
heard the outer door of the flat close, she leapt out of bed, muffled
herself up in a wrapper, and stepped out on to the balcony. She
could see that there were lights in the rooms occupied by the
Oriental Bazaar, and that the shadows of men passed and repassed
quickly on the inner side of the striped blinds. Leaning over the iron
railing, she watched in much excitement for her husband’s
appearance in the street below. In a very few minutes she heard the
wicket-gate in the porte cochére open, saw George cross the street,
and enter the house where Ben Hassan was established. She could
have cried out to him from where she stood, frozen by a great terror
lest these men, whom he had gone to punish, should be too strong
for him and should do him harm. But then, would they dare, would
they be able, even if they dared, to hurt him, the king of men? Little
by little the seed sown by patient kindness, by conscientious effort,
was moving in the earth and beginning to show itself alive. George
was not now merely the handsomest, straightest, gentlest of voice
among the men she knew, he was also the one person who never
did wrong, who if he was angry proved in the end to have what she
acknowledged to be a just cause at the bottom of his anger, whose
rather surprising notions of what one ought and ought not to do were
at least simple when one came to know him well; and whose opinion
was now beginning to have so much weight with her that this
evening it had even urged her in the strangest way to break through
her habits and make an uncomfortable confession of her own
accord. So she reasoned, arguing with herself as he crossed the
road whether or not she should try from the height of the fourth floor
to attract his attention. It would not be difficult, she felt. The influence
she was secure in possessing over him would make him stop and
look up at a call of her voice such as would scarcely be heard by the
neighbours in the adjoining flats. Suddenly she drew herself erect, a
thrill of passionate pride vibrating through her heart, and she laughed
aloud and stretched her little hands to the dark sky.
“He does not need my help, for he is one of God’s own sons,” she
whispered, and looking up steadily into the eye of night she waited,
with heart beating violently, but with head erect in valiant confidence.
He had to get up those long flights of stairs, but he would not be
long, she knew. She counted the steps he would take, picturing him
with grave, earnest face, wearing that look which, when she had
done something of which he disapproved, made her want to slide
along against the wall with her head turned away from him. The
entresol, first floor, second floor; surely by this time he must be at the
third. She clenched her fingers till the nails made red marks in her
soft palms, and strained her eyes in keen staring at the striped
blinds. The moving shadows behind them had disappeared. Ben
Hassan and Rahas—if it was he—had gone to the door when the
sharp ring came at the bell. Nouna held her breath. Surely, surely,
she heard sounds from the rooms; yes, yes, a noise of something
overturned, and then the lights were put out. The moment after, one
of the windows was burst open with a crash, and two people, whose
figures she could only see dimly in the darkness, sprang quickly, the
one after the other, out on to the balcony, climbed over on to that of
the next house, and disappeared through one of the windows. Then
there was silence for a time which seemed long to her, and she saw
a dim light reappear in the windows of the Oriental Bazaar. She
guessed that it was her husband, searching; in a few minutes the
light moved, and disappeared. She watched until she saw him
reappear in the street below, then she went back into her room, and
crept into bed again. When he came softly into the room, holding a
candle he had lit in the next room, he crept up to the bedside and
shaded the flame to look at her. As he did so, her face quivered, and
he touched her forehead lightly with his fingers. The muscles of her
mouth instinctively relaxed, and by the thrill that ran through her
frame and communicated itself to his he knew that she was awake.
“You are cold, dearest,” he whispered.
She sprang up, wide awake, full of life and love, with the bright
blood rushing up into her cheeks, and tender, passion-dark eyes.
“No, no, not now, not now,” she cried incoherently, as she threw
her arms about him. “I was cold when I thought you were going to
face those wicked men, all through my foolishness. But now you are
safe I am warm, warm, and listen, George, I am always going to be
good and tell you everything, so that you may never get into danger
through me any more.”
But George was frightened, for her feet were cold as marble, and
her lips hot and parched, and he sat up a long time beside her, afraid
lest her imprudence should have brought on a fever. Next morning
she insisted against his will on getting up. She did not feel well and
was very fanciful, astonishing him by the announcement that she
wanted to go to church. The day being Sunday, the Oriental Bazaar
was closed, and there was nothing for George to do but to gratify her
desire. He wished, as in duty bound, to take her to the English
church; but Nouna was not particular to a creed, and she had set her
heart on going to the Madeleine. So, with some scruples of
conscience, he took her to High Mass; and as she remained
perfectly quiet and attentive during the entire service, he comforted
himself with the reflection that, as what he had been taught to call
the “errors of Rome” were matters of the deepest ignorance and
indifference to her, it was hardly an ethical mistake to let her see
religion in an attractive light. When they came out he asked her
rather curiously what she thought of it.
“Oh, I liked it very, very much; I shouldn’t mind going to church
there every day,” she answered with enthusiasm.
“Why,” said George, “the service isn’t much more beautiful than
that at St. ——’s,” and he named an English ritualistic church to
which he had twice taken her in London.
“There is a difference,” she said thoughtfully.
“Well, what is it?”
Nouna considered a moment. “You know those friends of yours
that you took me to see acting in a piece at Saint George’s Hall?”
“Yes; well?”
“And then I saw the same piece acted at the Court Theatre just
before we left London?”
“Yes.”
“Well, the difference is just like that.”
George laughed. “I’ve heard people say something like that
before, Nouna.”
“Isn’t it right, then?”
“I don’t know, dear.”
“George, may I be a Roman Catholic if I like?”
“No, Nouna.”
“Why not?”
“You mustn’t choose a religion in a hurry, any more than you may
a husband. In both cases, one ought to be enough for a lifetime; and
if you once begin to change your mind about either, you never know
when to stop.”
“But I had my choice of a husband, and I didn’t of a religion; I had
to take what was given me.”
“You would never do for a Catholic, Nouna. They have to confess
all their sins, even very little ones that you think nothing of.”
“Well, that’s what you’re always wanting me to do.”
“See then. You shall go to Mass every Sunday and then confess
your sins to me, and you will be the very best of Catholics.”
“But, George, George,” she began, almost in a whisper, holding
his arm tighter, and looking away over the Place de la Concorde,
which they were now crossing, to the trees of the Tuileries, “there are
some things—not sins—that one doesn’t—like—to tell—I don’t know
why—but they make one think of so many things—that all seem new
—and make one feel—like a different person. I suppose a man—
never feels like that, but I’m a woman—quite a woman—now,
George.”
They walked on without speaking after that, till they got among the
trees; then both stopped and looked at each other—shy, for that little
whispered suggestion made each appear to the other in a new and
sanctified light. The influence of the solemn and impressive Church
rites was upon them still, and the bright sun was playing upon their
earnest faces through a moving trellis-work of leaves. They had
come to a moment which was to be the sweetest in all their lives but
one; a moment of perfect confidence, perfect happiness, perfect
hope. So they stood quite silently in an ecstasy of contented love,
each reading beautiful meanings in the other’s steadfast eyes, each
seeing and worshipping, in this moment of exalted human feeling,
what was best and most worshipful in the other. They felt so strong,
so radiant as they walked home, she leaning upon him and not
talking at all, that every evil which had been a burden yesterday and
would be a burden to-morrow, became a mere shadow slinking into
corners and dwindling into insignificance before the flood of sunshine
in their hearts. Chloris White, Rahas, Ben Hassan, and the odious
Gurton were mere names to George that day, and even when with
the following morning the drudgery and petty annoyances of
workaday life began again, he carried in his heart such a spring of
sweet human happiness that he received the snubs of his chief as
cheerfully as if they had been compliments, and bore with fortitude
the discovery that Monsieur Ben Hassan had “gone away for a few
days on business,” leaving his premises in the charge of a stolid boy
of thirteen or so, who knew nothing definite about his employer’s
movements. George therefore kept the earrings in his possession
and waited for some claim to be made. It came at the end of a week
in the shape of a bill for twelve hundred and fifty francs, ten of which
had been paid on account, for a pair of diamond ear-studs supplied
to Monsieur Lauriston. George sent back the ear-studs by registered
post with a letter threatening Ben Hassan with the police court. In a
few days he got back the ear-studs from the post-office, as the
person Ben Hassan was not to be found at the address given.
George took no further steps until he was summoned before the Civil
Tribunal, where he appeared in the full belief that he had only to
relate the facts of the case to confound Ben Hassan and lay him
open to the charge of perjury. To his great astonishment and
indignation, however, Ben Hassan solemnly swore that he had sold
the diamonds as real stones, and calling upon George to produce
them, challenged any one in the court to assert that it was possible
to suppose they could be bought for ten francs. Could the
Englishman’s wife assert that she did not know them to be real?
George had not dared to bring his wife into court, fearing the effects
of the excitement upon her. He weakened his case by asserting
emphatically that Ben Hassan was in the pay of a man who wished
to ruin him: for he had no proofs to bring forward, and the foreigner’s
halting French in which he made the accusation compared so
unfavourably with the torrent of eloquence with which the artful
Parisian refuted it, that, on Ben Hassan’s refusing to take back the
jewels, the magistrate ordered the Englishman to pay the amount
claimed, in monthly instalments of five hundred francs.
With the stolid resistance to unpleasant facts characteristic of his
nation, George treated this decision with utter contempt, and indeed
believed that Ben Hassan would not dare to push the case further.
But on arriving home one rainy day early in the following month, he
found his apartments occupied by two huissiers, who were busily
employed in dragging out into the hall poor Nouna’s trunks and such
furniture as they had bought themselves, which the landlady, anxious
to save her own things, was pointing out to them. Nouna, deathly
white and shaking from head to foot, was crouching on the sofa,
drawing her breath heavily, and watching them with bright and
burning eyes. Fear of what the consequences of this scene might be
to her sobered George in his first fierce outburst of indignation. She
had hardly moved when he came in, only glancing up at him in
shame and terror at what she knew to be the result of her own
indiscretion. He went up to the sofa and reassured her by the kind,
firm, protecting pressure of his hand upon her head, while he asked
the men by what authority they were acting. They showed him their
warrant; nothing could be more correct. He asked them whether they
would desist from their work and remain in the hall outside for half an
hour, while he went to a friend to try to raise the money. The men
consented at once, and retired while George, soothing his agitated
wife as well as he could, carried her into the next room, laid her on
the bed, and covering her with a rug, told her not to worry herself, as
it would be all right in half an hour, when he would be back again
with her, and the men would go away satisfied.
With his hand on the door he looked back yearningly. She was
quieter now, but as she leaned on her elbows and watched him with
feverish eyes, it seemed to him that her gaze was wandering and
unintelligent, and that the real matter-of-fact trouble which was
sending him on his unpleasant errand had melted in her excited
mind to a dim and horrible dread.
“George, don’t go, don’t go!” rang in his ears as he went down the
stairs and out of the house.
Poor George felt that he had never in his life had anything quite so
distasteful to do as the task he had before him now of asking a
favour of Mr. Gurton. But there was no help for it, and so he put the
best face he could upon the matter, got to the bank, where his chief
was, he knew, still at this hour to be found, and knocked at the door
of his private room.
“Come in,” called out the well-known husky voice.
Mr. Gurton was reading a letter. His face was flushed and his eyes
were dull, but he had as much command of himself as usual.
“Oh, it’s you, is it? What do you want?” he asked with the extra
shade of surliness which he used towards the people he did not like.
“Yes, sir,” said George. “I am sorry to disturb you after office hours,
but it is upon a matter of so much importance to me that I hope you
will excuse my coming to you.”
“Well, what is it? Be quick.”
The words, the appeal, stuck in the young man’s throat; but out
they must come.
“I am in pressing difficulties, sir; I can’t explain to you how now, but
it was through no fault of mine. Just now when I went home I found a
couple of men seizing my wife’s things. She is in a delicate state of
health, and I am afraid of the shock for her. Will you be so kind as to
advance me twenty pounds of my salary? I will write to my friends in
England to-night, and I shall have the money next week, and will
return it to you at once, if you please. It is a very difficult thing for me
to ask, but I hope you won’t refuse me.”
He hurried out the words, not daring to look at Mr. Gurton, who
had risen from his chair and walked over to the fireplace with a tread
which in its pompous heaviness told George before he looked up
that he had failed. There was a slight pause when he finished
speaking, Mr. Gurton rattling his watch-chain and clearing his throat.
George raised his eyes, and saw that his chief’s bloated face
expressed nothing but complacent satisfaction. Then the devil woke
in the lad with such a hungry fury that he turned hastily to the door,
afraid of himself. Mr. Gurton, unluckily, could not resist a little play
with his fish, and he called him back. George hesitated, and at last
turned slowly. Mr. Gurton paused again to find some particularly
offensive form of expression, for he thought he saw his opportunity,
by insulting the young fellow past endurance, to force him to resign
his post, and so make room for his own reputed nephew. He had
been put in possession, too, of a damaging fact against George, and
here was the occasion made to his hand, to use it.
“I’m sorry for this little misfortune, Lauriston, deuced sorry; not only
because it is quite beyond my powers to assist you, but because,
you see, it’s so particularly bad for a House that’s just starting, for
anything disreputable to be known about its employés.”
“Disreputable!” echoed George in a low voice, starting erect. “You
have no right to use such a word without knowing the facts, Mr.
Gurton.”
“Oh, I know all about the facts, and so does everybody,” said Mr.
Gurton with confidential familiarity. “You’ve got an extravagant little
madam for your wife, and somebody of course must pay the piper.”
George turned again to leave the room. Mr. Gurton, who was a
big, muscular man of six feet two, with two strides reached the door
first, admitted a lad with despatches who was waiting outside, and
held the door close as he continued:
“You must listen, sir, to what I have to say. You were received in
this House simply because we were informed that you were highly
connected, and that your social position would be an advantage to
the firm. What follows? You go nowhere, you know nobody; you are
seen in omnibuses, on penny steamers with a little oddly-dressed girl
—”
“Take care; you are speaking of my wife,” said George, in a low
tremulous voice which, with his bowed head, gave an utterly wrong
impression that he was cowed.
Mr. Gurton put his hands in his pockets.
“Well, sir, and if you choose to marry a courtesan’s daughter whom
you picked up in the slums—it is——”
Like a wild beast suddenly loosed George had him by the throat,
and with hands to which his mad anger gave a grip of steel, he
swayed the man’s huge frame once forward and flung him back with
all his force. Gasping, choking, without time to cry out, Mr. Gurton
staggered backwards, his head struck against the corner of an iron
safe that stood behind him, and he fell heavily to the floor. Lauriston
left the frightened errand-boy to pick him up, and rushed out of the
room. He had suddenly remembered that there was one more
chance; a fellow-clerk who was pretty well off lodged in the Rue
Saint Honoré. He made his way in that direction, through the still
heavily-falling rain, without another thought of the man he had just
left, except a savage wish that he had not humiliated himself by
applying to the cur.
But Mr. Gurton remained on the floor of his private room, and
neither spoke nor moved.