1: Introduction to Nursing Research in an Evidence-Based Practice Environment
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NURSING RESEARCH IN PERSPECTIVE
In all parts of the world, nursing has experienced a profound culture change. Nurses are increasingly expected to understand and conduct research and to base their professional practice on research evidence—that is, to adopt an evidence-based practice (EBP) . EBP involves using the best evidence (as well as clinical judgment and patient preferences) in making patient care decisions, and “best evidence” typically comes from research conducted by nurses and other health care professionals.
What Is Nursing Research?
Research is systematic inquiry that uses disciplined methods to answer questions or solve problems. The ultimate goal of research is to develop and expand knowledge.
Nurses are increasingly engaged in disciplined studies that benefit nursing and its clients. Nursing research is systematic inquiry designed to generate trustworthy evidence about issues of importance to the nursing profession, including nursing practice, education, administration, and informatics. In this book, we emphasize clinical nursing research, that is, research to guide nursing practice and to improve the health and quality of life of nurses’ clients.
Nursing research has experienced remarkable growth in the past three decades, providing nurses with a growing evidence base from which to practice. Yet many questions endure and much remains to be done to incorporate research innovations into nursing practice.
Examples of Nursing Research Questions:
· How effective is pressurized irrigation, compared to a swabbing method, in cleansing wounds, in terms of time to wound healing, pain, patients’ satisfaction with comfort, and costs? (Mak et al., 2015)
· What are the experiences of women in Zimbabwe who are living with advanced HIV infection? (Gona & DeMarco, 2015)
The Importance of Research in Nursing
Research findings from rigorous studies provide especially strong evidence for informing nurses’ decisions and actions. Nurses are accepting the need to base specific nursing actions on research evidence indicating that the actions are clinically appropriate, cost-effective, and result in positive outcomes for clients.
In the United States, research plays an important role in nursing in terms of credentialing and status. The American Nurses Credentialing Center (ANCC)—an arm of the American Nurses Association and the largest and most prestigious credentialing organization in the United States—developed a Magnet Recognition Program to acknowledge health care organizations that provide high-quality nursing care. As Reigle and her colleagues (2008) noted, “the road to Magnet Recognition is paved with EBP” (p. 102) and the 2014 Magnet application manual incorporated revisions that strengthened evidence-based requirements (Drenkard, 2013). The good news is that there is growing confirmation that the focus on research and evidence-based practice may have important payoffs. For example, McHugh and co-researchers (2013) found that Magnet hospitals have lower risk-adjusted mortality and failure to rescue than non-Magnet hospitals, even when differences among the hospitals in nursing credentials and patient characteristics are taken into account.
Changes to nursing practice now occur regularly because of EBP efforts. Practice changes often are local initiatives that are not publicized, but broader clinical changes are also occurring based on accumulating research evidence about beneficial practice innovations.
Example of Evidence-Based Practice: Numerous clinical practice changes reflect the impact of research. For example, “kangaroo care” (the holding of diaper-clad infants skin to skin by parents) is now practiced in many neonatal intensive care units (NICUs), but this is a relatively new trend. As recently as the 1990s, only a minority of NICUs offered kangaroo care options. Expanded adoption of this practice reflects mounting evidence that early skin-to-skin contact has benefits without negative side effects (e.g., Ludington-Hoe, 2011; Moore et al., 2012). Some of that evidence came from rigorous studies conducted by nurse researchers in several countries (e.g., Chwo et al., 2002; Cong et al., 2009; Cong et al., 2011; Hake-Brooks & Anderson, 2008). Nurses continue to study the potential benefits of kangaroo care in important clinical trials (e.g., Campbell-Yeo et al., 2013).
The Consumer–Producer Continuum in Nursing Research
In our current environment, all nurses are likely to engage in activities along a continuum of research participation. At one end of the continuum are consumers of nursing research, who read research reports or research summaries to keep up-to-date on findings that might affect their practice. EBP depends on well-informed nursing research consumers.
At the other end of the continuum are the producers of nursing research: nurses who design and conduct research. At one time, most nurse researchers were academics who taught in schools of nursing, but research is increasingly being conducted by nurses in health care settings who want to find solutions to recurring problems in patient care.
Between these end points on the continuum lie a variety of research activities that are undertaken by nurses. Even if you never personally undertake a study, you may (1) contribute to an idea or a plan for a clinical study; (2) gather data for a study; (3) advise clients about participating in research; (4) solve a clinical problem by searching for research evidence; or (5) discuss the implications of a new study in a journal club in your practice setting, which involves meetings (in groups or online) to discuss research articles. In all possible research-related activities, nurses who have some research skills are better able than those without them to make a contribution to nursing and to EBP. An understanding of nursing research can improve the depth and breadth of every nurse’s professional practice.
Nursing Research in Historical Perspective
Table 1.1 summarizes some of the key events in the historical evolution of nursing research. (An expanded summary of the history of nursing research appears in the Supplement to this chapter on ).
TABLE 1.1: Historical Landmarks in Nursing Research
|1859||Nightingale’s Notes on Nursing is published.|
|1900||American Journal of Nursing begins publication.|
|1923||Columbia University establishes first doctoral program for nurses.|
|Goldmark Report with recommendations for nursing education is published.|
|1936||Sigma Theta Tau awards first nursing research grant in the United States.|
|1948||Brown publishes report on inadequacies of nursing education.|
|1952||The journal Nursing Research begins publication.|
|1955||Inception of the American Nurses Foundation to sponsor nursing research.|
|1957||Establishment of nursing research center at Walter Reed Army Institute of Research.|
|1963||International Journal of Nursing Studies begins publication.|
|1965||American Nurses Association (ANA) sponsors nursing research conferences.|
|1969||Canadian Journal of Nursing Research begins publication.|
|1972||ANA establishes a Commission on Research and Council of Nurse Researchers.|
|1976||Stetler and Marram publish guidelines on assessing research for use in practice.|
|Journal of Advanced Nursing begins publication.|
|1982||Conduct and Utilization of Research in Nursing (CURN) project publishes report.|
|1983||Annual Review of Nursing Research begins publication.|
|1985||ANA Cabinet on Nursing Research establishes research priorities.|
|1986||National Center for Nursing Research (NCNR) is established within U.S. National Institutes of Health.|
|1988||Conference on Research Priorities is convened by NCNR.|
|1989||U.S. Agency for Health Care Policy and Research (AHCPR) is established.|
|1993||NCNR becomes a full institute, the National Institute of Nursing Research (NINR).|
|The Cochrane Collaboration is established.|
|Magnet Recognition Program makes first awards.|
|1995||Joanna Briggs Institute, an international EBP collaborative, is established in Australia.|
|1997||Canadian Health Services Research Foundation is established with federal funding.|
|1999||AHCPR is renamed Agency for Healthcare Research and Quality (AHRQ).|
|2000||NINR’s annual funding exceeds $100 million.|
|The Canadian Institute of Health Research is launched.|
|Council for the Advancement of Nursing Science (CANS) is established.|
|2006||NINR issues strategic plan for 2006–2010.|
|2011||NINR celebrates 25th anniversary and issues a new strategic plan.|
|2014||NINR budget exceeds $140 million.|
Most people would agree that research in nursing began with Florence Nightingale in the 1850s. Her most well-known research contribution involved an analysis of factors affecting soldier mortality and morbidity during the Crimean War. Based on skillful analyses, she was successful in effecting changes in nursing care and, more generally, in public health. After Nightingale’s work, research was absent from the nursing literature until the early 1900s, but most early studies concerned nurses’ education rather than clinical issues.
In the 1950s, research by nurses began to accelerate. For example, a nursing research center was established at the Walter Reed Army Institute of Research. Also, the American Nurses Foundation, which is devoted to the promotion of nursing research, was founded. The surge in the number of studies conducted in the 1950s created the need for a new journal; Nursing Research came into being in 1952. As shown in Table 1.1 , dissemination opportunities in professional journals grew steadily thereafter.
In the 1960s, nursing leaders expressed concern about the shortage of research on practice issues. Professional nursing organizations, such as the Western Interstate Council for Higher Education in Nursing, established research priorities, and practice-oriented research on various clinical topics began to emerge in the literature.
During the 1970s, improvements in client care became a more visible research priority and nurses also began to pay attention to the clinical utilization of research findings. Guidance on assessing research for application in practice settings became available. Several journals that focus on nursing research were established in the 1970s, including Advances in Nursing Science, Research in Nursing & Health, and the Western Journal of Nursing Research. Nursing research also expanded internationally. For example, the Workgroup of European Nurse Researchers was established in 1978 to develop greater communication and opportunities for partnerships among 25 European National Nurses Associations.
Nursing research continued to expand in the 1980s. In the United States, the National Center for Nursing Research (NCNR) at the National Institutes of Health (NIH) was established in 1986. Several forces outside of nursing also helped to shape the nursing research landscape. A group from the McMaster Medical School in Canada designed a clinical learning strategy that was called evidence-based medicine (EBM). EBM, which promulgated the view that research findings were far superior to the opinions of authorities as a basis for clinical decisions, constituted a profound shift for medical education and practice, and has had a major effect on all health care professions.
Nursing research was strengthened and given more visibility when NCNR was promoted to full institute status within the NIH. In 1993, the National Institute of Nursing Research (NINR) was established, helping to put nursing research more into the mainstream of health research. Funding opportunities for nursing research expanded in other countries as well.
Current and Future Directions for Nursing Research
Nursing research continues to develop at a rapid pace and will undoubtedly flourish in the 21st century. Funding continues to grow. For example, NINR funding in fiscal year 2014 was more than $140 million compared to $70 million in 1999—and the competition for available funding is increasingly vigorous as more nurses seek support for testing innovative ideas for practice improvements.
Broadly speaking, the priority for future nursing research will be the promotion of excellence in nursing science. Toward this end, nurse researchers and practicing nurses will be sharpening their research skills and using those skills to address emerging issues of importance to the profession and its clientele. Among the trends we foresee for the early 21st century are the following:
· Continued focus on EBP. Encouragement for nurses to engage in evidence-based patient care is sure to continue. In turn, improvements will be needed both in the quality of studies and in nurses’ skills in locating, understanding, critiquing, and using relevant study results. Relatedly, there is an emerging interest in translational research —research on how findings from studies can best be translated into practice. Translation potential will require researchers to think more strategically about long-term feasibility, scalability, and sustainability when they test solutions to problems.
· Development of a stronger evidence base through confirmatory strategies. Practicing nurses are unlikely to adopt an innovation based on weakly designed or isolated studies. Strong research designs are essential, and confirmation is usually needed through the replication (i.e., the repeating) of studies with different clients, in different clinical settings, and at different times to ensure that the findings are robust.
· Greater emphasis on systematic reviews. Systematic reviews are a cornerstone of EBP and will take on increased importance in all health disciplines. Systematic reviews rigorously integrate research information on a topic so that conclusions about the state of evidence can be reached. Best practice clinical guidelines typically rely on such systematic reviews.
· Innovation. There is currently a major push for creative and innovative solutions to recurring practice problems. “Innovation” has become an important buzzword throughout NIH and in nursing associations. For example, the 2013 annual conference of the Council for the Advancement of Nursing Science was “Innovative Approaches to Symptom Science.” Innovative interventions—and new methods for studying nursing questions—are sure to be part of the future research landscape in nursing.
· Expanded local research in health care settings. Small studies designed to solve local problems will likely increase. This trend will be reinforced as more hospitals apply for (and are recertified for) Magnet status in the United States and in other countries. Mechanisms will need to be developed to ensure that evidence from these small projects becomes available to others facing similar problems, such as communication within and between regional nursing research alliances.
· Strengthening of interdisciplinary collaboration. Collaboration of nurses with researchers in related fields is likely to expand in the 21st century as researchers address fundamental health care problems. In turn, such collaborative efforts could lead to nurse researchers playing a more prominent role in national and international health care policies. One of four major recommendations in a 2010 report on the future of nursing by the Institute of Medicine was that nurses should be full partners with physicians and other health care professionals in redesigning health care.
· Expanded dissemination of research findings. The Internet and other electronic communication have a big impact on disseminating research information, which in turn helps to promote EBP. Through technologic advances, information about innovations can be communicated more widely and more quickly than ever before.
· Increased focus on cultural issues and health disparities. The issue of health disparities has emerged as a central concern in nursing and other health disciplines; this in turn has raised consciousness about the cultural sensitivity of health interventions and the cultural competence of health care workers. There is growing awareness that research must be sensitive to the health beliefs, behaviors, and values of culturally and linguistically diverse populations.
· Clinical significance and patient input. Research findings increasingly must meet the test of being clinically significant, and patients have taken center stage in efforts to define clinical significance. A major challenge in the years ahead will involve getting both research evidence and patient preferences into clinical decisions, and designing research to study the process and the outcomes.
Broad research priorities for the future have been articulated by many nursing organizations, including NINR and Sigma Theta Tau International. Expert panels and research working groups help NINR to identify gaps in current knowledge that require research. The primary areas of research funded by NINR in 2014 were health promotion/disease prevention, eliminating health disparities, caregiving, symptom management, and self-management. Research priorities that have been expressed by Sigma Theta Tau International include advancing healthy communities through health promotion; preventing disease and recognizing social, economic, and political determinants; implementation of evidence-based practice; targeting the needs of vulnerable populations such as the poor and chronically ill; and developing nurses’ capacity for research. Priorities also have been developed for several nursing specialties and for nurses in several countries—for example, Ireland (Brenner et al., 2014; Drennan et al., 2007), Sweden (Bäck-Pettersson et al., 2008), Australia (Wynaden et al., 2014), and Korea (Kim et al., 2002).
SOURCES OF EVIDENCE FOR NURSING PRACTICE
Nurses make clinical decisions based on knowledge from many sources, including coursework, textbooks, and their own clinical experience. Because evidence is constantly evolving, learning about best practice nursing perseveres throughout a nurse’s career.
Some of what nurses learn is based on systematic research, but much of it is not. What are the sources of evidence for nursing practice? Where does knowledge for practice come from? Until fairly recently, knowledge primarily was handed down from one generation to the next based on experience, trial and error, tradition, and expert opinion. Information sources for clinical practice vary in dependability, giving rise to what is called an evidence hierarchy, which acknowledges that certain types of evidence are better than others. A brief discussion of some alternative sources of evidence shows how research-based information is different.
Tradition and Authority
Decisions are sometimes based on custom or tradition. Certain “truths” are accepted as given, and such “knowledge” is so much a part of a common heritage that few seek verification. Tradition facilitates communication by providing a common foundation of accepted truth, but many traditions have never been evaluated for their validity. There is concern that some nursing interventions are based on tradition, custom, and “unit culture” rather than on sound evidence. Indeed, a recent analysis suggests that some “sacred cows” (ineffective traditional habits) persist even in a health care center recognized as a leader in evidence-based practice (Hanrahan et al., 2015).
Another common source of information is an authority, a person with specialized expertise. We often make decisions about problems with which we have little experience; it seems natural to place our trust in the judgment of people with specialized training or experience. As a source of evidence, however, authority has shortcomings. Authorities are not infallible, particularly if their expertise is based primarily on personal experience; yet, like tradition, their knowledge often goes unchallenged.
Example of “Myths” in Nursing Textbooks: A study suggests that even nursing textbooks may contain “myths.” In their analysis of 23 widely used undergraduate psychiatric nursing textbooks, Holman and colleagues (2010) found that all books contained at least one unsupported assumption (myth) about loss and grief—that is, assumptions not supported by research evidence. Moreover, many evidence-based findings about grief and loss failed to be included in the textbooks.
Clinical Experience, Trial and Error, and Intuition
Clinical experience is a familiar, functional source of knowledge. The ability to generalize, to recognize regularities, and to make predictions is an important characteristic of the human mind. Nevertheless, personal experience is limited as a knowledge source because each nurse’s experience is too narrow to be generally useful. A second limitation is that the same objective event is often experienced and perceived differently by two nurses.
A related method is trial and error in which alternatives are tried successively until a solution to a problem is found. We likely have all used this method in our professional work. For example, many patients dislike the taste of potassium chloride solution. Nurses try to disguise the taste of the medication in various ways until one method meets with the approval of the patient. Trial and error may offer a practical means of securing knowledge, but the method tends to be haphazard and solutions may be idiosyncratic.
Intuition is a knowledge source that cannot be explained based on reasoning or prior instruction. Although intuition and hunches undoubtedly play a role in nursing—as they do in the conduct of research—it is difficult to develop nursing policies and practices based on intuition.
Solutions to some problems are developed by logical thought processes. As a problem-solving method, logical reasoning combines experience, intellectual faculties, and formal systems of thought. Inductive reasoning involves developing generalizations from specific observations. For example, a nurse may observe the anxious behavior of (specific) hospitalized children and conclude that (in general) children’s separation from their parents is stressful. Deductive reasoning involves developing specific predictions from general principles. For example, if we assume that separation anxiety occurs in hospitalized children (in general), then we might predict that (specific) children in a hospital whose parents do not room-in will manifest symptoms of stress. Both systems of reasoning are useful for understanding and organizing phenomena, and both play a role in research. Logical reasoning in and of itself, however, is limited because the validity of reasoning depends on the accuracy of the premises with which one starts.
In making clinical decisions, health care professionals rely on information that has been assembled for a variety of purposes. For example, local, national, and international benchmarking data provide information on such issues as infection rates or the rates of using various procedures (e.g., cesarean births) and can facilitate evaluations of clinical practices. Cost data—information on the costs associated with certain procedures, policies, or practices—are sometimes used as a factor in clinical decision making. Quality improvement and risk data, such as medication error reports, can be used to assess the need for practice changes. Such sources are useful, but they do not provide a good mechanism for determining whether improvements in patient outcomes result from their use.
Research conducted in a disciplined framework is the most sophisticated method of acquiring knowledge. Nursing research combines logical reasoning with other features to create evidence that, although fallible, tends to yield the most reliable evidence. Carefully synthesized findings from rigorous research are at the pinnacle of most evidence hierarchies. The current emphasis on EBP requires nurses to base their clinical practice to the greatest extent possible on rigorous research-based findings rather than on tradition, authority, intuition, or personal experience—although nursing will always remain a rich blend of art and science.
PARADIGMS AND METHODS FOR NURSING RESEARCH
A paradigm is a worldview, a general perspective on the complexities of the world. Paradigms for human inquiry are often characterized in terms of the ways in which they respond to basic philosophical questions, such as, What is the nature of reality? (ontologic) and What is the relationship between the inquirer and those being studied? (epistemologic).
Disciplined inquiry in nursing has been conducted mainly within two broad paradigms, positivism and constructivism. This section describes these two paradigms and outlines the research methods associated with them. In later chapters, we describe the transformative paradigm that involves critical theory research ( Chapter 21 ), and a pragmatism paradigm that involves mixed methods research ( Chapter 26 ).
The Positivist Paradigm
The paradigm that dominated nursing research for decades is known as positivism (also called logical positivism ). Positivism is rooted in 19th century thought, guided by such philosophers as Mill, Newton, and Locke. Positivism reflects a broader cultural phenomenon that, in the humanities, is referred to as modernism, which emphasizes the rational and the scientific.
As shown in Table 1.2 , a fundamental assumption of positivists is that there is a reality out there that can be studied and known (an assumption is a basic principle that is believed to be true without proof or verification). Adherents of positivism assume that nature is basically ordered and regular and that reality exists independent of human observation. In other words, the world is assumed not to be merely a creation of the human mind. The related assumption of determinism refers to the positivists’ belief that phenomena are not haphazard but rather have antecedent causes. If a person has a cerebrovascular accident, the researcher in a positivist tradition assumes that there must be one or more reasons that can be potentially identified. Within the positivist paradigm, much research activity is directed at understanding the underlying causes of phenomena.
TABLE 1.2: Major Assumptions of the Positivist and Constructivist Paradigms
|TYPE OF QUESTION||POSITIVIST PARADIGM ASSUMPTION||CONSTRUCTIVIST PARADIGM ASSUMPTION|
|Ontologic: What is the nature of reality?||Reality exists; there is a real world driven by real natural causes and subsequent effects||Reality is multiple and subjective, mentally constructed by individuals; simultaneous shaping, not cause and effect|
|Epistemologic: How is the inquirer related to those being researched?||The inquirer is independent from those being researched; findings are not influenced by the researcher||The inquirer interacts with those being researched; findings are the creation of the interactive process|
|Axiologic: What is the role of values in the inquiry?||Values and biases are to be held in check; objectivity is sought||Subjectivity and values are inevitable and desirable|
|Methodologic: How is evidence best obtained?||Deductive processes → hypothesis testing||Inductive processes → hypothesis generation|
|Emphasis on discrete, specific concepts||Emphasis on entirety of some phenomenon, holistic|
|Focus on the objective and quantifiable||Focus on the subjective and nonquantifiable|
|Corroboration of researchers’ predictions||Emerging insight grounded in participants’ experiences|
|Outsider knowledge—researcher is external, separate||Insider knowledge—researcher is internal, part of process|
|Fixed, prespecified design||Flexible, emergent design|
|Controls over context||Context-bound, contextualized|
|Large, representative samples||Small, information-rich samples|
|Measured (quantitative) information||Narrative (unstructured) information|
|Statistical analysis||Qualitative analysis|
|Seeks generalizations||Seeks in-depth understanding|
Positivists value objectivity and attempt to hold personal beliefs and biases in check to avoid contaminating the phenomena under study. The positivists’ scientific approach involves using orderly, disciplined procedures with tight controls of the research situation to test hunches about the phenomena being studied.
Strict positivist thinking has been challenged, and few researchers adhere to the tenets of pure positivism. In the postpositivist paradigm , there is still a belief in reality and a desire to understand it, but postpositivists recognize the impossibility of total objectivity. They do, however, see objectivity as a goal and strive to be as neutral as possible. Postpositivists also appreciate the impediments to knowing reality with certainty and therefore seek probabilistic evidence—that is, learning what the true state of a phenomenon probably is, with a high degree of likelihood. This modified positivist position remains a dominant force in nursing research. For the sake of simplicity, we refer to it as positivism.
The Constructivist Paradigm
The constructivist paradigm (often called the naturalistic paradigm ) began as a countermovement to positivism with writers such as Weber and Kant. Just as positivism reflects the cultural phenomenon of modernism that burgeoned after the industrial revolution, naturalism is an outgrowth of the cultural transformation called postmodernism. Postmodern thinking emphasizes the value of deconstruction—taking apart old ideas and structures—and reconstruction—putting ideas and structures together in new ways. The constructivist paradigm represents a major alternative system for conducting disciplined research in nursing. Table 1.2 compares the major assumptions of the positivist and constructivist paradigms.
For the naturalistic inquirer, reality is not a fixed entity but rather is a construction of the individuals participating in the research; reality exists within a context, and many constructions are possible. Naturalists thus take the position of relativism: If there are multiple interpretations of reality that exist in people’s minds, then there is no process by which the ultimate truth or falsity of the constructions can be determined.
The constructivist paradigm assumes that knowledge is maximized when the distance between the inquirer and those under study is minimized. The voices and interpretations of study participants are crucial to understanding the phenomenon of interest, and subjective interactions are the primary way to access them. Findings from a constructivist inquiry are the product of the interaction between the inquirer and the participants.
Paradigms and Methods: Quantitative and Qualitative Research
Research methods are the techniques researchers use to structure a study and to gather and analyze information relevant to the research question. The two alternative paradigms correspond to different methods for developing evidence. A key methodologic distinction is between quantitative research , which is most closely allied with positivism, and qualitative research , which is associated with constructivist inquiry—although positivists sometimes undertake qualitative studies, and constructivist researchers sometimes collect quantitative information. This section provides an overview of the methods associated with the two paradigms.
The Scientific Method and Quantitative Research
The traditional, positivist scientific method refers to a set of orderly, disciplined procedures used to acquire information. Quantitative researchers use deductive reasoning to generate predictions that are tested in the real world. They typically move in a systematic fashion from the definition of a problem and the selection of concepts on which to focus to the solution of the problem. By systematic, we mean that the investigator progresses logically through a series of steps, according to a specified plan of action.
Quantitative researchers use various control strategies. Control involves imposing conditions on the research situation so that biases are minimized and precision and validity are maximized. Control mechanisms are discussed at length in this book.
Quantitative researchers gather empirical evidence —evidence that is rooted in objective reality and gathered through the senses. Empirical evidence, then, consists of observations gathered through sight, hearing, taste, touch, or smell. Observations of the presence or absence of skin inflammation, patients’ anxiety level, or infant birth weight are all examples of empirical observations. The requirement to use empirical evidence means that findings are grounded in reality rather than in researchers’ personal beliefs.
Evidence for a study in the positivist paradigm is gathered according to an established plan, using structured methods to collect needed information. Usually (but not always) the information gathered is quantitative —that is, numeric information that is obtained from a formal measurement and is analyzed statistically.
A traditional scientific study strives to go beyond the specifics of a research situation. For example, quantitative researchers are typically not as interested in understanding why a particular person has a stroke as in understanding what factors influence its occurrence in people generally. The degree to which research findings can be generalized to individuals other than those who participated in the study is called the study’s generalizability .
The scientific method has enjoyed considerable stature as a method of inquiry and has been used productively by nurse researchers studying a range of nursing problems. This is not to say, however, that this approach can solve all nursing problems. One important limitation—common to both quantitative and qualitative research—is that research cannot be used to answer moral or ethical questions. Many persistent, intriguing questions about human beings fall into this area—questions such as whether euthanasia should be practiced or abortion should be legal.
The traditional research approach also must contend with problems of measurement. To study a phenomenon, quantitative researchers attempt to measure it by attaching numeric values that express quantity. For example, if the phenomenon of interest is patient stress, researchers would want to assess if patients’ stress is high or low, or higher under certain conditions or for some people. Physiologic phenomena such as blood pressure and temperature can be measured with great accuracy and precision, but the same cannot be said of most psychological phenomena, such as stress or resilience.
Another issue is that nursing research focuses on humans, who are inherently complex and diverse. Traditional quantitative methods typically concentrate on a relatively small portion of the human experience (e.g., weight gain, depression) in a single study. Complexities tend to be controlled and, if possible, eliminated, rather than studied directly, and this narrowness of focus can sometimes obscure insights. Finally, quantitative research within the positivist paradigm has been accused of an inflexibility of vision that does not capture the full breadth of human experience.
Constructivist Methods and Qualitative Research
Researchers in constructivist traditions emphasize the inherent complexity of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, constructivist studies are heavily focused on understanding the human experience as it is lived, usually through the careful collection and analysis of qualitative materials that are narrative and subjective.
Researchers who reject the traditional scientific method believe that it is overly reductionist—that is, it reduces human experience to the few concepts under investigation, and those concepts are defined in advance by the researcher rather than emerging from the experiences of those under study. Constructivist researchers tend to emphasize the dynamic, holistic, and individual aspects of human life and attempt to capture those aspects in their entirety, within the context of those who are experiencing them.
Flexible, evolving procedures are used to capitalize on findings that emerge in the course of the study. Constructivist inquiry usually takes place in the field (i.e., in naturalistic settings), often over an extended time period. In constructivist research, the collection of information and its analysis typically progress concurrently; as researchers sift through information, insights are gained, new questions emerge, and further evidence is sought to amplify or confirm the insights. Through an inductive process, researchers integrate information to develop a theory or description that helps illuminate the phenomenon under observation.
Constructivist studies yield rich, in-depth information that can elucidate varied dimensions of a complicated phenomenon. Findings from in-depth qualitative research are typically grounded in the real-life experiences of people with first-hand knowledge of a phenomenon. Nevertheless, the approach has several limitations. Human beings are used directly as the instrument through which information is gathered, and humans are extremely intelligent and sensitive—but fallible—tools. The subjectivity that enriches the analytic insights of skillful researchers can yield trivial and obvious “findings” among less competent ones.
Another potential limitation involves the subjectivity of constructivist inquiry, which sometimes raises concerns about the idiosyncratic nature of the conclusions. Would two constructivist researchers studying the same phenomenon in similar settings arrive at similar conclusions? The situation is further complicated by the fact that most constructivist studies involve a small group of participants. Thus, the generalizability of findings from constructivist inquiries is an issue of potential concern.
Multiple Paradigms and Nursing Research
Paradigms should be viewed as lenses that help to sharpen our focus on a phenomenon, not as blinders that limit intellectual curiosity. The emergence of alternative paradigms for studying nursing problems is, in our view, a healthy and desirable path that can maximize the breadth of evidence for practice. Although researchers’ worldview may be paradigmatic, knowledge itself is not. Nursing knowledge would be thin if there were not a rich array of methods available within the two paradigms—methods that are often complementary in their strengths and limitations. We believe that intellectual pluralism is advantageous.
We have emphasized differences between the two paradigms and associated methods so that distinctions would be easy to understand—although for many of the issues included in Table 1.2 , differences are more on a continuum than they are a dichotomy. Subsequent chapters of this book elaborate further on differences in terminology, methods, and research products. It is equally important, however, to note that the two main paradigms have many features in common, only some of which are mentioned here:
· Ultimate goals. The ultimate aim of disciplined research, regardless of the underlying paradigm, is to gain understanding about phenomena. Both quantitative and qualitative researchers seek to capture the truth with regard to an aspect of the world in which they are interested, and both groups can make meaningful—and mutually beneficial—contributions to evidence for nursing practice.
· External evidence. Although the word empiricism has come to be allied with the classic scientific method, researchers in both traditions gather and analyze evidence empirically, that is, through their senses. Neither qualitative nor quantitative researchers are armchair analysts, depending on their own beliefs and worldviews to generate knowledge.
· Reliance on human cooperation. Because evidence for nursing research comes primarily from humans, human cooperation is essential. To understand people’s characteristics and experiences, researchers must persuade them to participate in the investigation and to speak and act candidly.
· Ethical constraints. Research with human beings is guided by ethical principles that sometimes interfere with research goals. As we discuss in Chapter 7 , ethical dilemmas often confront researchers, regardless of paradigms or methods.
· Fallibility of disciplined research. Virtually all studies have some limitations. Every research question can be addressed in many ways, and inevitably, there are trade-offs. The fallibility of any single study makes it important to understand and critique researchers’ methodologic decisions when evaluating evidence quality.
Thus, despite philosophic and methodologic differences, researchers using traditional scientific methods or constructivist methods share overall goals and face many similar challenges. The selection of an appropriate method depends on researchers’ personal philosophy and also on the research question. If a researcher asks, “What are the effects of cryotherapy on nausea and oral mucositis in patients undergoing chemotherapy?” the researcher needs to examine the effects through the careful measurement of patient outcomes. On the other hand, if a researcher asks, “What is the process by which parents learn to cope with the death of a child?” the researcher would be hard pressed to quantify such a process. Personal worldviews of researchers help to shape their questions.
In reading about the alternative paradigms for nursing research, you likely were more attracted to one of the two paradigms. It is important, however, to learn about both approaches to disciplined inquiry and to recognize their respective strengths and limitations. In this textbook, we describe methods associated with both qualitative and quantitative research in an effort to assist you in becoming methodologically bilingual. This is especially important because large numbers of nurse researchers are now undertaking mixed methods research that involves gathering and analyzing both qualitative and quantitative data ( Chapters 26 – 28 ).
THE PURPOSES OF NURSING RESEARCH
The general purpose of nursing research is to answer questions or solve problems of relevance to nursing. Specific purposes can be classified in various ways. We describe three such classifications—not because it is important for you to categorize a study as having one purpose or the other but rather because this will help us to illustrate the broad range of questions that have intrigued nurses and to further show differences between qualitative and quantitative inquiry.
Applied and Basic Research
Sometimes a distinction is made between basic and applied research. As traditionally defined, basic research is undertaken to enhance the base of knowledge or to formulate or refine a theory. For example, a researcher may perform an in-depth study to better understand normal grieving processes, without having explicit nursing applications in mind. Some types of basic research are called bench research, which is usually performed in a laboratory and focuses on the molecular and cellular mechanisms that underlie disease.
Example of Basic Nursing Research: Kishi and a multidisciplinary team of researchers (2015) studied the effect of hypo-osmotic shock of epidermal cells on skin inflammation in a rat model, in an effort to understand the physiologic mechanism underlying aquagenic pruritus (disrupted skin barrier function) in the elderly.
Applied research seeks solutions to existing problems and tends to be of greater immediate utility for EBP. Basic research is appropriate for discovering general principles of human behavior and biophysiologic processes; applied research is designed to indicate how these principles can be used to solve problems in nursing practice. In nursing, the findings from applied research may pose questions for basic research, and the results of basic research often suggest clinical applications.
Example of Applied Nursing Research: S. Martin and colleagues (2014) studied whether positive therapeutic suggestions given via headphones to children emerging from anesthesia after a tonsillectomy would help to lower the children’s pain.
Research to Achieve Varying Levels of Explanation
Another way to classify research purposes concerns the extent to which studies provide explanatory information. Although specific study goals can range along an explanatory continuum, a fundamental distinction (relevant especially in quantitative research) is between studies whose primary intent is to describe phenomena, and those that are cause-probing —that is, designed to illuminate the underlying causes of phenomena.
Within a descriptive/explanatory framework, the specific purposes of nursing research include identification, description, exploration, prediction/control, and explanation. For each purpose, various types of question are addressed—some more amenable to qualitative than to quantitative inquiry and vice versa.
Identification and Description
Qualitative researchers sometimes study phenomena about which little is known. In some cases, so little is known that the phenomenon has yet to be clearly identified or named or has been inadequately defined. The in-depth, probing nature of qualitative research is well suited to the task of answering such questions as, “What is this phenomenon?” and “What is its name?” ( Table 1.3 ). In quantitative research, by contrast, researchers begin with a phenomenon that has been previously studied or defined—sometimes in a qualitative study. Thus, in quantitative research, identification typically precedes the inquiry.
TABLE 1.3: Research Purposes and Types of Research Questions
|PURPOSE||TYPES OF QUESTIONS: QUANTITATIVE RESEARCH||TYPES OF QUESTIONS: QUALITATIVE RESEARCH|
|Identification||What is this phenomenon?
What is its name?
|Description||How prevalent is the phenomenon?
How often does the phenomenon occur?
|What are the dimensions or characteristics of the phenomenon?
What is important about the phenomenon?
|Exploration||What factors are related to the phenomenon?
What are the antecedents of the phenomenon?
|What is the full nature of the phenomenon?
What is really going on here?
How is the phenomenon experienced? What is the process by which the phenomenon evolves?
|Explanation||What is the underlying cause of the phenomenon?
Does the theory explain the phenomenon?
|How does the phenomenon work?
What does the phenomenon mean?
How did the phenomenon occur?
|Prediction||What will happen if we alter a phenomenon or introduce an intervention?
If phenomenon X occurs, will phenomenon Y follow?
|Control||Can the occurrence of the phenomenon be prevented or controlled?|
Qualitative Example of Identification: Wojnar and Katzenmeyer (2013) studied the experiences of preconception, pregnancy, and new motherhood for lesbian nonbiologic mothers. They identified, through in-depth interviews with 24 women, a unique description of a pervasive feeling they called otherness.
Description is another important research purpose. Examples of phenomena that nurse researchers have described include patients’ pain, confusion, and coping. Quantitative description focuses on the incidence, size, and measurable attributes of phenomena. Qualitative researchers, by contrast, describe the dimensions and meanings of phenomena. Table 1.3 shows descriptive questions posed by quantitative and qualitative researchers.
Quantitative Example of Description: Palese and colleagues (2015) conducted a study to describe the average healing time of stage II pressure ulcers. They found that it took approximately 23 days to achieve complete reepithelialization.
Qualitative Example of Description: Archibald and colleagues (2015) undertook an in-depth study to describe the information needs of parents of children with asthma.
Exploratory research begins with a phenomenon of interest, but rather than simply observing and describing it, exploratory research investigates the full nature of the phenomenon, the manner in which it is manifested, and the other factors to which it is related. For example, a descriptive quantitative study of patients’ preoperative stress might document the degree of stress patients feel before surgery and the percentage of patients who are stressed. An exploratory study might ask: What factors diminish or increase a patient’s stress? Are nurses’ behaviors related to a patient’s stress level? Qualitative methods are especially useful for exploring the full nature of a little-understood phenomenon. Exploratory qualitative research is designed to shed light on the various ways in which a phenomenon is manifested and on underlying processes.
Quantitative Example of Exploration: Lee and colleagues (2014) explored the association between physical activity in older adults and their level of depressive symptoms.
Qualitative Example of Exploration: Based on in-depth interviews with adults living on a reservation in the United States, D. Martin and Yurkovich (2014) explored American Indians’ perception of a healthy family.
The goals of explanatory research are to understand the underpinnings of natural phenomena and to explain systematic relationships among them. Explanatory research is often linked to theories , which are a method of integrating ideas about phenomena and their interrelationships. Whereas descriptive research provides new information and exploratory research provides promising insights, explanatory research attempts to offer understanding of the underlying causes or full nature of a phenomenon. In quantitative research, theories or prior findings are used deductively to generate hypothesized explanations that are then tested. In qualitative studies, researchers search for explanations about how or why a phenomenon exists or what a phenomenon means as a basis for developing a theory that is grounded in rich, in-depth evidence.
Quantitative Example of Explanation: Golfenshtein and Drach-Zahavy (2015) tested a theoretical model (attribution theory) to understand the role of patients’ attributions in nurses’ regulation of emotions in pediatric hospital wards.
Qualitative Example of Explanation: Smith-Young and colleagues (2014) conducted an in-depth study to develop a theoretical understanding of the process of managing work-related musculoskeletal disorders while remaining at the workplace. They called this process constant negotiation.
Prediction and Control
Many phenomena defy explanation. Yet it is frequently possible to make predictions and to control phenomena based on research findings, even in the absence of complete understanding. For example, research has shown that the incidence of Down syndrome in infants increases with the age of the mother. We can predict that a woman aged 40 years is at higher risk of bearing a child with Down syndrome than is a woman aged 25 years. We can partially control the outcome by educating women about the risks and offering amniocentesis to women older than 35 years of age. The ability to predict and control in this example does not depend on an explanation of why older women are at a higher risk of having an abnormal child. In many quantitative studies, prediction and control are key objectives. Although explanatory studies are powerful in an EBP environment, studies whose purpose is prediction and control are also critical in helping clinicians make decisions.
Quantitative Example of Prediction: Dang (2014) studied factors that predicted resilience among homeless youth with histories of maltreatment. Social connectedness and self-esteem were predictive of better mental health.
Research Purposes Linked to Evidence-Based Practice
The purpose of most nursing studies can be categorized on a descriptive–explanatory dimension as just described, but some studies do not fall into such a system. For example, a study to develop and rigorously test a new method of measuring patient outcomes cannot easily be classified on this continuum.
In both nursing and medicine, several books have been written to facilitate evidence-based practice, and these books categorize studies in terms of the types of information needed by clinicians (DiCenso et al., 2005; Guyatt et al., 2008; Melnyk & Fineout-Overholt, 2011). These writers focus on several types of clinical concerns: treatment, therapy, or intervention; diagnosis and assessment; prognosis; prevention of harm; etiology; and meaning. Not all nursing studies have one of these purposes, but most of them do.
Treatment, Therapy, or Intervention
Nurse researchers undertake studies designed to help nurses make evidence-based treatment decisions about how to prevent a health problem or how to manage an existing problem. Such studies range from evaluations of highly specific treatments or therapies (e.g., comparing two types of cooling blankets for febrile patients) to complex multisession interventions designed to effect major behavioral changes (e.g., nurse-led smoking cessation interventions). Such intervention research plays a critical role in EBP.
Example of a Study Aimed at Treatment/Therapy: Ling and co-researchers (2014) tested the effectiveness of a school-based healthy lifestyle intervention designed to prevent childhood obesity in four rural elementary schools.
Diagnosis and Assessment
A burgeoning number of nursing studies concern the rigorous development and evaluation of formal instruments to screen, diagnose, and assess patients and to measure important clinical outcomes. High-quality instruments with documented accuracy are essential both for clinical practice and for further research.
Example of a Study Aimed at Diagnosis/Assessment: Pasek and colleagues (2015) developed a prototype of an electronic headache pain diary for children and evaluated the clinical feasibility of the diary for assessing and documenting concussion headache.
Studies of prognosis examine outcomes associated with a disease or health problem, estimate the probability they will occur, and predict the types of people for whom the outcomes are most likely. Such studies facilitate the development of long-term care plans for patients. They provide valuable information for guiding patients to make lifestyle choices or to be vigilant for key symptoms. Prognostic studies can also play a role in resource allocation decisions
Example of a Study Aimed at Prognosis: Storey and Von Ah (2015) studied the prevalence and impact of hyperglycemia on hospitalized leukemia patients, in terms of such outcomes as neutropenia, infection, and length of hospital stay.
Prevention of Harm and Etiology (Causation)
Nurses frequently encounter patients who face potentially harmful exposures as a result of environmental agents or because of personal behaviors or characteristics. Providing useful information to patients about such harms and how best to avoid them depends on the availability of accurate evidence about health risks. Moreover, it can be difficult to prevent harms if we do not know what causes them. For example, there would be no smoking cessation programs if research had not provided firm evidence that smoking cigarettes causes or contributes to a wide range of health problems. Thus, identifying factors that affect or cause illness, mortality, or morbidity is an important purpose of many nursing studies.
Example of a Study Aimed at Identifying and Preventing Harms: Hagerty and colleagues (2015) undertook a study to identify risk factors for catheter-associated urinary tract infections in critically ill patients with subarachnoid hemorrhage. The risk factors examined included patients’ blood sugar levels, patient age, and levels of anemia requiring transfusion.
Meaning and Processes
Designing effective interventions, motivating people to comply with treatments and health promotion activities, and providing sensitive advice to patients are among the many health care activities that can greatly benefit from understanding the clients’ perspectives. Research that provides evidence about what health and illness mean to clients, what barriers they face to positive health practices, and what processes they experience in a transition through a health care crisis are important to evidence-based nursing practice.
Example of a Study Aimed at Studying Meaning: Carlsson and Persson (2015) studied what it means to live with intestinal failure caused by Crohn disease and the influence it has on daily life.
TIP: Several of these EBP-related purposes (except diagnosis and meaning) fundamentally call for cause-probing research. For example, research on interventions focuses on whether an intervention causes improvements in key outcomes. Prognosis research asks if a disease or health condition causes subsequent adverse outcomes, and etiology research seeks explanations about the underlying causes of health problems.
ASSISTANCE FOR USERS OF NURSING RESEARCH
This book is designed primarily to help you develop skills for conducting research, but in an environment that stresses EBP, it is extremely important to hone your skills in reading, evaluating, and using nursing studies. We provide specific guidance to consumers in most chapters by including guidelines for critiquing aspects of a study covered in the chapter. The questions in Box 1.1 are designed to assist you in using the information in this chapter in an overall preliminary assessment of a research report.
BOX 1.1: Questions for a Preliminary Overview of a Research Report
· 1. How relevant is the research problem in this report to the actual practice of nursing? Does the study focus on a topic that is a priority area for nursing research?
· 2. Is the research quantitative or qualitative?
· 3. What is the underlying purpose (or purposes) of the study—identification, description, exploration, explanation, or prediction and control? Does the purpose correspond to an EBP focus such as treatment, diagnosis, prognosis, harm/etiology, or meaning?
· 4. Is this study fundamentally cause-probing?
· 5. What might be some clinical implications of this research? To what type of people and settings is the research most relevant? If the findings are accurate, how might I use the results of this study?
TIP: The Resource Manual that accompanies this book offers particularly rich opportunities to practice your critiquing skills. The Toolkit on thePoint with the Resource Manual includes Box 1.1 as a Word document, which will allow you to adapt these questions, if desired, and to answer them directly into a Word document without having to retype the questions.
· tudy: The effects of a community-based, culturally tailored diabetes prevention intervention for high-risk adults of Mexican descent (Vincent et al., 2014)
· Study Purpose: The purpose of the study was to evaluate the effectiveness of a 5-month nurse-coached diabetes prevention program (Un Estilo de Vida Saludable or EVS) for overweight Mexican American adults.
· Study Methods: A total of 58 Spanish-speaking adults of Mexican descent were recruited to participate in the study. Some of the participants, at random, were in a group that received the EVS intervention, while others in a control group did not receive it. The EVS intervention used content from a previously tested diabetes prevention program, but the researchers created a community-based, culturally tailored intervention for their population. The intervention, which was offered in community rooms of churches, consisted of an intensive phase of eight weekly 2-hour sessions, followed by a maintenance phase of 1-hour sessions for the final 3 months. Those in the group not receiving the intervention received educational sessions broadly aimed at health promotion in general. The researchers compared the two groups with regard to several important outcomes, such as weight loss, waist circumference, body mass index, and self-efficacy. Outcome information was gathered three times—at the outset of the study (prior to the intervention), 8 weeks later, and then after the program ended.
· Key Findings: The analysis suggested that those in the intervention group had several better outcomes, such as greater weight loss, smaller waist circumference, and lower body mass index, than those in the control group.
· Conclusions: Vincent and her colleagues (2014) concluded that implementing the culturally tailored program was feasible, was well-received among participants (e.g., high rates of program retention), and was effective in decreasing risk factors for type 2 diabetes.
Research Example of a Qualitative Study
· Study: Silent, invisible, and unacknowledged: Experiences of young caregivers of single parents diagnosed with multiple sclerosis (Bjorgvinsdottir & Halldorsdottir, 2014)
· Study Purpose: The purpose of this study was to study the personal experience of being a young caregiver of a chronically ill parent diagnosed with multiple sclerosis (MS).
· Study Methods: Young adults in Iceland whose parents were diagnosed with MS were recruited through the Icelandic National Multiple Sclerosis Society, and 11 agreed to be included in the study. Participants were interviewed in their own homes or in the home of the lead researcher, whichever they preferred. In-depth questioning was used to probe the experiences of the participants. The main interview question was: “Can you tell me about your personal experience being a young caregiver of a chronically ill parent with MS?” Several participants were interviewed twice to ensure rich and deep descriptions for a total of 21 interviews.
· Key Findings: The young caregivers felt that they were invisible and unacknowledged as caregivers and received limited support and assistance from professionals. Their responsibilities led to severe personal restrictions and they felt they had lived without a true childhood because they were left to manage adult-like responsibilities at a young age. Their role as caregiver was demanding and stressful, and they felt unsupported and abandoned.
· Conclusions: The researchers concluded that health professionals should be more vigilant about the needs for support and guidance for children and adolescents caring for chronically ill parents.
· Nursing research is systematic inquiry to develop knowledge about issues of importance to nurses. Nurses are adopting an evidence-based practice (EBP) that incorporates research findings into their clinical decisions.
· Nurses can participate in a range of research-related activities that span a continuum from being consumers of research (those who read and evaluate studies) and producers of research (those who design and undertake studies).
· Nursing research began with Florence Nightingale but developed slowly until its rapid acceleration in the 1950s. Since the 1970s, nursing research has focused on problems relating to clinical practice.