Nursing Research
Lecture №17
PART I
Is nursing a profession?
Q.#1: What are the criteria for a profession?
Nursing: Profession or Technical Occupation?
Pavalko’s (1971) Continuum Model for a Profession
Theory Relevance to social values Education Motivation Autonomy Commitment Sense of community Code of ethics
Explore the Meaning of a Professional vs. Technical
Practice
Describe the similarities or differences between the chef at the Brown Palace & the cook at the Village Inn?
Chef
Cook
Professional vs. Technicalfor all practice areas
Professional Practices Have a culture that
supports professional activities: frameworks, CE, research
Has a defined body of knowledge gained by formal education
Is a discipline with peer review and a code of ethics
Autonomy in practice with legislative and legal sanctions
Is an organized system of practice recognized by society
Technical Occupations Are more likely to have
more OJT than formal education.
Are skill focused Have trade journals or
technique trainings Do not focus on what
advances the practice Develop through
certifications Want less accountability
Professional vs. TechnicalThinking and Valuing
Professional thinking More is best Specialization in depth and
breadth Evidence-based education Invests energy beyond the
work-associations, research, reading
Expects self accountability Resilient with change and
believes change is valuable
Technical Thinking Least is best Specialization in depth Experience is the
primary educator Conserves energy
beyond the workday Prefers others be
accountable Enjoys consistency and
believes change is disruptive
Is research important to the profession?Yes!! Research is important for building a unique, systematic
body of knowledge about a discipline
Nursing needs a systematic body of knowledge to ...
Promote Evidence-based practice Give credibility to profession Provide accountability for practice Help document the cost-
effectiveness of care (Nieswiadomy, 2008)
What is Evidence Based Nursing Practice?
Knowledge from science & research
Knowledge from experts Knowledge from patients Knowledge arriving in many forms Has levels of power and rigor EBP IS NOT JUST FROM RESEARCH
Evidence Based Practice: Definition
“…the integration of current best evidence with clinical expertise and patient values” (Sackett et al., 2000)
“…a framework for clinical practice that incorporates the bestbest available scientific available scientific evidenceevidence with the expertise of the expertise of the clinicianclinician and the patient’s preferences patient’s preferences and valuesand values to make decisions about health care.” (Levin, 2006)
What is Research? Process of searching for new knowledge about
phenomena Validates and refines existing knowledge (Burns &
Grove, 2007) Systematic process of inquiry or study Builds new knowledge through the dissemination
of findings
Why Research??? To Describe
To identify and understand the nature of nursing phenomena
What is the experience of growing up poor in Manhattan?
To Explain Clarifies the relationship among
phenomena, and why certain events occur What are the factors that supported DSN
graduates to pass NCLEX at 95% in 2009?
Why Research??? To Predict
This allows us to estimate the probability of a specific outcome in a given situation
There is a statistical difference in baseline patient glucose levels when using basilar method over sliding scale.
To Control or Manipulate If we can predict, the next goal would be to
control or manipulate the situation to produce the desired outcome.
We can reduce bed sores at all stages by rotating patients every two hours maximum.
Ways We Acquire Knowledge Tradition Authority Borrowing Trial and error Personal
experience Role-modeling &
mentoring Intuition
Reasoning Inductive-gather Deductive-divide Rational-logic Unstructured
Research Quantitative Qualitative Mixed / Other
Research Defined
Research is a systematic, diligent inquiry that is necessary to address: What needs to be known-what is the
question, hypothesis, or interest area What research methods are needed to
examine this question or phenomena What meaning can be extracted from the
study through data analysis to build our knowledge base of that subject
Generate outcomes and disseminate new knowledge
Ways to Study Research By its components (questions, rigors,
sampling method, measurement method, etc) Divided into two major types
Qualitative Quantitative
By the name of the method (experimental, phenomenology, etc)
By the philosophy it uses to inquire (positivistic, naturalistic, both, neither)
Burns & Grove method: Examine Your Text
Table of Contents 7 Ch. 1 Ch. 2 = Quantitative Research Ch. 3 = Qualitative Research
(philosophy discussed) CH. 4 = tries to address both
qualitative and quantitative questions
Ch. 5, 6 = Lit review, Study Frameworks & Theory
Examine Your Text Ch. 7 = ethics Ch. 8 = Clarify Designs (quantitative) Ch. 9 = Outcomes Research Ch. 10 = Populations and Sampling
for quantitative and qualitative methods
Ch. 11 = Measurement of Data quantitative and qualitative
Ch. 12 = Understanding Statistics
Examine Your Text Ch. 13 = Critiquing Research for
qualitative (five Standards) and quantitative.
Ch. 14 = Building an Evidence Based Practice
Ch. 14 Evidence Based Practice Research Utilization (RU) may have a lag time
for Practice up to 20 years Involves being a Change Agent. (DSN uses the
I2E2 model for change in third quarter) Best Evidence by research type
Integrative Reviews (many types of designs) Systematic Reviews (focused on a particular type of
research designs) Meta-Analysis (has statistical evaluation of
quantitative designs). Metasummaries & Metasynthesis (qualitative
research)
Hierarchy of EvidenceCompare to Florczak article
Level I: A systematic review or RCTs, meta-analysis of many randomized controlled trials (RCTs)
Level II: Integrative Reviews of experimental designs
Level III: from a well-designed controlled trial without randomization
Level IV: From case-control or cohort studies
Hierarchy of EvidenceCompare to Florczak article
Level V: From systematic reviews of descriptive or qualitative studies, metasummaries, metasynthesis,
Level VI: a single descriptive or qualitative study
Level VII: It is an opinion from authorities on that subject, or expert committee
Recent Changes in Nursing Page 500, second paragraph, Using
ASA 81 mg. in at risk adults Page 517, I.V. flush using 0.9% NS
vs. heparin. P & P on page 520. Algorithms on page 524 for tx HTN. I.V. skin prep using chlorhexidine vs.
Iodine products like providone-iodine
Strait cath urethra prep
Mydsn.org, NRS 338 Evidence Based Research
www.cochrane.org/www.guideline.govhttp://www.cebm.utoronto.ca/resources/websites.htm
www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/
Research Philosophy Method:Positivistic versus Naturalistic
Inquiry This is a 100 year old debate It is often correlated to research
methodology It is a philosophy on the way we think about
human phenomenon & inquiry (research) We can integrate two different inquiry
methodologies, but philosophically they are very different (mixed or blended design)
Our philosophy is the foundation for how we design research
Positivistic Inquiry Naturalistic Inquiry (Constructivism)
Quantitative Triangulated Qualitative
Solomon Design Blended Designs Post-modern -four group design - use quantitative -pretest-treat-post test Intervention Res & qualitative -research self -pretest-no treat- post test methods -novel sounding -no pre- no treat- post test lacks theory -random group Quasi-Experimental Grounded Theory Phenomenology -validated tools -two of three -theory building - descriptive
Exp. controls -Basic Social Process - interpretive - hermeneutic Descriptive
Experimental Design - quantitative or Ethnography -random sample qualitative methods -living in the experience -control group -cultural
immersion -a treatment given Outcome Research
Case Study Epidemiology (humans & Ds) -single-double cases Analytic Epi -In-depth analysis Descriptive Epi - comparative analysis
Action ResearchAdequate time commitmentCollaborative effortOpenness to changeQuality of data collection and analysis Impact on one’s practice
Positivistic Inquiry Naturalistic Inquiry (Constructivism)
Quantitative Triangulated Qualitative
Solomon Design Blended Designs Post-modern Quasi-Experimental Grounded Theory Phenomenology
Constant Comparative Analysis
Descriptive Experimental Design Ethnography
Case Study
Scientific Rigors by DesignQuantitative Research RigorValidity & Reliability (internal-external) Qualitative Research Rigor Conceptual Framework Developed Descriptive Vividness Statistical Inference Methodological CongruenceGeneralizability Analytical PrecisenessTemporality Theoretical Connectedness Selection and Bias Heuristic RelevanceMeasurement validity / reliability Trustworthiness, Credibility, Controlling confounders and AuditabilityAppropriate study design for the questions Confirmability, transferabilityStylistic & Personal
Relevance, Heuristic
Sample Size by DesignPositivistic Inquiry Naturalistic Inquiry (Constructivism)
Quantitative Triangulated Qualitative
Solomon Design Blended Designs Post-modern Power Analysis 20-40 1 Quasi-Experimental Grounded Theory Phenomenology
>40 10-1000 10+saturation (10-30) Descriptive
Experimental Design 1-12 Ethnography
Power Analysis 1
Case Study 1-2
Action Research ?-100
Assumptions of Positivistic Thinking Reality is singular,
tangible, & and can be dissected
The researcher and those being studied are independent
Time and context-free generalizations are possible
Inquiry is value-free
value free singular reality
Positivistic thinking
generalizableindependentvariables
Assumptions of Positivistic Thinking There are real
causes or at least high probability of a relationship.
We believe we can have independent and dependent variables as separate entities
Validity of a design is very critical to results
value free
singular reality
validity
Positivistic thinking
generalizable
cause &effectindependentvariables
Assumptions of Positivistic Thinking
Reliability is based on how the design is reproducible
Generalizability is related to good internal validity and reliability with comparable samples
Hypothesis testing
generalizable
value-free
Positivistic thinking
validity
singularreality
hypothesistesting
reliability
cause & effectindependentvariable
Assumptions of Naturalistic Inquiry Realities are multiple,
pluralistic, and holistic The researcher cannot
really be separated from those being studied and relation-ships are explained
hypotheses are time and context bound - they are only working statements
researcher& subjectconnected
hypothesis is a focus area
multiple realities
naturalisticinquiry
Assumptions of Naturalistic Inquiry All entities are in a
state of mutual simultaneous shaping
Inquiry is value-bound
Validity is designed into the process
Reliability & general- izable are not concepts of value with this thinking
researcher& subject connected
hypothesisis a focusarea
Naturalistic inquiry
thick description
multiple realities inquiry is value bound
Differences in Scientific Rigorpositivistic naturalistic Validity Internal and external
reliability Hypothesis testing Statistical inferences Independent and
dependent variables Variable controls Generalizability
Descriptive Vividness Methodological
Congruence Analytical
Preciseness Theoretical
Connectedness Heuristic Relevance Others
Data Collection Differencepositivistic naturalistic Tools
surveys, questionnaires objective assessment &
identification Measure the dependent
variable Convert to numeric
symbols Apply statistical
inferences to numbers Large sample sizes help
with confidence levels
Tool is the investigator by
interview, focus groups, & observation
Data is subjective and objective. It is collected & not measured
Themes or clusters are identified and data is sorted in a theme analysis
The themes are supported by participants or experts
Differences in Results positivistic naturalistic Statistical
significance for pre-post treatment
Statistical correlations & relationships identified
Probability of errors & confidence identified
Causal relationships
The exploration & description of a phenomenon
Identification of linkages, relationships, or interpretations based on theory connections
Results are themes, clusters of ideas, or theory constructs
Positivistic Discussion of Results 250 nurses were surveyed with an 80%
response rate or N=200. Questions were rated using the Likert 5 scale. Question 1 had a mean of 4.2 with a S.D. of 0.5 suggesting the nurses had favorable opinions about continuing education. Compared to a 1994 survey asking the same question, there was a statistical difference that was less favorable (mean 3.1, S.D. 0.7, p<.05)
Naturalistic Description I sat in the classroom as a peripheral
member staying as unobtrusive as possible. The instructor came out from behind her desk, sitting on the edge as she opened with a question that brought all eyes in the room to meet her own eyes. She paused - looked at the eyes of the students.
The instructor displayed immediacy from the moment she started the class.
Ethics and Research (Ch. 7)
Starts with the study purpose, design, methods of measurement, and subjects
Guidelines for all of these It is still a concern today More recent ethical issues are:
Fabrication of a study Falsification or forging of data Dishonest manipulation of the design or methods Plagiarism
50% of the top 50 research institutions in US have been investigated for research fraud
Ethical Problems in History
Nazi medical experiments (1933-1945)
Tuskegee syphilis study by the USPHS (1932-1972)
Willowbrook study (1950-1970) Hepatitis study
Jewish Chronic Disease Hospital study with live CA cells in 1960s
Ethical Problems in History University –Atomic Energy Government Exp.
18 men and women injected with plutonium to determine body distribution (at the time said to be terminal) 1945-47
20 subjects ages 63-83 given doses of radioactive radium and thorium inj. or oral. 1961-65
64 male inmates at Washington St. Prison had testicular radiation to determine the smallest does to makes someone sterile. 1963-70
125 retarded residents were fed radioactive ir9n and calcium to see if a diet rich in cereal would block the digestion of those two minerals. 1946-56
Nuremberg Code-1949 Voluntary consent Must yield fruitful results for society Anticipated results justify the type of experiment Avoids all unnecessary physical-mental injury Cannot do studies that have a known injury or
death unless the exp. Physician is a subject Risk does not out weight humanitarian benefit Proper precautions to prevent injury, dis., death Conducted by qualified persons Subjects can always stop the study Researcher must always be ready to stop the
study (risk)
Declaration of Helsinki-1964-84
Differentiated therapeutic vs. non-therapeutic research
Clinical vs. Basic Greater care to protect subjects in non-
therapeutic research There must be a strong, independent
justification for exposing a healthy vol. to substantial risk
The investigator is to protect the health and life of research subjects
The Belmont ReportThree Ethical Principles
Principle of respect for persons Right to self determination and freedom to participate or
not Principle of Beneficence
Do no harm to others Principle of Justice
Treat everyone fairly without discrimination Led to USDHHS Code on Ethics
Title 45, Part 46 (45 CFR 46) Office of Human Subjects Research (OHSR) within NIH http://helix.nih.gov:8001/ohsr
Institutional Review Board (IRB) Provides oversight on all ethical
issues related to someone doing research
Consent forms (voluntary subjects) Disclosure forms Confidentiality Compensation disclosure Ethics documented in the research Accountability to rules, regulations, and
legal entities Protects at risk populations
The Literature Review Primary Sources Secondary Sources Theoretical literature Empirical (Research) literature Evidence Based Research Sites
www.cochrane.org/www.guideline.govhttp://www.cebm.utoronto.ca/resources/websites.htm www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/
Definition of a Literature Review (Ch. 5)
A systematic and explicit approach to the identification, retrieval, and bibliographical management of independent studies … locating information … synthesizing … developing guidelines …
Purposes of the Lit. Review Facilitate development of the Conceptual
Framework by summarizing knowledge Clarify the research topic Clarify the research problem Verify the significance of the research
problem Specify the purpose of the study Describe relevant studies or theories Develop definitions of major variables Select a research design, data measurement,
data collection & analysis, & interpret findings
Literature Searches Ebscohost with CINAHL:
http://search.ebscohost.com Log in: DSN Password: evidence Mydsn.org
NRS 338 Data bases
Understanding Research Designs Can have confusing terms Research Methodology
The entire process from question to analysis Research Design
Clearly defined structures within which the study is implemented
Is a large blueprint, but must be tailored to the study and then mapped out in detail
Quantitative Designs (Ch. 2)
What are the four types ofQuantitative Designs?
Quantitative Designs Experimental Quasi-experimental Descriptive Correlational
Aim to describe, compare, and predict in order to understand or control phenomena
Quantitative Designs
What characterizes true Experimental Research
Designs?
True Experimental Research Designs
Are characterized by: Random assignment of subjects to
groups
Comparison of treatment group(s) with a
Control or “business as usual” group
True Experimental Research Designs (cont.)
Also characterized by …
Strict control of extraneous variables to obtain true representation of “cause and effect” Note: use “causality” language with
caution!!! (there is always a P-value) Ex: Smoking and cancer
Randomized Controlled Clinical Trials (RCT)
True Experimental Design
Large N (# of subjects) Draw subjects from reference population Randomly assign subjects to treatment/experimental or control group Examine for baseline equivalence Multiple sites used for generalizability
Quasi-Experimental Research Designs
Are characterized by:
Treatment or intervention Comparison of treatment group(s) with a control or “business as usual” group Non-equivalence of groups--not randomly
assigned; group assignment often evolves naturally “convenience” sampling)
Ex: Pts. on one unit compared to pts. on another
Quasi-Experimental Research Designs (cont.)
Also are characterized by…
Aiming to represent “cause and effect” in situations where less control over variables exists
Most frequently used design in nursing
Correlational Designs Descriptive correlational designs
Used to describe variables and to examine relationships between or among variables
Predictive correlational designs Used to predict value of one variable based
on values obtained for another variable Independent variable used to “predict”
Dependent variable Regression Model-testing design
Looks at relationships among a # of variables
Correlational Designs Descriptive correlational designs
Used to describe variables and to examine relationships between or among variables
Predictive correlational designs Used to predict value of one variable
based on values obtained for another variable
Independent variable used to “predict” Dependent variable
Quantitative Design Concerns
Primary purpose (check question) Is there a treatment (intervention) Will the treatment be controlled Is there a control (untreated) group Is there a pre or post test (or both) Is sample random Will sample be a single group or divided
into several groups
Quantitative Design Concerns-2
How many groups will there be What is the size of each group Will groups be randomly assigned Will there be repeated measurements over
time or will the data be collected cross-sectionally at one or two points in time
Have extraneous variables been identified and controlled for
What strategies are being used to compare variables or groups
Research Question Considerations Ethics Significance Motivation Qualifications Feasibility
Hypotheses and Research Qs Hypotheses: Intelligent guesses
about predicted relationships
Problem statement what the issue/concern/problem is and why it should be addressed
Research Qs: “Burning question”
What are Criteria for Hypotheses? (Ch. 4)
Declarative Written in present tense Include population Identify variables Reflect the problem/concern Are empirically testable
Independent & Dependent Variables
Independent (IV) The treatment The intervention That which is manipulated
Dependent (DV) Outcome What is being measured The difference
Types of Hypotheses: Simple & Complex
Simple One Independent Variable (IV) and
one Dependent Variable (DV)
Complex Two or more IVs, two or more DVs, or both, being investigated at same
time
Hypothesis: #1 Average length of gestation is
shorter for infants of mothers who use cocaine than among mothers who use alcohol during the last six months of pregnancy.
Population? IV? DV?
Simple or complex?
Hypothesis: #2 The greater the degree of
sleep deprivation, the higher the anxiety levels of intensive care unit patients.
Population? IV? DV?
Simple or complex?
Hypothesis: #3 The total wt. loss of overweight
elementary students who follow a reduced calorie diet and exercise 20 minutes four times a week will be greater than those students who do not follow a reduced calorie diet and do not exercise 20 minutes four times a week.
Population? IV? DV?
Simple or complex?
Hypothesis: #4 The degree of stress reported by
flight-for-life nurses is greater than the degree of stress reported by ICU nurses.
Population? IV? DV?
Simple or complex?
Name that Hypothesis: #5 More domestic violence and levels
of anger are reported by veterans who served in the military in Iraq compared to those in the military who served in Afghanistan.
Population? IV? DV?
Simple or complex?
Sample of Research Topic & Questions
Topic: Adolescent sexuality Problem statement: (e.g., pregnancy rates in US
are much higher compared to most Western countries)
Research Question: Will high school adolescent males report higher levels
of comfort with their own sexuality than will females? Hypothesis:
Adolescent males in grades 9 – 12 will report statistically higher levels of comfort with their own sexuality than will females in the same grades.
Quantitative Design Concerns
Primary purpose (check question) Is there a treatment (intervention) Will the treatment be controlled Is there a control group (untreated) Is there a pre or post test (or both) Is the sample a random sample Will the sample be a single group or
divided into several groups
Quantitative Design Concerns-2
How many groups will there be What is the size of each group Will groups be randomly assigned Will there be repeated measurements Will the data be collected cross-sectionally
or over time Have extraneous variables been identified
and controlled for What strategies are being used for
comparison of variables or groups
Components of Study Validity
Definition: It is an examination of the approximation of truth or falsity of the propositions Statistical Validity (right stats used) Internal Validity (sample represents the
population being studied) Construct Validity (concept & Operational
def. of variable match, & instrument accuratly measures theoretical constructs it purports to measure.
External Validity (methods allow for generalizability)
(Cook and Campbell, 1979)
Statistical Validity Errors Violate assumptions about the data
Nominal, ordinal, interval, ratio data Type I and Type II errors Need for Power Analysis
Predicts the necessary N value Inappropriate use of certain statistics
for the various types of data Random irrelevancies in setting Random heterogeneity of respondents
Statistical Conclusion ValidityType I and Type II Errors
Accept the Null Hypothesis Reject the Null Hypothesis Reality is: Type I ErrorNo Desired There is no differencedifference caused by fishing
Reality is: Type II Error, there is There is a difference often caused Desired Difference by a low N value
Internal Validity Definition:
*It is the extent to which the effects detected in the study are a true reflection of reality rather than the result of extraneous variables;
* The independent variable did have an impact on the dependent variable and it was not by random chance (p value)
Threats to Internal Validity History: Natural events over time impacting
the subjects Maturation: A person’s growth in any area
impacting his/her response Testing effect caused by subjects
remembering previous testing Instrument reliability of treatment Selection process (randomized) Mortality threat Interaction with subjects No equalization of treatment
External Validity Definition:
To provide development of the design that allows it to be generalized beyond the sample used in the study.
Most serious threat is that the results can only be said of the group being studied
Threats to External Validity Small N No randomization when it is needed Poor sample representation either
by type, geography, or some other characteristic
Cannot be replicated for some extraneous variable
Factors Influencing Sample Size
Effect Size The degree to which the phenomenon
is present in the population or to which the null hypothesis is false.
It is hard to detect an effect from an intervention if the sample is small
Type of study conducted Case study, phenomenology,
experimental, Descriptive
Factors Influencing Sample Size
The number of variables This requires a power analysis to
determine the necessary N Measurement Sensitivity
The ability of the measurement to find what it thinks it is finding.
Data Analysis Techniques The various statistics can impact the
number of subjects needed.
Types of Probability Sampling Simple Random Sampling (select those
with specific characteristics)
Stratified Random Sampling (2 or more strata of population)
Cluster Sampling (all states, cities) Systematic Sampling (every nth) Random Assignment to Groups
(Treatment and Control)