Nursing Research Generating and Assessing Evidence for Nursing Practice PDF

2 Quick Guide to Bivariate Statistical Tests 3 4 Acquisitions Editor: Christina Burns Product Development Editor: Katherine Burland Editorial Assistant: Cassie Berube Marketing Manager: Dean Karampelas Production Project Manager: Cynthia Rudy Design Coordinator: Joan Wendt M...

2 Quick Guide to Bivariate Statistical Tests 3 4 Acquisitions Editor: Christina Burns Product Development Editor: Katherine Burland Editorial Assistant: Cassie Berube Marketing Manager: Dean Karampelas Production Project Manager: Cynthia Rudy Design Coordinator: Joan Wendt Manufacturing Coordinator: Karin Duffield Prepress Vendor: Absolute Service, Inc. Tenth edition Copyright © 2017 Wolters Kluwer. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2008, 2004, 1999 by Lippincott Williams & Wilkins. Copyright © 1995, 1991, 1987, 1983, 1978 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Polit, Denise F., author. Nursing research : generating and assessing evidence for nursing practice / Denise F. Polit, Cheryl Tatano Beck. — Tenth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4963-0023-2 I. Beck, Cheryl Tatano, author. II. Title. [DNLM: 1. Nursing Research—methods. WY 20.5] RT81.5 610.73072—dc23 2015033543 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based on healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings, and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of 5 products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com 6  TO Our Beloved Family: Our Husbands, Our Children (Spouses/Fiancés), and Our Grandchildren Husbands: Alan Janosy and Chuck Beck Children: Alex (Maryanna), Alaine (Jeff), Lauren (Vadim), and Norah (Chris); and Curt and Lisa Grandchildren: Cormac, Julia, Maren, and Ronan 7 Acknowledgments This 10th edition, like the previous nine editions, depended on the contribution of dozens of people. Many faculty and students who used the text have made invaluable suggestions for its improvement, and to all of you we are very grateful. In addition to all those who assisted us during the past 35 years with the earlier editions, the following individuals deserve special mention. We would like to acknowledge the comments of reviewers of the previous edition of this book, anonymous to us initially, whose feedback influenced our revisions. Faculty at Griffith University in Australia made useful suggestions and also inspired the inclusion of some new content. Valori Banfi, reference librarian at the University of Connecticut, provided ongoing assistance. Dr. Deborah Dillon McDonald was extraordinarily generous in giving us access to her NINR grant application and related material for the Resource Manual. We also extend our thanks to those who helped to turn the manuscript into a finished product. The staff at Wolters Kluwer has been of great assistance to us over the years. We are indebted to Christina Burns, Kate Burland, Cynthia Rudy, and all the others behind the scenes for their fine contributions. Finally, we thank our family and friends. Our husbands Alan and Chuck have become accustomed to our demanding schedules, but we recognize that their support involves a lot of patience and many sacrifices. 8 Reviewers Ellise D. Adams, PhD, CNM Associate Professor The University of Alabama in Huntsville Huntsville, Alabama Jennifer Bellot, PhD, RN, MHSA Associate Professor and Director, DNP Program Thomas Jefferson University Philadelphia, Pennsylvania Kathleen D. Black, PhD, RNC Assistant Professor, Jefferson College of Nursing Thomas Jefferson University Philadelphia, Pennsylvania Dee Campbell, PhD, APRN, NE-BC, CNL Professor, Graduate Department Felician College, School of Nursing Lodi, New Jersey Patricia Cannistraci, DNS, RN, CNE Assistant Dean Excelsior College Albany, New York Julie L. Daniels, DNP, CNM Assistant Professor Frontier Nursing University Hyden, Kentucky Rebecca Fountain, PhD, RN Associate Professor University of Texas at Tyler Tyler, Texas 9 Teresa S. Johnson, PhD, RN Associate Professor, College of Nursing University of Wisconsin—Milwaukee Milwaukee, Wisconsin Jacqueline Jones, PhD, RN, FAAN Associate Professor, College of Nursing University of Colorado, Anschutz Medical Campus Aurora, Colorado Mary Lopez, PhD, RN Associate Dean, Research Western University of Health Sciences Pomona, California Audra Malone, DNP, FNP-BC Assistant Professor Frontier Nursing University Hyden, Kentucky Sharon R. Rainer, PhD, CRNP Assistant Professor, Jefferson College of Nursing Thomas Jefferson University Philadelphia, Pennsylvania Maria A. Revell, PhD, RN Professor of Nursing Middle Tennessee State University Murfreesboro, Tennessee Stephanie Vaughn, PhD, RN, CRRN Interim Director, School of Nursing California State University, Fullerton Fullerton, California 10 Preface Research methodology is not a static enterprise. Even after writing nine editions of this book, we continue to draw inspiration and new material from groundbreaking advances in research methods and in nurse researchers’ use of those methods. It is exciting and uplifting to share many of those advances in this new edition. We expect that many of the new methodologic and technologic advances will be translated into powerful evidence for nursing practice. Five years ago, we considered the ninth edition as a watershed edition of a classic textbook. We are persuaded, however, that this 10th edition is even better. We have retained many features that made this book a classic textbook and resource, including its focus on research as a support for evidence-based nursing, but have introduced important innovations that will help to shape the future of nursing research. N E W TO T HI S E D I T I ON New Chapters We have added two new chapters on “cutting-edge” topics that are not well covered in any major research methods textbook, regardless of discipline. The first is a chapter on an issue of critical importance to health professionals and yet inadequately addressed in the nursing literature: the clinical significance of research findings. In Chapter 20, we discuss various conceptualizations of clinical significance and present methods of operationalizing those conceptualizations so that clinical significance can be assessed at both the individual and group level. We believe that this is a “must-read” chapter for nurses whose research is designed to inform clinical practice. The second new chapter in this edition concerns the design and conduct of pilot studies. In recent years, experts have written at length about the poor quality of many pilot studies. Chapter 28 provides guidance on how to develop pilot study objectives and draw conclusions about the appropriate next step—that is, whether to proceed to a full-scale study, make major revisions, or abandon the project. This chapter is included in Part 5 of this book, which is devoted to mixed methods research, because pilots can benefit from both qualitative and quantitative evidence. New Content Throughout the book, we have included material on methodologic innovations that have 11 arisen in nursing, medicine, and the social sciences during the past 4 to 5 years. The many additions and changes are too numerous to describe here, but a few deserve special mention. In particular, we have totally revised the chapters on measurement (Chapter 14) and scale development (Chapter 15) to reflect emerging ideas about key measurement properties and the assessment of newly developed instruments. The inclusion of two new chapters made it challenging to keep the textbook to a manageable length. Our solution was to move some content in the ninth edition to supplements that are available online. In fact, every chapter has an online supplement, which gave us the opportunity to add a considerable amount of new content. For example, one supplement is devoted to evidence-based methods to recruit and retain study participants. Other supplements include a description of various randomization methods, an overview of item response theory, guidance on wording proposals to conduct pilot studies, and a discussion of quality improvement studies. Following is a complete list of the supplements for the 31 chapters of this textbook: 1. The History of Nursing Research 2. Evaluating Clinical Practice Guidelines—AGREE II 3. Deductive and Inductive Reasoning 4. Complex Relationships and Hypotheses 5. Literature Review Matrices 6. Prominent Conceptual Models of Nursing Used by Nurse Researchers, and a Guide to Middle-Range Theories 7. Historical Background on Unethical Research Conduct 8. Research Control 9. Randomization Strategies 10. The RE-AIM Framework 11. Other Specific Types of Research 12. Sample Recruitment and Retention 13. Other Types of Structured Self-Reports 14. Cross-Cultural Validity and the Adaptation/Translation of Measures 15. Overview of Item Response Theory 16. SPSS Analysis of Descriptive Statistics 17. SPSS Analysis of Inferential Statistics 18. SPSS Analysis and Multivariate Statistics 19. Some Preliminary Steps in Quantitative Analysis Using SPSS 20. Clinical Significance Assessment with the Jacobson-Truax Approach 21. Historical Nursing Research 22. Generalizability and Qualitative Research 23. Additional Types of Unstructured Self-Reports 24. Transcribing Qualitative Data 25. Whittemore and Colleagues’ Framework of Quality Criteria in Qualitative Research 26. Converting Quantitative and Qualitative Data 12 27. Complex Intervention Development: Exploratory Questions 28. Examples of Various Pilot Study Objectives 29. Publication Bias in Meta-Analyses 30. Tips for Publishing Reports on Pilot Intervention Studies 31. Proposals for Pilot Intervention Studies Another new feature of this edition concerns our interest in readers’ access to references we cited. To the extent possible, the studies we have chosen as examples of particular research methods are published as open-access articles. These studies are identified with an asterisk in the reference list at the end of each chapter, and a link to the article is included in the Toolkit section of the Resource Manual. We hope that these revisions will help users of this book to maximize their learning experience. OR GA N I Z AT I ON OF T HE T E X T The content of this edition is organized into six main parts. Part I—Foundations of Nursing Research and Evidence-Based Practice introduces fundamental concepts in nursing research. Chapter 1 briefly summarizes the history and future of nursing research, discusses the philosophical underpinnings of qualitative research versus quantitative research, and describes major purposes of nursing research. Chapter 2 offers guidance on utilizing research to build an evidence-based practice. Chapter 3 introduces readers to key research terms and presents an overview of steps in the research process for both qualitative and quantitative studies. Part II—Conceptualizing and Planning a Study to Generate Evidence further sets the stage for learning about the research process by discussing issues relating to a study’s conceptualization: the formulation of research questions and hypotheses (Chapter 4), the review of relevant research (Chapter 5), the development of theoretical and conceptual contexts (Chapter 6), and the fostering of ethically sound approaches in doing research (Chapter 7). Chapter 8 provides an overview of important issues that researchers must attend to during the planning of any type of study. Part III—Designing and Conducting Quantitative Studies to Generate Evidence presents material on undertaking quantitative nursing studies. Chapter 9 describes fundamental principles and applications of quantitative research design, and Chapter 10 focuses on methods to enhance the rigor of a quantitative study, including mechanisms of research control. Chapter 11 examines research with different and distinct purposes, including surveys, outcomes research, and evaluations. Chapter 12 presents strategies for sampling study participants in quantitative research. Chapter 13 describes using structured data collection methods that yield quantitative information. Chapter 14 discusses the concept of measurement and then focuses on methods of assessing the quality of formal measuring instruments. In this edition, we describe methods to assess the properties of point-in-time measurements (reliability 13  and validity) and longitudinal measurements—change scores (reliability of change scores and responsiveness). Chapter 15 presents material on how to develop high- quality self-report instruments. Chapters 16, 17, and 18 present an overview of univariate, bivariate, and multivariate statistical analyses, respectively. Chapter 19 describes the development of an overall analytic strategy for quantitative studies, including material on handling missing data. Chapter 20, a new chapter, discusses the issue of interpreting results and making inferences about clinical significance. Part IV—Designing and Conducting Qualitative Studies to Generate Evidence presents material on undertaking qualitative nursing studies. Chapter 21 is devoted to research designs and approaches for qualitative studies, including material on critical theory, feminist, and participatory action research. Chapter 22 discusses strategies for sampling study participants in qualitative inquiries. Chapter 23 describes methods of gathering unstructured self-report and observational data for qualitative studies. Chapter 24 discusses methods of analyzing qualitative data, with specific information on grounded theory, phenomenologic, and ethnographic analyses. Chapter 25 elaborates on methods qualitative researchers can use to enhance (and assess) integrity and quality throughout their inquiries. Part V—Designing and Conducting Mixed Methods Studies to Generate Evidence presents material on mixed methods nursing studies. Chapter 26 discusses a broad range of issues, including asking mixed methods questions, designing a study to address the questions, sampling participants in mixed methods research, and analyzing and integrating qualitative and quantitative data. Chapter 27 presents innovative information about using mixed methods approaches in the development of nursing interventions. In Chapter 28, a new chapter, we provide guidance for designing and conducting a pilot study and using data from the pilot to draw conclusions about how best to proceed. Part VI—Building an Evidence Base for Nursing Practice provides additional guidance on linking research and clinical practice. Chapter 29 offers an overview of methods of conducting systematic reviews that support EBP, with an emphasis on meta-analyses, metasyntheses, and mixed studies reviews. Chapter 30 discusses dissemination of evidence—how to prepare a research report (including theses and dissertations) and how to publish research findings. The concluding chapter (Chapter 31) offers suggestions and guidelines on developing research proposals and getting financial support and includes information about applying for NIH grants and interpreting scores from NIH’s new scoring system. KE Y FE AT U R E S This textbook was designed to be helpful to those who are learning how to do research as well as to those who are learning to appraise research reports critically and to use research findings in practice. Many of the features successfully used in previous editions have been retained in this 10th edition. Among the basic principles that helped to shape this and earlier editions of this book are (1) an unswerving conviction that the 14 development of research skills is critical to the nursing profession, (2) a fundamental belief that research is intellectually and professionally rewarding, and (3) a steadfast opinion that learning about research methods need be neither intimidating nor dull. Consistent with these principles, we have tried to present the fundamentals of research methods in a way that both facilitates understanding and arouses curiosity and interest. Key features of our approach include the following: Research Examples. Each chapter concludes with one or two actual research examples designed to highlight critical points made in the chapter and to sharpen the reader’s critical thinking skills. In addition, many research examples are used to illustrate key points in the text and to stimulate ideas for a study. Many of the examples used in this edition are open-access articles that can be used for further learning and classroom discussions. Critiquing Guidelines. Most chapters include guidelines for conducting a critique of each aspect of a research report. These guidelines provide a list of questions that draw attention to specific aspects of a report that are amenable to appraisal. Clear, “user-friendly” style. Our writing style is designed to be easily digestible and nonintimidating. Concepts are introduced carefully and systematically, difficult ideas are presented clearly, and readers are assumed to have no prior exposure to technical terms. Specific practical tips on doing research. This textbook is filled with practical guidance on how to translate the abstract notions of research methods into realistic strategies for conducting research. Every chapter includes several tips for applying the chapter’s lessons to real-life situations. These suggestions are in recognition of the fact that there is often a large gap between what gets taught in research methods textbooks and what a researcher needs to know to conduct a study. Aids to student learning. Several features are used to enhance and reinforce learning and to help focus the student’s attention on specific areas of text content, including the following: succinct, bulleted summaries at the end of each chapter; tables and figures that provide examples and graphic materials in support of the text discussion; study suggestions at the end of each chapter; a detailed glossary; and a comprehensive index for accessing information quickly. T E A C HI N G– L E A R N I N G PA C KA GE Nursing Research: Generating and Assessing Evidence for Nursing Practice, 10th edition, has an ancillary package designed with both students and instructors in mind. The Resource Manual augments the textbook in important ways. The manual itself provides students with exercises that correspond to each text chapter, with a focus on opportunities to critique actual studies. The appendix includes 12 research journal articles in their entirety, plus a successful grant application for a study funded by the National Institute of Nursing Research. The 12 reports cover a range of nursing research ventures, including qualitative, quantitative, and mixed methods studies, an 15  instrument development study, an evidence-based practice translation project, and two systematic reviews. Full critiques of two of the reports are also included and can serve as models for a comprehensive research critique. The Toolkit to the Resource Manual is a “must-have” innovation that will save considerable time for both students and seasoned researchers. Included on thePoint, the Toolkit offers dozens of research resources in Word documents that can be downloaded and used directly or adapted. The resources reflect best-practice research material, most of which have been pretested and refined in our own research. The Toolkit originated with our realization that in our technologically advanced environment, it is possible to not only illustrate methodologic tools as graphics in the textbook but also to make them directly available for use and adaptation. Thus, we have included dozens of documents in Word files that can readily be used in research projects, without requiring researchers to “reinvent the wheel” or tediously retype material from this textbook. Examples include informed consent forms, a demographic questionnaire, content validity forms, and a coding sheet for a meta- analysis—to name only a few. The Toolkit also has lists of relevant and useful websites for each chapter, which can be “clicked” on directly without having to retype the URL and risk a typographical error. Links to open-access articles cited in the textbook, as well as other open-access articles relevant to each chapter, are included in the Toolkit. The Instructor’s Resources on the Point include PowerPoint slides summarizing key points in each chapter, test questions that have been placed into a program that allows instructors to automatically generate a test, and an image bank. It is our hope that the content, style, and organization of this book continue to meet the needs of a broad spectrum of nursing students and nurse researchers. We also hope that this book will help to foster enthusiasm for the kinds of discoveries that research can produce and for the knowledge that will help support an evidence-based nursing practice. DENISE F. POLIT, PhD, FAAN 16 CHERYL TATANO BECK, DNSc, CNM, FAAN 17 Contents PART 1: FOUNDATIONS OF NURSING RESEARCH Chapter 1: Introduction to Nursing Research in an Evidence-Based Practice Environment Chapter 2: Evidence-Based Nursing: Translating Research Evidence into Practice Chapter 3: Key Concepts and Steps in Qualitative and Quantitative Research PART 2: CONCEPTUALIZING AND PLANNING A STUDY TO GENERATE EVIDENCE FOR NURSING Chapter 4: Research Problems, Research Questions, and Hypotheses Chapter 5: Literature Reviews: Finding and Critiquing Evidence Chapter 6: Theoretical Frameworks Chapter 7: Ethics in Nursing Research Chapter 8: Planning a Nursing Study PART 3: DESIGNING AND CONDUCTING QUANTITATIVE STUDIES TO GENERATE EVIDENCE FOR NURSING Chapter 9: Quantitative Research Design Chapter 10: Rigor and Validity in Quantitative Research Chapter 11: Specific Types of Quantitative Research Chapter 12: Sampling in Quantitative Research Chapter 13: Data Collection in Quantitative Research Chapter 14: Measurement and Data Quality Chapter 15: Developing and Testing Self-Report Scales Chapter 16: Descriptive Statistics Chapter 17: Inferential Statistics Chapter 18: Multivariate Statistics Chapter 19: Processes of Quantitative Data Analysis Chapter 20: Clinical Significance and Interpretation of Quantitative Results PART 4: DESIGNING AND CONDUCTING QUALITATIVE STUDIES TO GENERATE EVIDENCE FOR NURSING Chapter 21: Qualitative Research Design and Approaches Chapter 22: Sampling in Qualitative Research 18 Chapter 23: Data Collection in Qualitative Research Chapter 24: Qualitative Data Analysis Chapter 25: Trustworthiness and Integrity in Qualitative Research PART 5: DESIGNING AND CONDUCTING MIXED METHODS STUDIES TO GENERATE EVIDENCE FOR NURSING Chapter 26: Basics of Mixed Methods Research Chapter 27: Developing Complex Nursing Interventions Using Mixed Methods Research Chapter 28: Feasibility Assessments and Pilot Tests of Interventions Using Mixed Methods PART 6: BUILDING AN EVIDENCE BASE FOR NURSING PRACTICE Chapter 29: Systematic Reviews of Research Evidence: Meta-Analysis, Metasynthesis, and Mixed Studies Review Chapter 30: Disseminating Evidence: Reporting Research Findings Chapter 31: Writing Proposals to Generate Evidence Glossary Appendix: Statistical Tables Index 19 Check Out the Latest Book Authored by Research Expert Dr. Polit If you want to make thoughtful but practical decisions about the measurement of health constructs, check out Dr. Polit and Dr. Yang’s latest book, a “gentle” introduction to and overview of complex measurement content, called Measurement and the Measurement of Change. This book is for researchers and clinicians from all health disciplines because measurement is vital to high-quality science and to excellence in clinical practice. The text focuses on the measurement of health constructs, particularly those constructs that are not amenable to quantification by means of laboratory analysis or technical instrumentation. These health constructs include a wide range of human attributes, such as quality of life, functional ability, self-efficacy, depression, and pain. Measures of such constructs are proliferating at a rapid rate and often without adequate attention paid to ensuring that standards of scientific rigor are met. In this book, the authors offer guidance to those who develop new instruments, adapt existing ones, select instruments for use in a clinical trial or in clinical practice, interpret 20 information from measurements and changes in scores, or undertake a systematic review on instruments. This book offers guidance on how to develop new instruments using both “classical” and “modern” approaches from psychometrics as well as methods used in clinimetrics. Much of this book, however, concerns the evaluation of instruments in relation to three key measurement domains: reliability, validity, and responsiveness. This text was designed to be useful in graduate-level courses on measurement or research methods and will also serve as an important reference and resource for researchers and clinicians. 21 PART 1 FOUNDATIONS OF NURSING RESEARCH 22  Introduction to Nursing Research in an 1 Evidence-Based Practice Environment N U R S I N G R E S E A R C H I N PE R S PE C T I V E 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 23 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 cred entialing 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 24 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 research001-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 ). 25  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- 26 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 27  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. 28  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). S OU R C E S OF E V I D E N C E FOR N U R S I N G PR A C T I C E 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 research001-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 29 “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. Logical Reasoning 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 30 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. Assembled Information 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. Disciplined Research 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 research001-based findings rather than on tradition, authority, intuition, or personal experience—although nursing will always remain a rich blend of art and science. PA R A D I GMS A N D ME T HOD S FOR N U R S I N G R E S E A R C H 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). 31 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. 32  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 33 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 34 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 35 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 36  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). T HE PU R POS E S OF N U R S I N G R E S E A R C H 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. 37  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. 38  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. 39 Exploration 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. Explanation 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 Drach001-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. 40 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. 41  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. Prognosis 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 42  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. A S S I S TA N C E FOR U S E R S OF N U R S I N G R E S E A R C H 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, 43  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. R E S E A R C H E X A MPL E S Each chapter of this book presents brief descriptions of studies conducted by nurse researchers, focusing on aspects emphasized in the chapter. Reading the full journal articles would prove useful for learning more about the studies, their methods, and the findings. Research Example of a Quantitative Study Study: 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 44  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 Quantitative 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. S U MMA RY POI N T S 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 45  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. The National Institute of Nursing Research (NINR), established at the U.S. National Institutes of Health in 1993, affirms the stature of nursing research in the United States. Contemporary emphases in nursing research include EBP projects, replications of research, research integration through systematic reviews, multisite and interdisciplinary studies, expanded dissemination efforts, and increased focus on health disparities. Disciplined research is a better evidence source for nursing practice than other sources, such as tradition, authority, personal experience, trial and error, intuition, and logical reasoning. Nursing research is conducted mainly within one of two broad paradigms— worldviews with underlying assumptions about reality: the positivist paradigm and the constructivist paradigm. In the positivist paradigm, it is assumed that there is an objective reality and that natural phenomena are regular and orderly. The related assumption of determinism is the belief that phenomenas result from prior causes and are not haphazard. In the constructivist (naturalistic) paradigm, it is assumed that reality is not fixed but is rather a construction of human minds; thus, “truth” is a composite of multiple constructions of reality. The positivist paradigm is associated with quantitative research—the collection and analysis of numeric information. Quantitative research is typically conducted within the traditional scientific method, which is a systematic, controlled process. Quantitative researchers gather and analyze empirical evidence (evidence collected through the human senses) and strive for generalizability of their findings beyond the study setting. Researchers within the constructivist paradigm emphasize understanding the human experience as it is lived through the collection and analysis of subjective, narrative materials using flexible procedures that evolve in the field; this paradigm is associated with qualitative research. Basic research is designed to extend the knowledge base for the sake of knowledge itself. Applied research focuses on discovering solutions to immediate problems. A fundamental distinction, especially relevant in quantitative research, is between studies whose primary intent is to describe phenomena and those that are cause- probing—that is, designed to illuminate underlying causes of phenomena. Specific purposes on the description/explanation continuum include identification, 46  description, exploration, prediction/control, and explanation. Many nursing studies can also be classified in terms of a key EBP aim: treatment/therapy/intervention; diagnosis and assessment; prognosis; harm and etiology; and meaning and process. STUDY ACTIVITIES Chapter 1 of the Resource Manual for Nursing Research: Generating and Assessing Evidence for Nursing Practice, 10th edition, offers study suggestions for reinforcing concepts presented in this chapter. In addition, the following questions can be addressed in classroom or online discussions: 1. Is your worldview closer to the positivist or the constructivist paradigm? Explore the aspects of the two paradigms that are especially consistent with your worldview. 2. Answer the questions in Box 1.1 about the Vincent et al. (2014) study described at the end of this chapter. Could this study have been undertaken as a qualitative study? Why or why not? 3. Answer the questions in Box 1.1 about the Bjorgvinsdottir and Halldorsdottir (2014) study described at the end of this chapter. Could this study have been undertaken as a quantitative study? Why or why not? S T U D I E S C I T E D I N C HA PT E R 1 Archibald, M. M., Caine, V., Ali, S., Hartling, L., & Scott, S. (2015). What is left unsaid: An interpretive description of the information needs of parents of children with asthma. Research in Nursing & Health, 38, 19– 28. Bäck-Pettersson, S., Hermansson, E., Sernert, N., & Bjökelund, C. (2008). 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