Week One Lecture on Nursing Research PDF

Chapter 1 Introduction to Nursing Research in an Evidence-Based Practice Environment What Is Nursing Research? Research – Systematic inquiry using disciplined methods to answer questions or solve problems Nursing research – Systematic inquiry to develop trustworthy evidence...

Chapter 1 Introduction to Nursing Research in an Evidence-Based Practice Environment What Is Nursing Research? Research – Systematic inquiry using disciplined methods to answer questions or solve problems Nursing research – Systematic inquiry to develop trustworthy evidence about issues of importance to nurses and their clients Clinical nursing research – Nursing research designed to guide nursing practice Copyright © 2019 Wolters Kluwer · All Rights Reserved The Importance of Research to Evidence- Based Nursing Evidence-based practice (EBP) – The use of the best clinical evidence in making patient care decisions – The basis for nursing decisions; influences many recent clinical practice changes – Produces decisions that are clinically appropriate, cost-effective, and result in positive client outcomes Copyright © 2019 Wolters Kluwer · All Rights Reserved  Evidence-Based Medicine (1990) E Evidence-BASED Systematically evaluate and use research evidence to make B decisions about the care of patients M E Evidence-Based Public Health (2004) Integrating science-based interventions with community B preferences to improve the health of populations P H Evidence-Informed Decision Making (~2005) Evidence-INFORMED EI Allows for additional forms for evidence – not all evidence has D to come from research M Evidence-Informed Public Health (~2007) EI National Collaborating Centre for Methods and Tools (NCCMT) P H Copyright © 2019 Wolters Kluwer · All Rights Reserved Evidence in EIPH Copyright © 2019 Wolters Kluwer · All Rights Reserved Typical Roles of Nurses in Research Contribute an idea for a clinical inquiry Assist in collecting research information Offer advice to clients about participating in a study Search for research evidence Discuss the implications of a study in a journal club in a practice setting; meeting to discuss research articles Copyright © 2019 Wolters Kluwer · All Rights Reserved Nursing Research: Past and Present 1850s: Pioneered by Florence Nightingale 1950s: First journal on research (Nursing Research) helped to propel nursing research 1980s: Clinical research increasingly important 1986: National Center for Nursing Research established at NIH 1993: National Institute of Nursing Research (NINR) established 2000s: NINR budget in 2016 just under $150 million Copyright © 2019 Wolters Kluwer · All Rights Reserved Future Directions for Nursing Research Continued focus on evidence-based practice Stronger evidence through confirmatory strategies Continued emphasis on systematic reviews Expanded local research in health care settings (e.g., Magnet schools) Expanded dissemination of research findings Increased focus on cultural issues and health disparities Clinical significance and patient input Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. Research findings increasingly must meet the test of being clinically significant, and medical practitioners have taken center stage in efforts to define clinical significance. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. False Rationale: 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 incorporating both research evidence and patient preferences into clinical decisions. Copyright © 2019 Wolters Kluwer · All Rights Reserved Sources of Evidence for Nursing Practice Tradition and authority Clinical experience and trial and error Assembled information – Benchmarking data and quality improvement and risk data Disciplined research: best method of acquiring reliable knowledge; evidence-based findings Copyright © 2019 Wolters Kluwer · All Rights Reserved Question What is the best method of acquiring reliable knowledge on which to base a clinical practice? a. Traditions and authority b. Clinical experience and trial and error c. Assembled information d. Disciplined research Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer d. Disciplined research Rationale: Disciplined research is considered the best method of acquiring reliable knowledge that humans have developed. Evidence-based health care compels nurses to base their clinical practice, to the extent possible, on rigorous research-based findings rather than on tradition, authority, or personal experience. However, nursing will always be a rich blend of art and science. Copyright © 2019 Wolters Kluwer · All Rights Reserved Paradigms and Methods for Nursing Research Paradigm – World view or general perspective of the world’s complexities Key paradigms for nursing research – Positivist paradigm – Constructivist paradigm Copyright © 2019 Wolters Kluwer · All Rights Reserved Positive Versus Constructivist Paradigms Positive – Reality exists; real world driven by natural causes – Researcher is independent from those researched. – Values and biases are to be held in check. Constructivist – Reality is multiple and subjective. – Researcher interacts with those being researched. – Subjectivity and values are inevitable and desirable. Copyright © 2019 Wolters Kluwer · All Rights Reserved Question What is a major assumption of the constructivist paradigm world view? a. Reality is mentally constructed by individuals. b. The researcher is independent from those researched. c. Values and biases are held in check. d. Subjectivity is not desirable. Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer a. Reality is mentally constructed by individuals Rationale: In the constructivist paradigm, reality is multiple and subjective and mentally constructed by individuals. The researcher is independent from those researched, values and biases are held in check, and subjectivity is not desirable in the positivist paradigm. Copyright © 2019 Wolters Kluwer · All Rights Reserved Research Methods The techniques used to structure a study and to gather, analyze, and interpret information – Quantitative research: most closely allied with the positivist tradition – Qualitative research: associated with the constructivist tradition Positivists sometimes undertake qualitative studies, and constructivist researchers sometimes collect quantitative information. Copyright © 2019 Wolters Kluwer · All Rights Reserved Quantitative and Qualitative Research Quantitative Qualitative Orderly procedures Dynamic design Systematic/prespecified plan Holistic Control over context Context-bound Formal measurement Humans as instruments Empirical evidence Qualitative information Seeks generalizations Seeks patterns Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. Quantitative research is allied with the constructivist tradition. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. False Rationale: Qualitative research is associated with constructivist tradition that involves a dynamic design and holism and is context-bound. Copyright © 2019 Wolters Kluwer · All Rights Reserved Common Features in Both Paradigms Ultimate goals External evidence Reliance on human cooperation Ethical constraints Fallibility Copyright © 2019 Wolters Kluwer · All Rights Reserved Purposes of Nursing Research Identification and description Exploration Explanation Prediction and control Therapy, treatment, or intervention Diagnosis and assessment Copyright © 2019 Wolters Kluwer · All Rights Reserved Copyright © 2019 Wolters Kluwer · All Rights Reserved Purposes of Nursing Research—(cont.) Prognosis Etiology (causation) and harm Meaning and process Copyright © 2019 Wolters Kluwer · All Rights Reserved Research to Achieve Varying Levels of Explanation Identification and description Exploration Explanation Prediction and control Copyright © 2019 Wolters Kluwer · All Rights Reserved Research Purposes Linked to EBP Therapy, treatment, or intervention Diagnosis and assessment Prognosis Etiology and harm Meaning and processes Copyright © 2019 Wolters Kluwer · All Rights Reserved Specific Purposes of Nursing Research Quantitative Qualitative Identification X Description X X Exploration X X Prediction and control X Explanation X X Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. Quantitative research attempts to identify a phenomenon. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. False Rationale: Qualitative research, not quantitative research, is used to identify a phenomenon. Copyright © 2019 Wolters Kluwer · All Rights Reserved EVIDENCE BASED NURSING Copyright © 2019 Wolters Kluwer · All Rights Reserved Evidence-Based Practice Evidence-based decision making should integrate best research evidence with clinical expertise, patient preferences, and local circumstances. A key ingredient in EBP is the effort to personalize “best evidence” to a specific patient’s needs within a particular clinical context. The emphasis is on identifying the best available research evidence and integrating it with other factors in making clinical decisions. Copyright © 2019 Wolters Kluwer · All Rights Reserved Research Utilization Using findings from studies in a practical application that is unrelated to the original research Translating new knowledge into real-world applications Reducing the gap between research and practice Copyright © 2019 Wolters Kluwer · All Rights Reserved History of RU in Nursing Practice Studies identified knowledge–practice gaps (e.g., Ketefian, 1975). RU projects sought to address the gap (1970s and 1980s): – For example, the Conduct and Utilization of Research in Nursing (CURN) Project RU efforts began to be superseded by call for EBP during 1990s. Copyright © 2019 Wolters Kluwer · All Rights Reserved Overview of the EBP Movement Archie Cochrane – Called for efforts to make research summaries about interventions available to health care providers – Efforts led to the development of Cochrane Center in Oxford and the Cochrane Collaboration. David Sackett – Developed a learning strategy called evidence- based medicine, which has broadened to the use of best evidence by all health care practitioners Copyright © 2019 Wolters Kluwer · All Rights Reserved Evidence Hierarchies Involve ranking evidence sources according to the strength of evidence they provide Ranking may depend on the type of question being asked. Within any level, evidence quality can vary considerably. Systematic reviews are at the pinnacle of the hierarchy. Copyright © 2019 Wolters Kluwer · All Rights Reserved Example of an Evidence Hierarchy Copyright © 2019 Wolters Kluwer · All Rights Reserved Best Evidence Refers to research findings that are methodologically appropriate, rigorous, and clinically relevant for answering pressing questions – These questions cover the efficacy, safety, and cost effectiveness of nursing interventions. – They also cover the reliability of nursing assessment tests, the causes and consequences of health problems, and the meaning and nature of patients’ experiences. Copyright © 2019 Wolters Kluwer · All Rights Reserved EBP Barriers Quality and nature of the research – For example, scarcity of strong research evidence Characteristics of nurses – For example, inadequate skills in locating and appraising evidence Organizational factors – For example, lack of financial support and staff release time for EBP Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. The strongest level of evidence is obtained from individual correlational studies. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. False Rationale: The strongest level of evidence is obtained from systematic reviews of randomized clinical trials (RCTs). Copyright © 2019 Wolters Kluwer · All Rights Reserved Resources for EBP Pre-appraised evidence: has been selected from primary studies and evaluated for use by clinicians – Systematic reviews: integrate evidence about a topic in a rigorous, systematic way Meta-analysis: technique for integrating quantitative research findings statistically Metasynthesis: less about reducing information and more about interpreting it – Clinical practice guidelines and care bundles: give specific recommendations for evidence-based decision making Copyright © 2019 Wolters Kluwer · All Rights Reserved Question A technique for integrating quantitative research findings statistically is known as: a. Metasynthesis b. Meta-analysis c. Care bundling d. PICO Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. Meta-analysis Rationale: Meta-analysis is a technique for integrating quantitative research findings statistically, which treats the findings from a study as one piece of information. The findings from multiple studies on the same topic are combined, and all of the information is analyzed statistically in a manner similar to that in a usual study. Metasynthesis is less about reducing information and more about interpreting it. Care bundling encompasses a set of interventions to treat or prevent a specific cluster of symptoms. PICO is a method to help practitioners develop well-worded questions that facilitate a search for evidence. Copyright © 2019 Wolters Kluwer · All Rights Reserved Clinical Practice Guidelines There is no single guideline repository. When multiple guidelines exist, the clinician must identify ones based on strongest evidence. Appraisal of Guidelines Research and Evaluation (AGREE) has ratings for 23 dimensions within six domains (e.g., scope and purpose, rigor of development, presentation). Copyright © 2019 Wolters Kluwer · All Rights Reserved Models for Evidence-Based Nursing Practice Dozens of models exist. Some referenced models: – The Stetler Model of research utilization to promote evidence-based practice – The Iowa Model of evidence-based practice to promote quality care – Rogers’ Diffusion of Innovations Theory Copyright © 2019 Wolters Kluwer · All Rights Reserved Copyright © 2019 Wolters Kluwer · All Rights Reserved Steps in EBP 1. Asking clinical questions that can be answered with research evidence 2. Searching for and retrieving relevant evidence 3. Appraising and synthesizing the evidence 4. Integrating the evidence with your own clinical expertise, patient preferences, and local context 5. Assessing the effectiveness of the decision, intervention, or advice Copyright © 2019 Wolters Kluwer · All Rights Reserved Question A clinician is using EBP efforts to research new methods of preventing HAP from occurring in an intensive care unit. What would be the next appropriate step to take after appraising and synthesizing the evidence? a. Ask clinical questions based on research evidence. b. Search for and retrieve relevant evidence. c. Integrate the evidence into own practice. d. Assess the effectiveness of the decision. Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer c. Integrate the evidence into own practice. Rationale: After appraising and synthesizing the evidence, the clinician would integrate the evidence with his or her own clinical expertise, patient preferences, and local context, and then assess the effectiveness of the decision, intervention, or advice. Answers a and b are steps 1 and 2 of the EBP process. Copyright © 2019 Wolters Kluwer · All Rights Reserved Asking Clinical Questions: PIO Population or patients: What are the characteristics of the patients or people? Intervention (influence or exposure): What are the interventions or therapies of interest? or What are the potentially harmful influences/exposures of concern? Outcome: What are the outcomes or consequences in which we are interested? May add time frame (T), comparison (C), or setting (S) to PIO Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Templates Templates can greatly facilitate wording of questions, for example, an intervention question: In _____ (population), what is the effect of ________ (intervention), in comparison to _______ (comparison), on __________(outcome)? Copyright © 2019 Wolters Kluwer · All Rights Reserved Appraising the Evidence for EBP What is the quality of the evidence? What is the magnitude of effects? How precise are estimates of effects? Is there evidence of side effects? What are the financial costs of applying the evidence? Is there relevance to my clinical situation? Copyright © 2019 Wolters Kluwer · All Rights Reserved Integrating Evidence in EBP Research evidence needs to be integrated with: – Your own clinical expertise and knowledge of clinical setting – Patient preferences and values – Evidence from qualitative research Copyright © 2019 Wolters Kluwer · All Rights Reserved EBP in an Organizational Context Select a problem. – Knowledge-focused triggers Begins with an innovation or research finding (e.g., might emerge in a journal club) – Problem-focused triggers Begins with a perplexing or troubling clinical situation Copyright © 2019 Wolters Kluwer · All Rights Reserved EBP in an Organizational Context—(cont.) Appraise implementation potential. – Transferability – Feasibility – Cost–benefit ratio Base actions on evidence appraisals. Implement and evaluate the innovation. Copyright © 2019 Wolters Kluwer · All Rights Reserved Implementing and Evaluating Innovation Developing an evaluation plan Measuring client outcomes prior to implementing the innovation so that there is a comparison against which the outcomes of the innovation can be assessed Training relevant staff in the use of the new guideline and, if necessary, “marketing” the innovation to users Trying the guideline out on one or more units or with a group of clients Evaluating the pilot project in terms of both process and outcomes Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. Clinical practice guidelines put evidence into a usable form. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer a. True Rationale: Clinical practice guidelines give specific recommendations for evidence-based decision making, putting evidence into a usable form for implementation. Copyright © 2019 Wolters Kluwer · All Rights Reserved QUALITATIVE AND QUANTITATIVE RESEARCH KEY CONCEPTS Copyright © 2019 Wolters Kluwer · All Rights Reserved Selected Key Research Terms Copyright © 2019 Wolters Kluwer · All Rights Reserved Faces and Places of Research Study subject or participant: people being studied or cooperating in study Study site: the overall location for a study (e.g., Portland) – Multisite studies: tend to yield more diverse group of study participants, potentially enhancing generalizability of findings Copyright © 2019 Wolters Kluwer · All Rights Reserved Question A nurse researcher is conducting a quantitative study to determine protocols for triaging patients in the emergency department. Which term is generally associated with this type of research? a. Phenomena b. Subject c. Pattern of association d. Inductive reasoning Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. Subject Rationale. The person contributing information in a quantitative study is called the subject. In the qualitative study, this person is called the study participant, informant, or key informant. That which is investigated is called a concept in quantitative studies and concept or phenomena in qualitative studies. Pattern of association and inductive reasoning are qualitative terms. Relationships and deductive reasoning are quantitative terms. Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. Researchers involved in quantitative research commonly engage in fieldwork. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. False Rationale: Researchers engage in fieldwork when performing qualitative studies. Copyright © 2019 Wolters Kluwer · All Rights Reserved Concepts and Constructs Concepts: abstractions of particular aspects of human behavior or characteristics (e.g., pain, weight) Constructs: slightly more complex abstractions (e.g., self-care) – For example, self-care in Orem’s model of health maintenance is a construct. Theories: knit concepts into a coherent system that purports to explain phenomena Copyright © 2019 Wolters Kluwer · All Rights Reserved Variable A characteristic or quality that takes on different values, that is, that varies from one person to the next Examples – Blood type – Weight – Length of stay in hospital The term “variable” is used almost exclusively in quantitative research. Copyright © 2019 Wolters Kluwer · All Rights Reserved Types of Variables Independent variable—the presumed cause (of a dependent variable) Dependent variable—the presumed effect (of an independent variable) – Often referred to as the outcome variable or outcome: Example: smoking (IV)  lung cancer (DV) – IV and DV terms can be used to indicate direction of influence rather than cause and effect. Copyright © 2019 Wolters Kluwer · All Rights Reserved Conceptual and Operational Definition Conceptual: the abstract or theoretical meaning of a concept being studied Operational: the operations (measurements) a researcher must perform to measure the concept and collect the desired information Copyright © 2019 Wolters Kluwer · All Rights Reserved Question What is the best description of a dependent variable? a. Outcome being measured b. A person’s gender c. Presumed cause d. Measurements performed Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer a. Outcome being measured Rationale: The dependent variable is the presumed effect or outcome of an independent variable (the presumed cause). Gender typically is a categorical variable. The operations (measurements) to be performed for data collection refer to the operational definition of a variable. Copyright © 2019 Wolters Kluwer · All Rights Reserved Data Data (singular = datum): the pieces of information researchers collect in a study – Quantitative researchers collect numeric (quantitative) data. – Qualitative researchers collect narrative (verbal) data. Copyright © 2019 Wolters Kluwer · All Rights Reserved Example of Quantitative Data Question: Thinking about the past week, how depressed would you say you have been on a scale from 0 to 10, where 0 means “not at all” and 10 means “the most possible”? Data: 9 (subject 1) 0 (subject 2) 4 (subject 3) Copyright © 2019 Wolters Kluwer · All Rights Reserved Example of Qualitative Data Question: Tell me about how you’ve been feeling lately— have you felt sad or depressed at all, or have you generally been in good spirits? Data: Well, actually, I’ve been pretty depressed lately. I wake up each morning and I can’t seem to think of anything to look forward to. I just can’t seem to shake the blues. Copyright © 2019 Wolters Kluwer · All Rights Reserved Relationships A relationship is a bond or connection between variables. – Cause-and-effect (causal) relationship (e.g., cigarette smoking and lung cancer) – Associative (functional) relationship (e.g., gender and life expectancy) – Qualitative study of pattern: Qualitative researchers may seek patterns of association as a way of illuminating the underlying meaning and dimensionality of phenomena of interest. Copyright © 2019 Wolters Kluwer · All Rights Reserved Major Classes of Quantitative Research Experimental research – Researchers actively introduce an intervention or treatment most often to address therapy questions. – Called clinical trials in medical research Nonexperimental research – Researchers collect data without intervening or introducing treatments. – Called observational studies in medical research Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Tell whether the following statement is True or False. Clinical trials are an example of observational research in medicine. a. True b. False Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer b. False Rationale: Clinical trials are a form of experimental research in medicine. Observational research is nonexperimental research in medicine. Copyright © 2019 Wolters Kluwer · All Rights Reserved Qualitative Research: Disciplinary Traditions Grounded theory research – Seeks to understand key social psychological processes Phenomenological research – Focuses on the lived experiences of humans Ethnographic research – Focuses on the patterns and lifeways of a cultural group Copyright © 2019 Wolters Kluwer · All Rights Reserved Question What is an example of a question that researchers ask when using phenomenology during qualitative research? a. What is the meaning of the phenomenon experienced by the people? b. What are the psychological phases that characterize a particular event? c. What are the patterns and lifeways of a defined cultural group? d. What is the core variable that explains what is happening in the social scene? Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer a. What is the meaning of the phenomenon experienced by the people? Rationale: The phenomenological researcher asks the questions What is the essence of this phenomenon as experienced by these people? or What is the meaning of the phenomenon to those who experience it? The focus of most grounded theory studies is on a developing social experience—the social and psychological phases that characterize a particular event or episode. Ethnography provides a framework for studying the patterns and lifeways of a defined cultural group in a holistic fashion. Copyright © 2019 Wolters Kluwer · All Rights Reserved Phases in a Quantitative Study Phase 1: Conceptual Phase Phase 2: Design and Planning Phase Phase 3: Empirical Phase Phase 4: Analytic Phase Phase 5: Dissemination Phase Copyright © 2019 Wolters Kluwer · All Rights Reserved Major Steps in a Quantitative Study: Phase 1: Conceptual Phase Step 1: Formulating/delimiting the problem Step 2: Reviewing related literature Step 3: Undertaking clinical fieldwork Step 4: Defining the framework and developing conceptual definitions Step 5: Formulating hypotheses Copyright © 2019 Wolters Kluwer · All Rights Reserved Major Steps in a Quantitative Study: Phase 2: Design and Planning Phase Step 6: Selecting a research design Step 7: Developing intervention protocols Step 8: Identifying the population Step 9: Designing the sampling plan Step 10: Specifying methods to measure variables and collect data Step 11: Developing methods to protect human/animal rights Step 12: Reviewing and finalizing the research plan Copyright © 2019 Wolters Kluwer · All Rights Reserved Major Steps in a Quantitative Study: Phase 3: Empirical Phase Step 13: Collecting the data Step 14: Preparing data for analysis (e.g., coding the data) Copyright © 2019 Wolters Kluwer · All Rights Reserved Major Steps in a Quantitative Study: Phase 4: Analytic Phase Step 15: Analyzing the data (through statistical analysis) Step 16: Interpreting results Copyright © 2019 Wolters Kluwer · All Rights Reserved Major Steps in a Quantitative Study: Phase 5: Dissemination Phase Step 17: Communicating the findings in a research report (e.g., in a journal article) Step 18: Putting the evidence into practice Copyright © 2019 Wolters Kluwer · All Rights Reserved Question Which action would be performed first when designing and planning a quantitative study? a. Developing intervention protocols b. Identifying the population c. Designing the sampling plan d. Formulating a research design Copyright © 2019 Wolters Kluwer · All Rights Reserved Answer d. Formulating a research design Rationale: The first step in designing and planning a quantitative study is formulating a research design. This is followed by developing intervention protocols, identifying the population, and designing the sampling plan. Copyright © 2019 Wolters Kluwer · All Rights Reserved Activities in a Qualitative Study Conceptualizing and planning the study Conducting the study Copyright © 2019 Wolters Kluwer · All Rights Reserved Activities in a Qualitative Study—(cont.) Conceptualizing and planning the study – Identifying the research problem – Doing a literature review – Selecting sites and gaining entrée – Developing an overall approach – Addressing ethical issues Copyright © 2019 Wolters Kluwer · All Rights Reserved Activities in a Qualitative Study—(cont.) Conducting the study: undertaking iterative activities through emergent design – Making sampling decisions – Deciding what questions to ask – Collecting data – Evaluating integrity and quality – Analyzing and interpreting data – Making new decisions Copyright © 2019 Wolters Kluwer · All Rights Reserved